49 year old weekend athlete tears ACL skiing, has it surgically repaired. Surgery, rehab, results.
A knee knows
I tore the anterior cruciate ligament (ACL) in my left knee skiing at Mt. Wachusett in central Mass. on January 18, 2007. This is a common injury to weekend warriors like myself, so I thought others might like to know what happens once you've done something unfortunate like this to your body. Maybe you've injured yourself too, and feel like the game's over. However, you can return to your sport -- you just need to stay focused and do the work.
Just had an exam on my non-reconstructed knee (right side) to evaluate some pain I've been having the last two months -- probably a tennis injury.
My doctor performed a series of manipulations, including McMurray's test, which was positive for a tear of the medial meniscus. Next step is an MRI, after which, we'll see what kind of options I have. My insurance probably isn't quite as comprehensive as when I had my ACL repaired, so could be some tough decisions ahead.
Just a quick note: The reason I haven't added to this blog since my recovery more or less completed is that I have nothing to report, and by nothing, I mean nothing.
The repaired knee feels the same as my other knee. I have no pain, no strength issues, and I give no thought whatsoever to the "involved" leg. If my doctor were to examine me, he would not be able to tell the difference between my repaired knee and the other one. I couldn't be happier with the results.
Same message as before if this is something you are facing: Make pre- and post-op rehab your mission in life.
You can't really control the surgical procedure and you can't change the extent of the damage to your knee. You can only control your response to these things. So own it, work it, make it yours. Whatever happens, you decide how it will affect you, how you think of it, where to take it.
I hope like hell that your experience and recovery are as good as mine was. Whatever you learn from your experience, I hope you'll share here.
The pain I was having playing tennis has completely stopped. I suspect that it was just a matter of getting used to serving again after a month, more or less, of not playing much. The left leg for a right-handed hitter, is the main source of power in a tennis serve. It's the leg you mostly drive from in launching upward to hit; it's also the leg you land on to complete the stroke. Since that initial experience a month ago or so, I haven't had any pain at all. But I need to step up my work to regain strength in the hamstring of my involved leg. I still have about half the strength of my other leg.
If you have any good exercises that focus especially on the hamstring, I'd love to hear about them.
The indoor tennis season began a few weeks ago, which means I'm playing now only once a week instead of three or more times. Not sure if that's a factor of not, but a week ago Monday, in warming up to play in the gym, I did a couple of sets of squats on the rack with two 45 lb. plates, so not that heavy, certainly not close to pre-injury load. Later, on the court, I noticed that landing on my left leg following a serve was pretty uncomfortable. I was feeling pain under my kneecap, so I'd sort of shake it off and keep going, but it limited my leg drive on the serve, and it did affect my mobility, especially moving to my right.
The only other time I have felt any pain since surgery was one occasion working outside where I was squatting down low with knees fully flexed, and it just felt like too much pressure on the joint. This has been the only pain at all I've ever felt since returning to athletic activity late last winter, so it gave me some concern. There was no swelling, and no appreciable pain doing ordinary things. In general, the knee feels loose and reasonably strong, but I need to get stronger. Ski season is coming up and I need to feel confident out there that it won't fail. Again, the hamstring autograft has kind of been an issue. I'm still significantly weaker on the left side and I need that strength to prevent another hyperextension injury.
I played tennis again this last Monday (skipped the squats this time) and did notice a little of the same pain initially, but it went away. So, here's what I've concluded. I'm 51 now (ridiculous, I know) and I'm aware that after about 40, you start losing muscle mass if you're not actually doing strength training. I haven't been doing that kind of exercise consistently for the last 6 months so I'm realizing now that if I don't get on the stick, the strength I need to keep from getting injured again won't be there and I'll start having more symptoms like the pain I've been feeling recently on the tennis court. So screw that -- it's back on the program. The squats I did before playing that one night just fatigued the joint enough, I think, that it wasn't operating smoothly and was probably a little imbalanced.
The fact is, every day is a struggle against a variety of forces that want to slow you down, dull your edge, and drain your willingness to keep fighting. My friend and neighbor Craig can be counted on, in any conversation, to say, "It's always something." It's how you respond that matters.
So last year, the year of pain, I had the knee reconstructed and a SLAP II repair of my right (playing) shoulder. It's now 17 months since the knee procedure, and 10 months since my shoulder and I couldn't be happier with the results of both. I can ski and play tennis without a brace and with full mobility and strength. The shoulder, in particular, is better than it has been in years. Kudos to Dr. Peters and John Palloff, my PT.
Saw this story in the Boston Globe this morning about a US skier, Charles Christianson, who tore three out of four ligaments in one knee in a crash, but has since recovered and is back at the top of his game.
Not sure how long the article will be available at that link. And too bad the online version didn't include the photo of Christianson taking a gate at a very dynamic angle. Here are some clips of him racing strung together. I don't know if these are before or after the injury. Awesome racer, for sure.
Tested out the knee on skis for the first time since getting injured in January 2007. Felt great. I was at Smuggler's Notch for a weekend and wasn't sure if I would ski or not. I did, though I stayed very low key -- the terrain wasn't anything intense. But the knee felt about 99% normal. I had posted a really poor video on YT, but pulled it.
Tried out my knee at Smuggler's Notch resort yesterday and was really pleased with how the leg felt. Walking from the condo over to the Village and the lifts, my knee complained a bit with the added weight of the ski boot, and the inherent nature of walking with ski boots on.
