9 Months

Thinking about starting a new blog: Medial Knee Plica Recovery. For the past six months now, that has been the main focus, the IT band almost completely fading to the background.

Overall, much like before, it's more of the same and slowly improving. The IT band itself is fine; the ligaments and tendons around the operated site are getting stronger and pretty much don't get sore any more. I'm still managing the plica irritation by keeping the cycling regular and controlled. The longest single ride so far has been some 32 km, the longest week just over 40 km.

I have been suspecting for some time that tights and knee warmers are contributing to the plica irritation, and I've been able to confirm it as the weather got warm enough to have a few rides with uncovered knees. If things keep improving as they have so far, I should be able to progress to longer rides more rapidly in during the summer. Unfortunately, it still doesn't seem likely that I'll be able to get anywhere close to three digit distances until next year; but, my endurance being what it is right now, I can actually make even the 30 km rides satisfyingly hard and that definitely helps with the outlook during this whole thing.

Other than that, I'm still doing weekly gym sessions to keep the core, glutes, quads and hamstrings fit, strong and coordinated. I've made a break in jogging, but I'm slowly including that back into the workouts as well. It's not a goal by itself at the moment, so I don't really care even if I don't really make a lot of progress with running as long as I do some from time to time. I am also still visiting the physio once every three to four weeks, primarily to keep my progress in check and to keep me honest, not skipping workouts and not overdoing the cycling.

Goals for the summer: keep improving. Hopes for the summer: get to at least 50 km single rides and 60-70 km weekly mileage.

6 Months

Now this was a long gap in posting. I just never felt like updating when I didn't really have anything new to post. My progress has been really slow recently due to the medial knee pain, and after a visit to the orthopedist this morning, I at least have the name for this new game: it's called synovial plica syndrome. The treatment is no different from what I've been doing so far, just keep working with the physiotherapist, doing the exercises at home and slowly be increasing the load all the time listening to the knee and how it feels. The long term plan is familiar too: if it doesn't improve, steroid shots are next, then arthroscopy as a worst case scenario.

On the bright side, the ortho has spent some time studying the old MRI scans of both of my knees, and he thinks the original diagnoses were a bit too eager to proclaim structural problems that would match the symptoms. In his opinion, there is no damage to the cartilage or the menisci in either of my knees, so that's a relief.

When it comes to cycling, as I said the progress has been slow lately. After several weeks of sporadic activity due to going on vacation etc, in the last month and a half I've been working on building a solid base of regular workouts and rides with intensity and volume that doesn't trigger pain in the knee. This means one solid gym or physio workout, including 25 minutes of run/walk intervals (still at 3:2 minute ratio), and one 20 km bike ride per week. At the moment this seems to be functioning well, with no pain in the knee, though I can still feel some irritation when cycling before it gets warmed up. The goal for the next few weeks is to introduce another, shorter ride in the week, and then work on bringing it up to the same distance as the longer one. If that works out well, I'll have built up a base of regular 40 km per week that I can then hopefully start extending into more serious distances.

Regarding the IT band, it is doing well, no complaints. The ligaments in the lateral knee area do feel bit strained and sore from time to time, but that's a sign that they are still adapting to the increased loads after the IT band release. I haven't had any pain from the IT band itself during cycling, running or walking (and I've had some long walks on consecutive days during the vacation a couple of months ago). It could be said that the focus of my recovery work in the last three months has shifted from the IT band to what I now know is the plica syndrome, so I consider the surgery to have been a success so far. There might be some doubt that the new issue is somehow related, but I have had some pain in the area even before the surgery. I'm thinking that it's just a combination of anatomical predisposition plus overuse, as is usually the case, and is something that would have probably happened anyway.

3 Months

It's been two weeks and then some of the new regime with one gym session per week. It's all good so far, seems like a programme that will be sustainable in the long term, providing the benefits but at the same time not too taxing. I've expanded the gym sessions into more of a full body workout with dumbbell shoulser presses, bench presses, bicep curls and one-arm rows in addition to the leg exercises and treadmill work.

