More theories

I unexpectedly struggled midway through a long trail run
near the Barrington Tops four months ago.

The longer it takes to see specialists about my Pulmonary Embolism (PE) and Atrial Fibrillation (AF), the more time I spend on researching the conditions on the Web, talking to other people, retrospective self-analysis and theorising about my prognosis.

I was quite depressed following the surprise (to me) AF diagnosis, but after researching athlete experiences for yesterday's blog post (see Endurance athletes and A-fib), I'm starting to feel cautiously optimistic that I will be able to resume running.  Maybe I have had Paroxysmal (occasional) AF for some time, triggered by exercise fatigue.  Many people have AF and are unaware of it.  Maybe AF explains the unexpected and sudden onset of severe fatigue during some long runs in the past six months, including the Melbourne Marathon (see blog post Reality check).  I had put them down to lower back issues affecting my stride, for want of a better explanation.  When AF occurs, the heart beats inefficiently and less oxygen reaches the muscles causing fatigue.  The long runs when I had trouble were all at a time when I was building from a lay-off and possibly going a bit too hard for my level of fitness.  Later long runs, when I was fitter, but running within myself, were faster without trouble.

Struggling in the Barrington Tops

This is all amateur conjecture, and perhaps there will never be certainty, but it does make me think, that once the PE and Deep Vein Thrombosis conditions are resolved through time and Warfarin, I will be able to make a return to running, much more aware of my situation and more able to manage it.

It was a beautiful summer morning for the regular Terrigal Trotters Saturday run.  I was there early to take care of runner registration as Kev, the Club Registrar was away in Parkes for the Elvis Festival, and enjoyed greeting the 100+ runners who turned out.  Many kindly asked after my health and I later had the benefit of talking to a couple of club-mates who recently had surgery for similar heart issues.  My regret at not being able to join everybody for the 11km "Round Drive" run was somewhat tempered by a pleasant 6km walk with some great coastal views and the usual post-run bonhomie.

Endurance athletes and A-fib

Greg Welch

My diagnosis with Atrial Fibrillation (AF) has had me researching the subject of endurance athletes with heart conditions.  My friend, Dr. Jon, forwarded me an article called "Atrial fibrillation and atrial flutter in athletes" when he heard of my diagnosis.  It reviews a number of studies of the subject and concludes "There is growing evidence that long-term endurance sports participation can result in.......the initiation and maintenance of AF......although the mechanisms explaining the relationship between these conditions remain to be elucidated".

It's not hard to find examples of endurance athletes who have had to deal with heart problems.  Just in Australia, high-achieving triathletes, Greg Welch, Emma Carney, Erin Densham and Chris Legh have all had treatment for serious heart conditions and, in some cases, been forced to cease elite competition.  It can sound scary!

Emma Carney

But they are all a lot younger than me (making it much tougher for them, of course) and maybe they were predisposed genetically to their problems.  Nevertheless, without having any personal knowledge, I doubt that they would change much about their competitive lives, and particularly the intensity of their training.  They achieved great things by maximising their potential through hard and disciplined effort, and I admire them.

Erin Densham

We are all individuals and the medical studies point out correlations, possible explanations and areas for future study with respect to cohorts.  There are no certainties, or even probabilities, that long-term endurance runners will have dangerous heart problems affecting their quality of life.

I would like to see a study that quantifies the enhanced quality of life enjoyed by endurance runners over the course of their careers.  I believe the benefits would far outweigh any costs.

Perseverance is not always good

Deep Vein Thrombosis is the formation
 of a blood clot (thrombus) in a deep
 vein, predominantly in the legs.

There are whole worlds out there that I know little or nothing about.  I'm a bit of a current affairs nut, and an avid reader on a wide range of subjects, but there's nothing like a new injury or illness as motivation to expand your knowledge of a subject.

During my running life I have had serious injuries to my Achilles tendons, knees and lower back, as well as the usual torn and strained muscles, tendons and ligaments.  In each case, I've learned a lot about those injuries, including through missteps I have made in dealing with them.

I like to think that my own experiences allow me to offer soundly-based views on the running-linked injuries of friends when asked.  In the case of soft tissue injuries, I generally advise patience and the avoidance of activities that worsen the symptoms.  If something seems more serious or inexplicable, I usually suggest starting with a doctor.  They have a range of diagnostic tools at their disposal and a broader range of knowledge about the possible causes than ancillary or alternative health care professionals.  I'm not a fan of starting with the latter because I believe their field of knowledge and the tools they have available make it less likely they will consider all of the possible sources of a problem.  This can lead to misdiagnosis and a delay in recovery.

Pulmonary Embolism  is a blockage of the main artery
of the lung or one of its branches by a substance
 that has travelled from elsewhere in the body
through the bloodstream (embolism).

In the last two weeks, through doctors, the Web, and articles given to me by others, I've become a lot wiser about the subjects of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) and Atrial Fibrillation (AFib), and their associated symptoms, treatments and prognoses.  Of course, there's much more I don't know about these subjects, but one thing I have learned is that runners need to be much quicker in seeking the opinion of a doctor if they start to feel inexplicably short of breath, dizzy or light-headed, or experience chest pains, hyperventilation or persistent leg pain.  There can be life-threatening medical conditions underlying these symptoms and endurance runners are at higher risk of developing them, especially if they have a long background of endurance training.

Atrial Fibrillation is the most common cardiac arrhythmia
(heart rhythm disorder).  The normal regular electrical impulses
generated by the sinoatrial node are overwhelmed by
disorganized electrical impulses usually originating in the
roots of the pulmonary veins, leading to irregular conduction
of ventricles impulses which generate the heartbeat.

