Fix You. Part III. Guest Blog by Melissa

This is the final installment and exciting conclusion of the Fix You blog. If you missed part II, click here: http://nateruns.blogspot.com/2015/03/fix-you-part-ii-guest-blog-by-melissa.html

“The brick walls are there for a reason. The brick walls are not there to keep us out. The brick walls are there to give us a chance to show how badly we want something. Because the brick walls are there to stop the people who don’t want it badly enough. They’re there to stop the other people.”

- Randy Pausch, The Last Lecture

I drove home with Nate in the passenger seat. I was fuming mad but also worried sick. This was a major spine surgery and Nate convinced the surgeon to let him go home, with next to no post-op recovery time, no post-op monitoring, just because he doesn’t like hospitals. Yes, I’m a nurse practitioner, but I’m in primary care. I’m not scrubbing in on surgeries, I’m not rounding in the hospital, I’m not seeing patients post-op. I’m doing annual physicals and treating sore throats. This is out of my specialty. If something went wrong, not only would I be out of practice on what to do, but I wouldn’t have any of the appropriate equipment to manage a problem at home.  It was completely unfair for him to put this on my shoulders. Not to mention I had to go to work in the morning.

I might have been fuming, but Nate was in his glory. Anyone who knows Nate knows he is a bit like Rain Man when it comes to running statistics. I frequently pick a random year and say, “Nate, Boston, 1982, Go!” and he will recite the top ten at the Boston marathon for that given year and give me their finishing times and personal best times. In his doped up state (it takes a while before the good drugs they use in anesthesia to wear off) he was even more like this, and certain that he would be running 2:10 in the marathon by the fall.

Nate flew up the three flights of stairs to our apartment. Part of me really hoped that he was having some sort of miracle recovery and that this would be a breeze. But a few hours later, Nate was in pain. He was laying in bed grimacing and told me his pain was suddenly eight out of ten. I had never seen Nate that uncomfortable, but he still had ninety minutes before he was due for Vicodin.

I explained, “Nate, I know you’re in pain, and that’s expected after surgery. But you’re not supposed to have any pain meds for another ninety minutes. Now, in a hospital setting things are different. They can hook you up to an IV and give you some Dilaudid, or maybe they’d even give you the Vicodin sooner, but we’re not in the hospital, are we. Someone wanted to go home, and so I need to follow the guidelines set out by the surgeon. So you’ll have to wait another ninety minutes. But I’d be happy to give you some ice.”

His vital signs were fine and the incision looked good so I knew his pain was due to the anesthesia wearing off. The tough love continued a few hours later when Nate tried to use the bathroom and found he couldn’t urinate.

“Honey?” He called, “Can you come help me?”

I went into the bathroom to find Nate standing over the toilet. I was confused. “What’s wrong?”

“I can’t pee. It won’t come out” he said.

This was not on my list of anticipated problems. Actually, if I had sat down for days and brainstormed possible post-op issues, this would not be on that list. But I didn’t even consider acute post-op problems because I was expecting Nate to be in a nice, safe hospital for his recovery. Not here. And now that the pain meds had worn off, there was almost no way I could get him back down the stairs to bring him to the hospital.

“Nate, you listen to me right now. I’ve got an old catheter kit we used for practice at Boston College in the back closet. If you don’t pee in the next five minutes, I will use it on you. I will. You wanted to go home? Now, you gotta pee.”

He peed. I was completely relieved that he didn’t call my bluff on that catheter kit.

After that first hellish night, Nate’s recovery went quite smoothly. He couldn’t bend at the waist for weeks, which meant I was dressing him every morning. I came home at lunch every day and checked on him, occasionally finding him “stuck” on the couch or a chair, unable to get up without assistance, but after the first two weeks or so he was strong enough to walk stiffly around the block.

By six weeks, Nate was running again. The next few months involved lots of physical therapy and a slow build up of miles. The goal was to be on the starting line at the 2012 Olympic Marathon Trials.

