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10 Days Post Op

This weekend I had plans. I was going to run 20 miles mostly at my marathon pace in the “Wimborne 20”. It’s a great training race before the London marathon. Last year I was going to “take it easy” but got excited for the last half. This year was going to be different….well it is certainly different. Goals slightly readjusted I’m hoping to be off crutches sometime in the coming weeks.

In comparison to post injury, the post op experience has been remarkably positive. I have a goal, a rehab plan & whilst progress may end up looking more like a stock market chart I plan to move in a positive overall trend. The last few days have been a bit “meh”. Little progress as I look at an increasingly flabby thigh (infact flabby everything) & I go through the process of rehab exercises, game ready, muscle stim. It feels like ground hog day. It’s ok to have these days, & these feelings but the important thing, just like an overall marathon plan, is to trust the process no matter what the self doubt on your shoulder tells you. Also not to feel guilty for feeling off days.

The other thing I need to realise is that just as I individualise treatments to my patients, this is my journey & it’s often unhelpful to compare to others around you. Just like in those first months/years of motherhood; take in the well meant advice of others but filter it & be kind to yourself. There are milestones and guidelines for approximate progressions but they are fluid & need to be led by achieving objective markers rather than a timescale. Finally this enforced handbrake means a slow down of general day to day expectations.

Yesterday I struggled to find a reason to get out of bed, but today was 150% better. I actually left the house – win! I had my first post-op physiotherapy appointment at the Harbour hospital & the best 20 minutes on a treadmill of my life. In attempts to sort out my hideous gait & re-educate my walking pattern I got onto the anti-gravitational treadmill.

Physio for the Physio

You get strapped into wetsuit type shorts, then zipped into a plastic tent type structure on the treadmill. It weighs you, figures out how much % of weight to take off & effectively fills with air to take the desired amount of gravity off your legs as programmed by the physio. I felt a bit like Violet who gets blown up in Charlie & the chocolate factory at first. With the visual feedback you get from a small screen on the front of the machine & information related to other aspects of your gait, it’s a really useful feedback loop to try & bring about change, with additional verbal feedback from your physiotherapist.

The anti-gravity treadmill was a big draw on physiotherapy location choice for me. I’m lucky to know lots of amazing local physiotherapists, but it’s also really nice to go to someone you don’t know! Plus I’m likely to be the world’s worst patient!

So a much more positive day. I can bend my knee to just over 90 degrees and extension is coming good. Bruising is settling. Surgical wounds are healing nicely & I’m back showering you’ll be pleased to know. I’m without wheels for the next 4 days as my long suffering parents have left. But I’m getting reacquainted with my pool bouy & a hydro pool as soon as I can get there which looks to be Monday. I’ve never been so excited to go swimming!

ACL injury, dorset, injury, knee injury, pain, physiotherapy, rehabilitation, Uncategorized

Post Op!

It took a little while to get pain under control post surgery. As I mentioned in my first post I’m not the kind of cat that likes to take painkillers any more than the next person! Straight morphine was all that was on the menu via my intravenous catheter & after much declining I gave in. The pain leaving me little option if I wanted to think about much else. I had to have a reasonable amount of that in the end & a little longer stay in recovery listening to one nurse doing her competencies which was an insight into recovery nursing!

The upshot was on returning to the ward I very Britishly informed the nurse I was nauseous. I think she thought I was kidding so was unprepared. She kindly didn’t make the student clean up after realising I most definitely wasn’t kidding.

A few hours later I was comfortable & frankly pleased to be the other side of surgery & back in the game. After an overnight stay, a check xray & the all important stair test with the physio I was off home fully weight-bearing with crutches and my lovely TED stockings back on to prevent DVTs. Sometimes these surgeries are only a day case depending on when in the day your surgery is. My stitches will be snipped in 5-7days , Physiotherapy with someone other than myself will be in about 7 days and a consultant follow up 6 weeks post -op.

