Black Canyon 100k race report

My road to Black Canyon was not a smooth one.  In mid-November, I was busy enjoying some newly-gained fitness (culminating in a big new marathon PR of 2:55!) when I put a minor tear in my hamstring tendon.  Apparently hamstrings don't like it when you keep them so tight that you can't even reach in the vague direction of your toes. I was able to start running again on December 21, but since I had taken the previous 6 weeks mostly off, I knew I was looking at a solid 6-12 weeks to regain all of the lost fitness.  Black Canyon was exactly 8 weeks away...

There were other bumps in the road too:  a mystery health problem which I discovered after the race to be hypothyroidism, the decision to go back to self-coaching, a tweak to the injured hamstring, and even a freak snowstorm which took over the trails on my last training weekend.  When Divesh and I arrived in AZ for the race, I felt like I was showing up for a car race in a battered old wreck that could barely survive the drive to the start line.

Spot the Minnesotan!

There was one benefit to this though, and that was that being super unready made slow but steady pacing my only viable option for running a decent race.  Black Canyon is a golden ticket race where there are two entries to Western States to be won, so I knew that plenty of people would start off too fast.  I resolved to hang back, run by heart rate at an effort level that I knew I could sustain for 100k, and hope that the race was long enough for me to start catching people before the end.

That is definitely easier said than done.  It took a lot of willpower to settle into the middle of the race pack during those first few miles, especially once we got onto nice singletrack--partly because it's hard not to want to run fast on good singletrack but also because the trail was very crowded and it was almost impossible to run at my ideal pace on both the uphills and the downhills.  I think I was 18th at the first aid station!  I just kept repeating to myself, "no racing until Black Canyon City [mile 37.4]," even as people passed me left and right.

By mile 30, I could already tell that starting out slowly was going to pay off.  I didn't feel fast, but I did feel solid, in the sort of way where you can tell you're going to be more or less fine for the rest of the race.  I started to pass people but still mostly kept to my resolution to maintain my low HR--except for the few hundred meters after I ran past Jamil Coury, who was out on "active spectator duty" with a video camera.  I don't think there is any amount of discipline in the world that can keep you running a sensible pace whilst being chased with a video camera on a downhill!

After passing Black Canyon City, I took the brakes off a little and started pushing on the long gradual uphills.  The heat was rough, but I was recovering a little at each river crossing, and I was pleased to find that the uphills were actually feeling pretty good.

From miles 47-50 I had my only real struggle of the day.  I had been getting progressively thirstier for the previous couple of hours, and around mile 47 the thirst started feeling overwhelming--all I could think about was wanting ice water.  I was sort of expecting this to lead to a downward spiral in my pace and placing, but I surprised myself by pushing through it.  I saw Divesh at the mile 51 aid station and was reunited with another bottle of my sports drink; it wasn't cold, but it was for sure better than the empty bottle I'd been holding for the past few miles.  Divesh told me I was only a couple of minutes behind the 5th place woman.  We were just starting one of the race's longer climbs at that point, and it happened that that climb was where I had done a tempo portion of my last long run before the race.  "I can run this hill faster," I reminded myself, and it was enough to get my feet moving a little more quickly again.

After maybe a mile, I spotted the 5th place girl less than 30 seconds ahead--but she also spotted me.  She sped up and for the next 4 miles or so I would alternately get a little closer to her and then get dropped.  I was exhausted and thoroughly ready to be done running for the day, but it was also the most fun section of the whole race:  friendly racing with both of us still running strongly enough to be competitive.  At the top of the race's last climb, she zoomed off on an initially technical descent, and I figured I no longer had any hope of catching her.  But a mile or so into the descent, I came around a bend and suddenly saw her just ahead, with me rapidly gaining ground.

I contemplated hanging out behind her for a while to make sure that I really was capable of maintaining a faster pace all the way to the finish, but I realized that I actually felt GOOD.  As in, the fastest I had been all race.  I went past 5th place and shortly thereafter passed the next girl as well.  After that it was a fairly easy 3.5 miles to the finish.  I felt like I was flying the entire way, with energy to spare.  I've never had such a good last section of a longer ultra, and I hope there will be more to come like this one.

So I ended up 4th in 9:46, which turned out to be only one place away from a golden ticket after one rolled down a place.  But given that I figured top 10 would be a stretch based on my fitness going into the race, I am completely thrilled with this.  In fact, it's possible that I'm the happiest occupant of the "tough luck spot" in golden ticket history.  And since learning about my hypothyroid situation explains the symptoms I've been struggling with when running, I'm optimistic that I can sort those out by the summer and still have a strong season of mountain racing.

It was a rough post-race evening for me; although my stomach had behaved perfectly the entire race, I promptly threw up after starting my rehydration a little too enthusiastically with the finish line lemonade.  Diluted apple juice went down a little better, but I still had to make Divesh pull over a few times on the way back to the Airbnb.  It did make me smile remembering my friend Nick and I simul-vomiting over a wall in a layby while my friend Dave drove us home from the Highland Fling. 

Oh, and total calories I consumed during the 100k?  150.  And my best miles of the day were the last five.  Hurrah for nutrition research!

Divesh had to put up with the most pathetic spotter ever the next day

Eiger Ultra Trail 51km race report

Thursday of race week: 

Really, Alicia?  Months and months of training, careful shoe and gear selection, lots of course studying, and then you forget to bring your race food to Switzerland?  Not a great start.  Fortunately I was saved by an East Asian market selling sticky rice flour.  Big cheer for globalization!

With the crisis averted, Divesh and I took the tourist train up to Schynige Platte to scope out support zone location and do some sightseeing.  Quality relaxation time!

Friday of race week:

The weather forecast has been confident all week that it will be raining and/or thunderstorming all day on Saturday.  Eeep.

Saturday, race day:

It's intensely sunny and in the high 80s.  *Slight* difference to the prediction!  The race started off with about a mile uphill on the road.  My stretch goal had been to try to win, but when I saw another girl take off up the road at about 6:30 pace whilst looking like she was going for a casual jog, I realized it would be suicide to follow, so I stayed back and did my own thing.

