Training log - Week ending 11/24/2019

This week was 25 miles of running, 31 "miles" of pool-running, and a whole lotta shoulder rehab work -- training log is here.

My first week of post-marathon recovery.  Like always, I started it in the pool, and then transitioned to land running.  However, while I normally do a lot of yoga in the first days post marathon, this time I had to hold off until the end of this week, when my shoulder finally felt good enough to fake my way through a class (skipping the planks and vinyasas).

A slight change this time around was my introduction of "medicine running" - this is my term for a short duration (10 minutes or less total) set of walk-slow jog intervals.  You don't build or maintain any aerobic fitness doing this, but it does present your body with a very gentle extremely low risk running stress.  It's just enough to remind the body that you are still a runner, and that the body needs to maintain its connective tissue accordingly.  But it's not going to aggravate any nascent injuries, unless you've got a broken bone sticking out of your leg or similar (in which case, medicine running will be impossible anyway).

I've recommended medicine running to others on a running break, and have used it myself when coming back from injury - it's a good stepping stone between not running and running.  I hadn't used it for marathon recovery before, but the more I thought about it, the more sense it made.  That first run back after a marathon can be rough on the body; this would hopefully make it easier.

So, I did medicine runs on Tuesday-Thursday of this week, before starting to run again on Friday.  And sure enough, Friday's run felt much better than the first run post-marathon normally does.  Of course, that is relative - I was still stiff and sluggish.  Just not awfully so.

I also officially started PT on Tuesday, working with the same physical therapist I use for all my running injuries.  There's such a huge advantage to working with the same PT over time - my PT knows what it means when I say "this hurts" or "this doesn't feel right" - which can mean something totally different when a different patient says it.   He (my PT) also understands my normal level of activity and my baseline strengths and weaknesses - something a new person would have to learn.

I continue to be pleasantly surprised by how quickly my shoulder injury (officially winged scapula due to serratus anterior dysfunction) is clearing up. If you look on the internet (which of course I did - who are we kidding), a winged scapula due to a traumatic blow supposedly takes months to a year or more to recover from.  

And yet, in just a bit over two weeks, I've managed to go from literally not being able to lift my left arm (in order to type, I had to use my right hand to lift and place my left hand on the keyboard) to having nearly full function for daily living.  I still can't grab or place things on a high shelf with my left hand, but I can dress myself, wash my hair, unload and load the dishwasher, pill cats, etc now.

And the gains continue to accrue daily.  Friday morning I couldn't hold a plank.  But...by Saturday I could, albeit for only about 5 seconds.  Sunday I made it 10 seconds.  So all very cool and exciting.  Though I still have a way to go before I can return to the pull-ups, push-ups, rows, and dumbell presses that used to be my norm.  I want to be able to swim again.  I might want to ride a horse again someday.  So this ain't over until those are available to me again.  But we're getting closer.

I think the credit for the so-far-quick-recovery goes to a few things.  

1) Since heavy upper body lifting has been a regular part of my fitness routine for over a decade, I have a lot more strength and proprioception there than the average person, or even the average runner.  Thus I have a better baseline from which to work.  It's similar to how my high level of aerobic fitness means that I can be having a bad asthma flare and still climb a flight of stairs.

2) I have a friend who is a PT, and her advice (plus connecting me to a good orthopedist) meant that I was able to start restoring the arm by doing the correct (gentle) exercises within 24 hours of the injury. Had I simply placed the arm in a sling and let it sit there for a week, I have no doubt I'd be much worse off now.  Motion is lotion (when done correctly). 

3) I'm ambidextrous, but my left arm is my dominant arm. Which made the whole left-arm-not-working thing mildly inconvenient at the start, but also means that it has been easier to relearn the use of that arm.  And, since my default is to use my left arm, I keep testing the limits of that arm in a way that I might not if it was my right arm that was injured.

4) I'm now working with a good physical therapist who understands my body and personal motivation very well, due to our past history.    So we're doing the exact right exercises for me to keep me on this path.  2-3 sessions with a good PT who knows the patient very well are a far better investment than 20 sessions with a stranger.

Hopefully this progress will continue.  And starting next Tuesday, my 10 day post-marathon make-no-commitments period will be over, and I'll be able to map out my spring racing plans.

Dailies

Monday:  10 "miles" pool-running. 