After riding the lift to the top of Morse Mt. I made a few tentative turns, and found the knee felt just great. I did four runs or so and then wrapped it up for the day to wait and see if there would be any pain or swelling. There was none. The next day, I went out and skied until about 1pm and felt strong.
All that really remains at this point is to continue strengthening my legs, and work especially on rebuilding strength in my hamstring. I don't think I could be any happier with the outcome, really. Three cheers for Dr. Peters!
Since having my type II SLAP repair about 5 weeks ago (right shoulder), the knee has not been top-of-mind. No surprise. But I've let the shoulder recovery derail my conditioning. Time to take care of business.
Today, I resolved to get back into a workout regimen. So today at lunch I did the following:
Single leg squat (a.k.a., one leg lunge) 4 sets of 10 each.
Theraband hamstring curls, 3x10.
Dumbell squats, 4x10.
Romanian dead lifts, 4x10. I realize now I've been doing them wrong, fortunately without lifting too much weight.
Because my autograft was taken from my left hamstring, it's basically shot. I'd guess I have about half the strength of the right leg. Otherwise, the knee is feeling great, and invariably, even if I feel some clicking or other noise during my workout, the knee tends to stabilize and start feeling even better during and after the workout.
Coming down the stairs, my legs were a little shaky so I know I got a good workout, but realized I have a long way to go, a long way. All I can do is work the lower body while doing PT on my shoulder, and hopefully start being able to strengthen the shoulder soon. Range of motion is already pretty good, but it's very weak.
Added a YouTube clip this morning showing me hitting a few groundstrokes on a clay court in Holden MA, October 3. The date is only significant because two days later I went in to have a SLAP tear repaired in my shoulder. This is pretty light hitting, but I've been feeling more and more 'normal' every day. This is the first video of myself hitting a tennis ball that I've seen in twenty years. I can see some holes in my strokes but given I haven't played a serious set of tennis since Oct. 2006, I'm pretty happy, very happy actually.
I've been running now as part of rehab, for about a month. Initially, on insructions from my PT, it was no more than three miles total, walking a half mile, then light jogging a half mile, and so on. Two days ago I ran/jogged for three miles without stopping for the first time since my injury last January. That was a good feeling.
Generally, the knee feels just about perfect. Some days, I'll notice a little ache or I'll just notice that it feels different. But for the most part it's feeling damn good. I have been hitting on the tennis court without going for too much for a month now, which has been fun. Moving to my right to hit a forehand with a neutral or slightly closed stance and the involved leg in front, has felt kind of sensitive. I must be putting some lateral pressure on the knee in that situation, so I still need to be careful.
With my shoulder procedure coming up Oct. 5, I'm trying to get on the court as much as I can (which turns out isn't much). The bathroom remodeling job I've been doing in my house has been eating up my cycles. Photos on my FB site.
Insurance coverage for PT ran out in August, so I'm on my own for the rest of my rehab. I don't plan to ski this year, I don't think. I want to focus my strength training on my lower body and my shoulder and try to be ready to go when the tennis season begins next spring. In retrospect, I can see that my ACL tear happened because I didn't have the conditioning I needed to protect myself. I won't make that mistake again. If you read back to the beginning of this blog, you can see that the injury was almost "incidental." A little more quad-hamstring strength and it probably wouldn't have happened. Also, beware of skiing anything but flat stuff with boots loose, as I was that night. It has been my habit on initial runs to ski with boots very loose, and then crank the buckles down after a couple of runs. But the loose fit allowed my leg to hyper-extend, and pop went the ligament. If I hadn't been headed down to an accident scene on my first run to help out Ski Patrol, I wouldn't have been on the Smith Walton trail at Mt. Wachusett, a trail with one little steep section, which of course is where I did the knee.
During PT day before yesterday, we worked through the usual set of exercises, including:
10 minute warm up on the bike
Hamstring curls on the slide board
Weighted bends on the involved leg
Afterwards, my PT, John, introduced a set of ladder drills. The ladder is a sectioned length of nylon webbing. You lay it down, and do in-and-out movement drills down its length through each box. So for the first time since the procedure on March 9, I was doing athletic lateral movements, first frontwards, then backwards, with cross-over moves, in both directions.
The link above shows an example called the Icky Shuffle that is like what I was doing, except that the PT wanted me to rotate my hips rather than keeping them facing forward as in the video. This made the motion quite a bit more like skiing, and allowed me to get a lot more lateral distance off the ladder than is shown in the Icky Shuffle video. We also did a version of the Billy Simms shuffle, but again with some hip rotation and as a result, greater distance off the center.
I was able to get a pretty good pace going, and felt very comfortable increasing the dynamic angle of my legs as I transitioned from one side to the other. Later in the day, I went out on the tennis court and hit with one of my former teammates and felt about 75-80% of normal out there. So things progressing well on the knee. Later, someone wanted me to hit on a hard court, and I declined. That might fall into the category of what my PT John would call "doing something stupid."
I was still favoring the leg a bit, but managed to hit with pace and spin. I reached most balls successfully without too much hesitation -- better laterally than up and back. The main difference from hitting last week was the degree of comfort I felt out there. I had enough confidence that I wouldn't wreck the knee that I was able to move quite a bit more freely than I had allowed myself to this point.