Many runners, and particularly males, think seeking medical advice about these symptoms is a waste of time and/or a sign of weakness.  All endurance athletes get used to dealing with fatigue and injury "niggles" and there's a strong temptation to dismiss them as a "cost of doing business".  Two friends, both distance runners, have recently been diagnosed with PE, but only after persevering with their symptoms for much longer than me and ending up in hospital emergency wards.

I will now be quick to advise any runners suffering from the symptoms described above to urgently seek the advice of a doctor.  Early intervention is important and delay could be fatal.  It's just not worth the risk of persevering.

After mentoring this morning's track session at the Terrigal Haven, I walked for about 6km, feeling fresh and healthy the whole way, and wishing I could be running my usual post-track session 11km.

Mental adjustment

The MacPherson Forest loop was my last long trail run

It is a challenging (character-building?) time for me.  I find myself constantly re-evaluating my situation, looking for plausible positive scenarios (while trying not to fool myself), and fending off the darker morbid thoughts that must come to anybody who suddenly finds they have a potentially life-threatening medical condition.  I always assumed that my serious running career would be brought to an end by some major joint failure.  I did not expect it to be threatened by a cardio-vascular event, and it's taking time to get my head around the consequences.  With joint failure, there were always going to be alternative forms of endurance exercise such as cycling, hiking or kayaking to fill the running void, but a cardiac problem will be just as much of an issue for those activities.

MacPherson State Forest trail run

It's amazing how quickly your perspective changes, especially with the resources of the Web and Google to inform you.  I'm already thinking about changing the title of this blog to "The Futile Pursuit of a Last Sub-3 Hour Marathon" as it's hard for me to believe that I will ever be able to subject my heart to the stress necessary to run that fast again.  New goals are formulating.

Of most importance to me is the ability to exercise most days and feel good about my health, well-being, and quality of life.  It would be great to include occasional long "no pressure" trail runs, and be able to go for extended hikes/rides in remote places.  Compromises will be needed, along with patience.

MacPherson State Forest trail run

I have already decided I'm willing to reduce daily and weekly distances, give up the pursuit of age-group podiums, and even walk up hills.  If it seems likely to reduce the risks, I'll cut out caffeine (despite my well-known penchant for Diet Coke and Pepsi Max) and stop using my asthma inhalant, Symbicort.  All of these things - too much endurance/hard running, caffeine, steroid-based asthma medications - are statistically correlated with Atrial Fibrillation and cited as possible risk factors.  Age (I'm 63) is another significant risk factor, but I can't do much about that.

There will be more tests and doctor consultations to come, and there are still plenty of "unknowns", but it will help me deal with the situation if I've started mentally adjusting to the life-style compromises that may be required.

Mixed feelings

Ultra-running legend, Pat Farmer, running
with friend, Dina, near the end of the
"Round the Bay"

Today was Terrigal Trotters' "Round the Bay" run, which is traditionally held on the first Sunday in the New Year.  At just over 37km of roads and concrete bike paths, and usually in humid conditions, this a tough run.  Three weeks ago, I had been planning to use it as a long training run, but the Pulmonary Embolism diagnosis a week ago changed all that.

The event, which circumnavigates Brisbane Water, and is followed by a picnic breakfast, has become increasingly popular within the running club, and today was no exception.  Fifty-five people completed the circuit, including one group of walkers who began at 2:00am!  Some slower runners started at 4:00am while the main bunch set out at 5:00am.

Despite injury, Wayne nears the end of
his 13th consecutive "Round the Bay"

To get some exercise, I drove down to the start in Gosford and then walked 4km out and 4km back along the last section of the course with my camera, photographing the runners and walkers as I encountered them.  It was inspirational to see so many of my friends out testing themselves, including some suffering from injuries and/or a lack of preparation.  In just about every case, I managed to coax a smile out of them, despite their exhaustion.  My friend, Wayne, who is the only person to have run every one of the twelve editions so far, and has had a bad couple of years with various injuries, still found the determination to finish and preserve his record.  We have had a few good tussles on this course in past years.

Trotters gather for breakfast and a low-key presentation
after the "Round the Bay"

The inspiration provided by my friends this morning was, sadly, somewhat offset at frustration with my own situation.  It was only eighteen days ago that I ran the same course on my own without pressing the pace in quite a reasonable time.  I need to remind myself that eighteen days is not that long, and that I was still running up until a week ago.  Assuming next week's Echocardiogram is clear, I may be jogging in another week, and won't have lost much fitness.  Other people with my condition would just be thankful to still be vertical, and I need to remember that too.

Lost opportunities?

Boney Mountain

I joined the usual throng of Terrigal Trotters at Terrigal beach this morning for the regular Saturday 6:00am run.  I was sad not to be joining them for "Bob's Hill", another of my favourites, but reflected that I was lucky to be there walking and sharing time with friends.  Several Trotters who share my demographic are dealing with significant health issues, including one who recently suffered a more serious and life-threatening episode of Pulmonary Embolism than me.  Fortunately, he seems to be on the road to recovery, but it's another reminder to live for today, particularly when you get older.

A year ago, almost to the day, I enjoyed one of my happiest racing experiences for some time.  Sharon and I were on the last day of a three-week vacation in the western U.S., and ran in the Boney Mountain Trail Half Marathon west of Los Angeles.  After a steady start, I worked my way through the field in the second half, which included a 2000ft climb, and after a helter-skelter descent, finished in 18th place in a field of over 300.  The next runner in the 60+ division was 33 minutes behind.  I didn't believe I could still run so fast and thought then that it was likely to be the racing highlight of 2013 for me, and that's how it turned out.

