Full History of My Right Knee Injuries...and How I Worked Around Them in 2019 to Run a 100 Miler

The right knee injury that ultimately led to the decision for surgery likely started in 2017 (or earlier). While driving home from my weekly hilly long runs, I experienced sharp pain in my right knee. It made driving home from these workouts (20-35 miles, with as much as 2000 ft. of ascending) very painful, but had no impact on my training.

In 2017 and the first half of 2018 I continued to train and race, completing two 100K races, a marathon, and shorter tune-up races. The knee continued to flare up while driving home after long and hilly workouts, but still did not impact training and racing. In the summer of 2018 I began to feel pain in my right knee during downhill running and fast running. After starting a VO2max interval training phase I noticed that my right knee started to malfunction...I just couldn't run fast and it seemed like my right knee wasn't completely responding to commands from my brain. I typically run these intervals at around 6 min/mile pace, but my form started falling apart when I went faster than 7 min/mile pace.

I took some time off, but that did not change the situation much. In late 2018 I gave up on running fast and running on hilly courses. I could still run long and pain free if I kept it relatively slow and ran on flat ground. I started piling up some easy mileage in the hope that my knee would recover and I would be able to run my first 100-mile race in 2019. (I did not yet realize the seriousness of the injury. After 40 years of working around minor injuries and making it to starting lines...I expected to be able to work around my knee issues.)

By December 2018 I was able to run 20+ mile runs at a pretty good (for me) pace. However, my ability to run downhill had fallen apart...very painful. Also, I couldn't do any faster running. I finally visited an orthopedist in late December and had an MRI on Jan 2, 2019. The MRI scan was performed at the facility where my orthopedist worked and after the scan he looked at it for the first time while I was present. Initially he said that my knee looked healthy, but he eventually spotted a cartilage defect on the lateral trochlea of my right knee. He immediately mentioned microfracture surgery as something that could be done to fix this, but after a discussion we agreed to try some physical therapy first. (I also had a smaller cartilage defect on the medial condyle and a very tiny degenerative tear of the medial meniscus, but I did not find that out until late 2020, when I retrieved the MRI report to go and get a second opinion.)

By the time I started physical therapy in January 2019, I was running a pretty high volume (>60 mpw) with long runs up to 25 miles. Even for running ultramarathons, I always like to have strong cardiovascular fitness developed through high-intensity training including maxVO2 intervals, tempo intervals, and time at "steady state" (a bit slower than tempo...about marathon race pace or so). The maxVO2 and tempo intervals were impossible to properly execute on flat ground with my knee injury. I just couldn't run fast enough to get my heart rate into the right range. I solved this by doing high-incline repeats on the treadmill. This helped me avoid the pain of running fast and running downhill. It really worked...I was able to get in some high-intensity training at similar heart rates compared with my usual training.

I had a few setbacks where my right knee flared up and swelled and I had to back off the training for a week. But mostly this approach was successful. I was able to get my peak weekly distance to around 90 miles, with a long run of 40 miles. 

On June 1 of 2019 I ran the Lighthouse 100 miler in 17:37 (despite running about 2 extra miles due to being sent off the course by an aid station worker and getting slightly lost a few times on my own). This was good enough for 2nd overall. I did not experience any knee pain at all during the race. I thought maybe I could continue to work around my knee injury by avoiding fast running, downhill running, and continuing physical therapy.

Unfortunately that is not how it worked out. 

After two weeks of complete rest, I started another slow mileage build hoping to run a late fall or winter race. I had worked my way back to a 55-mile week with a 22-mile long run, but then my right knee worsened. It became difficult to even stand up at work after sitting for a while. Driving was painful and difficult. I shut it down for some rest and then started running easy every other day.

In December of 2019 I went out for an easy 8-mile run and during the last 4 miles my knee started to hurt and stiffen. The pain was in the middle of my knee...not on the lateral side where my cartilage defect had been diagnosed. It felt like an acute injury...I may have taken a misstep on that run or tweaked it that morning when my right foot slipped off a curb while walking. I don't think I'll ever know for sure what caused the pain, but the pain continued to worsen that evening. The next day I could hardly walk.

I figured at this point that I had a second knee injury (duh)...perhaps unrelated to the cartilage defect. I took about 7 weeks off from running and then started again at the end of January 2020. I very cautiously and gradually increased my time running, and only ran every other day. This didn't help...after a couple of starts and stops, it was clear the newer "medial" pain was not going away. I knew I needed to return to the orthopedist...but by this point the Covid-19 pandemic had started and it didn't feel to me like the right time to start visiting doctors, getting diagnostics scans, going to physical therapy, having surgery, etc.

In August of 2020, I stopped running altogether and took up cycling (mostly indoors...via Zwift) to try and stay fit. The pain in my right knee had started to impact my ability to sleep. It became clear that I needed treatment for my knee injuries. Also, the pandemic wasn't going away any time soon, so I donned my mask and went to see a different orthopedist. (I wanted some fresh perspectives from a surgeon who treated athletes and was familiar with a wider variety of cartilage repair options than just microfracture.)

Orthopedist #2 ordered another MRI, which showed (in addition to the already known two cartilage defects) a larger (but still pretty small) horizontal degenerative tear of the medial meniscus. The surgeon discussed multiple options with me, but mosaicplasty seemed to offer the best combination of recovery time (long, but quicker than ACI) and durability (much more durable than microfracture). The surgeon has a track record of getting athletes (particularly basketball players) back in the game with the mosaicplasty surgery. 

Well that's the full story. Here I am nearly 4 weeks post surgery and wondering how this is all going to turn out. I may regret having started this blog...a happy ending is not guaranteed here. However, I hope that the information and thinking I'm sharing might help someone else in a similar predicament.