Tuesday: 7 "miles" pool-running and a "medicine run" of 8x30 seconds jogging with 30 second walking recovery.  PT for the shoulder in the afternoon.

Wednesday:  6 "miles" pool-running, a "medicine run" of 10x30 seconds jogging with 30 seconds walking recovery, and some core and shoulder work at the gym.  Sports massage in afternoon.

Thursday: very light upper body work, core and shoulder work, 8 "miles" pool-running, and a "medicine run" of 8x60 seconds jogging with 30 seconds walking recovery.

Friday:  3 miles easy (9:19), yoga, and 4 miles easy (8:45).  Foam rolling at night (!!! I could foam roll again !!!)

Saturday: 8 miles easy (8:52), very light upper body work, core and shoulder work.  Foam rolling in afternoon.

Sunday: 10 miles very easy (9:03) plus drills, followed by leg injury prevention work and shoulder work, and then a yoga class.  Foam rolling in afternoon.

Training log - Week ending 11/10/19

This week was 23 miles of running, 6 "miles" of pool-running, 500 yards of swimming, 2 hours on the elliptical or arc-trainer, and a whole lotta x-rays and shoulder rehab work -- training log is here.

On Wednesday morning, 3.5 miles into my planned 5 mile run (the last before leaving for Indy), I was hit by a pick-up truck while in a crosswalk.

I'm a planner.  And this was not the plan. 

Amazingly (if I do say so myself), I literally got up and walked away with non-life threatening injuries, though my entire left side was battered with my left shoulder taking the worst of it.  But it very quickly became obvious (if hard to accept) that there was no way I could realistically race the CNO Financial Indianapolis Monumental Marathon on Saturday.  Y'know - the superfast course with fast weather and a 2:55 pace group where I was a member of the elite field.  That one.

[goddammit]

As frustrating as it was, I was also frankly so relieved to be alive that the marathon no longer seemed that big a deal.  And all the x-rays so far (and I've had many) show no indication of broken bones.

But what I did end up with, in addition to a lovely assortment of lacerations and bruises, was a left arm that wasn't working well.  I could use the hand (good) but moving at the shoulder, including lifting my hand above my waist to the front or side, was absolutely impossible.  I just couldn't make the arm move at the shoulder joint on its own - it wouldn't listen to me - and having someone else move my arm was pretty damn painful.

[I should note here, that though I'm ambidextrous, my left arm is normally my stronger, slightly more dominant arm, making its sudden lack of function even more awkward.]

Needless to say, the latter part of the week did not go according to schedule.  Rather than tapering down and hopping on a plane to Indianapolis, I was rehabbing, with my wonderful partner putting his schedule on hold to chauffeur me to various appointments (I couldn't drive the first few days).  Rather than carb-loading, I was protein-loading, trying to give my body as much building material as possible.

And while there was a tiny part of me that wanted to crawl in a hole and cry, there was a much larger part that wanted to take a shot at a marathon to express my fitness, if I could pull it off.  And by "pulling it off" I mean have a decent shot at running a fast time while also being comfortable I wouldn't be making the shoulder any worse or risking anything else.   Marathon running as emotional coping strategy.  And Richmond Marathon, on 11/15, was still open.

So that was the challenge.  While protecting and rehabbing the shoulder, I also had to figure out how to do just enough aerobically to preserve my ability to race Richmond if the shoulder would allow.  I'm unfortunately not one of those people who can shut things down completely during taper - I get stiff and flat.   And my normal cross-training alternatives of swimming and pool-running were out.  (I could _kinda_ pool-run, but only by wearing a belt and crossing my arms). 

So...after consulting with a physical therapist friend, and getting fully checked out by multiple doctors, I turned to the arc-trainer and the elliptical.  To protect my shoulder, I either clasped my hands in a fist and held them at my chest or placed them on stationary handles.

At the same time, I was working on the shoulder - starting by walking in a shallow water pool (the water supported the weight of my left arm) while using my right hand/arm to grasp the left arm and move it around.  From there, I moved to exercises on land - I placed my left hand on my kitchen island, and let my fingers walk the arm out and back in.  Plus lots of icing to bring down the swelling (because of my ulcerative colitis, I can't take NSAIDS).

All very humbling - a week ago I was doing presses with 35 pound dumbbells.  And now, I can't envision doing a pressing motion with my unweighted hand.  But, you have to train where you are, not where you wish you were or used to be.