Reaching the bottom of the descent
from Boney Mountain

I do get frustrated when I miss races and other running opportunities, but know that physical brittleness and vulnerability come with age.  I can accept the injuries and illnesses, so long as I don't feel I have given up my quest to be the best runner I can be, and don't incur them through making stupid choices.  All runners have those moments when injury strikes and they just wish they could have a "do over" and avoid whatever caused the problem.  Sometimes it results from doing something foolish, but often it's just plain bad luck and could not reasonably have been foreseen.  The challenge is to strike a balance between testing your limits and being foolhardy in pursuit of your potential.

I would like to think I didn't make any poor choices leading to injury or illness since Boney Mountain last January, but know I have learnt a few things about myself, particularly the growing need to warm up longer and/or start slower for anything fast.  Good choices or bad, I still had plenty of downtime and failed to produce any performances comparable to Boney Mountain.  However, it was only a year ago, and common sense tells me that not too much athletic potential can have been lost in just one year.  I still believe that if I can string together three or four months of consistent and smart training and racing, there's no reason why I couldn't get back to that form.  This is what keeps me going.

Some cause for optimism

Near the start of the Dubbo Gully Run

As the early test results come back, I'm becoming more positive about a return to running.

So far, no evidence has been found of more sinister underlying conditions that could have led to a blood clot forming in my veins and migrating to my lungs.  However, I still need an Echocardiogram early next week to rule out any heart disease or other heart issues, so am not out of the woods.

On the other hand, an Ultrasound Doppler examination of my right leg yesterday, found a small clot just beneath my right knee and close to the site of severe knee pain I experienced following a 30km trail run on the Dubbo Gully course three weeks ago.  There is no pain there now, and there hasn't been for several weeks, so it seems reasonable to surmise that the clot may have been larger when the pain was greater.

Crossing Mangrove Creek on the Dubbo
Gully Run

What led to such a clot forming, and why didn't I pay more attention to it?

Firstly, I have had significant right knee pain for more than six years now (see Post titled "Adaptation"), so I expect it to be sore after a long run.  However, I recently switched from wearing Nike Pegasus shoes, a model I have worn for decades, to another brand that promised more cushioning.  I was wary about changing shoes because I know different brands and models can change the stresses and strains imposed on the legs making you potentially more vulnerable to injury.  However, I have also been struggling with a painful chronic right Achilles tendon injury and been stymied on several long runs, including the Melbourne Marathon, by lower back pain and associated sciatica.  A shoe offering a softer ride and different pressure on the heel was worth trying and I bought a pair.  After a couple of weeks and several long runs in the new shoes, positive signs were that my Achilles tendon was less painful and there had been no back trouble.  Offsetting this was a minor worsening of my knee pain, which seemed to have moved to just below the patella on the inside front of the leg.  Following the Dubbo Gully run, the pain was particularly intense, especially on the hour-long drive home, and was sufficiently painful to cause sleeplessness the next two nights.  It now seems likely this pain was associated with deep vein damage.

Part of the Dubbo Gully route

Three risk factors probably compounded the development of a clot in the vein.  I was dehydrated after the run, but drank sparingly in the next four or five hours, increasing the viscosity of my blood.  Unusually, I had a three hour nap (while still dehydrated) on my bed when I got home, during which my heart rate would have dropped to its usual low resting rate (~45 bpm).  Finally, I have low blood pressure anyway.

My guess is that the coincidence of the new shoes changing the stresses on an already damaged knee, dehydration, a post-run nap, and low blood pressure led to Deep Vein Thrombosis.  The next ten days saw parts of the clot break off and travel to my lungs and the development of Pulmonary Embolism.

Through gradually increasing the daily dosage of Warfarin, my International Normalized Ratio (INR), a measure of the clotting tendency of my blood, has reached 2.1 (the desirable range is 2.0 - 3.0) and the daily Clexane injections have ceased.  I'm still not allowed to run, but I played golf this morning and have been walking about 5km per day this week without ill-effects.  I haven't discussed it yet with the doctor, but I'm hoping I can resume unpressured jogging after a scheduled visit in a week's time, provided the Echocardiogram doesn't yield any concerns.  Fingers crossed!

A new challenge

Terrigal Trotters gather after their Santa Run

The New Year has brought some additional challenges in my quest to run a last sub-3 hour marathon.  When I started this blog, I thought my goal was possible rather than probable, and now it seems closer to impossible than possible.

Following my underwhelming Melbourne Marathon effort back in October 2013 (see post), my training was consistently around 100km per week up until Christmas and I could feel my fitness improving significantly.  Enough, in fact, to begin plotting my race calendar for 2014, culminating in another sub-3 hour marathon attempt at the Gold Coast Marathon in early July.  I entered races such as the Bogong to Hotham 64km in January and the Six Foot Track 45km in March, optimistic that, barring the unforeseen, I would do well in both.

Unfortunately, "the unforeseen" has arrived.  At the Terrigal Trotters Santa Run, on the Saturday preceding Christmas, I struggled around the 10km course for no apparent reason, breathing particularly hard on the hills.  It was warm and humid, I was wearing an Elf costume, and I had run 37km (comfortably) in training three days earlier, so I wrote it off to a combination of those factors.  Over the next three days, I ran just 10-15km daily, and didn't push the pace, but still felt fatigued and short of breath.  I even walked up a couple of steeper hills, a rarity, and quite demoralising.  I survived a long-planned 35km Boxing Day trail run with friends by running conservatively the whole way, and hoped that successful completion might have signalled some kind of recovery.

Me (centre) getting ready for the Trotters Santa Run,
unaware of my Pulmonary Embolism and how hard I
was going to find the run.

