first gym session

First time in training shoes in 7 weeks, and first time in gym.  Didn't do too much, just some light recumbent bike, ad and abductors, body weight PT exercises, and upper body.  Just one set.  

It was encouraging.  The knee feels better afterward, not worse.  

I have to keep reminding myself, I'm only 8 days off crutches and to be patient.  My right calf muscle looks really small compared to my L.   I do think this also has been good for my foot arthritis.  I can do 30 single leg heel raises, lightly supported with weight on hand with the right foot without (much) pain.  Before, I couldn't do any without significant pain.  I can definitely see light biking and hiking in 2 weeks.  

I was disappointed to see the ancient rotary hip glute machine was broken.  No one uses it and I will go in there and try to fix it myself.  It's at least 35 yrs old.  The cable has come off the main cog.  I really wanted to use that machine.  It's so old, the company doesn't support that model nor is there a manual available.  I'm really not sure how to attach it, fixing it will be trial and error.  

Lesley

Watching the Masters Indoor World Championships, one story of particular note.  Lesley, age 67, won the 800m World Title in the W65 age group.  The time wasn't massively special (2:53) but here's the kicker:

Leslie is racing on a Total Knee Replacement

My dad and Lesley's husband, Dr. Tom, met at my first Nationals win in IN in 2012.   I saw them at Hayward in 2022 when Lesley had to pull out of the Masters 800m Exhibition race.  She told me then she had decided to have a TKR.  Tom told me that her rehab was "double" what is prescribed for a typical TKR surgery and he owns one of those Alter G zero gravity running treadmills (like $40k).  

There is one at a facility in Chattanooga that I could book a session on for $10.  Maybe I'll consider it in July.   Anyway, I think this story could be inspiring for people who are struggling with knee replacements and shows that TKR isn't necessarily the end of the story.  I recently had communication with the M65 WR holder in the 5k who just had a hip replacement at age 69.  He fully intends to return to elite level and challenge the M70 WRs.  

I did a few new PT exercises today and will ramp up hopefully to full regime by next weekend.  Just living and walking around is actually PT.  This is just day one of post crutches and it feels weak and vulnerable.  Still put the soft brace on when carrying firewood upstairs and doing an errand.  Any kind of stress or accident now would be a huge mistake so part of this is just being super careful.  So far so good.  Noticeable improvement in a week.

Alter G zero gravity running machine:

PT regime

Schedule for my PT protocol for next few weeks.  Will include more strength exercises after this period.

Some things I can do from home and some things I will start at gym next weekend (end of week 7/ beginning week 8).

Week 7:

Leg

- heel raises/ dorsiflex toe  - 3x2x20 

- ham sets - start with isometeric, then ham bridges - elevate to straight - 3x2x15 (hold 5 sec)

- single leg full weight balance for 5x30 sec.  Progress to uneven surface (cushion)

- shallow double leg squats (30º) 3x2x20

- double leg bridges 3x2x20

- reverse lunge static hold 45º 10sec+ hold  3x10 (3x week)

Upper body / core 

- bicycle crunches 4 - 5 x 50

- pull ups - 1x18, 1x 10

- pushups 1x25

Week 7-8 - additional exercises

- zero resistance stationary bike

- hip adductor and abductor machine

- glute and hip flexor machine

------------------

Aqua running, hill walking, and first resistance strength exercises not until May.  Nothing like repeated deep squat, seated leg extension, ham curl type exercise - needs to be avoided for 4 months or until June.

Recovery update

My limited weight bearing is supposed to officially end on Monday, but I've been walking around my house and office.  I dutifully used crutches this week to walk from car to work, and wore my brace every time I left the house.  It does feel like the healing is a bit slower than last time, however, I do have about 90% range of movement in my knee.   I can walk but tend to keep my leg very straight and not a normal gait.  It's painless when full weight bearing when it's straight, but I sometimes feel pain when it's even bent slightly, 5-15º.  I've been doing some heel raises with about full weight.  Also mobility exercises in the hot tub, just bicycling while seated in the water, no resistance.  I'm not going to jump right into aggressive PT on Monday, but ease into it slowly.  Doing some ham bridges, heel raises, and eventually very shallow body weight squats.  It's good to have the blog from my previous recovery.  I hope to be doing some light hiking and casual biking in 3 to 4 weeks.   Hoping the pain will go away as I start mild resistance.  

Continue to eat a lot of collagen powder, capsules, and glucosamine.   Hopefully it will help over the long term.  Over all, I think I've had a good term of healing, no accidents or incidents where I may have caused damage.  I'm fairly certain the root repair is fairly well healed but the circumferential repair will take longer and may cause pain before this new cartilage 'gasket' is broken in.  Patience is hard.

I am tired of sitting around,  but it's been nice watching the IAAF World Indoor Championships from China.   I'll probably watch all 20 hrs of it this weekend.  Been hanging out on my porch by the porch wood stove on the futon in the evenings.  Still cold at night, getting down to 40º tonight.   Last night I tried to sleep with the brace on and that was a mistake.  The weight of the brace made the leg hurt more and I woke up early with the knee hurting in the usual spot.  After having my coffee and collagen, went back to sleep for a couple more hrs and it felt much better.  

Next weekend, I'll be going to the gym to work on bringing back the strength to peripheral areas like adductors and abductors, hip flexors.  Maybe some zero resistance stationary bike and upperbody.  All I've been doing today is bicycle crunches and pullups.  Really need to get HR up.  

I'm going to use my next post to organized my PT schedule.  Weight is under control, hanging about 144-145. 5-6 lbs lighter than after my first surgery.  