The first climb is not too steep and it's on very non-technical terrain, so you end up on the undulating section above Grosse Scheidegg (8km) relatively quickly.  Shortly thereafter, I ran into a roadblock:  cows.  There was a mother cow blocking most of the left side of the trail, a calf blocking most of the right, and not much room to go around on either side.  I stood around, considering my options and losing time rapidly, until I was saved by two friendly guys who told me to follow them.  "He's an animal doctor!" one of them announced, pointing to the other one.  It was an ideal little train to get behind, since we soon passed through several more cow sections and these guys definitely had their cow-dispersal technique mastered.

This whole section was very runnable and absolutely gorgeous.

The main issue here though was that starting around 14km, we were catching up to the 100k runners and had to overtake maybe half of the 800-person field.  This wasn't so bad while we were on the easy wide trails, but around 18km we got onto narrow singletrack that would continue for most of the rest of the race.  The options for overtaking were either to lose loads of time waiting for a wide spot in the trail or to leap around the 100k'ers on the rocky edges of the trail.  I started off with the latter but after several close calls with my bad ankle, I ended up going more and more for the former.  It was demoralizing though, and I fought with myself (mostly unsuccessfully) to keep the negative thoughts from forming.  I settled on the strategy of giving myself the goal of saying "good job" to each of the 100k people that I passed, but given the altitude and my effort level, I think all I really said to them was "ggghhhhhh."

We passed the summit of the Faulhorn, with absolutely amazing views, and went down a much more technical way than we had come up.  There were two spots for glissading, though!!

From about kilometer 30 on, the race became really only about heat survival.  It was SO hot.  I don't think I thought about anything other than how thirsty I was for maybe 15 kilometers.  I ran by Divesh at 35k and got my sports drink refill, which did provide a bit of an energy boost, but shortly after this the trail went into the woods and turned into a steep, technical, and tree rooty affair.  The trees were trapping the humidity and it was like being stuck in the jungle.  Back to thinking only about how thirsty I was...

With 6km to go, we finally reached the valley floor and started the easy section back to Grindelwald.  This part is a very gradually uphill combination of bike path and road, so my main goal for the race was to put in a solid effort here, and I mostly achieved that.  I passed three naked men (not runners!), stuck my head in a cow trough of cold water, and tried to decide if I had heat stroke.  Just your average day at an ultra, basically.

The little mini vertical wall that you have to climb up to get to Grindelwald was especially brutal in the midday sun, but once that was done, it was just a fun downhill 400 meters to the finish.  I ended up in 2nd place, about 20 minutes slower than I was hoping to go, but the descent sections had been much more technical than I was expecting, and the heat had a definite impact.  It's a beautiful area and I would come back for sure, but for avoidance of traffic jam stress, I think the 100k, not the 50k, is the race to do here!

Coastal Trail Series Sussex 55km race report

After every race I make myself notes of what went well and what I should have done differently. Sometimes the should-have-done-differentlys are on the ridiculous side ("don't, on a whim, triple the amount of coffee in your sports drink") and sometimes they're more substantial ("I needed more hill training for this course"). After the Coastal Trail Series Sussex 55km, I am, for the first time, completely at a loss for what I could write in the errors section of the notes. I've spent the better part of the plane ride home thinking about it and the best I could come up with is that I should have taken only half a water bottle instead of a full one at mile 15, since it was only three miles from there to my next support stop. Not exactly a disastrous mistake!!

prerace sightseeing along the course

Most of my prerace concerns had to do with weather. The race is over exposed ground right on the coastal cliffs, and it was supposed to be around 30mph winds with gusts up to 50mph. It was freezing cold at packet pickup just before the race start. The guy manning the t-shirt desk wordlessly handed me a size medium. When I asked for a small instead, he gave me an incredulous look and asked if I had seen what the small size was like. I was confused for a second, then realized I was wearing 8 layers of clothing and was not looking particularly small at that moment.

Actually I guess I spent most of the prerace period looking ridiculous. While every other runner wandered around stretching and jogging and generally looking professional and prepared, I was the one wearing overly short pink children's sweatpants and scraping hard caked mud out of my shoe treads with a hotel room key card. One day I will nail the not-looking-ridiculous part of racing, but that day was not yesterday.

After the world's longest briefing, we finally started running. The first section of the race is straight into the wind, over the Seven Sisters hills on the coast. It's beautiful but it was like trying to run into a giant hair dryer--there were a lot of runners chasing after lost hats! Fortunately I had been out here for a training run so I knew what I was in for. I took it pretty easy on this section, then sped up to race effort after 5km when we turned inland and briefly got a bit of shelter. And the reward for surviving each headwind section was an amazing tailwind section, or at least amazing until a sudden tailwind gust nearly blew me off a cliff.

we ran past the Long Man.  it was very long.

People were friendly at this race, and getting to talk to a few people made the first third go by quickly. Divesh, my support crew extraordinare, met me at several places for water bottle exchanges, and never being far from one of those also made the miles fly by. I also had a nice half mile or so with Alice, who won the accompanying half marathon.

My first 25 miles were basically spent in suspense, wondering if and when I was going to hit a wall or bonk or possibly go insane from the uncomfortably loud roaring of the wind in my ears. But by mile 25, none of those things had happened. I felt oddly... good. Like really good. I was running up hills I would have thought I would have had to walk. I never got nauseated. The math changed from wondering if I had a shot at the course record to knowing that, absent some sudden injury, I was going to get it by a decent margin. 

And that was it really! Nothing dramatic to report, just a nice steady race with possibly my most even splits ever. I feel like a completely different runner from my pre-injury year.  So what's different than in the past? First, I've sorted out better training through coaching from David Roche. Second, I've put in hundreds of hours of nutrition research and have finally reached what seems like the right answers. Conclusion: it's definitely still possible to get faster when you're old and missing foot parts! 

Peroneal tendon surgery part 3: the end?

I keep waiting for some sort of obvious "finish line" to signify that it's time to write a final wrap-up of the outcome of my injury and surgery.  But since I don't have a good idea of what that finish line would look like--running a race?  not thinking about how much my foot hurts every time I walk anywhere?--I decided that the triple achievement this week of wearing normal running shoes instead of hiking boots for a run, finishing a hard race, and filling out a weekly training log that wouldn't be too out of place in my pre-injury training would be good enough.

