An update: Not going to do surgery

Going into the second surgical consult, I knew that I needed to make a decision between running and medical school. Basically, the first surgeon told me I would need to take two weeks off of school. I don't think I would need this much recovery time, but during the second semester of my second year of medical school to do surgery with that possibility would be VERY risky. So my heart was breaking. I further discussed this decision with the dean, who had a similar opinion. I was guaranteed that the school would support me as best they could academically, but with the number of exams and all the information, to have surgery on Martin Luther King weekend would be very risky.

I entered the second consult with the plea that we need to find any and every non-surgical options. The second consult said that I *may* get by without surgery IF I find the best physical therapist around and he specializes in elite athletes. I have been getting better slowly, so as long as I adequately strengthen my leg before returning to running, it may not matter that I have both a torn meniscus medially and no cartilage laterally. 

So I had my first appointment yesterday at the physical therapist recommended by Dai Roberts, my triathalon coach. My left leg is now significantly weaker than my right due to extensively babying it these past few months. This is strange, because since I tore my ACL on my right leg in 2008, my left leg has been the stronger leg. And over the summer I was told by a sports specialist that I need to focus on strengthening my right leg because it is so weak.

The PT said I should be able to start running next week and gave me several exercises for my hamstrings and lateral rotators. And so rehab begins and the process of avoiding surgery at all costs. I will continue triathalon training and make this the year of triathalons... But I had a dream the other night about racing. Right before the (running) race began up this exceptionally steep hill, I looked at my teammate next to me, a girl. I told her "you have this, but don't slow down, because I will try my hardest and be right behind you. If you let up I will pass you." And so I will return to running, weaker, slower, but with no less heart or determination to be the best I can be and make the races that much more difficult for everyone else!

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!

Dedicated to my Dad: "Athletes aren't normal people"

Is what my new triathalon coach Dai Roberts said to me when we met for the first time on Friday (11/2). He was recommending that I go see a sports medicine doctor. who, unlike the orthopedic surgeon I saw about my knee, will understand my absolute compulsion to run.

For me my compulsion started as a little girl studying the religion of "soccer" with my dad. By high school practically every Saturday and Sunday morning I didn't have a team-game I would be up playing pick up soccer with my dad; usually out on the pitch by 6:30. I loved the feeling driving home and seeing almost no one else on the road, just me and my dad. And we were covered in sweat from running our hearts out for the last 2-3 hours.

When I would come home from college breaks (especially when I lived in Oregon with a 3-hour time difference), my mom would make my dad promise not to wake me up to go play soccer because "I would need my sleep". But he would come by at 6am (3am my time) and whisper "Courtney, are you ready, you sure you don't want to go play?" And I would get up and go.

My dad runs through every injury and always has. Growing up, he was always injured or had a black eye, or something else. Every year he would mention something about giving up soccer because it was hard on the body.... In fact, we were told that if it weren't for our bad knees, we wouldn't be here. My dad had played semi-professional soccer. Then the first lottery he ever won was the Vietnam War draft. His birthday was the first number picked. When he reported, he was rejected because of his knees. As he walked into the reject room, a football player looked up and said "what sport do you play?"

Now he still goes out there and gives it all he has got. He can't see peripherally or when someone sneaks up on one side because he has glaucoma (for which the dutiful man would never try marijuana :) and he is virtually blind in one eye. He also can't see depth because that needs two eyes. But he is out there giving it what he has got because he isn't a normal person; he is an athlete!

My Saturday morning Coaches league

Coming home to take care of my mom I played pick up on Tuesdays and Thursdays nights with one group and Saturday mornings with another. People played through all kinds of muggy, hot Virginia summer weather, and this normal/fun activity with these guys gave me a happy place which helped buoy me through the hell I was experiencing inside. Because of their strange athletic compulsion, I could trust that they would be out there trying their hardest despite whatever injury they were working through. These are my people.

Love this shot, note the head in the hands on the right :)

My dad made me into a Crazy Athlete long before I became a runner with high hopes two years ago. Now I have sustained another serious knee injury. This injury really scared me as I have already torn both my ACLs. But I will cross train and get healthy because I am an athlete, a part of this strange group of people with a crazy compulsion to play. Once healthy, I will put my all into working to qualify for the next Olympic Trials. What makes me crazy? Every day when I get up I think of running for as long as I can for as fast as I can. After that I want to ski, jump, climb, play soccer, kayak over waterfalls, and more! And some day I want to have children and get them up before dawn to go play soccer with other crazed athletes from around the world, showing them the beauty and fulfillment of having drenched their shirt with sweat hours before before there are any other cars on the road. I will make a great comeback because am an ATHLETE, eager to be on the pitch, and a little insane. It *runs* in the family. Tee hee, RUNs in the family!

Me, my sister, and my Dad

Family canoe trip when I was 5

       

My dad in my boat, life jacket, and paddle looking at the leaves  this past month

Me two summers ago going off a waterfall 2.5 months after I started kayaking

Me competing in Missoula a year after starting kayaking; lol, somehow I came in second :)

Survival...through an injured knee or vibrio cholerae

So I just swam my first mile in two years. While my mom was dying, before I ran my first competitive marathon time, I had a badly sprained ankle from soccer and was confined to swimming and biking.... I actually got recruited to be a spinning teacher because I'm so dang perky and excited at six in the morning. Strange... I know....  I was excited to do my first triathalon, but then I found out that I was really good at running. So decided to put my 100% into running. And then I decided that I could make the Olympic team trials for Brazil and swimming and biking suddenly seemed bleak. But then 2 weeks ago, I got injured, and I still can't walk down stairs without excruciating pain in my left knee.

