24hours post diagnosis: Feeling Kinda Lucky

Mulling over the news these last 24 hours doesn't leave me feeling any less fearful of what it means to not be able to put any pressure on my knee for two months including walking. But I do see that I am really lucky in the timing. I feel like I tend to get incredibly lucky. When I tore my right ACL playing soccer four years ago, it was 9 days before my mom's fall break. So I was able to arrange everything and have my mom fly out to take care of me for a week after surgery, which I pushed the insurance company, doctor's office, etc, etc to arrange only nine-days post injury. That way my mom was able to wake me up every four hours to take narcotics and change out my recirculating ice container and I healed very quickly.

The cartilage in my knee could have been torn as long ago as when I tore my left ACL thriteen years ago and was just a ticking time bomb, waiting to fall away. The back of my knee first felt loose last April. It didn't become painful until around the time of the Chicago half marathon at the end of July. At that point I couldn't squat down without a lot of pain, but I thought it must be a pulled muscle or something. My leg muscles have tightened up since then to protect or 'guard' it. It feels similar to when I tore my ACL in terms of how tight my muscles have become and that guarding response.

So if I hadn't run enough miles to get it to start falling away now or whatever else I did, then it could have fallen away at any other point during my career. But this is the year where I need to sit still on my butt and study. It is perfect! Next year, actually beginning in July, through my residency (the next 6.5 years) I will need to be up-down, on my feet, running around the hospital, beating attendings to the meetings. Having surgery and being unable to walk would not be an option. Which would mean that I would have to let something that is 100% fixable for the rest of my life go. Then I wouldn't be able to run without tremendous pain for up to 7 years at least! And the pain would get worse due to increasing damage to the bone without treatment.

When my mom got sick I got incredibly lucky as well. I had great support from Montana State, unreal even, as I took off the semester at the drop of a dime to go be with my mom. Also my background was perfect between a year in biochemistry and two years studying neuropharmacology of stroke treatment. So the teachers there let me put together a research project on the neuropharmacology of glioblastoma treatment (though glioblastoma was not the type of brain tumor my mom had) AND allowed me to finish my classes at a distance. This gave me time to put my 100% into researching my mom's brain tumor and e-mail the top people who were publishing about treating my mother. When I brought her to the National Cancer Institute to meet with Howard Fine's group, who by far had the most experience in treating gliomatosis cerebrii type II (my mom's type of brain cancer), I was offered a job in radiation oncology by the head of the department based on how informed I appeared on my mom's case... in the middle of a recession!

This meant that I got to have a job with understanding people while taking care of my mom, who had taken care of me when I couldn't walk. I got to have a job while being there for my mother in the middle of the night the way she had taken care of me! Once again, despite misfortune, I have come out incredibly lucky. I can get treatment AND do my job... sit on my butt and learn all day. Wow, I am lucky the cartilage broke off now instead of half a year from now, so I can get treatment and make a full recovery. Plus I now know that I can run a 1:22 half marathon without cartilage in my knee.... I can only guess what I will be able to do once I have full capabilities again. Now I just have to get through the next 2 months of not being able to put pressure on my leg while living in a second story apartment....

The Almost-Worst News Imaginable

So I need surgery to run again. The surgery will take some cartilage from a non-weight bearing region and place it in the weight-bearing region that is missing the cartilage. At some point a chunk of cartilage was traumatically knocked loose from my knee and must have just fell away sometime recently. Who knows where it is, probably attached to some soft tissue somewhere. The surgery usually has a high rate of success, meaning no complications for the rest of my life.

This is a view of the back of my left knee, with the right side of the picture being the left/lateral portion and the left being the right/medial portion. On the lateral side of my knee where the femur articulates with the tibia, the lucent space under the femur is where there is a rectangular chunk of cartilage missing. The light area in the bone above the chondral defect is from bone marrow edema as the bone has been breaking down over time due to the chunk of cartilage missing.

In this view of the lateral portion of my knee, you can see the lucent area on the posterior portion of my knee showing the cartilage is missing on the back of my femur. You can also see that the bone marrow edema/lighter portion of my femur goes up pretty far. Apparently this is why I have been betting bone pain on my medial knee and above my knee on the femur, because the bone is affected pretty far from the injury. Once again, the bone should all be dark.

