9 Weeks Post Op

I am excited to be able to wear pants!

No Brace!  Starting this week I do not have to wear the brace anymore. Without the brace I have to be especially careful to avoid twisting or pivoting on my bad leg since that can damage the graft.  But I'm still moving pretty slow with the crutches so that shouldn't be too difficult.

Range of Motion:  I continue to ride the stationary bike and do stretches at home for range of motion.  I am up to 105 degrees by the end of the week. Here is a video of what it's like to ride the stationary bike at week 9:  

         

Physical Therapy:  This week I am allowed to start weight bearing as tolerated.  What this means is my graft is strong enough to support my full body weight so I can ditch the crutches when I feel able to walk normally.

Here are my exercises for the week:

Monday

• AM
• 20 mins stationary bike
• 4 way SLRs w/BFR cuff - 30 reps 3x15 reps w/30 secs rest between sets (2 lb weight on ankle)
• 5 mins treadmill walking (1.0 speed-I have to hold onto the sides since I can't put full weight while walking yet)
• PM
• 15 mins stationary bike
• 20 mins Alter G treadmill - 60% at 1.5
• 20 mins range of motion stretching of knee

Tuesday

• AM
• 15 mins stationary bike
• 4 way SLRs w/BFR cuff - 30 reps 3x15 reps w/30 secs rest between sets (2 lb weight on ankle)
• Practice walking up and down stairs with 1 crutch and cane
• PM
• Pool therapy-3x laps walking, 3x laps backwards walking, 3x laps side stepping, 3x laps march walking, 2x laps flutter kick

Wednesday

• 30 mins arm bike
• 15 mins stationary bike
• core work

Thursday

• 3x 30 min knee stretching sessions for range of motion

Friday

• 3x 30 min knee stretching sessions for range of motion

This is about how fast I walk with 1 crutch.

Walking:  By the end of the week I am down to using one crutch for short distances around the house.  I still need two crutches for longer distances.  I concentrate on every step with one crutch to make sure I'm not excessively leaning to one side since this can cause neck and back pain.  Also the stiffness makes me want to limp so I have to focus on bending my knee normally when I walk.

Pain and Swelling:  Most of my discomfort is caused by the stiffness.  I feel the stiffness every time I bend my knee but it doesn't become especially painful until I reach the limit of my range and try to force it beyond that.  On a positive note, I don't have anymore sharp pains if I move my leg a certain way.  Most of the post op surgical pain is gone so I just have discomfort from the stiffness and scar tissue that has formed.  The swelling has started to go down however I still have excess fluid in the joint (effusion) which contributes to the stiffness.

Week 9.  The contours of my knee cap are
not as noticeable as my right leg due to
swelling and effusion still present. 

The pain I had last week in the graft site is still there but I only notice it in the Alter G when I'm walking faster than with the crutches.  I don't feel it standing or walking with the crutches or the cane.

Sleeping: This is the first time since the surgery that I feel I can sleep in a normal position.  Sleeping without the brace is wonderful and I have enough range of motion that I can bend my leg enough to sleep how I used to before the surgery.  I still wake up in the middle of the night sometimes with throbbing and aching but it usually goes away if I switch positions.

Other Thoughts:  I feel better mentally about the surgery this week than last week.  I'm trying not to focus on every little pain in the graft area.  I've accepted that it might be a few more weeks until the symptoms I had before the surgery go away.  It's a mental boost to be almost walking without crutches.  And getting rid of the brace is one step closer to "normal life."

8 Weeks Post Op Dr Appointment

I went back to see my surgeon at 8 weeks because I was worried about the pain in the graft area.  As I started to put weight on my leg I was having the same pain as before the surgery.  My surgeon said this was probably normal and pain moves around after surgery.  Ultimately, it's way too soon to think about graft failure.  He said I'm really not going to know if this surgery was successful until 10 more months down the road when I start running again.  At some point the pain should get better and I need to be more patient.  He didn't think what I was experiencing should prevent me from continuing the rehab protocol and working toward 100% weight bearing over the next few weeks.