Even better -- next day, the knee felt great.
I've got about three weeks before surgery for the SLAP lesion in my right shoulder. Hopefully in that time, the upstairs bathroom will be more or less complete, but that's a whole other story. May have to adapt this blog for the shoulder recovery, depending on if I wind up getting a Level 1 or Level 2 repair, the former involving essentially a debrading of a ragged edge, but not a significant repair. Repairing a Level 2 tear will mean 6 months before playing again. I'm pretty sure it'll wind up being the L2.
Rehab has been going well. I've dropped off daily exercises somewhat, favoring the occasional bike ride, working outside in the yard, and some light hitting on the tennis court. About three weeks ago I was cleared to start hitting tennis balls again, so the same day, I found someone to hit with. I wore a basic knee brace, just as a reminder, and managed to move about rather stiffly, though without any discomfort pretty well. The next day, no real affects -- no pain, no swelling. Feeling good.
Last weekend, I played some doubles, what I like to call "social tennis" and also felt good. I served very gingerly (shoulder procedure coming up in August for SLAP tear). I moved better, not as stiffly, but was very careful not to push it too hard by going for wide, deep, or short balls unless they were easy to reach. I especially wanted to get out there before I have the shoulder procedure next month (4 weeks to go), after which I don't think I'll even be lifting a beer with the involved shoulder for three weeks.
I can go for several days now and realize I haven't given my knee a single moment of thought, which is a good indication how solid and normal it feels. I'm ready to start some light running on grass inside the oval at the high school track. At PT, I'm doing two-legged and also one-legged hopping over low bicycle handle-like hurdles. The idea is to land softly, with as vertical a calf as possible, with butt out and weight centered.
In the meantime, I've been remodeling my upstairs bathroom, which means a lot of work on my knees working on the floor. This has mostly been tolerable, though there are some positions with my involved knee that are uncomfortable. No big deal though, and again, no day-after affects, soreness or stiffness.
So, going forward: Increase tennis until I have to go in for my shoulder. Also, start doing more weight work at the gym, especially after the shoulder procedure. Because of the autograft, my involved leg hamstring is about 50% as strong as my right leg, and I need to build up that strength to help stabilize and protect my reconstructed knee, especially if I'm going to be doing any skiing this year (haven't decided).
For the most part, the knee is a non-issue doing ordinary things. I haven't been cleared to start running yet, though my OS last week came just shy of giving me the OK. My PT has mentioned he'll probably have me doing some light "jumping" soon, which may mean at this morning's session. I have also been cleared to ride my bicycle, but haven't managed to get out on it yet.
I'm continuing to do my exercises, though I could be a little more rigorous about it. My OS and I talked a little about skiing this coming season, and he thought I'd be OK to get back out there, but I said I was a little nervous about that. I love to ski, but I can live without it, and I mainly do not want to put my knees at risk. I guess the assumption I'm working from is that tennis is less of a risk to my ACLs than skiing is.
As a Ranger at Mt. Wachusett, I do like volunteering and helping out on the hill, so I'll probably take it slow, start the season late, and ski like an old man. But only after feeling absolutely solid on the leg. My one-legged squats are still a little shaky. I need to get out on the bike and climb some bloody hills!.
Saw my OS yesterday, who was very happy with my progress and with the solidity of the knee. He's mentioned a couple of times that the ultimate test of the knee's stability post-op would be to do the Lachman test on both knees eyes closed and, say, forgetting which knee was "involved" not be able to tell the difference between the two. He said yesterday on examination that I was very very close to that point. I think one key element of this would be getting the tension right during surgery, once the graft is installed. My understanding is the OS uses some kind of tensionometer to do this, but I have to think that experience, and the unique feel that an excellent OS can give this process are what make the difference between a mushy feel and a nice solid joint.
My OS is a nice guy, and you can tell he's very precise in how he does probably everything, from making coffee to tying the knot in his necktie. That's exactly what you want in a surgeon doing this kind of procedure.
However, as good as the knee feels, he wanted to caution me that I need to remain vigilant about as my PT would put it, "doing something stupid" that would cause the graft to fail. At this point, as good as it feels, I will only walk out onto a tennis court to sweep it; I won't even go out there with a racquet -- too tempting.
The technique I mentioned at six weeks post-op, of using a piece of pipe to break up scar tissue in my hamstring really made a huge difference. I haven't had a single hamstring tweak or pull since starting that process.
I'm now doing a series of exercises to strengthen my leg/knee, as follows:
One legged bridging: Lying on back, feet flat on floor. Raise and hold knee of non-involved leg to chest, raise pelvis, pushing off heel of involved leg, raising as high as possible. Four sets of 10.
Mini one-leg squats. Standing on platform on involved leg, with other leg hanging off platform, do four sets of 10 squats touching heel to floor.
Hip hiking: Standing on platform or step with non-involved leg hanging, tilt pelvis so heel touches, then raise pelvis on non-involved side as high as possible. Again, 4x10.
Forward reaches off step. Hands behind head, keeping back straight, from platform, extend non-involved leg over edge of platform and bend involved leg until heel touches floor. 4x10
Nose crushers: Stand with feet about 6-8 inches from wall. Keeping back straight, weight on involved leg, bend only at ankle and touch nose to wall, and return. 4x10.
Doing these 4x/week.
