The Last Word on Knees

I've become something of a connoisseur of articles on knees. You know -- that concatenation of bone, ligament, muscle and tendon that separates your shins from your thighs? Endurance athletes tend to have a lot of trouble with 'em. I'm certainly no exception, as Velophoriacs know too well from early posts here, detailing part of my odyssey with knee issues.

In my Firefox bookmarks folder, I must have over forty articles on knees: Physiology, strengthening, stretching, self-massage, blah, blah, blah. But ever since I recently bought a nice pair of running shoes and started fooling around with trying to run again, I've done a bunch of research on knees in the running literature. That's when I found this gem. I was surprised; I'm disappointed by Runner's World's tendency to print quickie sidebars entitled something like, "Five Tips for Joint Health." Useless. Nonetheless, this full-length piece is the best (and most enjoyable) summary of all the thinking, past, present and cutting edge, about knees I have read so far.

If you have any good ones yourself, feel free to post in the comments section.

The Velophoric Year

I love this cartoon. The first time I saw it, I was standing in the service area of my former LBS (much lamented), where it was posted on the wall. (Click on the graphic to enlarge it.)

The beauty behind the humor, of course, it's that there's so much truth to it. Cycling can be much, much more unpleasant than work. And I'm not talking about the long hill-climb or final interval unpleasant; we all not-so-secretly love that pain, or we wouldn't train in this crazy sport. I'm talking about frustration... dark nights of soul... cursing the day you first rode a bike... That kind of thing.

Now, Velophoriacs don't come to this blog for sarcasm or hopelessness. I fall into the "What you put your attention on, grows" school of thought, and, being a therapist myself, I try really hard to walk the talk of staying positive. But it's also important to be real, and part of reality is that even the best parts of life have some extremely crappy moments. Sometimes, especially the best parts of life. So, given that New Year's is right around the corner, and in the spirit of making light of the darkness, I'll do a classic "Year in Review" type piece by re-capping some of my low points for the last year.

In the 15 months since I started training again (after decades away), most of my frustration has come from injury, as is well documented here on Velophoria. Maybe four or five of those months, at most, have been free of worries about or pain from recurrent knee problems. And there were far too many rides cut short, the second half of which I usually spent cursing and grinding away in pain, trying to spin and get home with as little further injury as possible. Also, lots and lots of riding hours spent soft-pedaling, wondering when I'd be able to discover my limits again. Better than not riding at all, but pretty gray winter days, nonetheless.

There were sources of frustration beyond injury, too. I haven't had the money to get the equipment that reflects the type and level of riding I do. I also don't have the money to get a proper, full-scale bike fit, which would probably alleviate the recurring injury. There have been repairs during which I have crouched sweating and cursing next to my bike, running through the directions for the fourth time and still not getting the right results. There were the six or eight weeks of barely riding while recovering from classic overtraining (written up here). I was caught in numerous thunderstorms of biblical proportions 20 miles from home (like this one, for example). The one in Acadia National Park was just miserable, though the first half of the ride was blissful.

I was pretty frustrated when I first moved out here to beautiful Western Massachusetts, because the terrain is way more hilly than eastern Mass; my average speed went way down and I felt like a much weaker rider all of a sudden. That's changed a bit since then, and I've become a stronger rider for it, but I'm still adjusting to the hills to some degree.

Finally, there's the frustration that comes from being a fan of the sport and having to constantly adjust one's head to the "new normal," all the doping, the scandals, the politics and idiotic moves from governing bodies. I took that one head-on in June, in one of my favorite posts ever.

Now, I could sit here and spin all these frustrations into positives, and it's no surprise to loyal readers that each of these challenges has produced its own excellent crop of rewards and lessons for me. I won't bore you with that here. I was just looking through old graphics files and came upon an excellent Calvin and Hobbes, and decided we could all use a laugh, before we turn the calendar over and bump up into Base 2. Happy Season!

Heal Already! Living With a Nagging Injury • iii

Third and Final Part. (Read Part One and Part Two.)

The second most annoying thing about nagging injuries: The variables.

Sometimes, I get to feeling a little better. I might even be able to do a hard ride and not suffer too much afterward. Was it the fish oil capsules a friend recommended to me? The glucosamine I started taking this week? The new stretch I’ve been trying? Or maybe it was just the cumulative effect of all the original stuff I’ve been doing for weeks and weeks – did I finally accrue enough benefit from the stuff the PT prescribed, so that I just now turned a corner?

Maybe it’s even some maddening, nebulous combination of the above. Probably is, actually.

Finding what I call “the end of the knot” (so I can pull on it and finally unravel the problem) can be really, truly, infuriatingly hard. Sometimes it seems foolish to even try; by tomorrow, I’ll probably just have another guess as to what caused my improvement. It takes a vast amount of will to keep at the project of figuring out what will help. I admit to three separate days when I was nearly in tears, wondering if I really cared for this sport enough to keep at this whole through the looking glass experience. I was barely a breath away from burying my bike under a bunch of junk in the back of my garage and resigning myself to long walks for exercise. Grim times.

And just going to the “expert” doesn’t usually dispel the darkness. Sure, I always walk out with hope springing eternal that the new diagnosis or exercise they’ve given me is finally the end of this. However, as I’ve said, doctors can be a bit glib about getting to the very bottom of a problem. Well, to be honest, it’s not very efficient for them to sit with me, digging endlessly through the layers of complication. So, I try to strike a balance: I do a little research on my own. I try out some stuff friends recommend. And when I get completely mired in the variables I’ve introduced by myself, I go back to the physical therapist (who is a great guy), do a brain-dump of the whole thing, and see if maybe I have managed to introduce some tiny new wrinkle that will help him finally solve this thing.