I found some interesting information about the recovery process published by the company who cultures the cartilage cells.  Genzyme is the company that created Carticel, which is the name given to the cartilage cells after they are grown and cultured in Genzyme's lab in Boston.  It is impossible to create the exact same type of cartilage that lines the major bones of the body.  However, Genzyme has been able to create a substance that closely resembles actual cartilage by using a person's own cartilage cells.  This substance is called Carticel and is the only FDA approved product to repair articular cartilage.  However once the cells are ready for implantation they are in liquid form and must harden in the body to work.  There are some studies which say the graft continues to harden for a period of 5 years but after 18 months the graft should be strong enough to support high impact sports.

Genzyme published a Carticel rehabilitation guide which has some great info.  I skimmed it the first time but then I went back and read it more closely.  I found something that eased my worry over the pain I was feeling.  The guide says it is during the remodeling phase which occurs between 12 weeks and 32 weeks that patients typically feel improvement of symptoms.

I highly recommend reading this guide prior to surgery.  It's located here: REHABILITATION GUIDELINES - Carticel

So if you're like me and you worry A LOT about how the graft is doing...stop!  You will drive yourself crazy.  As I've been reminded by my surgeon and therapist many times, this is a long process and improvement occurs incrimentaly over many months and pain is normal.  To put things in perspective, according to my rehab protocol my goal at 9 months is to walk 2 miles at 15 min/mile pace.  But if you have extreme pain or locking or catching of the knee during motion at this point in the recovery that might indicate an issue.  So bottom line, you'll probably know if something is really wrong.    

8 Weeks Post Op

Range of Motion:  I am up to 100 degrees.  Range of motion continues to be a slow progression and something I have to work at multiple times a day.  I have been doing at least 3x 30 minute sessions a day of motion exercises.  I do this at home typically while watching TV.  The stiffness bothers me a lot and I'm looking forward to being able to move my knee normally.  I am now allowed to use the stationary bike with no resistance to help with range of motion.  At the beginning of the week I wasn't able to get a full revolution so I would go as far as possible then reverse direction and go backwards.  At the end of the week I can get a full revolution but with much difficulty and lifting the hip on my bad leg.

Alter G treadmill.  This lady looks much happier than I was
in this machine.

Parallel bars for learning to walk

Physical Therapy: This is my last week before I am weight bearing as tolerated so my therapist added some partial weight bearing activities outside of the pool to prepare me for walking.  One of the new exercises was walking in the Alter G Anti-Gravity treadmill.  Basically this machine creates a vacuum around your legs and lifts you up so you are putting only a percentage of body weight on your legs.  You can choose what percentage of body weight you want to exercise with.  I started at 20% body weight and set the speed at a crazy 1.5 (40 min mile).  I felt some pain in my knee but it was mostly unstable, weak and stiff.  At first it felt like it was buckling and giving way.  By the end of the week I was able to walk with a normal gait at 50% body weight and a speed of 1.5 with slight discomfort.

I also spent a lot of time in the parallel bars placing some weight on my knee and using my arms to hold myself up.  By the end of the week I was able to walk back and forth using one arm to hold myself up.

This is what I feel like trying to walk

My exercises this week included:

Tuesday

• AM
• 20 mins on the Alter G treadmill-20% at 1.5 
• 4-way SLRs and quad set contractions with Blood Flow Restriction (BFR) cuff-1x30 reps/3x15 reps w/30 secs rest between sets (2 lb weight above knee)
• 15 mins stationary bike for range of motion
• PM
• Pool therapy for gait training-3x laps walking, 3x laps backwards walking, 3x laps side stepping, 3x laps march walking (neck deep water with flotation device barbells) 

Wednesday

• AM
• 20 mins on the Alter G treadmill-30% at 1.5
• Weight shifts in parallel bars
• 15 mins stationary bike for range of motion
• PM
• 20 mins on the arm bike
• Weight shifts in parallel bars
• 15 mins stationary bike for range of motion 

Thursday

• AM
• 20 mins stationary bike for range of motion
• 4-way SLRs and quad set contractions with Blood Flow Restriction (BFR) cuff-1x30 reps/3x15 reps w/30 secs rest between sets (3 lb weight above knee)
• Weight shifts and partial weight bearing in parallel bars for gait training
• PM
• Pool therapy-3x laps walking, 3x laps backwards walking, 3x laps side stepping, 3x laps march walking (chest deep water with flotation device barbells)

Friday

• AM
• 20 mins stationary bike
• 5x15 sets of SLRs (2 lb weight on ankle)
• Weight shifts and partial weight bearing in parallel bars
• PM

• 20 mins on the Alter G treadmill-50% at 1.5 (the machine said I burned 31 calories during this exercise.  Almost half a cookie...awesome)
• 20 mins stationary bike
• Partial weight bearing walking with crutches and a cane outside in grass, sand and different surfaces

8 weeks post op.  The thigh atrophy is less noticeable.
I attribute this to the BFR training.  It slows
down the atrophy and allows me to retain
some quad strength.