Sadly, two days later, I could only shuffle around the monthly Trotters 10km Hill Time Trial in 56 minutes, some 13 minutes slower than I should have been able to manage.  This convinced me something was wrong, and not getting better.  On returning home, I spent some time Googling my symptoms.  The most likely explanation seemed to be Pulmonary Embolism (PE) a condition that can quickly become fatal and requires urgent medical attention.  I didn't feel "on the edge" so resolved to visit my local Medical Centre the next morning.  The duty doctor thought PE unlikely, since I had no symptoms of Deep Vein Thrombosis (DVT),  but alarmingly, thought some kind of heart condition probable.  Nevertheless, she took my concerns seriously and prescribed a series of tests to check for heart and lung issues.

Being the Sunday between Christmas and New Year, I had to wait until the next day to get the first tests done and a Pulmonary Angiogram found evidence of PE in both lungs.  Often this would lead to immediate hospitalisation, but since I seemed otherwise healthy and stable, I was sent directly back to the doctor where I was given an injection of the anti-coagulant Clexane in the stomach and prescribed another anti-coagulant, Warfarin.  More tests were prescribed to try and determine the source of the original clotting, which I gather could include cancer, heart problems or injury.

Now, three days later, I'm still trying to come to terms with how this is going to change my life.  After more extensive Googling, it seems the best case scenario is that the clots are resolved by the anti-coagulant and I cease taking the Warfarin in three months and return to my pre-PE life.  The worst case scenario is that the PE is symptomatic of a more serious condition.  I feel healthy, when not running up hills, and have a sort of instinctive confidence that there is nothing seriously wrong.  On the other hand, I strive to be a rational being and know I'm getting older, I frequently test my body to its limits, and some time, barring accidents, a medical condition will lead to my demise.

I'm restarting this blog with the intention of tracking my progress through treatment and towards the Gold Coast Marathon in July.  At this stage, I really have no idea whether I will be running.  Chances are that I won't bother unless I feel fit enough to threaten 3 hours.  Right now, this seems a very slim chance, but I'm keen to try.

Who's up and who's down

Down - walking dejectedly away from the
finish of the 1982 Montreal Marathon
(46th, 2:29, "possibly my worst
performance ever") where I struggled
with an Achilles problem and the effects
of anti-inflammatories

I didn't get time to warm up much this morning for the Terrigal Trotters Flat (mis-named) 10km Time Trial, so started slowly and nursed my sore Achilles and knee through the early kilometres.  Consistent with the feeling I've had this week that I have somehow "bottomed out" in my running, I felt I was moving better and running more strongly than for the past month or so.  Nevertheless, I lack race fitness and stamina, flagged on the hills and found the last half hard.  My time of 44:52 was about what I had expected, though I had feared it might be worse as I slowed during the second half.
The monthly Time Trial is always a good bench-marking event, though you can't get too excited about who you beat and who beats you.  This is because nobody is at their peak or nadir all of the time.  There were runners in front of me this morning who I might have hoped to beat if fit.  At other times, when I was running well, they would have had the same thoughts about me.  Running and fitness is cyclical, maybe because of illness or injury, or maybe because of work or family commitments.  For some runners, staleness becomes an issue, training and racing become chores, and they seem to lose their "mojo" for a period of time.

Down - dealing with a serious lower
back injury in the early 1980s that
 cost a lot of running time

At a race like today's it is possible to identify people at all stages of the cycle.  You feel pleased for those on the upswing or at their peak, and sad for those whose performances are sub-par for some reason.  Within Trotters, it's great to see some people running very well at the moment who have struggled for the past year or longer.  They are loving that sense of capability and potential that comes with race fitness and are relishing the opportunity to compete in events denied to them in the last couple of years.  I feel very happy for them, but also want to tell them not to overdo it and to savour this period when everything is going well.

Up - running well and centre picture in the first
Melbourne Marathon in 1978 (2nd, 2:23)

Then there are others struggling to keep running with injuries or illness, or maybe just resigned to walking until they feel better.  At this stage it's easy for them to feel depressed and dispirited.  Every runner knows (and most non-runners don't) the frustration that accompanies the inability to run regularly for whatever reason.  Continuing to associate, socially, with those who are running regularly can make the pain even more exquisite, though those same people are also best equipped to empathise.  I feel sad for those who are struggling, but also want to tell them that their time at the top of the cycle will come again if they have patience, that they should use their downtime wisely, and that, believe it or not, there are more important things in life than running.

Some kind of bug

Terrigal Trotters tackle the Hastings Road
hill during this morning's run
(courtesy: Adam Couchman)

Not much forward progress today, nor much to write about.  I had a sleepless night and woke with a headache, nausea and tired legs.  Hoping that the usual large mug of black coffee would give me a boost, I headed down to Terrigal Trotters for the Fragrant Garden-Erina Valley 11km run, one of my favourites on a beautiful Spring morning.  A slow 1.5km warm-up jog did not improve my sense of well-being, so I started the run cautiously hoping I would feel better later on, but I never did.

My legs were heavy all the way up the Terrigal Drive hill and I was well back in the field thinking I might end up walking at any moment.  I did walk up some of the later steeper hills and was, unusually, one of the last runners back to Terrigal, although I'm starting to wonder whether I should get used to it.  No doubt I have some kind of bug, and in a few days will feel better, but it's hard not to get depressed.

To top it off, I was planning to run, slowly, our first Trotters night trail run tonight - 28km from Yarramalong to Somersby - but that now seems very unwise.  I will still go, as the organiser, but it will be hard watching the 25 runners head off for a night of adventure.  Instead, I will drive to a few access points just to make sure everything's OK.

Strategising

Crossing Austria as part of my 2012 Via Alpina hike

I did manage to run 5km this morning, but I felt slow and heavy-legged.  I took care to minimise the strain on my injured right knee and it survived the distance without getting worse, but my right Achilles tendon was sore and I didn't feel like I was moving well.  With an Achilles tendon injury, my body subconsciously responds to the pain signals by shortening my stride length and avoiding pushing off too hard from that leg.  The consequence is an inefficient gait, more effort to run at the same speed, and premature fatigue.

