The Bad Leg Blues Part 3: All’s Well that Ends Well?

Where were we? Ah yes, finally getting to see the orthopedist we should have been seeing in the first place. (You may want to read parts 1 and 2; I apologize for their unedited length. I needed to vent.) His assistant asks to bring the films of my MRI; as these are with the original orthopedist 50 miles away, I ask if I can bring the CD I was handed instead. I’m told this should be fine; they deal with them all the time. I do at least get the report faxed through to me, and it does indeed state ‘ruptured ACL.’ Shit.

In Kingston, the orthopedist, who comes so highly recommended by running friends, is initially brusque – on the surface even less outgoing than the one in Hudson. He asks for the CD with the MRI; he comes back five minutes later and tells me it’s unreadable. So much for technology. (Maybe he’s also on a Mac?)

But then he asks me questions the other doc did not ask. When I had the accident, did my bindings release? (Crucially, the answer is no.) Can I remember how I fell? Which way? What did I bump? How did I bounce? How did I land? How bad was the swelling? How quickly did it flare up? Was I stretchered off the mountain? Or did I ski down? How did I treat it? How long did I rest it? When did I go back out on it? Could I walk? Have I been running? How does it actually feel?

And then he does something the previous orthopedist did not – at least not when he read the MRI radiologist’s report and told me I needed surgery to repair my ACL. He gets me on the table and he undertakes a hands-on examination of my injured leg. (The shock! The horror!) He pulls, twists, turns, tugs, checks where I feel pain, where I don’t, where my leg follows him, where it doesn’t. And then he offers his opinion.

“You haven’t ruptured your ACL,” he concludes. “Not completely. If you did, your lower leg would effectively be coming away with me when I pull on it.” (Study the picture below and you’ll understand why he said that.)

A torn ACL is not a pretty picture.

Oh, mercy! I feel like dancing – even on my bad leg. I ask him if we can confirm it’s torn meniscus and whether I should just get this arthroscopic surgery over and done with?

No, and no, he replies. He’s not convinced it’s meniscus either. And even if it is, the problem is this: that while he’s qualified to do the arthroscopic surgery to repair damaged meniscus, he’s not qualified to repair ACL. So if he gets me on the operating table and gets inside only to find that he was wrong and it’s ACL after all, he has to close me back up and send me somewhere else. It’s not a risk he wants to take at this point.

(You’re probably thinking what I was thinking at the time: that if this highly focused, hands-on doctor is not qualified to repair an ACL, what makes the unfocused, hands-off doctor in Hudson qualified in his place?)

Besides, he says, he’s really not sure that there’s anything here that needs an operation. Given the circumstances of the accident, the nature of how I handled it, what I’ve been able to do and not do, and his certainty that my ACL is still holding together, he thinks I may just have scar tissue blocking my movement; he believes we can handle this through therapy.

He asks me to come back to him in two weeks – this time with the actual MRI films. He tells me, as for that matter did both the orthopedist in Hudson and my therapist, that he’s happy for me to run as long as I take it easy.
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Though his verdict is anything but certain, I leave his office with an overwhelming sense of relief. And, knowing that I don’t now need an operation – especially not a serious one – I determine to crack this nut. (Figuratively and literally; it’s been feeling like there’s an obstacle in the way of my knee’s levers. While a torn ACL would indicate that the levers themselves were broken, this second orthopedist is suggesting that the levers may just need perpetual oiling and some brute strength to force themselves to fully function.) Over the next week I see the therapist twice, who is mainly focused for now on getting my right leg back to the strength of my left leg, building back the muscle mass so that we can start in on trying to repair the actual damage. I also try acupuncture for the first time. (It’s no big deal.) And on a trip to New York City, I call up the sports massage therapist I used to see, who got me through an awful case of runner’s knee before my first marathon, and beg for an appointment. She finds time. She is notoriously brutal on her clients, but while busy putting me through nine degrees of hell on her massage table, she tells me that the injury is repairable without an operation. She’s not a qualified doctor, and I wouldn’t take her diagnosis unaccompanied, but as one more person adding to a wealth of opinion, it’s reassuring. She does tell me to stay off the running this summer, to go cycling or swimming instead, which is a little like telling our cat not to torture chipmunks, and she is the only one out of five professionals to have told me this, but I respect her opinion. (And my right to ignore it.) That night, my body battered by her treatment of my leg, I sleep nine hours solid.