So I have a shiny new Anterior cruciate ligament (ACL) courtesy of a graft from my right hamstring (muscle on back of thigh) and the other ligaments are healing by themselves. Whilst there is a little laxity, no further ligament reconstruction was required fortunately. The lack of range and pain at the anteriomedial (front inner) part of my knee was apparently the result of a plica (fold of joint lining) that had been inflamed & stuck to the damaged MCL (medial collateral ligament on the inside of the knee) and not due to getting stuck on the stump of the ruptured ACL. If you want to take a look at the surgery there are some pretty amazing online videos that detail the steps!

The consultant gave me “the look” & insisted that I do actually need to be a patient for 6 weeks. Quite literally I won’t be running before I can walk! Over 15 years of Physiotherapy tells me he is entirely correct….

What I do or don’t do for the next 6 weeks will have a big impact on the quality of my rehabilitation & overall goals of being back to running, kitesurfing, sailing, surfing and maybe skiing!

The key to the next 2 weeks is getting the swelling down and improving range of movement.

These are my tools:

  • Rest & elevation of leg above level of the heart. Optional extras of a decent book/Netflix/box sets.

  • Game ready (www.gameready.co.uk) or cryocuff to ice the knee. This helps to reduce swelling & relieve pain. I’m pretty much using the hourly & have hired it from a local private physio practice that I used to work at. Be careful if icing & limit to 20 mins ensuring skin is going pink & not white – no ice burns required! This unit is great as it also provides some compression which aids reduction in swelling & circulates the iced water through the cuff.
  • Muscle stimulation. My compex unit (www.compex.com) is back out in force to get my quadriceps (thigh) muscles firing which will not only help reduce swelling but will limit muscle atrophy (wasting) and ensure I’m ready to begin using and loading my leg. Ask your local physio about hiring a unit.
  • Pain relief. Keep it regular as this is going to ensure you can maximise the all important exercises to get moving and make sure you get some sleep. I’m currently taking ibuprofen 3x/day & paracetamol 4x/day. This will be directed by your doctor/surgeon & depends on your previous medical history and any allergies. I do have back up of stronger painkillers but haven’t needed them as I’m getting good blanket coverage of any discomfort by taking the simple stuff regularly.
  • Exercises. These will be guided by your surgeon’s rehab protocol & under guidance from your physiotherapist,

1. Focusing on gentle bending and straightening of the leg. My aim is 90 degrees bend ASAP. This range will be really dependent on getting swelling down and keeping pain at bay.

2. Tightening the quadriceps (thigh muscle),

3. Assisted Straight leg raise.

4. Gentle patella mobilisations.

5. Heel hangs. Ensuring I can straighten my knee to what we call “terminal knee extension” as soon as possible is going to be a crucial rehab milestone & help with gait and the ability of my thigh muscle to properly engage going forwards. Heel hangs are really helpful for this.

  • A solid support network. Crucial to functioning on crutches, with a dog & 2 kids! My Mum is exhausted already! The school run rota after half term is a work in progress. Thank you to a lovely bunch of friends & amazing patients alike for all your positive energy & kindness.

So we are in recovery mode. An enforced time to slow down, smell the roses & stare at a familiar sight! Some would call this relaxation ….

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Go time

The last 2 weeks have been full of work, running around after the kids & as much prehab as possible. Did knock 2 minutes of my mile pull buoy swim & cracked on with more circuit based full body workouts in the gym with adjustments where needed to accommodate the knee. Still can’t walk my dog, in fact my gait pattern is still unfortunately pretty rubbish!

However, surgery was agreed last week. The question is what exactly will be done? My hope is that it will be a simple ACL reconstruction using a hamstring graft. Depending on what the surgeon finds when he goes in further ligament stabilisation may be required. This would be a bit of a different ballgame in terms of time in theatre and recovery. I’m quietly confident it’s not going to come to that.

Today is surgery day. My son is off snowboarding in Austria, my husband is in Sydney, wonder Granny is downstairs & my daughter has snuck in my bed. It’s tricky to know who is comforting who but I’m definitely not kicking her out!

This is a routine elective operation. However, it’s always daunting sitting in the patient seat and putting your life in the hands of others. It’s fair to say I’m feeling fairly anxious but it would be odd not to be. I may be quite hangry by op time which is never good on a Monday! No food from midnight & no liquids after 5am.