Also, the WMAC indoor championship starts tomorrow in Gainesville.  I'm not real interested in it since I can't participate. I had originally thought I might just enter the 200, and try to get on the US relay team, but that's obviously not happening.  Whether I race again is uncertain.  Probably shouldn't.

 

Not heroic

I have to wonder.  

When masters athletes go too far.  Pushing themselves for the sake of competition and damaging their bodies in the process, in some cases, beyond repair.  That said, I think I have been repaired, although the jury is still out on the ultimate success of my surgery.

I've been extremely careful and only now, beginning the 5th week post op, I'm gingerly and only occasionally putting weight on my affected leg.  It still hurts sometimes, but not badly or alarmingly.  Mostly a throbbing feeling.

I recently was featured in Ray's "Geezer Jock" blog.  One of my masters colleagues was also featured recently and praised as a hero for running injured in an effort to defend his title.  I'm not going to mention names but I feel really sorry for him.  He revealed his MRI on social media taken after his race (finished out of the medals, well back), and it was far worse than the knee I just had repaired.  It is almost certainly unrepairable, especially at his age.

Another colleague had been running bone on bone for yrs and has apparently finally retired.  He has literally dozens of National masters 400m titles.  I see some short sprinters gutting it out, running obviously injured, 'just one more race' and not anywhere near where they used to be, like one former world champion I raced at Penn.   World champ, Allan came out of retirement to race the 60m at Nationals, finished 3rd and said he "did not have a good time."  

Another stellar athlete, WR holder won the 400m nationals in her age group and is competing on a torn meniscus.  It doesn't bode well for her future.  Short term goals for long term damage.  People think they can overcome a torn meniscus with PT.  Some even use snake oil chiropractic treatments like red light, cold laser, etc...  Actually, probably no better than a soak in the hot tub and some gentle massage.  All these things are really bandaids and won't help long term.  

It makes me think real hard about ever training to compete again.  

Two kernels of wisdom that Dr. LaPrade's assistant, Dr. Cook gave me... 

1) There are two types of people.  People who learn from their mistakes and people who learn from other people's mistakes.  

2) You have one chance for a surgical repair, and you want to hit a home run.  

I have 2 full weeks on crutches still left.  Last time I got off crutches and on to the underloader brace at 5 1/2 weeks.  I'm a bit behind that repair because I had 95% ROM by the end of 5th week.  I'm a ways away from that, at least 2 weeks I'd estimate.  Right now I can stand on it with full weight with no pain, but I am avoiding doing it.   Still wearing the brace all the time.  I still have a full 8 days before I have to work, which is great.

Staying at around 144 lbs.  Been eating a lot of fruit lately out of convenience.  

 

4 week mark, looking back and forward

Approaching the 4 week mark post op and still being really careful.  Wearing the brace all the time and only occasionally putting small amount of weight on the R leg just for balance.  Dr said 50% weight is ok but not even doing that.  Last 3 weeks have been a good period of healing.  My ROM is about 100º of flexion.

This weekend is the opening meet at Berry College where last year I raced a 400m in 59.75, finishing 36th out of 37.   I'm thinking it may very well be the last time I'll ever break 60 sec in a 400m.  

Back in 2016, I would have been disappointed if I failed to break 56.  I ran eight 400s that year under 56 sec.  I turned 56 that summer.  It was at this same meet at Berry in 2017 where I ran my last outdoor 400m under 56 sec and two weeks later, ran 55.17 in Daegu at Worlds.  For reference, with my 2017 time of 55.79 at Berry, I would have finished ahead of both those runners in the photo - 4 mo short of age 57.  Daegu would be my final sub 56 sec 400.  I did come really close to breaking 56 sec 4 yrs later at age 61, just 3 1/2 yrs ago in Canada with that WL 56.23.  

4 yrs ago I was beating HS kids on the new indoor track in Louisville at age 60.  Ran a 57.81 on that track in 2021.

Anyway, nice to look back.  

I was recently looking at colleagues races and thinking that I miss it, but also thinking how inane it is.  To win a meet, get that medal, while running a time that is ridiculously slow compared to just a few yrs ago.  The last 200m I ran in May '24 was 27.00.  The only time I failed to break 27 sec in a 200m.  My first 200m split in my 400m at nationals in '21 was 26.8.  Even 27.00 is a respectable time for M65. It would rank #3 in world right now M65.  So, at least I stayed relatively fast til the end, if that was the end.

Dates for 2026 World Masters Championships have been announced for Daegu, and it's end of August.  I am really dubious I could ever be ready to race by then, especially after taking 2 consecutive summers off.  I will likely only have been running a year at most by then.  Probably not worth it.  I'm thinking the healing process will be longer this time.  I have two more weeks on crutches and last time I was transitioning off crutches right after the 5th week.  I got a great deal on a brand new Ossur Rebound Cartilage under loader brace for $100.  They sell new for $900.  We'll see how that feels.  I will hit the 5 week mark a week from Monday and I'm on vacation til then, so time for some good healing.  Eating an ounce of collagen a day including an advanced formula (snake oil?) and a generic.  Types I,II,III,V.   Maybe it will help.

I'm not particularly heavy but definitely have gained 3 or 4 lbs of fat and lost muscle.  I'm about 144-145 lbs.  I went shopping for the first time yesterday.  At Walmart, you can shop on line and they will bring it to your car.  Getting it up the stairs was hard.  Used a canvas bag slung around my back.  2 trips.  I had my first fast food sandwich in probably yrs (other than a sub) yesterday.  Wendy's chicken sandwich and FRIES and sweet tea.  Was very good, but deadly.  

I have not worked out with my abs, pullups, and pushups circuit since Monday.  So, undisciplined.  Will definitely do that today.  

