Pain Management

I had an appointment with an anaesthetist on Tuesday, regarding a pain management program.  I took along the diagnosis from the spinal surgeon, which suggests 3 different injections; a right-sided pars block, l5-s1 facet joint injection, and a caudal epidural. 

The anaesthetist agreed with the diagnosis that I have disc degeneration disease (DDD) of the L5-S1 disc, but believes that if I have all 3 of those injections we will not actually find out what my pain causality is.  The DDD in my MRI is very clear, with the thinner and dark lumbar disc very much evident even to my untrained eye.  I also have a disc bulge, which at the moment is not too large, but could (and will likely) worsen in time.  He did however also point out a few other anomalies in my facet joints, differences in muscle mass, and also put forward a suggestion that my DDD could potentially have caused impingement syndrome, which as I understand it, is that the collapsed disc is sitting on, or interfering with, a nerve around my Sacroiliac joint (SIJ).  This could be the cause of the acute pain and muscle strength fatigue and failure as I run.  He advised that this was only another theory, and it was also difficult to treat. Possible long term management include an even higher orthotic in my left shoe to try and lengthen my left leg and easy any pressure on the my right side SIJ. 

He suggested rhizolysis could be a potential treatment.  This is an unpleasant sounding treatment where a probe is inserted into the spine, guided by x-ray until it is in contact with the nerve causing the problem.  The probe is then heated, to essentially kill the nerve signals, shutting off the pain.  There are of course other nerves in the area that carry muscle movement signals, so you have to be very certain you have the right nerve which only kills the pain signals.  I have read around and this treatment is partially or fully successful in 60-70% of patients. I believe that the procedure is carried out using a couple of doses of local anaesthetic into the area so the probe can be heated with manageable pain.

For now all of those treatment options are potentially months away.  For now, he has suggested I have a series of steroid injections to try and isolate what is causing my pain.  The first injections will be on 28^th may into my right side SIJ.

Regardless of my long term future running, which admittedly looks somewhat bleak at the moment, I have been researching road bikes.  Even if I am somehow able to bring the pain under control, I will have to change my training structure.  I want to be able to run ultramarathon’s but I would realistically have to train for them by predominantly cross training long distances on a road bike to retain my endurance, and also doing more strength and flexibility work.  This may allow me to still run short distances in training, and I hope, still participate in some long distance events as a runner.

I’m going to try a run a 3.5 mile fell race this evening.  The first time I have tried to run that far for weeks and weeks.  It’s very hilly too, but I figure it can’t really do he a lot of harm.  I may be dreadfully unfit at the moment, so it will do something for that at least.

MRI results, back injury

I've had by MRI results.  The spinal surgeon in London has reviewed the results and the diagnosis is that I have a Pars defect of my L5.  This is a healed fracture of an old injury, probably in my teens.  This can be very clearly seen below.  I've circled the break. I'm not an MRI expert but I'm pretty sure that's it! Click to enlarge

That is the primary injury, though that occurred years ago. 

But what I have now, likely as a result, is Lumbosacral disc degeneration disease  (DDD).  Basically, the disc is not as thick as it should be, it is thinner, more dehydrated (it's darker in colour). Look at the nice thick whiter discs above for a comparison. Consultant explained healthy discs are usually like crab meat and 85% water.  If they degenerate they turn dark as they lose water content, and get thinner.   You can see it circled on this different type of MRI scan.

DDD happens to pretty much everyone as they advance in age, but my old injury plus my running has accelerated mine.  This combo is what is giving me low grade lower back, buttock and hamstring pain all the time.  The pain increases as I run to about 10 miles, at  which point I effectively sieze up and struggle to shuffle along.

Ultimatey the disc collapses in time, and then the pain can go away.  That however will take the next 20 years. So I will be a pin free 60 year old at least, and resume my ultra running career then perhaps?

Well, I'm not quite ready to give up yet, so what are my treatment options.  If it was so bad I could not get out of bed then I could have the disc removed and the vertebrae fused together.  This might work, but in 5-10 years it would put so much stress on the other disc that the same would happen and I may end up worse.  Because I am still able to walk and run short distances without too much pain, then surgeon says I am not a case for surgery, and I agree with him.