Pain and Swelling:  In addition to the normal post surgical pain around the incision I have pain on the inside of my knee similar to what I had before the surgery.  I noticed it for the first time during the partial weight bearing activities.  The pain isn't bad enough to keep me from doing the exercises but this concerns me because I'm worried something is wrong with the graft.  I thought once I started walking I wouldn't have the same pain as before.  My therapist has tried to reassure me that this is normal.  There's still a lot of healing going on and the nerves need to get used to the graft.  However, he thought it was a good idea to talk to my surgeon prior to proceeding with further weight bearing activities.

Other Thoughts:  Overall this week has been frustrating due to the new pain on the inside of my knee.  It is bothering me more mentally than physically though.  The thought of having a graft failure is stressful.  Up to this point I felt the recovery was going well but I seem to be on a downward portion of the emotional rollercoaster of recovery.  I'm just not sure I should be having pain where I had the graft at this point.  So I'll see what my surgeon has to say and go from there.

7 Weeks Post Op

Range of Motion:  This is the first week without the CPM and my moral has soared.  It feels so good not to be chained to that dreadful machine all day.  Now that I'm out of the CPM I have to do range of motion exercises on my own.  Here's a video of one of the exercises I do:

Overall, this week has been frustrating for range of motion.  I was stuck at 90 degrees all week.  My therapist put me in the biodex machine to force my knee to bend past 90 degrees.  This machine is good for passively bending knees.

Biodex Machine

I got to about 95 degrees with difficulty.  Once again I've had to adjust my expectations for this surgery.  After my scope I got full range of motion back very quickly.  I have to keep reminding myself that this surgery was much more invasive and that range of motion is a long process.  Scar tissue that formed after the surgery and swelling along with fluid in the joint (effusion) makes range of motion difficult.  Once the effusion goes down it will be easier to bend and as far as the scar tissue, I just have to break that up physically by doing the range of motion exercises.  

Physical Therapy:  

My workouts this week were the same as last week:

Monday

• AM
• 20 minutes on the rowing machine w/one leg (other leg sits on the ab dolly and rolls back and forth)
• 4-way SLRs and quad set contractions with Blood Flow Restriction (BFR) cuff-1x30 reps/3x15 reps w/30 secs rest between sets (no weight)
• PM
• 20 minutes on the arm bike
• Upper body weight lifting

Tuesday

• AM
• 20 minutes rowing
• Leg extension, hamstring curl, and leg press on GOOD leg w/BFR cuff-1x30 reps/3x15 reps w/30 secs rest between sets
• PM
• Pool therapy for gait training-3x laps walking, 3x laps backwards walking, 3x laps side stepping, 3x laps march walking (I do this in neck deep water with flotation device barbells to put minimal weight on my leg) 

Wednesday

• AM
• 20 minutes rowing
• 4-way SLRs and quad contraction sets with BFR cuff-1x30 reps/3x15 reps w/30 secs rest between sets
• PM
• 20 minutes on the arm bike
• Core work   

Thursday

• AM
• 20 minutes rowing
• Leg extension, hamstring curl, and leg press on GOOD leg w/BFR cuff-1x30 reps/3x15 reps w/30 secs rest between sets
• PM
• Pool therapy-3x laps walking, 3x laps backwards walking, 3x laps side stepping, 3x laps march walking

Friday 

• AM
• 20 minutes rowing
• 4-way SLRs and quad contraction sets with BFR cuff-1x30 reps/3x15 reps w/30 secs rest between sets
• PM
• 20 minutes on the arm bike
• Upper body weight lifting

I feel much more comfortable in the pool than the first day.  I am able to laugh and joke while in the pool now.  My leg is still highly unstable and weak but I feel like I'm getting a handle on walking again.  

I am doing better with the BFR as well.  I do not have any light headedness or dizziness anymore.  I just feel intense muscle fatigue and burning while exercising with the cuff which is normal.  I am seeing amazing results with this on my good leg.  I can't believe how much stronger I am after just a couple sessions.  My good leg used to fatigue very quickly while on the crutches but I now feel like I can stand on it all day.