Crossing a river on the Old Telegraph Track in Far North
Queensland during my ride between the southernmost and
northernmost tips of the Australian mainland in 2006

Even accounting for the Achilles and knee problems, running has been a chore of late.  Apart from a very modest performance at the Woodford to Glenbrook 25km a few weeks ago, satisfying runs have been scarce for three months.  It's enough to make me wonder whether I need some kind of circuit breaker, a period where my body can get back on an even keel.  In the last ten years, such a circuit breaker has been provided by the annual hiking or biking adventures I have been lucky enough to enjoy in retirement.  In almost every case, I have finished the adventure feeling fit, strong, refreshed and ready to resume my running career.  Maybe it's been one of the reasons my running career has lasted through these last ten years.

My intention had been to dedicate myself to running the best marathon I possibly could in the period up until mid-2014, but I'm worried that my right Achilles tendon injury might be a show-stopper.  My favourite medico, Dr Jon, is away for a few weeks, but when he gets back, I intend to find out whether surgery is needed.  My expectation is that I have a calcification on the heel which is inflaming the tendon and will need to be removed.  An MRI will tell the tale.  If surgery is required, then it will almost certainly involve a lengthy rehabilitation period and the shelving of any short-to-medium term running ambitions.  It may be the right time to embark on another hiking expedition, once ankle function has been regained, and I'll be looking at the Pacific Crest Trail in the United States and the Te Araroa Trail in New Zealand (see Downtime post) as primary candidates.

For the time being, however, I'll soldier on as best I can, hoping that something turns up, and continue the blog.

Best laid plans

I had hoped to be running this trail in the
Australian Alps early next week (photo taken
 on my hike through the Alps in 2011)

Injured again!  Yesterday I was starting to believe that I had resolved my right Achilles problem with the new heel raises, and that I was getting over my bronchial problems.  I was looking forward to a few days down at Thredbo in the Australian Alps early next week, where I planned to run some favourite alpine trails while Sharon and Jack did some skiing on the last of the season's snow.  With just a month to go until the Melbourne Marathon, and less to the shorter Australian Masters Games events prior to the marathon, there seemed to be some chance I could perform respectably, at least.

Some more of my planned running scenery for next week

Now I don't think it will happen.  I started Terrigal Trotters 10.5km North Avoca Lake Run quite conservatively this morning, having warmed up for a few kilometres.  Although I found the whole run hard, particularly the hills, I gradually worked my way through the field.  I never caught the front-runners, and still lack freshness and zest, but at least I ran a lot better than last week.

I wasn't conscious of any particular problems during the run, though my chronic right knee and Achilles injuries were about as worrisome as usual.  The new problem became evident after the run, when a dull pain emerged behind my right knee and proceeded to get worse and worse during the day.  If I sit down for any length of time, the pain is significant as soon as I try straighten the knee and begin walking again.  I have a feeling that it is related to the Baker's Cyst, a fluid sac behind the knee, that can become swollen if the knee is unstable.  It's an injury I have had in the past and the swelling can take a long time to subside (friends have had the fluid in the sac removed via a syringe, but often the problem quickly recurs if the knee is still unstable).



Diagram of the knee showing the location of the
Baker's Cyst, which I believe to be my latest injury

Anyway, given that I am not in peak form nor believe I'm destined to run well in Melbourne, it's easier to be smart and see if the knee settles down rather than plough on with the planned training for this week.  Today was the first time I have run faster in the new heel raises, and my guess is that this slight change in the angles of the lower leg and foot biomechanics has increased the pressure on the knee and affected its stability.  I've only been wearing the heel raises for four days, and my muscles and ligaments have probably not had sufficient time to adapt to the change in the biomechanics, especially if I'm running faster and putting more pressure on all joints.  There's an outside chance that the pain will subside overnight, and I'll be able to run tomorrow, but already in my head I've written off the next month, including the planned races.

Training through races

Terrigal Trotters getting ready to head for the Avoca Steps

Tomorrow is the Woodford to Glenbrook 25km trail race in the Blue Mountains, west of Sydney, and I'm travelling down with a busload of Terrigal Trotter clubmates.  The event was originally scheduled for late June, but was postponed because heavy rain had led to the National Park, through which the event runs, being closed.  I'm not in shape to take the race seriously, but not having run it before, I decided to keep my place in the bus and in the event.

Rounding Avoca Lagoon

That meant a decision had to be made about whether I should do all of this morning's 13.5km Avoca Steps run with Trotters, or have an easy day and rest up for tomorrow.  In days gone by, when I was training for a big event some months in the future, I rarely let myself ease up for an interim race unless it happened to coincide with a scheduled easier week's training.  Over time, experience showed me that whether I eased up or not, didn't seem to affect the quality of performances.  If you eased up, you felt physically and mentally fresher, but by the middle of the race it seldom made much difference.  I'm not saying you should train hard the day before.  In any training schedule, even when there is a heavy load, there should be easier/recovery days between the quality days.  I would just schedule that easier day before the day of the race.

Near the top of the Avoca Steps

After mulling over my options, I decided that shortening today's run so I felt better for tomorrow's run was not consistent with my need to maintain some training intensity.  Instead, I decided to run the full distance, but take it easy and avoid getting competitive.  To deal with the bronchial trouble, I took two puffs of Ventolin about half an hour before the run.  Maybe this was the reason that climbing the first steep hill out of Terrigal, my heart felt like it was racing and I struggled to get any rhythm.  I plodded up the hill, hoping things would get better, but they never did.  Although my heart rate settled down, my legs felt leaden, perhaps the result of standing around at an art exhibition for three hours last night, or maybe connected to the earlier Ventolin-induced exertions.

