Pain in the Knee

Things had been going great at the gym..... until I did the leg press. For whatever reason this one was on an incline, not like the one at physio which is flat. Only did about 12 reps on the lowest setting but my knee didn't like it one bit. Still sore after about 3 days of icing, hope I don't have jumper's knee!

Jump Tests

So this is one of the tests they do to see if you're ready to do sports. First you jump with your good leg, lifting off and landing on the same leg as far as you can (a big one legged hop, basically). Then do the same with your involved (injured) leg. If you get to within 90% of the distance of the good leg you're good to go.

Note you should build up to that exercise by hopping from one leg to the other and noting that while the jump or hop should be big enough to be a challenge, you must land the jumps in a controlled manner... More running and bike this week. Feeling strong.

Bring on more sports!

Longer Runs...

Doing some great biking and running now. Last visit to the gym was 30mins on the bike (setting 11) and 30 running on the treadmill (between 6 and 7). Did the biking all in one go and 2 intervals of 15 minutes for the running. Knee felt excellent after, no icing needed at all!

Feeling a lot more confident about returning to sports as well. Before I kind of felt like it might not be worth it to play again, to go through it all again with the other knee or another bad injury. Now that I'm back running and there is light at the end of the tunnel the whole experience hasn't seemed too bad. Can't wait to be back firing in goals!

Physio says soccer is a possibility in around 2 to 3 months...

Fore!

Got the all clear to hit some golf balls on the driving range today! Not that I intend to in the very near future due to this rediculously cold weather. Wasn't sure if it would be OK as there is a lot of rotation torque that goes through the left knee on a (right handed) swing.

Apparently Tiger Woods had ACL surgery as well, here is a little more info on his surgery procedure. Some new fancy "double bundle" method apparently... He took 9 months to come back which seems a little long though the fact I don't have a Tiger swing should mean I can get back a little sooner. Sage words from my surgeon: "While I don't recommend Tiger's judgement for everything, it was sound with respect to his knee..."

Ice Skating

Did a little ice skating at the Rockefeller Center today, felt pretty good even if a little precarious! Did some exercises the last week or two to prepare. Basically involves exaggerated skating motions, standing upright and bending the knee down whilst shifting the other leg sideways and backwards (about 5 o'clock if you are facing 12 o'clock). Repeat for both legs.

Running, Running and Running Running

Ran for the first time on the treadmill today! Massive massive progress. Did about 6 minutes with the treadmill on 6, no incline. Felt like I could have done a lot more but kept it short to see how the knee will feel over the next few days...

3 Months Post Op

So the fact that I haven't updated anything here for 2 months says quite a lot about my progress I think!

Shortly after I got off the crutches I got rid of the brace as well as it started actually getting in the way of walking properly.

Physical therapy has been great and doing all manner of exercises to strengthen the hip, groin, quads and of course the knee itself.

Over the holidays I was able to comfortably (I should say as comfortably as economy class would allow) fly to Europe for a little vacation time. Also no issues with the metal detector at the airport which was a relief.

Last week I was able to do a casual dribble with the soccer ball in the PT room and a little passing the ball as well which felt great!

3 month post op visit went off without a hitch and the scar is looking really good, will post a picture for you soon...

Off Crutches

Got off my crutches today and it feels great to have both my hands back! Was beginning to get annoyed at bundling it into cabs and having to prop it up while in meetings and at the bar.

Also all the sticky patch dressings that were on my scars have finally dropped off. Scar looks thinner than I expected. I know it's the sign of a good surgeon, but was kinda hoping it would be a bit more gnarly...

So, victories this week were:

- walking without crutches
- climbing 5 flights of stairs like a normal person (ie not putting both feet on each step!)
- riding the bike with resistance set at 4
- up to 4 resistance springs on the leg press
- sent back the Game Ready icing machine, just not enough swelling to justify anymore
- getting "low" to the Flo Rida in the club......

5 week post op appointment on Wednesday.