The knee is feeling excellent. No pain at all apart from some stiffness in the morning and after sitting for a while at my desk. A week ago or so, I took to wearing a neoprene knee brace just as a reminder so I wouldn't try to do something I shouldn't. Wearing it less now, but probably should continue -- it's a very good way to maintain awareness so I don't try to pivot on the knee or etc.
So, having passed the 8 week point, the graft should be starting to strengthen after declining in strength since the surgery for 8 weeks, as my OS explained it. By July, I'm going to really be itching to get out on the tennis court.
In the meantime, my shoulder is not really improving much if at all. I'm doing rotator cuff and other strengthening exercises every day and while the exercises seem to help the short term discomfort (it hurts at first and then feels better as I continue working out), I think it'll be a serious problem when I try to serve a tennis ball. I've got a call in to my OS asking him to approve an MRA for the shoulder, where they would inject some kind of dye into the joint before doing an MRI. Now and then at my son's Babe Ruth baseball games, where I've been coaching, I'll throw the ball a bit and there's always some pain. Seems like I'm OK if I'm throwing up to maybe 25 feet or so, but beyond that it can start feeling pretty bad. Normally, I really feel it the next day too. If there's any improvement, it's very very marginal. So I just don't get it.
The hamstring is still very tender. I did manage to go two days in a row before pulling it yet again reaching casually to pat the dog one afternoon. In fact, it's gotten bad enough that I have a nasty looking bruise on the back of my leg that I didn't even notice until my PT session yesterday.
So now I'm working with a new PT on my knee: John P. He had me sit on the floor with a 4 foot long piece of 4 inch plastic pipe under my involved leg and then showed me how to roll the pipe against my sore hamstring to break up the scar tissue and help stretch it out. This hurt like hell, but I could feel it doing the job. The big lump I had on the back of my thigh was nearly gone after this session. He said I need to do this 2x/day. So, in one session, my new PT, John, is already giving me a way to deal with the hamstring that didn't occur to the PTs at Fallon.
The other thing I like about this PT shop is that while I'm booked for 30 minutes, I sometimes spend 90 minutes there, a lot of the time doing exercises that John tells me to do, or sets up for me. He might be treating three people at once, but I never feel neglected. The atmosphere in the big therapy room is collegial, funny, and supportive. We were all commiserating with a woman who was having an intense and clearly painful massage session on her hip by one of the senior PTs. Pain is basically a way of life for everyone there, either from a treatment perspective or as a patient dealing with its effects every day. They seem to get that, appreciate it, and moreover, accept it, which makes it easier for all to deal with it. We acknowledge it, work on it, and in the end accept that it's a part of our lives at this point. For a lot of people, it's a constant presence or force in their lives. I have it easy compared to a lot of these folks.
At my last session, my PT let on that she and the junior PT who's been working with me are a bit "bored" and clearly are not sure what to do with me. I get the sense they're accustomed to working with elderly and sedentary patients. It's not like I'm a marathoner or anything, but this is an indication to me that I need to find someone else. The guy I've been working with on my shoulder, who has a lot of experience working with real athletes, has been excellent, so I'm switching the remainder of my PT sessions to him. The first four weeks post-op have been fine with this group, but it's time to step it up and move on.
So the lesson is, and the reason my doctor hedged a little on deciding whether or not to use my hamstring for an autograft is this: The hamstring autograft is going to take a long time to heal.
I keep pulling / tweaking my hamstring with very painful results doing very ordinary things like getting out of bed or getting up from a chair. At present, I can only curl about 2 lbs. lying on my stomach using ankle weights. At the gym, I use the low cable with a velcro cuff and can only partially curl 2 lbs. It's frustrating since the knee otherwise is feeling excellent. I can see that this is going to take a while - a long stretch of systematically greater weight and persistent stretching to get it back. I can't imagine cycling the hills around here with the hammie in its current state. I'd have no climbing strength, especially from the saddle, as opposed to standing up on the pedals.
Range of motion continues to improve, along with strength. I've got very close to 140 degrees of flexion. Not much pain to speak of at this point, and the knee feels mostly stable. Now and then just moving around the kitchen, I'll get a little twinge from just lifting my leg and having the knee turn a bit. In general, it feels best when the quads are loaded. Unloaded, the knee sometimes feels wonky.
I'm doing regular workouts at the gym, including squats (yesterday, comfortably with 65 lbs. on the squat rack), also low cable adductor/abductor, leg presses, calf extensions, leg flexor raises, and sessions on the stationary bike. I haven't yet had the time for an aerobic session, but the knee feels plenty strong enough for it.
So, the knee progresses well, but the shoulder, not so much. Had a vigorous PT session day before yesterday, and it's quite sore, and feels worse actually. The fact that I can't tell at this point if I'm making progress or not is a bit discouraging, since the knee is better every day. I recently re-upped for quite a few more PT sessions on the shoulder, but it might be time to re-evaluate. I've been working this now for two months actively, with a brief hiatus for the knee surgery and while I'm definitely gaining strength in the back of my shoulder it's far from being in a tennis-ready state. What I need to see is a steady time line of progress, where the knee and the shoulder are both ready for tennis at more or less the same time later this year (October?).
This week, I've finally returned to a more or less normal workout regimen. I'm now alternating upper and lower body workouts with miscellaneous knee and shoulder rehab exercises on each day. Yesterday at PT started doing what you might call side lunges on the involved leg. Also did alternating lateral raises on each side to help improve balance and prioprioception in the involved leg. I was surprised doing these that I'll have to work a bit to regain a good sense of balance on the leg.
