Running - Post Op Performance Running by Cory Foulk
I love to run. I have run my whole life. During the Ultraman World’s this year, the winner, Alessandro Ribeiro, of Brazil , said that he had been running since he was six. He was never more comfortable than when he was running, he said. We all understood that. Hard or easy, it doesn’t matter to me. I am never more comfortable than when I am running. Yes, by the time you are sitting in a pre-race athletes meeting at the Ultraman World Championships, you have come to terms with running at many different levels. I have used running as a coping mechanism in life and a tool in business. I have used it to open doors and to close them, for fitness and for fun. I have earned my rent by running, put food on the table, and I have raised money for countless charities and causes the world round – with my feet. I have raced many of the world’s people on foot, running with Africans in Africa, Europeans in Europe . The Chinese in China . I have hosted them in my world as well. I have run with the Tamahuare and with Columbians. Running crosses all cultures and boundaries in my world. I have discussed food shortages in the Kalahari with a Swedish surgeon while running through the Gobi desert in Mongolia . Spent hours talking about the Kyoto Accord with a New Zealand sheep farmer while we ran up the flank of Kilimanjaro in Central Tanzania . The world around is filled with Cory’s, large and small, old and young. We run and we work, we work – and we run. The allure of running can never be explained, I have tried and stopped many, many years ago.
It is not about endorphins. Research shows that after about three weeks of a physical effort, the human body adapts and stops producing endorphins to compensate for aches and pains. The much hailed “endorphin junky” is no longer. Shoot. That had a certain cache I thought. Kind of a “bad boy” thing, without having to ride a Harley and carry a knife.
It is not about discipline, or structure, though it can be. It is just a part of some people’s lives and that part can be a lynch-pin; a pivotal part.
I have a BHR hip resurfacing device in my right hip. So very often I hear “it’s about time. We all said you would wear out your joints”. Oddly, joints use impact to flush blood through, with nutrients. After the age of 22 or so, our blood supply to the joints closes off, and impact squeezing cartilage like a sponge becomes the main source of nutrients for repair of joint surfaces. The less activity, the less blood is available to repair natural wear. Looking at my natural hip, it is very clear that a hip that is heavily used will not wear out, as long as it has no other chronic problem like OA. I have been running at the marathon distance and beyond since 1976, and my hip joint space looks like a 20 year olds.
I had an accident, one of many cycling crashes I have been involved in over the years, and broke my other hip. They pinned my femur together, and it worked fine. However, the pins interrupted blood flow to the joint – and I suffered OA via AVN. Ouch. Hence, the BHR.
My story is all around the net, so I won’t waste space here with that. What I am noodling at here today is a commentary on running, with a BHR device. I likely have more miles on a reline in this fashion than any person on earth, and those miles have been a roller coaster of achievement and failure, pain and knowledge gained. For all the runners out there, I have some ideas that may help. I have run long, hard, difficult races successfully and been fine. I have run them and ended up in a wheelchair as well. The idea here is to tend toward the former. It is very simple after all of it. Here goes:
When a joint is resurfaced, the ends of the bone that contain nerves are jacketed with metal, shielding the nerves from stimulation. It is exactly like capping a problem tooth. Once the dentist has put the cap in place, there is no pain whatever, simply because the nerves are covered. In the case of a Hip Reline, the metal “caps” are substantial in thickness and are very effective at permanently ending joint pain.
So why do I hurt when I finish running? Or while running? “If there are no nerves exposed, then the device must be failing for me to feel pain!” I hear this all the time from other hippies, and I have thought this many, many times myself in my recovery and return to sports. I hit a truck on my bike in one race, traveling at more than 25 MPH, and then had to not only get back up, but ride 130 miles more and then run 52 miles. I hurt badly. I broke my helmet in half I hit so hard! Yet, X-rays showed the BHR was entirely intact and in place afterwards. I realized then that it would take a lot to dislodge the device. I mean a lot.
I have a BHR on my desk. It is heavy. Incredibly heavy. It is solid steel. It would take a lot to wear it out. Way more than human tissue could apply it seems. So – why did I hurt when I ran. Most particularly, after I ran. If it was not dislodged, and was not worn out, then what?
Hip Resurfacing Clearances
This link shows a BHR in section. It is important to note that the two components are not perfectly symmetrical. The femoral component is perfectly spherical. The acetabular cup is not. It is dome shaped. The reason is so the two pieces together will draw synovial fluid into the space between as they move, lifting the metal up onto a cushion of fluid. Almost friction free.
