Compared to just one month ago, I have some notable changes recently!
I can run on TRAILS! Like actual singletrack trails! Of course it has to be pretty moderate, nothing crazy steep. But to be able to run on real dirt with scenery and hills and rocks is just glorious. I feel a sense of normalcy just being able to do this! I have to do a lot of "prep" - 15 minutes of neuro work, followed by skipping, then single leg agility, then agility t-test - then I can go for a run. It is programmed like this intentionally. I was also upping my running interval times 9% each week, but that proved to be too much change for the knee (increased times AND new running surface). I've decided to stop the increasing and just stick with 10 min running intervals, walk for 2 minutes and repeat for an hour or so, maybe for a few weeks just to get adapted to trail demands, and to just have fun and not make it so rehab-ish. I imagine I'll try for continuous running eventually. PT asks, "So what are the running goals?" I have no specific goals at the moment, I just want to run for enjoyment in the mountains and not end up in a pile of hurt! I imagine one day I'll train for a trail half marathon. I think that is off the table for this year. That would be a crazy amount of adaptation required in a few months and I'm still dealing with low level plantar heel pain. Biking - my favorite! This is the first real season (starting in March) of mountain biking I've had had in 2.5 years. Things are adapting! For my 45th birthday, I did a big ride with my husband in a new to us area. Thanks to a wrong turn, it ended up being over 45 km. I wanted to do something with "45" for my birthday, but 45 mountain miles or 4500 feet of climbing are still a bit out of reach for me right now. So I turned the wrong turn (which added a lot more climb) into a positive! My knee and body can handle 2 trail runs, 2 hikes, 2 bikes, 2 lift days, 2 agility days all in a week! I love it. PT says we have to do an activity 2x a week for things to adapt to it.
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I am not fully cleared from ACL rehab yet, but I plan to be this year (2021). It is totally possible. I still have much to check off, but it will happen this year. I feel confident enough that I bought a ski pass for next winter (winter 2021-2022) because I wanted to take advantage of the pre-season sale. I haven't had a resort pass in probably 12 years, but I am guessing I'm going to be doing 1-2 runs here and there to get my knee used to turning demands.
This is not because all of a sudden my knee is feeling great to give me this confidence - it's because I'm slowly chipping away at all the stages - despite the anterior knee pain. This was the last weekend to take advantage of the closed park road at Grand Teton National Park. Each April, they stop ski grooming operations, snowplow the road 15 mile inner park road, and allow bikes, rollerblades, skateboards, strollers, dogs on leashes to utilize the road for one month before opening it to cars (Yellowstone does a similar thing, but much longer distances, also on my list!). I've wanted to do this for many years after seeing several foot high snow banks along the road with people wearing T-shirts while riding bikes - bliss! It wasn't quite like that this year (not as much snow). Here has been the hold up:
Finally this was the year! I am back on a mountain bike after a 2 year wrist hiatus and I've done many long rides just to make sure I am able to do this ride (which turned out to be a pretty easy ride). Temps were great, still had to bundle up, but overall such a fun experience! We were able to hike to a few of the lakes too. We even did a ski tour the day prior. Just had to watch out for grizzly bears! They were coming out of hibernation (we did not see any, but had our bear spray on us). I am doing a new thing! Neurological physical therapy! It's done remotely. I was shipped a direct current device. I also Zoom with a neuro PT 3x a week at home. This is designed not only for post surgical care from ACL surgery, but a range of other things included neurological deficiencies, muscle deficiencies like atrophy and more. I have always suspected something was deeply missing/wrong with my ACL leg. Recently this paper by Lindsey Lepley et al. came out about effects of atrophy after ACL surgery.