My PT will start March 24 with some gentle ham bridges, zero resistance biking, and various other exercises.  

M95 WR 400m

This is Canadian Masters Track legend Earl Fee.   He broke the M95 400m record today (2:01.40).  He already holds the 400m WRs in M85 and M90.  He is the oldest man ever to run less than his age in the 400m, 89.15 at age 90.  

I was fortunate enough to break his 34 yr old M60 400m meet record in Canada in '21 when I ran the WL M60 time of 56.23.  

I'd be happy to be alive and to walk at 95.

Earl Fee - age 95, 400m WR.

Salute!

Brief exercise / lamentations

 I won't even call it a workout but...

5 x 50 bicycle crunches w/ 30 sec rest

16 pullups

25 pushups

9 pullups

It actually peaked my HR at 157.  Better than nothing.   

Just thinking about how this lapse in training is affecting my immediate and possibly future health.   If sprinting makes you young, not sprinting makes me old.  It has to affect my CV health and contribute to a susceptibility to CVD.  Due to my lipid profile, max HR sprint training was the only thing likely keeping me plaque free.  However, I got through it once and ate worse than I'm eating now.  I'm mostly vegan, the worst thing I eat is homemade granola bars.  I'm back on heavy collagen supplements, 2 types of peptides and capsules.   Eating about 22g day of collagen, couldn't hurt.  

The change was so abrupt.  I was struggling back after taking the summer off.  By 12/13, I was probably 2 months away from being back to elite level, or close.  Then, in one day, that Friday the 13th, my life changed, and maybe forever.   Now, forced to take 2 consecutive spring/summer seasons off, doesn't bode well for ever getting to competition level again.  I will likely start the same way, around the same time.  Run once a week Sept, then ramp up.  Sept would be 7 mo.  I may wait even longer.  This could take 9 mo to heal.  I'll be good to bike and swim all summer so looking forward to that.

There is very very little data on 60+ meniscus repair, certainly long term.  One small study of age 60+ with only 32 patients, showed a 78% success rate after 3 yrs, however only 13 of the 32 were body and horn repairs, the rest root repairs.  Anyway, it's a rare surgery for a 64 yr old and the healing time is going to be long.  Longer than last time.  

I don't expect to be doing any significant PT for 6 weeks other than mobility and quad isometrics.  I was really VERY happy to have found my PT protocol packet from the Steadman Clinic's Howard Head sports medicine institute!  PT will undoubtedly be very important to the future health of this knee, but even more, an abundance of caution and most of all ... time.  

PT protocol package from '19 - 

Repair details/ photos, meeting with Dr, healing strategy

Dr. Saliman explained a bit about the root repair and told me that after a week, "there is zero chance it has healed by now."  Which is obvious, but I needed to hear it.  It has changed my behavior.  I am now wearing the soft brace all the time and being much more conservative with movements.  He said that if that root repair gets loose, it may not heal.  Definitely needed to hear that too.  As he said, it was a "nasty tear."

The main radial tear was 1 cm from the native root site, my question was about how the root placement was handled.  It was an unusual repair as the root tear was 1 cm from the attachment, the longest distance from the native root attachment which root repairs are normally made.  On the diagram below, the tear was full width through the area at an oblique angle.  The typical 'type 4' (LaPrade term) oblique tear shown below is closer to the root, mine was further but extending into the root.  (diagram is approximate, of course).   What made this repair unusual was that both sides of the tear, the long side and the root stump side were sutured and reattached to raw bone.  Dr. Saliman said, "we usually don't do this."  

The tear

Meniscus root and meniscus body attachments

Knots on the root repair, 3 circumferential stitches on right

Pulling the meniscus root(s) down to bone for healing

So, this was really a state of the art repair.  There is definitely a risk of failure.  I really want this to work so I'm going to be super cautious.  He said 50% weight bearing ok, I'm going non-weight bearing like I did last time.  

surgical report

Tomorrow is the followup with Dr. Saliman.  In advance, I received the surgical report.  Here's an excerpt:

The medial compartment was evaluated carefully. The tibial-sided peripheral body region
tear was rasped to help stimulate healing, as was the radial root tear that was
approximately 10 mm away from the native root insertion site.  A shaver was used to
debride some of the central edge tissue as was the biter.  Middle third and peripheral
third tissue was not excised and instead was repaired back to the bone by creating a
tunnel through the tibia via an anterior tibial incision and a FlipCutter guide. A curette
was used to debride the cartilage from around the insertion site into the joint of the pin
to give a nice bony bed for the meniscus to heal into. The Smith and Nephew
NovoStitch device was then used to pass sutures which were shuttled out for 1.2 mm
mini-tape sutures and then passed within its own loop to create the locking loop
stitches. These were then pulled through the tibial tunnel and tied over a metal button.
The meniscus was probed and found to be securely repaired back to the bone. The
body region tibial-sided peripheral tearing was then fixed using the Smith and Nephew
NovoStitch device and spinal needle and a CHIA suture shuttle via 2 different
approaches in order to place circumferential compression stitches to adequately
capture the capsular side of the tibial tear. Revo knots were tied and cut in square
fashion. This tear came together much like a puzzle and required advanced training
and experience in order to anatomically reduce and uniformly compress the tear edges
adequate to hold them together during the 6 weeks it will take for this tear to heal.
Rachel S., a qualified physician assistant/associate provided crucial suture
management and intra- and extra-articular suture retrieval assistance throughout the
procedure, facilitating precise sewing and knot tying. This was particularly important
due to the complex nature of the patient's meniscus tears within the challenging
constraints of the peripheral and posterior knee compartments. 