Pain and Swelling:    I now have minimal pain with the SLRs.  It's mostly just stiffness that works itself out after the first few sets.  I'm still doing the scar massage and patellar mobilization.  With the scar massage I has some very tender places.  The worst is the scope incision on the inside of my knee.  I can feel a lump that is most likely scar tissue so I press on this pretty hard to try to break it up.  I also feel a lot of pressure in this area when doing range of motion.  I had a scope done in conjunction with the open knee surgery.  This was to check out the knee and make sure everything was good before the surgeon opened it up.  I believe my surgeon used the same incision as last time so that is the reason for the lump of scar tissue.  The swelling is the same.

Sleeping:  I am sleeping normally now.  It still takes me awhile to get comfortable with the brace.  I am looking forward to not having to sleep with that soon.

Picking up a water bottle

Other Thoughts:  Life on crutches sucks.  The crutches are starting to wear on me.  Everything takes more time:  Getting ready in the morning, fixing meals, going to the bathroom.  I don't do a lot of my daily rituals that I used to do such as spend time fixing my hair or putting on makeup.  You can't carry anything on crutches so I have a little bag with me that I wear on my back to carry things.  And when you drop something it is a whole event to pick it up.  On a good note, after 7 weeks my triceps and good leg are very strong and I have much more endurance.  I feel like I can crutch a fairly far distance without getting fatigued.
  

  

  

6 Weeks Post Op Dr Appointment

I had my 6 week post op appointment with my surgeon.  My biggest concern was whether or not the fall at 5 weeks injured the graft.  My surgeon basically told me the same thing as my therapist.  He did not think it damaged the graft since there was no additional swelling, pain, bruising, or catching during range of motion.  However, there is no way to know for sure.  An MRI would not show anything at this point.  And I really won't know if the graft is successful until a year down the road when I try running.

I also asked about the swelling and warmth on my knee since this really hasn't changed much since surgery.  His answer was that it is normal.  The swelling won't go down until I start walking and really using the muscles around my knee.  At that point the muscles will begin pushing fluid through the joint and I should start to see some improvement.  The warmth I feel in my knee is a normal part of the healing process.

Overall, I was satisfied with the appointment.  It was a little frustrating to hear I'll have to wait many months to know if the graft was successful but that is just the nature of this surgery.  My surgeon did remind me that there's no reason to think that it won't work since success rates are good and I'm not experiencing anything out of the ordinary.  

6 Weeks Post Op

Range of Motion:  This is my last week with the CPM!!!! I have religiously sat in the CPM 8 hours a day for 6 weeks and it's been the worst part of the recovery for me.  Being able to sit in a comfortable position and move around will be a huge mental boost.  I reached 90 degrees by the end of the week.  The last 5-10 degrees never got comfortable and I cringed each time the machine reached that range.  It's not so much painful but incredibly stiff which causes the discomfort.

Physical Therapy:  Here is my weekly workout schedule:

Monday

• AM
• 20 minutes on the rowing machine w/one leg (other leg sits on the ab dolly and rolls back and forth)
• 4-way SLRs and quad set contractions with Blood Flow Restriction (BFR) cuff-1x30 reps/3x15 reps w/30 secs rest between sets (no weight)
• PM
• 20 minutes on the arm bike
• Upper body weight lifting

Tuesday

• AM
• 20 minutes rowing
• Leg extension, hamstring curl, and leg press on GOOD leg w/BFR cuff-1x30 reps/3x15 reps w/30 secs rest between sets
• PM
• Pool therapy for gait training-3x laps walking, 3x laps backwards walking, 3x laps side stepping, 3x laps march walking (I do this in neck deep water with flotation device barbells to put minimal weight on my leg) 

Wednesday

• AM
• 20 minutes rowing
• 4-way SLRs and quad contraction sets with BFR cuff-1x30 reps/3x15 reps w/30 secs rest between sets
• PM
• 20 minutes on the arm bike
• Core work   

Thursday

• AM
• 20 minutes rowing
• Leg extension, hamstring curl, and leg press on GOOD leg w/BFR cuff-1x30 reps/3x15 reps w/30 secs rest between sets
• PM
• Pool therapy-3x laps walking, 3x laps backwards walking, 3x laps side stepping, 3x laps march walking

Friday 

• AM
• 20 minutes rowing
• 4-way SLRs and quad contraction sets with BFR cuff-1x30 reps/3x15 reps w/30 secs rest between sets
• PM
• 20 minutes on the arm bike
• Upper body weight lifting

Thigh Atrophy and Swelling at 6 Weeks

Pain and Swelling:  I have no additional pain from the fall.  I can move my leg around with minimal pain however I am still careful and slow when I move it.  If I move it a certain way I still get a sharp pain mostly on the inside of my knee.  The incision is healing nicely. 