Victories and Surgery Bills

Physical therapy going really well. Doing exercises on the leg press and with resistance bands. Warming up on the bike before sessions. Feels great to be riding, even on the lowest resistance level!

Also doing work strengthening my hip and spending time stretching my calf and hamstring. Everything feels quite tight but better after stretching.

Victories this week:
- Walking without crutches or brace
- Going to work with only one crutch
- Range of motion at 122 degrees

Knee looking great and swelling is mostly gone, as are the rainbow colors.

Count of friends with ACL surgery I never knew about is now 15 (!).

On another note, medical bills came in today. So far we have:

Surgery           $16,000
Anesthesia      $4,000

My share of these is about $1,500.

Ouch.

2 Week Post Op Appointment

Went to see the surgeon today, very quick visit which is a good thing I think! Managed to sneak a peek of the x-rays:

Small victories this week:
- Walking without brace and on only one crutch.
- Stitches taken out.
- Showering without brace and being able to wash my leg, 1st time in 2 weeks.
- Being able to bend knee enough to sit normally in a cab rather than across all the whole back seat!

Fourth Day of Physical Therapy

Last session today before my 2 week post op appointment with my surgeon. Really good session as was able to do full revolutions on the bike and also hit my target of 110 degrees ROM 2 days early.

Worked a lot on the swelling above my knee today and by the time I walked out of there is was almost completely gone! Something that really helped was the electric stim on my knee, we changed the order of the program so that some of the swelling would be worked out by the pulsing quad.

Physio said the progress so far was excellent and will update the surgeon ahead of my appointment! Feels good to be making progress. Target for the next 2 weeks is to get me off crutches he says. That's what I like to hear!

Knee felt so good I walked home with the brace unlocked to 40 degrees ROM. Still on crutches but felt really good. Ran into a friend on the way home and found out he's had his ACL done as well (Hamstring Autograft, 5 years ago) and hasn't had any issues with it. Count of friends with ACL operations I didn't know about is now 5.

Electric Stim picture as promised, knee looking good and much less swelling

Third Day of Physical Therapy

New exercise thrown into the mix today, dragging back a large beach ball with my heel is helping me straighten my leg as well as activate the hamstring.

90 degree ROM today which is great! Slightly ahead of schedule. Now have to hit 110 degrees ROM before my 2 week post op visit to the surgeon.

Straightening the leg fully is still difficult, I seem to have swelling right above the knee which is stopping my from achieving full extension. Got a new exercise to do where I lie face down on the bed with legs hanging off just above the knee. Hold for 1 minute and then 15 hamstring curls, repeat. Let's see how it works.

Walked home from physio today, I'd say it was about a mile...

Second Day of Physical Therapy

Second day basically a repeat of the first, except that my range of motion (ROM) is now 87 degress and electric stimulation has been increased to 12 minutes for each setting (24 minutes total).

Here are some examples of some of the exercises I'm doing. Obviously don't start doing any of these without the guidance of a trained physiotherapist.

Doing 3 sessions a week now for the next few weeks.

First Day of Physical Therapy

Today was my first physiotherapy session and also my first time out of the house since the surgery. Felt great to be outside and the physio is only located a few blocks away in a cab.

During the session he measures my range of motion (73 degrees) and does some passive movement on my knee to loosen it up. The main thing is straightening the leg to zero degrees. Not there yet (about 3 degrees) but have exercises now to improve.

Also started electrical stimulation in the knee. This helps to get my quads to "fire". Two different settings, one which makes my quad contract repeatedly with an ice pack on my knee. Second setting where busts or current are passed through my knee as I flex my quads at the same time. This will help get the muscles and brain going again, getting used to using the muscle. Will post a picture soon.

The physio seems to know exactly what he's doing and has also rehabbed a few other patients operated on by my surgeon. This is definitely comforting, specially at the end when he says he's seen this a bunch of times before and that everything will be fine.

Current daily regimen is:
- 100 leg raises
- 100 passive knee bends
- 100 quad bursts
- 100 heel slides

No painkillers for the first time today even with the physio, so far so good. Still icing like crazy with the Game Ready.

