A Running-Injury Journey

A tale of two sports docs and the importance of a proper diagnosis

Welcome back. For the first time this year, I will take a break and not publish next week because I’ll be wrapped up with family travel for Thanksgiving.

I’m hosting the monthly zoom this afternoon for paid subscribers—a fun, informative, casual, and optional meetup. This time, those who recently ran big goal races will share a bit about what they experienced and learned. Then we’ll take turns sharing some good news and/or gratitude. If you’d like to participate, please upgrade your subscription to the supporter level.

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For an upcoming newsletter, I’d like to tackle your questions about pretty much anything. Want to ask for advice about some aspect of your training? A question about my background? Something related to life here in southwest Colorado? Shoot me your questions, be they personal or practical, serious or silly, by replying to this email (if you receive the newsletter in email form) or by commenting below. You also can send a direct message through my Instagram @sarahrunning.

A shot from the 2021 High Lonesome 100, with my knee taped. That summer, I first noticed knee pain and began trying to manage it. Photo by Gary Wang.

The importance of a proper diagnosis and caring caregiver

Injuries happen. They can be acute (a sudden occurrence like a sprained ankle) or slow-building and chronic (like achilles tendonitis). I’ve been injured many times in many ways in 30 years of running, and one thing is true of each injury: It’s a great teacher.

Through injury, we can learn something new about our anatomy, biomechanics, and training, and ultimately improve the way we run and design our training to treat the injury and minimize chances of its reoccurrence. But this learning only happens after getting past the stage of denial and confronting the problem proactively.

I’m sharing an injury story involving two orthopedists to remind you that you need to thoroughly understand what’s going on anatomically and get an accurate diagnosis for treatment. You also need to be your own best advocate in our health system. You should follow your hunch and get a second opinion, and discontinue with a doctor, if you don’t feel good about their care.

I know it’s difficult, expensive, and time consuming. You want to self-diagnose by using the Internet and crowd-sourcing advice, and you want to jump straight to physical therapy rather than taking the time to see a sports doc first. Or perhaps you go to a particular practitioner and then feel stuck with that one. You want to believe that this doctor cares about you and you’re in good hands, so you ignore your doubt and disappointment with their care. I’m here to tell you, listen to your inner voice!

In the summer of 2021, my left knee started to bug me. I always took pride in my knees. They never were trouble spots, and therefore I pushed back against the common misperception that running inevitably “ruins” your knees. But my left kneecap started “talking to me.” It was fine when I ran a flat, smooth stretch. But on mountainous terrain, when I needed to take big steps up big rocks and run down several thousands of vertical descent on technical terrain, it started to ache. If I tried to bend it fully mid-run when it was inflamed—such as bringing my heel to my butt to stretch my quad—then it hurt in one particular spot on the kneecap.

But I could still run, so I didn’t do much about it. I began using KT Tape to stabilize it, figuring my kneecap wasn’t tracking properly and therefore wear-and-tear was occurring. I doubt the tape helped much, but it made me feel like I was doing something. I also started noting my symptoms in my training log and judging my knee discomfort on a pain scale of 1 to 10. It never got above a low-level ache (3 to 4 on the scale) unless I suddenly moved mid-run in a way that fully bent it. Then I felt a sharp “ouch” on the kneecap spot.

This continued through the summer of 2022 as I trained for another 100-miler. I vowed to get to the root of the problem that fall, once I was past my races.

In September of 2022, I saw an orthopedist who’s recommended by several locals and is based elsewhere in the state but travels to Telluride for clinics. She’s in high demand, so I felt fortunate to get an appointment with her and therefore predisposed to trust and like her, even though a friend who went under the knife with her for a knee replacement warned me about her tough personality.

“She’s good,” my friend said, “but she’ll probably make you cry.”

I suspected I had cartilage loss but wanted confirmation and a management plan. I wanted a doctor who acted like a partner and saw me as an athlete whose sport matters.

Dr. X (I won’t share her name) entered the exam room moving brusquely. I admire no-nonsense people, but her demeanor crossed the line from efficient to impersonal. She examined my knees and concluded what I suspected: the first signs of osteoarthritis from cartilage loss, aka chondromalacia patella.