Speaking of the treadmill, running is improving nicely. I've come up with a combination that seems to work well for my current ability: 2 min walking, 1 min jogging, 2 min light to medium speed running, repeat 5-6 times. No knee pain, no shin splints any more, cardio seems to be the limit to going much harder at the moment. I'll be slowly increasing the run-to-walk ratio, but there's no hurry.

Cycling is not going as well unfortunately. I've kept the rides to around 20 km, but it seems I've been riding a little too often, not giving the body enough time to adjust and re-adapt after the long break I had before and right after the surgery. As a result, I've developed some knee pain - not around the IT band, but the inside (medial) side of the patellas, both knees but more on the left one. Pain in this area is not new to me, and I've had MRI done on both knees at different times to see what's going on inside: meniscus damage in the right knee and some lesions in the cartilage of the left knee.

The damage on both sides wasn't deemed bad enough to warrant anything more drastic than some rest and rehabilitation at the time, and I'm hoping to get away with same now. The pain only appears when cycling, so I'm taking a week off and I'm switching to platform pedals for a while to let my legs re-discover the most comfortable position for pedalling after the break. Of course, I'll also ask the PT about it the next session.

The IT band itself is doing fine, further along the way back to full strength. As usual, there are occasional aches and pains, tension, or just feeling of something being not quite right, but it's getting less intense and less frequent all the time. There hasn't been any swelling that I could detect at any time in a few weeks now, and it just gets a little more sensitive to pressure if I've been working it a bit too much. No surprises overall, it's right about where I'd expect it to be at this time.

2 Months, 3 Weeks

It was good having the two weeks to settle into a workout schedule and really see what the effects would be. I did gym sessions every three days on average, alternating the focus between squats and deadlifts, with leg press and knee extension added at the end of each session plus the full complement of stretches. As a warm-up, I'd spend 20-30 minutes on the treadmill doing walk-jog-run combinations. In between the gym days I did some home exercises, mainly elastic band work for the gluteus medius and some balance work, but not frequently. These were the results.

The good:

• I improved noticeably at doing squats and deadlifts.
• I improved a little at running.
• I no longer get the feeling of tension and pulling in the area halfway between the kneecap and the incision site - I used to get it while walking at first, and later while running ever since the surgery.

The not so good:

• It takes me time to recover properly from the gym workouts, three to four days at least. In the days between sessions the muscles would feel tight and a little sore and the legs would feel heavy. I wasn't able to push myself on the bicycle and I never really felt like running or doing any exercises other than on gym days.
• The muscles improve faster than the joints. I started feeling some soreness under the kneecaps when crouching or kneeling if I wasn't warmed up. It wasn't a major pain, just a warning that I was starting to work them more than they could recover from.
• The area around where the IT band inserts into the top of the tibia started feeling sensitive under my fingers (I got into the habit to poke and prod the area every morning to see how it's doing, if there's any swelling etc.).

The obvious conclusion was that I should ease off on the gym work and replace it with more exercise for balance, coordination and proper muscle activation. The PT agreed with my conclusions and additionally suggested to decrease the loads on all exercises that strain the knees, so squats, leg press and knee extensions. 

The PT recently started training as an ultrasound technician and he acquired a machine for the office, so we used the opportunity to take a look under the skin during this week's session. Everything looks like it has healed up fine and there seem to be no residual swelling in the tissues. He noticed that the surgery was done very cleanly and neatly without any unnecessary damage. The hard bump looks like normal bone under ultrasound. The PT thinks it's most likely the normal epicondyle being more prominent since it's no longer being hidden by the IT band, but to me it still seems like it's slightly enlarged compared to how it was before the surgery. I still need to make an appointment at the hospital for the ultrasound that my doctor prescribed, so we'll see if they have anything interesting to add.

The bump is definitely smaller than before, but is nevertheless still prominent

The next PT appointment is in three weeks from now, so I'll have plenty of time to develop a new exercise routine. So far I've been a bit lazy this week - I've done just one workout session at home, but I did ride the bike more. I've upped the ride distance to over 20 km and so far all is good. I won't be increasing the distance next week since I've made quite a jump, but I will try to do some running outside. That't the plan at least, we'll see how it goes.