Sometime in June I got completely fed up with my situation and was saying to a friend that it had gotten to the point where it felt like I would never get back to normal running.  He replied with the excellent point that it might well not ever go back to normal, but that it might not be better or worse, just different.  And this is exactly what I've found.  Unless I get a revision surgery (more on that below), my ankle is always going to be weak.  This is just what happens when you're missing a major ankle tendon--you can only train the surrounding muscles so much, and you can't train something that's not there.  I may never be fast on technical ground.  I may have to wear my heavy, uncomfortable hiking boots in races for the foreseeable future.  I may be even more pathetic than I was pre-injury on steep downhills, even though my pre-injury standard is a standard that's difficult to fall below!

But...I may have been forced into a decision about what types of races to focus on, which might make me faster in those races eventually.  Since I can't run downhill very well yet, I've started running some uphill vertical races, which I'm not totally sold on yet but may grow into liking.  I am becoming more efficient about making my mileage count, because I can only do a fairly limited amount of miles.  And possibly most importantly, I discovered that there's nothing like being unable to run for six months to teach you exactly what kind of running you missed the most, which is very useful for deciding what type of running to do when you are finally able again!

So, it's different.  If I could choose, I would opt to have not lost a foot tendon, along with vast sums of money spent on medical care, not to mention six months of my life.  And it certainly grates on my mental well-being every time I think about how the outcome could have been improved had I not picked such a lazy and/or money-hungry surgeon.  But given that this is the situation that exists, it's not all bad by any means, just different. 

It's not yet clear whether this is the end of the saga or not.  When I saw surgeon #2 in March, he was somewhat appalled at what surgeon #1 did ("Why did he do that?!" was the exact reaction, which definitely made my heart sink a bit...) but he wasn't particularly positive on the idea of a second operation to try to repair the damage.  His thought was that he might be able to fix what surgeon #1 did by creating a new peroneus brevis out of my FHL tendon, but he felt there was a good chance I could come out of a second operation in even worse shape than I'm in now.  His advice was to only get the second operation done if I were very unhappy with my running ability after 9-12 months of rehab.  This was exactly the same advice I got from another good foot surgeon via email, so it's promising having the two opinions coincide.  I'm currently at 7 months post-op, and given the massive progress my foot has been making the past few weeks, I think it's unlikely I'll go for the second operation, unless running in the mountains proves to be too much for the current repair and it fails.

I'm never one for the whole "just be optimistic" outlook--you don't build new tendons out of optimism.  But I do have to mention one of the big positives that came out of this injury, and that is the people who were a part of my recovery.  That started right from day 1, when two now-friends who I had only known for 12 hours came to rescue me from the hospital on a cold winter night, followed shortly by Divesh rescuing me from my hotel room of doom. Then there was all the help and support from friends and family while I was on crutches, and finally there were the new people I met because of the injury, such as my injury twin Diana, and Jordi, the world's best physical therapist, who is a rehab expert and all-around excellent person rolled into one.  If there is at all a good part of being injured, this is it.

And now?  I've made a list of all of the things I missed out on while injured, and I'm going to be making my way through it over the coming months.  And if all goes really well...I'm entered in the 110km Ultra Pirineu for September 29.  Even 40km is currently a very long way for me, so I'll have to see what my ankle says about the idea of 110km in only a month's time, but if it's possible, I'll be there!

 

Peroneal tendon rupture, surgery, and rehab, part 2

It has only been two months since my post about part 1, and already it feels like several lifetimes have gone by...

Lifetime 1:  visit with surgeon #2 and improvements

Surgeon #2 was excellent and it was well worth going.  For a start, he gave me 15 minutes of uninterrupted appointment time, practically a miracle compared to my experience with surgeon #1.  Surgeon #2 was concerned about the fact that surgeon #1 had placed a tenodesis anchor right on the site of my metatarsal fracture and thought that might be the cause of all the pain.  He did an x-ray to check that the anchor hadn't caused the fracture to re-open, which fortunately showed that it hadn't, although it could still have been causing the pain.  However, surgeon #2 also did an ultrasound, which did show a large bone fragment stuck right next to the tendon repair, making it a prime candidate as a pain cause. 

The next month was full of slow, steady improvements.  Of course, there were plenty of "bad foot" days, and I still suffered from perma-red foot from all the inflammation, but it was definitely an upward trend.

The mental crux that I hadn't been expecting was the time period where I was able to walk but not yet able to walk far enough or fast enough to get any aerobic exercise.  As depressing as it was, I had to resign myself to going out on the crutches or the pegleg for the "exercise" portion of my activities, and then practice walking separately.

Somewhat ironically, I got less and less fit aerobically as my foot improved, since I started doing more walking and stopped doing my uphill crutching repeats!

Finally, at 13 weeks post-op, I did my first outing that could, if you were feeling unusually optimistic, be called a run:  5 miles on a vertical k course, mostly walking the steep uphill, running the gradual uphill, and running nearly all of the downhill.

Lifetime 2:  infection

The improvements came crashing to a halt when my surgical wound got infected at 13.5 weeks post-op.  An infection that shows up that late in the game is a very worrying thing, since it makes it highly likely that the infection is a deep one.  Cue total rest, elevating my leg, hours of frantic research and quality advice from the most qualified medic I know, and a trip to the doctor, who prescribed antibiotics and never managed to answer my question about when I should come for follow-up care if the infection didn't clear. 

It didn't clear.  After 5 days of antibiotics and no improvements, I sent a panicked email to surgeon #2, who was kind enough to look at a few photos of my foot and then told me to get it seen sooner rather than later.  Two days later, I was in surgeon #2's office.  He did an ultrasound to check if it might be a stitch abscess (it wasn't) and then confirmed what I had already suspected from my reading:  the doctor I had seen a week ago had prescribed an incorrect choice of antibiotic.  So I moved on to antibiotics round 2, took a deep breath, and talked myself into handling the mental pain of going back on crutches for exercising.

I'm not wearing the orthopedic boot because I need it for walking, I'm wearing it to prevent walking.  It's the runner equivalent of the cone of shame.

