Thursday, March 8, 2018

Is it May yet? Peroneal tendon rupture, surgery, and rehab, part 1

Opening up my blog to start this post made me notice that my last post was about a medical problem.  I guess this is fairly appropriate--my year was largely a sequence of lurching from one problem to the next, with a few nice runs and climbs in between.  If things don't improve soon, I'll rename the blog something like aliciasrestingandrehabilitationwoes.

The closest I'll get to running Zegama this year

At the end of a great long run in the mountains, I was running down a moderately technical descent when I landed badly and injured my foot.  I heard a loud cracking noise so was fairly sure there was a broken bone.  I limped off the hill, hitchhiked back to my car, and drove straight to the hospital.  This was the start of a cascade of comedy errors that leads to my current situation.

The emergency room doctor took an x-ray and reported that I had a broken 5th metatarsal.  She thought it was a Jones fracture and thus might need surgery, so she told me to see a specialist.  This was incorrect--it was a fracture to the base of the metatarsal and not a Jones fracture--but her mistake turned out to be lucky for me.  The surgeon who I went to see about the fracture was able to tell immediately that it wouldn't need surgery, but fortunately for me, he noticed that I seemed to be missing my peroneus brevis tendon.  After multiple errors with the MRIs and an inexplicable order for a second x-ray, and thus plenty of delay, it was determined that I had a complete rupture of the peroneus brevis at the point where it inserts into the 5th metatarsal.

This could only be fixed with surgery, but there were an endless number of delays to getting a surgery date, and I finally went for the operation 7 weeks later.  By that point the metatarsal fracture seemed to be healed and I had been able to walk a little, but I had been on crutches 95% of the previous 7 weeks.  That meant my peroneus brevis stump had had 7 weeks to retract and atrophy.  Sure enough, my surgeon reported after the surgery that there was hardly any of it left.

What he didn't report was that he had done an entirely different repair technique than what it appeared he had been planning.  I learned from my hospital discharge form that what he did was tenodesis--sewing the peroneus brevis stump to the peroneus longus tendon--whereas I was under the impression he would be doing an allograft (cadaver tendon) repair.  It appears that this type of tenodesis is a common way of dealing with a lack of intact tendon to work with, so I can see why he would have done that.  However, I had made it abundantly clear to him that I was a competitive runner, that I ran in the mountains and needed maximum ankle stability, and that my priority was getting back to this.  Tenodesis is not at all ideal for any of these things (I believe you can read a good article about different repair options here without a paywall, so I was not particularly pleased, to say the least.  If my surgeon had been experienced at treating athletes, I could feel confident that he had correctly weighed the pros and cons of each option in deciding what to do.  However, it was clear from our pre-surgery conversation that he had little experience with athletes.  At the time, I thought this was okay because there was no question of what needed to be done; all I really needed was an experienced surgeon who could do the repair well.  It simply never occurred to me that this particular type of problem ("two tendons enter, one tendon leave"...?) might occur.  It was also clear from pre-surgery appointments that my surgeon was very interested in seeing the maximum number of patients possible, and this does suggest he may have chosen tenodesis on the basis that it's a much simpler and thus quicker procedure.

Frankenfoot, about 5 days post-op

After the surgery, I wasn't about to waste my time and money on more rushed, interrupted appointments with my surgeon (his appointments are 3 minutes long and mostly involve him talking to his assistants), so I took advantage of a friend's student status and downloaded all the relevant rehab articles listed in this review,  It immediately became clear that there is a vast range of opinions from surgeons on the appropriate rehab program for this surgery.  Everything from immediate weight bearing to 8 weeks in a cast was on the table!  I went with a protocol that fell in the middle of the options, which was:

