Bring It

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NaBloPoMo 2017: Field Notes from a Life in Medicine

Had my knee MRI yesterday.  I had been looking forward to it for over a week, trying to predict what it would show.  I was thinking a serious meniscal tear, since I have had crackling in my knee for so long and I surely must have arthritis by now, from all the falling on it I did in my youth.  I lay perfectly still and started to get sore where I expected to feel medial meniscus pain.  I could not wait to know the results.  I just wanted to know what I’m dealing with, so I can figure out next steps, get moving.

Since it’s a weekend, I won’t know the radiologist’s report until tomorrow.  Suddenly part of me doesn’t really want to know.  What if it’s really bad and the only option to regain function is surgery?  What if it looks like I’ll be permanently disabled in some way, never able to get back to my previous level of activity?  What if that prognosis totally throws me off and I let myself go, become a sedentary lump, weigh over 300 pounds, and die in five years from heart disease and depression?  Truly, this could end my life, some poisonous voice hisses in the recesses of my mind.

But hubs is the ordering physician and he looked at the images with me tonight.  Lots of fluid/swelling.  Bruises on both bone ends of the joint.  Good news, the menisci are intact and look normal!  Woo hooooo!!  Posterior cruciate ligament also looks normal—thick, uniformly black (swelling and inflammation are light on this image), well-positioned.  Can’t find the ACL.  Huh.  He says 10% of people don’t have one.  That’d be cool, because if I never had one then it couldn’t be torn.  But the bone bruises alone are not enough to explain the swelling and pain.  So either it’s so inflamed that the fluid obliterates it on the MRI, or I have completely ruptured it and the little stumps have retracted out of view.

I had wondered which I would rather have, a serious meniscal or ACL injury.  I had leaned toward the latter, because the ACL can be fixed.  Meniscal tears really don’t heal; the body smooths them over somewhat with time, but the end result is just less cartilage, faster wear, and more tear.  The problem with an ACL injury, however, is that it increases the risk of future meniscal tears.  So either way, the knee will never be the same and now I have to deal with it.

We will wait for the official report, and I may see the sports orthopod.  Here’s what I don’t want from that appointment: For him to tell me, “Cathy, you should stop playing volleyball or anything that requires jumping, sudden movements, or the like.  You’re too old and your knee will just be hurt again.”  I will be polite, but in my mind I will think, “You can’t tell me what to do, I’ll play f*ing volleyball if I want to, and I will do it with or without your help.”  What I would love for him to say is this:

“Cathy, here is what’s going on in your knee.  It’s likely that these factors contributed to the injury (lists possible risk factors that he knows from my history), and also it was a freak accident that can happen to anyone, especially jumping female athletes (which is true).  It’s a good thing you’re pretty healthy to start with, and that you had gotten fit these last few years.  What do you want to do now?”

I’ll tell him that I really want to get back on the court and play.  I’ll tell him I want to keep doing all the training I’ve been doing: elliptical, Kangoo running, TRX, pistols, golf, and Betty Rocker workouts.  I want to take up new things like Orange Theory, kickboxing, martial arts maybe, and who knows what else?  I want to be the most active person I can be, and I want to JUMP.  I’ll tell him that I want to be responsible about it; I’m not going to ignore the risks and be stupid.  I want to know the risks, the evidence as it applies to me as specifically as possible, the 44 year-old mom with lax ligaments and super-flat feet.

Then I hope he tells me, “Okay then here’s the plan.  We gotta rehab the knee really well.  Ya gotta be patient.  Keep up with your trainer, strengthen all the muscles around your knees, continue working on core, posture, and form.  When you start jumping again make sure you know better how to land, train that muscle memory and get it down, own it.  Take your time, and take it easy when you start again.  There are braces you can use when you play that will help keep the knee stable.  And you still might hurt yourself again, there’s no way to predict what will happen. But if that’s what you want to do, I’ll do my best to help you get there.”

Because here’s the deal, my friends:  I own my decisions, but I need help to make them in the most responsible and informed way possible.  I don’t need someone paternalistically telling me what to do, how to live my life.  I need the doctor to explain to me the risks, benefits, and costs of what I may want to try.  Then I need to him to trust that I will make the best decision for myself, based on my own core values and goals.  I understand that nobody can predict the future.  But I also have a clear vision of the future I want.  I want to live a very active life, able to try new things and connect mind with body with spirit, and with other people.  I want to look back in 10, 20, and 30 years and say, “I did what I wanted to do, I made my decisions with the best information I had at the time.”  I may hurt myself again.  I may end up with a knee replacement before age 60, and never run or play volleyball again after that.  But if I get there having thoroughly assessed the risks of my actions, having taken all reasonable steps to proceed safely, and having continued to have fun and enjoy my mobility as long as I could, then hopefully I will regret very little.  I would much rather live this scenario, than get to that age wondering, “What more could I have done?  Did I sell myself short?”