The PT cleared me for riding a stationary bike for as long as I'm comfortable. To this point, I haven't put in more than 15 minutes. After a session the other day, I was a bit sore afterwards, but that could be the resistance training too. I pushed 50#, barely, with the involved leg, being careful not to flex or extend too far. It might be better to go down to say 45# and shoot for more reps.
At PT this morning, my therapist was impressed with the ease of my pedaling stroke. I went in cold and my knee flexion was 120, about the same as two days ago. After pedaling the bike for about 5 minutes, flexion measured out at 130. He had me do some leg presses, the first I've done since surgery, and was able to very easily push about 80 pounds, being careful not to straighten the leg or flex too far.
Before my injury, I could push my own body weight (170) without too much trouble. Hamstring was sore later in the day. Best to combine workout, stretching, and ice. Friday is two weeks post-op, and on 4/12 I see my orthopod again. I'm still using crutches when I leave the house, but I'm hoping I can give these up in another week or so. Also, I'm hoping to get cleared for riding an actual bicycle soon. Leg strength is the key to health -- that is my conviction.
During my workout yesterday, did my usual low cable leg exercises (abductor, adductor, etc.) and then also threw in a set of very conservative squats on the squat rack, with no added weight. Was careful to keep the back straight and the knees over the feet (sticking butt out behind), and not going too low. Also was able to ride the bike for 10 minutes and get the rpm's up to about 70. Earlier this week I was just barely able to turn the pedals over. As a result, I am sore today, especially in the hamstring at the graft site. But a little icing and ibuprofen should take care of that.
Yesterday, I iron-transferred the following onto a t-shirt:
In the last day or two, I've tweaked my hamstring a few times with very painful results. One time, I was just pulling on a shoe, another time I got up from a chair too quick. The trick is to avoid putting any real pressure on the hamstring until it fully heals.
Pedaled a stationary bike at the gym today for ten minutes not even fast enough to turn the bike on really, but enough to loosen up the joint very nicely. Then did three sets of low cable hip adductor, abductor, and leg lifts (quads) at low weight settings without too much trouble. It was easy enough to ride and do the exercises, that I should be able to increase the duration and intensity on the bike next time, and the amount of weight I'm pulling on the cable machine.
Went into PT this morning feeling a little tight. First thing I did was get on the stationary bike and use it to stretch the knee. After a few minutes of stretching, I was able to do a complete pedal stroke, so I then pedaled the bike for another 5 minutes or so. It was great to get to this point, since now I can go to the gym and start working on the bike. Afterwards, knee flexion measured out at 120 degrees, 10 degrees more than two days ago. After stretching and icing, the knee felt pretty good. Excellent progress, very pleased.
Knee flexion measured out at 110 degrees today. I feel pretty weak in my hamstring, but that will improve. I'm now doing leg lifts, adductor, abductor, and stretching 2x/day. Also, I'm going to step up the icing to try to get the last bit of swelling to go down so I can get some more flex in the knee.
The PT put me on a stationary bike today, and while I couldn't actually pedal a full cycle, I'm pretty close. Their recommendation is to use it for now as a way to stretch, and before long I should be able to pedal continuously.
Doing well, though I'm still not consistenly getting a great night's sleep. I'm finding it tough to get settled for some reason. However, my knee flexion continues to improve. I'm well beyond 90 degrees, say about 110 at this point, and walking around is pretty routine. I'm not having any significant pain at all, just achiness after doing my exercises, or if I've been walking around a bit. When I leave the house for any significant walking around I take my crutches which just help me take some of the weight off the leg. I'm also not having any trouble with the rehab exercises so I'm really hoping to be able to pedal a stationary bike this week. If so I can start going back to the gym.
Had my first day back at work today, and found it pretty tough to sit at my desk for very long before the knee got sore. I think I'm still tight enough that sitting for some time, even at less than 90 degrees flexion, I get a little sore, which makes concentration a little tough. So I'm still icing the knee a couple of times every day, after which it feels better.
Had the best night's sleep yet since the procedure a week ago. The knee was feeling a little tight so I took an 800mg ibuprofen before getting into bed. Also, with the sutures out and the ace bandage and knee brace off, I was finally able to get comfortable. Felt great.
This morning I combined my knee exercises with shoulder rehab, and even swung a racquet a bit. It's been 4 months since I played tennis, and I'm definitely missing it. The shoulder felt pretty good. It had been bothering me a lot the week leading up to knee surgery so I knocked off the shoulder exercises altogether. I had just been overdoing it I think. The break really helped.
Next week I'm hoping to be able to start working the knee on the recumbent bike at the gym. I need to burn some calories doing something real or risk fattening up, which will only put my knees at further risk.
Here's an image of my new 4 strand ACL. Each strand is very distinct. This was created by taking a length of my hamstring tendon and folding it twice into a 4-strand graft. You can also see how tightly it fits into the guide hole at the top right of the image frame. The PCL crosses behind the ACL from top left to lower right.
My orthopod had me in today, a day early because of a snow storm coming tonight and tomorrow. They removed the sutures and the staples, and I came away with a CD of arthroscopic still images of the procedure.
