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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.

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The accident

We celebrated New Year’s Eve with a bunch of friends powder skiing in a Steamboat Springs Colorado. It was a gorgeous blue bird day & we had an epic time. I’ve been lucky enough to ski nearly 20 days & ran 6 out of every 7 in the early stages of training for a good for age entry to the London Marathon 2020. I’ve been following Matt Fitzgerald’s slow running 80/20 plan.

As I skied through a bunch of narrow aspens it passed through my head that I’d made it to the 14th run of another epic powder-cat day unscathed. 10 metres from the end of the run & the road below things get a bit hazy. I clipped something & my left ski got stuck in between 2 aspen trees & I rotated around ending up both skis still attached with my right ski up & behind me. There was a “pop”sound that I both heard & felt as my knee hung at about 90degrees with a big valgus (outwards time inwards) stress. I wailed like some injured animal knowing in that instance what had happened & that I wasn’t going to be running or doing much of anything for a while.

A bit more guttural wailing & some calls for help. All I could concentrate on was alleviating the pressure on my right knee by literally hugging the offending aspen tree! Help arrived in the form of friends who disentangled me & unclipped my skis while we awaited the snowcat. A unceremonious mini sled ride of about 10m got me back to the cat & in I bum shuffled not wanting to put weight on my knee.

Next stop the ER (no George Clooney wasn’t on shift). My husband Chris sorted my travel insurance details & we were in. No waiting room. I clutched to the notion that maybe I was being melodramatic & overthinking the injury. It only throbbed a bit after all. A brief examination of knee ligament stress tests revealed I had too much laxity and no “end feel” as us physio’s call it & a Anterior cruciate ligament (ACL) rupture was suspected along with a sprain of the medial collateral ligament (MCL).

The anterior cruciate ligament is one of 2 ligaments that cross inside your knee. It attaches diagonally from the femur (thigh) to tibia (shin bone) and maintains the stability of your knee by stopping the tibia sliding forwards on the tibia. It also has a key role in rotational stability (twisting) or the knee.

Without it the knee tends to give signs of instability by giving way on turning or side to side movements. Now sometimes you can get away with a truck load of rehab. Primarily this is aimed at your hamstrings to act as a breaker if you like to stop that sliding forwards of the tibia on the femur. Also it depends on age of the person and what activity they want to do. If I was sedentary and not particularly active this injury may be fine to manage conservatively (without surgery).

My buddy on the ski trip Katie has managed for 20 years sans ACL. She’s a furious skier & ran her first 2 marathons last year. The risk can be that if the knee isn’t stable enough you can’t function at high impact sports particularly those involving twisting. Running is fairly linear (except when your dodging runners in big races!)

It’s also pretty useful to have stability on the inside of your knee or medial collateral ligament. On initial assessment it seemed I’d sprained this. These examinations aren’t always hugely sensitive /specific but as there wasn’t yet any knee swelling as I’d come straight off the snow they were likely accurate. ie a lot of laxity with no end feel gives a pretty reliable likelihood of ACL rupture.

So not more than 45 minutes after arriving in the ER I’d been examined, had an X-ray & was wheeled in for an MRI from a spangly new machine. This would give insight into both the state of ACL & MCL.

The ER doctor confirmed ACL rupture from the MRI but I’m still awaiting radiology report on the MCL. With these kind of injuries the outcome isn’t generally great for early surgery. Most surgeons like to wait until the haemarthrosis (bleeding of the joint) and swelling reduce before surgery which can be 4-6weeks plus. That also gives an opportunity to prehab & see how I fair symptomatically.

Homeward bound I gingerly walked with some lovely ted stockings & mini aspirin to prevent a DVT (deep vein thrombosis), a swelling wrap to reduce inbound joint effusion, a robo style leg brace fixed from 0-30degrees which will enable me to walk without instability, also some ibuprofen/paracetamol for the inflammation & pain respectively.

My main aims over these next few days are to be a top student & ace the “RICE” advice. Rest/ice/compression & elevation to reduce swelling & maximise range of movement. Oh & it might be useful to stop blubbing every 5 minutes!

Welcome to the rehab journey. I’m sure it’ll be a bumpy journey this next 6-9 months. I’ve walked plenty of patients through it on the otherside . Now it’s my turn! I have my eyes on the prize & let’s face it I’m sure I’ll learn a thing or two along the way.

That powder though!