2 Months, 1 Week

No posts for a whole week (and some change), but, honestly, there wasn't really much to write about. The knee generally feels about the same as it did a week ago, and I haven't been doing anything new or particularly challenging in the mean time that would show improvements or expose weakness. The one somewhat noticeable improvement that comes to mind is that, while the knee still doesn't like it when I stand in place for too long, it doesn't seem to swell up as much when I it happens.

I've been to the PT last Tuesday as usual, but even that was more of the same with just a few updates. I did the longest uninterrupted jog to that point, which would amount to maybe 200 meters or so. Then we did some jumping from one foot to the other, side to side, front to back and diagonally with random interruptions to balance on one foot, plus some throw and catch on top of it to make it even more challenging. Finally, he showed me two new exercises to include in my home or gym sessions. One is one leg deadlifts with dumbbells and the other is squats with a jump at the top where the jump is done into the squat and not out of it, so to say (so I fully stand up before jumping and going straight into a squat upon landing).

I have quite a list of exercises to pick and choose from now. The idea is not to try and jam them all in every session, but to have a variety to keep challenging the body in different ways. These are the exercises so far (in no particular order):

• One leg balancing - combinations with throw and catch, shallow squats, touching the foot with the opposite hand, with and without the balance board).
• Gluteus medius exercises - leg raises on the side, leg abductions, clamshells, side steps all with an elastic band and so on.
• Supermans and one leg deadlifts.
• Glute bridges on an exercise ball, one and two legged.
• Squats - standard squats with weights, squat and shoulder press combination, jump squats, single leg squats while holding an exercise ball against the wall with the opposite knee.
• Knee extensions.
• Leg press.
• Lunges.
• Elliptical trainer (I've replaced this with running intervals).

This week I won'be be having PT sessions and I can say that I am looking forward to it. I will use the opportunity to make a workout program that I will hopefully be able to use in the long term with occasional tweaks, or at least see in general what works best for me, how much rest do I need and how hard should I go on different days. At the moment, the PT sessions always break my weekly rhythm a bit since they are never truly hard sessions, but at the same time they tend to be hard enough to require some recovery afterwards. Next week I'll go to the physio with any conclusions and see what he thinks about it.

I have had one gym session so far this week. To begin with, I did 30 minutes of 4+1 walking/running intervals (4 minutes walking, 1 minute running) where I tried to do actual running instead of jogging once I warmed up. There are various theories about whether cardio should be done before or after weight lifting workouts, or in the same session at all, but seeing as I can't really run hard enough or long enough yet to significantly tax the cardiovascular system, I think this is a good general warm up.

After the running I did squats to shoulder press combinations, two sets, then a set on the leg adductor trainer as a sort of a break for the hams and glutes. This I followed with four sets of barbell deadlifts with progressively increasing weights. To finish it off, I did three sets of knee extensions and then two sets of bicep curls just to give the arms some work as well.

The idea was to focus more on deadlifts in this session, while doing some squat-based exercises as well. Since I'm limited by shoulder strength in the squat to shoulder press, this exercise served more to warm up the posterior chain muscles, while deadlifts really worked them. For the next session the focus will be on squats, so I will start with single leg deadlifts and then do proper barbell squats. I will also alternate leg press and knee extension workouts. In the days between the two gym sessions I will do some of the exercises that don't use weights, plus at least one or two full rest days.

Other than that, I will try to bump up the cycling distance a little. I've been commuting by bike almost every day, but I haven't really been cycling other than that. The longest ride so far is still the 8.5 km or so from a week ago. It's time to get into the double digits finally.

2 Months

It's exactly two months today since the operation. Looking back, I was hoping that by today I would be close to 100% by today, though I was ready to take it as slowly as necessary to make sure the recovery complete and permanent. Yet, when I look back where I was even weeks ago and compare it to where I am now, I really am pleased with how it's going. I think the biggest unexpected thing is the discrepancy with what I can actually do - cycling, running, gym workouts - and the little aches and pains that still happen on the first few steps after I've been sitting for a while, or the way the incision site gets swollen after standing in one place for too long. I guess I wasn't expecting those little things to persist the longest.