The downfalls. I will not be able to bear weight on that knee, meaning no walking for a fairly significant period of time (possibly up to two months), as the part that is going to be fixed is directly where I bear weight on my knee. Apparently I should be able to swim about 2 weeks following the surgery. I will apparently not be able to bike for ~3 months following surgery because of no weight bearing. I will not be able to run for 5-6 months following surgery, once again because it will be on the weight-bearing portion of my knee. The upsides include that I will be able to run again because this isn't one of those overuse injuries i.e. from running. Many forums I have viewed the people are never able to run again. But if I get the surgery in january by june or july I will be able to run :)

I'm trying to arrange to have the surgery Marthin Luther King Jr weekend, that thursday to be exact. But this will take a lot of planning and I don't know how I will get to class the following week, hopefully I will be able to crutch and be off narcotics by then. My goal will to be able to run by the time I take the USMLEs in June. That way I can run during my next vacation before rotations start and I will really have no time to call my own for many years to come.

To people in the Norfolk area, I will probably need some help following surgery. I will probably look incredibly pitiful as I did following ACL surgery. I will try to line up a handicapped sticker for the time right after surgery so I don't have to crutch to and from school. I have distinct memories of trying to crutch to and from class following ACL surgery in Montana and they aren't pretty. The narcotics made me dizzy so I would regularly do what I called crutch-by vomiting. I didn't want to stop crutching to where I was going, so I would just lean to the side and vomit as I mosied along my way to and from class. This is going to be an unpleasant experience. But that's life, sometimes you just gotta roll with it.

Making a Comeback

Tomorrow I meet with an orthopaedic surgeon about my knee. It seems from the MRI that I do need surgery after all and until I have surgery it will be incredibly painful to run. But nothing will be sure until I meet with a surgeon. Something that has been interesting is how everyone says but you are a medical student, you should understand what is going on. My knee has multiple ligament tears, some appear healed from the previous surgery. It also has a cyst, "densities," and a large chunk of cartilage missing in a manner that looks as though it must be "traumatic", not an overuse injury... meaning I was hit by something and I'm not sure what. Oh, and also a bit of bone missing with bone marrow edema. I had surgery on that knee thirteen years ago after tearing my acl from a sideways hit while playing girls' "powder puff" football. The acl snapped the rest of the way while I kicked a ball during a soccer game the next day. Every doctor that has looked at that knee since has said that acl is loose, meaning the surgeon probably didn't do a great job of fixing up the knee.

So in summary yes, I am a medical student, but I am NOT an expert or even a doctor. One very important aspect of medicine is that expertise means something. I will be better every year that I work and every case that I see and contemplate. That is why I chose the field. So no, I cannot diagnose myself. Further, I am going to try to see at least two surgeons so that I can prevent the knee from getting worse.... because every doctor's opinion is formed by the cases he or she sees and my case is complex. Different surgeons may have different opinions and capabilities. The more complex the case, the more different doctors' opinions will vary on how to  best treat the problem(s).

In the meantime I have been learning how to swim and doing a lot of spinning classes. This has put a huge hamper on my writing, so I apologize for going missing. But when I run my mind and heart are free. I used to compose poetry and songs while running, using the beat of my feet as a metronome. Not having that outlet really changes the way I process information and in a way who I am.  I want to write about swimming, which really is so very very very different than running, but still similar. Mostly I want to disprove the notion that if you are a runner and haven't been a swimmer that means you have pegged yourself into a hole and can't adopt a healthy balance of a sport into your regimen. It frustrates me every time people tell me they don't swim, they are a runner. I am a runner who stinks at swimming. I was never on a swim team and I never competed. Also I was chubby growing up so I didn't want anyone to ever see me in a bathing suit if I could avoid it! I played soccer and occasionally went rafting.

But I'll tell you what I am not. I AM NOT A GIMP! When I am fifty I am going to have kids and take them skiing. I'm going to laugh with them as they beat me down the mountain. I'm going to kick the soccer ball around with them and run after it. If swimming = long term happiness then heck yeah, I am going to keep being a swimmer, even if I suck, don't enjoy it very much, etc, etc. Also when I am 70 I am going to be in those old lady pool workout classes. I'm going to jump around in that water and enjoy it. Because I am not a gimp and never will be! So cheers to swimming and being a runner and don't tell me you aren't a swimmer but a runner because I will roll my eyes and work my hardest to beat you in a running race as soon as I have surgery and can run again! Because I used swimming to keep in cardiovascular shape and strengthen my hamstrings, quads, hips, back, stomach, and lungs so I can be all I want to be!