I’m now settled into hospital. Having walked in this morning the wrist tag & gown have gone on which means I’ve taken on a whole new vulnerable role of patient & couldn’t possibly sit in a chair! I have seen the surgeon (Mr Hancock). He agrees after further ligament testing that 95% sure just ACL reconstruction today but final decision during op. The anaesthetist is ready to do her thing & I’ve ordered some food for the other side!

Super Granny has taken Lily off to monkey world & as I’ve somehow been bumped to number 2 on the list looks like It’s go time!

I’ve hired a game ready (ice compression machine), my muscle stimulator is on standby & I’m ready to start rehab. I have a family to look after, patients to get back to treating & goals on the horizon.

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Week 4

Still in a bit of a holding pattern as I await final surgery decision via telephone consult on 10th February. In my mind I’m all systems go for 17th February.

Not much has changed in terms of range. Still lacking terminal extension & flexion above 95-100 degrees. It’s easy to think you’re not getting anywhere, but keeping track of function, pain, painkillers helps me to see this isn’t the case. A useful patient app to chart progress in ACL recovery is “recoaware”. You can enter in parameters, chart progress & get support from others rehabbing ACLs. I’m pretty much off painkillers & anti- inflammatories unless I do to much. If I avoid “boom or bust” approach have consistent daily activity, time on my feet, time driving, space out patients I’m all good.

Tuesday night was a great example of classic overdoing it. At the back end of last year I booked standing tickets to the razor light & kaiser chiefs. Brace on I cautiously braved the BIC fearful of jostling crowds & mosh pits. It’s weird to feel vulnerable & Its a bit new. But it quickly became apparent the average age of the crowd was 40+ & it was a Tuesday night in Bournemouth! Feeling less vulnerable a lot of one leg hopping ensued & funnily enough that wasn’t great for pain or movement for 36hours!

Probably would recommend seated tickets for a little while!

This just about sums up general feeling at the moment. Just slight pent up aggression.

Had a go at some punch bag intervals today balancing on 1 leg… Great to get the heart rate up & feel a bit of burn. The general position where you swivel on the back foot would not be a good idea for me at the minute! Seated on a box where the knee is not at risk of giving way could work to mix up upper body workout or in a static squat position with brace on.

Continuing on trying to get my thigh muscles (quadriceps) fired up as much as possible through the day any which way I can & also my hamstrings (back of thigh).

The quadricep muscles in particular can be inhibited or “switch off” after a knee injury due to pain and swelling. This muscle inhibition quickly results in muscle wasting or atrophy. The loss of muscle bulk was pretty evident to the untrained eye 10 days after my injury. Initially it was really hard to activate the thigh muscle no matter how much I stare at it and try to make it work. The big aim pre-op is to get atleast really good quality activation into the quads (thigh) before surgery. One way to do this apart from exercise is through a muscle stimulator. A compex has been really useful to help me limit the muscle atrophy in my thigh and get the muscles “switched back on”.

 

 

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Progress 2.5-3.5 weeks post injury

A few sped up videos to show some of the things I was up to in week 2.5-3.5 post injury as I was feeling more confident weight-bearing on the right side.

These exercises are specific to me & the stage I felt ready for. It is not a one size fits all. Some people may be struggling to weight-bear & others might be ready for far more loading. It will all be dependent on specific injury, swelling, instability, range of movement & pain. I do not recommend removing your brace except under guidance from orthopaedic consultant or your physiotherapist.

My main aims during this stage were to maximise knee movement, improve walking pattern (gait) and tolerance to weight-bear. Getting activation in my quadriceps (thigh) as well as hamstrings (back of thigh) and glute muscles (buttocks) whilst respecting pain and limiting swelling.

I caught up with a local physio friend yesterday who has been through a similar injury & agreed with the stage I’m currently at. Exercises we went over were very similar. We also worked to gain a little more range of movement. My main limitation at the minute is a “block” & pain when bending the knee past 95 degrees and lacking 5-10 degrees off extension. I’m respecting this & not forcing through it given the structures injured, it would be unwise at this stage. It could be the stump of what is left of the anterior cruciate ligament (ACL) is preventing the movement.

Pretty excited to give this a gentle go on the reclined bike, without fixing my foot in the pedal & fixing the seat with plenty of extra leg room.

