Age Group Triathlon Nationals A Crazy Go and Injury Update

Last week I was at one doctor's office or another for FOUR days out of the week trying to figure out what my leg injury is. My sports medicine doctor, Dr. Bolin, thinks I have popliteal artery entrapment. I know, popa-what? Check out my last blog for that description! He is sending me to a vascular surgeon next. Please note it is still NOT diagnosed. I would need to go to the vascular surgeon for an MRI and a non-contrast MRA (angiogram) before that could even be diagnosed. In the meantime my extremely awesome friend and fellow triathlete suggested I go see her very awesome chiropractors from Kennedy Chiropractic in Salem, VA. The chiropractor was one light in the darkness! He thinks he can fix me right up!

Last week at their office I had tons of X-rays taken and infrared images of my feet. Looks like I don't bear weight on my feet well and my pelvis is quite out of alignment so I'm putting alot of weight on my injured leg. Today they worked on me some and I'm totally happy and willing to give it a go, as it sure beats surgery!

In the meantime I decided I AM GOING to the Age Group National Championship. I might be the most out of shape triathlete and the last one in but I'm going AND I'm going to have a good time! No, I have not been training, yes, I'm in pain all the time, yes, I'm sure I'll be walking most of the course and resting during the swim and bike  - BUT - I WILL BE THERE! 

Pre-Race Checklist:

1. Totally out of Shape - Check!

2. Doing it Anyway - Check!

3. Sure I can't hurt myself any worse than I am - Check!

4. Looking forward to a good time - Check!

5. Feeling reunited with my Tri Bag and Gear - Check!

6. Oversized pink bag stuffed with kids clothes and my clothes - Check!

7. Toes painted - Check!

Ok, this is NOT my typical pre-race checklist but I'm going for it no matter how ugly it might be! Goody Bag and post race beer here I come!! See you at Nationals! 

The Continuing Case of the Undiagnosed Triathlete

Having an undiagnosed sports injury has been a long process and I've learned how much you have to be an advocate for your own health.

Quick Recap:

1. Left shin became inflamed while running on 4/29 to the point that running, biking, and swimming hurt and were almost impossible; I tried running through 5/15 but couldn't get through any runs and went REALLY slow so I realized I had to give up running

2. Orthopedic Physician Assistant called it a Shin Splint on 6/5, stopped biking because of the pain, took rest, even swimming hurt

3. Doctor thought it might be a Stress Fracture but a bone scan on Monday July 15th showed it was neither a shin splint or a stress fracture

So - what could it be??

On Wednesday July 17th I had an appointment with Sports Medicine Doctor, Dr. Bolin in Salem, VA as a follow up to the bone scan. He thought my problem was either:

A. Popliteal Artery Entrapment or

B. External Compartment Syndrome

Both are rare and difficult to diagnose overuse injuries. Both are due to a loss of blood flow in the leg. Popli-What you say? The popliteal artery is the artery behind your knee that carries blood to your leg. In short if it is out of position or entrapped in the gastrocnemius (calf muscle), the blood flow is decreased to your leg. There are different ways in which the artery becomes entrapped as seen in the images below:

Schemas show the six types of popliteal artery entrapment syndrome. In type 1, the artery follows an aberrant medial course around the normal medial head of gastrocnemius muscle; in type 2, the artery is displaced medially by an abnormal head of the gastrocnemius muscle, which inserts laterally on the distal femur; in type 3, the normally positioned artery is enveloped and entrapped by an aberrant accessory slip from the medial head of the gastrocnemius muscle; in type 4, the artery is entrapped by its location deep in the popliteus muscle or beneath fibrous bands in the popliteal fossa; in type 5, the artery and vein are both entrapped; and in type 6, the functional, normally positioned artery is entrapped by a normally positioned but hypertrophic gastrocnemius muscle. AS = accessory slip, LGN = lateral gastrocnemius, MGN = medial gastrocnemius. (Source: http://radiographics.rsna.org/content/32/1/E33/F29.expansion.html)

The least expensive diagnostic test is a doppler ultrasound, however, there are a large number of false positives and completely missed diagnoses with this test. When your toes are pointed (plantar flexion) and the gastrocnemius (calf) muscle is contracted there will be less blood flow shown in the doppler ultrasound and this would suggest but not confirm popliteal artery entrapment. An angiogram is more useful but costs thousands and thousands of dollars, and an MRI can be used as well but it is also more costly. However, just an ultrasound of the leg cost $900! That is pretty steep!