This is how I discuss decision making with my patients, particularly when it comes to screening.  Their decisions must originate from their personal values and health goals, not mine or anyone else’s.  How do they understand the risks, and which worst case scenario of screening or not screening, treating or not treating, will they regret less?  A very athletic yet osteoporotic 65 year-old woman really does not want to take medication.  So we review her daily dietary calcium, vitamin D, protein, and vitamin K intake.  We make sure she continues weight bearing exercise every day.  We pay attention to balance, flexibility, strength, vision, and fall risks.  We reassess her risks and goals every year to make sure that we are still on the path she chooses for herself.  I present her with as much evidence as I can, for efficacy of medication, her personal fracture risk, and potential consequences of fracture.  In the end the decision is hers and hers alone; I serve as consultant and guide.

Meanwhile, knowing what’s likely happening in my knee gives me peace and confidence.  Now I can make a plan.  I’m convinced this is why my knee feels better tonight than it has in days, although the ibuprofen I took this afternoon probably also helps.  I have a new compression sleeve that fits under my dress pants.  I can get back to my workouts, and maybe add on a little every week.  My motivation to eat healthy just got a fierce boost (Betty Rocker really helps with this—I have no financial interests in her business, I just really like what she does and how she does it).  I’ll start physical therapy soon.  No volleyball for likely 6 months.  But I got this.  Bring it.

Mobility is Confidence

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It is Day 11 of NaBloPoMo 2017: Field Notes from a Life in Medicine, Day 10 of Bum Knee Cathy.

So far, so good!  This third time through NBPM is definitely easier and less stressful than before.  It’s not my best writing, but it’s not bad.  I’m spending less time thinking and writing, and having ‘way more fun.  Can’t say that much for BKC, though.  I’ve never had an injury like this and I’m not quite sure what to expect.  The good news is, swelling is decreasing and I limp a little less every day.

I had not gone 7 days without exercise in almost three years, and it was starting to feel a little too comfortable.  It also did not help that we had a bag of Kit Kats left over from Halloween—bad planning.  So on day 8 I decided to see what I could do in the gym.  Turns out, I still need to avoid activities that require me to plant my feet or fully extend the knees.  But there is still a lot I can do, and today I found a full suite of moves, some modified, that were enough to break a sweat, woo hooooo!!  Even though I wrote that I was good about losing my training discipline, I was still worried.

Today, however, I have my confidence back.  Earlier this week I reconciled with the possibility of not playing volleyball anymore, but I have not given up on my intention to get back on the court.  And if that’s not possible, then I can try the other things on my list: martial arts, kickboxing, tennis, and who knows what else?  Still so many possibilities!

The day before I hurt myself I passed a lady on the way to work.  She was older, obese, walking with a limp and a cane.  I came up behind her, slowed down, and passed her when space opened up on the sidewalk.  I suddenly appreciated my unencumbered gait.  How ironic.  My parents are almost 70 years old and they just returned from a month-long tour of China and Taiwan.  He golfs and she still precepts nursing students in the hospital.  Neither of them has ever had a prolonged period of immobility, even after major surgery.  They still move through life confident in what their bodies can do, looking forward to their next trip.  I know many orthopaedic surgeons.  With them I have shared patients who got their lives back after joint replacement surgery—able to walk, golf, and even ski again—without pain, and with confidence.

Tonight I appreciate that much more what my parents have achieved and what my colleagues do.  I appreciate my body that much more, and what is required to maintain it.  I appreciate the importance of conversations with my own patients, when we talk about establishing habits in middle age that will allow us all to be strong and healthy in old age.

How much do we take our mobility for granted?  For myself, not as much today as I did 12 days ago.

What If I Slip?

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NaBloPoMo 2017: Field Notes From a Life in Medicine

40 hours out from my non-traumatic, sports-induced knee collapse, I’m off crutches, woo-hoooooo!  The knee is still swollen and stiff, and people still look twice when they see me limping.  I’m thinking of ordering from Peapod–the thought of walking around the grocery store, which I normally love doing, makes me wince a little.

I’m much more afraid, though, of the back slide that may ensue in these next days and weeks.  I’ve worked so hard the last few years, establishing and entraining an excellent exercise habit, and I was just hitting a period of new growth and ability, so exciting!  I was getting lighter and nimbler on my feet, and now I lurch clumsily, Trandelenburg-like (not really, but kinda).  All year I have felt sluggish and tense if more than two days went by without a work out.  I barely moved yesterday and I loved it, which scares me.