So what's left?  Combo of two steroid epidural directly into the spine, periodically.  It's just a temporary fix to settle it down and would potentially need repeating every 6-12 months if it works.  I can als try some ongoing chiropractic, hamstring stretching and back strengthening to help ease the symptoms.  It's my hamstrings that murder me as well as the miles pass by, so I think a solid and regular hamstring stretch routine may be called for in an effort to lengthen them.  These strategies are all pain management, beause disc degeneration is not reversable, yet.  I think it will be one day, but medical technology is not there yet.  We'll need some kind of breakthrough, maybe stem cell repair, who knows? I found an old study where a 5-10% improvement was found  by taking Gluco and Chondr supplements, but that study is hardly statistically significant, being a case study of 1.  I've always been very skeptical about the benefits of taking those two, but I guess it can't really do any harm can it.

Oh, there is one more option.  I could take up another sport.  Cycling or swimming! I'll bear those options in mind while I book in for an injection pretty soon and see if that settles this down.  Maybe I can eek out a few more years.  If not, then I could end up one of those MAMIL's you have read about (Google it). Despite this very bad news, I remain optimistic about my chances of returning to long distance running by using a combination of the strategies outlined above.

However, I also have race directing to keep me occupied.  Dusk til Dawn Sunlight takes places in 6 weeks, and The 12 Labours of Hercules takes place in July.  So, it's not all doom and gloom and it looks as though I finally know what's wrong, and can try and do something about it.

Have a good week!

SI Joint stress fracture?

It’s been a year since I first had ‘pain in the arse’ symptoms, and couple of months later mentioned it on my blog.  I remember running in lastyears Anglezarke Amble.  I remember falling on my arse very hard a couple of times, due to the appalling conditions.  I have no idea if that caused or contributed to my current situation but I am more and more suspicious that it did.  A couple of months after (April 2012) that I wan the Coventry Way 40, very badly.  Suffering lower bag and hamstring pain.  Since then I have been more or less limited to 10-15 miles running before pain coming from my sacrum, coccyx area, slows me to a painful walk or half jog.

I have pain in my right buttock all the time, when seated, when walking. Sometimes it is low level dull ache, sometimes it’s sharp.  It never really goes away.  When I run the pain gets considerably worse until that 10 mile mark where it’s pretty much a show-stopper.

I’ve tried physiotherapy, osteopath and chiropractic with no joy. Finally I saw a UK Athletics physio, a guy I saw for my old groin injury.  He referred me to see a spinal surgeon in London.  The surgeon saw me for probably only 10 minutes yesterday, listened to the story, did a brief exam and said he suspects I have a stress fracture of my right SI Joint, and possibly a L5 issue.  He has ordered 3 MRI scans. The scans will take place next Wednesday. The scans are, the right hip, L5 spine, and a STIR (a fat suppressing sequence as I understand it). Reports are due to go to several radiologists for analysis, then I go back to see the consultant in London in a couple of weeks.

He briefly mentioned increasing Vitamin D, calcium levels and getting metabolically built up.  Beyond that he didn’t outline any treatment, as at the moment he needs to see the imaging results to be certain.

Having put on my internet doctor hat and read around yesterday, it seems a surprising diagnosis as it seems most fractures heal within a couple of months.  Maybe because I didn’t get the appropriate diagnosis and treatment at the onset, and just tried to run through it, I may have delayed the correct healing process and caused complications?  I don’t know, but I do know that it’s not getting any better on it’s own, much like the long term Gilmore groin injury I had in 2010/2011 that required (successful) corrective surgery.

The literature online suggests ultra runners are the classicpatient to present with a Sacral stress fracture (so those heavy arse falls at Anglezarke may not necessarily be the blame).  Anyway, hopefully the surgeon is onto something and I can get answers finally.

In the meantime, I am continuing to organise my own ultra events in 2013, and that is all going well.  I may not be the one leading the organised recces of the courses this year but I’ll sweet-talk my ultra-running wife to be into that ;)

Have a good week!

12 Labours of Hercules Ultramarathon

I'm continuing to work through my SI joint injury with an appointment with a Spinal Surgeon happening soon.  In the meantime my company Beyond Marathon Ltd have organised several ultramarathon's this year.

Dusk til Dawn last October was a huge success and will be again repeated this October, with version taking place in May, called Dusk til Dawn: Sunlight.

As well as that there is a totally new ultramarathon concept we've created called The 12 Labours of Hercules, which see's competitors run between 1 and 78 miles in a 24 hour period.  It has elements of a mountain marathon and adventure race pure is an ultramarathon at heart!

We're really excited about this, and so far the reception has been really good with bookings from some great UK ultra distance runners.

I'll post an update on my SI injury as soon as I know more!