Doppler Ultrasound

On Wednesday July 24th I was sent to the Imaging Center in Blacksburg, one hour from Roanoke, because a specialist was supposed to be available who knew how to identify popliteal artery entrapment. However, only a technician did the scan and she was doing a venous study of both legs. I asked her "So, why are you looking at my veins when we should be concerned about my popliteal artery?" and she responded "Can I tell you the truth?.......I have NO idea". I asked her again and again to have the doctor call me. By the second day I had no call from the doctor and the Imaging Center wouldn't even tell me if he had read my ultrasound images. After hours and hours of playing fax tag with the medical records department they finally told me they would NOT release my medical records to me electronically but they would give it to my doctor's office. My local doctor's office refused to give me the results and told me I had to wait until my doctor's appointment on August 2nd. I told them it was very important for me to know  the results because if it is not popliteal artery entrapment, then I need to have the $2000 test for compartment syndrome ordered. Finally a person in medical records agreed to mail me my results which I have not yet received. 

I had the technician show me the picture of my popliteal artery and vein

Knowing that looking at the artery was important and knowing you had to contract your gastrocnemius to see if there was less blood flow, I realized they had done the wrong test but I couldn't get a doctor to call me back. During the ultrasound they never had me contract my calf muscle and they were looking at my veins. Today I called the Imaging Center AGAIN, and said "Hey, I know you are going to think I'm crazy, but I really think you did the wrong test". Luckily the woman who answered the phone actually listened to me and had the head ultrasound technician call me back and she told me I was correct. The wrong test had been ordered and done and she will bring me back in on Monday July 29th for the correct ultrasound! 

So, what it comes down to is that you have to be an advocate for your own health. Read as much as you can about what they think you might have. Google images of the diagnostic tests being performed. Luckily I had educated myself because it didn't look like anyone was contacting me to let me know they had done the wrong test! You would think the doctor reading the ultrasound images would have noticed a vein study was done when they were trying to diagnose popliteal artery entrapment?? In the meantime, the pain continues, it's constant and it's getting old. Daily tasks are tiring, difficult, and painful. The Age Group National Triathlon Championship on August 10th and 11th in Milwaukee and the Age Group World Triathlon Championship in London in September is not looking so good anymore.

After the failed ultrasound we did have a great time in Blacksburg at Bull and Bones, a restaurant with great craft beer! Goodness knows I think I needed it after that ha ha!

Lunch Pale IPA

I was also super excited to run into an amazing fellow triathlete, Tanya LeRoith!

Bone Scan for a Stress Fracture

Something I thought I would never hear my daughter saying : "Mommy, step back. You are radioactive!".  I went for a bone scan on Monday July 15th to see if my shin injury is a stress fracture. X-rays are unlikely to show stress fractures and my X-rays were clear.

A bone scan is a pretty long process and you have to go back to the hospital twice in the same day. First you go in and they inject a radioactive isotope in your bloodstream. The isotope they use is different based on what they are trying to see. In my case they used Tc99m-MDP (Methylene Diphosphonate). It's injected while you are laying under the machine that will take an initial flow reading as the isotope moves through your body. The radioactive waves move through your body and bone and the camera is able to take a picture of those radioactive particles. 

Yep, smiling for the camera ha ha

Initial Flow

Initial Flow

Towards the end of the Initial Flow

Initial Flow Images

Then you return hours later because the radioactive material needs time to soak into your bone and they can at that point take more pictures to determine if there is an anomaly. In my case the technician would be looking for a brighter than expected spot at the site of the injury. Scanning the area of interest only takes 10 minutes, 5 minutes each for two separate leg positions.

