Life Through a TV Screen – PT. 8
Disclaimer: This next chapter will be part personal experience, part physical therapy education based on existing research literature and medical guidance from Derek’s providers. It is not necessarily universally applicable medical advice, and you should contact your doctor for specific medical advice matching your individual needs.
September 2022
“Are you happy with where you’re at?”
One of my very good college friends and I are catching up over dinner and talking about philosophical life questions. The ramen I had ordered was very mediocre (like 2/5 stars if I’m being generous), its saving grace being that it was something to attend to while we talked. The question posed was an excellent question of course, one I have thought a lot about time and again in the last few years. My current take on it? I could certainly find pockets of happiness and gratitude despite the myriad of life challenges and debilitating injury that took up a large portion of life, and that being happy with my life doesn’t necessarily mean that everything has to be perfect. It is important to acknowledge that life as whole will never be absolutely perfect, but a little bit of gratitude for the people in one’s life, the support they provide, and little wins go a long way.
The last time I sat on a plane was in the winter of 2021. It was one of the most excruciatingly painful things I had ever experienced. I couldn’t stand up straight, my right leg would lose sensation, and massive amounts of pain would surge down the back of my thigh when trying to stand up straight. Just past 6 weeks post-surgery and a few hours before the above conversation, I was able to fly to Colorado. I incorporated a couple short standing breaks every 40 ish minutes on the flight but otherwise the flight was very smooth. Getting off the plane was no problem, and walking through the airport was just as straightforward. What a contrast from the struggle I had with travel less than a year ago.
The occasion to travel to Colorado this month was to visit friends and former teammates, as well as to take a trip down memory lane. In a place as beautiful as Colorado, going for a hike at some point is a must.
I decided for my first hike of the trip to stop by the Spruce Mountain Open Space in Larkspur, halfway between Denver and Colorado Springs. In college, a fair share of long runs were grinded out on the trails and roads of the Spruce Mountain Open Space and adjacent Greenland. Sitting at an average elevation of 7,000 ft., long runs on either the rolling hills of the roads or the technical single tracks were always challenging. There would be no identical grind today though, just an ex-college runner going for a self-paced hike to reminisce and ponder about my current level of function in contrast to my level of function during my other visits to this area.
The highlight of the weekend was watching the UCCS men’s cross country team open up their season at the 15th annual UCCS Rustbuster race as well as celebrating the 27th anniversary of the UCCS cross country program. (you can read about the recap of the weekend here). Facebook reminded me on the day of the Rustbuster that 9 years ago to the day I had received my UCCS team gear freshman year of college. The caption on the post talked about how I had almost given up on running the year before, and it is so interesting to find myself 10 years later now in the midst of another journey back to getting healthy enough to run.
When I returned to Colorado, I was just past 7 weeks post-operative, and it was time to start the walk-run program. On the first day, as I got dressed with running clothes, there was a sense of curiosity as to how my body would react to running. I had last tried running a few steps in May of this year and I had immediate, decently excruciating pain that shot down the back of my right thigh and turned my attempt into an immediate limp. Would it be different? Would it be the same? There was really only one way to find out. I walked a lap around my neighborhood as a warm-up, swapped into running shoes, and walked back to the sidewalk. Here goes nothing I guess. I walked until my watch hits 6 minutes, and then I began to slowly jog.
The seconds ticked by, no obvious pain shooting down the back of my thigh yet or nerve related symptoms developing in my right leg. 10 seconds go by. 20 seconds go by. I continue to jog while checking my watch, making sure that I don’t exceed 30 seconds. My watch read 30 seconds. I hit the lap split and begin walking. As I walked, I used the next minute to reassess my status. I felt a little weird mechanically just from not running for over a year, but otherwise symptoms were minimal. I hit 60 seconds. I went again, checking my watch every 10 seconds as I ran for a second round of running. At 30 seconds, I split again and walked. No significant symptoms yet, just residual soreness in my muscles from the new changes I implemented with my strengthening exercises. I started to wonder: could I run for 60 seconds non-stop? I was curious to find out.