It's funny looking back on my changes in perspective since the injury.  When the accident happened on December 2, my first thought was "will I have enough time to train for Transgrancanaria?"  TGC is in late February!  After finding out I needed surgery and then getting delayed for a couple of months on that, my worry was whether or not I'd be able to race this summer.  After finding out I had been robbed of a key foot tendon whilst unconscious during surgery, I was concerned about whether I'd ever run on technical ground again.  And by late April, with a late-onset surgical site infection, I was ready to consider it a win if I didn't have to have my foot amputated.

Luckily for the chances of continued attachment of my foot, the second round of antibiotics worked, but...

Lifetime 3:  sural nerve issues

...getting rid of the infection did nothing to change the unbearable level of pain I'd been experiencing.  Neither did two weeks of total rest, so it was clear it wasn't a simple case of overdoing it on the newly-repaired tendon.  The type of pain--white-hot, coming and going in flashes--didn't feel like tendon pain, either, and I did more reading and starting thinking it could either be an allergic reaction to the biocomposite material in the tenodesis anchor (shows up, if it's going to happen, when the anchor starts to degrade around 3 months post-op, so the timing fit, plus the inflammation seemed to respond a bit to an antihistamine) or damage to the sural nerve. 

I finally deployed the weapon I should have deployed two weeks earlier:  a visit to my amazing physio.  He was almost sure the problem was with the sural nerve; it runs alongside the peroneal tendons and it's common for it to get damaged or entrapped in scar tissue after peroneal tendon surgery.  I left after an hour of serious poking and prodding to try to extricate the nerve, with instructions to perform twice daily exercises and to wait at least 5 days before trying to run.

And today, 5 days later...I ran!  Four repeats of 5 minutes each, on very flat and soft ground.  There was still definitely nerve pain going on but at a much more manageable level than before.  It's a start...

 

Is it May yet? Peroneal tendon rupture, surgery, and rehab, part 1

Opening up my blog to start this post made me notice that my last post was about a medical problem.  I guess this is fairly appropriate--my year was largely a sequence of lurching from one problem to the next, with a few nice runs and climbs in between.  If things don't improve soon, I'll rename the blog something like aliciasrestingandrehabilitationwoes.

The closest I'll get to running Zegama this year

At the end of a great long run in the mountains, I was running down a moderately technical descent when I landed badly and injured my foot.  I heard a loud cracking noise so was fairly sure there was a broken bone.  I limped off the hill, hitchhiked back to my car, and drove straight to the hospital.  This was the start of a cascade of comedy errors that leads to my current situation.

The emergency room doctor took an x-ray and reported that I had a broken 5th metatarsal.  She thought it was a Jones fracture and thus might need surgery, so she told me to see a specialist.  This was incorrect--it was a fracture to the base of the metatarsal and not a Jones fracture--but her mistake turned out to be lucky for me.  The surgeon who I went to see about the fracture was able to tell immediately that it wouldn't need surgery, but fortunately for me, he noticed that I seemed to be missing my peroneus brevis tendon.  After multiple errors with the MRIs and an inexplicable order for a second x-ray, and thus plenty of delay, it was determined that I had a complete rupture of the peroneus brevis at the point where it inserts into the 5th metatarsal.

This could only be fixed with surgery, but there were an endless number of delays to getting a surgery date, and I finally went for the operation 7 weeks later.  By that point the metatarsal fracture seemed to be healed and I had been able to walk a little, but I had been on crutches 95% of the previous 7 weeks.  That meant my peroneus brevis stump had had 7 weeks to retract and atrophy.  Sure enough, my surgeon reported after the surgery that there was hardly any of it left.

What he didn't report was that he had done an entirely different repair technique than what it appeared he had been planning.  I learned from my hospital discharge form that what he did was tenodesis--sewing the peroneus brevis stump to the peroneus longus tendon--whereas I was under the impression he would be doing an allograft (cadaver tendon) repair.  It appears that this type of tenodesis is a common way of dealing with a lack of intact tendon to work with, so I can see why he would have done that.  However, I had made it abundantly clear to him that I was a competitive runner, that I ran in the mountains and needed maximum ankle stability, and that my priority was getting back to this.  Tenodesis is not at all ideal for any of these things (I believe you can read a good article about different repair options here without a paywall, http://www.foot.theclinics.com/article/S1083-7515(13)00104-6/pdf) so I was not particularly pleased, to say the least.  If my surgeon had been experienced at treating athletes, I could feel confident that he had correctly weighed the pros and cons of each option in deciding what to do.  However, it was clear from our pre-surgery conversation that he had little experience with athletes.  At the time, I thought this was okay because there was no question of what needed to be done; all I really needed was an experienced surgeon who could do the repair well.  It simply never occurred to me that this particular type of problem ("two tendons enter, one tendon leave"...?) might occur.  It was also clear from pre-surgery appointments that my surgeon was very interested in seeing the maximum number of patients possible, and this does suggest he may have chosen tenodesis on the basis that it's a much simpler and thus quicker procedure.

Frankenfoot, about 5 days post-op

After the surgery, I wasn't about to waste my time and money on more rushed, interrupted appointments with my surgeon (his appointments are 3 minutes long and mostly involve him talking to his assistants), so I took advantage of a friend's student status and downloaded all the relevant rehab articles listed in this review, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4823352/.  It immediately became clear that there is a vast range of opinions from surgeons on the appropriate rehab program for this surgery.  Everything from immediate weight bearing to 8 weeks in a cast was on the table!  I went with a protocol that fell in the middle of the options, which was:

--2 weeks in hard splint
--Staples out at 2 weeks
       --If you're having this surgery done:  ask for stitches rather than staples!!  I would say as much
         as 50% of my pain in those first two weeks was from the lovely feeling that is 26 bits of metal
        digging into the area around a recent stab wound.
--Dorsiflexion/plantar flexion stretching exercises starting at 2 weeks
--Partial weight bearing in a walker boot from 2.5 weeks, starting VERY lightly with just a few toes on the floor and progressing extremely gradually as tolerated
--Full weight bearing when tolerated
--Standard physical therapy range of motion and strengthening exercises starting from 6 weeks
--Running on an alter-G treadmill
--Back to regular running no earlier than 12 weeks but potentially more like 14-16
--Plenty of sleep
--Lots of protein and very little sugar (high glucose diet seems to impair tendon healing in rats, and it certainly won't hurt to try!  https://www.salk.at/DMS/41598_2017_Article_700_1920815.pdf)
--Restricted eating window and coconut oil to encourage BHB production, which may have an anti-inflammatory effect:  https://www.ncbi.nlm.nih.gov/pubmed/25686106/.  My hypothesis was that this would give me the benefits of a ketogenic diet without the increase in cortisol I would get if I actually went on a ketogenic diet.