6 Week Incision

I am concerned about the swelling though.  It really hasn't  gone down since the surgery.  My knee cap is still unrecognizable.  On the photo to the right you can't see kneecap definition like I have on my good (right) leg.  I ice 2-3 times a day and it helps with the  pain but doesn't have much effect on the swelling. My therapist says swelling may stick around for months and probably won't resolve until I start walking and really using my muscles.  At 6 weeks the atrophy of my left thigh is starting to be noticeable.

Sleeping: I am able to sleep through the night most nights.  My brace is now locked out at 90 degrees to I can sleep on my side and bend my leg.  If I do wake up in the middle of the night I experience throbbing and aching that sometimes prevents me from getting back to sleep.  I feel this in the morning when I wake up but it goes away once I start moving.

5 Weeks Post Op

Range of Motion:  According to my rehab protocol I am now able to increase the CPM from 40 degrees to 5 degrees per day until I get up to 90 degrees.  This week 5 degrees a day has proven difficult so I usually increase the CPM 5 degrees every other day. I am now at 70 degrees and the last 5 degrees are very stiff.  I am now allowed to unlock my brace to 30 degrees and will continue to unlock it more as range becomes available.

Physical Therapy:  I am still limited to the same few exercises:  4 way SLRs with weight above the knee, quad sets, patellar mobilization, and scar massage.

BFR:  This week I have been introduced to blood flow restriction (BFR) theraphy which I do in conjunction with the SLRs.  BFR is a new therapy that has been developed in the last 2 years and there's only a few places in the US that does it.  However, the results and studies are very favorable.  BFR involves exercising with a tourniquet.  The science behind BFR is that when a person exercises with limited blood flow to a muscle it allows the person to lift very light weight but still get the same effect as lifting heavy weight.  For instance a person that leg presses 200 lbs would instead apply the tourniquet and leg press only 20 lbs to get the same benefits without wear and tear on the joints and muscles that is caused by lifting heavy weights.  This is good for people with injuries such as myself that are unable to put weight on joints and have surgeries with long healing times.  Additionally, there are added healing benefits.  As a result of BFR, the body produces human growth hormone which speeds healing.  Here's how it works:  An ultrasound is used to find out what pressure completely stops the blood flow.  This is done by raising the pressure on the tourniquet which is similar to a blood pressure cuff and recording the pressure at which a pulse can not be found.  Then the BFR cuff is set to 80% of that value during exercise so the blood flow isn't completely cut off.  For each exercise you do a set of 30 reps then 3x sets of 15 reps with 30 secs rest in between each set.   

This is a picture of the machine where you set the pressure in
mm HG.  The cuff is attached to the machine which continually
inflates/deflates the cuff to maintain the selected pressure

 
I've set into a routine where I do BFR on my bad leg Mon, Wed, and Fri and my good leg on Tues and Thurs.  I am still not allowed to lift weights or do any other exercises on my bad leg so I just do the 4-way SLRs.  I do 3 exercises with my good leg with the BFR cuff (leg extension, hamstring curl, and leg press).

BFR is pretty miserable.  The first day I felt light headed, dizzy and almost passed out.  There was an intense burning sensation in the muscle being exercised.  The first exercise I tried was leg extension on my good leg.  I was lifting 5 lbs but it felt like 100 lbs.  I wasn't able to complete all 4 sets on the leg extension.  But as with anything new, I'm sure it will get better with time.  

This person is doing SLRs with the BFR cuff on.  This is
what I spend a lot of time doing.

Pain:  My overall pain this week is good.  I'm totally off the Percocet.  I still have pain around the incision when I have to lift my leg to move but it's manageable.  I still wake up in the middle to the night with throbbing and the occasional spasm.