My doctor also explained that the ACL is at present probably 150% the strength of my ACL prior to injury. He said that this strength actually declines over the next 8 weeks or so, as the graft develops a blood supply and so on. At 8 weeks, he said it would have about 75% the strength of a normal ACL, but that the knee would feel very good. A lot of people who have the procedure might wonder at that point why they couldn't return to normal athletic activity, but it's important to allow the healing process to continue, and not to risk re-injury by doing anything too vigorous too soon. He also sat with me and talked me through the arthroscope images.
Saw my physical therapist for the first time yesterday and came away very encouraged. My quadriceps strength is still very good, flexibility is also good. You start losing strength and muscle mass very quickly if they're not used, but especially when you spend a lot of time in bed. My PT thought I'd be playing some tennis this summer, which could be one of two things: Either she assumes tennis is like croquet, or she thinks I can progress rapidly.
Didn't sleep well last night, but did manage to do so without my brace. I had started off with the brace on, but it was pressing against my ankle bone and really irritates the incision above my knee. For some reason, that incision is the most bothersome. After wearing the brace for a little while last night, I just took it off. I don't think I'm going to injure myself in bed. I think the main risk is taking a fall. My quadriceps is in good shape which is what will protect the stability of the knee.
Yesterday, walked without crutches to and from the kitchen, slowly, but steadily and with no pain. I wouldn't do this, of course without the knee brace, which helps stabilize the leg and gives me some confidence that it won't collapse under me.
I had two 800mg ibuprofen tabs yesterday, one in the morning, one at night. Otherwise no pain meds necessary at all. Now and then I do feel a sharp twinge at the incision highest on my leg, but if I stay relaxed, it doesn't bother me at all.
Back on the CPM this morning, my butt is getting permanently numb. Even so, my goal today is 70 degrees. With the ability now to walk around, I'm thinking rehab should probably include some walking with crutches on a smooth surface, like at a mall, so I'm going to check with my PT tomorrow.
I'll be seeing how well I can get in and out of a car today, including a test to see if I can drive. Our Subaru, which is a manual shift, is out of the question, but the Corolla should be no problem.
I have always hated being injured, but this is a little different knowing recovery is long term. I just hate crutches -- these things will kill you.
Good progress so far. Up to 61% flexion on the CPM, and started moving around the house on my crutches and putting some weight on the leg, and it's feeling very good. I'm now off Percosets and switching to ibuprofen for the little bit of residual pain and to reduce swelling. I'm not feeling a lot of pain except for some achiness when I wake up, and I think that's mainly the result of swelling overnight and not being able to use the Cryo/Cuff.
Got the dressing off this morning and had a look for the first time at the leg. There are actually four small holes, plus the long stapled incision beside the shin. I haven't yet seen the video or any stills of the surgery, so I'm not yet sure which holes were used for what.
One thing that surprised me is that I was sure before removing the dressing that I had an incision on the lower back of my thigh where I assumed they harvested the hamstring graft, but there's nothing there! I've felt some real tenderness there. I'm guessing the long incision is where they did this work, but I can't quite figure out how that would have worked. I'll have to get the whole story later this week when I have the stitches/staples removed. The incision that is the most sensitive is the one at the top, highest on the leg, but it's mostly just surface tenderness.
Awoke a bit sore today, though I've been scaling back the Percosets. Once I reloaded the Cryo/Cuff and popped a tablet, I felt a lot better. Today, I'm planning three 2-hour sessions on the CPM (and three movies to go with) and to get the bandages off for the first time and have a look at the holes in my leg. Before bed last night, I was feeling pretty good and even boasted I'd be able to give up the Percosets altogether, but that was crazy talk. My goal on the CPM is 10 more degrees today, up to about 58. Sleeping a bit better, though I do wake up a lot with a completely dried out mouth and tongue.
Last night I dreamed I was playing tennis even though I knew I shouldn't and without a brace. It felt scary and I didn't move at all for fear I would do something bad. There was also a part in the Alps, and though there was snow, I wasn't skiing.
My family has been great, especially my wife Diane, who doesn't want to let me do even the most trivial things, like refreshing the Cryo/Cuff with ice water. I haven't tried putting any real weight on the leg yet, and I think that will have to wait maybe a couple more days.
Here I am wearing my Cryo/Cuff, riding the CPM, and plugged into my iPod.
Interesting day yesterday. It was like being prepped for space travel was all I could think.
After changing out of my clothes, getting the IV put in, and being wheeled into holding, I waited for about 4 hours before the anesthesiologist gave me the femoral block. It was a little painful, but also fascinating as he probed for the right nerve strand. With each probe, a different part of my lower leg jumped. Then as I'm sitting up, and signing forms answering the "are you allergic to anything" question for the hundredth time, one of the nurses slipped some kind of narcotic into my IV, and as I'm talking to her things began to swim a bit. This was just a taste, as she put it, to keep me relaxed.
Finally, they were able to wheel me into surgery. I noticed as I shifted from the gurney to the operating table, that it had a nice memory foam kind of bed. They put a mask over my face, I took one breath and I was gone.
It took at least two hours post-surgery to wake up, I kept trying to open my eyes, but they wouldn't cooperate. The nurses were getting a little anxious since it was now pretty late on a Friday in the Day surgery department, and everyone no doubt wanted to get home. They were ostensibly dangling the option of staying the night since I was feeling pretty out of it, and very nauseous, but I could tell they didn't mean it. So with the help of my wife and daughter, I was packed into the back seat of the Corolla and driven home.