Nate started training in earnest. However, the coordination issue wasn’t magically solved. Prior to surgery Nate could only make it two miles into a tempo run before losing coordination. After the surgery he could go ten kilometers before he lost coordination. Nerves are funny things and their recovery does not always follow a smooth trajectory. We knew we needed to give the nerves time to heal before they “came back”, but the dramatic improvement immediately post-op was very promising.

However, by mid-summer, the nerves weren’t coming around quick enough. Nate ran a hot and hilly half marathon in 1:06, but struggled with coordination problems during the race. He wasn’t able to train appropriately for a marathon, and he knew he wouldn’t last very long before losing coordination if he tried. We hoped the nerves would heal if we just gave them more time, but as the months went by the improvement he saw stagnated, and some days were actually worse.

A year out from his surgery, his shoe company dropped him. He missed the Olympic Trials. We were standing on the dock as the ship faded into the horizon. It was so ambitious to think that he could recover within a year of major back surgery. Nate was an inch shorter than before his surgery, that’s how much bone and disc material was removed. How could we have possibly expected that he would be back so quick? I reassured him that, despite it all, the nerves would eventually come around and he would make it back. We just didn’t have enough time.

But things didn’t improve and by the fall Nate started teaching math at a local middle school. He continued to run over one hundred miles a week, but it was just running. He was not capable of running any of his favorite workouts without losing coordination. He could cobble together a half marathon, which was a great improvement compared to before the surgery, but the later stages of the race would be ugly.

Nate settled into life as a teacher with a running problem. We bought a house. The nerves never improved more than they had initially after surgery. I started to wonder if something else could be done. I encouraged Nate to follow up with the surgeon and ask.

Unfortunately, the surgeon felt like he fixed the source of the problem and there was nothing else for him to do. This was entirely true from the surgeon’s perspective, but heartbreaking for Nate to hear. Dejected, he went back to his new life, stopped posting his blog, and started to accept that this was his fate.

I felt stupid for sending him back to the surgeon. Of course the surgeon wouldn’t have any further answers because there was nothing left to cut. It was foolish of me to think the surgeon would have an answer. But I already knew that Nate’s problem was a nerve problem, so there had to be some doctor who could help us. I found that there was a neurologist that worked in my hospital network who had certification as a sports neurologist. A sports neurologist! How perfect! Someone who knows nerves within the context of sports. A match made in Heaven.

I was so excited to tell Nate about it. This doctor was in Winchester; Nate could just leave school early one day and see him. But when I told him, his face hardened. He did not share my excitement.

“I am not going to another doctor to be told that there’s nothing else that can be done. Frankly I don’t think I could handle being told that again. I’m not going.”

This was a blow. I pleaded with him. I apologized for sending him back to the surgeon, it was a really dumb idea, but this sports neurologist is not a surgeon. He’s a doctor and he can at least point us in the right direction.

Nate finally agreed and a month later he saw the sports neurologist. This doctor was a mad scientist type; extremely interested, extremely thorough, a doctor whose whole life is his work. I wouldn’t be surprised if he actually slept in his office. It was a breath of fresh air. Just in the office, the sports neurologist determined that Nate had less strength in his right leg; in fact his right leg was smaller in circumference than his left leg.

The sports neurologist needed some hard numbers. He needed to determine how much of a success Nate’s surgery truly was, and if there was any persistent impingement. This meant another EMG. I felt like I was torturing Nate. If you read blog II, (find it here:  http://nateruns.blogspot.com/2015/03/fix-you-part-ii-guest-blog-by-melissa.html ), you’ll remember that undergoing an EMG is significantly worse than undergoing a root canal. For Nate, it was yet another blow he accepted with quiet resignation.

The second EMG showed function in both legs within the normal ranges, with the right leg function less than the left, but still normal. The sports neurologist concluded that the surgery was successful, but Nate’s piriformis might be pinching the nerve a bit and causing some increased dysfunction on the right side.