Second Reading

Front View of Bone Scan

Bone Scan Side View

However, you are emitting higher than normal levels of radioactivity for at least two days. You are also advised to keep your distance, at least three feet, from children. They injected me with 2 years worth of normal radiation you would receive in one go. So, "distant" parenting for a stay at home mom has been interesting to say the least. It is hardest for my three year old cuddle bug and even my daughter said "I haven't hugged you ALL day!!". Ofcourse the family jokes about "glowing" started pretty quick and my husband had to say "You look 'HOT'!". Yes, ha ha.

I had to pile all three kids in the back row of the van so they wouldn't be too close to me!

While I have an appointment with Dr. Bolin, the sports medicine doctor, on Wednesday July 16th, I was impatient and went by the hospital to get the Radiologist's results from my bone scan. Just as I had seen when they did the scan, there is "no focal accumulation" to suggest I have a stress fracture or shin splint. So that leaves me with a bum leg and still no diagnosis. I'm sure the doctor will have some ideas on Wednesday. At least this makes me feel better about not being able to swim, bike, or run! I'm so tired of reading and hearing about people with stress fractures and shin splints that can still swim and bike and those people with shin splints that can still run! Let's hope a real diagnosis and solution is in my near future. I hear you calling Age Group Triathlon Nationals. Let me be well in time!

Coping With Injury Mid Season and the Emotional Impact

2013 Season Recap

How I spent most of my summer - hanging out with chickens!

I was really looking forward to this season! I stayed quite focused this winter and biked in really frigid conditions and even with snow flakes falling on my tri bike and cute Zipp wheels! I got up at the crack of dawn to get to the pool and made my poor family get up earlier as well because my husband would drop the kids off at the pool at an early hour in the morning before he headed to work. I worked hard. I was focused. I am determined. I am a triathlete.

In January I was struck with plantar fasciitis and that hampered my run training but by April I was up and running and did three sprint triathlons. The plantar fasciitis is still a problem however. A couple of days after that third triathlon my leg "blew" up when I was running on April 29th. It was only a couple of miles but I couldn't finish the run. My leg became very inflamed on my left shin and a lump developed that is still present. I continued to attempt running until May 15th and even did another triathlon the first weekend in May but I came to realize that it was impossible and the pain was too much. I continued to bike but really I knew I shouldn't have been biking. I was sobbing attempting to "get through" rides. I was determined and I pushed on no matter the pain. Although there were several times I got off my bike sobbing thinking there was no way to continue on. Still pushing I did the swim and bike portion of a sprint in the first weekend in June. I continued to ignore the pain and really couldn't push in the swim or bike.

As it is impossible to actually get an appointment with a doctor I ended up with an appointment with a Physician Assistant at an orthopedic office. It was 6-8 weeks out to actually see an orthopedic physician in our area. The PA had an X-Ray done which was clear, called my injury a shin splint, and sent me away with 12 days of steroids. He told me I couldn't race and really couldn't do anything and it might heal in 6-12 months, but possibly I could speed walk in 7 weeks. I rested. It did hurt to swim. The pain was really sharp when I attempted to kick. It did hurt to bike. I knew it was time for me to rest.

Rest with steroids for 12 days you say?? If you have ever taken prednisone before you will know you will become a hyper devil that accomplishes great feats and doesn't have to go to bed until 2 A.M. or later. So that was me for 12 days. I was off the hook, repainted most of the house, stayed awake through all hours of the night, and let triathlon go. 

I was ok with letting it go the first week. In 6 days I painted the kitchen, the kitchen cabinets, the mud room, the deck, the baseboards, the hallway, and the side porch. And by paint, I mean all kinds of crazy colors of PAINT. I was ok. I could paint and not think about triathlon. Take Caution: You might just get tired only by looking at THIS much paint!

