29 July 2013

Date With A Killer

Despite the fact that I’m happily married, I’ve got a date coming up, and it’s not not with Dearest Spouse.  In fact, I’ve got two dates, really; the first with my old buddy, Dr. Foot Doctor, and the second with a killer.  Yes, I’ll be spending the weekend with a pain-killer, or more likely multiple such killers.  Gee, I can’t wait.

In the roller-coaster of life, there’s a dip ahead, and I don’t mean that slightly lost-looking guy down the street.  In my uneducated way, I saw hope in that seemingly devoid-of-white-spots MRI.  A high point, perhaps the pain was in my mind, perhaps I could beat it down with a few meds, beat it in general.  Then a drop in fortunes when I was reminded that I am not, in fact, a doctor, and just because an MRI looks pretty doesn’t mean all is pretty.

At that point, coming off the meds, feeling pretty good, yet having been told that Sir Achilles wasn’t truly whole, there was only one way to find out what was really happening:  run.  And so run I did, leaving Dr. Foot Doctor hanging for a week while I tested out the healed / no-healed state of the heel, not with easy jogs but with some real miles.  Within a few days it was right back to its old tricks, and the verdict was clear.  Once again Dr. Doctor had been right when he told me that this kind of injury simply wouldn’t heal by itself without less than about a year of inactivity – an option I’m just not willing to entertain.  Having absorbed the verdict, it was time for the sentencing.  I made the call.  Let’s fix the bugger.

And on that call, Dr. Doctor reminded me why he is such a favorite and why I recommend him frequently.  When last we’d met, we’d talked about treatment options, the best being the use of the Topaz wand, the very same device he used as part of my foot tendon repair five years ago.  This time, however, with nothing severed like before, the procedure was simply to use the wand to initiate blood flow to promote healing, since the reason that tendons don’t heal is that they simply have no blood flow – especially for an internal partial tear like this.  His thought was to do this as it is commonly done, right from the outside, simply piercing the skin for each Topaz puncture.

But during that week when I’d left him hanging on my intentions, he’d taken the initiative to contact the firm that makes the device and related the details of my case to them.  (I was tickled when he relayed to me that he told them that his patient was an ‘elite athlete’!  Really?  Cool!)  They advised him that additional precision was in order for my case, and despite the additional healing involved, he should open it up to see exactly where to apply the Magic Wand, rather than stabbing blindly from outer space.  A little more on the recovery side, but more likely to be effective.  I’ll take that trade-off.  And I’ll say thanks to the good doctor for making the extra effort!

All things being equal, once that decision was made, I’d just as soon get it done in the next five minutes, not stew over it, and be on the road to recovery that much sooner.  But life being as it is, there’s simply too much stacked into the next few weeks to make myself into an invalid right away.  Thus I’ve got another twenty-five days to think about it before we slice and dice.  And besides, Darling Daughter the Eldest might be having her wisdom teeth out at that same time, so what could be more fun than to down Vicodin together for a weekend?

With twenty-five days to wait, knowing I’m going to fix this thing anyway, what to do between now and then is obvious:  run, run, run, hike a bit, and run.  No racing, nothing foolish of course, but certainly running.  There’s simply no point in going into a long break in any worse shape than I have to be.  I’m already up a few pounds from cutting mileage and taking much of June and early July off.  Might as well work it off now and start from a better place.  Besides, when Dr. Doctor opens that tendon sheath, I’d like it to be real obvious which part he needs to fix!

The fall season is shot, no cross country, Mount Desert Island Marathon won’t happen this year, but if all goes as hoped, an eighteen-month nagging pain will become a thing of the past.  It’s time to live what I preach and worry about making sure I’m running in ten years instead of next month.