If you take the BHR on my desk, and spin it, it will spin for a very long time. The tolerances are unbelievable. However, if you spray it with Windex, which has about the same viscosity as synovial fluid – WOW! It will spin and spin, almost like a perpetual motion machine. This is because there is no solid in contact with another solid. It is all hydraulic with the cushion of fluid between.
When we use a BHR or other reline device, it initially bears very slightly metal on metal. Because the two pieces are not exactly the same shape, this initial bearing is along a line which traces a ring around the inside of the cup. This is called “ring-bearing” for that reason. With motion, the device fills with fluid, gradually lifting the surfaces away from each other. The more impact that is being applied to the joint, the more fluid depth is required to keep the pieces apart.
Ring-bearing causes higher friction on the two parts, and so they shed metal ions. Specifically the femoral cap. These ions are primarily chromium, and they seed soft tissues in the area initially. This seeding causes an inflammatory response, irritation and – pain. Very deep seated, intense, awful pain. Worse than any AVN or OA related pain I ever had.
Additionally, the higher friction I believe forces the muscles to work harder, and the tendons therein to be under higher tension. All of this adds up to – pain. The more impact, the more friction, the more pain.
If you are a runner with a reline, you know the point at which this happens.
When I run, there is a lot of impact at higher paces. I am able to run a 5 minute mile pace today, and hold onto that pace. That means my legs are covering around 6 and a half feet per step, and are taking around 90 steps (each) per minute. That is a lot of impact, and a lot of impact cycles per minute. I am currently running around 85 miles per week. That is a lot of minutes.
How on earth can we stand the kind of pain that would generate? Any BHR runner out there knows exactly what I am saying. Exactly. Are we tough? Nuts? Superhuman? Hardly.
I am a student of physiology, and sport, and human response. So are my cohorts. No matter our trades, we all come together in this part of our lives. Lab rats all, we subject ourselves to any number of scientists and docs, crackpots and shaman. From this we have found several keys to running on a resurfaced hip at higher speeds and for longer distances.
The first is warming up. How simple is that. We all warm-up. Every runner knows to warm-up. We all do it differently. Sometimes we skip it, no time. But we know to do it. However, with a resurface, the warm-up is no longer optional. It took me years to learn this. YEARS. The warm-up is not optional, and it is not something to sort of do, or gloss over. After a lot of running I found that if I wanted to run fast, and well, and not be crippled after, I had to warm-up for 20-30 minutes, at a very low rate. This allows the device to fill with fluid, and lift clear of itself. It then produces very little in the way of ions, and what is produced can be handled by your system, removed from the area and carted off to the kidneys for processing. I have heard every type of warm-up, and have tried every way I could imagine to speed the process, as not only did my race results demand this, but my life in general did. Nobody has a spare 30 minutes in their day, I don’t care who you are.
You cannot cheat the mechanics of this device. Mister McMinn is genius and changes lives with the brilliant simplicity of this device. It cannot be made simpler. It requires a fluid film to adjust for impact, period. After finally accepting that this heartless little piece of metal was always going to demand this, I got over it and began to figure out my workout days to allow this time. Far easier than changing my diet to generate more joint fluid (yes, did that), doing a million yoga and Pilates stretches to open the joint space (did that), or any number of things me and others tried. The foil hat crew I hang with has some interesting ideas for certain, none of value in this instance. The device has to be in motion, under lesser load, and operating through the range of the planned activity. These three things are absolutely paramount. Stretching, swimming, cycling – anything you do before running to warm-up will be to no avail in this. We have tried it all.
So plan on doing something like this:
I begin with a [regular length stride] walk. I gradually pick up my speed, from around a 20 minute mile pace to a light jog (14 minute mile pace) in the first 10-12 minutes. I do not increase my forward stride length as I increase speed. NEVER increase your forward stride length at any pace. Your foot should land under your torso or inches in front, and then push backwards. If you run faster, then push backwards harder. This is proper form. All runners know that you can increase speed with higher turn-over or longer stride length, or both. But few casual runners know that longer stride length comes behind you, not in front.
BHR runners are particularly sensitive to this improper “in-front” form. It is higher impact. It also recruits the hip flexors and psoas muscles, which are often scarred and calcified, compromised from years of dragging across boney cysts in diseased pre-op joints, to move the leg forward and up. At the very same time, it forces the piriformis muscle to hyper-extend - many times per second at high paces.
