On June 26, just as dusk began to settle, I took my final strides across a line that I didn’t expect to cross again some 20 hours earlier. The Lavaredo Ultra Trail, which traditionally begins to the dramatic soundtrack of “Ecstasy of Gold”, was the first race I participated in after a serious surgery in November 2020. Despite ample experience with long-distance running, this intervention decidedly shuffled the deck against me, and put me in a similar position as back when I confronted such a distance for the first time. There are a few things I learned along the way that are worth sharing—it is, after all, a story about getting back up after getting knocked down; about dealing with a serious setback like the ones we’re all confronted with at some point of our lives. These lessons may well have some general appeal, but contrary to my previous articles on the subject, the focus here is a bit more narrow: What it means to going from averaging 80 km a week to not being able to walk without crutches — and back again.

What happened? In 2019, when I moved to Paris for a new job, I was asked to to join the company’s soccer team (a sport I hadn’t practiced for ages) for a game. Having just started the new job, I felt like it’d be a great opportunity to socialize (which it was) and discover what skills were still left (not too many). Long story short, I promptly twisted my knee. Bad luck, yes, but not too surprising either — leg muscles in runners are optimized for different things than those of contact sport athletes, and apparently it’s quite common for runners to injure themselves when they let themselves talk into joining for “just one game”. It did hurt quite badly, but since I had none of the typical immediate symptoms (instability, swelling, bruises) or heard the characteristic snap of a tearing ligament, I didn’t give it much thought at first. In fact, despite limping like a sore-footed soldier, I still entertained the idea that I wouldn’t have to cancel my participation for the Ecotrail Paris that was due three days later! Eventually I realized that it wasn’t going to happen, and I decided that a few weeks of taking things easy would probably fix the issue.

The weird thing is that it kind of did. I wasn’t quite so foolish as to deliberately avoid learning about what might have happened, but I didn’t exactly make a great effort either. I went to a GP who did a routine examination of the knee (casually moving it in a few directions, if you want my honest opinion) and declared that if it wouldn’t get better within two weeks, I should probably get the ligaments checked. Well, the pain and the limping went away, and I prematurely declared victory.

[Why did I not take the initiative and get it scanned directly? Many reasons, but most importantly it was unclear exactly what would be covered by my health insurance, if anything — setting up those kinds of things in France easily takes half a year, if not more. If nothing else, it helped me to understand why people feel so strongly about single-payer universal healthcare, even if they understand the various ways in which such a system is inefficient.]

For the next year or so, I just continued my usual routine. I stayed the heck away from soccer, but I went cross-country skiing (and even snowboarding!) a few times. I also (successfully) participated in a handful of races, without really noticing any problems. I was quite attentive to the signals the knee was sending, but the inconveniences seemed minor — not being able to flex it completely, being a little less stable on the board. It was only a year after the accident happened that I finally managed to book an appointment for a CT scan, after a friend of mine (who’s a physiotherapist) repeatedly suggested I’d take a look just in case.

Well, the news weren’t great: I was told that I had quite likely torn my anterior cruciate ligament (ACL), and the doctor was rather baffled when I told her that this had happened a year ago. Amazingly, however, I still didn’t do anything: The examination took place a few days before France went into its first lockdown, and I left the country for a few months. Amidst all the uncertainty around Covid, the diagnosis simple faded a little from my center of attention. It wasn’t until another 6 months later (during which I established a new personal marathon record and ran my hitherto longest distance) that I came around to see a specialist, get another CT scan, and talk to a knee surgeon. Their opinion unanimously pointed towards surgical treatment, especially since (as it turned out) the meniscus was also affected. We fixed a date for early November 2020.

The first thing I want to be clear about is that a random blog on the internet is not where you should be getting medical advice from. If you suffered a similar injury, you want to talk to a specialist in the field, read up on the relevant research, consult a soothsayer — anything but “this guy on Medium said I should do X!”. In what follows, I’d just like to provide a general idea of how things look to me.