12 July 2013

Not Right Either

When my generation (wow, that sounds funny, doesn’t it?) was growing up, the catch phrase of feigned expertise was, “I’m not a doctor, but I play one on TV.” Anyone in my age bracket remembers that famed commercial, even though none of us can recall what it was for Today’s equivalent would likely be, “No, I’m not a , but I did sleep in a Holiday Inn Express last night!” And yes, if any representatives of that fine firm are reading, I do often sleep in them on my business travels, and a few free nights for the family would be a pleasant way of saying thank you for the plug. I’m just sayin’…

Being trans-generational, which either means I’m old but refuse to behave as such, or simply that I live in Massachusetts where anything trans goes, save trans-fats, I tend to use both phrases roughly evenly. This week proved that playing a doctor on TV, or in this column, or even sleeping in that hotel chain really doesn’t qualify me to read an MRI. So while last week I was worried about the sport-legality of medications and carefully did the research to declare myself Not Guilty on that count, I must re-visit the portion of that column where I seemingly skillfully interpreted those ghostly images, and state that while Not Guilty, I was Not Right Either.

Having done the MRI-of-the-tendon thing a few years back, and having scoped out various respectable web resources like WebMD and the Mayo Clinic (which I cite here due to my one loyal reader there…woot!), I’m pretty well versed that injuries, swelling, and other tendon-nasties generally show up as unwelcome white spots. Check out last week’s images, representative of the hundreds of images on the handy CD that the staff of my local hospital always cheerfully provides, and to me at least, they looked clean. This was both a relief and a concern, since neither Dr. Foot Doctor’s initial diagnosis of a partial vertical tear, nor his preliminary recommendation of a surgical (minor, yet still surgical) fix, were welcome. Seeing nothing on the MRI hinted instead that I was clear. On the other hand, seeing nothing on the MRI hinted that I had no idea what the route to recovery was. I spent the week during which the good doctor relaxed on a beach somewhere cooling my jets and finishing my meds. But come Monday morning, Doc was back, and it was time to get the official skinny.

I always like to say that I love physics until I open my old college physics textbook and I remember why I didn’t like it then. It’s all Greek. Literally. I can say the same thing about medicine. It’s fascinating, until you go about reading the stuff that doctors write. It’s not only Greek, it’s often apparently non-sensical. I quote to you from my report, HIPPA rules be damned:

The Achilles tendon is enlarged with a rounded cross section configuration centered approximately 4 cm above the posterior calcaneus. There is no abnormal increased T2 signal within the area of thickening. There is no discrete disruption of fibers or surrounding abnormal signal. Findings compatible with partial tear/tendinopathy.

I translate this as…first, my Achilles is big. OK, that might mean it’s swollen, which is bad, or just that it’s big. I’ve been told that my heart is big (physically at least, metaphorically is a separate discussion). I’ve been told that I have great cambium on my tibias. You train, things grow. Right, but we’ll assume that they mean swollen, and so it’s puffed up about an inch and a half above that posterior bony thing, a.k.a. my heel. Hey, that much I knew without getting an MRI. Oh, and its round. Isn’t it supposed to be round?

Then the language gets interesting. There’s no increased T2. I take a guess and read this as meaning there are no white spots, as previously noted. I agree. But the next part is most curious: there’s no disruption of fibers. Getting past the wisecrack of whether the fibers are sleeping peacefully, undisrupted, wouldn’t a tear be a disruption of fibers? And they say there is no such disruption? So with this, the last sentence left me scratching my head. Findings compatible with partial tear/tendinopathy. All of this means it’s torn? Or, there’s that word, tendinopathy, which simply means its beat up. So, umm…

OK, Dr. Foot Doctor will have to explain this to me. The swollen part I get, but isn’t the idea of an MRI to see the “increased signal” and “fiber disruptions” to identify an injury? That’s certainly how it worked a few years back when I really snapped one. I just don’t see how we get from this to that. But they’re the doctors, and I merely slept in a Holiday Inn Express. I have to trust they know something that I don’t.

And that leaves me not knowing something else, that being, what to do? A quick chat with Dr. Foot Doctor makes clear he advocates aggressive treatment, read, surgery. This isn’t just about his boat payments; he suffered through the same issue personally, opted not to treat aggressively, and found it took eight months of inactivity to heal. He’s trying to save me from that.

But aggressive treatment means six to eight weeks entirely out of commission, back to the crutches, the Dreaded Boot, the long road back, the works. Other than the momentary joy when the Vicodin hits your system, there’s nothing attractive about it. Unless it works, of course.