Got a few more miles of arms in the pool this week. Still feels like I’m in a fight! However, it’s so good to be moving & getting some endorphins flowing.

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Week 2

Oh what a difference a week makes! No big improvements in knee range of movement but a lot more function.

Courtesy of some decent travel insurance (world nomads with all skiing boxes ticked) I got a business class seat home from America on the 10th January, after a less comfortable 4hour minibus transfer. Got to love an upgrade at the best of times! I nearly felt guilty that the family were at the back ….but quickly got over that asthey’d skiied all week without me!

The seat / bed allowed me to keep my leg up & swelling at bay whilst getting some decent rest. Happy days. A shot of a blood thinner pre -flight & continuing basic mobility/quads/glute exercises helped to prevent DVTs (deep vein thrombosis).

Once I got home, I quickly realised how great the delayed return had been. In your own home you inevitably end up on your feet doing jobs, sorting the kids & the return to school tasks. I’d forgotten how much I got love a uniform list. My activity suddenly jumped a few notches. For the first few days that was without consequence but then your body lets you know with an increase in pain & /or swelling.

The name of the game is pacing. I’ve needed to find my activity limits, overstep them and slow down on occasions. My main measures are has my knee stiffened or can I still get it moving? Is it more swollen? Is it more painful? If yes then I need to dial back.

On Wednesday after checking with my insurance company & ensuring I can do an emergency stop I started driving short distances.

This week I also joined a local gym with a decent length pool. In desperate need to get some endorphins flowing I cracked on with the ironically cracked on with the ski ergo. I taken back my dislike of swimming & swam a mile of arms with a pool bouy. I’m not sure some of the older ladies appreciated me tacking up & down the pool but I loved being able to get moving.

So on the orthopaedic front I did catch up with a surgeon. With any investigations it is important not just to read the report or view the MRI but also take into how your patient is presenting!! The consultant seemed perplexed by the physical assessment findings compared to the MRI report. Admittedly once the swelling & protective muscles have kicked in ligament testing often proves difficult. But he didn’t feel my knee was as unstable as the MRI suggested. So we agreed to review in a month. This would give me the chance to prehab before possible surgery & also see how far I can get my function. His suggestion that I could attempt to avoid surgery & just rehab….

This pup hasn’t been impressed not to be out running or walking with me! All of this week including walking Isla has been made possible by my fab husband Chris & some fantastic parental support.

With some pacing & spacing between clients I’m also back to work this week! Feel free to book in & thanks for the support.

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Week 1 Post ACL injury

So the first week went by in a bit of a haze. At first I’ll admit I couldn’t stop crying for about 3 days. I kept getting flashbacks to the position my knee was in during the accident & to the popping noise. The shock of new found immobility, impact on family, work, sport saw me have some dark days. I felt like my brain had turned to total mush as I couldn’t even remember what painkillers I’d taken & when.

This at the end of the day is a “just” a knee injury. But, whoever you are & whatever your injury is it will still have a impact on your quality of life & mental health in the short term. This is individual to everyone & can’t be overlooked in the patient journey.

Obviously sleeping was pretty uncomfortable & difficult to get with new found lack of activity or exercise I didn’t feel that tired. That with my new found Netflix obsession hasn’t been helping my sleep hygiene!

It’s actually been quite useful not being at home & tempted to do things. I’ve listened to my own advice of RICE. Rest, ice, compression & elevation. What do you know ..,it’s paid off! With any Physiotherapy rehab it can be difficult but have a goal in mind & hold up your end of the bargain. Half hearted attempts are unlikely to get the job done.

I’ve kept my leg elevated above the level of my heart pretty much for 50mins of every hour, iced every other hour and done simple range of movement and quads exercises atleast 5 times a day. Consequently, when I saw the orthopaedic surgeon here in Steamboat Springs, Colorado, on Monday he said the swelling had gone down enough & range of movement improved enough that he would have been willing to operate that day. However, US healthcare costs being what they are I’ve opted to return home, rehab 4-6weeks prior to surgery.