In the last few days I've done all the three main activity toes: cycling, running and gym work, and are improving. I've increased the weight for the squats up to 25 kg (I didn't plan to, but the previous weight really felt to easy), I expect to increase the weight of squat to shoulder press from 8 to 9 kg dumbbells next week, and I've done the first few sets of deadlifts. In cycling, I'm pushing harder and harder as well, though I'm keeping the distances low for the moment. I've done the same 7.5 km loop as last weekend, but my average sorted has increased from around 18.5 to around 23.5 km/h.

I've made the least obvious improvements in running, but that's hardly surprising; I was never a runner, so I'd be staying at zero even if it wasn't for the knee surgery. I've done one session of walk/run intervals, purely by feel. The running intervals were around 200 paces each (this is still jogging pace, so I guess 150-200 meters), at which point the muscles in front of my shins would start complaining. If then switch to walking for about as  the same distance as the running part, but I want really trying to be too precise with it. I've no idea how far in total I went, but I was out for maybe 30-40 minutes I guess. I was surprised by the shin pain appearing so quickly, but at yhe same time I was pleased that there were no major complaints from the knee, just a vague feeling of tension from time to time.

I've done only one session of balance and elastic band exercises, but this is according to plan since a lot of the same muscles are now being targeted in the gym. This combination of harder exercises with more rest in-between send to be producing very good results so far, and the lighter exercises are just there to improve balance and coordination further.

1 Month, 20 Days

PT session was Tuesday. Since I'm able to do short distances in a full run without pain or significant discomfort, we decided to start including some light jogging into the daily exercises. The program for this week is once a day, ten intervals of light jogging with normal walking in between; start with around ten meters for each interval, increase by feel. Other than that, he corrected my stretching technique to target rectus femoris muscles more, and introduced a quad stretch to add to the daily routine. He also gave me a new exercise for the gym, a composite squat plus shoulder press with dumbbells.

Since the exercises are getting harder, the muscles are needing more recovery now. I will be going to the gym three times a week to do exercises on the elliptical trainer, stationary bike, squats (two days normal barbell squats, one day the dumbbell shoulder press combination) and bridges on the exercise ball. In between I'll be doing the balance board and leg abduction exercises. Only stretches and jogging will be done daily.

1 Month, 16 Days

The idea to push the knee out of its comfort zone is working well so far. I went to the gym twice since the last post. The first time was more of a learning experience, while the one today was a harder workout (compared to how hard I was able to work as little as a week ago):

1. Warm up on the stationary bike, 5 minutes.
2. Elliptical trainer, ~75 RPM, ~155 BPM, 6 minutes (+ 1:30 cooldown).
3. Stationary bike, ~100 RMP, ~140 BMP, 8 minutes (+1:30 cooldown).
4. Squats, 3 x 6 repetitions with a 20 kg bar.

The knee is feeling better daily. I am now able to run with a normal gait with just a little tension and pain - about how walking felt like in the second week after the surgery. As usual, I just ran some fifteen-twenty meters as a test, but it was especially encouraging that the pain stopped immediately when I stopped running. I expect I'll start doing some actual running training with the physio the week after the next at the latest.

Day 28 (4 Weeks)

No physiotherapy in the last couple of days, and I took a rest day today. Well, it was rest from exercising, but I did go for a nice walk, leisurely pace but a good 2-3 km covered. The knee started hurting a little near the end, but I think I managed not to overdo it too much.

I've noticed that I can really feel the left glute medius, TFL and hamstrings working, and even straining a little, when I start walking a little faster. That's interesting, seeing as my left side now feels stronger than the right when doing the exercises targeting those muscles, yet the right side doesn't complain while walking. It could be a combination of many factors, but the top two I can think of is 1. that those muscles on the left side are now waking up and activating more than the on the right side thanks to all the exercises, and/or 2. that the left side is getting better at doing the exercises, but the functional strength in real world conditions is still not up there compared to the right.

Whichever is the case, I think the following course of action will be in order:

• increase work on the right side to bring it up to speed when it comes to exercise proficiency;
• start mixing it up with different exercises still targeting the same muscle groups in order to improve actual functional strength - so for example do leg abductions one day, side steps the next, and so on.

