12 weeks post op. That’s a new milestone. 3 months seem short but when you’re recovering from a sports injury, it is eternity. I can feel myself getting impatient to do more every single day. The truth however is that - the ACL graft is the weakest it can be at around 12 weeks. After undergoing 2 months of healing and subsequent graft necrosis, the new ACL is at its weakest. This is when the “proliferation” phase starts when new cells start getting added to the new graft. Previous blood vessel formation (aka. vascularization) is important for recovery, but cells come in from various sources 1. So, Rob, my PT, has been advising caution.
A recap of last 4 weeks is due.
July has been chaotic. I spent the first two weeks shuttling myself around between Mid-coast Maine, Boston and Stamford. Flying in from Seattle - it was weird weather. It was hot and humid when sunny. Else was foggy. Or was pouring rain with thunderstorms and flooding. Summer of 2023 has been chaotic for east coast weather too. There was a lot of driving and I missed PT for most of the first two weeks. I however did a good job of exercising everyday - on a stationary bike, a rowing machine or downright walking a few miles. While I tried for activity long-long 5-6 hour drives along the eastern seaboard did not help my knee. I could tell that my knee wasn’t happy about the flights or the drives. There was also a fair bit of sailing involved. While I manuevered ok on the deck of the sail boat, it was with caution and was at times harrowing. Getting on an off the rowing dinghy was tricky and I managed to slip once and cause some quad pain. It dissipated the next day without any swelling. Oooofff! Got lucky there.
Back in Seattle - I have been riding to work everyday and getting atleast 10-15 miles of biking daily. I take the long way home. Weekends have been more fun. I managed to paddle board on the lake once - 100% sitting position. Did not feel worth risking standing or kneeling. It was however super fun to be on the warm water. Did a 75km (~46 miles) bike ride around the city and knee did very well. I do realize slowly however that my contralateral (aka. good side) is taking more load and bearing the brunt of hard climbs.
Now, I managed to get in a 9 mile/2100ft hike in to Rachel lake this Saturday 7/29. It was an awesome experience with me learning what I can and cannot do. Getting to know my current limits. The imbalance in load sharing was even more evident on this hike. The way up was better balanced. My left knee was able to take most 1ft step ups and climbed without discomfort the whole way. The way down was brutal. With heavily rooted and rocky descent it was a 30/70 load sharing between my knees. The right knee felt it, so did the right quad. It is quite sore now. It worked out ok, but I think I’ll take it slow and work my way up to it. Balancing load is important to avoid contralateral injuries and I think I’ll focus on that.
I met with the surgeon on 7/28 for the 12 week post-op checkin. It was uneventful with him checking my knee for 20 seconds and answering my questions briefly. He just cautioned me to avoid excessive massaging on internal sutures which are bumpy when I bend my knee.
PT has been going ok - I’ve reduced the frequency to once a week. We’ve been working on balanced squat, single leg squats, core strengthening exercises. Starting to jog/run has been on the horizon. Honestly, I don’t mind not running for another month while my graft heals. More to find out next week.
Outdoor biking baby! Yeah! That’s right. I’ve waited for this moment for 2 months now. Finally feelign a bit more normal. It makes such a big difference to my life to be able to bike. It is my primary transporation, it is my workout. It has been amazing to be out on it. It was surprising that my knee felt stiff the first few days on it however - was expecting to be less so given I was on the stationary bike for a few weeks now. But the starting stiffness dissipated quickly. I do notice me pedaling harder on the right - I have to consciously shift weight and load to the left. I can do uphills, about 150m worth with ease. The first few days I was quickly winded, but then it got better.
Everyday, I’ve been taking the long way home, over South lake union, over the Burke Gilman and through Interlaken park. It is about 15km give or take. Initially it made my quad sore, so I eased off to a shorter route. But in a week it was quite normal again. This weekend on 6/24, I did a 51km ride around the north of Lake Washington. AMAZING. Did not feel any knee troubles, the quads handled it gracefully. The quad graft site was a bit sore overnight, but seems fine the next day. I’m so happy to be able to do longer rides again. Wow!
