Baby Steps-A religious walker recovers from knee surgery

When I first started to write this I was 5 days post-arthroscopy. In late March I'd come downstairs in the wee hours of the morning, head half-fogged by sleepiness and the fugue calculus of character arc for a short story I'd been working on. I needed a glass of water before bed. In my reverie I missed the last step on our ancient stairs and ended up on my ass with my left leg twisted under me. It didn't feel great but after a quick self-assessment, assuring myself I'd been careless, but had broken nothing or had done no permanent damage, I rose gingerly, shook it off and continued my walking regimen in the days that followed. After each workout, I typically paid a little in pain premium the next day but I didn't think much of it. With exercise, once I got going, my reliable endorphins kicked in and I'd be fine.

Then three weeks later in April came "the afternoon of the big backpack." Typically I meet my youngest son after school two to three days a week. We walk the 2.5 miles home and I shoulder his 18 pound backpack, brimming with textbooks. I have strong concerns about a 10 year old back shouldering that kind of weight, so I cheerfully relieve him of it. That night I was a bit more ginger than usual.

The next day, when I awoke, I could barely walk.

Still, I'd agreed to meet a friend at Whole Foods, usually a brisk, effortless seven minutes from our house. It took me at least 20 excruciating minutes to get there. Another 20 to get back. I've always said walking changes your perception of time but now my own perception had shifted to senior citizen time and at a spry 53, I am in no way ready for that. In hindsight, agreeing to the walk to Whole Foods was ridiculous, but I wasn't yet fully aware of my new limitations. I was functioning on an inertial level. That was the first time, really in my life, that I realized that something had radically changed and inertia no longer was a factor.

When doctors take your history, they ask you to measure pain on a scale of zero to ten. One is mild, low level and tolerable. Ten is excruciating. One is a "booboo." Ten is bone cancer. My initial pain, post fall was in the 3-4 range. The Whole Foods incident peaked at 7. One second's careless distraction and I had unwittingly joined the company of chronic pain. When you are painfree and walk the streets you do not notice the pained. I noticed them now. Their mouths are set in a tight, unsmiling line, wanting nothing but escape. Their eyes have a distracted look, a certain cloudiness, as if set on a distant and better place. The fellowship of pain is huge and is not networked. We do not acknowledge each other. We have nothing to offer that can illuminate or improve each other's suffering. Pain comes from an infinite variety of sources, from torn skin, to a tumor clawing at the soft tissues to raw bone grinding bone, compressing inflamed nerves.

Old injuries are like old friends. One adapts and accommodates them. New injuries are new enemies, constantly shocking in the myriad ways they disrupt one's routine. My own pain was a big distraction from my daily routine which averages 90 minutes of walking which in better days effortlessly accumulates about 30 miles per week. The Buddhists extol the virtues of mindfulness of each moment of life. I don't think they had knee pain in mind.

Fluidity is not just a state of physicality. It is a state of mind. I was broken, shattered—undone in the one area that I'd hooked my future health and well-being on. The Philadelphia spring days were crisp and sunny but this is a low, dark period for me. About the lowest I've ever experienced.

I had an initial consultation with Dr. Brian Sennett, Associate Professor of Penn's Orthopaedic Sports Medicine Center. The Sports Medicine Center services U of PA's athletes. Their rehabilitation center in Weightman Hall is attached to the examination suite and has an atrium skybox view of Penn's Franklin Field. The Hospital of the University of Pennsylvania has many fine orthopaedic surgeons, but I'd chosen this one deliberately. I wanted a knee-cracker with a mindset of restoring athletes to peak performance. I told him I'd accept no less. I would not put myself in the care of somebody who saw just saw an overweight 53 year old man with a damaged knee who'd be happy to waddle from the livingroom to the refrigerator – painfree or not. I wanted him to see me like I see myself.

As a born-again walking athlete.

