When Ryan Larson laces up his running shoes – preferably a pair of Brooks Pure Grit –and sets out on a trail, he’s met with a few different things along the way.
“It’s a way to get physical activity through more personal enjoyment,” he said. “I love getting into the woods and being in nature, regardless if it’s a quick 30-minute run or a 4-hour training session.”
Community and comradery.
“It’s pretty great how much everyone encourages each other in this sport,” said Larson. “We’ve found others who enjoy running as much as we do, and they’ve become our community.”
Patience and perseverance.
“You really have to take it mile by mile, especially for the longer 75-100 mile races,” he continued, “as you never know what’s going to be round the next switchback, or when the weather might turn, or if you might not feel great at some point. You figure out ways to work through everything.”
That last sentiment hits home for Larson, who faced his third ACL repair and an osteotomy in February 2020.
ACL injuries: Right, then left, then right again
It wasn’t running that led to Larson’s first two ACL injuries though.
“I went for a layup during seventh-grade basketball. Something went wrong with my right knee,” he said. “The swelling eventually subsided and I just went on with sports as any kid would.”
Fast forward to Larson’s sophomore year of high school. He was playing soccer and noticed a lack of stability in his right knee, and it continued to bother him. One straightforward ACL repair later, and he was good as new.
Flag football during graduate school in 2010 led to the second surgery, this time with his left knee.
“It hurt like hell, and I knew immediately what happened,” said Larson. “I went to an urgent care initially, and a month later had left knee ACL surgery.” Statistically speaking, this is not uncommon, with 12% of patients treated with ACL reconstruction on one side experiencing the same injury on the opposite knee.
Following the operation, Larson acknowledged he may not have rehabilitated and trained as much as he should have to get back to full strength, and that he probably wasn’t as physically active after the injury either.
Then thanks to a friend, he discovered trail running.
“I did one year of indoor track in high school, but past that, never really ran that much,” he said. “Now, there’s 26-mile marathons, 50-mile races, 100-mile ultramarathons.”
In September 2019, Larson had his best run ever during Run Rabbit Run, the 50- and 100-mile endurance races held in Steamboat Springs each summer. He set a goal of completing the 100-mile race in 27 hours and did so at 26 hours, 55 minutes – the first time he’d met his time goal in an ultra.
He’d already set his sights on ultramarathons for 2020, when right before Christmas, he was out for run on a road and felt a change in the stability of his left knee.
“The first thing I thought of was that feeling from high school – something wasn’t quite right,” he recalled. “I’d suspected my knee had issues for the last few years. I tried another run a few days later and knew it wasn’t good.”
Third time’s a charm?
After a left knee MRI and consultation with Dr. Alex Meininger, an orthopedic surgeon in Steamboat Springs and a member of the medical staff at UCHealth Yampa Valley Medical Center, the extent of Larson’s injury was more clear.
“The repaired ACL graft had likely weakened over time contributing to additional damage,” said Meininger. “The giving way episode while running was the straw that broke the camel’s back.”
That’s why Larson didn’t feel the injury as quick.
“We discovered there were really three parts to Ryan’s injury – the torn ACL, a substantial medial meniscus tear, as well as damage to the cartilage that could predispose to arthritis in the future.” said Meininger.
Meniscus tears are commonly associated with ACL injuries. The normal meniscus acts like a cushion, protecting the surface of the knee. However, a tear of the meniscus – or surgery to trim out the tear – can reduce the effectiveness of the cushion. In fact, up to 50% of patients who have ACL and meniscus injuries will develop osteoarthritis within 10-20 years.
Osteotomy for ACL injuries
“Thankfully, we got to Ryan’s knee in time to repair it,” said Meininger. Not only did Larson’s knee require a repeat – or revision – ACL reconstruction, Meininger also recommended changing the alignment of his knee through what is known is an osteotomy.
“During an ACL revision, our first choice is to use the patient’s own tissue, followed by a cadaver graft,” said Meininger. “Since Ryan’s patella tendon had already been used, I used part of his quad tendon and bundled it up as a new ACL.”
Additionally, Meininger performed an osteotomy, a procedure in which Larson’s bone was cracked and wedged open in order to better align the weight-bearing line with his tibia. By shifting his alignment a mere 5%, Larson’s ACL is now better protected from another failure, and his meniscus and cartilage damage are under less pressure, too.