--2 weeks in hard splint
--Staples out at 2 weeks
       --If you're having this surgery done:  ask for stitches rather than staples!!  I would say as much
         as 50% of my pain in those first two weeks was from the lovely feeling that is 26 bits of metal
        digging into the area around a recent stab wound.
--Dorsiflexion/plantar flexion stretching exercises starting at 2 weeks
--Partial weight bearing in a walker boot from 2.5 weeks, starting VERY lightly with just a few toes on the floor and progressing extremely gradually as tolerated
--Full weight bearing when tolerated
--Standard physical therapy range of motion and strengthening exercises starting from 6 weeks
--Running on an alter-G treadmill
--Back to regular running no earlier than 12 weeks but potentially more like 14-16
--Plenty of sleep
--Lots of protein and very little sugar (high glucose diet seems to impair tendon healing in rats, and it certainly won't hurt to try!
--Restricted eating window and coconut oil to encourage BHB production, which may have an anti-inflammatory effect:  My hypothesis was that this would give me the benefits of a ketogenic diet without the increase in cortisol I would get if I actually went on a ketogenic diet.

This all went reasonably well for the first 5 weeks, with plenty of bad days mixed in but overall it was a steady upward trend.  I did have a deviation from the plan though:  my walker boot, which I had been using for the metatarsal fracture, was very painful for the newly-repaired tendon.  I experimented a bit and found that a compression sock + ankle brace + wide-foot running shoe + running insole actually felt much better and more stable than the boot, so I switched to that early in week 3.  This may or may not have been a mistake...

By early in week 4 I was walking with two crutches and with about 50% of normal weight on my injured foot.  Later in week 4 I progressed to walking with one crutch and felt strong enough to try a few steps unaided.  They felt fine, and I did maybe 20 steps in intervals of 5 at a time, although the next day my foot was quite sore so I went back to two crutches and tried to generally stay off my foot.

Then things took a turn for the worse.  Divesh and I were headed to India for a week, and my foot was not pleased with two days of crutching around airports and the long flight time.  When we got to India, I took a day completely off any weight-bearing.  On the second day, I went back to walking with two crutches--and it did not go well at all.  My foot developed a raw, stabbing pain that evening and it was so painful that I couldn't sleep through it.  The next day was about the same.  It eventually calmed down to a more manageable pain level, but something is clearly different than it was during the first 5 weeks.

And that is why this is only part 1...I'm currently booked in to see a different surgeon, one who has just had an impressive result with my runner friend Diana's complex ankle repair surgery, in a few days to discuss my options for where to go from here.  I'm interested to hear whether he thinks it's possible and/or worthwhile to reverse the tenodesis and repair with an autograft or allograft instead (so far I've had conflicting information on whether or not this is possible; a 2014 case report says it was done but a very experienced surgeon in this area discussed it with me via email and said he doesn't think it can be done).  I'm also obviously keen to hear what he thinks may have happened to the current repair and whether or not there's any way of determining in the near future if the repair failed.

For now I've bought a different style of walker boot and I'm back to almost zero weight bearing.  I'll write part 2 when I've got an idea of where I go from here!

Friday, July 14, 2017

And then there were two? Magnesium, cortisol, insomnia, and athletes

I have been having trouble sleeping.  I first had insomnia for 18 days in April.  It was the worst experience of my life with any kind of illness; the mental trauma of being utterly exhausted but unable to sleep, every single night without respite, was worse than anything I've ever experienced with physical injuries, including having to take 9 months off of running for an ankle injury.  So when the insomnia reappeared in late June, I knew I had to get it resolved as soon as possible.

Google searches for athletes' personal experiences with insomnia brought me the horror stories of Bobby Curtis and Tera Moody (don't click on those links if you think your insomnia might be made worse by anxiety about not sleeping!) but other than that, the sum total of anecdotal information was essentially a few forum posts by athletes saying they were having trouble sleeping and wondering if anyone else had had the same issue.  There were virtually never any real answers or any follow-up from the athletes themselves.  Relevant journal articles are out there, but they took a fair bit of time to collate into anything useful.

Given the difficulty I had finding information on the subject, I thought I'd provide some details on what happened with my insomnia and what I've learned along the way, in the hopes that this will be useful to someone else going through the same struggle.