Femoral Nerve Block Wears Off!

So my femoral nerve block wore off at about 3am this morning, not pleasant! Made up for it with a few extra doses of pain killer. So far so good.

Shower felt great and a lot easier to get in/out than I expected. Still needed help though. Get those swim trunks on in the shower!

Game Ready still a regular fixture, doing about 3 to 4 hours a day at the moment. It really seems to help with the pain and the swelling is way down already.

2 Days Post Op, Bandages Off

Last 2 days have been a bit of a blur. Spent a lot of time on the Game Ready and popping Percocet. My folks are here now to help me out (thanks Mum & Dad!) which is a Godsend as I really can't do too much at all!

Bandages and dressing comes off today, as long as there is no bleeding I can take a shower tomorrow. You'd think that would be good but my leg is so weak I'm not sure how I'm going to step into the shower. Should be interesting.

Looks kinda gnarly but a lot less swelling than I expected. No bleeding or leakage.

Slightly concerned about my shin, there is a numb strip from my knee right the way down to the top of my foot. Think this is just the femoral nerve block but not sure. Hope it's not any damage from the surgery...

Day of Surgery

Got the call from the surgery late last night, surgery time set for 12.15pm and need to be there 2 hours before to get prepped up. Filled out a bunch of forms (including my will!) at the hospital and escorted to a pre-surgery ward. Once there I'm visited by a nurse to insert an IV into my hand, resident physio who gives me my post surgery exercises already. The surgeon stops by for a chat and to sign the knee I'm going to have surgery on. In fact, every single person who stops by asks me to confirm which knee is being operated on. Also confirm the autograft and the allograft is sent back to the tissue bank.

Last pre-op picture of my knee, already signed and shaved ready for surgery.

Most interesting conversation was with the anesthesiologist. If they offer you a femoral nerve block, take it! it will greatly reduce your pain over the next few days, trust me.

I get walked over to the operating theater and it's a pretty serious feeling walking in there with equipment all over the place. I get up on the operating table and am covered with what I can only describe as an awesome heated blanket. The assistant tells he's putting some sedation into the IV, do I feel it yet? Nope, I say as they push me forwards to insert the epidural into my back. That's the last thing I remember....

I have no idea if I was asleep during the operation. When I came to it wasn't like I woke up, more like a livening of consciousness. I woke up back in the pre-surgery ward and was not alarmed at all, felt very relaxed. They kept me there for an hour or so to observe me and then my buddy was escorted in to take me home. Whole thing took about 8 hours, 10am to 6pm.

My leg looked and felt great (as in no pain). The knee was nicely bandaged up and strapped in to a serious looking brace as well. I was able to swing around on my crutches without much difficulty and we went home. Note they only give you enough pain killers to last you the journey home, so good idea to have one of your friends fill your painkiller prescription ASAP!

For the record, Percocet makes me talk non stop and not remember too much of what I say!

Be warned...

Pre Surgery Diet

The surgeon has told me to follow a special low fiber diet leading up to the operation. Makes sense really, if you're going to have an epidural and lose feeling from the waist down you don't want any accidents during the operation!! 

Anyway, I have a whole list of eligible foods. Opt for spaghetti Bolognese without any cheese or onions. Should be fine for tomorrow.

Made up my mind on the graft (finally!). Going patellar autograft. It's gonna hurt more and tougher rehab but ultimately has the best long term prospects which is the most important thing I think.

Time Off Work

So after discussions with the surgeon I'm going to take 2.5 weeks off work (Operation on October 13th and back at work November 1st). This is slightly more than usual, though everywhere I've looked people have said they wished they had stayed home a little longer.

Anyway, I can always come back earlier from 2.5 weeks off if things go really well.

Animation of the Surgery

If you were wondering how exactly it is that the surgeon is going to get my patellar graft into my knee, here is the answer:

Click HERE to see the video on YouTube

Click HERE to see the video on YouTube

Disaster!