But what I recall most, as we talked about my anatomy and physical therapy options, was her negativity and blaming—which, as my friend had warned, made tears spring to my eyes. She said things such as: “You’re an ultrarunner. What do you expect?” “It’s like a worn-out brake pad, it happens with age.” And the worst: “You have a knee replacement in your future. You can keep running—it’s your choice—but then you’ll need the replacement sooner.”

It wasn’t just what she said but how she said it, with a tone of “duh.” Her skirt revealed her knees, both of which have long vertical scars, and I couldn’t help concluding that her lack of sympathy and her critical tone might stem in part from the fact that she’s been through knee replacements, so she perhaps feels I should suck it up and accept the inevitable.

She ordered an MRI, which I got in November of 2022. It showed “moderate chondral [cartilage] thinning medial patellar facet with minor subchondral cystic change. Mild chondral thinning and softening of the lateral patellar facet.” Diagnosis: “mild to moderate patellar chondromalacia.”

In the months that followed, I did everything I could—PT, acupuncture, joint supplements, and a lower inflammatory diet. I took extra care to run with good form, fresh shoes, and a light footstrike. On the downhills, I used trekking poles and planted them in a way that reduced lower-body impact, or I shifted to a lower-impact gliding stride instead of hammering. And you know what? My knee felt pretty OK. I was running well enough. It seemed manageable.

And yet, I carried a feeling of doom and anxiety that I was jeopardizing my long-term mobility. I started telling people, “My knee has a shelf life” and, “I have a knee replacement in my future,” and, “I need to get into Hardrock before my knee gives out.”

Fast forward to early this summer, and a new problem cropped up with my knee. Oh god, I thought, I need to see Dr. X again.

This pain was on the outside of my left knee, near the head of the tibia. It was an inflammatory response—it would flare up on longer runs, and sometimes if I took a break mid-run, then it hurt acutely to restart running—but then the next day, it would “calm down” and feel normal.

A mark showing the newer sore spot on my left knee.

Of course, I went to Dr. Google first. Research led me to self-diagnose that the pain seemed too low down to be an IT band issue, and it seemed related to the bone. Could it be a stress fracture on the tibia head? I made an appointment with Dr. X, believing I’d need an MRI to understand the problem.

“I’m worried I might be developing a stress fracture, and I’d like to rule that out,” I told her during our appointment last June.

Once again, she was brusque. She asked questions but only briefly touched my knee. She concluded my problem likely has to do with the Hoffa’s fat pad, which is a fatty tissue between the kneecap and tibia, and it can get impinged and inflamed. I hadn’t heard of it.

“I can order you an MRI to rule out a stress fracture, it’s up to you,” she said. She wouldn’t make a recommendation one way or the other. I did not find this helpful, but what choice did I have to figure out this pain? An MRI costs about $900 out of pocket. I decided to get it done, largely because I didn’t think she had diagnosed me and I wanted a clear diagnosis. She just advised me to rest and run less (even though I was training for a 100-miler in September).

Only now, looking back at my patient record online, do I see she put down a diagnosis of “Hoffa’s fat pad disease,” though I was not aware of this diagnosis at the time and not given any treatment plan to resolve or manage it. I got the MRI, which showed no stress fracture and no worsening of the cartilage loss. I was out 900 bucks and left mystified as to what was causing the pain on the side of my knee or what to do about it.

I kept training for September’s Run Rabbit Run 100, managing the aches by icing and trying to be extra careful with my running form. Often I hiked rather than ran the downhills on training runs, to reduce impact. My knee felt bothersome but not awful, and it didn’t seem to be worsening.

I went to see Dr. X one last time, to try a hyaluronic acid injection before the 100-mile race. These injections can help relieve osteoarthritis symptoms by lubing and cushioning the joint with a fluid that mimics the natural fluid in the joint. Unfortunately, miscommunication ensued between her office and me; I didn’t get the info ahead of time that I needed about whether it was covered by insurance, how much it would cost, how much time I’d have to take off from training, and what brand she uses. I went to the appointment expecting to get my questions answered there.