My insomnia

I had what is apparently termed sleep maintenance insomnia.  I could fall asleep easily at bedtime but I would wake up about 4 hours later.  As the April period of insomnia wore on, this got worse and I started waking up only 2 to 3 hours after going to sleep.  When I woke up I would feel almost instantly wide awake and my heart rate would be racing.  If I managed to relax, I would sometimes start feeling sleepy again in about an hour, but absolutely nothing, including the sleeping pills that I eventually tried, would get me to actually fall back asleep.


There is maybe no way to make this part *not* super boring, but I think a few things about the timing of the insomnia may be relevant, so here goes...

--April:  Training block with lots of hillwork in and around Atlanta. Mostly went really well.

April 4 and 5--training diary says I felt awful and took two days off

April 8--first night of insomnia, which would continue every night until April 26ish

April 8 and 9--did two hard runs; felt fine

April 9 to 21--ran very little as the insomnia got worse and worse

April 22--raced a hilly 50k

April 23--overseas flight

April 24--slept 7 hours (sleeping pill aided...) after being awake for 36 hours

April 26--first night of truly normal sleep

Month of May--normal sleep; bits of hard training in cooler climate interspersed with having a sinus infection and not being able to run

May 26--hard 24 hour run in the mountains

May 27 to June 23--sinus infection; didn't run at all except for a couple of 10-20 minute jogs

June 26--started training again with a VERY easy week, although I was in Atlanta and it was about 90 degrees every day.

June 30--first night of Round 2 insomnia

July 1 and 2--only managed 4 hours of sleep

July 3--started taking magnesium supplements (more info below); also stayed up all night to try to force better sleep the night after

July 4-6--normal sleep but took diphenhydramine at bedtime

July 7 and onwards (so far!)--basically normal sleep without any diphenhydramine, although I do still tend to wake up once for a couple of minutes in the middle of the night.

Treatments I tried on round 1 (April, 18 days til normal sleep returned)

In no particular order:

-No caffeine the entire period, including cutting out chocolate
-No computer use after dinner
-Blackout curtains for the bedroom
-After waking up in the middle of the night, getting out of bed and doing some mindless task.  Only worked once, on day 16.
-After waking up in the middle of the night, staying in bed and trying to relax, including listening to talks or meditation podcasts.  Never worked.
-Melatonin, which I had only used about twice in my life previously, both at bedtime and after waking up in the middle of the night.  This did actually work on one night--I woke up in the middle of the night, took 3(?) mg melatonin, and got back to sleep and slept for one hour after taking it.  It didn't work any of the other times I tried it.
-5-hydroxyryptophan at bedtime
-"Lightweight" sleeping pills with the antihistamine diphenhydramine, which is possibly not detrimental to sleep quality, after waking up in the middle of the night.  Made me extremely sleepy but I couldn't fall asleep.
-Days 12 and 13:  600mg of phosphatidyl serine (a phospholipid which potentially lowers cortisol) about an hour before bedtime.  Didn't work on either of these two nights.
-Days 14-18 and onward for another week:  300mg of phosphatidyl serine about an hour before bedtime; dosage lowered after I read a study suggesting any potential effect wouldn't happen if the dosage were too high.  Didn't help on days 14 to 18 but perhaps the cumulative effect of taking it since day 12 finally kicked in on day 18...??
-Days 14-18 and onward for another week:  200 to 300 mg per day of magnesium supplement in the form of a dimagnesium malate tablet.  Didn't help on days 14 to 18 but potential cumulative effect??

Treatments I tried on round 2 (June/July; 5 to 7 days til normal sleep returned)

-Starting on day 2, magnesium supplementation.  About 200mg a day of powdered magnesium citrate and another 200mg of dimagnesium malate tablet (hedging my bets!)
-Also starting on day 2, 300mg of phosphatidyl serine one hour before bedtime

I should also say, I didn't cut back on running at all during round 2.  In fact I increased my training load slightly.

So, what's going on?

The fact that I was able to see much more rapid improvement to the insomnia on round 2 while simultaneously maintaining or increasing my training load suggests that overtraining is not the cause.

