it’s not you – it’s me.

Last week, I detailed my sudden propensity for skateboarding across pavement on my palms and stomach. This week, I want to turn to a psychological analysis of the kind of human being who could, in the face of so much objective evidence suggesting a mechanical failure, nevertheless attribute an immediate and profound increase in the number of falls he experiences to everything other than that root cause.

the history: 2011

I began regularly running again close to a year ago. I started with short 1.5 mile jogs in a loop around my house, which soon expanded to 2 miles and later to 3. At no point during this initial phase did I fall while running. This was consistent with my history – as soon as I learned to use a prosthetic leg, I almost never fell. I say “almost” because I’m sure that I did at some point, but in all honesty, I can’t remember.

In August 2011, I went out for a 3-mile run in foreign territory (Atlantic City), got lost, and ended up logging 4.6 miles instead. This suddenly opened up a world of distance running that had previously eluded me as an amputee. The 3-mile run that had been my upper limit only weeks before quickly became my new short-distance run, while 6 milers became my average outing, with a few 8 milers thrown in for good measure.

November saw another barrier fall, as I went out for what I thought would be a personal-best 9 mile run. However, fueled by perfect running weather, an easy pace, and my body blessedly holding up, I ended up completing 13.5 miles. I closed out 2011 having covered more distance on a running prosthesis than in any year since becoming an amputee at age 27. And I hadn’t fallen. Once.

the history: year-end tune-up

As the year closed out, my prosthesis went rogue on my, the hydraulic on my knee finally giving out to the miles behind it. It happened in the middle of a run, abruptly and noticeably. One step I was experiencing the regular rhythm of knee and foot working in harmony, the next my prosthetic knee was slamming loudly into full extension every time it swung the foot through, the report at terminal impact echoing like a hammer on PVC piping.

Communications with my prosthetist resulted in an immediate diagnosis that we confirmed by toying with the knee’s resistance to no avail. And so, I found myself traveling south on the Jersey Turnpike to get the knee switched out only a few days before last Christmas.

With a new unit in place, I took it for a test run, logging a hard 6 miles on the treadmill in my prosthetist’s office. Everything worked perfectly. Back into the leg back it went, and I made it back to New York secure in the knowledge that I had another year of trouble-free running ahead of me.

the history: 2012 problems

The next run I took upon returning home revealed that the knee had what sounded like a parakeet living inside it. It emitted an audible, alarming, bird-like chirp with every swing from flexion to extension. (Most people wouldn’t normally consider the sound of a parakeet chirping alarming. But if they didn’t have a bird in their residence, I posit that the sound would be alarming, just as my knee’s noise was to me.) I shot video of the knee imitating a small winged creature – a clip that was slightly complicated by the fact that the song bird in my son’s room appeared to think he had a new friend in the house, leading him to serenade this potential cage mate.

A telephone call between me and my prosthetist led to the following conclusions: (1) he had never heard this kind of knee emit that kind of sound; and (2) aside from the sound, the knee was working perfectly. In subsequent runs, the noise disappeared, and I quickly forgot about it.

The second week in January, while jogging in place in my hotel room before going out for a run, I suddenly and violently fell to the floor when the knee collapsed. I assessed the damage – other than embarrassment, none – shook my head in bemusement, and exited my room to meet my running partner for the day. And promptly fell again while jogging to the previously agreed-upon meeting place.

These two falls in rapid succession foreshadowed an ominous trend. Over the course of the next 6 weeks, I would hit the ground approximately 6 more times. In retrospect, my analysis of the problems leading to this state seem almost laughable.

dave’s dim-witted analysis

I should first point out that my approach was not always moronic. It just became increasingly dumber the longer this went on.

My initial reaction was that as a result of the first two falls, I had somehow altered the alignment of the knee and foot underneath the socket as the prosthesis suddenly felt much less stable than it had the previous 12 months. This was not an entirely illogical hypothesis, and I set about trying to validate it by checking all of the attachment points, particularly those connecting the knee to socket. The problem was that everything looked perfect – no loose screws, no new “play” anywhere. The alignment of the prosthesis hadn’t changed.

Taking my first tentative steps into the pool of stupidity, I concluded that I had just gotten careless and fallen a few times in rapid succession. Greater awareness and attention to my physical activities on this prosthesis would no doubt remedy the problem.

But the falls continued. And I noticed that it felt like the knee wasn’t swinging through as quickly as it should, especially when running at faster speeds. At this point, I should’ve realized immediately what was happening: the hydraulic on the knee was obviously shot. I was running on the functional equivalent of a hinge, which accounted for the increased issues at faster speeds, the lack of stability at foot strike – in other words, it explained everything.

“But,” I kept reminding myself, “this is a brand new knee. It can’t be the knee!” So I called my prosthetist and explained only that it felt like the foot was getting hung up behind me. Now waist-deep in stupidity, I noted that a simple tweak of the resistance settings should fix everything. My prosthetist immediately opined that it sounded like there was a problem with the knee, a conclusion that I rebutted by pointing out that it was only a few weeks old. I reasoned that if I could just get the knee to swing into extension faster then the world would be perfect again.*

He walked me through the necessary steps to promote knee extension, which I followed. Rather than make any dramatic changes to the knee extension resistance, I opted for a staggered, conservative approach, and planned to incrementally increase the resistance over several runs.

After the first adjustment, the knee didn’t feel dramatically different. “But,” I concluded, “I didn’t fall, so it must be working.” This reasoning is a prosthetic example of the “Black Swan” fallacy – “I haven’t ever seen a black swan, therefore no black swans exist.” Just because an event hasn’t happened doesn’t mean that it can’t or won’t. The fact that I didn’t fall on this particular run didn’t mean that I had “fixed” my prosthesis – it just meant that I hadn’t fallen that day.