I split my watch again, this time intent on hitting 60 seconds of continuous jogging. I checked my watch every 10 seconds or so. A minute passes and I split the watch. No significant changes in nerve related or back related symptoms. This was a good sign. For the next few minutes, I alternate 60 seconds of jogging and 60 seconds of walking until I reached about 14 minutes. I then transitioned towards just walking to round out the session. A successful first day. I sit down to take off my running shoes and ponder at my current status. My heart rate definitely climbed by the end of the session running at only 9-minute mile pace or so, but most importantly I didn’t feel any significant changes in leg or thigh pain.
The next 2 days, I left the house for my morning walk-run. By the third consecutive day, my adductor magnus muscle on both legs was getting very muscle sore, probably because I haven’t run this much in a long, long time. I decided to call this my temporary limit, and from there started to gradually build the walk-run program and biking. Including a rest day helped, and I was able to get back into running and biking consistently again.
On the 8-week post-operative day I woke up suddenly inspired to go to a track. I hadn’t run on a track since partway through residency, and the last time I visited a track in general was back in April. It was time to make a return to the track. I gathered some things, drove over to my local community center with its newly re-surfaced track, and did my run for the day there. For as long as I’ve been a runner, I have always enjoyed being on a track and running intervals on a track. Racing on the track was where I first found my love for running, and coming back to the track was now going to be a part of continuing my gradual comeback. As I circled the track during my run intervals, I reminisced about my days in PT school grinding out kilometer repeats with 60 sec. recovery, one of my all-time favorite workouts to do. There would be no threshold kilometer repeats or 150 meter sprints at max speed today though. Today was just about getting a steady rhythm going while staying symptom and injury free. With the beautiful clear weather and a smoothness in my stride, I made my circles around the track, absorbing the moment and enjoying it for what it was worth.
Later that week, I traveled out to Portland for a weekend trip to visit one of my college roommates, a very good friend who I hadn’t seen since pre-COVID 19 pandemic. Saturday was a big day in terms of running and general physical capacity. In the morning, I made my way to the Nike World Headquarters to see if I could get a run in. I managed to find a place to park, and decided to walk across the street to run around the Hollister Trail. A mostly flat, pristine 1.5-mile dirt loop that traveled through a forest, it was a place that brought me good memories. The last time I ran around this loop, I was in Portland in 2019 to race the mile at the Portland Track Festival. Never would I have guessed at the time that that mile race would be my last track race for over 3 years. I finished my morning run just as the leaders of a Bowerman Track Club hosted community 5k race ripped by, the leaders going through the mile marker in right around 4:30 mile pace. As I stopped to observe for a minute, I found the simplicity of the scene refreshing. At this portion of the course, there was no fanfare or music or loudspeakers. It was just the sound of shoes pounding the pavement, ragged breathing of runners straining as they focused on a singular task of moving through space rapidly, and the passage of time announced by a man with a stopwatch.
I left the campus shortly after to continue with the plans for the day: lots of hiking and driving. After accounting for 2 hikes and a lot of walking around, my total distance covered for the day came out to over 12.5 miles on foot, the most I’ve ever done since the surgery. As anticipated, my back was kind of sore by the evening but I was still able to go about my day the next day without thinking too hard about it.
At end of the 8th week transitioning into the 9th week, I went back to work. Work has thankfully been a gradual transition as my managers did not just hand me a full caseload of patients to treat. It has been a night and day difference being back at work. I thought about the ease with which I moved through space, opened doors, treated patients and documented on my computer. I thought about how far I had come from the low point of trying to work back in May, when I was driving home in tears from the amount of pain I was experiencing. Even as I find myself with some slow time in the clinic, I find myself just enjoying being back to work.
With every rehab plan of course, there are things along the way that can pop up that may not be anticipated. I started to experience some extra soreness with my right fibularis longus muscle right after I came back from Portland, on the borderline of a mild strain. While I have been managing it with my mix of biking and running, it is a reminder that my body still has a way to go before I can fully compete, and I am okay with that.
Right at the end of my second week back at work, I surprised myself with my longest continuous run since August 2021. I ended up running for 14 minutes continuously at my local park, which was a big milestone for me! It was certainly something to be celebrated, and I can now proudly say that the last time I ran longer than 10 minutes was not August 2021, but this month.