Regarding recovery in general, I have been able to do a few steps of something resembling a jog - the last time I tried, it a few days ago, it was still not at all doable. It still takes focus however, and when I tried to RN the last couple of stops across the street without really thinking about it, I reverted to a hobbling locked-knee gait.

The hematoma/swelling is mostly gone now, with just a pea-sized bump and some redness right around the middle of the scar. The redness doesn't look very good, but it responds well to icing, so I'm not too concerned yet. All in all, it seems to be getting better at an unchanging pace, which is perfectly fine with me.

The bump is between the third and fourth suture marks; picture taken after icing, so it's not very noticeable

Most of the swelling is gone

Day 10

The stitches are finally out! That feels a bit better. I can't really tell what the scar looks like yet as I have a new adhesive bandage over it, not to be removed for two more days; luckily, I can shower with this one on.

In other news, the swelling around the incision is actually the hematoma doctor told me to expect - I thought a hematoma would include more visible bruising for some reason. I told the doctor I wasn't really icing it so far since the thick adhesive bandage on it make it really hard for the cold to actually reach the site. He urged me to start using ice regularly now. Other things to look forward to are:

• Start physiotherapy next week to rebuild the quads.
• Free to start swimming next Wednesday.
• Free to start cycling and/or running in six weeks, so beginning of September. I can do very short runs or rides before, but nothing longer than 20 minutes.

Otherwise, the knee is improving slowly. I'm walking up stairs almost normally now, though it still hurts a little. I'm also going down stairs facing forward (no longer sideways), but with a sort of a hop-skip on the left leg to avoid the painful eccentric contraction. Still doing glute and hamstring stretches daily, but I've given up on hip flexors and TFL, it seems to hurt more than it helps at this time.

Prologue

Hello!

This is a blog where I will be presenting the progress of my recovery from the surgery that I had to fix the IT band issues in my left knee. I presume people reading this blog already know that the Iliotibial Band Syndrome is and probably have some experience with it, so I won't be going into the subject here.

At the time of my surgery, I've been able to find very few blog or forum posts from people who had similar surgery done with more details than "Had surgery X months/years ago. Ran a PB X months later." In fact, the only detailed account I know of is this one, though it describes a more complicated intervention than my own. (I've no affiliation with that blog, I found it through Google and the only parts of it I read are the ones related to the author's surgery and recovery.) I hope to make this blog a useful resource for anyone facing a similar surgical procedure for their ITBS.

I'm a recreational road cyclist, and my ITBS started while cycling, though an ill-advised run was probably a factor as well. This is a short history:

• The pain first started midway into a 130 km ride in February of 2015. The ride was unusually long for me at the time, but I was well used to rides of around 90 km, so having the pain start at 60 km was unexpected. The best guess was that it was caused by a combination of factors: first I made made my first attempt at running just a few days before the ride, where I ran far beyond my capabilities at the time; then, I went for a long ride before fully recovering from the run; finally, I had raised my saddle as an experiment right before the long ride.
• During the spring of 2015, I made some attempts of taking a break and then gradually getting back into riding, but pain would invariably come back after a while.
• During the summer I didn't ride at all, but I did experience some pain on easy hikes a couple of times.
• In September I finally found an orthopedist with some experience with ITBS. Under his orders I did some passive physiotherapy during the autumn including stretching, massage, ultrasound and ESWT (link), followed by a gradual return to cycling during the winter. I had gotten back to 90 km long rides with no pain until it returned again in February 2016.
• Had a couple of cortisone shots and did a round of self-guided hip and glute strengthening exercises during the spring of 2016 with no success.
• Finally had a surgical procedure done on the 18th of July 2016.

The procedure done on my knee is resection of the posterior portion of the IT band, also known as open surgical release. This type of surgery typically includes removal of a piece of the IT band where it presses against the lateral femoral epicondyle, but in my case just a straight, perpendicular cut was done form the rear edge and about halfway across the band. I asked about the option of an arthroscopic technique to remove some of the synovial tissue under the IT band, but my orthopedist opted for the more conventional approach after consultation with one of the doctors who originally developed the arthroscopic procedure.