Still come the personal anecdotes; like I said last time, it’s amazing how many people you discover have been through similar escapades. A man I see every day in our village finally explains why he has a limp; he tore not only his ACL but his PCL, and that one can’t be repaired. His experience means he knows enough about it to know that if I did the Pine Hill Arms triathlon, a complete ACL tear is absolutely and totally out of the question. Another friend tells me that he tore his ACL down to its last thread, and could barely walk for months; choosing not to operate because of the risks, it was two and a half years before he could run again properly. If I was back out running without weeks, there’s no way my damage can be worse than his. At the therapists, I meet the kind of person I’d like to be: a ski bum who has a home up here but is on his way to teach telemark skiing in New Zealand for the next few months. He’s just had his third meniscus operation and is whizzing through the therapy like it’s routine homework before catching his plane to the southern hemisphere. We get talking and I tell him about doing the Pine Hill Arms. He asks which part I did best. When I tell him it was the running, he assures me there’s no way I’d have done that on torn ACL.

Finally, another friend offers maybe the most instructive tale of all: back at college, he took a fall in the frat house. (I don’t ask.) A local orthopedist insisted it was torn ACL and recommended surgery. A second opinion was inconclusive. Coming home for Christmas, his parents paid for him to see a professional sports orthopedist – the kind I tried in vain to see at the Hospital for Special Surgery – who thought it was meniscus and performed arthroscopic surgery. My friend woke up from the operation to be told he hadn’t needed it: there was nothing there that couldn’t be fixed by therapy and exercise and time.

And then someone else points out to me what should have been obvious all along. Medical practices in America get paid by insurance companies for what they do, not what they don’t do. My ACL operation would generate a nice $15-20,000 invoice for the practice in Hudson, regardless of whether I actually need the work or not. I don’t want to think that this is how the system works, but it is – at least for some doctors.

I do, however, want to think that my insurance company will be glad I’m trying to save them the expense of the operation. Not so. After a couple more visits to the therapists, I get a phone call from them telling me the insurance company won’t cover the treatment. They only pay for therapy after an operation, not to prevent one. There’s common sense for you – not. I’m already on a $20 co-pay every time I walk into a medical office, and it’s been adding up. But the therapy is only $50 a visit, a drop in the ocean compared to what medical practices charge for MRIs, EEGs and operations. I’d sooner pay that $30 difference than not get treated. We reduce my regime from twice a week to once a week – and the therapists invite me to come in any day, any time, and use the exercise equipment. That actually seems like the best deal I’ve had out of the whole damn system – and of course it has nothing to do with insurance.
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I return to the orthopedist in Kingston two weeks later, as scheduled, MRI films in hand. The doc sees me on time, pulls out the films in front of me, spends three minutes looking at them, then offers me the nearest I think we’ll get to a (in)conclusive opinion. “OK,” he says. “You did tear your ACL. The MRI shows it.” Shit. (Again.) Determined to see for myself, I have him show me the film. You’d think these MRIs would offer space age definition, but it’s like a Google satellite map of a tennis ball inside a garden shed. I take his word for it. “But you can’t have torn it completely. We figured that out last time. The radiologist offered his best judgment based on what he saw. But hands-on tests confirm it’s still partially intact.”
By now, I’ve done my homework. Almost. “And if there’s still just a little piece of it holding on, it will grow back, right?”
“It will firm up, yes.”
“So did I tear my meniscus?”
“No.”
“You’re sure?”
“I’m looking for the signs. I see this one thing” – he shows what looks like something out of place behind my knee, exactly what I think we should be looking for – but then says it’s not visible on other angles, and it’s not the “buckethandle” that indicates torn meniscus.

He gets me back on the table, examines me again, repeats that he doesn’t think I’ve irreparably damaged the ACL, confirms that he thinks it’s reparable through therapy. I tell him my therapist thinks there’s something physical blocking my movement. He asks who I’m seeing. I tell him. “Tell her to give me a call,” he says.

He urges me to persist with therapy. “Sometimes you need somebody to push you through a repair, even if you have the best intentions yourself,” he says. “Someone to force you to do what your body needs to do. I want you to take that route.”

And if it doesn’t work? I ask. As of yet, I don’t feel like I’ve regained any motion in two months.

“If you come back to me in a few months and say you’re not getting anywhere, and there’s something you need to do in your life and your injury is preventing you from doing it…” He leaves that open to interpretation, but I’m thinking of future escarpment runs, getting back on the football field, “then you can come to me and tell me you demand arthroscopic surgery. In which case we’ll do it. Until then, I don’t believe in operating if it’s not necessary. Come back to me in a month. And have your therapist call me.”

I leave the office even more upbeat than last time. My emotions have been going for a rollercoaster these last few weeks – hardly helped by the head injury and the discovery of that inexplicable ‘mass’ – and now I return to therapy, greatly encouraged. I decide not to persist with the acupuncture, not because I don’t believe in it, but because my insurance is leaving me high and dry and I need to focus on one method of repair. I also decide to follow my own instincts and, also for my own sanity – because this is how I stay physically fit and mentally alert – I resume running. But I do it on the high school track, on the soft surface. I start with a lap or two and I decide to work my way up to a couple of broken miles. The Onteora Mile is coming up on June 12. It’s the third of our Grand Prix events. (The first one I ran slow. The second one, a 15k on Memorial Day, I wisely sat out.) There’s no reason I can’t prepare for a one-mile race.