Over a few days of careful rehab, I got to the point where I was comfortable trying to run.  I have a fairly low arm swing, so I don't need that much range of motion or strength in the arm to run.  Test runs on Saturday and Sunday went well - good enough to build confidence that Richmond would happen if the doctor signed off.  [I will NOT race Richmond if there is a possibility that it will make anything worse or create a new injury.]

So that was the good news.  Unfortunately, independent of the arm, I didn't feel great on Sunday - just stiff, sluggish, flat.  But I think this is not that surprising.  I've had to cut out a LOT of my daily routine - I can't even do a plank, let alone swim.  I can't foam roll, since I have to brace with my shoulders in order to do that.  And my DIY yoga mobility routine has been out of bounds, though I'm now able to do some of it again, as long as I clasp my hands to my chest.    Plus, the physical and emotional strain of the past few days has to have taken its toll on my reserves.

Hopefully, now that I'm able to at least run again, some of that flatness will go away.  I'm thinking that with a few more short runs before Richmond, I'll feel sharper.  And if I work hard at it, I should be able to restore and top off my reserves over the next week.

Some observations from this experience:

• If you slam your Garmin hard enough, it will stop automatically.
• 8:30 am on a weekday is a great time to go to the ER.  No wait at all.
• If you can't raise your hand above your waist, you can still put your long hair in a pony-tail or bun by doing "standing forward fold" pose from yoga.  It just won't look very good.
• If you're ever going to have a non-working arm, it's best to have a collection of button down shirts.  If you are like me, and despise button down shirts with a passion, and live in sportsbras, close-fitting tank tops, and long sleeve technical shirts, then you have a problem.    In that event, I recommend that you save at least one old stretched out super thin strap bathing suit.  Because you'll probably be living in that thing plus sweat pants for a few days.
• When donning said stretched out bathing suit, or a coat, put the injured arm in first.  Correspondingly, when taking off a coat or stretched out swim suit, the injured arm comes out last.
• If you are going to get majorly bruised and scraped up, the last week of marathon taper is a surprisingly good time to do it.  I am amazed how quickly the superficial stuff has healed.  I suspect that it's because my body was stocking up on all sorts of resources to throw at a marathon, and it just threw those at this instead. 

Dailies

Monday: DIY yoga and 6 "miles" pool-running.  Foam rolling at night.

Tuesday: 7 miles, including a track workout of 3x800 in 2:58, 2:54, 2:52 (recoveries of 2:13 and 2:28).  Also 500 yards recovery swimming.  Sports massage in afternoon.

Wednesday: 3.5 miles (8:54) followed by x-rays.

Thursday: Off except for shoulder rehab exercises.  And more x-rays.

Friday:  A total of 60 minutes on the arc-trainer, mostly with hands clasped in front of chest.  Added in 4x3:00 hard with 1:00 easy to remind my body that we're not done for the season yet.  More shoulder rehab.

Saturday: 2.5 miles very easy (8:43) to test shoulder and then 60 minutes on the elliptical at easy run effort, with hands on stationary handles.  More shoulder rehab.

Sunday:  10 miles aerobic, split as first 5 easy (8:19), second 5 moderate (7:08).  Followed with some careful leg injury prevention work (all stuff that didn't need arms).  More shoulder rehab.

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.

Two weeks.

Way back when, in the dark ages of my broken foot, I went for an aqua jog.   It was a day or two after I had broken the darn thing, and I was trying to wrap my mind around the reality of 3 months no running.

Misery loves company, and so do pool-runners.  And so, when I saw what appeared to be another runner bobbing about in the "leisure swim and aqua jog lane" I struck up a conversation.  Yup, he was a runner (for a local high school) and injured.  His coach had told him to do nothing but aqua-jogging.

Of course, I asked the question that applies equally to prison or injury-induced cross-training:  "How long are you in here for?"

He glanced back at me, his face full of misery and suffering and agony.

"TWO WEEKS."

***

Of course, I made it through my broken foot.  Returned to running, built up, trained hard, and became significantly faster than I had been, pre-broken foot.  And that's something I've tried to remember ever since.  Layoffs and setbacks aren't exit ramps; they're rest stops on the way to greater things. 

And many times, I've been the obliviously chipper one, voluntarily pool-running along a friend, offering up positive talk and experience, while they journey through MRIs and PRP injections and missed races.

