I didn’t fall off the planet but I did need some time to myself which got a bit longer than I thought it would. So what happened month 4-5…I’ve always kind of thought if you don’t have anything good to say don’t say it!
I envisaged it being a month to press on & make strength gains but anterior knee pain put paid to that! Instead I had a rehab holiday. A total break for 10 days (except basic quads ex’s) to let things settle then gently build up & reintroduce activity. It definitely helped but was a knock emotionally as it felt like I was treading water. It nearly broke me.
Surprisingly I went to some pretty dark places this month and wasn’t much fun to be around. With a social life based around being active & exercising I found I was missing the friends I used to DO things with & it was hard going. Suddenly I wasn’t much use to anyone despite the fact I had come so far! I even let a little anger creep in unnecessarily, but all the while I needed to keep my eyes on the prize and try not to project my issues onto anyone else. I was also aware I didn’t want my kids to pick up on how I was dealing with the challenge and start copying any of my less than positive behaviours in relation to injuries.
Also I struggled with guilt about how I was feeling. It was just a knee! I was sooo lucky & fortunate to be back walking, working, breathing whilst others have everything a lot harder particularly as a result of a global pandemic or any manner of other medical or non-medical reasons. What struck me this month was that I had underestimated deeply the psychological aspect of my own rehab & how it was also mixed up in my expectations of myself as a physiotherapist. Geeezzz ….deep.
I did also do some positive things after my rehab holiday that made me smile!! I started a few more faster off-road walks whilst accompanying my daughter hacking, great for proprioception, balance & confidence and continued on with the paddle boarding – yay!
Everyone feels better with some vit D, so after a triumphant finish to homeschooling we planned to head off with the kids via eurotunnel for a massive road trip to Spain to spend some time as a family on my parents boat. Not needing to take a flight we felt we could isolate as much as we needed to offshore. But it did mean a 16 hour drive! It built confidence that I tolerated 6 hours of driving a day and I have to admit it was great to get away.
We’re emerging from lockdown! Whilst things are far from usual I’m now back seeing patients again. The sun is shining and all things knee are moving forwards.
Four months post op slightly reminds me of emerging from the first few months of motherhood. It does get easier! The differences between ACL journeys can also be just as diverse as raising kids. If you’re struggling you aren’t alone, likewise if things are going great & you’re returning to running & into plyometrics that’s equally great.
Just like any other challenge, surround yourself with support from people that are helping make that journey positive. Get in touch if you want some advice, motivation or just to swap stories.
I did start with a treadmill jog in recent weeks as impact loading assessment more than anything else. 5mins walk, 1 min jog, 5mins walk 30secs. This session did build a bit of confidence but did feel “odd” & that was enough for my patella-femoral joint at the moment which is irritable.
You need the sound to truly appreciate this epic! 🤣
I made it back to physio myself this week & it was great to be back on the Alter-G for some work towards running. I started with backward walking, followed by forward fast walk. I jogged for 7 mins with 60% of body weight taken off. That’s the baseline at the moment. It’s useful (compared to my 1min on treadmill) to get more time in running whilst analysing & working on gait with less impact. You get feedback on stride length, weight distribution, time in stance phase & can change things. Hopefully when I get back to full weight bearing I will be as near even gait pattern as possible and will have gradually built up tolerance to loading. Hopefully this will limit me reinforcing suboptimal movement patterns and stop any longer term issues from picking up bad habits.
One example is my heel kick. On the Alter G, I could see from the rear camera I wasn’t pulling up my right heel as high as the left, probably because my hamstring isn’t working as hard on the operated leg where the graft was taken. A quick correction & I could see in real time things change.
Strength work continues to progress. I’ve now introduced some low level plyometrics (jumping type activities) into my rehab and added in some variation too. I’ve been outside on the mountain bike but am not ready for the road bike outside yet. It’s a standard environment in the house with no traffic & limited opportunities to fall off! I can also pull my foot out of the shoe instead of the twisting motion of uncleating. I have started using cleats on the turbo trainer which is a game changer. I also did my first interval ride on Zwift & was promptly dropped by the group! Great to be adding some different workouts in though. Variety in rehab keeps things slightly more interesting!