Now at the end of the month, I am halfway between post-operative weeks 10 and 11. Next month will be the return to continuous running, as well as one step closer to racing on Thanksgiving Day as planned. Although a couple bumps in the road have arisen, the bumps are manageable, my overall symptoms for my back and nerve related pain have been going very well and my overall trend is continuing upward. The hope now is that we continue to build as we get into the heart of the fall in October.
Let’s keep getting this bread 🍞
Addendum
This section is just to explore more of my rehabilitation process and thoughts/research behind it. Now that I am past the 6-week post-operative mark, the next phase of my rehab will now begin to unfold for Week 6 – Week 10. The theme of this phase is now progressively shifting from general conditioning towards more sport-specific conditioning. If I had to make a list of the top three primary impairments that hinder my return to running, it would include:
- Decreased R. calf strength + power
- Decreased R. glute strength (glute max and glute med)
- Decreased bilateral adductor strength
Long-term, I eventually would like to be able to do single leg RDLs and get back into deadlifting so there will be a component for getting re-acquainted with a hip hinge movement pattern. New exercises are being integrated in and programmed with a focus on muscle endurance parameters based on research cited in the previous chapter of the series with the exception of calf strengthening now moving towards a combination between muscle endurance and muscle hypertrophy parameters. I also began to integrate some hopping to work on my body’s ability to perform rapid vertical loading of force through the legs and spine. Below is the program that I built for myself, along with notes of any changes that I made throughout the block.
Return to running – s/p 6 weeks – 10 weeks
- Double leg hopping, 2 sets x 30 sec., 60 sec. rest, 2-4x/week
o Progressed to single leg hopping, 2 sets x 30 sec. each leg, 60 sec rest, 2-4x/week
- Calf raises 2 up, 1 down, 4 sets x 8 – 12 repetitions, 60 sec. rest, 5x/week
o Progressed to single leg calf raises, same parameters
o Modified to perform Single leg with knee bent (more emphasis on soleus)
o Also reduced to 3-4x/week to reduce overall soreness.
- Sidestepping with resistance band around feet, 3 sets x 20 repetitions each direction, 30-60 sec. rest, 5x/week
o Combined in with the lateral stepdowns
- Bulgarian split squat, 3 sets x 15 reps. each leg, 30 – 60 sec. rest, 5x/week
o Progressed to lateral stepdowns with the same parameters
- Hip hinge, 3 sets x 15 repetitions, 30-60 sec. rest, 5x/week
o Progressed with weight based on symptoms
- Sidelying adductor leg raises, 3 sets x 15 repetitions, 30-60 sec. rest, 5x/week
o Progressed to Copenhagen planks, 3 sets x 30 sec. holds, 30-60 sec. rest, 3-5x/week
- Seated hip flexion with weight, 3 sets x 15 reps, 30-60 sec. rest, 4x/week
Other ancillary strengthening
- Diagonal resistance band/cable pulls each direction (4 directions total), 3 sets x 15 reps, 30 sec. rest, 2x/week
- Front planks, 3 sets x 15 – 60 sec. holds, 30 sec. rest, 3x/week
- Side planks, 3 sets x 15 – 60 sec. holds, 30 sec. rest, 3x/week
o Combined into Copenhagen planks
Cardiovascular re-conditioning also changed. I still chose to maintain some level of walking and hiking as needed, but I have now started to re-incorporate bike riding after getting clearance and guidelines from my surgeon’s PA. With clearance from my surgeon’s PA, I also began to incorporate a walk-run program. Below is a log of what my running and biking time looked like for the month of September (with data catalogued on Strava):
The month of September in runs and bike rides (The top week does not have all the training week’s data since there’s a couple days in October)
What is the optimal return to run program? Is there a best practice for set volume or time that one should start with? Is the 10% rule the golden rule of thumb? Despite the myriad of return to run protocols that exist, the amount of high-quality research evidence available supporting a best protocol is practically non-existent. The 10% rule for increasing mileage each week can also be subject to scrutiny, as the change in physiological demand for someone increasing from 10 miles per week to 11 miles per week is a different story from someone increasing from 70 miles per week to 77 miles per week. What I ended up deciding on was a little bit of trial and error to work up towards 60 seconds of continuous running at a self-selected pace and integrate alternations between walking and running until I got close to 15 minutes. The biggest guidelines for day to day and week to week progression was my body’s ability to recover and the degree of symptom intensity present during and after sessions. If I could recover and pain was minimal and stable, then I could gradually increase running duration. If I had a day where I was feeling a little more sore than normal, I would take a day off of walk-run and then resume the day after. This applied for not just low back related symptoms, but any sort of musculoskeletal pains and aches that I developed (including the Right fibularis longus soreness towards the end of the month).
