Training log - Week ending 11/24/13

This week was 19,000 yards of swimming, 85 minutes on the arc-trainer mimicking easy pace running, and several test runs (up to jogging 5 minutes at a time)  -- training log is here.  

And now, we're cooking.  I've been told that sometime in the third week is when the PRP kicks in, and yup, that's been my experience.  Healing a soft-tissue injury is generally like watching water boil or paint dry - you just don't see changes from day to day.

Supine plank. 
No, I'm not up to the leg raise yet

Except I am seeing the changes from day to day.  For example, I do a supine plank every day to assess how the hammy feels (when I can do the supine plank with all my weight on the bad leg without pain, I'll know the hammy is healed).  On Monday of this week, I rated my pain during the plank as a "4".  By Wednesday, the pain was a "3", by Friday a "2".  And on Sunday there was no pain for the first 20 seconds of the plank (felt about a "1" on the last 10 seconds).

Similarly, on Monday I took a few "test jog" steps of running.  No go.  Hurt.  But by Thursday I was jogging pain free.  Very slowly.  But jogging.

And that's how things have been progressing.  I've been upping the jogging day by day.  Nothing noteworthy - I'm not even at my normal easy pace yet.  But I'm making progress surprisingly fast.

New bathing suit on order.

At the same time, I'm also progressing my swimming.  During the past few weeks, I've just been doing straight continuous freestyle at an aerobic effort.  I understand that that is the least effective way to improve one's swimming (well, besides not swimming).  But I was OK with it, because I'm not a swimmer - just someone trying to maintain some basic aerobic fitness.

But now, I've decided to add in some interval work.  It should make the time pass a little faster, and
also has a mental callousing effect that I've been missing the past few weeks.  Staying focused and tough during workouts is a skill, and I haven't had much of a chance to practice that recently.

I did some reading, and started with sets of 4x100m on 2:30 - I was swimming these all out in about 2:02-2:04 (we all have to start somewhere, right?)  Any experienced swimmers care to comment on whether this is a reasonable way to structure a basic swimming workouts? 

Other suggestions for workouts are welcome - please keep in mind that front crawl is the only real option for me strokewise right now (breaststroke is too much for my hamstring, I veer all over the place in backstroke, so don't want to do in while sharing a lane, and butterfly is a complete no go).


Dailies

Monday:   In the morning, injury prevention/rehab work, 20 minutes on the arc-trainer, and 4000 yards swimming.  Also got some ART and Graston done.  Foam rolling at night.

Tuesday:  In the morning, injury prevention/rehab work, some leg strengthwork and then 3000 yards of swimming.   Foam rolling at night.

Wednesday:   In the morning, injury prevention/rehab work and 20 minutes on the arc-trainer.  Foam rolling at night.

Thursday:   In the morning,  injury prevention/rehab work, a test jog of 3x75-90 seconds SLOW jog (3.0 mph) with 1:00 walking, and then 3250 yards of swimming.   Foam rolling at night.

Friday:  In the morning, injury prevention/rehab work, a test jog of 4x90 seconds (up to 4 mph), followed by 20 minutes on the arc-trainer and 2500 yards of swimming.  Foam rolling at night.

Saturday:    In the morning, injury prevention/rehab work plus test jog  (2:00 run, 1:00 walk, 3:00 run, 0:30 walk, 3:00 run - speed maxed out at 4.2 MPH). 

Then I did 3500 meters in the pool, including a workout of 2 sets of 4x100m on 2:30 (Splits were:  Set 1: 2:02, 2:05, 2:07 (stuck behind guy dolphin kicking ), 2:03;  Set 2: 2:06, 2:04, ?, 2:04).

Brian and I did a couples massage class at night.  Wow - giving a massage is hard work.

Sunday:   In the morning, injury prevention/rehab work and leg strength work, followed by a test jog (segments of 3:00 (at 3.5 mph), 3:00 (at 3.5-4.3 MPH), 5:00 (at 4-5 mph). One minute walk between each).  Then did 25 minutes on the arc-trainer, followed by 2750 yards of swimming.  Foam rolling in the afternoon.

Training log - Week ending 11/17/2013

This week was 22,000 yards of swimming  -- training log is here.  

Besides the swimming, I also did a bit of walking - the goal here was just to start reintroducing activity to my legs without the impact and stress of running.   I also test drove the arc-trainer on Sunday to see if it aggravated anything.  It didn't seem to, so I'll try more this coming week.