SIDE PORCH:

Photo complement of Carrie Cox, Academy St. Photography

KITCHEN:

Kitchen

Kitchen Cabinets

Kitchen Cabinets

MUD ROOM:

HALLWAY:

DECK:

Ok, that was painting in just SIX days. The painting continued down to the chicken coops:

COOPA CABANA

LE POULET CHALET/CHICK INN

We had a party that weekend at our house. I was distracted with cleaning, painting, and then partying. We hosted the June Brewer's Guild meeting.

Imperial IPA judging before the meeting
Photo complement of Carrie Cox

Lots of food and people!
Photo complement of Carrie Cox

Lots of homebrew!
Photo complement of Carrie Cox

Photo complement of Carrie Cox

Serious meeting stuff!
Photo complement of Carrie Cox

Then Monday hit. I think I was tired of painting. Then I was just sad. I was sad I had worked so hard for so long for this to happen. I had to let triathlon go for a while. I didn't blog. I couldn't find anything positive to say. I didn't read triathlon articles. I have months of Triathlon magazines sitting in my house UNREAD. I have months of great triathlon articles delivered to my inbox UNREAD. I let it go. It was SO much of my identity and I thought about it ALL the time. It was probably good to let it go because it really CONSUMES me.

Then I was just sad ALL the time. I pretty sure I've been quite happy all my life and I usually feel happy on the inside but I was finding it hard to really smile. How can something as simple as swimming, biking, and running affect me so deeply? This is something that has only been in my life since 2010. I knew I loved it but I didn't realize how much happiness and freedom it really brought me. Nobody ever really talks about the emotional impact of the sport and the emotional impact of an injury. The graph below is a great representation of the feelings experienced. 

Clearly I was in denial for a long time. I thought, this will just get better. I was still in denial the first week of real rest but then anger and depression definitely kicked in. I had never "felt" or experienced depression but I have been SO down and on an emotional roller coaster. One day I completely broke down in tears sobbing realizing I was unmotivated. This was one of the hardest things for me to cope with. After so much time of having SO much motivation, I just didn't care anymore. Yes, I could have done some upper body weights, but I wasn't motivated. There was really not much positive to be found. Being unmotivated was a really awful shock to my system. To top it off I have been in pain ALL the time. It hurts to walk, it hurts to sit, and it hurts just doing nothing. The pain is there and it is constant. I can't live "normally". I can't run after the kids and can't even catch the chickens if I need to! I have to live life slower with controlled movements. For a Type A person, this is a TOUGH way to live! I usually do most things at high speed! It wasn't until my doctor's appointment on Monday July 8th that a veil had been lifted some for me. I'm at the "Decision" stage of the Kubler-Ross Change Curve in which I'm feeling more positive with the hopes of having a real diagnosis and a real treatment for the problem.

I finally had an appointment on Monday July 8th with an actual doctor, a sports medicine doctor, Dr. Bolin in Salem, VA. Within a minute he quickly said "stress fracture". This is what I had been saying all along but the PA I saw quickly shoved me out the door telling me I can't believe everything I read online. On Monday I finally go for a bone scan and on Wednesday I meet with the doctor again for a plan of action.

My lesson for the 2013 triathlon season has been to listen to my body and to be an advocate for my own health. Go see a sports medicine doctor. They can help! Stop ignoring the injury. It may not get better and it could get worse. My shin pain really started in November. I ignored it and it never got better. I've also learned I'm not invincible, I'm not immune to depression, and maybe I don't need to be THIS consumed with triathlon. It WILL still be there when I'm better. 

The Age Group National Championships are a month away on August 10th and 11th in Milwaukee, Wisconsin. This race predicts who will make the 2014 TEAM USA triathlon team. Clearly it is not realistic at this point I can go but I'm not throwing in the towel yet. I signed up for the Olympic and Sprint and while the Olympic is out for sure, I will keep a very small glimmer of hope for the sprint if I am healed by then. I might be the most out of shape triathlete there but if I am 100% I WILL be there! The Age Group Triathlon World Championship in London is definitely NOT out. I am there. I have time to heal. I am determined. I AM a triathlete! Injury is just part of what comes along with the journey!