Revision ACL Surgery and Rehab

For most city commute I prefer to ride my bicycle. This early March I was in a dilemma to ride my bike to a work meeting at EGL. It was a 4PM meeting, clear day, I rolled in a formal shirt into my laptop bag. At Trinity circle, as if like a premonition, the bungee cord from my pannier snapped and got stuck in my rear wheel. Fortunately, there was no damage done, I thanked my stars and carried on. But just after command hospital, as the road narrows down a bit, I could hear a car blare its horn to an empty stretch of road. In the next minute, the car behind this one brushed past my cycle. For a brief second I crashed into the rear door of the blue car, half cursing, half balancing, half bracing for the impending fall. The next thing - a big thud as the back of head met the tarmac. The familiar ligament pain the left knee was back.

Lying face up on the road, my cycle, bag, phone scattered around, all at the mercy of oncoming traffic, I let out a loud scream (Kantara style ;), - this would change many things in my diurnal life.

A lot changed - Ooty Ultra and Hennur Ultras were the first to go. I was adamant with recovery, hoping (almost sure) that the knee will be good in a few days. The few days turned to a few weeks. I began to use an elbow crutch to walk, but the exertion caused calf strain right up to the back of the knee. It took me 3 days to release a brick-like calf muscle and then a spasmed popliteus muscle.

After about a week, when the mobility did not improve, I started physio sessions with a focus to improve knee extension. These sessions caused excruciating pain, but it had to be done. Eventually after a month of grief, I went in for an MRI, only to confirm the Anterior Cruciate Ligament (ACL) had torn, with some damages to the cartilage.

My first issue with ACL was way back in 2001, a freak football injury. Then my first Arthroscopic surgery in 2006 (read here) and then another bicycle accident in 2015 (photoblog here).

I have mixed opinion of Ortho / radiology experts. The MRI reports are seldom clear and one has to interpret them with a lot of contextual background. One physio suspected bone chipping, MRI second opinion indicated that my previous screws were not in place. Amidst this confusion, I suspended my physio sessions. The knee mobility got back and I started strengthening my knee at the gym.

I eventually visited my Ortho of last resort - Dr. Hemanth Kalyan. He had had conducted my surgery way back in 2006. We discussed the option of a second surgery, but decided to give it 3 months of strengthening to see if we could avoid surgery.

The surgery option that was prescribed was using a Hamstring tendon graft and an arthroscopic procedure using an Endobutton & a bio screw. Dr. H was confident of finding another tunnel without disturbing the previous tunnel or screws.

In the coming weeks, I was able to shuffle jog about 1-2kms with lot of discomfort. I was able to lift weights, deadlift (up to 80kgs), lunges, leg extensions & curls. I used the time off running, to do what I could in the gym. Not too bad, eh.

I also added a few sessions of swim. Running was out of question, even a busy day with lots of walking would give me pain by evening.

I decided to get it sorted out - once and for all! My ACL "reconstruction" had to wait till our dream home "construction" could be complete. Within 3 days of Grihapravesh of Tadvanam our new home, on Vijayadashami, I did my hospital-pravesh - same knee, same injury, same hospital, same doctor, separated by thousands of miles of running and 16years!

Revision ACL Surgery

Technically speaking, the surgical / therapeutic procedures performed was:

Revision arthroscopic ACL Reconstruction left knee using 6 stranded ipsilateral semitenidinous and gracilis with microfracture chondral lesion and medial meniscus balancing left knee done by Dr. Hemant Kalyan (HK)

I was wheeled into OT room2, after an overnight fast in hospital overalls (incl. a disposable underwear) at 7:30am. Mine was the first surgery for HK, I spent sometime in the waiting room. By 8, I was wheeled into a super large OT with some massive overhead lights and lots of sophisticated equipment. The anaesthetist and 2 orderlies got working on me. I was seated on the OT bed and felt a few pricks in my lower back - spinal anaesthesia done. Soon the legs felt heavy and then felt nothing. HK came in and started going over my case with another doctor, spoke to my awake "upper half" briefly.