Family bike ride
Another training variation was the addition of a stand up paddle board. It is soooo nice to finally (6 months after the injury) to be a bit active outside & it’s great for balance training. I would say if you are thinking about getting on a SUP, go in flat & deep water in these relatively early months. Keeping any excited kids well clear of capsizing the board means you have the perfect opportunity for some alone time too!! The potential risk of injury to the ACL graft could come from a slip & twist off the board or landing awkwardly if you fall off in shallow water. If in doubt check with your physiotherapist before you head out.
Freedom at last!
A few of the plyometric exercises I have added in are below. As you will see I have plenty to work to do & compensations to iron out. There are a plethora of exercises that you can be doing at 4 months post op depending on how your rehab is progressing. Get in touch if you need some ideas.
Hopefully your personal rehab is heading in the right direction & you are starting to see the benefits of the work you are putting in. Stick with it….
A whopping 3 months on! We’re still in lockdown but the old right knee is improving.
As anyone rehabbing knows it can be monotonous, frustrating & let’s face it dull! What has helped me is structuring my days. So one day I’ll focus on strengthening with weights and for the last week or so aim to walk 10,000steps. The next day will be focused on a bike turbo session 50-75 mins where warm up for 10mins then gradually maintain increasing wattage for 40mins, then cool down with an easy cycle. I add on balance work and controlled movements challenging different directions. I might add in a Pilates class once or twice a week.
My focus is doing something everyday that is going to help improve my overall outcome with my knee & get me closer to getting back to running. Lots of small goals, building up to the one main goal.
This last week I started impact testing. Basically seeing how the knee responds to more loading. So I did my first jog on the spot. It felt slightly like I was co-ordinating legs that didn’t quite belong to me & as soon as there was any discomfort I stopped. So 30seconds is the current tolerance & I’ll do that every other day now & see how I react. Then I’ll gradually build that up. Hell…..you got to start somewhere!!
30secs jog on the spot
Returning to running can be a messy path with lots of twists & turns & surprisingly little evidence to guide the route. A stepwise return to running programme that you can stop or adapt is key. When we run 1 mile we essentially hop for approximately 750 reps on each leg. So having the ability to tolerate and manage that explosive movement is really important. Hence, plyometric work will be a keystone of the next phase of rehab once built on strength and proprioceptive control. This is sometimes also called jump training- you use your muscles to their maximum over a short period.
My dog walks are getting faster, longer & more adventurous. I need to be completely pain-free walking for at-least half an hour prior to considering a return to running. Any slight downhill is slightly nerve racking, add in a slightly infirm surface & I have no confidence. A lot of this is in my headed & gradual exposure will help build my confidence in my knee over the coming months. I suggested a family walk to a hill yesterday, loved the hike up but gripped onto my husband’s shoulders for every step when we navigated vaguely slippy terrain on the way down. Uneven slopes and rocky trails I would have loved bounding down pre- accident.
Hambledon Hill
Which leads us to my next challenge and barrier to progression. The terminal knee extension! I’ve mentioned it since day 1 and it’s critical to have extension equal to the other side. For me I have a reasonable amount of hyperextension of my left leg, but not quite the same on my operated leg. This is often a barrier post op to returning to activities like running. Without gaining it the knee cap or patella-femoral joint can get irritable and overloaded. My main challenge is that I hadn’t achieved that range pre-op. I’m working hard to regain it! The long slow weighted stretches are 100% hideous, if you’ve ever had to do them I’m sure you’ll agree. Over a day my aim is 30 mins of stretch at the end of my current range. Little by little the hope is that this will improve.