The Ides of April

Dr. Sennett, a trim, authoritative orthopaedic surgeon favors stylish, tailored suits and crisp but casual, mock turtle shirts. He looks like the kind of guy who'd eat your lunch on a squash court then go home and run ten miles. He and his resident saw me and made an initial diagnosis of pes anserinus tendonitis/bursitis. They recommended therapy and a MRI. While I waited for my MRI appointment I diligently applied myself to the therapy for the following two and a half weeks. The MRI appointment was scheduled for April 15, tax day, already an ominous day in my book. Therapy had not improved my condition, so I approached my scan with foreboding. I was not subjected to full donut immersion, which was all well and good. Though I'm not particularly claustrophobic I really wasn't looking forward to putting that to the test. Even with the noise dampening headphones and user selected music the MRI techs give you, the whirs and clangs and clunks of the machine in operation sound like the infernal contraption is about to fly apart. It sounded like I felt. The next week I saw Dr. Sennett for a followup and we discussed the MRI findings. He was cheery and chatty and I got a little annoyed with him.

I said something to the effect that "I've been listening to you for ten minutes and you still haven't addressed the $64,000 question."
"Oh," he replied with a half-smile, trumping my cocky tone with one of his own, "And what is that?"
"Do you want me to have surgery?"
"The sixty-four thousand dollar question isn't what I want. It's whether you want to have surgery."
"I don't. No!"
"Then let me tell you that ten percent of cases like yours respond to therapy and heal spontaneously over time. The healing process is long and painful and the chance of reinjuring the area is high. You have to be patient if you go that route and you don't strike me as a particularly patient man."
"I'm not." Like my MRI, he'd read me unerringly.
"I have an opening next Friday, then I'm on vacation for a month. What do you want to do?"
"Book me," I replied, without a second's additional hesitation.

Under the Knife

The arthroscopic surgery on April 30th repaired two meniscal tears of the posterior horn of the medial meniscus and an osteochondral defect involving the medial aspect of the femoral trochlear notch.





One of the tears was tiny. The osteochondral defect, an area of worn cartilage exposing raw bone was also tiny, less than 8mm2. However the larger horn tear was complex and left a ragged edge of meniscus flapping around that had been the principle source of my constant pain with every step—low level when I did nothing and when I stressed it—not so low level. Surgery took about 3 hours. By mid-afternoon, Kara had picked me up and deposited me at home. Using one crutch, I hobbled outside, smoked a cigar and read Stieg Larsson's "Girl with the Dragon Tattoo."

My bandaged knee had two small holes in it from the arthroscope. I did not feel them. I felt no pain. It's another gorgeous spring day. I greeted passing neighbors who stand slackjawed over me while I recounted my day's adventures. I even called one neighbor up and suggested that we set up the block's projector to do a movie on the Perelman wall.

Then the analgesia wore off and I was no longer sociable. I hopped back inside and collapsed on the couch. When you get this combination of analgesia (pain-killer) and anesthesia (knock-out), they warn you "not to sign contracts or make important decisions" for the rest of the day. The anesthesia, Propofol, Michael Jackson's very last drug of choice, is nicknamed "milk of amnesia." It's every bit as good as its handle. I was in twilight sleep during the surgery. I remember nothing except that before being injected, I'd laughed at the notion that my executive function would be impaired.

When will I learn?

Road to Recovery

I saw Dr. Sennett and crew on Tuesday, five days post surgery. On Saturday, I'd thrown away the crutches and gingerly walked Spencer to the Azalea Garden for a game of toss. On Sunday, I'd rested. On Monday I took Spence to his piano lesson. On Tuesday, I'd walked down to Market Street and hopped the bus. I think even the good doctor was impressed, because he turned to his resident and said, "See, this guy is only five days post-op." Then he told me he loves his line of work, because the recoveries are so rapid. He prescribed a laborious ramping up process by which I should add a few hundred feet every day to my walking regimen. I asked if I'd damage my knee if I was to overtax it. He said that I wouldn't, but that I'd pay for it (in pain) and that my recovery curve, instead of having a smooth uphill slope, would be jagged. I told him that I'd read an article that suggested that over 50% of the people who'd had my surgery developed osteoarthritis and what I could do to avoid being among that unhappy majority. He glanced down at the 40 pounds of excess baggage I carry in my midsection and then met my eye again.

"You already know what to do," he replied.
"You've just got to keep doing it."