I had seen this video explaining the Endobutton ACL reconstruction technique earlier. I had a sense of what is coming. (It's quite a procedure, check out the video)

Right through the 1.5 - 2hr surgery I didn't sleep. I had a cloth wall at my waistline to prevent me seeing the procedure. I could "feel" the drilling and the hammering of my joint, but no pain, like it was being done to the bed or something.

While I was being sewed up after the surgery, HK walked across to my conscious half and gave a summary. "We got a nice 10mm graft from the hamstring tendon (usually 8mm is sufficient). The earlier screws did not come in the way, so we left it as is. There was some cartilage damage, which we fixed via a procedure called the microfracture which allows for tissue from the bone marrow to form the cartilage naturally. All's well!"

I now have a bioscrew, an endobutton and 2 titanium screws in my left knee!!

I was transferred to the recovery room, where I waited for over 2hours to get some sensation back to my legs. My knee was all strapped up in crepe bandage and the immobilizer brace. Weird sensations, stiffness, dull pain came by during the post op evening, with it discomfort while lying down in the bed all day and disturbed sleep during the night.

On his evening visit, HK mentioned that I it was ok to put all my weight on my operated leg already and should begin my physiotherapy session on Day1 itself.

The IV line was a pain, with constant pain killers, antibiotics, etc. and other injections. The food was good, I was able to get to regular food from the next day. The support of my wife during the hospital stay alleviated the discomfort to a great extent.

I was discharged after 2 days at the hospital. I am now in my 4th week post surgery, the vastus medialis oblique (vmo) muscle needs more tlc but in general I'm recovering well. If I feel inspired enough, I will create another post on the rehab.

Thank you for reading and your good wishes for my recovery! 

“Life is not a journey to the grave with the intention of arriving safely in a well preserved body, but rather to skid in broadside, thoroughly used up, totally worn out, and loudly proclaiming, “Wow what a ride!” ― Hunter S. Thompson

Cheers and have a good day!

Ps: fellow biker and dear friend, Shilpi added a pretty accurate illustration

Malnad Ultra 2021 – the reluctant 80k

 

Malnad Ultra has always been one my favorite races – the organizers love for the trails resonates perfectly with me. I have had decent previous finishes – in 2016 (read report here) and in 2019 (read report here)

There was whole lot of “reluctance” right from the beginning – the dates were announced in a hurry, right in the middle of my marathon training, and then the date was just before the gala opening of my company’s Bangalore Office.

Which means, I was running less mileage, more speed work. I was to be in Mysore the day after the run, meaning changes to travel plans. And then there were rains – of all kinds, cyclonic depression, drizzles, to thunderstorms. But wait till you hear of the “elephant in the room” – literally!

Training: The training was also, therefore, somewhat reluctant! I combined a speed run with 50k long run the week before the event and struggled with cramps. The recent BMF 60k Ultra, where I finished joint winner in 5:47 was a confidence boost. The rains played havoc with the training as well – I was juggling between risking a cold rain run and staying warm indoors.

Come race week, my travel plans changed, but my car-pool mates – Ashwati, Ahamed and Rama from Chennai Trekking Club (CTC) were accommodating. The Mysore plan was completely dropped. We decided to start from Bangalore at 6am to give ample time to reach the homestay in Mudigere (Hoysala Stayinn), get to the bib collection point at Robusta valley Inn and get some rest ahead of the D-day.

The course: Ok, which course do I talk about?

1. There was one course given in the information booklet that was emailed a week before the race.
2. Then there was one course that was described in great detail during the bib collection on the previous day – with changes to the start point and some sections of the second half.
3. And then this was revised further at 5:55AM on race day – we were told that we will not be able to run up Yettinabuja (which was one of the key attractions) and will be guided on the right trail
4. Then, 6km into the run at Yettinabuja base, there were further changes

The starting point was Urubage gram panchayat. The route was supposed to take us to the popular local trekking routes & temples – Yettinabuja, Bettada Bhairaveshwara temple, Nanya Bhairaveshwara Gudi.

The instructions regarding the marking was – “If it is a single long trail, there will be no marking. If you come to a fork, the correct trail will be marked with red ribbons on the “left” side. If there are ribbons on both sides, that section is used both ways (back to this later).

