Post-MRI diagnosis

Last Thursday I met with David Johnson, a sports medicine orthopedist who works out of Washington Hospital on Irving St. and the Foxhall Medical Building on New Mexico. He looked at my X-Ray, saw nothing wrong, and I recounted to him the last couple months as it relates to my knee. He agreed that there was likely some issue since PT hasn't helped and it may only be visible on an MRI. He prescribed the MRI and identified regional MRI offices that have newer machines and shorter waits. In addition, he said I could try a specific PT exercise to try and help my knee.

• While sitting in a chair, cross my left leg over my right and let it lay there. Extend my right leg and hold it out to strengthen the quad muscles and increase bloodflow to the knee.

Ultimately, I was able to schedule an MRI at Foxhall MRI in NW for the following day (Friday). An MRI works by introducing intense magnetic fields that cause the nuclei in that part of the body to create their own magnetic fields that are then detectable by the scanner. The machine will take "slices" of the body part to get more highly-detailed images and can view the body part from numerous angles and axis.

I went in and relatively quickly got situated. The technician emphasized the need to stay still during each of the sessions in order to reduce the potential for blurred images.  I had at least five series taken that were 3, 3, 5, 5.5, and 3.5 minutes in duration. I had to focus on my breathing to ensure my leg wouldn't move. Sometimes, it takes a mandate to not move your leg in order to believe that restless leg syndrome might actually be a thing. In any event, they handled the images and I requested a separate CD to keep as an electronic copy. The following are the applicable images followed by highlights of the injured area.

Although Dr. Johnson couldn't get me in the same day, I was able to schedule the follow-up for Monday. After waiting 45 minutes, Dr. Johnson arrived and viewed my MRI films. What he noticed was white with a black line on the medial (inside) side of my patella (kneecap) in the series looking up my leg from below. Everything else, MCL, ACL, LCL, etc looked good. He said that the white and black indicates fluid built up in-between the medial ligament and the patella. Typically, this occurs when there is some injury to the knee where the kneecap is pulled from its natural position (for example, a dislocation). Another ortho friend of mine named it as a medialpatellafemoralligament avulsion. Essentially, the ligament was pulled away from the kneecap and the resulting inflammation and gap allowed fluid to build which has been the source of my pain. 

The good news is that there is no surgery. Also, I'm glad that there was an actual culprit as I would have been extremely flustered to go through all this just to find out that nothing was visible on the MRI. Dr. Johnson said it could take 3-4 months from the initial event for the injury to heal which puts me at the end of April and definitely takes me out of Comrades since I won't have a qualifying race and won't have really any miles in training. During the interim, he encouraged me to continue forward-motion activities (swimming, biking, elliptical). In addition, he said I should continue to do the seated leg extensions and can incorporate the occasional use of ice in a cloth but only for 8-10 minutes at a time.

Once any pain is gone, he said I can try to start running again. Very slowly. He provided the following suggested plan (dayweek):

Mon1 - 1/4 mile

Wed1 - 1/4 mile

Fri1 - 1/2 mile

Sun1 - 1/2 mile

Tue2 - 3/4 mile

Thu2 - 3/4 mile

..and continue in that fashion until I get up to two miles per run. At that point, I can increase my mileage by 10% on a weekly basis. For example, in the week where I am able to do 3 2-mile runs (6 miles), the following week I can do 6.6 miles. Obviously, back off if I feel pain and it's a small increase but will more or less amount to exponential growth.

So, in lieu of Comrades and the beginning of my ultramarathon career, I need to identify some races later in the season so I can accumulate an adequate amount of training.

Time for an MRI

Another couple weeks and nothing to show for it. I have had a couple decent runs. Last Friday after visiting Sonya, she taped my knee with some cover roll and lueko tape. The idea is to pull my kneecap inward. Running with it was an improvement but walking more uncomfortable than running. I have since run without taping and it has been about the same so the taping didn't really do much. I was feeling good about things after running Wednesday when pain was minimal but it increased again today while running the 2/3 intervals. Again, the pain/discomfort was worse when walking. While running, I have been able to maintain an aggressive forefoot strike and it has become much more comfortable.

Biking has been less painful although I don't seem to have the same leg strength while working the indoor trainer, i.e. it's been more difficult to maintain 20mph than it was previously. Swimming has gotten better, in large part because I have been kicking from my hip instead of my quads. Also, the strength routine I'm on, including a fair number of pull-ups, seems to have given me a bit stronger stroke. I've also been focusing on maintaining a good body roll through the stroke.

This week Sonya had me add:

• One-legged ball pick-up squats (one leg at a time, one leg in air behind body, squat down to pick up a ball. Stand up, squat down to replace it on the ground. 20 reps each leg)
• Lateral hip exercises (theraband at ankles, walk laterally ~20 steps in each direction)
• Foot arch strengthening activities (with heel, ball and toes on ground, arch foot). These are all intended to work the whole system of me leg.

After more than a month of PT and performing the recommended exercises at home, I would expect that there has been some strengthening of the supposedly guilty muscle groups. This leads me to believe it may be a more serious issue. Therefore, next week I have an appointment to see Dr. David Johnson for a second opinion and hopefully, an MRI. The MRI should provide some additional details regarding cartilage depth that the Xray could not.

I looked into Comrades policy for transfer for a registration. They only allow substitution meaning that somebody wishing to get into the closed race needs to finds somebody that cannot or no longer wishes to do it. I'm thinking I may try and find somewhere to post the bib and perhaps get paid back by the substitute for the effort.

Stagnation

I've been back to Sonya a couple times and there hasn't been any noticeable improvement in my knee. Sonya suggested that if things are still not improving over the next two weeks that I go back to the orthopedist and get an MRI. That does not bode well.

Yesterday (2/1), she added some new activities to my rehab, these focus on strengthening the knee. In addition to the stretching and side leg lifts I've been doing since I started, she has me doing these:

• Bosu Ball squats. With Flat part of bosu ball up, legs shoulder-width apart, perform 3x10 squats ensuring that legs are moving in one axis and not tracking inward.
• Modified Lunge. Get into lunge position and perform lunge ensuring front knee does not extend past front foot and knees do not track inward. 2x20.
• Step Downs. One-leg step downs front 2x20, each leg, each direction, ensure knees do not move inward.

Also, for years I've felt my left shoulder socket has been off, starting with a church softball game in high school when I over-swang (sp?) and pulled it out of the socket. Sonya gave me the following strength exercises to improve the stabilizer muscles in my shoulder.

• With back against the wall and elbows touching the wall, forearms out 90 degrees with palms up. Rotate arms outward staying at 90 degrees and touch the wall. 3x10. If that is not a problem, stand with back against wall top of hands touching wall at waist level. Raise hands above head while maintaining contact with the wall. 3x10.
• Take a ball and extend arm forward, holding ball against the wall and make sure shoulders are square to the wall. Makes circles with palm on ball and rotate 10 times clockwise and 10 times counter-clockwise; repeat 3 times.
• Lay on stomach with arms at sides. Pinch shoulder blades together as a first move and then raise arms off the ground. If that is too easy, add some light weights to increase resistance. 3x10.

Sonya also said that if I want to try running again, that I need to approach it in 30 minutes increments according to the following breakdown.

1 minute run, 4 minutes walk. Once that doesn't hurt..

2 minutes run, 3 minutes walk. Once that doesn't hurt..

3 minutes run, 2 minutes walk. Once that doesn't hurt..

4 minutes run, 1 minute walk. Once that doesn't hurt..

Gradually increase time and distance.

Clearly, I still have a ways to go.