One point of pain I’ve been having is the lateral calf pain. It was a part of my initial injury where I tore my lateral gastrocnemius. The pain hasn’t gone away - could it be scar tissue now? I don’t know. It is quite painful when trying to achieve better flexion. I’m now at 135° and pushing any further induces a sharp pain in the gastrocs. This is worrying me more and more. I’ll mail the surgeon to get his opinion on it.
At PT, we’ve started strength training. Step up on 8-10 inch steps. Leg presses. Calf presses with body weight. Balancing squats - these are still quite right heavy. I’m still learning how to get equal balance on both sides.
The knee is quite bumpy - at the graft side. It seems totally normal with an extended leg. When bent however, the Patella pushes on the incision and it looks bumpy like a pagoda. This seems very abnormal to me. There isn’t any pain, but it’s definitely lacking movement once the Patella bumps up. :/ When will things stop seeming weird?
Week 6 was progression over activity in the last weeks. I’ve been getting more walks in and more time on the stationary bike. I don’t have to increase the seat height on the stationary bike to get full revolutions in anymore. I even try with lowered seat height to get some extra flexion going. I stopped driving to work everyday and have been mostly walking to and from work. It is exactly a mile away, but a steep downhill to get there. Walks downhill are still harrowing and I have to take it slow. My brain still does not fully trust my left knee to handle downhills.
Reflexive dependency is my new challenge. Now that I can walk and do activities without crutches, I’ve been unconsciously loading my right (good) side more. This happens according to PT, but one should deliberately correct it. To prove the point, Rob put on two scales - one leg on each. He then made me do 20 squats and observe the scale when I did so. Mind blowing. The right side was always 20-40% overloaded than the left. I’ve been spending time consciously correcting it.
I was also time to go meet the surgeon. I met with the surgeon on 6/2. Generally, he checked my extension and was happy with it. He wasn’t at all worried about my flexion. His impression was that healing was above average and scar tissue is forming quickly. The surgeon advised my to mobilize my patella more often break up scar tissue. As for scars, he advised using silicone strips to keep the scars moisturized. I asked him about biking outdoors to which he wanted to me wait a couple of weeks. Mostly due to fall risk. He explained that due to revasularization, the graft might be the weakest at 6 weeks or so. Don’t do anything crazy!
In the mean time, sloppiness is kicking in. I don’t do PT everyday now. I do however get activity and bike time. I do think the PT routines are important and I should take 10 mins to do them everyday.
Week 7. I spent the memorial day weekend in Sequim with a few friends. Driving long distances makes the knee stiff however. Motion has been key. We had long walks without the brace. Rob greenlighted me to walk on flats without a brace on. Yay for that! The weekend of 4th of June, 12 friends gathered in a mega bash in Hoodsport, WA. What fun times in a large house, by the Hood canal. I went into the water to take a cold dip. Didn’t swim however - freaking sharp barnacles. Also, I was just plain afraid to kick my feet so soon. But hey, walking without a brace is solid now. So much so that I don’t have to think about it anymore. It is quite amazing how much our brain can get used to in a week’s time.
Finally, passed that one month mark. Week 4 was the miracle week. Walking has been wonderful. Stiff, but wonderful. On 5/21 Alee and I travelled to the Orcas Island for a few days of chill time. While we just wanted to hang out on the shores of Cascade Lake, we decided to take a small walk. Very soon it became obvious that I was doing ok, except for the annoying brace which kept slipping over the knee. We took it off and armed myself with a single crutch just in case. We did a 3.5 mile hike round the lake! Wow! I surprised myself. Parts of it were harrowing while going down rooty slopes. I used my crutches and Alee supported the other side. But OMG, end of week 4 lifted the vail on spirits. When I told Rob, my PT, about it he wasn’t thrilled. Fall risk is real and he cautioned me against it. Fair.
I have been getting 20-25 mins on the stationary bike every day. I can do full revolutions now and it is JUST GREAT! I love being on the bike although I have been advised to not add too much resistance as I bike. Going on longer walks and getting 10K steps is easier now. I can do so most days. The knee does get stiff, but that’s the game as you start using it normally.
The incision scabs have fallen off and the only part left is the bump on the Quad tendon harvest site. The PA told me it was probably due to dissolving sutures underneath the skin and I should expect it to fade. It hasn’t really been fading. But I’ll give it a few more weeks.