Sleeping:  Much better this week.  I can now lay on either side and switch positions much easier.  But I still have to be careful how I move my leg.  If I move it wrong I get a sharp pain on the inside of my knee.  Since my brace is unlocked now it will allow me to bend a little so it's easier to get into a comfortable sleeping position.

The Fall:  At the end of week 5 I had my first serious fall.  I was icing at PT and there was a fire alarm so I had to go down the stairs.  I stumbled on the last stair and fell forward.  I caught myself with my bad leg.  My knee bent and stopped at 50 degrees because that's where my brace was locked out at.  I put my full weight on my leg and jammed my knee pretty good.  My first thought was "OMG I just ruined the graft!"  Then my second thought was "Ow that hurt."  My therapist immediately grabbed some ice and called my surgeon who was in surgery so he left a message.  I was terrified I had ruined my surgery.  After an hour or two I calmed down a bit.  My therapist said he thought is was ok since I didn't have any additional swelling, bruising or pain.  If something was really wrong I would have felt it.  My surgeon called a few hours later and concurred with my therapist and he said I didn't need to come in unless things got bad later that night.  I felt about the same that night but I was still very worried that some damage had occurred.

These pics were taken during an arthroscope to show how long it
takes for the graft to harden.  This demonstrates why non weight
bearing during the first few weeks is important to prevent damage.

    


The consistency of new cartilage at various stages:

• after 1 week like WATER
  
• after 3 months like YOGHURT
  
• after 6 months like DOUGH
  
• after 9 months like CHEESE
  
• and after 12 months like RUBBER 
  

4 Weeks Post Op

Range of Motion:  I am at 40 degrees on the CPM which is pain free.  At the end of week 4 I will begin increasing flexion again slowly working toward 90 degrees.  The CPM is really wearing on me.   With 2 PT sessions a day I spend just about every free moment in this damn machine.  I really am starting to despise it.  It is hard to get comfortable with my leg in the machine and body is starting to hurt from laying on my back all the time.

Physical Therapy:  My exercises still consist of 4-way SLRs, quad sets, patellar mobilization, and scar massage.  I am able to lift my leg completely on my own and have no issues "getting it started." At the end of the week I am able to complete 5x15 sets of 4-way SLRs with 10 lbs strapped above my knee.  The first set is the most painful but as my leg warms up it gets easier.

I also started pool therapy this week.  I will be spending an hour in the pool on Tues and Thur to practice walking with a normal gait.  The exercises were very basic on the first day.  I stood in water up to my neck and held a flotation barbell in each hand underwater to decrease the amount of weight on my legs.  Then I walked from one end of the pool to the other.  I tried backwards walking and also side steps.  I was pretty miserable in the pool and close to tears.  My leg was highly unstable and the water was moving it around causing pain.  Walking was difficult since I am not bending much yet and extremely weak.  Also, I had a lot of mental difficulty putting any weight on my bad leg.  It physically hurt but I was more concerned with the thought of damaging the graft since it is still in liquid form at this point.  My therapist had to explain at that depth and with the flotation devices I was only putting 20 lbs of my total weight on my leg and it wouldn't hurt anything.

Though my first pool experience was unpleasant I had to laugh a little as I had images of the movie "Cocoon" while I was struggling to do the most basic tasks in the water.

      
Pain:  I don't have much pain when I'm not moving my leg.  When I need to get up, it's  sore to move around but much better than the previous weeks.  I don't need to lift my leg with my hand or have some else move it anymore.  When I need to move I flex my quads and move my leg where it needs to go.  The constant use of my quads has caused some muscle fatigue but no extra pain.  Another issue that has come up is the soreness in my neck and back.  I spend a lot of time in bed mostly in the CPM and my body is not used to being in the same position all the time.  The only saving grace is I  get up and go to PT twice a day.  Also my arms and wrists are sore from the crutches. I'm guessing this will go away as I get stronger.

Sleeping:  Sleeping has not changed much since last week.  I can only sleep on my back or side with my bad leg up.  Changing positions is still an event and I have to move very carefully.  When I've been sleeping for awhile and then have to change positions my leg has stiffened up and it's more painful.  Sometimes my quad muscle contracts when I'm asleep.  It's sort of like a spasm.  It's quite painful and wakes me up.  This happens because my body is still getting used to having my quad fire again.  I can't wait until this stops.

Other Thoughts:  Overall this week was difficult more mentally than physically.  I am a month out of surgery and it's becoming apparent how slow this recovery will be.  It is hard to stay positive but I keep reminding myself how far I'm come.  