A return to sport plan isn’t complete without an estimated timeline or idea of probable outcomes. As stated in a previous chapter of this series, my surgeon recommended 12 weeks after surgery. What does the literature say for the timeline for return to running after a microdiscectomy and the percentage of people that return to sport? After searching through the existing literature (spoiler, there isn’t a whole lot), this is what I came across:
- For return to sport in both professional and non-professional athletes across multiple sports: The time for return to sport ranged from 5.2 to 8.7 months among professional athletes, while for non-professional athletes the return to sport time ranged from 7.5 weeks to 6 months (1).
o Due to the heterogeneity and low methodological quality of the studies included, the authors of this study concluded that they could not accurately determine a rate of return to sport
- Elite athletes return to competition 83.5% of the time after undergoing a single level lumbar microdiscectomy (2).
- One study looking at 14 NCAA athletes found that 90% were able to return to sport after a single level microdiscectomy (3).
- In the population of high school and college athletes, 71% of the 38 patients in this study had returned to play at an average of 4.5 months postoperatively (4).
- One study recommended six to eight weeks for return to sport for non-contact sports, and 4 – 6 months for return to contact sports (5).
Overall, most of the data suggests a pretty high rate of return to sports, and that the time range of return to sports is variable. There are multiple factors that can contribute to variable timelines and degrees of success, such as age, quality of surgical procedure, quality of rehabilitation, motivation and gender (5). It is worth noting that the studies mostly combine all sports together (as opposed to examining return to running specifically). For these factors, age and motivation are both positive factors in my case, and the quality of rehab is well within my control. I have some clinical metrics that I currently like to use when assessing readiness for return to running, but that will be explored more next month.
For the overall stage of running that I have entered, we can re-visualize that with this infograph from last chapter’s post (6):
For the stage that I’m at, I would consider myself to be in the Return to Participation step of the journey, with the anticipation being that I will likely reach Return to Sport within approximately a month or so after the 10 week mark (slightly behind the 12 week mark established by my surgeon).
References
1. Reiman MP, Sylvain J, Loudon JK, Goode A. Return to sport after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation: a systematic review with meta-analysis. Br J Sports Med. 2016;50(4):221-230. doi:10.1136/bjsports-2015-094691
2. Overley SC, McAnany SJ, Andelman S, et al. Return to Play in Elite Athletes After Lumbar Microdiscectomy: A Meta-analysis. Spine (Phila Pa 1976). 2016;41(8):713-718. doi:10.1097/BRS.0000000000001325
3. Wang JC, Shapiro MS, Hatch JD, Knight J, Dorey FJ, Delamarter RB. The outcome of lumbar discectomy in elite athletes. Spine (Phila Pa 1976). 1999;24(6):570-573. doi:10.1097/00007632-199903150-00014
4. Cordover JB, Fleisig GS, Raszewski JA, Dumont AS, Cordover AM. Return to Sport After Lumbar Microdiscectomy in High School and College-Age Athletes. World Neurosurg. 2022;163:e516-e521. doi:10.1016/j.wneu.2022.04.025
5. Majcen Z, Pungartnik T, Sarabon N. Consideration for Lumbar Disc Degeneration and Herniation in Sports. The Internet Journal of Allied Health Sciences and Practice. 2014 Apr 01;12(2), Article 6.
6. Ardern, CL., et al. (2016). 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. BJSM, 50(14), 853-864