The race:

We started the day at 5:30am with first signs of “wrong route” trouble. Eventually we landed at the Gram Panchayat field of Urubage. Our host at Hoysala Parkinn was kind enough to show me an Indian style loo for my morning ablutions. I met Deepak and Opendro at the parking and we got ready under mobile torchlights. The race started on time at 6:45am.

I found myself leading the pack with Sampath and Mani in hot pursuit, we were clipping the first 2kms in 4:30 pace. Open joined us and we were then this “formidable four” (ff) till we hit 55kms or so. It was a crazy adventure right from the start. Our first turn, off the road was in 2kms, the ribbons were barely visible. And then in another 3km, we had to head towards Yettinabuja on the tarred road, again, the marking were all over “the fork”. Somehow, we decided to head uphill. Then, at the temple on the foothill to Yettinabuja (Nanya Bhairaveshwara Gudi), we were turned back by the support team, “not allowed” to go further. Issue with local forest officials – Elephants were spotted and it wasn’t safe!! 3km of what was to be the best part of the trail was gone.

At this point, the ffs were still tearing down the slopes. Back to “the fork” with ribbons all over, now we didn’t know where to go. We had company, even the volunteers didn’t! Then while we ambled there for everyone to catch up, the race director, Anand came to our rescue and directed us.

From there on, I began to enjoy the trails. At the lead Open and I, passed a support tractor carrying supplies for our support station ahead. Running along the ridges of this Ombattu Gudda was perhaps the most memorable section (and the picturesque section) of the run. We had to take a U-turn at a lone tree on the trail. Many runners apparently missed taking a U-turn at this point. Again, the markings were inadequate here too!

Once out of the ridges, the trail took us into some deep undergrowth of forest and Byrapura estate. Since we were first ones here, it was quite a pleasure to explore these virgin trails. Then came the river crossing at about 20km. All the ffs simply ran into the stream with gay abandon.

Again, at the fork, we had to guess the trail, it was also an opportunity to cut short 3-4kms of the trail.

All along, I was trying to keep to a schedule of water, gels, salt tablets. Getting out of the forest to the road section after Jenukallu Gudda near Bettada Bhaireshwara Gudi at 28km, it was already apparent that I was losing salts (see pic). The “Nataraja pose” was to show how I was bleeding from leech bites.

We had done about 35km in 4 hours and the 11am sun was shining bright. Once we got off the estate, it was back on the road for the next 10 odd kms back to the start area. Somewhere near the marathon mark, Open and I came across an overflowing overhead water tank. We detoured to take a nice shower and pressed on. We saw these milestones to Urubage and knew we were getting closer, till we saw a nice big bold arrow turning us left at “the T junction”. So we took it! A km into that we realized that the mile markers were now showing 70km and 72km. We then saw Amit and Suman, who were leading the 50k running in the opposite direction and quite peeved that they were made to take the wrong route with less than 2kms to their finish line!

We U-turned and ran back to “the T junction” and then made our way to the start area. I had 46kms on my Garmin and 5hr:25min on the clock. The missed turn had cost us our lead position and Sampath and Mani had arrived a few mins back. We took a quick 10min break, had some Bisi Bele Bath and curd rice and quickly got back on the track. I also picked up the 2 gels in had hid in the bushes in the morning.

The next 5kms was some craziness. 200m to the main road and we were already confused which way to go – no markings, no volunteers to direct us, we just sat on the road waiting for Sampath to join us and hoping he would be wiser. Then we decided to go left and check out, there were markings. Next 500m, there was a right turn (“the junction”), we considered taking it, did a quick search around, found no shredded paper marking and continued on. By now the sun was in its blazing glory, we ran down 2kms before turning back since we had found no mile markers either. When we got close to “the junction”, we saw 2 volunteers in a jeep, I flagged them to stop and help us with the route. They had no idea, and started doling out random gyan. I insisted they call and find out, they had no signal. Then they decided to jeep back to the start point to find out, while we walked in scorching sun – frustration and dehydration is not a great combo. By then time the jeep came back, we were back at “the junction” and they directed us back towards the start point. And when we slow jogged back, the race directors – AA and Brijesh in a jeep in the opposite direction stopped us and said, guess what, “wrong way!”. They went on ahead, placed a volunteer at “the junction” where we were now told to take the right turn towards Yettinabuja!