I was her last appointment of the day, and she saw me about a half hour later than scheduled. When I told her I had just driven straight to the clinic from the Montrose airport, she told me offhandedly that she was trying to get there this afternoon to catch a flight. Hearing this made me worried, because I realized she may be rushing for the sake of getting to the airport on time.

She moved rapidly, unboxing the injection and preparing the needle. But I said, “Wait, wait—I have questions about how much this will cost and what the time off will be, and whether it’ll work.”

She got her assistant on the phone and asked some rapid-fire questions. They couldn’t tell me what it would cost—they would need to submit my insurance info first. She also couldn’t tell me whether it would be beneficial. She shrugged, “Some people find it helpful, others don’t. I can’t promise you anything.” I told her I had my doubts and was rethinking this treatment.

“It’s fine, we don’t need to do this today,” she said, sounding relieved, as if she’d like to get out of there rather than talk to me and administer the medication.

I didn’t want a hurried doctor to stick me with a big needle when I didn’t know the costs or side effects. I walked out of there without getting treatment, feeling totally frustrated and confused, and resolved never to visit her again.

I vowed to find a different sports doc and get better treatment after the Run Rabbit Run 100. But how? Options are limited in our region.

When I got a massage after the successful 100-miler in September, I told the therapist about my knee situation.

“Go to the Steadman Clinic in Vail! Don’t see her,” the massage therapist said and went on to describe how my doctor had mistreated her partner’s knee ligament, which he then had repaired by the Steadman Clinic.

Of course I knew of the Steadman Clinic—the state’s premier center for sports med, where all the pro athletes go. But Vail is a 4.5-hour drive away. To take an entire day to drive there and back for an appointment seemed daunting and excessive, almost selfish. Should I spend that much time and money on myself? I’d already spent over $1800 on two MRIs and a lot more out of pocket to see Dr. X, a PT, and an acupuncturist. The whole thing made me feel guilty and self-indulgent.

I messaged an ultrarunning doctor friend in Montrose and asked if he could recommend any orthopedists closer by in Montrose or Grand Junction. Nope, not really. He also said I should go to the Steadman Clinic, and he recommended some doctors there.

I flashed back to a saying my wise first coach used to repeat: “Your health is your wealth.” My health—my running—is essential to well-being. Knees are precious. If I’m going to spend a lot of time and money on myself, shouldn’t it be for this?

That’s why and how I spent all last Monday driving to and from Vail to see Dr. Godin at Steadman, and it definitely was worth it.

This little video shows my exam room. Every wall in the clinic is covered with photos that have notes from athletes—many pro, many amateur—thanking the doctors for their care.

I noticed the difference in care immediately. They had my prior MRIs ready to examine and had studied my background info ahead of time. First an assistant to the doctor took ample time to examine me, and he ordered X-rays of my whole lower body, not just the knee, to see the bone alignment from hips to heels. Then Dr. Godin examined me, my MRIs, and the new X-rays, consulting with his assistant. Nothing about their demeanor seemed rushed. They seemed truly interested in my training as an athlete.

One of the first things the doctor said, which shocked me and put a big smile on my face, was: “Your knees look great!”

Yes, he and his assistant were wow’ed by my knees. The doctor said I must have good genetics because my knee anatomy and cartilage look remarkably healthy for a 54-year-old who runs as much as I do. My ACLs and MCLs are “perfect.” They pinpointed the spot of cartilage thinning under the patella and said it looked “mild” and “not that bad.”

My head was spinning. “But—but—what about a knee replacement?”

Dr. Godin chuckled and said, “You do not need to worry about a knee replacement anytime soon, for many years at least.” He told me I could manage and minimize the cartilage wear, and that a hyaluronic injection was worth doing in a followup visit, after getting insurance approval.

I felt as if a weight had been lifted from my chest, unleashing my heart. Suddenly, my future as a runner looked bright again. Suddenly, I wasn’t a bad or stupid person guilty of self-inflicted damage.

“But, what about the pain on the side of the knee?”

It wasn’t a problem of the Hoffa fat pad being impinged. They said my pain has to do with Gerdy’s tubercle. Say what? The Gerdy’s tubercle is a bony point on the upper part of the tibia. It’s the point of insertion for the Iliotibial band of the lateral thigh.