I usually say something like "it seems like forever while you're stuck in the pool, but when you look back a year from now, it will seem much shorter in retrospect.  Promise."

And it's true.  The time off never seems that bad in retrospect. (Nor does race discomfort, come to think of it.)  And it also never seems that bad if it's not YOU experiencing it.  (Also just like race pain.)  It's all about perspective.

But that's the funny thing about perspective - it's context specific.  When you're sentenced to three months, two weeks off seems like nothing.  When you're in the heat of training, even a day off, or one missed workout, is hard.  Especially if it's YOU.

But of course, now I'm there again.  Two weeks in the pool, to take care of this stupid yet-to-be-completely-defined heel issue.  Several years ago, I was (mentally) very dismissive of the anguish of the kid who had to take two weeks no running.  Compared to three months, that was nothing.  But now that it's me?  Compared to two weeks of training with friends?  Two weeks in the pool is everything. 

But that's perspective for you.  Funny thing.  And I know that some day, in the not too far future, I'll look back at this, and note how short this period was.   Probably while accompanying a friend serving his or her own aqua-jogging sentence, trying to cheer him or her up.

I just need to get there first.  And that point is likely at least two weeks away.

Mix tape

So, I know plantar fascitis.  I've dealt with it again and again, missing key races (including my goal marathon last fall).  Currently, I'm doing well, but I'm always aware of the potential for it to reappear.  Sadly, I also have friends who battle it.

One of my big allies against plantar fascitis is tape. There's a wealth of information on how to tape, with two methods getting the most attention:  the lo-dye taping method (using athletic tape) and kineseo taping.  I've tried both, and found neither to work perfectly.  The kineseo taping method gave too little support when running.  In contrast, the lo-dye method was too restrictive -- the arch of the foot acts as a spring, and the lo-dye method completely locked that spring in place.  As a result, my foot felt like a block, not a spring, and all sorts of other muscles became stiff and sore in compensation.

However, a combo of the two taping methods -- essentially the lo-dye taping method, but substituting kineseo tape (can be KT tape, Rock Tape, or something else) for certain parts, works fantastically.  Here's how I do it.

What you'll need:

-one roll kineseo tape (I prefer Rock Tape, because it seems most durable and has cool pattens)
-one roll sports tape (1.5 inch wide)
-one roll cloth or sports tape (1 inch wide)
-scissors
-one knee length stocking

Note - when applying this tape, keep your foot gently pointed.  The objective here is to contract the plantar fascia slightly (to take the strain off) and then lock it in that position.







Step 1: 

Place an anchor strip of 1.5 inch sports tape
across the ball of your foot.

Step 2:

Take a long strip of 1" tape, and
run from ball of big toe across foot to heel,
loop around the heel and then back to ball of big toe.

Step 3

Take a long strip of 1" tape, and
run from ball of little toe across foot to heel,
loop around the heel and then back to ball of little toe.

Step 4-5

Take two more long strips of 1" inch sports tape;
loop one from ball of big toe to behind heel to ball of little toe;
loop the other from ball of little toe to behind heel to ball of big toe
(essentially making two "X"s, one atop the other)

Step 6

Take several short strips of 1.5" sports tape,
and run each laterally across the bottom of the foot,
starting at the heel and working forward to the ball of foot.
Each strip should overlap the previous one slightly.

What this step looks like when completed.

Step 7

Now you get to use the Rock Tape. 
Run a long strip of it (stretching it very slightly)
from the outside of your little toe
around the outside of your heel to
the outside of your big toe.
You want to cover the ends of the strips of sport tape
that cross your foot.

 Step 8

And...take your second strip of Rock Tape,
and run it laterally from the top of your foot
(above the metatarsals) laterally under the ball of your foot
and around to the other side, essentially circling your foot at the ball.
Slight tension here.  This locks the whole thing in.
(it should cover both ends of the previous strip of Rock Tape)

Another view of the completed job

Step 9

Final step - cut the knee length stocking so that it just covers your foot,
and then slip it on over your tape job. 
This makes it much easier to put on socks/shoes without disrupting your tape job.

Fin!  

[goes without saying, but I'll say anyway - I am not a Doctor, PT, or other rehab expert.   (nor do I own stock in Rock Tape).  Use this at your own risk.  And if you're at the point where you're taping your PF, you really need to see a professional anyway.  But hopefully this is still helpful.]