Muscle Atrophy After ACL Injury: Implications for Clinical Practice. https://journals.sagepub.com/doi/pdf/10.1177/1941738120944256 There are several hidden atrophy-induced factors that follow ACL injury. It's not just disuse, there are cellular signaling cascades, neural alterations and various levels of dysregulation among others that make regaining muscle mass in the post-traumatic knee especially difficult. I feel like this is me 100%. The neuro therapy is can help with this. "Unlike concentric exercise, progressive overloading achieved via high-load eccentric exercise provides the muscle with the necessary mechanical stimuli that are needed to promote muscle hypertrophy and improve neural activity (two critical components of muscle function that are negatively altered after injury)." https://southcoastseminars.com/blog/grooms-lepley-acl?fbclid=IwAR3lrnecErZrZJSKGyWQZljC5A1oHF-nvg-wGL1uMOZw5IGFDANVnDsHUxE This therapy is a supplement to my existing therapy, so yes, just when I thought my plate could not get any fuller, I piled this on! I'm only 30 days in, and I have another 30 days to go. I think the root of my constant nagging plantar heel pain and posterior tibial tendon issues have to do with some deep muscular/neurological deficits. The mapping process with this current device already show the majority of my hot spots have been all on my lower leg. I'm sure the moths I spent in a moon boot also did not help. Hopefully this will make a difference in some way and help overall with breaking the cycle and with reducing knee pain! I am a couple weeks late, but my 1500 recovery day came and went and I forgot! Maybe that is a good sign! Anyway, I like to summarize my past 100 days in a couple of sentences, so now it only looks like I'm 15 steps in LOL. My 1400 day was back in December.
What is next? Agility will start to segue into single leg bounding moves, like landing and jumping on one leg. I can't imagine doing this right now, but we'll work up to it like everything else I'm doing. I imagine we'll keep working on running. I would like to segue to running on trails in these next 100 days. Day 1600 is in early July, I could be very close or already done with the agility part and cleared by Mick Hughes himself! Just depends on how things progress. Unfathomable to think I could be cleared in the next 100 days, but it's not impossible. I would still need to do sports specific training but it wouldn't have to start until September/October.
I am officially in the Agility Phase! I have completed about 3 weeks so far. The changes to my program involve box jumps both up and down (two separate movements) where I increase the height of the box from 20cm to 40cm over 8 weeks. I'm at 30 cm and have 5 weeks left before I meet with my PT again. I bought an adjustable pylos stand so I can do these at home. The other changes are agility runs. I was running 3x a week before, but now 2 of those runs are around cones/curves and shuttle runs, where as one run a week is the run I focus on extending the run times. I'm at 6:00min intervals now, and the goal is to get to 10:00min intervals in 8 weeks (which is only 5 weeks away at the time of this post). I'm increasing my interval times about 9% per week.
As with life and the nature of rehab, things don't always go as planned! I was having such a good streak too. I have plantar fasciits/fasciopathy again. I think I just added on too many ski tour days honestly. I was both increasing my running times VERY gradually 3x a week, but also working on multiple ski tours a week and eventually back to back ski tours. I kept track of every mile I took on feet (treadmill, hike, ski, walk) and used the Acute:Chronic Workload Ratio formula to ensure I was always in the sweet spot. I don't think that method worked well enough because my increases were not crazy at all, but yet I was still increasing. To manage this, I've cut out hiking, walking and ski tours for now (this is sad, but I know it's temporary). I just tried out fatbiking/snowbiking today to see how that works. I can still do my rehab running at the moment, but I've cut down the number of intervals quite a bit so I'm not running over 20 minutes total (includes the walk breaks). This seems to keep the foot manageable for now. We also added in more days with calf raises (body weight only, with metronome, towel under toes, to fatigue). I had 5 weeks with a mental performance coach recently. This was pretty fun and I felt like my recovery really needed it. It was a complimentary offer from a coach in Germany. I've got a daily mindset plan that I am doing, I've added visualization to my days which really is neat to do, and gets easier the more you do it. It was a great experience and I'm sure I'll use him in the future when needed. Mindset is everything! My four year ann-knee-versary fell over a 3 day weekend (Valentine's weekend). I had the perfect idea in mind - a ski backpacking trip! This would utilize my new back to back ski day capabilities and I felt like the camping part would be fine. It was great! My husband and I found low angle for me canyon and we skied up a couple hours to find a lovely spot in a meadow and near some slopes that he could ski the next day. We have this really light teepee/tent and it comes with a really light stove, so this was my first time being able to stay in the teepee. It's best for winter because you don't want a floor in your tent for winter camping. I would likely want a floor if I'm camping in any other season. We already have winter quality sleeping bags and pads too.