Now, here's where I admit that he actually seems to have done just that, about ten days ago. I went back to him after a long stretch of trying to solve it myself, and did one of those brain-dumps. I just blurted out, with no small relief, all the ups and downs and each and every desperate measure I've tried. He actually listened very carefully (you can't imagine how good that feels after weeks of obsession), and then he started trying a little of this and a little of that, all the while explaining some new levels of skeletal detail.

While he was chatting away explaining stuff, he almost off-handedly tried something that felt really different to me. I made him show it to me, went home and expanded on it, and voila – nearly instant and apparently reliable improvement. I won’t bore you with the fine points; if you have chondromalacia or ileotibial band issues, feel free to post a comment here and I’ll be glad to give details. The point is, I think… for today… that I’m out of the woods. Like the twelve-step people say: “One day at a time.” Fingers crossed!

And maybe that’s the upside of all that maddening confusion: You just never know when the next stinkin’ thing you try is actually going to be the end of all your worries.

Heal, Already! Living with a Nagging Injury (ii)

Part Two (Part One can be found here.)

So I actually did manage to be patient and follow the physical therapist’s strengthening and stretching regimen pretty religiously for a few months. And slowly -- very, very slowly -- I got better. It was very much two steps forward, one step back, but at least it wasn’t the other way around.

By March, I was riding a little harder and longer, and by April, I had almost forgotten I’d been injured. I’d been promising myself for months that, once I got to May and the insanity of my final semester of a multi-year grad school program was done, I would reward myself by riding as much and as hard as I wanted. I was salivating for this. Seriously.

By early May, I had gotten confident, strong and very happy. I was riding a little more intensely each week. I was building up carefully. I got to the point where I was doing climbing repeats on the steepest hill in town, and loving them to death (when I wasn’t heaving pieces of my lungs onto the blacktop.) It was going to be a great spring, after all. I was going to be at the front of the pack. I was going to shine.

And then one day I did one extra repeat on that hill, and felt a little twinge in my knee.

What? Did you expect a happy ending? Come on.

Now, the number one very most annoying thing about a nagging injury is that it’s impossible to tell the difference between healthily pushing the limits, and dangerously aggravating it. Often, I’ve pushed a little beyond my safety zone, felt a little ache here and there, and found out the next day that I had done a good thing. Instead of more discomfort, I would actually feel stronger. Then the next week, I might push it exactly as hard (or so it seems), and that night feel the hot irritation that signals the beginnings of re-injury. Then I have to pull back, and maybe even lose weeks of progress.

It was just that way on the very day of my last class in graduate school. I felt great after repeat number two, and so went for number three for the first time. That’s when I re-injured myself, and pretty good, too. It’s now seven weeks later and I’m still in the throes of recovery, progressing, backsliding, angsting over Web research, calling my PT. Yay!

Next: Repeat After Me: "My Knees Are My Teacher"

Heal, Already! Living with a Nagging Injury (i)

Part One

I’ve been living with a minor sports-related injury for about seven months now, and the fancy name for it is patellofemoral pain syndrome. Really, that’s just a ten-dollar way of saying that I have a problem that the experts don’t understand. It basically amounts to irritation and pain behind the kneecaps, and most of the gurus think it’s due to poor tracking of the patella when the leg flexes. Of course, the leg flexes many hundreds of times on a typical bike ride, right? So there you go: Recipe for nagging, recurring injury.

That’s the bumper sticker version of the science. What I really want to write about today, though, is the way that a nagging injury gets inside your head and fouls up your confidence, your athletic life and your sanity. There doesn’t seem to be much out there about that – which is surprising, considering how common sports injuries are.

When the injury first came along last fall, I buzzed off to my primary care doctor. He sent me to an orthopedist. Who sent me to a physical therapist. Which was where I wanted to go in the first place, but you know the wisdom of insurance companies: You have to go through the chain of command, or you get court martialed.

All three experts told me I had rock-solid knees, and I’d be back to 100% in no time. The cocky young orthopedist even turned on his million-dollar smile and said something like, “I promise you another 100,000 miles on those knees.”

Now, you’ll remember I said at the top “seven months,” right? It’s so easy for doctors to be optimistic about your recovery. If they turn out to be wrong, they just get more business. If we could sue for giving false hope, like we can for leaving surgical tools inside us, they’d be more circumspect, don’t you think?

The PT was one of those no-nonsense sports doctors: Young, confident, handsome. Runs his own business, always checking his Blackberry. Man of few words. Very nice guy, actually, and I think he’s probably pretty good. But I always worry that he’s finds me a bit neurotic. I go on and on about my symptoms, when they come, when they go, what the variables are, asking a hundred questions. I think he wishes I would just shut up and follow his exercise and stretching regimen. He knows I would get better; he's seen it many times. Meanwhile, he could put his attention on his other patients. There seem to always be other patients in PT offices, lined up on treatment tables and specialized equipment, waiting for attention from the doc, as if he were the maharishi about to bless them with his miraculous hands, so they could finally go run or swim pain-free. I wish they would all go away. Can’t they see that I need to get these knees fixed?

NEXT: The physical therapy actually works. For a while.