As one can see, a large part of my daily schedule has been rehab exercises.  What does that mean?  

Well...two of my biggest exercises are:

1) What I call "bridges on the ball".  Take an exercise ball, and position yourself so that your shoulderblades are on the ball while your feet are on the floor, with knees bent at 90 degrees.  Your torso and thighs should be parallel to the floor.

That's pretty easy, right?  Should be.  But...what makes this tricky is to start marching, lifting one leg or the other while keeping your torso stable.    Basically, you do the first exercise shown here.  

This one was about impossible for me at first, but I've gotten much better at it (I've been practicing a lot the past few weeks).

2) Eccentric hamstring bridges. The better term for these is probably bridge walks - there's a good description of them here (second exercise).  You start in a normal bridge position - feet and back on floor, glutes contracting to raise your hips off the ground.  Then you take alternating "steps" with each foot, marching out until you are nearly prone.  Then march back in.

Over the last few days, I've gotten to where this exercise is totally comfortable and easy (I do 2 sets of 10 twice a day).  So, per my PT's instruction, in the next few days I'm going to introduce eccentric hamstring ball curls.  A video demonstrating the general idea is here - the only difference is that instead of lifting my hips up with my legs straight, as he does in the video, I'll lift up with my knees bent, so that I'm in a bridge position.  Then extend the legs out by straightening the knees (this is the eccentric part), lower my hips to the grounds, and pull the ball back in.
 
As for whether the PRP is helping?  I'm past that first two weeks stage where it makes things the same or worse, so hopefully I should see steady, measured improvement.  I'm seeing glimpses here and there - feeling better when I get out of bed in the morning, for example.  And my massage therapist raved over how good my left hamstring felt - a good sign.

The other area I had treated was my right foot.  I got two shots targeting the ligaments on the outside of my ankle, which are very loose.  You don't really think of flexibility as a problem, but in my case it apparently is. 

More specifically, the looseness of the ankle ligaments means that more stress gets placed on all the tendons (especially when I wear shoes with a higher heel-toe drop and/or more cushioning - all that stuff just adds more lateral forces/instability to the ankle).  The result of the loose ligaments was exactly what I dealt with - a bit of every type of tendonitis in the foot/ankle.   The hope is that the PRP will tighten up the ligaments and prevent recurrence.  So far the ankle does feel stiffer, and that's a good thing.  The acid test will be when I run again.


Dailies

Monday:   In the morning, injury prevention/rehab work and 4000 yards swimming, 50/50 with and without pullbuoy.  Foam rolling at night.

Tuesday:  In the morning, injury prevention/rehab work and then 3000 yards of swimming, 1/3rd with pull buoy. 2/3rds without.   Foam rolling at night.

Wednesday:   In the morning, injury prevention/rehab work and then 4250 yards of swimming -  1/3rd with pull buoy. 2/3rds without.  Sports massage at night.

Thursday:   In the morning,  injury prevention/rehab work, upper body strengthwork and walking 2.5 miles.  Foam rolling at night.

Friday:  In the morning, injury prevention/rehab work and 3750 yards of swimming, 25% with pull buoy.  Also some walking.  Foam rolling at night.

Saturday:    In the morning, injury prevention/rehab work and 4000 yards of swimming, with about 500yards pull buoy (rest without).  Foam rolling at night.

Sunday:   In the morning, injury prevention/rehab work (including testing out the arc-trainer for a few minutes) and 3000 yards of swimming (no pull buoy).  Foam rolling in the afternoon.

Training log - Week ending 11/10/13

This week was 20,000 yards of swimming  -- training log is here.  

And yes, that's a LOT of swimming.  About 12 miles worth, according to internet calculators. Much of it was with a pull buoy, which makes it both easier (not as much aerobic effort) and harder (that's a lot of upper body work).

That's pretty much all I'm doing right now.  I have a standard injury prevention/rehab routine (includes some basic core, back, and glute work - lotsa bridges and front and side planks), plus plenty of swimming to keep a bit of aerobic fitness. 

The swimming means that I've cut way back on my normal upper body strength routine - doing pull-ups, triceps dips, and push-ups combined with a huge uptick in swimming strikes me as a good way to get an overuse injury.  And, of course, no squating, lunges, etc for me right now.  Yoga is also out, except for restorative (which is essentially coached reclining on pillows).  And obviously I'm not running, elipticalling, pool-running, biking, rowing, or stepmilling.   Whey you're rehabbing an injury in your hip, you have a lot less options than when you've injured an extremity.