The setting up the tent - or rather the packing of the ground - took about the same hours as the ski in. This was the hard work, lots of packing/stomping going back and forth. I was not cold at all with all this movement. The goal is to make the ground firm enough so you can walk around the tent in ski boots and not sink. The stove dried out our gloves and ski boots nicely, we made our drinking water on the stove with melted snow. It was really fun and I hope to go again in March, just need to time it with my foot and a sunny weekend. I am very grateful for how far I've come. I started agility a week before this trip. Never before could I ski two days in a row (i really trained for it the weeks leading up). So this was the perfect activity to commemorate the journey so far! Every year is different! Feet just need to get with the program now! I am on a good streak right now! I'm going to say it out loud and I am not going to jinx myself! When you've had such a long recovery and so many setbacks, you can't help but use past data to guesstimate how the future will go. But I realized that I can change that thought. I don't have to always feel like the "other shoe is going to drop." Instead, I'm going to stay super hopeful, optimistic and open to the idea that rehab may continue on this good streak. The 4 and 5% increase plan for running has been working great. The increases are small enough that my knee and body don't really feel the changes, but at the same time I'm making progress. I like having a new run goal every running day. Around the 2 min interval mark, I felt like I could bump up my intervals to 5% every run day and it's working. I am currently running 3:30 min intervals, 6 times. I should be at my 5:00 min interval goal in less than 3 weeks (end of January 2021)!!!!!! I plan to set up a Skype appointment with my physio before I actually get to that date because I really want to start agility before my 4th ankneeversary date (coming on 14 Feb 2021). It's a secret goal that I have, I think it's going to be a mental boost! This agility phase has been the "carrot at the end of the stick" since about July 2019. Yes that is a LOOONG time to have one goal in mind, but I had a lot of setbacks throw me off course during this time. That goal never changed, but I really had to be flexible on the time frame. I think two things have helped my running progress this year post double-tendon flare up. First is skipping. I skip for 10 minutes before every run, then do one set of weighted calf raises, one set of seated calf raises, and one set of weighted leg extensions. This really got me over my 1 min hump and my hip tendon flare ups. Second is TINY increases. Even 30 second jumps were too much for the knee just this past summer, so I went with a percentage, like 4 or 5% increase per interval. Over the holiday winter break, I had nearly 2 weeks off straight (and paid) which was amazing. I was as giddy as a kid on Christmas break! How often does a 40 something get almost 2 weeks off paid? This is the FIRST FULL WINTER where I can recreate outside from the beginning of the season, and hopefully the entire winter assuming things keep going well. This has not happened since early 2017! Last winter I was in a boot for most of the time. The winter prior I was just starting to snowshoe but still pretty limited on distance and terrain and no skis. The winter before that was really rough, pain and lots of limitations. Now, my knee can handle a lot of things now. Over my 12 day break, I was able to straight line ski 6 different times, 2 fatbike rides, 6 runs on treadmills, 4 lifting sessions, a couple of snowy hikes. I was active every single day, sometimes doing double activities in one day (I found I can run in the morning and then hike/bike later in the day). My arm I found has the limitations. I'm still rehabbing my arm/wrist 4 days a week with this intense case study program. It's allowing me to do more, but it has its limits still which I need to be mindful of. Using my arm too much for biking or skiing will lead to lingering lateral neck, subscapularis and bicep pain. The image below really captures how my recovery and my ever increasing abilities. Every year I get a higher baseline (thanks to rehab) and every year there is a new tissue capacity line. I can do more and more. This is from the NOI Pain Science group with Dr. Moseley and Dr. Butler.