3 Weeks Post Op Dr Appointment

I have my first post op appointment with my surgeon at 3 weeks.  The appointment was very short and the Dr. looked at the incision to make sure it was healing well and there was no sign of infection.  I'm good to go in this area since I'm healing well.

I do have an area which is completely numb near my incision.  It's about a 1 in x 1 in  area to the left of the incision.  Apparently this is fairly common.  Over the next few months I should regain feeling as the nerves repair themselves.  According to my surgeon some people never regain feeling but it typically doesn't bother them.

One pleasant surprise after this surgery was I had no sutures to remove.  The incision was closed with internally dissolving stitches and surgical glue.  So that was nice not to have someone poking around the tender skin to remove sutures.  

3 Weeks Post Op

Range of Motion:  After week 2 I am supposed to go up to 40 degrees on the CPM.  I did 35 degrees the first 2 days of week 3 then got up to 40 degrees.  40 degrees was a little painful at first but the pain improved throughout the week.

Physical Therapy: After week 2 I am allowed flat foot weight bearing (FFWB).  All this means is when I'm standing straight I can touch my foot to the ground but I'm not really allowed to put any weight on it.  When I crutch around I still have to keep my leg off the ground.  It's nice to let my foot touch the ground so I'm not doing a constant balancing act.  But I have to be more careful than ever not to accidentally put weight on it.

My knee exercises still consist of straight leg raises (SLR).  I can now do the leg raises without the brace and add light weight above the knee as I get stronger.  I do the leg raises 4 ways to work my inner/outer thighs and my glutes.  For the most part I can do the leg raises on my own but sometimes I need my therapist to help me get started and lift my leg.  I have a fairly strong quad set now.  I am able to contract my quad and hold it.  However, when I contract my quad I am unable to hyperextend my knee and lift my heel off the ground like I can with my other leg.

Pain:  SLRs are still very painful and the scar massage and patellar mobilization makes me light headed and dizzy.  With the SLRs I sometimes can't get my leg to lift because my brain knows it will cause pain and shuts down my muscle.  So no matter how hard I try it won't move.  That's when my therapist helps me out and lifts for me so I can get started. I still take the occasional Percocet to help sleep at night.

My leg is laying in the CPM in this pic. This
is the scar at the end of week 3. There is
still quite a bit of swelling but you can make
out the sides of my kneecap.

Sleeping:  I am finally able to sleep on my side.  I can only sleep on the side with my bad leg up though.  If I try to sleep on my other side my knee begins to throb and my foot falls asleep.  It takes me about 10 minutes to arrange all the pillows and get in a comfortable position for sleep.  I sleep with a body pillow between my legs so that helps me get comfortable with the brace.  My brace is still locked out a 0 degrees so sleeping with my leg perfectly straight is still awkward.

Other Thoughts:  By the end of week 3 I felt good enough to take a short trip into town to go to Starbucks. Though the exercises during therapy are painful all the motion is helping with the overall pain control and I feel stronger.  Moving around is much easier and I now feel very confident on the crutches.      

2 Weeks Post Op

Daily Routine:  I have settled into a routine.  I wake up, eat breakfast, and get 1 hour in the CPM.  Then I go to my morning PT session.  After PT I come home and get another 2 hours in the CPM, eat lunch, then go to my afternoon PT session.  I get home around 3 pm and immediately jump in the CPM for another 2 hours.  I typically take a break around 5 pm and take a shower or do other small chores. I eat dinner then spend the rest of the evening in the CPM typically watching tv or reading.

Range of Motion:  I have reached 30 degrees on the CPM and it is relatively pain free.  First thing in the morning it is very stiff and I have to work up to 30 degrees but by the end of the day I'm relatively pain free while doing it.

Physical Therapy:  My morning PT session focuses on my knee exercises.  I am very limited to what I can do due to how fragile the graft is.  I am still focussing on trying to contract my quad.  I have been able to do this but it is weak and I can only hold the contraction for a few seconds then I lose it.  I also do straight leg raises (SLR) with the brace on.  I need help from my therapist to lift my leg and lower it. However, he applies the minimal pressure so I am still using my muscle.  The straight leg raises are extremely painful but I am able to work through the pain by focusing on breathing.