Nate started physical therapy again to address the tight piriformis, and he also started Bikram yoga. Bikram is a form of hot yoga that Nate and I had both previously tried. It was created by a yogi who healed a bad knee injury without surgery just by doing yoga. Nate liked it because, with his back surgery, there are certain yoga “postures” he shouldn’t perform, and in Bikram yoga the postures are always the same. Unlike a traditional yoga class, where the instructor might choose to focus on a series of postures that Nate shouldn’t perform, Nate always knows what to expect in a Bikram class.

Nate found that the combination of Bikram and physical therapy improved the overall function of his right leg. He was doing much better, still not as well as he hoped, still not enough for a marathon, but much better than he was the first year after his surgery.

Full disclosure, this is where I gave up. I thought we had all the answers to Nate’s injury. I thought the nerves had come back as much as they were going to, and that getting the piriformis to loosen up was the final piece of the puzzle. I thought the improvement we saw was the most we would see. I thought if Nate had his surgery sooner, if it was shortly after the problem first started, we might have seen greater improvement, but sometimes once nerves are damaged, especially for any length of time, they don’t come back fully. Nate’s nerve function was at least in the normal range now. It all made perfect sense to me, and I could think of nothing else that could possibly affect the function of his right leg. I sent Nate to multiple top doctors, sports doctors, doctors who know a lot more than I do, and they felt this was the answer to Nate’s injury. I didn’t question it any further than this. I regret giving up, though admittedly I don’t think I would have ever guessed the final piece of the puzzle on my own.

I may have given up, but, to his great credit, Nate never did. The improvement he saw in his coordination from physical therapy and Bikram inspired him, and made him feel that he could fix his leg the rest of the way. Enough to run a marathon. He’d occasionally ask me if I had any other ideas. I didn’t. I truly felt like the case was closed. I was disappointed, because my original goal was to restore Nate to glory, but I felt like I had found the problem and got it fixed, and sure there was some residual damage, but I couldn’t have anticipated that. I had done my best.  As Robin Williams said in What Dreams May Come, “Sometimes when you win, you lose.”

Everything changed for Nate in November, 2014 when Josh McDougal beat him in the Manchester Half Marathon. This day flipped Nate’s injury on its head and opened a whole new world of possibilities. I am forever grateful that Nate chose to run that half marathon, that he was capable of running a half marathon, and that Josh McDougal met him at the finish line.

For those who don’t know, Josh McDougal is probably most famous for winning the 2007 NCAA cross country championships, defeating golden boy Galen Rupp in the process. He was struck down by injury shortly after that, and Nate was aware through various internet postings that Josh had an injury very similar to his own.

Josh beat Nate at the half marathon and waited for him to finish. Once Nate crossed the finish line, Josh asked him how he was doing with his recovery from the injury, had the surgery fixed him?

Nate told Josh that honestly he felt that the surgery helped to improve the leg function by about 50%, enough for him to run half marathons again but not what he had hoped for. Bikram yoga helped as did physical therapy to loosen the piriformis. Nate asked Josh how his recovery was going.

Josh responded that he felt his loss of coordination had been fixed for about six months. The significance of this news really cannot be understated. This wasn’t an anonymous Joe online who said he’d fixed his injury, this wasn’t a healthcare professional who was confident he could fix the injury, this was a man who knew the hell that Nate knew. A man who had felt his leg flop like a rag doll and who was able to fix it. He had literally been to hell and back. It was like magic.

Josh explained to Nate that his injury had two parts. The first part was tightness and dysfunction in the lower leg and ankle. Josh was doing physical therapy for this and Nate’s surgery had fixed this part. The second part, the part that Nate and I were totally in the dark about, was dysfunction in the thoracic spine.

The thoracic spine. A place I would have never dreamed of considering for a problem in the hip and leg. I immediately remembered looking at Nate’s MRI several years prior in my friend’s kitchen. He had herniated discs in his thoracic spine, too.

Nate’s reputation is that of a grinder, and he has the form to match. He looks like a man who is running incredible paces through sheer force of guts and will, and his shoulders are always rolled forward as he leans into the pace and grinds. Over time, this form likely caused the herniated discs to develop in his thoracic spine.