Rob hasn’t cleared me to ditch the brace yet. His standards are higher than what the protocol says and he’d like me to do 3 sets of 20 SLRs with no lag whatsoever. I fade around SLR 18 on each set. I’ll hold on to the brace for outdoors for now. He has cleared me to walk without a brace indoors however which is great!
One common annoyance of a large degree was pain and discomfort while sleeping. While this has reduced significantly over the last 2 weeks, it still exists. I wake up in the middle of my night wondering which side I should sleep on. My preferred stomach sleeping is still painful as my Quad incision presses into the mattress. Side sleeping is getting better, although I have keep shifting positions to avoid pressure on the knee. Consequently getting uninterrupted sleep has been challenging. Oh well can’t have it all.
But, but, man week 5 has been the greatest so far. I can’t wait to get on a moving bike, but I realize I have to hold off a few more weeks for that.
Past week 3 and onto week 4! It has been a week of progress. First things first - DRIVING! I managed to squeeze myself in and out of the driver’s seat on day 18. What a relief it is to be able to drive and get around by myself! It is a process, but it is getting easier every time I do it. The leg needed a boost for the first 5 days. Today on 5/13, I can move my left leg in and out under its own power. Yay for that!
I’ve made progress on several fronts this week. First, quad activation is getting better. I can now feel my quads working although I don’t have full control just yet. This let me do my first SLR (Straight Leg Raise) without a strap. It is still painful on the anterior side, but manageable. Next, I took baby steps without the assistance of crutches. Hooray! I can trust my knee a bit more and I’ve been getting around the house without crutches. The first few steps are still harrowing, but I can move. Building proper gait is important, so I switch back to crutches when it gets painful.
At PT on Thursday, 5/11, I worked on two new exercises. Stationary bike with back and forth rotation. I don’t have enough flexion to complete a full revolution yet. I love being on stationary bikes to relieve stiffness. Can’t wait for that full revolution. Next surprise was single leg balancing on a curved stool. Rob made me do with the left leg while tapping to disturb balance. My body’s servo mechanism seemed to kick in alright! I was able to keep balance and take full weight on my left knee. Flexion wise, I’m close to 90° (95° with assistance). I am a bit worried about my progress on the flexion front. I was expecting myself to do better. My hamstrings are still guarding and the knee itself is still quite stiff. How can I break through this literal rut?
Two weeks crossed! I’m ready to recount the last week now. It has been a tough week I admit. It was a struggle with pitting edema starting day 5 all through day 12. I tried switching my meds such that I can alternate between Tylenol and Ibuprofen vs taking Oxy. It did not work very well. The problem is the spacing between NSAIDs. Since I take Aspirin every morning, I try to space the next NSAID 10-12 hours away and this caused lots of inflammation during the day time.
Next, elevating the leg for hours together was impractical. Having your heart below the knee essentially means sleeping and no work whatsoever. I’ve mostly been sitting upright with my leg extended out the full day. This did not work out very well. During my PT on 5/1 my entire leg was so swollen that I was reprimanded to move and keep the edema down. I lost my flexion back to around 60°. :(. It was a tough day. I switched back to Meloxicam that night and started pillow train elevation for periods in the day. The combination worked wonders bringing swelling under control almost right away.
Wearing the brace was extremely painful this past week. Especially about 2-4 inches below the tibial tunnel incision on the shin bone. It was sore and extremely painful and tender for 3-4 days. Apparently, synovial fluid and fluids from the tunnel flow down and collect at the shin bone having no where to go. THis causes an extrement inflammation reaction making it very very painful to walk or wear the brace. It did subside a bit after 4 days, but there is still droning come-and-go pain on the shin. The PA told me to expect discomfort for another week or so. Another painful region: the entire thigh. The whole operation and tight torniquets, nerve blocks made it very sore. It was quite painful when my PT, Rob, messaged it down. It felt good after, but at the time - very painful.
Medication wise, I fully stopped taking Oxy on 5/1. I continued with Tylenol and Meloxicam until 5/5. No medications after the two week mark. I can now tolerate full days and nights and PT without any meds.
With the PT on 5/4, I can a bit more ROM thanks to reduced swelling. Now at 70°! Huzzah!
