Training log - week ending 10/18/2020

This week was 24 miles of running and 18 "miles" of pool-running -- training log is here. 

I got PRP injections in my right ankle on Tuesday afternoon, and so spent the next two days trying not to move very much so the platelets could settle in the right place.  Then I carefully started resuming activity.

It is amazing how sluggish even a few days of couch potato can make one feel.

My right ankle is screwed up in multiple ways, with a torn posterior tibial tendon AND torn ligaments.  The doctor agreed with me that the torn posterior tibial tendon (which is now really two parallel tendons) was healed and working just fine as is, so no need to mess with it.  So we just injected the ligaments.  

I was expecting it to be really really painful, per my past experiences.  But, it ended up just being pretty painful.  My doctor said that there's always a careful balance in how much numbing he injects.  He can't inject too much because it dilutes the PRP.  But if he doesn't use enough, the procedure is too painful to be tolerated.  He's using slightly more numbing than he did 7 years ago, which meant the procedure was much easier than I expected.

Which was a good thing, because they had no squeeze balls.  In the past, when I got PRP, they handed me a squeeze ball. So I showed up this time and asked for my squeeze ball.  And...no more squeeze balls, due to Covid 19 concerns (since the squeeze balls would be shared between patients, and are hard to disinfect).  Bummer.  I just bunched up a corner of my sweatshirt in my hand and that worked decently well.

The PRP will take about 2.5 weeks to kick in (and that was my experience in previous sessions).  My ankle is already slightly more stable, but that's just due to some residual swelling in the joint effectively stabilizing stuff.  

I was a bit disappointed to learn that my doctor thought I needed two sessions.  But...if that's what it takes.  My next session is scheduled for exactly 4 weeks after the first set.  Then hopefully I'll be done.

Dailies 

Monday: 7 "miles" of pool-running and upper body weights/core. Foam rolling at night.

Tuesday: 8 miles, including six 90 second hill repeats up a 5% incline with 3 minute recovery.  Followed with leg strengthwork, streaming yoga, PRP injections into my ankle, and crutches.

;

Wednesday: Couch potato.

Thursday:  Couch potato.

Friday: Upper body weights/core, 2 "miles" of pool-running, and gentle streaming yoga. Foam rolling at night.

Saturday: 4 miles easy (8:57) plus streaming yoga and 5 "miles" pool-running.  Foam rolling in afternoon.

Sunday:  12 miles, structured as the first 8 miles averaging 8:40 pace, the next 2 averaging 7:38 pace and the next 2 averaging 6:56.  Followed with leg strengthwork and streaming yoga.  Doubled back with 4 "miles" pool-running and foam rolling in afternoon.

Training log - Week ending 5/4/2014

This week was 37.5 miles of running and 3,000 yards of swimming  -- training log is here. 

The aponeurois is where the two muscles
meet, right at the pelvis.

PRP week.  Or as I like to call it – Jabapalooza 2014.  The goal behind this round was to address my right groin issues.  The formal term of the issue is "mild chronic tear of aponeurosis of adductor and rectus abdominus."  I usually refer to it as "deep stabby pain for a few days if I run downhill too fast."

It's been an annoyance for longer than I've been running (it hurts during other things, not just running downhill fast).  And additionally, I do wonder sometimes if my issues with that right adductor have been contributing to my injury cycle, and even provoking my back.  

GIven how well the PRP worked on my hammie, I decided it was worth splurging on a round of PRP to see if I could improve the groin (it's nowhere near bad enough to justify surgery).  Since I was getting PRP anyway, I also got my back done at the recommendation of PT and orthopedist  – specifically the areas around the L4/L5/S1 vertebrae.

So, showed up for the session, and Dr. Wagner suggested that I just get everything done while I was there – everything meaning that we’d also do the left hammy and right ankle/foot again.  He usually doesn’t like to do more than two sites on a patient at a session, because of patient “tolerance” for the procedure.  But apparently I’m pretty “tolerant” (I can hear everyone laughing…), we had plenty of platelets, and it wouldn’t cost me anything more to get the old places “touched up” while I was there.  So…what the heck.

(I can’t say I was thrilled about getting the ankle done again, but I couldn’t come up with a good reason not to do it, other than “it hurts.”  Which I felt silly saying, and wasn’t a good excuse.  So, away we went.)

Since I am now somewhat of a PRP connoisseur, I can state definitively – not all places hurt the same.  The groin was the big surprise – I thought that one would suck.  Nope.   Felt like three pin pricks.  Dr. Wagner said that the groin almost never hurt for anyone, as surprising as that was.  Hamstring, back, and plantar (we did the site where I’ve been having some plantar flares) were a bit ouchy, but not too bad.  The ankle sucked, but at least it sucked less than last time.  I’m guessing that's because we only did 3 shots there, not 8-9ish like last time.

The best part, in a weird way, was that the injections to the spaces between L4 and L5 provoked many of the symptoms I’ve been experiencing in my left leg – the “funky"/weak feeling in my left hammy, some dull aching down the leg, and cramping in my left foot.  It was confirmation that my issues do stem at least in part from that area, clean MRI notwithstanding.   (and yes, I know that back MRIs are unreliable and trumped by a clinical exam, but it was still nice to have the additional evidence here.)