It's also looking like psychological stress is not the cause.  In April, my insomnia didn't go away once I had run the race I was training for.  It also didn't come back when my big May event approached.  And in June, when it did come back, I was in a fairly low-stress period with no races at all in the near future.

Another thing that stands out to me is that this is now two rounds of insomnia which went away 4 to 6 days after I started taking both phosphatidyl serine and magnesium.  This could be a total coincidence, or it could be a placebo effect, or it could mean that one or both of these were the cause of the improvement.  Without much other information to go on, it has made me move magnesium deficiency or wonky nighttime cortisol (either rising too early in the nighttime or rising too high) into position as the two prime suspects.  Magnesium deficiency in particular makes an interesting candidate since it could also explain why it took my body two months to kill off a relatively minor respiratory infection (magnesium deficiency may amplify decreased immune responses induced by strenuous exercise) this May and June.  

Why it might be magnesium deficiency

When I first considered magnesium deficiency as a possible cause of my insomnia, I wasn't too convinced.  Magnesium deficiency is very common in the US population as a whole, but my diet is full of magnesium-rich foods--I eat a lot of leafy greens, oats, fish, and dark chocolate--and hardly any processed food. I figured that if anyone were going to be deficient in magnesium, it probably wouldn't be me.

I changed my mind on this after doing some reading.  First, there are many reasons why people in general can be deficient despite getting a sufficient amount of dietary magnesium.  The interaction with other minerals, such as calcium, can decrease absorption.  Gut inflammation or other gut problems can also decrease absorption.  You, or specifically your kidneys, can also be guilty of magnesium wasting.

Second are several athlete-specific factors.  There is some evidence that prolonged endurance exercise increases the body's magnesium requirement.  This may be due to increased sweat and urinary losses.  In particular, large amounts of magnesium may be lost when exercising in a hot and humid environment.  I live in Atlanta...  Second, athletes participating in sports that require weight control often consume less than even the recommended daily allowance of magnesium, which itself is most likely too low for the general population, not to mention for athletes.  So...prolonged endurance exercise, running in a hot and humid environment, and dieting?  Sounds a bit familiar!

But does magnesium deficiency lead to insomnia?  It's commonly said that it does, although I don't think the actual evidence of a connection between the two is amazingly strong.  However, it is definitely looking possible that one exists.

In one study, magnesium supplementation was associated with statistically significant increases in sleep time and with marginal improvement of early morning awakening.  One possible mechanism for a connection between magnesium and insomnia is that magnesium is an essential cofactor for the activation of tryptophan hydrolase and for the binding of serotonin to its receptor.  In at least one study, in healthy individuals there was a positive correlation between platelet magnesium and serotonin concentrations (this was not the case for patients with depression).  There is also the suggestion that magnesium plays a role in sleep regulation through its function as an agonist of gamma-Aminobutyric acid (GABA), which is involved in sleep.

Unfortunately it's not an easy proposition to simply get tested for magnesium deficiency.  The most common version of the test is a serum magnesium test, but since only about 1% of the body's magnesium stores are found in serum and red blood cells, the magnesium content of these is often not representative of total magnesium status. There is a magnesium retention test, which tracks changes in serum magnesium and excretion following oral loading of magnesium, but one researcher notes that this test is lacking in standardization, plus it appears to me that the results would be affected by anything that causes your kidneys to waste magnesium.

At this point, if I had to place a bet with only the information I have, it would be on magnesium deficiency as the cause of my insomnia.  If I were allowed two guesses as to the cause, they would be magnesium deficiency or wonky cortisol.  I'm not willing to risk losing any more sleep by taking only the magnesium supplement or only the phosphatidyl serine next time this happens, sorry!  If I ever end up with any reason to think that neither of these were the cause and that the real cause was Option C, I'll update this blog.  Though I *really* hope I never have the need to investigate any further...