This additional 5k cost us nearly 45mins. But more critically, the next water stop was only 5km away, which meant I had to go without water in the hot sun for nearly 10km. This was no force majeure incident. There is no excuse for not marking the course correctly within a kms radius from your start point. I promised myself, at this point, that I will not run this race for the next 5 years!

From there on, after about 60km we entered the Haleakimane forest area for another 5km or so. This stretch of 10kms also had the most climbs, about 330m over 10k. Also, the inclines were very technical and were un-runnable. Open and I were now in the lead. At one point Open looked at my watch and noticed that my heart rate was 150+ and remarked that it was high. After nearly 8hrs of running, the Sun beating down on us as we walked up brutal inclines, his heart rate was a shocking 115 or so!!

He was, of course, holding on to me till the forest section was over. After the water stop at 68km (again, with unripe bananas, bread without jam spread over it, jam in bottles minus spoons, ditto for butter), Open decided to run on ahead.

By this time, I was cramping quite badly and was walking almost all of the now completely road sections. In another 3-4kms, as I was leaving a water stop, I glanced back to see Sampath and Mani jogging in. In the next km, they passed me.

I continued to trudge along and reached “the T junction”, which had led us astray in the first loop – 70kms in 9h:20m and the uphills were unabated. Finally, I got off the road, into a trail section, another 2kms or so to the finish. I wanted to keep under 11hours to save some pride and seemed to be on track to do so. With some 500m to go, I heard a cheerful shout from behind – turned to see Navin. Navin warned me of 2 other runners who were on his tail and told me to keep it steady till the finish. It never occurred to me that he was also doing the 80k, until he gracefully allowed me to finish ahead of him at the finish line. The clock read – 10:49:37, my Garmin read 80.24kms.

The photographer at the finish did not capture my shot and asked me to run around again. This led to some drama, with me cramping on both legs, the other top-5 finishers rushing to me – offering a chair, water, massage, etc. I managed to relax and get this shot after 10mins or so.

Open had finished in 10:11 and Sampath & Mani had just finished about 5mins back. Navin was placed 4^th (rightfully so) because of the net time considered. I had managed a 5^th place finish.

This Malnad Ultra was a mixed bag – the route changes, getting lost, my own poor performance (I really struggled in the last 20k).

The Last word: In a very candid feedback sharing with AA at the end of the race, he said “In spite of all this, I don’t know why I still do this (event)”. To which I replied, “In spite of all this, I don’t know why I still run this race”. I guess till we figure out, he will organize it and I will run it. Just like the other pass time that we have signed up for called “life”.

As always, would love to hear your thoughts. Please leave a comment below. Also, follow me on Instagram @ultrabhat

Ultrahuman and experiments with Fasted Running

I have been experimenting with "Running on Empty", which loosely defined translates to running on a carb depleted state. I now regularly run all my morning runs on a overnight fast of about 10hours, by which time the blood glucose is almost depleted.

More from curiosity than anything else, I decided to be a Cyborg for 2 weeks - to try the UltraHuman program from the Bangalore based start-up. It uses a sensor patch which detects interstitial fluid to measure glucose via a probe. The patch transmits live glucose data to the "Continuous Glucose Monitoring" (CGM) app.

Day0:

Wearing the sensor. The product comes in a sleek package. During the recommended overnight fast before inserting it, I was quite anxious. Esp. after the instruction video indicated that there could be a "few drops of blood splatter". My heart rate went up as I inserted the plunger into my arm, cringing for pain, but lo! nothing happened. I was a Cyborg!!

After a warm-up, there is an apparent, 24hr calibration period. My sensor went flat during this time (see pic below). The customer service was prompt and shipped a replacement the very day.

I had to peel off the dysfunctional one and do the insertion all over again, minus the anxiety this time. It did take that 24hr to calibrate, see the night readings being haywire on day one below.