So, it seems the radial tear was close to the native root insertion site, that it became the 'new root.'  Probably better that this tear was close enough to the root that it could be treated as a root repair.  Pretty high tech surgery, virtuoso technique.

one week

Bandage off.  Still sore on medial side.  Don't really need ice machine any more but using it once or twice a day for comfort. 

Doesn't look too bad compared with some surgeries I've seen (especially out of the UK).  In a few weeks, there will be no visible trace of surgery
 

 

Training begins

Just kidding... but, I am absolutely stunned at how relatively painless this surgery has been and how quick the recovery is going.   Haven't taken one pain pill and am sleeping ok.  

I already have greater than 90º flexion, naturally, not forced, no swelling, no Bakers cyst, nothing.  I can actually do body weight heel raises (2 footed).  Still cycling between hot tub and ice machine 2x / day.    For 5 days out, this is amazing.  Haven't work the brace at all, but I will when I eventually leave the 2nd floor of my house.  

I am being extremely careful, crutches, pretty much non weight bearing except once in a while - some slight weight.   I am exercising doing bicycle crunches (keeping surgical leg locked at an angle), pushups, pullups.  However, can only get the HR up to just over 105.  My first mini workout on Thurs, 3 days post surgery:

4 x 50 bicycle crunches w/ 30 sec rest

25 pushups

15 pullups

Not to say it is completely painless, but it's all relative to my previous experience.  I still feel soreness on the medial side.  I will likely take another week off to make sure of the healing.

Post op zoom meeting with Dr. on Tues.  

One peripheral benefit from this lack of R leg weight bearing is that it's the same side as my arthritic foot.  So, that may lead to some improvement.

Tonight's workout:

4 x 50 bicycle crunches w/ 30 sec rest

30 pushups

16 pullups

Max HR - 152

HR 128-144 - 3:15

HR 145-152 - 0:32

Interestingly the max HR was the pullups. 

 

Fixed

I just completed a combination complex medial meniscus and meniscus root repair.  Surgery went well and surprisingly, there is very little pain.  I haven't taken one pain pill since the surgery, except aspirin.

Dr. Saliman was a bit more liberal with his post op than my previous.  His root repair protocol says "50% weight bearing for 6 six weeks".  LaPrade was non-weight bearing for 6.  I asked if there was any down side to being more conservative and he said, "I don't want you just laying around.  Because that's how people get blood clots."  Fair enough.  

The whole experience was much easier that I expected it would be.   Especially the return.  However, it started off a little strange,,,

I took a $50 taxi ride to the surgery center at 5:15 am.  My appointment was at 6:00, got there at 5:40, still dark.   The front door to the facility was locked so I was walking the streets of W. Hollywood looking for a back door.  Found a back door and a delivery guy said I had to go around and he'd tell them I was there.  Waited 10 more min at the front door then called at 6:00 am.  They said to come back to the same side door and enter through a different hallway.  Finally found the surgery suite.  For a while it felt like I was seeking a back ally abortion or something.  After a bunch of paper work and interactions with some stunning beautiful Asian and Persian nurses, I got prepped for surgery.   Surgery was supposed to be at 7am but Dr. Saliman came in about 8, reviewed the MRI, then met with me and diagramed out on paper what it looked like and strategies for repair, which he would decide on when he saw the extent of the issues.  He was sharp, personable, and assuring.  At 8:45, I actually walked from my recovery bed to the surgeons table with my IV tree.  I was out in a few minutes.  Surgery took about a 80-90 min.

I awoke with a stack of photos of the procedure on my bed .  Dr. Saliman called me that night in my hotel to see how I was doing.  We discussed the surgery and generally what he did.  But I didn't have a list of questions prepared and I didn't ask him some things I meant to.  I will meet with him again in a week via zoom so hopefully, he'll have notes from this surgery and my case file for our brief meeting.  

There are 30 photos of the procedure and some are not really discernible.  The photo above shows small circumferential stitches on the right for the complex repair, and the larger root repair fiber on the left.  My main question is what was done with the main oblique tear?  Was it close enough to the root that one end of the tear was drawn down to bone for healing?   How much was trimmed?  

Anyway, it seemed to have gone well, and I'm optimistic.  Dr. says I'll be running again.  

The trip back was great.  Booked an extra leg room seat and with an empty seat next to me, it was one of the most comfortable flights I've been on.  3:40 hr flight went by fast.  Got wheelchaired to the parking shuttle and was in my truck by 4:20ish.  Best of all, no problem driving with my surgical right leg.  Can pump the calf within no pain or problem.   I was expecting it to take 3-4 hrs post landing to get home.  It took 2 hrs.  Coincidentally, I pulled in my driveway at the same time Roya was arriving from Atlanta.  

Saliman is on the forefront of meniscus repair, taking on cases no one else will.  I interacted with a fellow patient whose meniscus was so shredded he required 17 stitches.  I think I had 4 or 5 beside the root repair.  Dr. told him that he "turned chicken shit into chicken salad, no one else would have repaired it."  

I'm certain that meniscus injuries are one of the most poorly and inconsistently treated of all orthopedic injuries, especially in the over 55 yr old age group. Since I joined a meniscus tear support group, I've seen  some really ill conceived advice and primitive treatments and surgeries (especially from the UK).  

I'm really happy with my decision and happy to get this done.  I can still certainly exercise, can do pullups, core work like bicycle crunches, pushups off of one foot.  Rehab starts now with active leg extension, patella mobility, isometric quads, leg raises.

APPROVED

My surgery was approved by my insurance company today, according to my physician's office.