It wasn't a particularly good night, but I didn't expect it would be. I had a lot of pain, and slept fitfully, not being used to sleeping on my back at all. But the meds helped a lot. By mid-day (today) I'm feeling a lot better and managed my first two-hour session on the CPM. I've got big plans to work on my gardening strategy, a design for an arbor for the front of the house, posting to my blog of course, and watching a movie on my PC. Today's choice is Smiley's People, a PBS adaptation of John le Carre's cold war espionnage novel with Alec Guinness.
My knees before. My left is the one being repaired.
I have my instructions for appearing at the hospital tomorrow (10:15 procedure starts 11:40). And earlier today, the CPM and knee brace were delivered to my house and fitted. The CPM is very quiet to use, and, no surprise, passive. I could easily see falling asleep with the thing on. The tech who delivered it has been through two ACL recons himself quite a while ago, but thought the machine would probably make a difference in short-term rehab but not so much long term. I'm not sure how to reconcile that, but I feel like I still need a definitive plan from my OS following surgery tomorrow. I'm really hoping to get some imagery or video I can post here.
My dad (retired orthopod) is planning to visit tomorrow to lend moral support.
I'm stocked with movies and a couple of good books. The only thing I don't have that I wish I had was a Tivo unit. Hmm, BestBuy is open tonight...
Expecting tomorrow to be fitted for a post-op brace and to have a CPM (Constant Passive Motion) device dropped off. The medical tech who called to schedule the drop off said that most people use the machine for a week to 10 days or so. I have a lot of uncertainty about my immediate post-op condition, like the amount of swelling to expect and so on.
Just heard from my doctor that an Aircast Cryo/Cuff, will be provided for post-surgical cryotherapy, which is a good thing. I was thinking I'd have to get my own. Definitely something you want to have:
Otherwise, I'm starting to let people know at work that I'll be out next week. I'm a little nervous not having ever had general anesthesia before, or surgery really, of any kind. The Fallon system is so full of complete idiots that I feel like I have to be super-proactive. Keep hope alive! I will survive!
Three days to go -- this Friday. Just saw a post from a 44 year old USTA 4.5 who explained he was doing great after his procedure. He was back on the court in 5 months with a brace and near 100% at 7 months. Of course, he could be like those new parents who claim that their baby is sleeping through the night.
Discovered lively and active forum on ACL reconstruction: Bob's ACL WWWBoard. I'll be posting regularly to the forum and cross-referencing this blog as I work my way through this.
When I describe the procedure to my friends, they always cringe at the part about drilling holes in the tibia through to the femur. Frankly, I do too. It seems to me the part of the process that dictates more than anything else, how well the knee performs afterwards.
This reminds me of the old salt my father found to help him drill a long hole into the rudder of his cat boat. The procedure called for using a long bit, probably about 1/4" in diameter about 12" into the rudder. The rudder is only about 3/4" thick. A long drill bit can often wander off course, so it takes a very fine sense of feel to steer the bit correctly so it doesn't break out either side of the rudder. My father was a little uncertain about doing it, but this old guy he found, this boat carpenter, held the rudder between his knees, seated the tip of the bit and drilled the hole perfectly, in one smooth stroke. This is how I imagine the surgery works -- it requires a steady hand, a good feel for the proper angles, and an intimate understanding how the knee functions, and needs to function with its new ACL.
When I was thinking about the prospect of surgery, and given how good the knee has been feeling, I have noticed a tiny element of doubt sneaking into my mind now and then. I never had any swelling or significant pain after all. Now and then I feel a little twinge on the outside of my knee, and bending the knee too far causes some pain. But one part of me is comparing the gravity of the surgery I'm facing with the apparent lack of symptoms. Is it the right thing to do? It's a question of weighing post-surgical risks against what I want to be able to do with the leg.
Lately, the knee has been feeling a bit achy. Nothing too specific. But it reminds me that not doing something about it invites other problems to develop. That's one strong reason for going through with this. The knee can start breaking down over time if the ACL is left untreated.
For me the main issue is mobility on the tennis court. My quickness and movement on the court is a serious requirement and an advantage for me against other players in my age group. Where I may lack in shot making or situational play, I can often make up by getting to balls and maintaining balance and fluidity. If I elected not to have this procedure, I'd have to give up singles forever, and I'm not at all ready to do that.
I spoke to my orthopod yesterday about a few pre- and post-op details. I had a few questions about what to expect post-op, like how quickly I'd be starting PT, whether a knee brace was covered by insurance, that kind of thing. These are my notes from the call:
A surgical pre-test has been scheduled three days before the procedure. Not sure yet what's done at the pre-test, but I assume they cover all the day-of details, run some basic tests, etc.
On the day prior to the procedure, March 8, I'll be fitted for a post-op knee brace and supplied (loaned, I would think) a CTM, which I understand to be a constant-motion device
Dr. Peters I don't think is convinced the CTM is all that necessary but I guess it's part of the package.
He suggested using the CTM a few times a day for 30 mins. to an hour, but that it was up to me. I got the impression that he didn't think it was that important.
Swelling the first week or so is the main issue. Keep knee elevated.
I'll be on crutches first 3-4 weeks and then walking freely.