As he leans forward, those herniated discs impede nerve signals traveling up and down the spinal cord. Shortly after learning how Josh fixed his injury, our physical therapist ran into Nate at the gym and told him he had just attended a conference and heard about how herniated discs in the thoracic spine can sometimes be the cause of persistent leg injuries.

Josh was addressing his thoracic spine dysfunction with physical therapy and saw his symptoms resolve. Nate came home from that race and asked me if I knew of any exercises for the thoracic spine to help keep his shoulders back.

I knew several great exercises for the thoracic spine. Since high school, I enjoyed attending running camps where much focus was put on proper form and form exercises. I shared some very simple exercises with Nate, and he was so weak he could hardly even perform the exercises. In fact, with one of the exercises, called YTIs, Nate was so weak he could hardly hold his arms up against gravity. In contrast, when I do the exercises, I generally use three pound weights, and I am a weakling!

Nate’s weakness was striking and surprising. Imagine, someone who competed in the World Championships could be so weak in his shoulders that he couldn’t hold his arms up and out to the side while laying prone on the ground. I didn’t know how we could miss such a major weakness.

Nate and I ran together so I could help him with his form. He would strain to hold his shoulders back and ask me if the form was right. Despite the strain he felt, his shoulders were still forward. It took about a week of constant work before he was able to hold his shoulders back for even brief periods.

Nate heard that Alberto Salazar had his athlete, women’s phenom Mary Cain, run in an equestrian harness to keep her shoulders back and fight her own tendency to run with her shoulders rolled forward. We purchased the Equifit “shoulders back” harness on Amazon, and we affectionately refer to it as Nate’s “back bra”, because that is exactly what it looks like. Nate found that wearing the back bra was difficult, as his shoulders strained against it not only when running but also when wearing it around the house. His underarms chafed against the straps, but each day became easier. Each day he was able to hold his shoulders back a bit more.

Nate started to attempt workouts that challenged his injury. Workouts he was physically unable to do over the past seven years. He found that each time his right leg threatened to lose coordination, if he consciously forced his shoulders back, his symptoms would resolve. As time passed he was able to keep his shoulders back for the vast majority of runs and workouts. After his workouts, despite how challenging the workouts themselves were, Nate complained not about sore legs, but his sore shoulders.

With this final piece of the puzzle, Nate has returned to the workouts he loves best. The impossibly long workouts that take up most of the day. The workouts that Nate says “make a man out of you.” He has longed to complete these workouts and for the first time in seven years, he is. He is fully capable of completing a marathon without loss of coordination being an issue. It truly took a village, but he, like Josh, has crawled his way back.

The final piece of the puzzle was only solved in November; Nate has worked hard to improve the strength of his shoulders since then. He started his Boston preparation before he could keep his shoulders back for a full run. That, along with working full time (he is in the middle of the school year) makes Boston a rather ambitious goal. If we were only considering Nate’s injury then I think an early summer or a fall marathon would have been a better choice. A fall marathon would have allowed him to train in the summer, when he is not teaching.

But there are many factors that go into choosing a marathon. Nate chose to do Boston because he would have a training partner with him, Ruben Sanca. The difference between training with someone versus training alone is huge, and Nate has really enjoyed training with Ruben. There aren’t too many people who can keep up with Nate. I feel it has been beneficial for Nate both physically and emotionally to have Ruben there. The training he is putting his body through is so daunting and so taxing, and it has been so long since he’s done it,  it’s helpful  and reassuring to have someone out there with him.

I think there was also an element of striking while the iron is hot; Nate chose to run Boston before he woke up from the wonderful dream that his leg is fixed. Thankfully, I have seen the workouts, I have watched Nate run, and I know it is not a dream.

It will be amazing to see Nate compete in Boston, but more than that, it is amazing to know that Nate has marathons ahead of him. I am more excited to see what’s in store for Nate over the next couple of years. Because, for the first time in seven years, there will be marathons.