The Avoca Steps were very hard work, as was the last hill up Tramway, and I finished the run near the back of the field, very tired and somewhat demoralised.  My painful right Achilles had restricted my stride, and my right arch was still a little sore, so they may also have been factors.  I just have to remember that, although not stellar by any means, I ran better on Wednesday and last Saturday, so this morning's run should not be seen as representative of my current fitness.

I'll give the Ventolin a miss for tomorrow's run, start slowly, and hope I can redeem myself a bit.

Problem management

The path followed around the edge of Cockrone Lagoon at
McMasters Beach during this morning's run.

My right Achilles was still stiff and painful this morning as I headed out for an easy and flat 7km across the Cockrone Lagoon sandbar and through McMasters Beach.  I'm still wheezing and coughing a lot, but there is a very high pollen count on these warm spring days, and allergies may be exacerbating the problem.  Despite these two significant problems, I did feel like I was moving a bit better this morning, but I need to get these issues to a manageable level.

In the past, prior to surgery, I have managed chronic Achilles problems through the use of heel raises.  I recently purchased some at a sports store, but they are softish and more designed to cushion the heel strike.  I wonder if they make the problem worse, because there seems to be greater friction between the heel and the shoe as the pad compresses.  Thirty years ago, I used more rigid heel raises and often wore them for years on end.  The theory behind these heel raises is that the heel is higher relative to the front of the foot and therefore, with each step, the angle defined between the lower leg and foot is less acute.  We are talking millimetres, but it does make a difference.  I used to make my own heel raises by carving up the heels of old thongs (flip flops) and velcroing them to the inside base of my shoes.  Sadly, the thongs of these days seem to be made of softer and thicker material, and making my own heel raises hasn't been practicable.  An alternative I once used were Sorbothane heel pads and I've found they are still available on the web, so have ordered some.  If they don't work, I think I'll be visiting Dr Jon and getting an MRI.  I suspect there is a heel spur that needs to be removed, and that will put me out of running for months.

Cockrone Lagoon from the Copa side

The breathing difficulties I have been dealing with recently may be a consequence from ceasing use of the asthma medication I have been on for the last few years.  I stopped taking Seretide because it was giving me headaches, and before that, the doctor recommended I stop taking Symbicort which has had some adverse findings concerning long-term use.  Ventolin seems to help a bit, but I'm only taking it on days when I race.  I'm not sure that it is wise to be taking it before every run although a web search hasn't revealed evidence of any long-term use side-effects.  Two other major considerations for me are that I don't like the idea of taking anything long-term, and I don't want to take anything that is prohibited by the World Anti-Doping Agency (WADA) or the Australian Sports Anti-Doping Authority (ASADA).  The latter has a "Check your Substances" facility that allows you to make sure you are not contravening the rules and the FAQ on the Australian Sports Drug Medical Advisory Committee (ASDMAC) also provides good information.  Both of these websites show the medications I have been using comply with the rules, but that leaves the problem of avoiding long-term use.  I've made an appointment with my doctor next week to discuss the best option.

Running with a cold

The last part of the Cape Three Points Road climb
out of Avoca

I'm trying to gradually increase my training intensity, while taking care not to overtrain as I come back from the right arch injury.  This makes me reluctant to step back when something such as a minor cold comes along.  Since Sunday, my nose has been running, my sinuses are blocked and I'm coughing a lot.  Like most runners, I believe that running with a head cold is unpleasant but not such a big deal.  However, I also believe that it can risk bronchitis, or worse, if the congestion goes to your chest or you get too run down.  The rational thing would be to back off for a few days and avoid hard running and breathing, but that also means less mileage and a slower comeback when the cold may just pass by anyway.

I have never been very good at backing off for illness (or injury).  For many years, my personal rule was that, if I was too ill to run, then I was too ill to work, and because I always wanted to run, I was rarely sick enough to miss work (in fact, I can't ever recall missing a day through illness, though there were probably a few early in my career).  Of course, I was lucky to never suffer a serious illness, though I did run a few times with a high temperature and flu symptoms, and occasionally against medical advice.  It's hard to draw the line.  There's no point in ending up in hospital or worse, but none of us feel 100% every day and I don't want to miss training unnecessarily.

Copa beach

In recent years, I have modified my illness rule to be no running with a temperature.  I have heard a few horror stories of runners collapsing when training or racing with temperatures, and have no desire to join them.

With just a cold to worry about, I set off for this morning's 14.5km road run knowing that it might not be pleasant.  I ran a regular course, but in the opposite direction to usual, making it easier for the early kilometres and back-loading the toughest hill - Avoca's Cape Three Points Road.  It was yet another beautiful warm sunny morning as I crossed the lagoon sand bar to McMasters Beach and cruised along the shaded Scenic Highway.  After a few kilometres, I spied another runner up ahead and thought I might catch them, but wasn't running fast enough and suddenly they had disappeared.  The first hill elevated my cold symptoms, and I was soon coughing, hawking and wheezing as I struggled up the climb.  My head felt stuffed up and I was sweating profusely around the eyes, a tell-tale sign of sinus problems for me.

Despite all that, I was moving better than a week ago, and it really was a beautiful morning for a run.  Even the first part of the Cape Three Points Road hill wasn't too bad, but the hill has a concave shape, meaning it gets steeper as you get higher, and I really struggled up the last part, spluttering all the way.  The reward, of course, was the run down the other side into Copa with it's magnificent coastal views, and the icing on the cake was a brief stop on the beachfront to watch a whale wallowing just beyond the surf break a hundred metres from shore.  I finished in 1:17, which was an acceptable time, two days after a hard long run, and the good news was that  my right arch injury was barely noticeable (though my right calf muscle had a tender spot).