5/5 was the first post-op appointment. It was quite uneventful. The nurse took out runaway sutures. I was a bit anxious about suture removal, but I did not feel anything whatsoever. It went by in a jiffy. Not even a pinch. Then there was X-ray to examine the graft tension. The PA answered most concerns or questions I had amassed during the two weeks. I did not take away anything memorable from the appointmnent. It was however reassuring to hear that the incisions were healing well and the progression was in the right direction.
I’ve also had a lot of social time this week. Friends coming over to play board games. Alee and I went over to Volunteer park for picnic dinner to watch the sunset. Visits from Marlin to play guitar, which turned out to be a dramatic SciFi reading of “I am Genghis Khan” and Pizza making. It has been a week of ups and downs. I have gained more interest to solve on more interesting problems at work and even a couple of breakthroughs! My mood has been mellow - with damped expectations. I’m hoping for a better trajectory next week!
Past the week mark now. I have completed 3 PT sessions with progressive improvement 40° -> 60° -> 66°. I find it hard to do PT at home for a couple of reasons. First being, I still can’t sit on the floor to stretch fully. It is too hard. I do PT half sitting on a couch. The pain is real. I now have sharp pain and tenderness 4 inches below my tibial tunnel on the shin bone. I hurts the most with the brace on, moving. I’ve also switched to alternating Tylenol and Ibuprofen but take Oxy for PT or moving. Heel slides, Quad sets and belt assisted leg raises - that’s my whole day. I have been able to get mental attention to work at stretches of 1-2 hours. I’ll have to get back to full time work starting 1/5 and I’m not looking forward to it. I’m still very dependent on crutches - not sure how I’ll wean off the next week. My brace was supposed to be unlocked after 1 week, but PT thought better to leave locked until I have better quad control.
First day of PT. This was the first time I left my apartment after the surgery. 5 days! Also the day of my first shower since surgery. I’ve changed my PT to Rob at Proformance Rehab. It was an experience of stiffness and pain. After some calf stretches and knee bending, my knee flexion was about 40° with 0° extension. Low flexibility and a lot of steristrip stretch stiffness.
Day 3. Yesterday went by slowly, but the pain was under control. I’ve started was replays of The Wire to keep me entertained. Took off the ace wrap and the dressing today morning. The sutures seem all tangled. The whole knee is ripe swollen. The brace which is currently locked at 0° extension and is super painful to wear and walk in. The brace pushes on all the swelling and the sutures. The nights are harder with muscle spasms and twitches going through a restrictive brace. Transitioning from sitting to walking to sitting is mightmarish. Sitting on toilets needs careful manuvering. It all seems like delicate play and care. I wanted to get off Oxy as quickly as possible, but sleeping without them has been challenging for now.
Surgery day! Bright and early, my surgery was scheduled at 6:45am. Checked myself in sharp on the clock. I had an entourage of nurses and doctors checking in with me. First was the PA who discussed post-op medication. Then came in the surgery nurse who shaved my knee. Next came in the Anesthesiologist who spoke about general vs spinal anesthetic use. I chose the spinal. A few mins later I was changed and ushered into the OR. Spinal anesthetic and IV and I was out. I woke up 2 hours later the post-op room to some chips and apple juice. I had to hang out for an hour longer for the spinal anestheric to wear off before we were given PT instructions and discharged. Loaded into the back of our car and arrived home. I was surprisingly awake and spent the rest of the say watching The Empress on Netflix. There wasn’t as much pain and fell asleep with 5mg Oxycodone. The whole day went by swiftly with little time left to ponder over anything.
Waiting for surgery schedule has been the most frustrating part of this ordeal. More frustrating than the actual injury itself. It took 3-4 weeks of waiting for the initial consultation with a surgeon. Then another 8 weeks of wait for the surgery itself. I’ve been researching and reading publications on ACL injuries. Curiously, I have not found research on wait times and injury risk that leads to worse post-surgery outcomes due to long wait times. This is important because of the risk associated with worsening your injury during wait. A friend of mine, also having injured himself on the same day as me, had to wait 4 week to get an MRI. 4 weeks. MRI showed multiple meniscal tears and partial ACL tears. How can one not worsen this injury when not diagnosed early? While life threatening conditions need to take priority, no doubt, quality of life ailments deserve early intervention too. American medicine with all its whistles still cannot solve the bandwidth problem. Sure, another friend tells me it is worse in Canada. I fail to however comprehend where the bottleneck is. Surgeons? Operating rooms? Assistants? All of the above? My surgery has now been advanced to 4/20 (!). 2 more weeks to go. Meanwhile, I keep biking. 10k+ steps on days during a recent Boston trip left my leg stiff, but recovered a few days later. Flying was uneasy, with all those long airport walks and needing to amble around on the plane to allow circulation.