I'm on for Monday, Feb 10.  I should be hiking by wildflower season.   Very happy to have cleared this hurdle.

pool, no word

Pool on Sat and tonight, Monday.  Still no word on my pending surgery or final disposition from insurance.  Very unsettling not knowing, although I have travel arrangements in place for a Mon surgery. This would be the 3rd surgery date they've given me but it's not confirmed yet.  It would be nice to have a bottom line by Tues.  

Sat pool:

6 x 50yd w/ 65 sec rest - 39, 42, 43, 46, 47, 48

Max HR - 157

Mon pool: 

6 x 50yd w/ 62 sec rest - 39, 41, 43, 45, 47, 45

Mon was a bit better, both hard.   Maintaining upper body strength, still able to do 22 cheater pullups (not full extension hang).   Weight is ok, hanging around 142 lbs.

My father is disappointingly negative.  He thinks I shouldn't endeavor to run, just use up my knee and go to a knee replacement like him when necessary.  He was 71 when he got his knee.  I'm not even close to bone on bone.    He's also been relatively sedentary and overweight most of his last 30 yrs, while half that time I've been maintaining the training and competition schedule of an active college athlete.  I respect he's almost 85, in decent health, but I don't want to live my life like him.  

It gives me hope looking back at my recovery from the previous surgery.  I was casual biking and light hiking in 8 weeks, hard effort biking in 10 weeks, light running in 5 mo, hill running in 6 mo, sprinting in 7 mo, and full scale training in 8 mo, and running a 62.5 400m in just 9 mo (Oct. '19).   I was also battling plantar fasciitis during that fall so was hampered a bit, which kept me out of indoor season.  Covid hit the following spring and there were no meets til late summer.  The one and only 400m I ran in'20 was in late July and was an M60 WL -  57.49.   I don't consider that completely legit due to covid, nevertheless, that was the start of me holding the WL for 2 yrs.  

pool

 Same workout in the pool.  Pretty much the same times.  This set is always a good workout and brief.

Pool

6 x 50 yd w/ 1 min rest - 40, 42, 43, 45, 49, 50

HR max - 160 (40 sec after the last rep)

HR avg - 128 (including 12 min of getting dressed and walking out)

After dropping to 107 several min after the workout it went back up walking out and up the stairs.  Surprised my HR stayed in the mid 120s for so long and got to peak after last rep.  I can really feel the stroke efficiency suffering in the last 2.

I do like this workout, takes 10 min and it's hard.  Feel really pumped afterward.  

142 lbs after workout.  

Still in Limbo, the denial system

My surgery has been rescheduled for the 2nd time.   Now it's Feb 10.   As I had mentioned before, I am waiting this 'vendor' of the BCBS insurance company to respond to my surgeon's request to appeal their initial denial for authorization of the knee surgery.  This vendor is called TurningPoint Health.  So, I did a little research on this outfit and saw what the requirements were to be a reviewer of "peer to peer" cases like mine.  I'm really just writing all this for myself for reference.  

I found on their website a job listing for a "Clinical Peer to Peer Reviewer" for this company.  (This specific job was for peer to peer evaluator for spine).  I was shocked.  These are the qualifications of someone that represents my insurance company, who must decide on my medical treatment, and is supposedly an 'expert peer' that will evaluate my case with my world renown surgeon who is a specialist in the procedure that I need.  Here are the basic qualifications for a "Clinical Peer to Peer Reviewer" for the TurningPoint Health vendor:

Education, Experience and Licensure: 

• Master's Degree as a Nurse Practitioner or Physician Assistant 

• A Board certification as Primary Care and or Acute Care Nurse Practitioner or Board certification as Physician Assistant; Active State Licensure 

• Minimum of 5 years' experience. 

Un-FN-believeable.   Not a physician.  Not even any specific training in surgery, orthopedics, research, or most importantly, not any specifics related to spine! 

Here's another health company and their peer review requirements:

Acentra Health must have qualified peer reviewers who meet the following federal regulations: Must be a doctor of medicine, osteopathy, dentistry, podiatry, or optometry, or another individual who is authorized under Federal or State law to practice medicine, surgery, osteopathy, dentistry, podiatry, or optometry Have a current state license. Are board-certified.  Active practice means that the physician usually practices (on a routine basis) a minimum of 20 hours per week.

Seems that TurningPoint Health has under qualified peer review compared with industry standards.  They mention "peer reviewers who meet the following federal regulations: Must be a doctor of medicine."  

Further, the American Medical Association (House of Delegates) states:

"... the reviewing P2P physician must have the clinical expertise to treat the medical condition or disease under review and have knowledge of the current, evidence-based clinical guidelines and novel treatments."

It seems to be the law:   § 476.98 Reviewer qualifications and participation. LII Electronic Code of Federal Regulations (e-CFR) Title 42—Public Health.  Subpart C—Review Responsibilities of Quality Improvement Organizations (QIOs)  

42 CFR § 476.98 - Reviewer qualifications and participation. (a) Peer review by physician. (1) Except as provided in paragraph (a)(2) of this section, each person who makes an initial denial determination about services furnished or proposed to be furnished by a licensed doctor of medicine or osteopathy or by a doctor of dentistry must be respectively another licensed doctor of medicine or osteopathy or of dentistry in the QIO area.

In case of a denial, this sure will make my case for an external review or lawsuit pretty strong.  Are you kidding me?  A masters degreed nurse practitioner telling an expert surgeon what he should or should not be doing?  This is f-ing crazy.   

Pool, still in limbo

Did the same pool workout tonight, intervals a little more even.  Good short workout, takes only about 10min.  HR higher tonight.  Stuck closer to my 1 min rest interval.