Centre of gravity

The start of the Vicary Road hill on Mark's Run

After feeling so bad for what was only a short run yesterday morning, I decided it might be smart to run a few kilometres as a warm-up for this morning's Terrigal Trotters run.  So, at 5:30am, I headed off to the nearby Haven to run a few laps.  It was hard to imagine, as I hobbled along, that I would soon be running at five minute kilometre pace with my fellow Trotters.  My most recent injury, the right arch, seemed to be the least of my worries.  It was the older chronic right knee and Achilles injuries that were causing me the most grief.

I have a theory that if one of my Achilles tendons is sore, then I don't stretch it as much as I drive off with that leg, my stride shortens and my centre of gravity is further back than usual.  The consequence is that my running form is less efficient and it takes more effort to maintain a certain pace.  As the Achilles loosens up, the centre of gravity moves forward and running efficiency improves.  On my warm-up, my form was anything but efficient, and my Achilles was very sore, but I didn't try to force it (see earlier post titled "Managing a chronic Achilles").  Instead I just hoped that if I took it easy for the first kilometres of Trotters' "Mark's Run", the Achilles would loosen and I would be able to cope with the very significant hills later on the route.

Mark's Run passes through the very tranquil Erina Valley

As it turned out, the Achilles didn't loosen up to the point where I could stride out and feel balanced until after 10 kilometres.  Prior to that it was manageable running downhill and on the flat at slower speeds, but I was well back in the field.  When we reached the tough hills, which would normally be a strength, I just had to take them very gingerly and avoid putting any severe pressure on my right ankle, trying to prevent the Achilles from stretching too far.  It was frustrating and unpleasant.

The last 4km of the run were actually quite enjoyable as I finally began to run properly, and at a reasonable speed, for an old bloke.  The Achilles problem comes and goes, and it's not always possible to work out what triggers it.  Maybe I tie the shoes too tight and they grip too firmly on the tendon, or maybe it's running on an uneven or soft surface.  Eventually, I suspect more surgery will be needed.

Tomorrow's 42km trail run will be a challenge, but I will be running slowly and in a different pair of shoes.  I'm keen to do the run both because it's through a beautiful part of the world, and because I need some long runs to build fitness.  One bright spot today was that, although I could feel some sensitivity in my right arch, it continues to improve and seems to be the least of my current problems.

Familiar companions

As you get older, you get used to running with
 chronic injuries.  Nearing the finish of the
1991 Watford (UK) Half Marathon (~75mins)

After an "easy" day yesterday, I wanted to run a bit further this morning.  I'm still coming back from the right arch injury and my goal is to be back in full training by the end of August.  However, because the injury is still present to a degree, I'm reluctant to adopt my usual "get fit quick" plan of long runs every three or four days.  Instead, I'm alternating easy runs with "longish" runs and gradually increasing the distance.

So, despite feeling slow and unfit, I set out on a 16.5 km loop from The Haven after the Thursday morning track session.  I felt I was barely making forward progress up the first steep hills on the Scenic Highway, and my right leg was a bit of a basket case, with the knee, arch and Achilles tendon, all painful.  As it flattened out and I covered more distance, I began moving more freely, but the right leg problems remained extant.  It was never an easy run, and the hills were particularly tough, but my time of 1:26 was just a couple of minutes slower than last time I ran the same course two months ago.

A non-athlete might ask why anyone would not only continue to run, but increase their mileage, when they are carrying injuries.  I say non-athlete, because most sports people, and especially those past their prime, frequently train and compete while carrying injuries.  Often these injuries are as familiar as old friends, or maybe companions is a better word.

I don't enjoy the pain I get from my right knee and Achilles tendon, but they are well known to me and I don't expect them to stop me running, though accept it will happen some time.  My recent right arch injury is beginning to enter the same category.  For the last few weeks, the pain is always there, some times worse than others, but I now have enough experience of the injury to know that I can back up and run the next day without it getting worse.  The pain is becoming familiar and manageable.  It's more tolerable because I have less fear that it will become worse, or affect my running form enough to cause compensatory injuries.  The injuries are most likely connected, and my optimistic view is that my body will gradually adapt and the pain will diminish.

It would be nice to run injury-free, and I know there will be occasional purple patches ahead of me when everything is functioning well, but more often than not there will be some pain while running.  I judge the benefit from continuing to run as far outweighing the costs.  The pain generally stops, or is vastly reduced, when I stop running and I then enjoy the health benefits and sense of well-being that accompanies fitness.

Orthotics or not

Representing Croydon Harriers in the UK National
League 3000m Steeple (9:43.8, 4th) in May 1975

I put my orthotic insoles into my running shoes this morning with the intention of running an 11.5 km course after the Thursday morning track session at the Terrigal Haven.  I hadn't worn them since Tuesday morning's run, and they felt uncomfortable as I walked around during the track session.

Afterwards, as usual, I returned to my parked car and stripped off to prepare for my own run.  My feet still didn't feel comfortable with the insoles, so I decided to take a chance and remove them for my run.  It was at this point I realised that I had put my orthotic insoles into my shoes without removing the original shoe insoles.  Duh!

This still left me in a quandary as to whether or not to I should run with the orthotic insoles.  My preferred long-term option is to return to the regular insoles, but as mentioned yesterday, I have short-term concerns that my sore arch still has some way to go before reaching full function.  I had managed an easy 5km yesterday, but would a harder 11.5km this morning set me back.  To a non-running reader this issue would seem trivial, or even insignificant.  But most runners can identify with the small decisions that need to be made on a daily basis with respect to shoes, socks and insoles, especially when dealing with an injury.  What works best, and what is the cost of a poor decision?