Knee extension exercises
*Be sure to do exercises appropriately for your stage of rehab and relevant to your surgeons protocol as instructed by your physiotherapist*
Outline criteria for progression 12 weeks – 20 weeks post op
-No patellofemoral pain
-120 degrees of knee flexion
-Sufficient strength and proprioception to initiate unweighted running
-Minimal swelling/inflammation
Goals for rehab
-Full range of movement
-Achieve full terminal knee extension prior to full weight-bear running
-Improve strength, endurance, proprioception, of the leg in order to prepare for sport
A friend caught me in a funk this week whilst I had a knee that felt like a lump of wood. She asked “But are you progressing?”. Truth be told some days it may be difficult to see through the haze! The focus is to chip away each day at what is going to help you progress & try not to take your eye off the end goal, whatever that might be or how far away it may seem.
I am pleased to report great progress in the last 4 weeks with increases in knee bend, walking pattern and ability to tolerate load. I’m the turbo trainer but trying not get too carried away with that otherwise the knee let’s me know I’ve pushed too hard. Pain and swelling being the tell tale signs I’ve done too much.
Whilst moving forward with rehab this isn’t a time to get complacent or push too hard and create any further swelling as the ACL graft is actually at its most vulnerable at approx 8-12weeks post op when it revascularises. Mechanical properties of the graft are actually at their weakest. You want some loading to stimulate graft cells but without compromising graft integrity. After 12weeks the ligamentisation phase of graft healing begins & it is able to accept more tensile loading. It becomes more similar to an intact ACL ligament but this process takes atleast 1year in human biopsy studies.
Generally speaking from 6 weeks onwards I have been focusing on strengthening hamstrings, quads (thigh), glutes (buttocks), calf complex. To achieve this without aggravating swelling or pain may mean a smaller range of movement or adapting the load to suit you better. Primarily the most controlled way to add load at this time (as mentioned in my last post) is in a closed kinetic chain position when the feet are in contact with the ground. So exercises such as bridging, squats, calf raises, single leg squats (adapted as needed) are really useful. Finding the sweet spot of adding the right amount of load, reps, sets to help improve strength is key! Make sure to be guided by your therapy team on this. Also don’t neglect your balance work.
If we ignore the major elephant in the room of the global pandemic, the quiet life can be a useful time to be rehabbing as long as you feel you have the correct support at the end of a phone or video-call to keep you on the straight & narrow & offer support. However, it does mean being a little more creative with loading and potentially the progression of your balance exercises if you suddenly don’t have access to a gym and equipment. It is unfortunate not to be able to jump in the pool as by now full front crawl (still no breastroke) would be an option.
If you feel you’re struggling to progress at this point is definitely worth analysing where things are going off track. Are you respecting pain and swelling? Are you sticking to your exercise prescription or deviating and working too hard or going offpiste? Did you follow up a new strength session with a tonne of housework/gardening and now wonder why you’re sore? Are you getting your joint moving prior to strength exercises? The ability to get terminal knee extension as mentioned is going to be critical to the ability to strengthen the quads (thigh muscle) effectively. A long, slow simple weighted stretch needs little equipment & can be a game changer.
It’s definitely worth keeping a log just as you might do with training of your activity levels, cardio-vascular exercise effort/duration, exercises completed with loads, sets, reps and any flare ups. This will help you & your therapist work to iron out and tweak your rehab programme as appropriate. It will also help you see progressions when it can sometimes feel like the gains are minimal!
If you are going through this process it is definitely a long old slog & still many months lay ahead on the journey to full fitness or perhaps your chosen sport. Whilst it may feel like a long haul I hope that if you are 2 months+ post op you can look back over the last few weeks and see positive progress.
Lindsay Vonn knows a thing or two about knee injuries ….
Lindsay Vonn in an UnderArmour advert
Onwards through the current storm with positivity.
…..Wow what a 2 weeks. I feel there are plenty of places to get updates, facts, opinions on the Coronavirus pandemic and it’s bewildering impacts near and far. However, my remit for the next few hundred words is documenting this right ACL (anterior cruciate ligament) journey as promised….