Monday, June 5, 2017

Charlie Ramsay Round report

The Charlie Ramsay Round in a nutshell, for anyone who's not familiar with it:  a 56+ mile loop on Scottish mountain terrain with 28,500 feet of ascent and the same amount of descent, with a time limit of 24 hours for an "official" finish.  The round takes in 23 Munros (originally 24 but one was demoted following a survey!), which are peaks that are more than 3,000 feet high.  Most people have support runners on the various sections, but there aren't many easy access points to the loop so support can be somewhat limited.  Compared to England's Bob Graham round, which I did last year, the terrain is generally rockier and there are more sections of semi-scrambling.  And for my American friends, the loop is generally not on "trails" like we think of them; there are some sections with a path but you are mostly running on rock or grass.  When I started my round, there were 99 previous finishers, only 5 of them women.

You can go either clockwise or anticlockwise, and I chose anticlockwise for the aesthetic value of ending on Ben Nevis.  The round is essentially four parts:  first the Mamores, a difficult section of 10 peaks on mostly rocky terrain, second, a largely flat six miles on the valley floor which nevertheless involves a fair bit of bog and thus isn't as fast as you would think, third, a circumnavigation of Loch Treig and its five Munros, and fourth, the most difficult sections of the round, the Grey Corries, Aonachs, Carn Mor Dearg, and Ben Nevis.

The crux of this report is no doubt going to be keeping the writing from being as long as the round itself.  That is as good a reason as any to gloss over the first few hours of my run, which can be summed up as way too hot, humid, windy, and slow.  Despite working much harder than I would have liked to, I was 10 minutes behind schedule by the second peak and only a few minutes better than that by the third.  My first thought was to avoid pushing any harder so as not to risk a blowup later on.  My second thought was that there was no point carrying on at a pace that wasn't going to get me to the finish in less than 24 hours.  I upped the effort level significantly and gained my 10 minutes back, plus a couple to spare, by the seventh peak, An Gearanach.

I knew I was in dangerous territory, working at what was essentially an effort level that I could reasonably expect to maintain for only about 9 hours. But getting back on schedule was a massive morale boost, which in turn seemed to reduce the amount of effort needed to maintain my pace.  A further boost just afterwards was heading up Na Gruagaichean, which is my favorite peak of the whole round, with its impressive views, friendly descent, and the fantastic ridge running that comes after it.

The rest of the Mamores went  reasonably well, at least relative to how my run had been going so far, and I had good company from Jim for part of the time.  On top of the last summit in the Mamores, Sgurr Eilde Mor, I even ran into Charlie Ramsay's neighbor!  She took a quick photo--I was nervous about time and in a hurry to get going--and then it was off for the big descent.

From Sgurr Eilde Mor it's a big, steep descent to the valley floor and then there is the easy section to Corrour.  It didn't feel very easy on this particular day but I tried to ignore that fact and concentrate on what was coming up next.  Which was...

Carrie and Giles!  And Chuck, who was off doing some proper running when this photo was taken.  I had been starving when I made it to Corrour, but I tried to spend as little time as possible there and instead ate on the move during the nice gradual walk up Beinn na Lap.  It took me all of about two seconds to steal Giles' delicious hummus wrap, an improvement over my previous best of waiting roughly an hour to steal his food during my Bob Graham.  

After some good food and a lot of fun catching up with everyone (Giles had done the Bob Graham just two weeks earlier so it was a great surprise to even get to see him), it was suddenly a completely different day--not a day full of heat, suffering, and difficult running but rather just some enjoyable time out in the hills with friends.  We all managed to make it up Chno Dearg, which I thought was the hardest hill of the round and which had apparently been the scene of more than one relationship "incident" in the past, in one piece and ahead of schedule by a solid 10 minutes, a cushion that we maintained coming into the next support point at Fersit.

I had a longer stop at Fersit in order to try to get some more substantial food and drink down before the night section.  Well, maybe slightly more truthfully, I knew there would be two kinds of cake at Fersit and I wanted plenty of time to sample both.  Sadly for my weight, my friends Dave and Claire are both expert bakers...  And Helen had made me a coffee and Beth had made me pasta; total support stop luxury!  