The first part of this week, I did nothing but swim with a pull buoy, to rest the hammy as much as possible.  My plan had been nothing but pull buoy for two weeks (most people I know who have had PRP said that resting the treated body part for 14 days was key to their success).  However, my PT said that I was 5 days out (past the time of immediate inflammation) and I needed to start using the area, albeit gently and carefully, to keep some range of motion and activity.  He suggested going back to normal swimming, and then phasing in some elliptical.

[the doctor didn't give me much guidance other than resting for first 48 hours, and then letting discomfort be my guide]

Since my normal swim had been 3000-4000 yards of freestyle, which had NOT been bugging the hammy pre-PRP, I started back with 3000 yards.  Unfortunately, that ended up being a bit too much - the hammy got sore afterwards.  I was ready just to go back to the pull buoy, but my PT advised that I just switch to mixing pull buoy and normal swimming, and gradually transition to just normal swimming.  So that's what I've been doing.  Shifting between pull buoy and normal swimming actually has the benefit of making the time pass faster, so that's great as well.

But I can't wait to start on the elliptical.  

I also can't believe I just typed the above sentence.

[as for the key question of "do you see any improvement yet in the hammy?", the answer is yes, but it's subtle.  The hammy is still weak and achy, but the range of motion, tested very carefully, has improved significantly.  And range of motion and flexibility is not generally improved just by resting a joint, so the PRP seems to be having some effect already.]


My understanding is that the benefits of PRP don't really start to kick in until after the initial 2 week period, and even then take some time to ramp up.  So the real test will be in the weeks to come.]



Dailies

Monday:   In the morning, injury prevention/rehab work and 3250 yards swimming, all with pullbuoy.  Foam rolling at night.

Tuesday:  In the morning, injury prevention/rehab work, a bit of upper body strength work, and then 4000 yards of swimming, all with pull buoy.   Foam rolling at night.

Wednesday:   In the morning, injury prevention/rehab work, plus a solid core workout.  PT appointment mid day.  Foam rolling at night.

Thursday:   In the morning,  injury prevention/rehab work and 3250 yards of swimming, nearly all without pull buoy.  Foam rolling at night.

Friday:  In the morning, injury prevention/rehab work and 2750 yards of swimming, all with pull buoy.  Foam rolling at night.

Saturday:    In the morning, injury prevention/rehab work and 4000 yards of swimming, mixed with and without pull buoy.  Foam rolling at night.

Sunday:   In the morning, injury prevention/rehab work, a solid core workout, and 2750 yards of swimming, all with pull buoy.  Foam rolling in the afternoon, and some restorative yoga at night.

Training log - Week ending 11/3/13

This week was 12 miles of “real running,” 3 miles of pool-running, and 13,000 yards of swimming  -- training log is here.  

This week was front loaded, as I got PRP done on Friday, and just vegged the rest of the weekend.   Which was different.  It's been a LONG time since I've done nothing but lay on the couch. 

BTW, not like I was in a huge amount of pain requiring me to rest.  By Saturday midday, nearly all of the soreness was past.  As of Monday, the only thing that really hurts is my left sitbone (where the tendon attaches) if I sit directly on it.  The whole couchbound thing was because you are supposed to rest as much as possible after getting PRP, to let it settle.  Many times, people wear boots for a few days after, but not an option for me because a) they don't really make boots for hips, and b) if I wore a boot on my right foot, it would just place more work on the left hamstring.  So I just rested as much as possible.

[I also want to make sure people know - PRP wasn't THAT painful.  Not like I was crying or flinching.  It was just fairly unpleasant, and I wanted to make sure I didn't conceal that from others considering it.  It's not just a simple shot and then you're fixed]

Plan for the next bit of time is swimming with a pull buoy.  Hamstring doesn't feel much different - still stiff in the normal places.  But I know that's normal and expected for PRP - the results aren't instant.  I just need to take care to really spare both my hamstring and foot for the next several days, to ensure I get the max benefit from the PRP.

That means swimming with a pull buoy.  And studying up on fancy words like "catch" and "pull" and phrases like "elbows high" as I work on my swimming form.  Because I'm happier when I have something to work on.

Dailies

Monday:   In the morning, injury prevention work and 3000 yards swimming.  Foam rolling at night.

Tuesday:  In the morning, injury prevention work, 2.5 miles easy, and then 3000 yards of swimming.  PT appointment mid day.  Foam rolling at night.