In other words, I have Iliotibial (aka IT) Band Syndrome—inflammation where the IT band inserts—which is a very common running injury. It’s something that I know how to treat because I had it before years ago, only slightly higher up my knee and also on the tensor fasciae latae (TFL) by my hip, and many of my coaching clients have had it.

I felt like laughing out loud. I have garden-variety tendonitis! Not that big of deal! But then the realization that I had been misdiagnosed for months—delaying treatment—and had spent a lot of money on an unnecessary MRI tempered my enthusiasm. I couldn’t believe I (and Dr. X) had overlooked this diagnosis.

We talked about how to treat it—but I already know all the PT exercises, stretches, and foam-rolling to do, and how to modify my training while it heals (e.g. avoid running hard downhill and avoid running canted surfaces). If I had known this diagnosis, I would’ve doubled down on doing those things weeks or months ago.

To hasten my recovery, they recommended a cortisone shot. I told them I have always viewed cortisone shots as a last resort insofar as they act as a BandAid to mask pain without really healing the problem, and they can cause further damage if the athlete trains hard on an injured but numbed area. I also believe that inflammation is part of the body’s healing process.

They told me I was generally correct, and repeat cortisone shots to mask an underlying chronic problem should be avoided. But, they said, a cortisone shot is a safe and effective way to reset the area—to get rid of the stubborn inflammation, and regain mobility—so the healing and physical therapy process can start with a knee that feels and functions more normally. They warned me to reduce my training load and run smart, focusing on physical therapy, but they also reassured me I could keep training.

I got the shot, and it felt great. I’m on a path to healing now. I feel empowered, respected, and motivated by this doctor visit.

This injury has been a teacher for sure. Lessons (re)learned: don’t self-diagnose, and don’t stick with a doctor who makes you feel badly and whose diagnosis you doubt or don’t understand. Don’t give up. Get a second opinion. Take the long view for management through PT, mobility, and strength exercises that keep the body running well. Keep doing all those “extra” but essential things to stay healthy and injury free.

Your health is your wealth.

Odds and ends

• Last week I wrote about the buzz over UTMB-Ironman’s growth and its launch of a new race in Whistler, BC, which I and others view with alarm. On Monday, an announcement about nine independent ultras from around the globe banding together in an association called the World Trail Majors created more buzz, with many interpreting the new group as an alternative to the UTMB-Ironman series. I recommend this iRF article and the comments under it, as well as Andy Jones-Wilkins’ commentary. My take: It’s important to choose your races wisely, not only to support the values and mission of certain race directors, but also to reduce the cost and carbon footprint of our sport. While the races in the World Trail Majors sound awesome, I don’t want to encourage runners to fly far around the globe many times in a year. It’s better for the planet to run and race regionally, with less travel. I’m struggling with whether to do just one race abroad next year, given that I’m flying abroad for a family vacation also. I applaud those race directors for joining forces to support each other’s independence and counteract the monopolizing forces of UTMB’s series, but we don’t have to get caught up in the hoopla and the FOMO around racing these marquee events. In my next post, I’ll share advice about how to wisely choose and calendar races for the coming year.

• This column by Joe Uhan, full of advice for older runners about maintaining health and longevity in the sport, is worth a read. I’m happy to report I’ve made changes in lifestyle and training over the past couple of years to follow each of the points he makes.

• If Thanksgiving triggers you food-wise, and you feel you have to “earn” your special festive meal with extra exercise and/or calorie restriction on the days before or after the holiday, read this: “Please, Enjoy Some Pie,” my post from two years ago. Holidays are a time for celebration, and you can aim for moderation, but please don’t deprive yourself or feel you have to exercise more. The post shares sensible advice from dietitian Cara Marrs. I also recommend the Instagram account @flynutrition3 for wise yet down-to-earth sports nutrition advice.

I feel a great deal of gratitude toward all of you readers. Thank you for making time to read this newsletter. I’ve developed some special relationships in the 2+ years of writing it and feel a sense of community around it.

Have a safe holiday, and try to promote peace with kindness and compassion toward others.

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