I left Fersit with Tim and Beth plus their border collies Pip and May.  I had first met Tim and the collies while we were supporting Meghan Hicks on her Bob Graham round, and I had watched in amazement then as Pip navigated BG leg 4 without any help.  It turned out that Pip knows the Ramsay Round as well, so Tim and Beth may want to start hiring him out...  Oh and Meghan, after your BG I found that Oreo that I tried for so long to feed you.  As a joke, I brought it on the second half of the Ramsay with me, but I never ended up eating it so it is now one very well-traveled Oreo.

It doesn't really get any better than this--great company, warm sunny evening, and views in all directions.  I had some nausea for the first time that day but other than that I was thoroughly enjoying myself.

After the Easains you drop right down into a col below the Grey Corries.  This marked the end of what I had seen of the route; all of the remainder, except the descent from the Ben, was going to be new to me.

It was slightly intimidating setting off on the steep climb out of the col with the sun going down and with no idea of what lay ahead.  Tim and I had picked up Pete as a second support runner, though, and with both Tim and Pete having finished the Ramsay Round themselves, I knew I was in good hands.  Plus Pete brought coffee, which tasted delicious even if I did throw it back up every time...

I wish I could say that I could have made it to the finish in under 24 hours even without Tim and Pete, but I can't.  Pete took care of the navigation while Tim did an impressive job of keeping me fed and hydrated despite my reluctance to accept most food.  The nausea was fully set in and all I wanted to do was (a) stop eating, and (b) sleep, neither of which would have been conducive to a sub-24 hour finish.  We spent the first part of the night a little bit ahead of schedule but quickly became just behind schedule, which shortly turned into a fair bit behind schedule.  

There was also plenty of pure physical difficulty in the terrain on that last section.  The grass slope leading up to the gully on Aonach Beag was so steep that Tim showed me his gorilla crawl technique.  I remember finding it vaguely hilarious that it was the middle of the night and I was out there literally crawling up a hill in the dark, but I was too tired to laugh.

Unsuccessfully trying to get Tim and Pete to let me have a nap at the top of the Aonach Beag gully

Aonach Mor was a much easier ascent ("like running in the Peak District" Tim told me, fighting words for me as a former Sheffield runner!) but the descent down to the col before Carn Mor Dearg was brutal and by the time we made it down, I felt like I had absolutely nothing left.  But we were also about 20 to 25 minutes behind schedule and there were only two peaks to go.  I knew this was it--if I didn't turn things around immediately, I would have no chance of making up enough time to finish in under 24 hours.

I would love to be specific here and write about how I managed to go from a semi-zombie state to making fairly good time.  Sadly I've got no idea.  It certainly wasn't more food, and I didn't have any caffeine.  I suppose the lesson is that sometimes even the boring approach of simply trying harder can work.  Whatever it was, we arrived at the summit of the last hill, Ben Nevis, more or less on schedule.  It was quite a special moment when we topped out in the early morning light of 4:30 a.m.

At this point Tim and Pete were reasonably convinced that I could make it down to the finish in the remaining 1 hour 15 minutes.  I was not so convinced.  By UK standards I am terrible at descents, and for me, a rocky/grassy 4+ miles with over 4,000 feet of elevation loss, coming at the end of 24 hours on the go, is a tall order.  I was getting more and more stressed by the minute as we started down from the summit.  As we went through the only remaining snow patch, disaster struck--Pete took a scary fall and hit his head.  The result was alarming:

But I was relieved to see Pete stand back up and to hear him speak without any obvious signs of concussion.  It only took a couple of seconds for Tim and Pete to assure me that they had everything under control and that I should keep running for the finish.  Pete quickly decided he could make it down on his own and sent Tim off after me.  By this point I had become convinced that I wasn't running fast enough to make the 24-hour cutoff, and I think Tim was starting to share that view.  He took the lead and sped up, with my only job to follow behind at the same pace.  It's amazing how much better you can become at running over grass and wet rock when the alternative is brutal failure at something you've been wanting to do for a year!

In the end I needn't have worried quite so much--the youth hostel suddenly came into view sooner than I expected it to.  We made it to the end in 23:46.  Project for the year = done!