It was pretty awesome to see the readings and the variations - preprandial, postprandial and nocturnal - live and on the app. Also, the gamification built into the app, with a KPI of "metabolic score", it kept me checking the app quite often in those days. My glucose range stayed within the recommended range of 70mg/dL to 110mg/dL.

That got a bit boring and I decided to "run" some experiments! These are not your typical "I order XYZ from restaurant ABC on swiggy and my glucose went up to 180..." experiments. 

The guinea pig (read: me) has been on a "fat optimization" journey for the last few years. Bear with me, these were with n=1, age: 41kg; BMI: 21, with no randomized or blind test control sets.

Experiment #1: Tempo paced run

Control variable: 24k at tempo (5min/km) pace 

Treatment1: with '0' calories (empty run)
Treatment2: with carb intake at 5k and 14k during the run

The near linear drop in the glucose level on the top graph is probably an interpolation, but the important thing to note is that the end state glucose level at 8am. In the empty state, it was 60mg/dL, whereas with the gels it was at 70mg/dL. Also notice how the body recovered from the 60mg/dL to 70s without any card ingestion post workout. This probably indicates Gluconeogenesis, where the body is breaking down protein and fat and converting into glucose. Read more on this here -> Ultrahuman Blog 

Result: No Perception of Effort (PE) effort with or without gels

Experiment #2: High Intensity Interval Training (HIIT)

Type: 400m x 20 repeats at 90% of Heart rate
Treatment1: overnight fast and '0' calories during
Treatment2: overnight fast, Gel (110k calories) after 6 intervals

In highly fat adapted athletes, Glucose should rise from stressful workout, without ingestion of carbs. The Gel seemed to have arrested the slide in glucose levels. In the past, I used to feel a serious lack of energy during the last few intervals. But overtime, this feeling has faded a bit - either I am not pushing hard enough OR I am getting better fat adapted (or both!).

Result: The Gel did make a difference, but needs some more experiment to discern if it was the gel or the water that went along with the gel!

Experiment #3: Easy 10k

Type: 10k at 60% - 70% of Heart rate
Treatment1: overnight fast and with '0' calories during
Treatment2: 35hour water-only fast and with '0' calories during

This was interesting. The first 10k after an overnight fast is the regular easy early morning run. As for the second 10k, after the 36hr fast, the first 2km or so felt tired - notice the glucose levels dropping to sub-60 levels. Then it felt good till the end of the run. Also notice how the glucose levels go up to about 70mg/dL post the run. Lipolysis, gluconeogenesis could be either or both in conjugation.

Result: There is a lot of merit in medium intensity exercise combined with fasting, to promote fat metabolism and maybe even accelerate autophagy. Certainly plan to continue this. My best is a 50km run bring up a 36hr water-only fast in 2019.

Experiment #4: Long Slow Distance (LSD) 50k

Type: 50k at 60% - 70% of maximum Heart rate (MHR)
Treatment1: overnight fast and with '0' calories during

Treatment2: increase in pace to about 80% of MHR 3.5hrs into the run for 2km

An early start on a cool day in Bangalore, ran for most of this around Cubbon Park, since it was weekend lockdown with the park closed. Paced a friend, Akhil for a sub-2 hour half marathon. The speeding up was from 35k to 37k, where we went from 5:30pace to about 4:45pace. You can see how this shot up the glucose levels. All this was done on an overnight fast. Initial dip in glucose level to 60mg/dL. This could be indicating fat adaptation. The increase can also be due to cortisol level increase leading to glucose increase. Notice how the increased glucose kept rising, despite no crab intake, even as I resumed running at 5:30 pace from 40k to 50k.

Result: This was one my easiest 50k runs, LSD on empty? Check.

Experiment #5: Typical day

Type: No exercise
Treatment1: No exercise, typical regular home-cooked food

Treatment2: Full day, water-only fast

Fasting has lots of benefits to keep the metabolic score (a term UltraHuman uses generously (Read details here). It keeps all the 3 vectors - glucose variability, average glucose and time in target zone, within the limits.

In closing, even without having to go through these "experiments", the UltraHuman CGM is certainly a great biohack to get you good insights to how your glucose levels react to your typical day. I do wish they include lactate and ketone level monitoring in addition to glucose to given a wholistic perspective of stress & fueling.