Pool

6 x 50yd  - 44, 43, 45, 47, 48, 49

Max HR - 164

HR 145 - 152 - 3:15

HR 153 - 163 - 1:00

 It was hard, but short and sweet.  I'm sure I could improve my times with an aggressive flip turn, but I'm only pushing off gingerly due to my knee.

Doesn't look like my surgery will happen on Thurs unless something big happens tomorrow.  The insurance company Drs have failed to timely confirm a meeting with my Dr. and as a result, I will likely lose $300 in a non-refundable airline ticket.   I may have an option to have surgery Mon, 2/3.  So crazy, the way I've been jerked around by this insurance company.  

 

Pool, crazy limbo

Here it is coming up on 2 days before I leave for LA for surgery and it's not going according to plan.  I did finally get back to the pool today amidst a hectic first week of classes where I've arranged to be gone the next 2 weeks from MTSU, but Sewanee is crazy ... huge turnout, biggest ever.  I have to teach 5 hrs without a break on the Tuesday before I leave Wednesday.  

My insurance company rejected authorization for my surgery pending a 'peer to peer' review with my surgeon that took place last Friday.   Generally, physicians are 90% successful in justifying surgery, after asking 2 that I know, one a thoracic and the other an orthopedic.  However, it could very well be denied and then, the cost out of pocket could be in the range price of a new car.  I'm talking $30k.   

I have no doubt that Dr. Saliman can make a convincing clinical case for surgery as he likely has these meetings all the time, but he doesn't have my medical records and doesn't know me and why I specifically am a good candidate for the surgery:  most convincingly that I rehabbed a similar previous surgery completely, demonstrated by elite level athletic performance and no reinjury.  Also, normal BMI.  Plus, the insurance covered it completely last time, and they are only obligated to cover 60% this time.  However, the facility and the anesthesiologist claim independently and may offer more coverage.  I should find out by end of day Monday.  And, here's one more crazy thing.  The person who files insurance and delivers cost estimates for the surgery center I was told she has been out sick since Wednesday.  This is nuts!

After 35 yrs under the TN State BCBS insurance plan, I have never had a claim denied.  Here was the verbiage for the initial denial:  

Denial Reason: Lack of sufficient clinical documentation Your records were carefully reviewed. The request to fix a torn cartilage cushion meniscus in your knee cannot be approved. More information is needed regarding your diagnosis and planned surgery. This needs to include your BMI height-weight measurement. Also surgery to fix the tear works better for those who are less than forty years old. It also works better for patients who are forty to fifty years old and very active. Your records do not show that this is the case for you. Please talk with your doctor about treatment options. A copy of this letter went to your doctor.

Yea, they ask about my BMI and say "your records were carefully reviewed."  I have never heard such a level of absolute bullshit.  For years, I've received the full $250 cash incentive awarded by this same company for, in part, keeping a normal BMI.  And.., hmmm, I'm "not active"???   When I chatted with a phone rep of BCBS, she said the decisions were made by their 'vendor' Turning Point Health.  She would not allow me the contact info for this decision maker (although their number is on their website) and was acting as an intermediary between me and them on the phone.  They said something incredibly stupid and ignorant to her about first trying "conservative treatments" before surgery.  Yea, conservative treatment to mask the pain so as to make my meniscus degenerate and become unrepairable.  Dumbasses.    

So, age being the biggest factor, Saliman has debunked that on his website and two studies state at least an 80% success rate of such repairs over age 60.  Due to my previous rehab experience, I would say I'd be closer to 90%+.  

Studies show, successful repair is obtained up to age 70 years.... age, as an independent factor, should not be considered a contraindication for meniscus repair: https://pmc.ncbi.nlm.nih.gov/articles/PMC9891740/ 

https://www.mdpi.com/2077-0383/12/21/6922

Anyway, the next phone call I get from them could be worth $20K either way.  I'll be pretty out of my mind if I don't find out definitively by tomorrow.  I am fortunate that I can afford to pay it, and there is both internal review appeals, and an external independent review process, and of course litigation.  I think I could compile a slam dunk case for an external review.  

Maybe this is a sign of the times.  

The general Republican MO in regard to healthcare, Big Pharma, the VA, etc… is to privatize, maximize profits at the expense of consumer, usually the sick and elderly.   The first things Trump did when he came into office was to eliminate price controls on pharmaceutical drugs for those on Medicare and Medicaid, freeze hiring for VA, stop all research and information sharing for the National Institute of Health (effectively halting cancer research), and for the CDC (in the midst of a severe bird flu pandemic), and withdrew from the WHO.  War on science and gifts to big pharma, CEOs, stockholders, etc...  

Anyway...

In the pool today, I did my usual interval workout and I was really winded but HR never got above 153.   Of course this is from my highly inaccurate watch.  Only 2:30 over 145.    I wonder if this time away from leg use and sprinting will lower my max HR?  

It was pretty much like the previous:

Pool

6 x 50 yd w/ 70 sec rest - 40, 41, 43, 46, 49, 50

I did feel pretty pumped when I finished.  I am quite light.  140.2 lbs.  Maybe losing muscle mass?  

pool, orthos

I've settled on a short simple interval set.  I can be in and out of the pool in about 15 min, and I can do it everyday if I want.  Using watch is inaccurate for HR but I'll post it anyway.

Pool laps  6x50yd w/ ~1:10 rest - 40.3, 45.9, 45.2, 46.3, 49.2, 50

Max HR - 154 

          HR avg - 128 

HR< 128 - 5:09

HR 128-144 - 6:49

HR 145-152 - 1:15

Not exactly 'running the engine hot' like the anaerobic power of track sprinting... more like a zone 2-3 workout.  