The last few months also saw a shift in my eating, recapturing a sense of control.  I was eating less without hunger or feeling deprived, and though my weight had remained roughly the same, my figure was noticeably streamlining.  I liked looking in the mirror again.  Last night I found myself grazing steadily after dark.  …Stress eating sucks.  I only recognized a few years ago that I do it, and I have since had much more empathy for my patients with similar patterns of food, tobacco, alcohol, and other ‘substance’ use.  I know I should not be shoveling tortilla chips, ice cream, cookies, and candy in my mouth at 10pm.  I know I don’t need the calories, I’m not really hungry, and I will feel guilty on the other side.  And I do it anyway.  It comes in cycles, and I have yet to find a healthier behavioral alternative in those moments (drink a full glass of water, get on the elliptical, drop and 20 push-ups!  Ooo, that last one might work…).

The point is, I really worry how this setback with my knee will derail and reverse all that I have accomplished until now.  (hyperventilation) GAAAAAHH!!

But wait, the injury was less than two days ago…  And I continue to feel better, regaining range of motion and limping slightly less with the help of ibuprofen and RICEing.  What did I write the other night about resting and recovering?  And what I have been preaching to patients about mindfulness, radical acceptance, and doing what you can at the time?  About small change steps sustained over time, and about how worry is counterproductive, because to paraphrase Michael J. Fox, if what you’re worried about actually happens, now you’ve lived it twice!?

Okay, I’ got this.  Plenty of movement I can still do with a bum knee (including maybe push-ups when I feel a late-night ice cream hankering).  I’m still the same motivated workout beast I was 60 hours ago, the same person who just got through a 30 day food challenge with only minor transgressions.  And JEEZ, it’s only been 40 hours.

Well thanks for helping me work through that, my friends.  I’m good now.

The Doctor Becomes the Patient

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Grandma Has Hurt Herself.

Tonight at volleyball, I was given the perfect set, my timing was getting better, I sprang and hit the ball over the net… I think it landed in, but I was distracted by the crunching sensation and noise I felt in my left knee, and then breathtaking pain as I landed the jump.  Immediately I went rolling, writhing on the floor, lamaze breathing long and slow (nice how that comes in handy at times like this).

As I sat sidelined, the medical inventory began:  No torsive forces, just a buckle.  No ankle or hip pain, only knee.  It’s the bad knee, had similar pain landing a little jump a few months ago, though not nearly this bad.  Pain primarily posterior, deep, left of center, worse with knee extension and dorsiflexion.  Anteromedial joint line pain with weight bearing.  Immediate but mild swelling/effusion.  Hmmm, maybe medial meniscus, possibly also PCL strain/tear?  When should I get the MRI?  How long before I can start PT?  Where is that knee sleeve I got before?  600mg ibuprofen STAT.

The young people were so loving, gathered around asking me where it hurt, getting ice, helping me up, grabbing blocks to put my leg up, glancing over empathetically as I RICEd.  I felt cared for and also embarrassed.

Not just embarrassed.  I felt guilty, maybe even ashamed.  What had happened?  I’ve been training, I’m a good jumper, what did I do wrong?  Was it karmic payback?  I left home just as my kid was struggling with some homework—but nothing I thought she couldn’t handle.  Or maybe I had been getting too cocky that I could actually do this at my age?  Just yesterday I posted videos of my most recent progress on the TRX—I was openly bragging–“toot-toot!” I wrote gleefully.  Or it was an error in judgment: I have not slept enough this week, and I knew I was tired before I went tonight.  But I wanted to go meet my new friends, I wanted to play and have fun.

The frustration came all at once, and with considerable force.  Thankfully I had a friend nearby with a consoling ear and some crutches to lend.  All athletes get injured, she said.  I didn’t do anything wrong.  Yes, I’ve been training, and I was also weekend warrioring it all these months.  This has been my problem knee for at least 15 years, maybe it was going to happen anyway.  It’s still interesting to watch, almost from outside myself, the emotional lava lamp of fear, regret, anxiety, dread, catatrophization, and sorrow.

Experience and maturity, however, make me optimistic.  It’s a temporary setback, and I have resources available to me for recovery, growth, and even enhancement.  Now I get to learn how to use crutches, and I can relate much better to my patients with knee injuries.  I also get to test my newly formed theory that though we may slow down in general with age, we need not resign ourselves to inevitable and morose decline.  Patients ask me often, what should they expect to be able to do at this age or that, how can they know their limits?  For a long time I had no good answer.  But as I have regained strength, endurance, stability and mobility these last few years (tonight notwithstanding), I now tell them: It depends on what you want and how much you invest.  My 1977 Oldsmobile will not run like my 2012 Highlander.  But if I really want to drive that thing, I can put in all the special care and maintenance required and make it roadworthy.  It’s the same with our bodies.  They are incredibly resilient and adaptive, and also mortal.  So we must Fuel and Train, then Rest and Recover appropriately.

I guess I pushed past my current limits tonight.  Setback acknowledged.  I don’t regret the last five months–I made new friends and played and had fun!  I anticipate a high-learning road to recovery.  And I think I’ll get back before they forget me.