This all went reasonably well for the first 5 weeks, with plenty of bad days mixed in but overall it was a steady upward trend.  I did have a deviation from the plan though:  my walker boot, which I had been using for the metatarsal fracture, was very painful for the newly-repaired tendon.  I experimented a bit and found that a compression sock + ankle brace + wide-foot running shoe + running insole actually felt much better and more stable than the boot, so I switched to that early in week 3.  This may or may not have been a mistake...

By early in week 4 I was walking with two crutches and with about 50% of normal weight on my injured foot.  Later in week 4 I progressed to walking with one crutch and felt strong enough to try a few steps unaided.  They felt fine, and I did maybe 20 steps in intervals of 5 at a time, although the next day my foot was quite sore so I went back to two crutches and tried to generally stay off my foot.

Then things took a turn for the worse.  Divesh and I were headed to India for a week, and my foot was not pleased with two days of crutching around airports and the long flight time.  When we got to India, I took a day completely off any weight-bearing.  On the second day, I went back to walking with two crutches--and it did not go well at all.  My foot developed a raw, stabbing pain that evening and it was so painful that I couldn't sleep through it.  The next day was about the same.  It eventually calmed down to a more manageable pain level, but something is clearly different than it was during the first 5 weeks.

And that is why this is only part 1...I'm currently booked in to see a different surgeon, one who has just had an impressive result with my runner friend Diana's complex ankle repair surgery, in a few days to discuss my options for where to go from here.  I'm interested to hear whether he thinks it's possible and/or worthwhile to reverse the tenodesis and repair with an autograft or allograft instead (so far I've had conflicting information on whether or not this is possible; a 2014 case report says it was done but a very experienced surgeon in this area discussed it with me via email and said he doesn't think it can be done).  I'm also obviously keen to hear what he thinks may have happened to the current repair and whether or not there's any way of determining in the near future if the repair failed.

For now I've bought a different style of walker boot and I'm back to almost zero weight bearing.  I'll write part 2 when I've got an idea of where I go from here!

And then there were two? Magnesium, cortisol, insomnia, and athletes

I have been having trouble sleeping.  I first had insomnia for 18 days in April.  It was the worst experience of my life with any kind of illness; the mental trauma of being utterly exhausted but unable to sleep, every single night without respite, was worse than anything I've ever experienced with physical injuries, including having to take 9 months off of running for an ankle injury.  So when the insomnia reappeared in late June, I knew I had to get it resolved as soon as possible.

Google searches for athletes' personal experiences with insomnia brought me the horror stories of Bobby Curtis and Tera Moody (don't click on those links if you think your insomnia might be made worse by anxiety about not sleeping!) but other than that, the sum total of anecdotal information was essentially a few forum posts by athletes saying they were having trouble sleeping and wondering if anyone else had had the same issue.  There were virtually never any real answers or any follow-up from the athletes themselves.  Relevant journal articles are out there, but they took a fair bit of time to collate into anything useful.

Given the difficulty I had finding information on the subject, I thought I'd provide some details on what happened with my insomnia and what I've learned along the way, in the hopes that this will be useful to someone else going through the same struggle.

My insomnia

I had what is apparently termed sleep maintenance insomnia.  I could fall asleep easily at bedtime but I would wake up about 4 hours later.  As the April period of insomnia wore on, this got worse and I started waking up only 2 to 3 hours after going to sleep.  When I woke up I would feel almost instantly wide awake and my heart rate would be racing.  If I managed to relax, I would sometimes start feeling sleepy again in about an hour, but absolutely nothing, including the sleeping pills that I eventually tried, would get me to actually fall back asleep.


Timeline

There is maybe no way to make this part *not* super boring, but I think a few things about the timing of the insomnia may be relevant, so here goes...

--April:  Training block with lots of hillwork in and around Atlanta. Mostly went really well.

April 4 and 5--training diary says I felt awful and took two days off

April 8--first night of insomnia, which would continue every night until April 26ish

April 8 and 9--did two hard runs; felt fine

April 9 to 21--ran very little as the insomnia got worse and worse

April 22--raced a hilly 50k

April 23--overseas flight

April 24--slept 7 hours (sleeping pill aided...) after being awake for 36 hours

April 26--first night of truly normal sleep

Month of May--normal sleep; bits of hard training in cooler climate interspersed with having a sinus infection and not being able to run

May 26--hard 24 hour run in the mountains

May 27 to June 23--sinus infection; didn't run at all except for a couple of 10-20 minute jogs

June 26--started training again with a VERY easy week, although I was in Atlanta and it was about 90 degrees every day.

June 30--first night of Round 2 insomnia

July 1 and 2--only managed 4 hours of sleep

July 3--started taking magnesium supplements (more info below); also stayed up all night to try to force better sleep the night after

July 4-6--normal sleep but took diphenhydramine at bedtime

July 7 and onwards (so far!)--basically normal sleep without any diphenhydramine, although I do still tend to wake up once for a couple of minutes in the middle of the night.