Call to Action: If you have come this far into this post, follow me on instagram @ultrabhat (link here)!!!

Excerpts from talk with Aleksandr Sorokin

 Aleksandr Sorokin is a Lithuanian ultramarathoner holding the current world records for the distances covered in 24hours [309.4kms], in 12hours [177.4kms] and fastest time for 100miles [10:51:39]. He ran at a stunning 4:03/km pace for 12hours at the Spartanion 12hr race in Tel Aviv, Israel, last week, taking down his own previous records for 12hr and 100mi.

Check out his Wiki page here for more (link here)

Thanks to Sunil, some of us had the privilege to chat with the legend this Friday. Some excerpts from the chat here:

How did you get into running 24hr events?

I moved from half marathon to 100k, to overcome the life habits that he had picked up when he gave up exercise at 24yrs till he was 32yrs old.

Have you quit any race?

At the beginning it was challenging, run hard in the first half and suffer the second half. But I never quit the distance.

How are your second half more faster now? What have you done differently now?

No special secret – it comes with experience. It is more distributed power, more slower in the first half and it comes with experience

Training and Nutrition: Is there a big difference between 100k and 24h if any at all.

Not much difference in preparation. I have to keep a diet since I have a tendency to put on weight. The training week doesn’t differ much between 12 and 24hr. Peak weekly mileage is about 200k to 300k, with 40k to 50k as long runs and with 2 or 3 tempo runs. There is no run beyond 50k distance in training.

You like to eat colas and chips during the run. In training, do you do the same?

No special diet or food preference in training, chocolate bar and any drink for long runs, anything works. No special sport food or ingredients.

On coaches: Up to 2019 I didn’t have a coach and also had a job. In 2019, I turned professional and have a coach now. In 2017, I won Spartathlon without a coach, I would work on training plans and experiment with speed runs – speed and duration. {all you want to know of Spartathon - link here} Spartathlon was the turning point. Before that there was a world championship which didn’t go well. At the world championship I tried to run with a uniform running and it didn’t work. For Spartathlon, I reverted to an old tactic - to run as fast as he could in the first half and get a good lead, this tactic worked. From there I started believing in myself.

2019 world champion in Albi 279k, could have been more if there were less runners?

Yes. But I was happy with the results, because it was one of the best in the history of the event

In less than 2 years, you have gone up by 30km in 24hr race to 309km, breaking the 22 year world record.

Due to pandemic, work closed down and he had more time to focus on running and then also had a coach. Improved 12h run with specific training coach brought about – could do up to 2 to 3 training per day, coach tweaked the blends and made it more optimal.

Do you cross-train?

I do gym with weights and swimming and winter cross country skiing

What are your new goals, now that you have world records in 12h, 100mi and 24hrs in your name?

New goals: Primary focus is 24h to improve that record.

Do you plan to enter trail races?

Not into trail running prefer flat surfaces, may sign up for a 8hr trail run in the future.

What is your nutrition during run?

Prefer to eat as little as possible (only water) to stress the body to produce energy from reserves. During a run I take about 400k calories/hr - 200k per half hour. Sandwiches, banana or oranges or some drinks in the first part of the run. Hydration depends on the temperature - half liter per hour for the race.

Do you feel lack of motivation during these runs?

Night part in the 24h run is the tough part, it’s a wave you feel better and then feel bad, its about patience and waiting for the good phase. Try to be positive, think about his wife who support him, understand that it will be ok and just finish the run

You have some fun videos on Instagram w.r.t gym workouts?

Just teasing around and funny video is a way to entertain himself. Usually 2 or 3 sessions per day – run + weight training + recovery run in the evening. Speed runs max 2 times a week

What’s your favorite distance?

Favorite distance is from sofa to fridge!

How do you recovery from these runs?

Sleep is very important, sauna and physiotherapist who gives good massages.

How do you celebrate after a record-breaking run?

Just relief and no specific celebration

Key Learnings for me and couple of closing observation from my side:

There is no silver bullet to getting better – you got to put in the hard work. Sorokin’s humility reflects in every single aspect of his running – nutrition, training and racing. More legs to you, Sorokin!