Wednesday:   In the morning, injury prevention work, 3.5 miles easy running, and 3750 yards of swimming.  Foam rolling at night.

Thursday:   In the morning,  injury prevention work, lower body strengthwork and 30 minutes of easy pool-running for "3 miles".  Also a blood draw, and foam rolling.

Friday:  In the morning, get blood drawn, run 3 miles easy, get a shot, run another 3 miles.  Then 3250 yards of swimming.  PRP in the afternoon.

Saturday:   Watched 12+ hours of National Horse Show.

Sunday:   Watched the NYC Marathon, the Maclay Championships, and The Devil Wears Prada.  Of the three, the Maclay was by far the best.

Pincushion me!

The three letters that convinced me to try PRP. 
On the right is my MRI.  On the left top is my Boston acceptance. 
On the lower left is a totally unexpected check from
the bank that held the mortgage on my recently sold home.

I've been fighting multiple injuries over the last few months, including a) a combination of tendonitis/plantar fasciitis/ligament issues on my right foot, and b) a low grade tear in my left hamstring tendon at the attachment.  Yesterday, I had my first treatment with PRP to address these issues.

PRP stands for Platelet Rich Plasma.  You extract normal blood from someone, process it in a centrifuge to concentrate the platelets, then reinject it at injury sites.  The theory behind it is that the increased platelet concentration stimulates a healing process that is faster and/or more complete than what your body is doing on its own.  It's been used all in sort of locations (joints, muscles, tendons) with the greatest effectiveness noted in cases of tendonosis and/or ligament damage.

At least that's the theory.  In humans, there's just not that much evidence, especially from large scale studies.  Just lots of anecdotal experience.  And as for how it works?  Well, no one's quite sure about that either.

I wasn't too worried about not knowing how it works - that holds for lots of proven treatments, including aspirin.  I was more concerned about the lack of large scale studies that supported its use.  However, the lack of evidence may be linked in part to the lack of standardization for the PRP process.  Not all PRP is the same - there's a wide variance in a) platelet concentration, b) what else is taken out of the blood (red blood cells?  white blood cells?), and c) the recovery process.

Of course, that begs the question: how do you know you're getting the best process?  Every practitioner will tell you that their process is superior to others, and there's not much research comparing the different methods.  In the end, I decided to take comfort that I was going to a doctor that effectively used PRP to treat my same injury in another athlete.

***

PRP usually involves a single appointment per injection - you show up and have your blood drawn.  Then you wait about 15 minutes while they process it in their centrifuge, and then get the injection.  Whole thing should take an hour or less.

In my case, we decided to do it a bit differently, for a few reasons.  For one thing, I'm a very difficult blood draw - I have Raynauds, low blood pressure, a low resting heart rate, and veins that are deep, narrow, move around, and collapse.  It made sense in my case to schedule a blood draw the day before, to ensure that we had plenty of time to get what we needed, and also so that I could come back the next day if we couldn't get enough.

Doctor Wagner also wanted to be absolutely sure that he was treating the correct area for the hamstring.  So he proposed that I set up a diagnostic appointment where I'd run some, then get a shot of lidocaine (short duration local anesthetic) in my tendon, and then run some more, keeping track of how I felt on each run.  Then I'd report back to him when I came back in for the PRP.

So, we scheduled three appointments:

• Thursday at noon: get blood drawn
• Friday morning - run for about 20-25 minutes, get a shot in butt at 6:45 am, run some more.
• Friday afternoon - PRP.

And then, of course, rest for the weekend.

***

The blood draw on Thursday went as I expected, of course.   Poorly.

I went in right at noon; an hour and seven sticks later, we had about 3/4ths of the blood needed.

The residue from
Thursday's bloodless draw

At this point I was told I had my choice of a) going with a mix of PRP and prolotherapy or b) coming back at 6:00 am on Friday morning to take a second try at the blood draw.  I chose the second.  Dr. Wagner had recommended PRP rather than prolotherapy - I was going to get PRP.

Fortunately, when I returned at 6 the next morning, the blood was flowing more freely (it was ridiculously warm outside, which I think helped).  With two more sticks (9 sticks total so far), we had enough blood, and I was dismissed to go run laps of the office park in the dark.

Laps done, I returned for two ultrasound-guided shots into my hamstring (we're up to 11 jabs), and then did some more running before returning home to work for the morning.  The hamstring was improved, though still weak and tight.  That same afternoon, I returned for the grand finale.