So to add insult to injury (literally) my wisdom tooth got infected and was removed today! Following discussion with the knee surgeon the tooth needs to be removed as the infection could spread to the knee after the operation if it gets into my blood stream. Apparently the metal would attract it somehow and if I were to have a total knee replacement the operation would have been postponed due to significantly more metal being used in the operation.

Anyhow, the surgeon says that as long as I take the 5 day course of antibiotics following the surgery I will be good to go. Sweet.

Got an advance taste of Percocet pain killers. Can see how people get addicted to these, they make you feel great! Not a care in the world and not nearly as nervous about my surgery on Wednesday... :)

"Game Ready" Icing Machine

So the surgeon has recommended I get one of these. Looks pretty cool and should help a lot with the swelling in the first few weeks after surgery. It ain't cheap (rental for 21 days is about $300) and not covered by insurance, at least not mine. If you want one new I hear they are about $3,000 so maybe renting isn't a bad idea!

Click HERE for the website

There is another cheaper option called Cryo Cuff which only costs around $125 to BUY. Also looks good but in the absence of having time or opportunity to try them both out I went with the more expensive one on the assumption that it would be better.

For the Cryo Cuff website, click HERE.

ACL Discussion Forum

Great forum here to ask any questions or just read through, helped me a lot...

Click HERE.

Autograft Vs Allograft

So what is the difference between autograft and allograft reconstructions? Basically, the autograft is a tendon that is harvested from elsewhere in your own body and used as a replacement ACL. The ones that are typically used are part of the patellar tendon (it joins the kneecap to your shin) or a part of your hamstring. The allograft is a donor tendon from a cadaver, usually the achilles tendon is used.

I've been researching autografts and allografts for days now and there doesn't seem to be a clear favorite. The patellar autograft is often referred to as the "Gold Standard" for ACL repair, but research on other grafts is scant. Here is a summary of what I've found so far:

Allograft (Positives)

- Less pain in recovery as the surgery is just for reconstructing the ACL, there is no donor site.

- Rehab is much shorter as there is no donor site to rehabilitate.

- Surgery is quicker and less expensive.

Allograft (Negatives)

- Risk of disease transmission such as HIV, Hepatitis and more.

- Treatment of tendon for disease and preservation may weaken it.

- Takes longer for the tendon to vascularize (around 9 months).

- Higher failure rate than autografts.

- May not be sufficiently strong to endure frequent sporting 

Patellar Autograft (Positives)

- Considered the "Gold Standard" by which other grafts are measured.

- No doubts about tissue quality or disease transmission.

- Quicker vascularization (around 3-4 months).

- Higher success rate.

Patellar Autograft (Negatives)

- More pain and rehabilitation required.

- Possible numbness at donor site

Here are some of the articles I read to come up with the list. Click on the links below to see, plenty of details here:

Graft Choices for ACL surgery
Risk of Disease in Your Allograft
A Systematic Review of Anterior Cruciate Ligament Reconstruction Rehabilitation 
Graft Selection for ACL Reconstruction: A Level I Systematic Review Comparing Failure Rates and Functional Outcomes
Beliefs and Attitudes of Members of the American Academy of Orthopaedic Surgeons Regarding the Treatment of Anterior Cruciate Ligament Injury


There is plenty more if you google as well, either you will find all the info useful or it will drive you crazy :)

First Surgeon Visit

The appointment at HSS today went really well. The surgeon patiently answered all of my questions which he has probably answered a million times before. We went through the MRIs in detail which was interesting and got a much better picture of what had happened in my knee.

On the MRI you can see the bone bruising on the front of the femur joint and the back of the tibia joint in the form of light white speckles. This shows exactly where the two bones jarred against each other when I dislocated my knee.

Also, the meniscus tear is evident on the MRI. It's torn on the edge and goes right the way through. The surgeon said he'd shave off the area around the tear in a semi circle so that the tear is basically cut out of the meniscus and cannot tear any further.