Treatments I tried on round 1 (April, 18 days til normal sleep returned)

In no particular order:

-No caffeine the entire period, including cutting out chocolate
-No computer use after dinner
-Blackout curtains for the bedroom
-After waking up in the middle of the night, getting out of bed and doing some mindless task.  Only worked once, on day 16.
-After waking up in the middle of the night, staying in bed and trying to relax, including listening to talks or meditation podcasts.  Never worked.
-Melatonin, which I had only used about twice in my life previously, both at bedtime and after waking up in the middle of the night.  This did actually work on one night--I woke up in the middle of the night, took 3(?) mg melatonin, and got back to sleep and slept for one hour after taking it.  It didn't work any of the other times I tried it.
-5-hydroxyryptophan at bedtime
-"Lightweight" sleeping pills with the antihistamine diphenhydramine, which is possibly not detrimental to sleep quality, after waking up in the middle of the night.  Made me extremely sleepy but I couldn't fall asleep.
-Days 12 and 13:  600mg of phosphatidyl serine (a phospholipid which potentially lowers cortisol) about an hour before bedtime.  Didn't work on either of these two nights.
-Days 14-18 and onward for another week:  300mg of phosphatidyl serine about an hour before bedtime; dosage lowered after I read a study suggesting any potential effect wouldn't happen if the dosage were too high.  Didn't help on days 14 to 18 but perhaps the cumulative effect of taking it since day 12 finally kicked in on day 18...??
-Days 14-18 and onward for another week:  200 to 300 mg per day of magnesium supplement in the form of a dimagnesium malate tablet.  Didn't help on days 14 to 18 but potential cumulative effect??


Treatments I tried on round 2 (June/July; 5 to 7 days til normal sleep returned)

-Starting on day 2, magnesium supplementation.  About 200mg a day of powdered magnesium citrate and another 200mg of dimagnesium malate tablet (hedging my bets!)
-Also starting on day 2, 300mg of phosphatidyl serine one hour before bedtime

I should also say, I didn't cut back on running at all during round 2.  In fact I increased my training load slightly.


So, what's going on?

The fact that I was able to see much more rapid improvement to the insomnia on round 2 while simultaneously maintaining or increasing my training load suggests that overtraining is not the cause.

It's also looking like psychological stress is not the cause.  In April, my insomnia didn't go away once I had run the race I was training for.  It also didn't come back when my big May event approached.  And in June, when it did come back, I was in a fairly low-stress period with no races at all in the near future.

Another thing that stands out to me is that this is now two rounds of insomnia which went away 4 to 6 days after I started taking both phosphatidyl serine and magnesium.  This could be a total coincidence, or it could be a placebo effect, or it could mean that one or both of these were the cause of the improvement.  Without much other information to go on, it has made me move magnesium deficiency or wonky nighttime cortisol (either rising too early in the nighttime or rising too high) into position as the two prime suspects.  Magnesium deficiency in particular makes an interesting candidate since it could also explain why it took my body two months to kill off a relatively minor respiratory infection (magnesium deficiency may amplify decreased immune responses induced by strenuous exercise) this May and June.  


Why it might be magnesium deficiency

When I first considered magnesium deficiency as a possible cause of my insomnia, I wasn't too convinced.  Magnesium deficiency is very common in the US population as a whole, but my diet is full of magnesium-rich foods--I eat a lot of leafy greens, oats, fish, and dark chocolate--and hardly any processed food. I figured that if anyone were going to be deficient in magnesium, it probably wouldn't be me.

I changed my mind on this after doing some reading.  First, there are many reasons why people in general can be deficient despite getting a sufficient amount of dietary magnesium.  The interaction with other minerals, such as calcium, can decrease absorption.  Gut inflammation or other gut problems can also decrease absorption.  You, or specifically your kidneys, can also be guilty of magnesium wasting.

Second are several athlete-specific factors.  There is some evidence that prolonged endurance exercise increases the body's magnesium requirement.  This may be due to increased sweat and urinary losses.  In particular, large amounts of magnesium may be lost when exercising in a hot and humid environment.  I live in Atlanta...  Second, athletes participating in sports that require weight control often consume less than even the recommended daily allowance of magnesium, which itself is most likely too low for the general population, not to mention for athletes.  So...prolonged endurance exercise, running in a hot and humid environment, and dieting?  Sounds a bit familiar!

But does magnesium deficiency lead to insomnia?  It's commonly said that it does, although I don't think the actual evidence of a connection between the two is amazingly strong.  However, it is definitely looking possible that one exists.

In one study, magnesium supplementation was associated with statistically significant increases in sleep time and with marginal improvement of early morning awakening.  One possible mechanism for a connection between magnesium and insomnia is that magnesium is an essential cofactor for the activation of tryptophan hydrolase and for the binding of serotonin to its receptor.  In at least one study, in healthy individuals there was a positive correlation between platelet magnesium and serotonin concentrations (this was not the case for patients with depression).  There is also the suggestion that magnesium plays a role in sleep regulation through its function as an agonist of gamma-Aminobutyric acid (GABA), which is involved in sleep.

Unfortunately it's not an easy proposition to simply get tested for magnesium deficiency.  The most common version of the test is a serum magnesium test, but since only about 1% of the body's magnesium stores are found in serum and red blood cells, the magnesium content of these is often not representative of total magnesium status. There is a magnesium retention test, which tracks changes in serum magnesium and excretion following oral loading of magnesium, but one researcher notes that this test is lacking in standardization, plus it appears to me that the results would be affected by anything that causes your kidneys to waste magnesium.

At this point, if I had to place a bet with only the information I have, it would be on magnesium deficiency as the cause of my insomnia.  If I were allowed two guesses as to the cause, they would be magnesium deficiency or wonky cortisol.  I'm not willing to risk losing any more sleep by taking only the magnesium supplement or only the phosphatidyl serine next time this happens, sorry!  If I ever end up with any reason to think that neither of these were the cause and that the real cause was Option C, I'll update this blog.  Though I *really* hope I never have the need to investigate any further...

Charlie Ramsay Round report

The Charlie Ramsay Round in a nutshell, for anyone who's not familiar with it:  a 56+ mile loop on Scottish mountain terrain with 28,500 feet of ascent and the same amount of descent, with a time limit of 24 hours for an "official" finish.  The round takes in 23 Munros (originally 24 but one was demoted following a survey!), which are peaks that are more than 3,000 feet high.  Most people have support runners on the various sections, but there aren't many easy access points to the loop so support can be somewhat limited.  Compared to England's Bob Graham round, which I did last year, the terrain is generally rockier and there are more sections of semi-scrambling.  And for my American friends, the loop is generally not on "trails" like we think of them; there are some sections with a path but you are mostly running on rock or grass.  When I started my round, there were 99 previous finishers, only 5 of them women.

