The Journey From Knee Cartilage Surgery Back to Ultramarathoning: What Helped and What Didn't

Okay, so after 4.5 years, 2 knee surgeries, and 1000+ hours of physical therapy, I've been able to get back to ultramarathoning. What exercises, strategies, and approaches seemed to work for me and what didn't seem to help? I'll explore that below.

So, what worked?

Start from where you are. Progress rehab and training very, very gradually. Patience. The general approach that ultimately helped me return to ultramarathon form was the same one that enabled to me to become successful at the sport in the first place: play the long game and sneak up on amazing a little at a time.

To return to running, what I needed to do first was to re-learn how to walk. Once I could walk for 5 minutes without my knee swelling so much that I couldn't walk again for several days...I had the foothold I needed to get started. It is important when you are starting a training program to begin from where you are. The first several weeks should be boringly easy. You need to not only start with something that you can do, but also something you can repeat multiple times a week for multiple weeks...and not break down with excessive soreness and fatigue. You can be fooled initially that something is within your capabilities, but fatigue is cumulative and it could catch up with you. Start with something "stupid easy" and make sure it remains easy as you develop a routine. If it gets hard...you need to back down and do less.

Once I was able to walk 5 minutes without my knee overreacting, I repeated that. Then I added one minute and repeated that...and so on and so on. I very gradually worked my way (one minute at a time) to being able to walk 20 minutes every other day. I was recovering well and my walks were getting quicker without trying to push the pace.

Finally I added 15 seconds of running to every 5 minutes of walking. So I started my running comeback by running 1 minute total embedded in a 20-minute walk. I repeated this workout. The I ran for 30 seconds out of every 5 minutes. I followed this pattern, adding just 15 seconds at a time, until I could run for 20 minutes uninterrupted. 

Whenever I experienced a setback in my training...I backed way down in mileage and pace and slowly worked my way back.

Slow down! As gradual as I tried to be (see above) in my approach, I got a little carried away with faster running. Twice I experienced setbacks after 11.5 mile runs where I was running under 10 min/mile. My longest runs of the week were also my fastest runs of the week. After those two setbacks I slowed down my long runs and worked on speed separately in the form of 30s "striders" embedded in a short midweek run. This allowed me to focus on endurance during the long run and increase my "dose" of speed in a more systematic gradual way.

The treadmill can be your friend...or your enemy. Okay, I'm being a bit overdramatic here...the treadmill is a great training tool. However, I got a bit carried away with doing short intervals on the treadmill. I had a setback in my training when I pushed up the pace too fast on some repeats. I was a bit sore and stiff going into a workout where my goal was to dial up the pace to 9.9 mph (after I had gotten up to 9.7 mph during the previous speed workout). I did the workout anyway and dialed it up to 9.9. Mistake. My knee became sore and sensitive and I had to back down in my training and very gradually build up again. Months were lost trying to return to that level of training.

How did I fix this? I took my speed training outside. I removed all worries about hitting a specific speed and ran my 30s intervals by feel. I only went as fast as my knee would comfortably allow. If I was a little bit stiff or sore, I ended up doing slower intervals than the previous workout. This focus on "feel" and effort really worked for me. On the treadmill it is very easy to press the buttons and dial something in...that you realize (a bit too late) is a bit too much.

Strength exercises. I've not been a big believer in strength training for running, but in the case of trying to rehab my right knee...strength training was important and I am still continuing to do it. I've been doing a few right-leg only exercises (leg extensions, Bulgarian split squats) and a few exercises involving both legs (back squats, deadlifts). I got through the ultra I just ran with very little quad soreness...despite the fact that I didn't do any hill training. I credit the strength training for that.

Protein. I took a few supplements during my years of knee injury, knee surgery, and knee rehab (e.g., took chondroitin for a while and gelatin (for collagen) for a long while). I don't feel like any of them helped at all. However, a practice I started during my ultramarathon training years...taking in frequent doses of protein...has been important in speeding up my recovery from difficult workouts. I use protein bars (Kirkland brand, mostly), high protein milk, and protein containing snacks to make sure I get over 100 grams/day. After a very long run (30 to 40 miles) I would have a 20 gram protein snack every two hours after the workout and the following day. As a 50+ year old I was recovering much faster from 35-40 mile workouts than I recovered from 20-mile long runs in my early years of marathoning.

What didn't work?

Treadmill striders and "hills" didn't get the job done. As described above in "what worked," doing fast treadmill striders was not as effective as doing them outside. It is too easy to dial up a high number on the treadmill and overdo it. Focusing on "feel" instead of numbers worked better for me.

I thought that running intervals at an incline on the treadmill would force my brain to send stronger signals to my leg muscles to hasten the rebuilding of my stride which had disintegrated before knee surgery due to my knee injuries. This didn't seem to work as well as getting outside and running fast on flat ground.

Sustained speed. Developing endurance through long runs and volume and speed through short intervals has worked well...but attempts at more sustained fast running has led to setbacks. I do intend to try and work towards being able to do longer intervals and eventually tempo runs...but I'll have to build towards that very gradually.

Anti-inflammatories (including cortisone, gel shots, NSAIDs, and ice) were mostly ineffective and may have made things worse. Okay. There I said it. My one experience with a gel shot and cortisone was a compete flop. All I got out of that was an even more swollen knee that interfered with physical therapy. 

I think that icing my knee in the immediate aftermath of surgery helped get swelling under control and allowed me to (perhaps) start PT exercises sooner. However, the longer term use of ice did not appear to have any benefit...as soon as I was done icing and stood up...my knee would swell again. Same story for NSAIDS...short term relief, but no longer term benefit. The inflammatory process is one that kicks off repair and rebuilding processes. If you stop all inflammation, you may stop these healing processes as well. Anti-inflammatories and ice should be used very sparingly and with an understanding that they are providing only temporary relief of symptoms and may delay healing and adaptation to exercise.

…and some things I'm not so sure about...

Range of Motion (ROM) exercises. When I was pouring on the ROM exercises (3 times per day!) after both surgeries, I would get this paradoxical tightening (and pain!) behind the knee that would make it harder to straighten my leg. Backing off on some of those exercises seem to help ease that. I realize ROM exercises are critical to restore ROM after surgery and keep adhesions, scar tissue, and inflammation from causing a loss of ROM. However, the frequency and types of ROM exercises may need to be varied to avoid discomfort and tissue injury.

Cycling. After my first surgery I clearly overdid the cycling and it made my knee worse. After my second surgery I became more cautious with it and it became part of my routine. However, I'm not certain it really has benefited me in any way (other than burning some calories). I know that cycling works for some patients recovering from knee surgery and PTs seem to love it...but maybe I would have been better off without it.

Blood Flow Restriction (BFR) strength training. I think in the very earliest stages of surgery recovery, this makes sense. Using lighter weights helps you stay within the mechanical limitations of recovering cartilage, tendons, etc. However, home-use equipment is pricy and the brand I used was unreliable. When I gave up on BFR and switched to regular weights...I had no issues with my surgically repaired knee and improved rapidly. I would advise surgery patients interested in BFR to find a physical therapist that has quality BFR equipment and take advantage of that. I wouldn't waste money on BFR cuffs if I had to do it again.