On a business trip in Boston and I received a call from the surgery scheduler over at Proliance. She left a voice mail to reschedule my surgery for 4th of April. Wow! I called right back and the spot was taken. Gosh darn, how did I miss that?? Later that evening I was at a restaurant and I received another call and this time it was for 4/20, I snagged it. Yay, happy to have my surgery a month early.
I met with another surgeon from Proliance at the Orthopedics Specialists of Seattle (OSS). The surgeon was pithy and suggested Quad autograft. The surgeon did not think Hamstring or BTB grafts were the best choices for me. We also spoke about BEAR implants, which the surgeon does. It was deemed inappropriate as my ACL was torn clean off without a stump. Next was surgery scheduling and the first date I got was 22nd of May. Coincidence?
Went on a long bike ride (20+ miles) around the bridges yesterday. Felt pretty stable overall and I was happy about it. There is however occassional sharp pain inside the knee and it makes me wonder what is causing it. Walking has been easier, so is going down stairs. The knee does buckle and lose control once in a while which is a bit harrowing and unpredictable. A bit of swelling still exists within the joint and doesn’t want to go away.
My knee doesn’t turn to a brick every morning. Huzzah to that. I have been upping the PT game to push bending (143°) and extending (2°) the knee further. I bicycled to work yesterday and it went well. I am left leg planter to stop and get off my bicycle which does need pivoting. I am a little worried about doing that naturally to my detriment. It is hard to switch sides, but I am trying. Almost at 10k steps today and there is little discomfort.
Spent a good weekend in Vancouver, BC. It was great to get out of town, walk around Granville market and eat great food. Walking was slow, although pain free - just stiff. I was slow enough that it prompted friends to park closer and checking in with me every so often. Regardless, it is good to get out of the headspace of Seattle. I’ll have to start a new surgeon hunt tomorrow.
Met with surgeon at UW Sports Medicine Center for consultation. They took their time to answer all my questions; a product of all the reading and research I’ve been doing for two weeks. We agreed on autograft ACL reconstruction surgery which is the only way the stabilize the knee for any sport. I was asked to schedule an appointment. When I tried to schedule the appointment, however, the scheduler informed me that the first slot was not until 25th May 2023. That’s almost 3 months away. It is disappointing to put pause my whole life for another three months more when the road to recovery is already a year long. This is with all the insurance in the world. I can only imagine the struggles with the American medical system without any insurance. I am unsure about what I have to do next. Keep looking for Orthopedic surgeons?
The knee turns to a stiff brick every morning, both calf and adductors immobile. Heel slides needed before I can walk at all. Still walking with a significant limp. Started elevating my leg with a full knee stretch, a pillow under the heel does the trick. Walked home from work today, about 5000 steps. Quads cramped, so did the calf. A bit of pain under the knee cap too. Feeling general joint now.
Heel slides feel slightly better today. I can stretch my knee more. Still stiff in both calf and hamstrings. Tried releasing with a roller foam, which didn’t help much right away. Have been icing the knee a few times today.
First PT session at GoPT. Strength in my left leg seems ok. Squats are painful in the calf. Got three exercises: 3-point touch while standing on left leg alone, heel slides and calf lifts.
Can walk slightly better today. Calf and hamstring still so stiff that I can’t straighten my knee. There is no pain, but just a lot of tightness and pressure. The joint is still swollen. It feels like something is stuck behind the knee cap not letting in lock all the way.
Swollen knee. Following RICE. Can only hobble with my knee bent. Too stiff and painful to straighten the knee.
Left knee has a torn ACL, sprained gastrocnemius and abductor muscles. Pivot shift bone contusion.