I took a calculated risk and went with the regular insoles (originally supplied with the shoes) and could immediately feel the difference.  The ground felt harder underfoot and both calf muscles were very tight.  This wasn't surprising and confirmed to me the wisdom of ditching the orthotic insoles as soon as feasible.  They are more cushioned than the regular insoles, with the advantage of softening foot impact, but I fear the extra cushioning will atrophy the foot muscles that usually take the strain.  Similarly, the orthotic insoles have a slightly higher heel and this will lead, over time, to the Achilles tendon and calf muscles shortening.  This is fine as a short- or medium-term strategy for dealing with Achilles tendon injuries, but I believe there is a cost in terms of stride length and running balance.

My arch was maybe a little more sore at the end of the run, and the run seemed very hard work, especially the two long climbs.  However, I was happier when I saw my time was just under 58 minutes.  I had set out cautiously and slowly and never felt like I was trying to run fast.  Assuming my arch doesn't become more sore in the next 24 hours, I'll have to decide whether to use the new, lighter and lower (in the arch), insoles that arrived in the mail today.

Adaptation

The use of trekking poles has made a big difference to the
ability of my knees to deal with long hiking expeditions.

I'm in a bit of a quandary about my new insoles, bought to alleviate the pain in my right arch.  As you would expect, wearing these orthotics feels a bit strange in my shoes when running, and although they have certainly eased the arch pain, they have also affected me in other ways.  Normally, after resuming very easy running for a week, I wouldn't expect to have the aches and pains I'm currently experiencing in my feet, ankles and legs.  This morning, I couldn't even manage a quadriceps stretch in my right leg because of the pain it generated in my right knee.  This is unusual, and a bit of a worry.  My right knee has been very troublesome in recent years and I don't want to aggravate it.  It is the same knee on which I had surgery in 1980 (see previous "Lack of patience" post).

On two occasions in the last seven years I have had to stop running for extended periods because of pain in this knee, and on both occasions, scans revealed significant damage.

"Large chondral crater of the lateral patellar facet"

"Marked patellofemoral joint arthrosis, particularly laterally. Subchondral
bone change. Patellar tendinopathy. Torn medial meniscus."

Extended rest allowed the painful inflammation generated by these problems to abate and then careful resumption of walking and running enabled my gait to adapt, but I'm keen to avoid a recurrence.

That's not me, but I spent many hours hanging in
inversion boots to alleviate a lower back problem.

Similarly, thirty years ago, the stress fracture of a small bone in my lower back (left minor pars articularis) led to the displacement of a vertebra and years of significant sciatic pain that severely impacted my running.  Time has stultified the tissue around the vertebra, providing local support, and my posture and muscle strength have adapted, to gradually take pressure off the sciatic nerve.

For both injuries, doctors and specialists said surgery was an option, but might not improve my ability to run and might cause future complications.  It was suggested, explicitly and implicitly, that my running career was over.  Yet, I'm still running!

I don't put this down to a tolerance of pain, or to single-minded determination.  I suspect that most people my age, if they had their knees or lower back scanned, would get a scary picture.  However, I believe that our bodies adapt, we consciously and subconsciously change our gait, and we take more care in situations likely to aggravate the injury.  Pain is still present, but we know what it means and how to manage it.

I toyed with the idea of walking instead of running this morning, and also thought about removing the new insoles to see if that made a difference to my niggles.  However, in the end, I decided an easy 5km wearing the insoles was the best course.  My thinking is that my body needs time to adapt to the insoles and gentle running is likely to aid that process.  There were lots of twinges in the first kilometre, but none crippling, and I persevered.

I remain keen to ditch the insoles as soon as I can and get back to the running form I'm confident my knee can handle.

No silver bullets

Oh to be young again....
Leading in a 3000m Steeplechase at Croydon Harriers
track in 1975 (finished 2nd in 9:34)

It's still too early to say the worst of my right arch injury is over, but I am getting more optimistic.  I ran 6km after supervising this morning's track session at The Haven and finished no worse than I started.  Maybe I'll run further on Saturday, although the scheduled Trotters' run is Muzza's Run which, at 16km, may be just a little too far to step up.  However, there are some obvious short-cuts that will give me 10-12km, and that will work fine.

I give myself no chance of getting fit in time for a sub-3 hour Melbourne Marathon in October, although it's still possible I might run it for training (I have already entered), with my eye on the Cadbury Hobart Marathon on 12 January 2014 for a serious attempt at a fast time.  Even writing such an objective down, makes me apprehensive.  As the past few months have shown, I'm very vulnerable to injury, and just marking a date on the calendar seems to risk disappointment.

For the moment, my focus is just on getting fit again.  Diagnosis by Google seemed to indicate the likelihood of a ligament injury, as discussed in a previous post, and it seems ligament injuries can take six to ten weeks to heal (I'm generalising, of course).  It is now almost six weeks since I sustained the injury, so provided I don't set myself back, it does seem feasible that I will be back to hard training in four weeks.

Over the years, I have definitely become more cynical about the treatment of injuries, especially muscle and ligament tears.......or maybe I have just become lazy and cheap.  I believe that most soft tissue injuries will repair without third party intervention, given time and rest.  We are all very tempted, including me, to seek ways of shortening recovery time through medication, physiotherapy, etc., when we sustain an injury.  But there are no silver bullets.  Injuries take as long as they take to get better, and there are few short-cuts.  It may seem that treatment is making a difference, but usually those treatment regimes take time (and money), and during that time, the body is healing itself anyway.  My theory is that, at best, you are probably just fiddling at the margin.

I absolutely accept there are injuries that do need medical intervention, and I'm no doctor.  My advice to athletes who ask me about their injuries is to start with a doctor if they are in doubt about the nature of the problem.  The doctor has access to the best diagnostic tools and can refer you to specialists or recommend a range of treatments, including from allied health professionals.  If you start with these allied health professionals, then maybe not all possible diagnoses and treatments will be considered.