You can go either clockwise or anticlockwise, and I chose anticlockwise for the aesthetic value of ending on Ben Nevis.  The round is essentially four parts:  first the Mamores, a difficult section of 10 peaks on mostly rocky terrain, second, a largely flat six miles on the valley floor which nevertheless involves a fair bit of bog and thus isn't as fast as you would think, third, a circumnavigation of Loch Treig and its five Munros, and fourth, the most difficult sections of the round, the Grey Corries, Aonachs, Carn Mor Dearg, and Ben Nevis.

The crux of this report is no doubt going to be keeping the writing from being as long as the round itself.  That is as good a reason as any to gloss over the first few hours of my run, which can be summed up as way too hot, humid, windy, and slow.  Despite working much harder than I would have liked to, I was 10 minutes behind schedule by the second peak and only a few minutes better than that by the third.  My first thought was to avoid pushing any harder so as not to risk a blowup later on.  My second thought was that there was no point carrying on at a pace that wasn't going to get me to the finish in less than 24 hours.  I upped the effort level significantly and gained my 10 minutes back, plus a couple to spare, by the seventh peak, An Gearanach.

I knew I was in dangerous territory, working at what was essentially an effort level that I could reasonably expect to maintain for only about 9 hours. But getting back on schedule was a massive morale boost, which in turn seemed to reduce the amount of effort needed to maintain my pace.  A further boost just afterwards was heading up Na Gruagaichean, which is my favorite peak of the whole round, with its impressive views, friendly descent, and the fantastic ridge running that comes after it.

The rest of the Mamores went  reasonably well, at least relative to how my run had been going so far, and I had good company from Jim for part of the time.  On top of the last summit in the Mamores, Sgurr Eilde Mor, I even ran into Charlie Ramsay's neighbor!  She took a quick photo--I was nervous about time and in a hurry to get going--and then it was off for the big descent.

From Sgurr Eilde Mor it's a big, steep descent to the valley floor and then there is the easy section to Corrour.  It didn't feel very easy on this particular day but I tried to ignore that fact and concentrate on what was coming up next.  Which was...

Carrie and Giles!  And Chuck, who was off doing some proper running when this photo was taken.  I had been starving when I made it to Corrour, but I tried to spend as little time as possible there and instead ate on the move during the nice gradual walk up Beinn na Lap.  It took me all of about two seconds to steal Giles' delicious hummus wrap, an improvement over my previous best of waiting roughly an hour to steal his food during my Bob Graham.  

After some good food and a lot of fun catching up with everyone (Giles had done the Bob Graham just two weeks earlier so it was a great surprise to even get to see him), it was suddenly a completely different day--not a day full of heat, suffering, and difficult running but rather just some enjoyable time out in the hills with friends.  We all managed to make it up Chno Dearg, which I thought was the hardest hill of the round and which had apparently been the scene of more than one relationship "incident" in the past, in one piece and ahead of schedule by a solid 10 minutes, a cushion that we maintained coming into the next support point at Fersit.

I had a longer stop at Fersit in order to try to get some more substantial food and drink down before the night section.  Well, maybe slightly more truthfully, I knew there would be two kinds of cake at Fersit and I wanted plenty of time to sample both.  Sadly for my weight, my friends Dave and Claire are both expert bakers...  And Helen had made me a coffee and Beth had made me pasta; total support stop luxury!  

I left Fersit with Tim and Beth plus their border collies Pip and May.  I had first met Tim and the collies while we were supporting Meghan Hicks on her Bob Graham round, and I had watched in amazement then as Pip navigated BG leg 4 without any help.  It turned out that Pip knows the Ramsay Round as well, so Tim and Beth may want to start hiring him out...  Oh and Meghan, after your BG I found that Oreo that I tried for so long to feed you.  As a joke, I brought it on the second half of the Ramsay with me, but I never ended up eating it so it is now one very well-traveled Oreo.

It doesn't really get any better than this--great company, warm sunny evening, and views in all directions.  I had some nausea for the first time that day but other than that I was thoroughly enjoying myself.

After the Easains you drop right down into a col below the Grey Corries.  This marked the end of what I had seen of the route; all of the remainder, except the descent from the Ben, was going to be new to me.

It was slightly intimidating setting off on the steep climb out of the col with the sun going down and with no idea of what lay ahead.  Tim and I had picked up Pete as a second support runner, though, and with both Tim and Pete having finished the Ramsay Round themselves, I knew I was in good hands.  Plus Pete brought coffee, which tasted delicious even if I did throw it back up every time...

I wish I could say that I could have made it to the finish in under 24 hours even without Tim and Pete, but I can't.  Pete took care of the navigation while Tim did an impressive job of keeping me fed and hydrated despite my reluctance to accept most food.  The nausea was fully set in and all I wanted to do was (a) stop eating, and (b) sleep, neither of which would have been conducive to a sub-24 hour finish.  We spent the first part of the night a little bit ahead of schedule but quickly became just behind schedule, which shortly turned into a fair bit behind schedule.  

There was also plenty of pure physical difficulty in the terrain on that last section.  The grass slope leading up to the gully on Aonach Beag was so steep that Tim showed me his gorilla crawl technique.  I remember finding it vaguely hilarious that it was the middle of the night and I was out there literally crawling up a hill in the dark, but I was too tired to laugh.

Unsuccessfully trying to get Tim and Pete to let me have a nap at the top of the Aonach Beag gully

Aonach Mor was a much easier ascent ("like running in the Peak District" Tim told me, fighting words for me as a former Sheffield runner!) but the descent down to the col before Carn Mor Dearg was brutal and by the time we made it down, I felt like I had absolutely nothing left.  But we were also about 20 to 25 minutes behind schedule and there were only two peaks to go.  I knew this was it--if I didn't turn things around immediately, I would have no chance of making up enough time to finish in under 24 hours.

I would love to be specific here and write about how I managed to go from a semi-zombie state to making fairly good time.  Sadly I've got no idea.  It certainly wasn't more food, and I didn't have any caffeine.  I suppose the lesson is that sometimes even the boring approach of simply trying harder can work.  Whatever it was, we arrived at the summit of the last hill, Ben Nevis, more or less on schedule.  It was quite a special moment when we topped out in the early morning light of 4:30 a.m.