In an ideal world I would have accessed a “game ready” or similar ice compression machine which are unavailable to rent here. They are really useful to aid pain and swelling management in acute injuries. Also a muscle stimulator to facilitate thigh muscle (quadriceps) contraction would also be useful.

The other thing I have been doing is regular anti-inflammatories (ibuprofen) & paracetamol. I would very rarely take either & one thing I commonly hear patients say is that they don’t like taking painkillers or “masking” the pain. However, regular analgesia & anti-inflammatories (assuming no contraindications) in the short term may enable you to reduce excessive swelling, get the exercises done, improve range and return to function quicker which is a big bonus! Also if I’m more comfortable I’m more likely to get some sleep which we know is incredibly important in recovery.

I’ve achieved 0 degree extension (with caution) to 100 degrees flexion currently. I am walking but always with my brace on, even to the bathroom as the knee feels very unstable. It is now fixed to 0-90 degrees flexion on advice of the orthopaedic surgeon. I’m also wearing compression stockings & taking a baby aspirin to prevent deep vein thrombosis (DVT) due to immobility.

So the MRI report came through 1 day after injury. Remember how I said that those ligament tests weren’t always the most specific (testing what you think they’re testing & avoiding false positives) or sensitive (unlikely to overlook a structure your testing or avoiding false negatives)? Well it turns out there was also damage to the Lateral collateral ligaments (LCL) on the outside of the knee, which seemed fine on initial testing. However, it is often difficult to tell in an acute knee injury hence the need for further investigation. Also with an acute injury it can be difficult to assess deeper structures such as meniscus of the knee (cartilage) due to reduced movement and pain inhibition. The LCL injury was somewhat of a surprise given the mechanism of injury (how the injury occurred). Essentially I put a lot of strain on the inside of my knee. But having thought about it there was also a lot of rotation of the shin bone which may account for the damage to the LCL & posterior lateral corner.

So the MRI report makes quite a list…..:

-Total rupture Anterior Cruciate Ligament (knee joint ligament that prevents shin bone moving forwards on the thigh bone)

-Sprain Medial Collateral Ligament

(Ligament on the inside of the knee, usually braced)

-Tear posterior horn Medial Meniscus

(The back of the c -shaped ring of cartilage in the knee which provides cushioning & improves congruency of the knee. Injury is common alongside ACL injuries)

-Partial tear Lateral Collateral Ligament (ligament on outside of knee)

-Evidence of posterior lateral corner injury including the arcuate ligament

(Basically a complex interaction of both static & dynamic stabilisers on the outside of the knee, usually treated with brace in extension but this was not the consultants advice in my case)

-Medial & lateral tibial plateau bone contusions (bone bruises which are to be expected in this type of ligament injury)

Now I could just try to rehab this knee & see how I fair & what function I can achieve. However, I’ve damaged 3 of the 4 main ligaments of the knee as well as meniscus & the posterior later corner. Ligaments connect bone to bone & provide stability to the knee. The cartilage provides cushioning & improves the congruency of the knee. Given the multi-ligament damage & my goals of returning to running & skiing my personal choice is to opt for surgery.

In order not to compromise possible ACL reconstruction it is going to be important to ensure that the other ligaments including the posterior lateral corner are either well healed or managed surgically as well if there is more damage than expected.

So there we go! More than was bargained for but not insurmountable with the right surgery & truck load of rehabilitation. For now the family are enjoying their last day of champagne powder before we start the journey home.

Tips for acute knee injuries:

-Rest – limit you’re activity & be guided by your pain & swelling.

-Ice – 20mins every other hour with bag of peas ,ice packs, cool packs wrapped in a damp cloth or game ready or similar ice compression machine. Ensure skin is going pink & not white, so as not to give yourself an ice burn.

-Compression – ACE wrap at all times except when doing exercises. Also apply compression when icing.

-Elevate- try to keep the knee above the level of your heart for 50mins in every hour.

– Take regularly NSAIDs and painkillers as directed by your doctor to enable adherence to exercises and improved mobility.

-Get lots of sleep and try to avoid turning into a night owl.

-Do your regular exercises as prescribed by your physiotherapist!

-Eat a balanced nutritious diet. Despite the lack of activity this is not the time to be dieting. You need to fuel your body for recovery.