I haven't done a knee score report in quite some time (May 2019). I like to do these when rehab is going as planned with no major hiccups in the way. That hasn't really happened in the last 17 months until recently, hence the gap!
There are some notable improvements both overall and compared to last test. I definitely have added functionality. I can do more running, broad jumps, skipping, Nordic skiing. I see my high looking scores from May 2018, but honestly it's all relative (you don't know what you don't know) and the questionnaires are not all inclusive. That high score in 2018 was just after my first mountain bike ride, but I was not hiking and took another year to get to running, so capacity was quite low despite the high numbers. I do not believe my 2018 80 Lysholm and 82 Kajula are the same levels as last month's 80 Lysholm an 83 Kajula. I take them with a grain of salt, but I am looking for overall trends. In the KOOS scores, overall lots of improvements in all the categories compared to the first time I took the test as one would hope! Compared to last test 1.5 years ago, I have a big jump in sports/recreation category thanks to new skiing and other things I can do. My QoL seems to be the same however as last year (likely due to the lack of actual progress from numerous setbacks), same with pain and ADLs. Slight improvement in symptoms however. Overall, all category scores for the latest Day 1357 are looking "ok-ish" if you were to read them in a journal article, except for the QoL category, that is really on the low end in general. Tegner Activity Level - I am not quite a 5 so I labelled it as 4 even though 4 lacks some clarification. I can cross country ski and bike, but not at a competitive level where exertion is hard. I am running, but not yet on uneven ground. I feel like I could get there in 2021. Day 1400 is here and time to add one more "step" to my list!
I can see my summary updates are getting longer, there are many layers of recovery going on. I may pare them down later, but right now they feel like they just happened. I really hope I am able to report in the next step 1400-1500 that I have made it to agility. I believe I will, but the last few years have shown that you just never know what may happen, hard to plan things out or put a time frame on anything for fear of disappointment. Photo from last weekend's ski tour. Tour #3 of the month. I'm trying to be careful to monitor my outside fun so that I don't upset my rehab. That's right skiing and running happened in the same week! Who would have thought? Yes I'm sore! This has never happened at the same time! This is going in my Milestones document. I didn't even realize, I guess I have a good explanation to be sore!
RUNNING: I've completed 5 full weeks of running now (since the big toe joint mystery). At the moment I'm up to 1:24 min of running / 2 min walking, repeat 9x. I started at only 30 seconds of running (10x) just 5 weeks ago. Now the tricky part, the part I have not done so well in the past. Increasing my running interval times. My husband suggested Increase like 3-5% each running day, for each interval. So I did the math, I'm going with a 4% increase every run day. In this particular week, that is only 3 extra seconds per interval. Originally I thought I'd increase maybe 15 seconds per interval on a weekly basis, but ultimately either plan still gets me to 5 minute intervals around the same time a few months from now. I'm going to trick my knee to 5 minutes! SKIING: I have done 2 flat ski tours already! The first tour of the season was already longer than any ski tour I did this March. I felt worked, but I wasn't hobbled. I didn't intend to go out that long, but I guess I was really fixated on a certain turn around point. The second tour I did with my husband. He planned a lovely, scenic, no turns tour that was right up my alley. The only problem was that it did have a good bit of climbing which was difficult cardio wise. It was a 4 hour long tour, and at the VERY end of the day to get back to the truck, I had to do some plowing to slow me down, on VERY tired legs, through VERY tight aspens. It was not a good recipe, probably should have scooted on my butt. I think that may have done me in. I have been in a week long flare up since and the run I did on Tuesday (that I majorly contemplated whether running was even a good idea) really added to the knee swelling. Oof. My advice to myself: Stay in the right gear, know when to turn around, don't let the outside fun derail you, time to get the rehab plan moving forward. |
AuthorA 45 year old active female who tore her ACL in January 2017 (at the age of 40). Reconstructive surgery in February 2017 with bone-patellar tendon-bone autograft. Archives
November 2022
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