At least I'm not heavy - 141. 3 lbs after workout.

About undertaking this surgery, I'm thinking it's going to be a helluva miserable inconvenience. Crutches to early/mid March.  With my time off and spring break, I'll only have to endure 3 weeks or so of crutches at work.  I'm going to follow Dr. LaPrade's more conservative protocol of 6 weeks non-weight since it worked before.  I asked Justin about it, he said I'm more than welcome to follow a more conservative protocol but he says 50% weight bearing ok.  I asked him why, and he said, 'because my stitches are strong.'  Not worried about the stitches breaking, but what they're holding.  Curiously, his radial tear protocol is more like LaPrade's, 6 weeks, no weight.  So, since I do have a radial tear, that's what I'll follow.  LaPrade's decision to not treat this doesn't bode well for my chances for a complete fix.  He saw the risk and chances of success, and at this stage of his career at age 67, didn't want to deal with it.  Justin however, I feel is at the top of game, only 50, and willing to take on the tough cases.  

surgery

Dr. Justin scheduled me for surgery in 2 weeks, 1/30.  My meeting with him was OK.  He described my injury as a oblique root tear along with other parts of the meniscus.  He noted some wear already on surfaces and couldn't be certain the level of repair he could accomplish 'til he got in there'.  I wouldn't say he was brazenly optimistic, nor roundly pessimistic.  Perhaps a bit aloof.  I do like him, trust him, I like what I've seen from his staff, his prompt scheduling, and his willingness to work with my insurance company to reduce my out of pocket expenses.  He did push the BMAC stem cell treatment which I declined (because I don't think it really works that well and is expensive) and like last time, opted for PRP only.   He also mentioned the MISHA knee device, an internal prosthetic, but I'm pretty opposed to that at this point since it is so new, only FDA approved 4/23.  It would be last resort before a knee replacement.  

The logistical issues involved with doing this in LA, in the W. Hollywood area, are formidable.   I know it will not be at all like it was in Vail at Steadman.  It's basically check in, surgery, and adios.  No PT meetings, just bye-bye.   Followup via zoom.  His post op protocol is far less conservative than LaPrade's.  I'll be flying in Wed, surgery Thurs, home on Friday.  At least I won't need to drive.  One of the worst parts is finding someone to check me out.  They will not release me alone to an Uber.  Roya found someone through her caregiver network that I could hire for $150 to check me out and drive me to the hotel, will be worth it, LA during rush hour.  Good, so I don't have to drive in LA.  I'll checking out of the hotel to the airport shuttle only about 15 hrs after I return to my hotel after surgery.  I'll be glad to get home.  

I remember the trip to Vail, this same time of year, 6 yrs ago, it was truly epic 

 

short intervals in pool

At the pool again today, I tried a short interval workout.  50s.  Found that my bicep heart monitor does not work in the pool swim setting, and when it's activated using another mode, like track or gym cardio, it doesn't consistently connect.  So I use the watch, inaccurate HR but it measures distance and strokes quite well.  I'm not going to put absolute data for this workout but I did 6x50yd w/ 1min rest in 40-48 sec.  Pretty slow considering DIII college swimmers cover this distance in 21-22 sec, with a turn, but they also start from a starting platform.  

Tomorrow is my consult with Dr. S.  I'm really quite nervous about it.  I'm happy to see the fires in LA have spared his office and hospital, Cedars-Sinai.   Still no significant pain in the knee.  Looking back, I think I was biking up the mountain just days, maybe even the next day, after the Oct. '18 meniscus tear.  I think pain is not an adequate indicator of the severity of knee injury.  Meniscus injuries seem to have a great variability in treatment, but it seems to me, to achieve a higher level of athletic function, requires a higher level of treatment expertise.  

Pool

Pool opened today and I was there.  I had the place to myself.    Don't yet know how to structure my workouts so I tried to do something similar to what I do on the track.  I tried intervals of 100m, then a few 50m at the end.  Didn't swim much, 450m I think.  Didn't want to do a lot because it's a new thing.  Probably get sore in the lats.   I did 3x100m and 3x50m.  At the end of my 3rd 100m interval, I did just hit a max HR of 170 for a second.  My HR sensor was not connecting well with my watch so I don't have good HR data.  If I'm reading this right, my best 100m pace was about 1:21 sec,  slowest 1:45 sec.   I'm going to do this more often and see if I can get a routine going.  Don't enjoy it that much because it's upper body oriented, but it's better than nothing.  

Another CVD prognosticator

Another study.  Another possible risk factor indicator:  Triglyceride/HDL ratio.  Here is the study issue paraphrased:

Low-density lipoprotein cholesterol (LDL-C) has been cited as the main responsible factor in CVD. Nonetheless, even when LDL-C is well regulated, mainly with statin therapy, a residual risk for CVD still occurs, and it is attributable to other lipid components, namely triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C). Increased TG and decreased HDL-C levels have been associated with metabolic syndrome (MetS) and CVD, and their ratio, TG/HDL-C, has been proposed as a novel biomarker for predicting the risk of both clinical entities... Inflammation plays a crucial role in the pathogenesis of cardiovascular disease (CVD), as it has been linked with both the initiation and progression of atherosclerosis. HDL-C has been linked to cardioprotective effects via its antioxidant and anti-inflammatory properties.

The above paper cites numerous studies showing the relationship between the TriG/HDL ratio and CVD.  

Looking back at my previous test results, when my LDL reached it's highest, 203 (on the egg diet in '21), my HDL also reached it's highest, 59, while my TriG were low, 73.  That gave me a TriG/ HDL ratio of 1.24. Best it had ever been.  Then 4 months later, I congratulated myself for lowering my LDL to 105.  But, my TriG/HDL ratio actually increased quite a lot:  117/44 = 2.70.   Not terrible, but significantly worse.  

