Trails and my knee

I have been focused this year on just running healthy, losing some weight and enjoying my runs. It has gone well, the knee has held up with manageable pain but I have not ventured onto the trails.

In my desire to get back to the trails, I had a recent email exchange with a Dr Ben Shatto (check out his blog - The Physical Therapy Advisor) who has been on the Marathon Training Academy (thanks Trevor and Angie) podcast where he has provided insight on running injuries.

So I decided to ask for advice and I was pleasantly surprised that he got back to me almost immediately and when I asked a follow-up question, he again got back to me. I also think his advice is worth pursuing as I have tried the traditional methods without any success. Check out his site and take a listen to the Marathon Training Academy podcast, I especially enjoyed their recent show where Trevor provided his recap of the Flying Pig Marathon which was my first marathon of the year and things went well. My next race was MedCity and things went ok from as it related to the knee but it was a bit warm and my back acted up so I just slowed it down and got to finish line in one piece.

Next up for me is Grandma's and then my intent is give Dr. Ben's advice a try to see if I can work myself back on the trails

Here are the emails:

Hi Dr. Shatto,

I have a question for you and it may be too specific to me to be worth answering on your page so I will understand if you don't answer, as well as if there is no answer.

I am a 59 year old marathon and ultra runner (50+ marathons, ~10 ultras up to 50 miles) and have had medial meniscus surgery on both knees, the injuries happened while playing indoor soccer and basketball in the 90's. After my surgeries I was able to resume running on all surfaces with no limitations or issues. Unfortunately I injured my left knee again in 2014 and had a second meniscus surgery. After the surgery, I was told I had no functional medial meniscus left but was told that I have no arthritis of note and I again was able to resume running a few weeks after the surgery. Prior to the surgery, I had adopted the Galloway run-walk method (90 seconds of running, 30 seconds of walking) to help manage the pain and as an attempt to continue with the races I had signed up for. 

The one thing though after the 2014 surgery I have not been able to run trails as the knee stability isn't good and after a few downhills or uneven surfaces the knee hurts to where running is problematic. I tried braces and they didn't help enough to be able to run trails. As a final note, last year I had an issue around mile 20 of a long run, eventually had a MRI, they noted another medial tear and a cyst on the joint towards the lateral side. He thought the cyst might have been related to the tear but didn't think that there was enough left to cause the pain so figured it was the cyst. We discussed that I might have some loose material or something else but decided to take some time off along with PT which focused on core stability and that seemed to help resolve the issue plus avoiding the trails.

I would love to get back to running trails and I know I need to always work on my core and proprioception but is there anything else I can do that might help my knee to get me back on trails? 

I very much enjoyed your podcast on MTA and appreciate the info on Facebook and your website.

Thank you,

Mike

Hi Mike,

Thanks for the email and kind words.  Sounds like your knees have been through a lot.  It is hard to say if you can get back to trail running but it is always worth the try if that is what your goal is.  So I know you have don't a lot of core stability work which is good and I would encourage you to keep up with it, along with the proprioceptive training.  I would also hope that you have been doing a lot hip strengthening work.  Particularly for the hip external rotators and glut medius.  In addition I would put a "strong" emphasis on weight training of the legs in general.  The stronger the legs are the more they can help absorb shock and support the joint.  

Thinking a little outside of the box I would also make sure you have adequate hip and especially foot/ankle mobility.  As you know the uneven surface of the trail can be an issue so if your foot/ankle and hip can accommodate for the unevenness even a little bit more then the knee would need to do less.  So foot/ankle mobility is huge.  Also, there is newer evidence that in the cases of medial knee pain having a flatter shoe without much medial support (basically without a lot of arch support or built up too much) is helpful.  It goes against what may appear logical or traditional thinking as often times one would build up the shoe with a medial post to help support the medial knee but that added support is like a beacon and the body tends to move towards the perceived extra stability.  What we want is you to move away from it.  The only way to know is to try.  Also a less support shoe allows the foot/ankle complex to do more.  Though this does expose you increased risk of ankle sprains.  

Lastly you may consider a knee off loading brace.  This would be a custom fit brace.  They can be pricey and would need a bracing expert to measure and fit for you.  But they can work well.

Hope that helps.  Good luck!

Ben

Ben,

It actually does help out a lot, if I could ask a follow-up question to make sure I interpreted your response correctly. I have run generally in mild support shoes but have migrated to low drop shoes like Brooks Pure Cadence, Altra Provision and Intuition and more recently Hoka Infinite and Claytons. 

So my question is do you mean minimal drop and no support like the Kinvara or Merrell Vapor Gloves or is what I am running in ok? I have found the Hoka's to be generally too narrow or too cushioning but the Infinites I like as they are wider and somewhat firm, of course they are discontinued :-) so I will need to find an alternative. I do like my Altra's and have found that they work well.

If so, if I notice some knee tweaking as move away from stability do I keep the mileage low and let the knee and more importantly the foot adapt?

Thank you once again,

Mike

Hi Mike,

Yes I would suggest moving to more of a minimal drop shoe and particularly something without a lot of medial posting.  Meaning a shoe that offers some support for a more flat foot.  The theory has always been to support the arch and foot to help keep the knee from wanting to roll inwards. (the Infinites or something similar may work fine).  But some research now shows that it actually encourages the knee to roll in more as it feels there is external stability there.  This of course is not what you would want.  You want your body to naturally try to stay clear of the medial side.  So try to find a shoe that is wider and if possibly not overly rigid to allow the foot an increased ability to adapt to the trail surface.  

Though as you eluded....the progression onto the trails needs to be very slow as the foot and entire leg need to adapt to the surface.  This may be the hardest part of all as you are used to long distances but for a while you need to keep them short.  The rest of our body will be capable but the leg may not be.  And of course during this process keep working hard on all the other strength and stability drills.

Best of luck.

Ben