I was now drowning in stupidity, as illustrated by my reaching back out to my prosthetist after this run to complain about the continued instability I experienced during it. I knew that the knee wasn’t working properly, but continued to convince myself that things were improving.

My prosthetist and I traded voicemails on the topic. Importantly, we didn’t speak to each other directly, which might have led to a different outcome. Left only with a recording that described the instability I was feeling, my prosthetist left me a detailed voicemail containing the information necessary for me to make a minor alignment adjustment that would increase the knee’s stability. I broke out my 4 mm Allen wrench, adjusted the applicable screws, and further ramped up the knee extension assistance.

For my next run, I tried something that I hadn’t done since probably 2005 – instead of a long, steady road run, I went to the track and ran intervals. After an 800M warmup, I ran 10 laps as follows: 100M at a fast run, followed by 300M to recover, repeat. The good news was that I didn’t fall. At footstrike, the prosthesis was noticeably more stable. The bad news was that especially on the 100M intervals, it felt like crap. I found myself having to consciously slam the prosthetic foot down onto the track with an unusual amount of force to ensure that the knee was locked at footstrike. The amount of energy this required seemed inordinately high to me, and though it seemed like I should be able to run these intervals faster, the prosthesis was slowing me down.

I know had yet another data point suggesting that the prosthetic knee wasn’t functioning correctly. However, over the course of that day, I convinced myself otherwise. I noted to myself that I hadn’t run at faster speeds in such a long time that I probably lacked both the strength and control to do it effectively. Also, I had never run that fast in this particular knee. Therefore, it stood to reason that part of my experience on the track had to do with my lack of familiarity with my current component. In short, was obviously the problem here.

A few days later, I went on what would be my final run with my new knee. It did not go well.

Two falls in less than a mile on level ground left me unwilling to continue trying to diagnose and fix the problem remotely. I called my prosthetist and explained the situation to him. He restated his initial reaction, delivered to me (and disregarded by me) a few weeks earlier: the hydraulics on the knee must be malfunctioning. I scheduled an appointment with him for this past Wednesday, and that’s where I left you, Dear Readers, last week.

the diagnosis

My prosthetist’s eyes widened as he held the socket between his hands and swung the prosthesis back and forth to watch the knee limply flail about. “You were running on a hinge!” he exclaimed. It had taken him roughly 5 seconds to confirm his original suspicion, an outcome I had dismissed for weeks believing that a new device couldn’t just be bad “out of the box.”

He seemed impressed by the fact that I had run for so long on a system that was fundamentally broken. I suspect, however, that at the same time he had to be questioning how a seemingly lucid, articulate, and knowledgeable patient could fail to diagnose a complete mechanical failure for roughly 6 weeks, instead using the prosthesis for high-impact/performance activities during that entire period.

He switched the knee out and we went to the local track. I logged 3 miles and did 8 intervals of 100M. As I started each of those intervals, the knee swinging immediately and smoothly into extension, pulling me forward instead of dragging me back, I realized just how badly I had analyzed the situation from the beginning.

I had known as early as mid-January that something was very wrong. All the evidence showed it: I never fall and suddenly I was falling all the time; I never felt stable in the prosthesis, even when not face-planting on the pavement; and I couldn’t get the knee into extension fast enough to run comfortably at anything other than low speeds. But one irrational thought kept me from acknowledging the very apparent reality of what was going on: this was a new device, therefore it can’t be broken.

I don’t know why I chose to believe that when every objective piece of data disproved it. Perhaps it’s the fact that when I owned my own facility, I used to regularly talk to patients who identified component failures that weren’t component failures once we saw them in person. Maybe it’s because I know how extensively these products are tested before they ever get sold to prosthetists and fit on patients.

As Seinfeld’s George Costanza once correctly pointed out when a suddenly ex-girlfriend proclaimed, “it’s not you, it’s me,'” it was him. (She replies, “All right, George, it is you.” And he responds, “You’re damn right it’s me!”) But in the Bizarro world of self-doubt and insecurity that I occupy, when I utter those words, I actually believe that it isn’t you: it is me who’s the problem. Sadly, at some point I transposed this worldview onto my relationship with prosthetic devices.

For the last 6 weeks, I’ve been sitting across the table at a diner trying to break up with my knee, saying, “It’s not you, it’s me.” But I said this even though my now-defunct knee was the equivalent of a psychopathic girlfriend sending me 75 texts a day to question where I was and who I was with. In this instance, it wasn’t me – it was the knee.

I have a new girlfriend now who keeps me from falling when I run. I really like her. But when she fails me, as she someday will, you’ll never hear me say again, “It’s not you, it’s me.” It’s definitely her. That is my new prosthetic component creed that will guide me safely through the rest of my prosthetic-wearing existence.

(I do not recommend unilaterally applying this new rule I’ve developed to all of your relationships. I suggest using it predominantly with inanimate objects that betray you.)


* A logical reader, at this point, might ask the following question: “Dave, you ran a lot in the past and you had 12 months of recent experience with this knee in your immediate rearview mirror – how can you be so ignorant as to not even know how to make the kinds of adjustments you’re describing on your own, without your prosthetist’s input?” To avoid looking like a complete and utter moron, let me provide a multi-pronged partial defense to the charge implicit in this question: (1) the knee I began using in 2011 was not the same knee that I learned to run on and knew so well from 1997-2010; (2) because the 2011 knee worked perfectly on day 1 until it’s very obvious failure in December, I never had to make an adjustment of any kind to it; and (3) I don’t generally believe in making adjustments without my prosthetist knowing about them and having the opportunity to provide input – I need him to protect me from myself.

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