And then I rested.  Saturday morning would have been 48 hours, but I decided it wouldn’t hurt to take another day off (and use the time to run errands), so I kept it to a bit less than 20 minutes of easy swimming.  I ran on Sunday, and things were predictably sore.  But I know that’s how it works.  In two weeks or so, we’ll see where I am.

In the meantime, I’ve got a trip to Chicago this coming week for work.  So, a nice opportunity to run around the lake, and practice running SLOWER while I’m there.  I’m trying to slow down my easy runs, but haven’t been terribly successful so far - I get too focused on correct posture, and start running faster inadvertently.  I’m thinking I’ll turn the Garmin’s HR alert feature back on in order to slow me down – the Garmin signal/pace indicator isn’t accurate enough to rely on.

Dailies

Monday:   In the morning, 5 miles easy (8:15) and a yoga class.  Foam rolling at night.

Tuesday:  In the morning, 10 miles easy (8:23 pace).  Took a yoga class in the afternoon and did some foam rolling.

Wednesday:  In the morning, 4 miles easy (8:30 pace) and then a yoga class.  Later did another 3 miles (8:27 pace), followed by 2000 yards of swimming.  Massage at night.

Thursday:   In the morning, 7 miles easy (8:34) miles easy, and then got PRP done.

Friday:  Off.

Saturday:   1000 yards of swimming in the afternoon.

Sunday:   In the morning, 4 miles easy (8:12), followed by a yoga class.  Later ran another 4 miles (8:21).  Foam rolling at night.

Training log - Week ending 12/22/13

This week was 20 miles running, 14,000 yards of swimming, and 90 minutes on the arc-trainer mimicking easy pace running -- training log is here.  

After some debate, I opted to get a second set of PRP injections this week.  I wasn't sure I needed them, but I decided I'd rather be on the safe side.  So, a great 9 mile pain-free run in the morning was followed by an injection and crutches in the afternoon. The irony wasn't lost on me.

This time, the recovery was much quicker than before.  I was told to take it very easy for 48 hours (the platelets apparently need to settle, so the less I move, the better), and then to resume my normal activity (including running), but to take it easy.

So that's what I did.  Got the shots on Thursday at 2:00 pm, and then camped out on the couch until Saturday at 2:00 pm.  I got a whole bunch of paperwork done, caught up on my X-Men comic book backlog, and read This Town and Slow Getting Up.   

The latter was darkly amusing to me, as part of the book was focused on the author's injuries and treatments in the NFL.   As he described stuff like icing injuries, ART, e-stim, physical therapy, and PRP, he made them sound like the most barbaric things in the world.  Obviously, I disagree, as I'm guessing most of my runner friends do.  Heck, seems like most people I know enjoy stim.  

All I could think of as I read his narrative was "dude - you didn't even need to pay for this stuff - that's the part that really hurts."

I also watched Blackfish, which I really strongly recommend.

It is absolutely a hatchet job on Seaworld, and has to be watched with that in mind.  But it also outlines the many issues with keeping orcas in captivity.  I really don't feel good about the human race as a species after watching that movie.  At least with regard to killer whales, due to our complete misunderstanding of their social structure and nature, we've done something very wrong.

Anyhoo, having served out my 48 hours of stall rest, I did a gentle 15 minutes on the arc-trainer on Saturday afternoon, followed by some swimming.  Everything felt OK, so I did a careful 5 miles on Sunday.  I'll continue to ramp up the running this week.


Dailies

Monday:   In the morning, injury prevention/rehab work and 3000 yards of swimming, including a set of 600 yards swum as 75 easy/25 hard, and then 4x100 yards on 2:00 (1:42.67, 1:40.61, 1:40.81, 1:40.34).  Foam rolling at night.

Tuesday:  In the morning, injury prevention/rehab work, 6 miles outside (8:17 pace) followed by 30 minutes on the arc-trainer. Foam rolling at night.

Wednesday:   In the morning, injury prevention/rehab work, 30 minutes on the arc-trainer, and 4000 yards of swimming, including a 300 yard time trial (5:09.77) and 12x100 yards on 2:00 (splits were 1:45.75, 1:47.12, 1:46.04, 1:44.05, 1:45.00, 1:46.79, 1:46.07, 1:46.59, 1:46.52, 1:45.27, 1:46.70, 1:43.07). Foam rolling at night.

Thursday:   In the morning, injury prevention/rehab work, 9 miles outside (7:58 pace) and then 1250 yards swimming.  Foam-rolling mid-day; PRP injection in the afternoon.

Friday:  Couch potato.

Saturday:    In the morning, more couch potato.  In the afternoon, did injury prevention/rehab work, 15 minutes on the arc-trainer and 1750 yards swimming.  Foam rolling at night.

Sunday:   In the morning, injury prevention/rehab work, 5 miles running (8:22 pace), 15 minutes on the arc-trainer, and then 4000 yards swimming -  including 1000 yards straight (18:04, split as 9:07/8:57), 600 yards swum as 75 easy/25 hard, and 6x50 yards on 1:10 (48.70, 48.52, 48.91, 47.61, 46.93, 46.70). Foam rolled 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.