***

During my previous visits to this doctor, I had filled out normal forms - insurance information, HIPAA disclosures, diagram of where I hurt, etc.  But now I had new ones to fill out - they basically fell into two categories - those that said VERY CLEARLY that this was an experimental procedure and not part of the standard process of care, and those that said EVEN MORE CLEARLY that insurance would not cover this procedure and that I was responsible for the cost in full.  Then they collected my payment before I went back.

The magic cart.

When I returned to the examination room, I was greeted by the physician assistant and a cart with syringes.  She showed me the bag that my syringes had been provided in, to demonstrate that it was my name on the bag,  and  then I got up on the table.

Dr. Wagner walked in, and after some pleasantries and an update on my morning run, he pulled the cart over.

"My apologies in advance.  I'm afraid this is going to hurt."

I've heard that before from doctors, and usually dismiss it.  The normal population's pain tolerance isn't the same as a runner's, and many times I've gotten this warning and the procedure itself has been nothing.  But something about his tone (and knowing that he had done PRP on a lot of athletes) told me this was different.

Oh well.  Needed to be done.

And so we began.  And yes, it wasn't pleasant.  For each place I got injected (the ligaments on the outside of my right ankle, my right plantar fascia, and my left hamstring at the insertion onto the pelvis) he first applied two-three shots of an activator.  Then the PRP itself as 2-3 ultrasound-guided injections in the area - it wasn't the shot itself that hurt as much as the extended injection of the fluid, which made each location feel like it was "too full."

[I lost count of injections at this point.  I'm pretty sure I ended up with 6 injections of PRP - 4 in the foot and 2 in the hamstring tendon.  Plus multiple activator shots.  Combine these with the preceding 11 jabs, and I'm gonna put myself at 20-25 needle pokes over a bit more than 24 hours.  It's a truly wonderful thing that I'm not trypanophobic]

Since people are always curious as to just how much it hurt, I'll express it this way.  In terms of pain ranking, I've had the following at various points: deep tissue massage, cross-frictional massage, dry needling, Graston technique, ART, cortisone shot, nerve conduction study.  I've also raced both mile races and a marathon, and have broken bones.

I want to be here.  I'm not.

I'd rank the PRP above most of these.  It definitely hurt more than a cortisone shot, ART, Graston, or dry needling (or marathons and mile races).  I'd rank it slightly less painful than cross-frictional massage on an inflamed tendon.  It's probably about equivalent to a masseuse's use of his elbow on a really deep muscle knot, but imagine that the pain continues on, and even increases, after he's done. 

So yeah. not pleasant.  But it hurt less than missing the Sunday long run.

***

Then I was done, and Brian carted me home, where I've been ever since.  Tips for others that get PRP, based on my experience:

My foot apres-PRP. 
No, I didn't take any ass shots.

1) Don't plan on driving yourself home afterwards, even if you're not getting work done on your right foot.  You'll be pretty sore.  Sore enough to distract you from concentrating on the road.

2) It's a pretty good idea to plan on being home (and couch) bound for a day or two. You'll be sore, and you're also supposed to be resting.  Don't plan on going back to work the same day.  Don't plan on coming home and catching up on your housecleaning or laundry.  I stocked up before hand on groceries, reading materials, and plans for internet use, and I'm glad I did.

3) I do wish I had brought Tylenol with me to the appointment, so I could have taken it right away.  I won't make that mistake again.

As for the recovery?  It seems that everyone that gets PRP gets different advice here, which I think ties back to the fact that there is no set standard for how to manage it.  In my case, in addition to the standard advice to avoid NSAIDS for at least a week, I was told 24-48 hours of just rest.  After that, I can return to activity by starting off with swimming with a pull buoy.  After that, I can shift to swimming, then to weightbearing activity and rehab exercises, and then to running, letting discomfort be my guide. 

Dr. Wagner explained that there were two reactions that occurred from the PRP.  The first is an immune reaction that causes the pain and swelling.  That's at its worst for the first several hours before trailing off - the total duration of this reaction is about 7-10 days.

Separately, there's a stimulus to the body's healing process.  That is no by means instant - it starts slowly and ramps up gradually over time (and time is weeks and months).  PRP is NOT an instant fix or a way to get back to running workouts within the next week.  It IS a way to hopefully shorten the healing time for tendons and ligaments substantially, increasing my chances of starting a marathon training cycle after the new year.

Whether it works for me?  We'll see.  In the meantime I'll be parked on the couch on my side, watching streaming horse show and the NYC marathon.