At this point Tim and Pete were reasonably convinced that I could make it down to the finish in the remaining 1 hour 15 minutes.  I was not so convinced.  By UK standards I am terrible at descents, and for me, a rocky/grassy 4+ miles with over 4,000 feet of elevation loss, coming at the end of 24 hours on the go, is a tall order.  I was getting more and more stressed by the minute as we started down from the summit.  As we went through the only remaining snow patch, disaster struck--Pete took a scary fall and hit his head.  The result was alarming:

But I was relieved to see Pete stand back up and to hear him speak without any obvious signs of concussion.  It only took a couple of seconds for Tim and Pete to assure me that they had everything under control and that I should keep running for the finish.  Pete quickly decided he could make it down on his own and sent Tim off after me.  By this point I had become convinced that I wasn't running fast enough to make the 24-hour cutoff, and I think Tim was starting to share that view.  He took the lead and sped up, with my only job to follow behind at the same pace.  It's amazing how much better you can become at running over grass and wet rock when the alternative is brutal failure at something you've been wanting to do for a year!

In the end I needn't have worried quite so much--the youth hostel suddenly came into view sooner than I expected it to.  We made it to the end in 23:46.  Project for the year = done!

I climbed my project

On my most recent trip to Margalef, I finally climbed my project.  It was a route called Voladerum, and it was my first 7c (5.12d).  It was also the result of a multi-year saga.  One day back in the winter of 2008, I was on a short trip to Margalef with my friend Lucy.  It was a cold week, with some snow and probably a bit of rain, and one day we woke up to find that virtually everything we wanted to climb was wet.  There was one roadside 7c at Laboratorio that was dry though, and Lucy suggested I try it.

I thought the idea of trying a 7c was insanity:  I had only climbed one 7b and no 7b+s, and this route in particular was the exact opposite of my style.  I liked long endurance routes with no especially hard moves, and this route was short and bouldery, with a difficult crux straight off the ground.  It wasn't even short-person friendly, unlike most of the routes in Margalef, which generally favor the short.  But I decided I might as well give it a shot.  On my first try I could do...none of the hard moves.  Zero.  I played around on it until I was exhausted and then came back down, assuming that was the beginning and end of my 7c career.

But the next day, for some reason, I decided to have one more go.  Suddenly I was able to do not just one but several of the moves.  From then, I was hooked.

Working on the upper half

I've been back to Margalef many times since 2008.  For several of those trips, I wasn't nearly strong enough to even try my route, since after 2008 I mostly stopped climbing and started running instead.  On one of the trips, I was able to make some progress on the route but then couldn't replicate any of that success on the next trip.  While I was enjoying working on the moves, I wasn't convinced that I'd ever actually climb the route.

Sometimes (okay, most of the time) the belayers thought it was hopeless too

The big breakthrough came in August of 2015.  My patience for merely working the route started to wear thin and I started to enter the mindset of wanting to actually do it.  My friend Dave and I scheduled a trip to Margalef for November, and I decided it was time to start doing some training.  Not just going to the climbing wall once a week like I had been doing for the past few years, but real, focused training.

This new mindset led me to search for videos of my route on the internet, and I was lucky enough to find something on Vimeo.  The climber in the video did the crux in the most bizarre way possible, but I filed the info away in the back of my mind, and when I got to Margalef and decided it was worth at least one try that way, it worked.  The crux was still desperate for me, but at least with the new method my success rate was higher than with any other method.  The rest of the route started coming together slowly; after the crux there is a steep, burly section followed by an upper half that is only about 7a but a consistent 7a, with no real rest, and the moves didn't always have an obvious method so it took several goes to work out the best sequences.

My best effort of the November 2015 trip saw me get through the crux and the burly section but run out of gas soon afterwards.  It was the same story on the January 2016 trip, although the crux had gotten a bit easier due to some winter bouldering on a burly roof problem.  Dave diagnosed me with a lack of upper body strength, as well as fingers that could do with a bit of strengthening, and sent me home with a prescription for pullups and fingerboard work.

It was an agonizing wait until the next opportunity to go back, which was November 2016.  I was determined not to forget my hard-learned sequences, so before I left Margalef in January 2016 I made sure to take photos of all of the hard sections, and when I got home I rehearsed the moves in my head every night before falling asleep.

My phone's gallery is still filled with fine works of photography such as this.  This one is the crux--the route is almost fully horizontal here.

The autumn of 2016 was an even more focused version of the training from 2015.  I made myself a written training schedule, complete with several sessions a week of fingerboarding, pullups, core strength work, bouldering, and endurance circuits.  I played around with my diet, too, and managed to lose a little weight.

It all worked.  My first day in Margalef, I did the crux first try.  I was so surprised that I instantly forgot how to do all of the upcoming moves and fell off.  The next time on the route, I got through the crux, through the burly section, and partway through the easier section.  I had been having trouble remembering my sequence for the easier section, so I spent a full session on it, working the moves over and over again.

Then I took a rest day.  And bought a bottle of wine, just in case it should be needed for celebrations the next day before the shop opened in the evening.

My project is in the sun all day until about 5pm, and it was far too hot to climb in the sun that trip, so I had to endure a nerve-wracking wait for my try at the redpoint.  I distinctly remember being so nervous that I thought I might throw up, and I told Dave that I was never having another project again, so that I wouldn't have to go through this another time.  Just before 5pm I headed to the cave at the far lefthand end of Laboratorio for my usual warmup, and then it was time to climb.  By this time of the evening the weather was virtually perfect, crisp and dry with a nice cool breeze.

I pulled on and redpointed the route first try.  It felt unreal--kind of like a dream and kind of like an out-of-body experience.  It also felt easy.  I was expecting a big fight, especially when trying to clip the chains (a mini-crux for the short), but the fight never came.

I felt complete happiness sitting at the top of the route, trying to take in what had just happened, and then I felt complete sadness at the realization that it was my last time on the route.

There was nothing left to do but strip the route, go home, and drink wine...and find the next project.  And for the next one, I'll know that if I'm not failing as much as I failed on Voladerum, I'm not trying something hard enough.