Somewhere in the back of my head, the idea was already forming that he probably tells all the athletes he patches up to take it slow and easy. I left the office. It was a glorious sunny day and I walked from Spruce back up to Market Street. Riding the 33 Bus for the 14 blocks or so from West Philly to Center City, I knew that the first opportunity I'd get, that I'd put the good Doctor's work to the test. I got off on 23rd and Market and walked home. About another mile.

That Friday, I walked my usual, pre-surgery five miles. It was slow and uncomfortable, but oh so blessedly, hallelujah fluid. The clockwork was back. I was back. I used the painkillers I was prescribed sensibly. Sennett had written me a prescription for Percocet which I took sparingly. I didn't like how it fogged me, even though it knocked the pain out. After every walk I paid a little, but it was a price well worth paying.

Beyond Recovery

On June 15, two months to the day after my MRI, I saw Dr. Sennett for the last time. I told him about my walking adventures and he smiled when I said that I couldn't restrain myself, that I felt compelled to push myself to the limit, the very day of our previous appointment. I told him that walking wasn't just an athletic endeavor for me, but a lifestyle and a philosophy.

He said, "Walking is more than a philosophy for you; it's a religion." Again, he'd read me to a tee and that was the exchange that nailed it for me. I'd chosen my caregiver well. Dr. Sennett dismissed me with wishes for a lifetime of walking happiness and fitness which he said he had no doubt that I'd pursue with every fiber of my being. Every day after that, I felt my strength returning a bit more, the pain receding a little more, the feeling analogous to watching a scar heal and shrink. I'd left the land of the pained, but I would never forget my stay there.

See, to my way of thinking, the fall in April wasn't just a random accident, but a symptom. A symptom that I'd have to get to the bottom of if I wanted to maintain my longterm vision.

It's good to have a vision. Mine is me at a spry 90 years old, stepping nimbly into a canoe on a hiking/camping trip with my grandchildren. But we all know how falls disrupt those kinds of goals and I was still left with the fact that my entire life, even as a teen, that I'd been prone to stumbling. Wasn't so big a deal when I was young. But as a guy halfway through my life, I have to face the grim fact that haunts every citizen—my age to senior. Every trip is a potential fall. Every fall is a potentially life altering event that could end my "athletic career." This is not acceptable. Not now, not in my 70's. Not in my 90's. Not ever.

So, two days before the 4th of July, I saw another orthopedic surgeon. This one, Dr. Keith Wapner is a foot and ankle specialist.

(An aside here—is anybody else as baffled as I am about how "differentiated" orthopedics is? Another topic, another day.)

Dr. Wapner is a tall, 6'4" silver-haired man who looks like a close cousin of basketball great Bill Bradley. He x-rayed my feet and we talked about what happens when I walk and when I stumble—in my humble, the true weak link in Rick's locomotion system. Dr. Wapner confirmed my concern and put a name on it.

I have proprioception issues. The proprioceptive sense refers to the neural input and feedback that tells us about movement and body position. Its receptors are located within our muscles, joints, ligaments, tendons, and connective tissues. It is one of the "deep senses" and could be considered the "position sense." My ankle/foot proprioception dysfunction isn't a candidate for surgery, but can be managed by "balancing therapy." That is the good news I was hoping for.

Dr. Wapner gave me new shoe inserts and a prescription for proprioception PT. I like where this is heading. I've always had problems with balance. Maybe it's the way I'm built. Maybe it's something else. But it doesn't matter, because it's something that finally has a name and a strategy I can manage to. Seven years of diet/behavior modification have taught me that I can change my body. It may be a challenge, but I can change my life. I can be incrementally better and it's under my control. This is a familiar motif. I beat back diabetes with diet and exercise. I lost nearly 80 pounds in the process. I blew out my left knee and have brought it back from crippled mobility to full, fluid function.

I see Dr. Wapner again in about a month. I start therapy this week. The joy of walking is restored in my life. The dark period is over. I'm back up to my 20-30 mile a week walking routine. I even rode a bike yesterday for the first time in over 15 years.

So far, my experience of middle age is that I'm not just back to where I was, but am in a better place. Sure, eventually a day will come; a "bullet" will come that I will not be able to dodge. But that day is not today, nor is it in the foreseeable future. The road is clear and elevated. Step by step, I'm pulling ahead of my previous game. You can't ask for better than that.