Surgeon tugged around on my legs and wiggled my knees to get an idea of looseness in my knees and also tested range of motion which was good, I think he said zero to 140 degrees.

So turns out there is another choice to make. Either the ACL reconstruction surgery can be done with a donor tendon from a cadaver (allograft) or it can be harvested from another part of my body (autograft). We talked a long time about this and seems there is no easy decision to be made here, there are pros and cons to both. Mmmm... more research required here.

In the meantime the surgeon has ordered a donor tendon (achilles I think) in case I decide to have the allograft. Apparently I can make this decision as late as the day before my surgery without any financial penalty.

Got given a bunch of instructions for pre-surgery, some exercises to do with the knee.

Surgery scheduled for October 13th.

Picking Up My X-Ray and MRI Files

So I needed to pick up my X-Ray and MRI images (conveniently on CD-ROM) along with the report from Beth Israel to give to the surgeon tomorrow.

After forking out my $40 the radiology assistant looks at my diagnosis on the file and says "Were you in a car crash?"

"Errrrr, no."

Great.

Crutches

So in Europe we have a different style of crutches than the ones in US where I am being operated. The American ones go under your shoulder and frankly tend to hurt a lot in my armpit, I know this from fooling around on friend's crutches when they have had their operations. Also, this style of crutches has not been used in Europe since the Second World War!

So I picked up these in anticipation of my surgery and recovery, I think they'll be much better. Each to their own I guess, gotta do what's comfortable.

Choosing My Surgeon

So I decided to have the operation in my last post. I certainly haven't ever had to choose my surgeon before but here's what I've decided what my criteria should be:

1) Must be a specialist in ACL reconstruction, not just a general orthopedic surgeon.
2) Must be recognized as an excellent surgeon by his/her peers.
3) Must frequently perform ACL surgeries and be aware of the latest techniques.
4) Must come highly recommended by patients.

Ask your friends for recommendations of hospitals and surgeons, you will be surprised how many of your friends have had ACL surgery that you didn't even know about (4 in my case!).

I'm based in New York City and the hospital that wins hands down for these types of sports injuries is the Hospital for Special Surgery (HSS). So I called my insurance company and got a list of the 5 best surgeons covered by my insurance who are at HSS.

I've chosen my surgeon now and couldn't be happier. The department works with the New York Mets, Giants, Knicks, Nets, Red Bulls and a bunch of college teams. Appointment scheduled for Wednesday 29th.

Click here to go to the website.

Anatomy of the Knee

A great website that explains the anatomy of the knee with regards to the ACL much better than I ever could!

Click here.

MRI Follow Up

So the knee is feeling a lot better today and I'm thinking I might have gotten away with a strain of some kind or a small tear that will heal itself. With a bit of physio and better stretching I should be OK in a week or two I'm sure.

The doctor walks in, I shake his hand and I'm quietly confident.

"So Nick, it's as we though. You've torn your ACL..... and your Meniscus."

Boom.

The doc walks me through the MRI and it's not even close. The whole ACL is not even visible on the MRI, it's completely disintegrated. The meniscus also has a tear in it (turns out about 70% of all ACL tears have some meniscus damage because of the twisting motion needed to tear the ACL).

The doctor tells me I don't have to have surgery right away, and in fact he says I don't ever need to have it. "With physiotherapy you could live an active lifestyle, but a return to "cutting sports" is unlikely."

It's a no brainer, I decide right there and then to go for the surgery because:
1) I want to play any sport I damn well please;
2) I don't want to risk further injury to my meniscus which may lead to arthritis; and
3) Physiotherapy to compensate for not having an ACL will probably take as long as rehab from surgery anyway.

The last thing the doctor tells me is that if I choose surgery I get to choose my own surgeon and that I'm not restricted to the ones at Beth Israel Medical Center. Interesting...

MRI

Once again Beth Israel came good and I got an appointment today for 12.30, again at short notice! I don't think there are any specific guidelines for a diagnosis but I just want mine as quickly as possible! Was a little wary as I've heard that people get dizzy and disorientated with all the strong magnetic fields. In the end they placed me half in/half out of the big MRI cylinder (my own non-medical term!) with a smaller cylindrical scanner just around my knee.