So today I joined the YMCA and I swam my first mile, not using my left leg because it hurts to kick. With about 500m left to go a fat bald man got in next to me and passed me doing freestyle while I was doing backstroke. So I decided to race him. It was so much fun because we were both pretty pitiful and slow and he didn't know I was waiting for him to finish so I could race him for another 50m. And neither of us could do flip turns, so there were a lot of pauses.

But I left feeling like a hero because I was back to the mindset I had when I was taking care of my mom. My hero mindset, where I am my own hero. Where I can go swimming in the morning, work a full day, go home and be with/take care of/read to my mom, and get up and do it all over again. Where nothing could stop me, not my anger with the world that would mercilessly destroy my idol (my mother), and not an ankle that I couldn't really walk on.

So I left and thought of one of my old goals in life: to never have to drink my own urine. I made that a goal when I was 9 or 10 and read about a man who got trapped under his house during an earthquake in India. He drank his own urine to stay alive. My goal made me never want to live in California, or anywhere near a fault line (it may seem ridiculous, but the desire to not drink my own urine was actually a factor in me turning down some california colleges to which I was accepted). Recently this goal has been modified to never having to drink my own urine or my own diarrhea to stay alive. One of my professors mentioned how in third world countries if someone has a bad bout of cholera, you can feed them their own diarrhea to give them to fluid and electrolytes necessary to keep them alive through the bout of diarrhea**.

I realized today what it means that the goal  of never drinking my own urine has influenced my life decisions... It means that if necessary to stay alive (i.e. if I were in that situation), I would drink my own urine (and maybe diarrhea). That I am strong enough that I will do almost what is necessary to survive and thrive and be the best that I can be. Fortunately, in my life that has meant joining a swimming pool at 26 years old because I sprained my ankle and can't walk. Hence, I know that my knee injury will help me become as strong as I was became when I hurt my ankle and within months became an elite runner. This injury will help me become as strong as I was when I had to be strong for my mother and figure out a way to get her to smile even when she was crying. Because she could die at any second if her tumor felt like making that her last.

** Note that I will never endorse Urine Therapy: http://en.wikipedia.org/wiki/Urine_Therapy
This is NOT endorsed by the medical establishment. But if someone wants to get back to me on what spreading urea on their skin does to help prevent wrinkles or help get rid of their hemorrhoids, I am ALL EARS! Though I may giggle a little while listening.

Beckley Half Marathon 2012: My first injured race

As this is my boyfriend's birthday weekend, I flew out to visit him in Fayetteville West Virginia, home of the Gauley & New Rivers. There just happened to be a half marathon ~1/2 hour away in Beckley, so I figured I would try it out.

There were a few factors against me from the start. First of all I have runners knee and have barely been able to walk down the stairs this week. My knee started to ache after my 21 miler last weekend and got pretty bad after my monday workout, so I did crosstraining on the bike or eliptical for the rest of the week. As I lay in bed this morning, just the act of raising it made my knee hurt.

So if I can't walk down the stairs without limping, what kind of course is Beckley. Well it is an out-and back course that is up or downhill the whole time, except for ~1 mile loop around some soccer fields and a .75 mile loop around a school. Ha!

It was so steep that at ~mile 7.5 I was running down what I thought was a fairly steep hill, I realized while I was running up the other direction I had thought I was running on flat ground because it was so less steep than the rest of the course.

My knee gave out soon after this point. My quad starting cramping up painfully on my knee the way it hurt to walk down the stairs. I had to stop and stretch for the first time in my life during a race. This is also soon after the temperature dropped from 60 degrees to about 50 degrees with a cold rain and brutal wind. Also there was a complete dearth of powerade, electrolytes, or sugar along the course. Lots of water set ups with everyone having a big smile on their face cheering you on. At some of the water stops people even jogged along with you to give you water (so wonderful and adorable!!!!) But when doing this hilly of a half marathon in cold rain and having your quad cramp up on you, all you want is some sugar and salt... and there was none anywhere along the course.

At about mile 10 on a downhill my knee gave out on me again and I prayed that there would be some sugar and/or salt as I stopped to stretch my quad & try to elminate some of the pain in my knee. After that, I couldn't run down hill, it was just too painful. I had to kind of hop-skip down, but I could still run the uphills! so it was a weird kind of speed workout :) I was passed by men #3&4 at ~mile 12 and one of them turned around as I was hoping down the hill in pain and said "you can do it you're almost there." Just one more example of the great personality that pervaded this rural race.

I came in 5th overall and 1st for women with a time of 1:25:?. My boyfriend was there to help me limp to the car because I couldn't walk without support my knee was so angry and painful. I cried a little from cold, hunger, and pain. And then I laughed at how stupid I was for running the hilliest half marathon I have ever seen with a hurt knee. I hope to come back next year and reap revenge on the course that destroyed me. I will have lots of goodies and electrolyte pills in my back pocket though! The support was great, the route was beautiful and challenging and strength-building. There were lots of cops to direct you were to go and to make sure traffic didn't hit anyone. Other than having gotten my butt handed to me, it was an amazing race! But that's why I will be back next year without a hurt knee and lots to prove!