So…staying at home has its benefits. I now have the company of my wonderful family & all that entails. I’m keeping myself occupied without face to face patients, by homeschooling which includes joining the kids for a very modified* Joe Wicks workout last week! I’m now 6 weeks post op and still should not carry out plyometric (jumping) type exercises as the graft still needs protecting. But I can modify, do some of my own rehab exercises and get moving with the kids. They loved me joining in where I could.
Below is 1 of 2 videos showing a mix of rehab exercises I’m doing. Not all at the same time & this doesn’t represent reps/sets. Some will look familiar from just prior to surgery.
Progress has definitely been made in the last 2 weeks. Activity around the house, whilst modified where necessary is more normal. Sadly that means all cleaning is back on! I’m also able to spend longer on my feet. Work on gait (walking pattern) continues, but I’m up-to a mile to our local field. The thing that limits my walking distance is not wanting to reinforce a poor pattern once the technique has gone.
Cycling on the turbo-trainer now involves sweat! I have my own avatar on Zwift and am up-to 30 mins every other day. Zwift is essentially an online virtual game. You rig your bike up & can ride with others whilst viewing all your stats. Going forwards the stats available will be really useful to monitor progress whilst gradually increasing time/resistance. Currently the bike is beneficial for getting a stiff joint moving and is a safe activity which doesn’t compromise the graft.
Stiffness of the knee is still my primary complaint- still. It is a common post op issue. It’s also a seesaw…. you work on heel hangs for 10 mins , prone (on tummy) heel hangs over edge of a bed, then you stiffen up into flexion. You work on that & vice versa. It’s a balance! Currently I have 0-120 degrees knee flexion.
Given that I haven’t achieved full range of movement yet and I still have intermittent pain in the medial joint line (inner part of knee joint) and patella-femoral (knee cap) joint I’m not rushing on to progress. If a gym were available at present I’d be using the leg press with light weights at this point, focusing on using the anti-gravity treadmill, hydrotherapy pool, and being in the swimming pool! It isn’t so rehab will adjust to factor that in. But here’s some of the exercises I’ve been doing.
I’m breaking up exercises & not doing then all in a block. Some mobility, gait and basic activation exercises I may do 2-3x /day. A bit of progress last week was catching up with Tom Goom “the running physio” whose runs one of the conferences I was due to attend in the coming months. Sometimes as a physio it’s tricky to be objective about your own care! He suggested I also focusing on breaking up strengthening and cardio-vascular (CV) days just as I would when training. This has definitely helped settle some anterior knee pain (pain at front of knee).
Another important feature historically in ACL rehabilitation has been that open chain kinetic exercises not used post surgery for 6months +, due to belief they would overstress the graft leading to laxity or failure. However, more recently this has been disputed. What is important is that these exercises are controlled and implemented at the correct time for individual patients and within a restricted range. This isn’t easily achieved within the home environment.
Open kinetic chain knee exercises allow the foot to move without contact with the floor and can isolate muscle group and increase strength assuming load is appropriate.eg leg extension machine (quadriceps) or leg curl machine (hamstrings). Straight leg raise can be thought of as open chain at both the hip and knee. Closed kinetic chain exercises include exercises such as squats and lunges which involve the foot being in contact with the floor.
Whilst as physiotherapists and as patients we are keen to progress and for new exercises each patient needs to be ready! Underlying weaknesses can lead to compensation, poor quality, potentially injury or graft damage. I catch up with my physio on the phone tomorrow as face time face contacts are not currently an option.
*Be sure to do exercises appropriately for your stage of rehab and relevant to your surgeons protocol as instructed by your physiotherapist*
Outline criteria for progressions weeks 4-12 post hamstring graft ACL reconstruction
-Full Extension/hyperextension
-Quality quadriceps set and straight leg raise (SLR) with no lag
-Flexion to 90 degrees
-Minimal swelling /inflammation
-Normal gait on level surfaces
Goals for rehab 4-12 weeks
-Restore normal gait on stairs
-Maintain full extension
-Regain full flexion ideally by week 6
-Protect graft & fixation
-Increase hip, quadricep, calf and hamstring strength (respect soft tissue healing times of grafted hamstring site).
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