The Onteora Track: I determine not to take these words literally.

And then one day, I get somewhere. I’m doing my stretches one day and my leg passes through that nut, with such a loud click it’s almost like breaking something. It’s painful, but I’m on the other side. I’ve broken through the wall. The therapist is equally relieved; having spoken now to the orthopedist in Kingston, she’s willing to believe it’s just scar tissue and that we can push further it. I don’t know whether to credit the therapist, the sports massage, the acupuncture, my discipline and determination, or the Kingston orthopedist for making me believe. Most likely it’s all of the above.

In the meantime, I use the exercise machines, I ride my bike, I spend an hour a day at home doing my assigned exercises, I even get out to swim on Memorial Weekend. And on alternate weekday evenings, rather than go home for dinner, I head back out to that track at the High School. There I stretch. I walk a lap. I jog a mile. I walk two laps. I run a mile. I walk a lap. I stretch again. And over the course of three weeks, I get down from 9 minute miles to 7 minute miless. Two days before the Onteora Mile, I get it down to 6:30.

At the Onteora Mile on Friday June 12, a few of the other runners are surprised to see me. In stifling conditions – about 80F with absolutely no shade or shelter and extremely high humidity – my sub-group of six-minute milers runs a few seconds slower than last year. I can’t kick the way I want to on the final lap; it’s just not in me, and I’m beaten to the tape by two people I bested last year. But I bring myself in at 6 minutes, 1 second, just 11 seconds behind last year’s time which, given my lack of fitness these past few months, is almost a PR. My quads are inflamed, I’m perspiring like crazy, and the high school senior who ran a 67 second final lap to come in under five minutes needs medical treatment. But my knee thanks me. Seriously. I wake up next morning physically tired but mentally elated. And my knee feels better for being allowed to race.
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It’s now two weeks, a couple more light runs and a few bike rides later, and the front of my right knee is still sore at (lots of) times from exercise, the whole of my right leg still feels weaker that the left, I can’t stand on it with the same ease as I can the other foot, and it continues to hurt like crazy when I bend it backwards through the ‘click.’ But at least I can do it. The last time we measured my range of motion, it had increased to over 130 degrees, from 120 degrees. The normal range is 140 degrees, so I’m halfway there. I can’t do the Escarpment run this summer, and many of the shorter trail races I was looking forward to are also off limits. I have redefined my goals for the year, and I believe they’re manageable. In fact, I’m looking forward to all the short-distance Grand Prix events for the next few months, and hope to be good for the one long 20k race in November. The next time I go back to the doctor in Kingston, he might say ‘I told you so.’ And I will say, I’m so glad that you did.

And what is the ultimate moral of the story? There’s the problem.I don’t think there is one. Every body is different, every injury is different, every doctor is different, and we all react in different ways. I do know this much:

1) To get myself to a doctor or therapist much earlier in the game next time; that’s what insurance is for, after all.
2) To rest myself longer, not to get back out running roads when I know I’m not fit
2) Diagnosis is not an exact science,
3) MRIs, especially on the knee, are near enough a waste of time and money.
4) To run a (five-minute?) mile from any doctor whose immediate diagnosis is a drastic operation, and
5) That I hate the American insurance system and all the bureaucratic bullshit it puts you through even as I respect that it offers you the right to get a second opinion and keep seeing specialists until you’re comfortable with the diagnosis. I particularly hate that it would have paid for a $20,000 operation I didn’t need but won’t cover $30 once a week for therapy.

And I am having a hard time getting over my anger at the orthopedist in Hudson for wanting me under the knife for an operation I didn’t need. His willingness to accept a radiologist’s written report without follow-up hands-on testing, and his apparent enthusiasm for an operation that was never guaranteed to be a total success, leaves me hurting for the others who will see him in similar situations and perhaps trust him.

And yet there is still this: that my initial instincts straight after the accident– that I had hurt myself badly, but that nothing was broken that couldn’t repair itself in time – turned out to be correct. I did know my body after all. I just needed some serious help in repairing it. And to do that, I needed to talk it out with people who’d been through it themselves.

And yes, I know the first and most important lesson: Don’t ski on tired legs, when you know your reactions are slow.

But then there’s this:

My friend, the football player and runner who tore his ACL down to its last thread and couldn’t run for two years? He tore his ACL not on the football field, not on the trails, but by picking up a heavy bag of shopping and twisting his knee at the same time. That must have hurt.