As I had discussed in a previous post, the other metric that serves as a prognosticator for both CVD and stroke is the apolipoprotein B1/A ratio discussed in detail in this study.

possible Drs appointment cancellation/ postponement

Who could have thought my Drs appointment next week with Dr. Saliman on my knee would be affected by an out of control wildfire?  Are you kidding me?  My MRI disc was supposed to arrive Monday but tracking says it's delayed "by weather conditions" although it is in LA.  

Dr. Saliman's office on Sunset Blvd is literally one block away from a level 2 fire evacuation zone.  Level 2 means "get ready."  Level 3 means "go."  

I've been waiting for this appt for 2 weeks but some people in LA have obviously far more serious problems.   Assuming I get a meniscus repair, it will take 18 mo to get back to elite level.  Really not even enough time to get ready for '26 if my surgery is delayed much past Feb or March.  

We're about 36 hrs away from a major winter storm, and for here in the deep south, a "major winter storm" means more than 3-4" of snow.   And, due to gross incompetence at the Chattanooga Capitol Toyota dealer's repair shop, I will be without my 4x4.  After a month and 3 different diagnoses, I was told the truck needed a new transmission and transfer case for $9000.   I called BS, took it to the local transmission shop and it was what I originally thought and told them from day 1.... an electrical short in the wiring.  Cost for a new wiring harness installed:  less than $600.   Unbelievable!

Totally sedentary except for my daily 20 pullups, ab wheel, pushups, and bicycle crunches with ankle weights.   My V02 max is gone.   Pool opens Monday.  

MRI with contrast 2/19

2/6/19 just after my previous knee surgery I went to the ER with a heaviness in my chest, I was worried about a pulmonary embolism or clot.   After D-dimer tested high they recommended a CT chest scan with contrast.  I went down to the hospital and picked up the report and disc of that test today.  The report was very detailed and basically said the word 'normal' about 10x in regard to my heart and coronary arteries.  No mention of blockages.  Not really very informative.  FWIW...  

CV Study - dietary LDL / carb intake

This is an odd one.   Purely an anecdotal case study, but references a cohort study on a subclass of individuals who are “Lean Mass Hyper-Responders” (LMHR):  

A recent cohort study of 548 persons on carbohydrate-restricted diets (CRDs) revealed inverse associations between triglyceride/HDL-C ratio (TG/HDL-C) and LDL-C change, and between BMI and LDL-C change, on CRD. This means leaner persons with lower TG/HDL-C ratios generally exhibit larger increases in LDL-C on CRD. Individuals with a particularly pronounced high LDL-C, high HDL-C, low TG ratio are termed "Lean Mass Hyper-Responders." This report provides a clinical vignette of a patient who exhibits the Lean Mass Hyper-Responder phenotype, with LDL-C as high as 545 mg/dl, despite normal pre-CRD LDL-C of 95 mg/dl and consuming a CRD with a high unsaturated/saturated fat ratio. Coronary CT angiography conducted after 2.5 years of extremely elevated LDL-C reveals no detectable plaque development.

This seems to correspond to the time when I was on the zero carb 'egg diet'. Although I didn't exactly meet the criteria for this phenotype -  LDL-C ≥ 200, HDL-C ≥ 80, and TG ≤ 70 mg/dl, I was close:

March '21 - mean body weight about 138.5 lbs, likely about 9-10% body fat, LDL - 203, HDL -59, TriG - 71.   Never had my HDL been that high at the same time my TriG were that low.   My Trig/HDL was never better.  

The case study "LM" was only in his 20s, but after having a LDL reading as high as 545, after two+ yrs on the diet, angiography showed he had accumulated zero plaque or heart disease.  

Back to square one.  It's all very individual and complex.  

Reviews and discussion

I was reading some online discussion on meniscus repair specialist, Dr. Saliman.  Seems like he is willing to tackle the tough and difficult repairs no one else will.  He has a technique called 'circumferential compression repair' which he wrote a paper on in '13.  

Here is some of the discussion I've read from his recent patients who've had surgery with Saliman in just the past few months:

"I had an extremely complex tear that was repaired by Dr. Saliman on September 5th (I’m 7 weeks post-op today). It required 11 stitches to repair and Dr. Saliman said he had to piece it together “like a puzzle.” I traveled from Virginia to see him after doing a second opinion with him because my local orthopedic doctors could only offer a meniscectomy... My physical therapist is super impressed with how I’m doing given being in a straight leg brace for so long. And after seeing the pics from my arthroscopy, she is also amazed that Dr. Saliman was able to repair my tear so well (she mentioned she had never seen a tear so “wavy” before)."

"He said same thing about my repair, it was “like a puzzle” :)))...   I counted 6 stitches. 

"08/26/24 had my ACL and meniscus repaired by Saliman. He really cares about ur success. Told me 85% chance of success.  He told me my meniscus was one of the worst torn ones he's ever seen ...so longer surgery (2 hrs). High character guy. BS free.  Used BioBrace Graft reinforcement & Regeneten reinforcement grafting to the medial meniscus repair."

I think Saliman is a good choice from what I've read but it won't be cheap.  I'll probably pay several $K out of pocket, but that's ok.  My insurance will still pay 60% (for out of network) and I have a $7200 out of pocket max.   His use of new technology (i.e. MISHA knee system, BioBrace, Regeneten, etc...) demonstrates he is very current, and he shows meticulous attention to detail.  So, I think he might be able to help me.   

Hope the new year brings a new knee.  Will be a long recovery.