I asked him if I'd need to get fitted for a sports knee brace but he said he thought I wouldn't need one at all once I was fully recovered.
Plan to start PT the week following the procedure, say Wednesday the 14th. He'll send over the prescription (for PT) to the Fallon PT clinic in Worcester. I should call to confirm and schedule prior to the surgery.
I've worked at Fallon PT before and wasn't too impressed. Tennis has been good to me, but also hard on the body, especially my shoulder. Right now, I'm dealing with a probable impingement issue that seems to be responding well to strengthening exercises. The physical therapist I'm working with now on my shoulder is John Pallof at South County PT in Auburn, and he is really good. The only draw-back is that Auburn is more than twice as far away as Fallon. We'll see how it goes.
I had my second visit with the orthopod last Monday, Feb. 12. Doctor Peters confirmed the ACL tear and mentioned that the pain I feel now and then on the outside of my knee is from a small tear in my meniscus. The goal of this session was to determine the course of action. But the question in my mind wasn't so much what to do (have the surgery) as it was when to do it (as soon as possible). The discussion about whether to have the surgery at all really hinged on the level of mobility and the type of activity I felt I needed to have afterwards. I said that there was no way I would consider skiing or playing tennis on the knee in its present state. It's just too unstable.
My feeling was, let's get as much mobility back as possible so I can have a chance to get a USTA ranking in the 50-55 age group, as well as be able to compete in singles at the 4.0 level. So, we agreed to go ahead with the procedure. The only remaining question was where to get the tissue to use for my new ACL. Dr. Peters explained that, because of my age, I was on the borderline for the use of an allograft (cadaver tissue) or my own tendon, probably a part of my hamstring. Finally, it was decided the allograft would be on hand as a backup. Sometimes it's used in combination with your own tissue. I don't have a problem with the use of the allograft. What I'm interested in is the highest statistical probability of long term success -- I don't care where the tendon comes from.
We also settled on the date: March 9: Three weeks from today. So now, I'm reading up on post-op recovery, rehab, and physical therapy.
Here's how it happened. As a Ranger at Mt. Wachusett, I go out on the hill two times a week at night to help the Ski Patrol with injured skiers and snowboarders, and to help maintain a certain amount of sanity among the nutjobs flying around like unguided missles. January 18th, I arrived and immediately went up the lift to help out at an accident scene on a trail called Smith Walton, or trail 5 as we refer to it on the radio. Just after going over the first pitch, I washed out on an ice patch, and in trying to recover my balance (instead of just taking the fall, as I should have) I hyperextended my left knee. I felt a small 'twang' in the knee, not exactly a pop. There was no twisting, wrenching, and nothing especially violent about the fall. I was not going very fast, either.
When I got up, I knew I'd done something, but it didn't hurt a lot, and I was able to keep going. I remember saying to myself, 'jeez I hope I didn't do what I think I just did.' From the accident scene, I skied down, following the Ski Patrol sled, taking the injured skier's own skis on my shoulder and skiing more or less normally, though a little unsteadily. Turning to the right was a little exciting. Later on, during a single run, I fell twice, which I almost never do, and realized something was up.
Taking a break for coffee, I noticed walking around in my ski boots that there was some definite pain on the outside of my knee, so I decided to quit for the night and put some ice on it. I'd read about ACL injuries, and while I suspected that could have happened, I wasn't convinced. I assumed it took a lot more violence to tear an ACL. The fall I'd had was almost incidental. I'd never hurt myself skiing and was having a hard time accepting the idea that I'd done something serious.
First doctor's visit
But I was concerned enough, never having injured my knees, to get it looked at right away. I was able to get an appointment with my family practice physician the next day, who gave my leg some tugs, noted that there wasn't a lot, if any, discernable swelling, and sent me on my way with the advice to ice it, stay off skis for 4 weeks, and not to worry. We figured it was a sprain.
The specialist
I was already scheduled to see an orthopod early in February to look at my shoulder, so I figured I'd have him take a quick look at the knee while he was at it. During the appointment, we spent 20 minutes talking about the shoulder, which I'd had some trouble with over the last tennis season. In October I'd elected to quit playing until I figured out how to alleviate the pain I was having. I had assumed that the problem was a small rotator cuff tear and that we would be talking about when to schedule arthroscopic surgery. As it happened, he didn't think it was a tear -- the MRI was inconclusive -- so instead, he offered to give me a cortizone shot and put me on a physical therapy regimen. Then we had a look at the knee.
Now, the knee had not really been bothering me at all. It never swelled up much. I could walk a straight line and do stairs without any discomfort at all. I figured a little rest and I'd be back in action. The one thing that nagged at me was that it felt unstable, like I could really do some damage if I stepped off a curb wrong.
He got me on the table, did a few manipulations of my good leg, and then moved over to my left leg. After about two seconds of examination, he told me I had a definite tear in my ACL. This was quite a shock to me at the time. He said he didn't need an MRI to confirm it, but that he'd order one anyway to determine if there was any other damage to the knee, which is pretty typical of an ACL tear, apparently.
The Lachman and drawer tests he did were dramatic. On my good leg, the calf moved forward slightly and stopped with almost a 'thunk.' On the bad leg, the calf moved forward twice as far, and stopped with a certain mushiness. So in a moment, my ski season and my 2007 tennis season disappeared before my very eyes. As I've been saying to friends, "I went in with a shoulder and came out with a knee."