The MRI machine seems to be unnecessarily noisy, like the smoke monster from LOST or something with lots of loud banging. Got some headphones with mellow music to drown out the sound a bit which was good. Anyway, in the end the whole thing lasted about 30 minutes but remember to keep still or they have to do them again! The MRI technician gave me a glimpse of the end product but couldn't make head or tail out of the black and grey swirls. Made me wish I'd googled knee MRIs beforehand so I knew what I was looking at.

You don't get any interpretation when you get the scan done, a specialist will review it within a few days and write a report on what they see. MRI results appointment scheduled for Friday 18th.

No dizzyness or disorientation by the way. Result.

First Doctor Visit

So, worried about my knee I made an appointment to see an orthopedic specialist. I didn't bother to see my regular doctor as I knew he would just refer me to a specialist. In any case my insurance does not require the referral so I figured this way would be much quicker.

I have to say that getting an appointment at short notice was extremely difficult. The only advice I can give you is to call the bigger practices and see if you can be squeezed in or go on a waiting list. In the end I went to the Beth Israel Medical Center in NYC, and I can highly recommend them and also thank them for seeing me so promptly!

More important though, is to check with your insurance companies to get a list of eligible specialists. What you don't want in addition to your knee injury is a great big bill from the hospital that your insurance company won't cover!

So I went to see the doctor who requested several x-rays be taken of my knee in different positions. Not a lot of fun if you can barely walk, let alone stand still with bended knees in front of an x-ray machine! They did give me lead padding to shield my crown jewels which was thoughtful.

The doctor pushed and pulled both my knees in several directions and compare the two. He seemed quite happy with everything and was surprised at how little swelling there was in the knee which I took as a good sign. As far as the bones went everything was OK, however ligaments and tendons don't show up on an x-ray (they don't contain calcium) so I have an MRI scheduled for next week.

The Accident

So most people who tear their ACL do it while playing sports with "cutting" movements involving sharp changes in direction such as Basketball, American Football or Soccer as in my case. I'd like to tell you I went down in a blaze of glory being tackled by 3 defenders but alas there was no one even close to me when it happened!

I usually shoot with my left foot but I found myself in front of goal with the ball sitting up on my right side. As I went to lash the ball into the top corner of the goal *cough* I pivoted on and extended my left leg full stretch to shoot with my right. As I went to shoot my left leg buckled "the wrong way" and felt my knee dislocate and twist with a "pop".

I have to say that even though I'd had the dislocated feeling I also felt everything get pulled back into place and though that maybe I'd been lucky and got away with a twisted knee and a few weeks on the sidelines. It wasn't until a team mate told me about his previous ACL injury that I thought there might be a problem. According to him the "pop" was probably my ACL........

Got a ride home from the field but walking around my apartment felt weird. Knee felt weak and unstable and also nearly buckled on me a couple of times, though thankfully only the "right way" this time.

Urban Soccer League Champions, Summer Season 2010

(I'm at the back, last one on the right. Also, last known picture of uninjured left knee!)

Reason For Blogging

So..... I don't normally do this kind of thing! I tried looking around the internet and there is enough information about the actual ACL surgery and rehab but not so much about the actual experience of going through a process like this.

The best I've seen are Henry (ACL Allograft Revision) and Eric's (ACL Hamstring Autograft) blog which is here. However, now I have done my surgery (ACL Patellar Autograft) I am noticing big differences between their blog and my experience, probably due to the different graft being used, so decided to start this blog up.

I'll put up the links that I used in doing my research, hopefully this will be useful and save you a bit of time and help making some difficult decisions a bit easier! In the interest of keeping everything chronological I'll backdate this post and some of the others. I'm currently 10 days post op, but wanted to keep everything in order you can read it through logically.

Please feel free to add comments with your experiences, or just check in from time to time and follow the ride!

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