When I asked my surgeon, Vijay Bose, why my piriformis was always an issue, he said, well, “I took a pair of scissors and cut it in half”. Oh. Okay then. I get it. Yikes [somehow I guess I must have thought the BHR got in there on its own?].
The piriformis of a post-op reline patient has a line of scar tissue all the way across it where it was reattached. Vijay’s “scissor-line”. This scar tissue will never stretch again. With use, it will tear and heal longer - tear and heal longer still - until it is the length it needs to be for the activity asked of it. Over-striding forward will increase the tearing initially, and you will suffer mightily for that. Been there, done that, jumped that fence. It will cause your lower back to seize up, or your gait to return to the “swinging pelvis” pre-op condition. Or both for the lucky winners. Yikes! I have lost weeks of training time because of this. So watch your forward stride, and pay attention to the pain in your middle glute, when it begins, back off for a little while. It will get continually better as it heals longer. Do full bend stretches, and leg across your centerline stretches with your foot up at waist high like you would do for an IT band. These will help mid-run. If you do not pay attention to this pain, it will tear the scar tissue a lot, and that means you will be unable to run for a few days or a few weeks, that is not okay with most runners. Slowing and stretching gently will prevent this time off.
The next ten minutes or so I run strides, with 60 second intervals at ever faster paces, and 30 second walks / jogs between. I found it is critical to get a few workout pace strides in before you actually start your run. This opens up the joint I believe, and then the walk break allows fluid to enter the joint fully before you subject it to sustained cycles of impact.
After that, I run my workout. I pay attention to form, and I pay attention to pain. If I feel pain in any of the tissue around the region, I do not “run through it”. I slow my pace and jog / walk through it. More than likely it will get better and you can pick up your pace again. I have found it far better to do a lot of little runs strung together like this in a single workout than to follow my “plan” and do a single tempo run.
It will continually get better if you do it right. Day after day. Year after year. As long as you WARM-UP properly.
Other soft tissue problems cause deep pain, and are not resolved by warm-up. Most of these are related to the compensation you did pre-op, the damage you did pre-op, and the surgical incisions, retractor damage and so on from the surgery itself. This procedure is not microsurgery. It is heavy duty, with massive amounts of controlled damage to soft tissue. Less incision length likely means more retractor use, and damage, not less. So be prepared for a certain amount of scar tissue tearing, healing, lengthening to accommodate your new range of motion. My joint was so compromised I could not lift my foot more than a couple of inches off of the floor pre-op - so my tissue had already shortened up a lot, splinting the damaged joint and protecting it. Yours likely did too. This will stretch out slowly and quickly, depending on the tissue. Remember, it will always get better.
Do not do leg extensions while seated. This standard of the industry quad strengthening routine will leave a BHR patient half-crippled within hours. I have no idea what the exact mechanics are, but I think the tendon for the hip flexor somehow chaffs across the pubic tendon or something else in that area and will get hugely inflamed and raw. If you have done it you know what I mean.
Today, I do standing leg extensions instead, using a cuff on my ankle and a cable coming from above. With the leg in line with the body, I have none of the after pain of seated extensions – yet get the quadricep development I need to run faster and to stabilize my knee and prevent injuries. I also believe that legs should be developed so that 1/3 of your mass is quadricep, 1/3 is adductor, and 1/3 is hamstring. Any type of light weight adductor move is good, hamstring too. Developing the grosser leg muscles properly and in balance will really add to the legs ability to absorb shock, something that is critical for your natural joint, maybe saving another BHR!
There are many other tips and techniques out there, and I am happy to write more later on what I know and have learned from other athletes – and will. For now however, just remember that you cannot cheat the mechanics of the device, and if you do it right, you will be able to run any workout you want, race any distance, and get up the next day without having to cripple around and take a ton of Ibuprofin and so on. I am running 440’s in the sub-minute range today, same pace as high school, no issues from the relined joint. I am working on a 15:30 5000 and will be able to run that very soon. On the other end, I am running in two 100 milers this year as well. Warming-up correctly is the key. Remember the three keys to warming up a BHR:
The device has to be in motion, under a lesser load, and operating through the range of the planned activity. All of these for twenty to thirty minutes.
Good luck and let me know how you are doing!
RBHR Bose 21 Dec 05