Given that ACL ruptures are so common (roughly 250,000 cases per year in the US alone), one would expect that the medical establishment knows fairly well what works and what doesn’t. But (and this never fails to surprise me, given that medicine occupies such a prominent role in our society) the verdict is far from clear. As one recent study puts it,

There is a notable shortage of high quality research comparing outcomes following the management of patients with an ACL rupture with high-quality rehabilitation compared to ACLR. A recent review of all randomized controlled trials (RCTs) for ACL injury identified only 1 (The KANON Trial) out of 412 trials that compared outcomes following ACL management with rehabilitation plus optional delayed ACLR vs. ACLR and postoperative rehabilitation [34]. The two groups had similar two-year and five-year self-reported physical activity levels, rates of meniscus surgery, symptoms, pain, QOL, and radiographic joint changes [35], [36]. Notably, there was also no difference in outcomes between patients, who had an early ACLR, patients managed with rehabilitation alone, and those initially managed with rehabilitation who underwent a delayed ACLR (51% after five years).

In other words, we basically don’t know whether surgical treatment is indeed superior to conservative therapy that strengthens the muscles around the knee (yes, the two aren’t mutually exclusive). In my case (young age and intense exercising), the sports physician recommended surgery because of likely adverse effects (arthritis) I might otherwise experience in midlife. And given that around one third (!) of young individuals who undergo ACL surgery suffer another rupture within 2–9 years after, this better be the case. Unfortunately, as far as I can tell, the evidence is rather mixed. The above article points out that “studies referenced to support this belief are typically retrospective reviews of surgical records, and show more severe joint injury in patients presenting for ACLR months or years after ACL rupture, following unknown/no rehabilitation”.

All of this would explain why I was able to continue to perform high-intensity activities during all the time the ligament was torn in two. It also suggest to ideally shop around for perspectives regarding the advantages and disadvantages of conservative vs. surgical treatment. I have to admit that I could have done more research prior to the surgery; I’m not quite sure how knowing a little more about the base rates would have influenced my decision.

The surgery itself is actually rather straightforward. Minus anesthetics, it takes barely an hour to perform the operation (you can watch a nice animation here), and you can go home the very same day. Still, it was a very strange experience for me, not only because I had somehow managed to stay clear of the OR until then: You have to picture that I was out for a run the day before the surgery, walked into the OR without any noticeable problem, and left on crutches, unable to return to my apartment without help. Physiotherapy starts immediately after the surgery and takes a fair amount of time in the beginning, but it’s all very slow: About a month until you can take your first steps without crutches, about three months until you can start to take up your training again (don’t be fooled: the first running sessions are 10 minutes long and alternate between easy jogging and walking). It’s only until half a year afterwards that the knee has stabilized enough to make trail running an option again.

Okay, fine. France went through a second lockdown at the time when I was immobilized, so I had every reason to take it easy and recover fully. On the flip side, Covid was also the reason why a lot of races I had signed up for pre-surgery were moved to the next year — including some that are really hard to get into, like the Lavaredo Ultra Trail and what’s maybe the world’s most famous trail event, the Ultra Trail du Mont Blanc (UTMB) — and if there was any chance not to lose my spots, I wanted to take it. The only problem is that these things take time to prepare — ideally some 6 months if you’re already kind of an active person. My first training session took place 5 months before the a 120k ultra in the Dolomites, and I basically started again from scratch.

I don’t want to say this is something I’d recommend doing. It comes with a lot of worries and doubting, because while preparing for it, you’re constantly wondering by how much you can increase your training volume (which you have to, to be able to finish an ultra) without impacting the healing process, or risking a new inflammation. There wasn’t much leeway — having to pause even for just two weeks because of, say, a tendinitis, would be the death knell for my racing plans. I was mostly pain-free, fortunately; by contrast, my knee retained some liquid for a very long time (it’s still not fully gone) and it was unclear to the physiotherapists and doctors exactly how problematic this was. Similarly, the flexibility of my knee joint remained limited, and I suffered from a strained hamstring for most of the rehabilitation process which never quite went away.

In the end, it all worked out, but the odds weren’t always in my favor. Going through all these months of physical therapy even helped me to improve my training routine — strength training for the legs is really quite a powerful tool, and something I’ll definitely incorporate more into my training routine from now on. It wasn’t until three weeks before the race that I finally managed to do a serious, long trail run, but how amazing it felt! How much you appreciate being able to do things again that you somehow started taking for granted! It’s a kind of addiction that’s very hard to put in words, because so much of it is frankly quite unpleasant, and it still doesn’t make much sense to me — what evolutionary advantage did it confer upon humans to enjoy the majestic scenery from a mountaintop? Whatever it may be, I’m glad to be back and quite excited about this year’s running highlight — the UTMB at the end of the month. Let’s see if, after two failed attempts, I can finally put a checkmark behind the mythical 100 miles distance!

Le bonheur et l'absurde sont deux fils de la même terre.