“The combination ought to allow Ryan a stable, painless knee that affords him a return to full activity,” says Meininger.
Preparation before osteotomy is key to success
Just like he would with an ultramarathon, Larson began to prepare mentally and physically for his Feb. 19 surgery.
“Physically, I didn’t have the same recovery of an acute injury. But mentally, I knew the uphill challenges I’d face post-surgery,” he said. “There’s always anxiety with surgery. I knew I’d have to be patient and that recovery would be slow. I had to remind myself of that more than once.”
Pre-surgical physical therapy was new for Larson this time around. He knew firsthand the importance of getting as strong as possible before the procedure and building up his strength.
“I did exercises that as a runner I usually wouldn’t usually do,” he said, such as lunges and squats.
The work begins following osteotomy for ACL injuries
Following a successful procedure, Larson began physical therapy at UCHealth SportsMed Clinic with physical therapists Alyssa Hornbrook and David Grinnell.
Three weeks post-op, Hornbrook said he was right on track.
“It was a gnarly surgery, and it takes a while for the bruising to go away, the swelling to go down and the contours of the knee to appear normal again” she said. “Being non-weight bearing for six weeks while the tibia is healing takes its toll on muscles, too.”
“The biggest difference I recognized right away was not being able to put weight on my leg. After my first two knee surgeries, I was walking right away. Not being able to do so after this surgery was a huge difference,” said Larson. “I felt like my leg was going to be able to do more and more quickly. It’s uncomfortable. Imagine a cramp in your leg – it’s that kind of tight all the time.”
Hornbrook could literally see Larson’s leg muscles start to work, thanks to the home exercise plan he followed. And, knowing the importance of keeping his cardiovascular endurance in check during recovery, Larson became a master at the hand cycle at Old Town Hot Springs for cardio.
Then the world changed
About one month after Larson’s surgery – almost to the day, the impacts of a worldwide pandemic hit Steamboat Springs. Due to COVID-19, non-urgent, elective surgeries and procedures were postponed at YVMC, and visitors were no longer allowed in the building. Larson’s in-person physical therapy appointments were reduced, putting even more emphasis on his at-home routine.
“Since PT was critical for my recovery being only six weeks post-op, I was fortunate I could still go to SportsMed once a week. It was my check on what I could do next and how I was progressing,” said Larson. “I found a lot of progress on a stationary bike, and it was so helpful for range of motion and just mentally to get a little bit of an increased heart rate. I wanted to do more and feel less pain, but where I was at is what I expected.”
Walking crutch- and brace-free was a big milestone for Larson.
“It’s amazing the freedom I felt being able to carry things in my hands instead of juggling with crutches,” he said. “Walking around freely was huge, as was being able to get around better at work and at home.”
Mental progression through recovery was also something Larson recognized throughout his physical recovery.
“The exercises during recovery aren’t exciting, and motivation was mentally challenging,” he said. “The progress with doing more meant I was further from surgery and closer to recovery. Since this is the third surgery, I knew it’d be a slow-go. But every day got me a little closer.”
And while he felt for his fellow running enthusiasts that nearly all races got cancelled in the spring and summer, the fact that he didn’t miss races helped.
Back on the trails
By the six-month mark in August 2020, Larson was running up to 10 miles on trails and felt great.
“I’m exactly where I hoped to be, maybe a little ahead,” he said. “I started doing limited running at the end of June and now feel about 85%, with hopes to gain about 5% each month. I should be at full endurance soon.”
“Patient commitment and cooperation in recovery is important, and Ryan has been exemplary,” said Meininger. “His knee is free of inflammation, the new ACL ligament is solid and his stability is there, and his strength is coming back. The work he put in prior to surgery has served him well.”
He’s still focused on strength, especially in his calves, to give him the power and control he needs to run ultra races again. Weights in the gym and interval running will help get him there.
“Quick power off the ground, like a hop or jump, is hard, but I’m getting there,” said Larson. “Thirty days ago, I felt ok running uphill, but downhill was painful – I’d last 4-5 miles at most and it was really slow. Now, uphill feels 95%, and downhill is easier and less painful.”
Not only can Larson feel the improvement as he continues to rehab, his mile times show it, too.
“The times are getting faster and faster, which means I’m another step closer to getting back to where I was before the injury occurred,” he said. “As I progress in recovery, I feel endurance in running will be the last challenge.”