I told him I’d sleep on it. I sat out a couple more days to let the meds clear my system so as to get a good read on reality, then yesterday I began my own diagnostic test: I hit the road for a few miles at a pace that I couldn’t call fast, but was at least respectable, well above the “tenderness jogs” of late. And I did it again today. Not trying to break things, but to see if maybe, just maybe, the time off in combination with those magic meds did what I hoped they’d do, and promoted healing without breaking skin.

After the second stage of the Tour de Tendon, I’m wearing the yellow jersey. Though my legs were a bit sheepishly sore after yesterday’s mini-spurt – oh how quickly things like fitness wear off – the Achilles is so far holding up. It is of course way too early to tell. I’ll give it a few more days and hope for the best. If it degrades, I’ll have to lean toward the aggressive treatment; that option will always be there. But like a Cubs fan, I hold out hope, maybe, just maybe…

Sudden Topic Change / Amusing Small World Incident Department: It’s one thing to meet up with someone you’ve heard of in the running world while you’re circulating in running circles. It’s amusing when it happens randomly in the real world. I posted an item for sale on Craigslist, an item with utterly no connection to running, and who ended up responding? None other than the author of the standing nutrition column in New England Runner who it turns out is married to the gentleman who created that fine magazine itself before retiring a couple years back. What an honor to be paid a visit by such a distinguished pair! Thank you both for your fine work on the best running magazine, period.

03 July 2013

Not Guilty

Nearly a month has passed since last my twisted thoughts graced your screen.  Hey, if I’m not running, how presumptuous would I need to be to think you’d want to hear periodic whining on the progress, or lack thereof, of the pesky injury that finally brought me to what many have stated is a well-deserved break.  I don’t agree, as the phase “well-deserved break” implies getting away from something you don’t want, whereas I miss my miles significantly.  But still, there just hasn’t been much to talk about.

I’m past the grouchy stage, I’m past the annoyance of inching toward a normal, rather than slightly emaciated weight, and I’m past the grief over the death of both the every-day streak (seven hundred and fifty, R.I.P.) as well the two-hundred-mile-month streak (twenty-seven, ditto).  I’m simply waiting around, trying to figure out when to pull the trigger again.  As Tom Petty (and the Heartbreakers) sang way back in 1981, the waiting is the hardest part.  When is healed really healed?  When can I go back?  Gently?  When can I hammer it?  How long before I cry, “Uncle!” and seek professional help?

After a week’s break with no big improvement, I worried not; after all, it was only a week.  The following week brought a bit of a science experiment.  It was bad enough to not be running while on our annual trek to Acadia – the carriage roads are simply divine for wonderful miles – but not hiking was entirely out of the question, so hike we did.  All that walking up steeply slanted slabs of granite, stretching Mr. Achilles, which I hoped would have a positive effect, sadly didn’t bring on any improvement either.  The following week, looking at three straight, with my log feeling lonely, the “To Doctor or Not To Doctor question, which had been percolating for weeks if not months prior, reached the tipping point.  I declared the emergency, broke the glass, and phoned up Dr. Foot Doctor.

Lesson to America’s youth:  make friends with your doctor.  The difference between, “He’ll see you in three weeks” and, “We can slide you in tomorrow” is more valuable than gold.  And it found me in his office, catching up on the latest in our respective adventures shortly thereafter.

That which we believe is normal may not be, and Dr. Foot Doctor showed visible alarm at the somewhat misshapen appearance, let alone the tenderness of my battered Achilles, both of which I’d simply grown to live with.  Concerned over the possibility of a potential vertical tear, which is not even in the league of severity compared to my severed foot tendon years back but still falls into the category of “simply won’t heal by itself and might need minor surgery”, he sent me packing for the restful donut of our local MRI machine, restful that is if you like construction sites, noisy plumbing, automotive backfires, war, and other similarly quiet entities. After the unreasonably early Saturday imaging appointment, I took defiant delight in leaving the hospital on foot for an easy jog with my local club, knowing they were about to pass by anyway.  But I’m a bit ahead of myself.

Seemingly indescribable topic change:  My employer, like many large companies, insists that we all endure mindless ethics training.  The most value anyone gets out of it is the fun of deriding the inane videos and certification tests over the modem version of the water cooler.  After all, if you didn’t have a moral compass before, no web-based video is going to instill one in you, and if you weren’t smart enough to know not to collaborate with the competition, take bribes, or play Edward Snowden with company secrets, well, you were pretty much a basket case anyway.

