Detail (part 2)
April 2007: I had both knees MRId at the Eliot MRI center. Since they
only did my knees, there was no claustrophobia to worry about. The
machine is noisy and although they do offer you music, it is not over
wire but rather the air tubes like airplanes used 20 years ago. After
the MRI report was complete, things were not really any clearer. The
report read (and I'm paraphrasing) "The left knee is essentially a
normal MRI. The right knee shows signs of chondromalacia patella and
a fluid pocket consistent with a lateral meniscus tear." The
translation from the orthopedist was that it is not a stark diagnosis
with an obviously solution. He suggested three options in order of
invasiveness: RICE + exercising; Synvisc/Euflexxa (aka "the grease")
which is hyaluronan, a substance naturally found in the cartilage.
I should pause here and mention that the cartilage itself does not
have a direct blood supply, but rather derives its nourishment and
disposes of its waste products via the synovial fluid in the joint and
the process of squeezing it like a sponge, which naturally occurs
during joint movement.
The third option was to get 'scoped and investigate and possible clean
up or repair the cause of the problem. This was unattractive to me,
and to their credit, neither orthopedist suggested I was ready for
scoping just yet. Option 2 was a possibility.
May 2007: I decided to get a second opinion. I picked a knee
specialist orthopedist in Ashland (Dan O'Neill, NH Knee Center). It's
an hour from my house, but the guy answers his own e-mail, and returns
(or answers!!!!!!!) phone calls promptly. He also lists among his
hobbies "Road Bike and Cross Country racing, Alpine and Nordic skiing,
Hiking and Snowshoeing". He works with an athletic trainer as a team,
and focuses on getting athletes performing again, rather than just
functional. He did the usual physical exam, again saying things
looked/felt mostly good, although the clicking does indicate wear and
tear. He also reviewed the MRI and pointed out the items mentioned in
the report. He recommended trying a cortisone shot, as the ibuprofen
was ineffective. I figured one can't hurt (many can harm your liver)
so again I opted to treat the left, and currently more problematic
knee. (Much to my delight, Dan called me personally the next morning
to see how my treated knee felt.) He also strongly recommended I seek
out a sports trainer, rather than a PT, to continue the strengthening
and training, and said not to be surprised if it takes longer than 4-6
weeks that typically go with PT. His final recommendation was to take
my bike to the shop and have them check the fit.
I was dubious about the bike fit - after all I've been riding forever,
and any maintenance I do involves careful measuring and reassembly so
as not to change the geometry on any way. Being desperate enough, I
went. To my surprise, the bike fit check revealed my saddle was at
the extreme low-end of the acceptable range. I went home and measured
it and gosh-darn-it-all, the thing had slid down almost 2 whole
inches. That's what I get for trusting the shop when the previous
seat post failed. I am sure I measured it when it was returned, and I
am sure it was correct, but obviously the sleek new carbon fiber $110
post didn't stay put. And, it had bonded to the steel seat tube and
had to be cut out. Whether or not this contributed to the knee
problems is unknown, but I was not at all happy at being out $110 for
a nice seat post plus $100 labor to cut it out of the seat tube. I
replaced it with an old aluminum post I had lying around and so far it
feels so much better. My theory is it had been sliding down a tiny
bit every time I went over a bump and I just never noticed it.
June 2007: I start seeing the sports trainer recommended by
Dr. O'Neill, a man named Scott Prunier from Top Fitness in Nashua (at
the Conway Arena.) He took classes taught by O'Neill. He put
together a program which included self-massage (using a foam roller
system), activation, movement preparation, strength training, bicycle
intervals for energy system development, and regeneration (cool down)
aka stretching. Unlike PT, which focused on stretching the ITB,
hamstrings, and strengthening the VMO, this is a training program
designed for performance and includes an emphasis on not just the
legs, but the core (abs, back and glutes), which figures prominently
in ascending and descending mountains while carrying a load on your
back. I did this for 5 weeks with Scott, and have continued it on my
own, twice per week, for about an hour, and I can do it from home
having purchased only a foam roller, stability ball and a few
dumbbells. I've also adopted the streching routine any time I watch
TV (Red Sox, Les Stroud, ...)
June 23, 2007: Up to this point, I'd done some smaller hikes with
various subsets of my family, such as North Uncanoonuc, Pack Monadnock
and Major. I wanted to give the 4Ks another shot. I chose Tecumseh
from Tripoli Road: 6.2 miles and 2600 feet, which I completed in 4
hours. I took my time. I worked on landing each foot fall carefully,
keeping the foot, knee and hip in a line. No twisting or rolling or
"bounding along". Combined with cycling intervals 2 days later, I had
the worst knee pain in a while, but it was not as bad as even simple,
flat XC skiing back in March. I put the 4Ks back on hold, but did
continue all the other programs. Meanwhile, Dr. O'Neill recommended a
bone scan.
July 2007: The bone scan is done to detect osteo-arthritis (OA).
Presumably, if I was causing damage to my knees due to lack of
cartilage, then I would be accumulating calcium deposits (this is what
OA is), and faster-growing bone such as this (and bone cancer for
example), are easily detected using the bone scan. A bone scan is a
nuclear medical procedure where you get an injection of technetium,
specially-manufactured and dosed for your height and weight, and
shipped in a lead-encased syringe, go away for 4 hours or so, and come
back for a CT scan. Luckily, or unluckily (depending on your
viewpoint), it came back all clear. The good news: all diagnostic
information so far points to nothing really being wrong. The bad
news: no presidential traverse in sight.
August 2007: I got a new job, and took 3 weeks off. During that time,
I hit five more 4Ks over 4 trips: Pierce and Ike, Cabot (and The Bulge
and The Horn), Isolation, and Waumbek. With each trip, there was less
and less reaction. All the while, I've continued the
strength-training program. The activity level graph is trending
upwards nicely while the pain level graph is trending downwards
nicely. A bright light is visible at the end of the tunnel!
Beginning with Waumbek, I started leaving the knee brace behind with
no adverse effects. I'm not sure it ever really helped me, and it did
kind of rub the back of my knee raw.
September 2007: Since last year, I've been holding the date for Flags
on the 48. Various combinations of trips have been mulled over for
weeks. In the end, the weather, and a desire to both feed the gray
jays and increase my peaks-per-trip average, pushed me into bagging
Tom, Field and Willey. During this trip, as with the previous few,
there has been nary a hint of pain while hiking. Of course I have
been following the prescribed warmup and stretching program before the
hike, and the stretching and cooldown post hike (including icing
during the trip home.) While not northern-presidentials-steep, both
the Avalon Trail and A-to-Z Trail have fairly long, fairly steep,
fairly rocky sections. This trip is the biggest test of my knees so
far. Historically, the post-hike reaction has been at T+48 to T+72
(2-3 days) and diminishing at T+96 (4 days).
In the end, I'm not really sure what the cure was. It may have been
one or more of the various treatments above. Or it may simply have
had enough time to get better. I'm pretty convinced it was both --
the stretching and strengthening preventing further inflammation and
time allowing things to heal themselves.
I think DougPaul was right when he said something to the effect of
"once you find the right treatment, plan on 6 months to recover to the
point of no pain".
Is this the end of the story? I'm not sure. It sure feels like I am
98.6% recovered and on the way to 100%. I do hope that someone finds
this useful or interesting (anything beside just long
).
If you're still here, thanks for reading
Tim