But it’s not to say that ethics aren’t important, because they are.  It’s just that simple training can’t prepare you for when the questions get hard.  And ethics are hard precisely when, well, they’re hard.  Like when you’ve been struggling with an injury for over a year and your doctor recommends that you hit it with some oral steroids, because the alternative might well be surgery, and though you know they aren’t the kind of steroids everyone talks about – in fact, you’ve checked this out to be certain because you have to be certain – you’re still somewhat worried as to whether these are within the rules.  And these are rules that aren’t just there to catch the modern version of East German Amazon Women, but rules that are based in the ethics of fair play.  And you’re close to both of these reasons, because you race on a well-known team with a stellar reputation that you cannot afford to sully no matter how obscure the chances, and because you personally feel disgust at society’s craze to bulk up, diet down, and keep your manliness with testosterone underarm roll-ons that will grow hair on your wife if she comes within twelve feet of you.  It’s just not right.

But you’re not doing this to keep your manliness or improve performance, you’re only looking at a short-term therapy to heal an injury.  Medical care.  Then again, it’s an overuse injury, so does healing it, which allows resumption of training, translate to improving performance?  Some might say so, but so do eating, sleeping, ibuprofen, and Band-Aids to stem the flow of errant bodily fluids also allow resumption, or continuation, of training.  Where does this gray line lay?

It took a little research to allay my fears, if that’s not giving away more of the punch line than the title of this post already did.  The common “dose pak” of oral steroids, the ones where you take six the first day, and slide down to one six days later so as not to collapse in a hormonal crisis, are in fact glucocorticosteroids, and in fact are on the World Anti-Doping Agency’s list of banned substances.  Ouch!  Worry danced through my walnut-sized noggin.

But there’s a big distinction that I missed the first time through.  The list is broken into substance banned at all times, and those banned in competition.  These common yet magical chemicals in question fall into the latter category.  Relief, at least somewhat.  My feelings, of, “How can a few days of treatment for a medical condition constitute a grievous violation?” began to subside.

More research turned up some insight into why these are listed as such.  While everyone has heard of Sammy Sosa and Roger Clemens style accusations of abuse of anabolic steroids for bulking up muscle, apparently there are those who also misuse the gluco versions for their own special reasons, using them for long periods in high doses.  Knowing very personally that one risk of steroids of any sort is the possibility of weakening of tendons, I can’t fathom why you’d want to take that risk, but some do, and thus the rule, and it’s a good rule.

Still I fretted to a level that Dearest Spouse found puzzling until I related to her that any foolish mistake on my part could have nasty repercussions on my club and beyond.  Would I need to apply for a Therapeutic Use Exemption, or TUE, granted when medical needs require the use of otherwise banned substances?  A TUE which is supposed to be applied for twenty-one days in advance, which, when adding administrative time, would make trying this route to a healing rather meaningless?

More research brought closure to my fears.  According to the U.S. Anti-Doping Agency, those of us who are competitive but not God-like don’t need to worry about stuff like this that is banned only in competition, not in general (see http://www.usada.org/tue-determine/ and the embedded image).  And if through some unfathomable combination of events one were to be tested and have something like this turn up, implying use in competition, the process is educational, not harsh.  So in short, even though I expect (and insist) that this stuff will be long gone from my system well before I race again, a freak combination of unlikely events won’t bring shame upon my family for a generation.

I’m probably overeacting to all this, but I consider this stuff extremely important, both because it is, and because I want the guy racing next to me to feel the same so that we’re racing on a level playing field.  After all, fair is fair.  Now work that into your corporate ethics course!

Verdict:  Not Guilty, playing within the rules.  I’m glad for that not only because it stands on its own merit, but also because I came home from that MRI, played doctor, examined the images (I always ask for, and they always provide for me a copy on CD, what fun!), and in my highly non-professional opinion, I can’t see anything torn that can be surgically fixed.  Conveniently, nice images of torn Achilles are available on the web and mine happily looks nothing like them.  Since Dr. Foot Doctor had by then headed out on vacation, I won’t know for sure for another week, but it appears that non-invasive healing appears is the only option. So bring it on, let’s make it happen and get back on the roads.  Fairly.