In addition to the quad sets and SLRs I now do scar massage and move my knee cap around (patellar mobilization) to break up scar tissue.  My therapist does this for me but I will begin doing it myself at home when I can stand the pain.  Also I have a hard time finding my kneecap due to the swelling.  I attached a video of me doing patellar mobilization and scar massage at post op week 7.

My afternoon PT session focuses on the rest of my body.  I do some form of cardio such as an arm bike or one-legged rowing.  Then I do exercises which focus on my core and upper body.  The afternoon PT sessions are my choice to go.  I was very worried about losing my fitness level due to this surgery.  My therapist is fantastic and works with me to maintain my overall level of fitness.  The rehab center I go to has a full gym so my therapist helps me get into weight lifting machines and designs exercises for me that I can do despite crutches and being locked out in a bulky brace. Being able to workout the rest of my body and stay in shape has helped me more mentally than physically.  Exercise is such a big part of my life and I am glad that I can keep some level of fitness.

Pain:  I am off Percocet for the most part.  I take it occasionally at night to help sleep.  The Percocet has been tearing up my stomach so I am determined not to take it unless I really need it.  My pain level is much better than the first week.

Sleeping:  I still have trouble getting comfortable at night.  I still have to sleep on my back since lying on my side is still too painful.  I usually wake up around 3 am with painful throbbing but I am able to drift back asleep sometimes.  I am supposed to wear the brace at all times unless showering, in the CPM, or at therapy for the first 8 weeks.  It is bulky so that partly contributes to my issues getting comfortable at night.

Other Thoughts:  I am able to move around easier.  Getting in and out of the car is much less daunting.  I only shower every 2 days since it's a pain in the ass and I'm worried about falling.  Sometimes I just don't have the energy.  I haven't felt up to going out and doing any activities yet.

1 Week Post Op

Day 1:  My leg is locked out at 0 degrees with a brace that extends from my hip flexor to my ankle. Underneath is a dressing over the incision and an ace bandage wrapped around my entire leg.  I have a cryo cuff under my brace and over my bandages.  This cuff plugs into a cooler filled with ice and circulates cool water throughout the cuff.  The cryotherapy helps a lot with the pain and swelling.  I was pretty much hooked up to the ice machine 24/7 during the first 3 days after surgery.  I have pain anytime I move but it's managed with the Percocet.  I can't move my leg on my own so I either have to pick it up myself or have someone lift it for me.

Day 2 and 3:  These days were pretty much the same as the first day except my pain was worse.  It maxed out at a 7 if I wasn't quick enough with the pain medication. I needed 2 Percocets every 6 hours around the clock.  Moving is still difficult and I only get up to use the bathroom.  Showering still seems like too difficult a task.

Day 4:  I felt a little better today.  The pain is better and I'm down to taking 1 Percocet at a time. I took my first shower which was extremely difficult.  Moving is a challenge and I needed help to get set up in the shower.  I wrapped a plastic bag around my leg since I haven't removed any dressings yet.  After the shower I felt light headed and weak and had to lay down for awhile.

Day 5: Pain is a little better today.  My rehab protocol directed me to begin using the constant passive motion (CPM) machine today.  I am supposed to use this 8-10 hours a day.  To use it I place my leg on the machine and use the hand controller to set the desired degree of flexion.  According to my protocol I am supposed to bend 0 to 30 degrees for the first 2 weeks.  During my first attempt I realized 30 degrees was too much so I started at 10.  I immediately needed a percocet as I started the motion.

Day 6:  Today was my first day at physical therapy and my first day outside.  I did not do any exercises at PT.  My therapist just took a look at the incision and bended my knee a little.  My knee pain was excruciating when he bent it but subsided after he stopped moving it.  I will start exercises tomorrow.  My plan is to increase the CPM 5 degrees a day until I get up to 30.

Day 7:  This is my best day so far.  I did not need any Percocet during the day even in the CPM.  Instead I take a Naproxen in the morning which is a strong anti-inflammatory.  At PT I am working to reactivate my quad muscles.  After knee surgery the quad muscles stop working as a defensive mechanism.  When the quad contracts it moves the kneecap.  The brain shuts down the quads to protect the kneecap from moving so it will not produce pain.  It is a medical enigma as to why this happens but the first step after major knee surgery is to regain quad control.  I was not able to contract my quad yet but it was only the first day of trying.  Today was also the first day I removed the dressing and took a shower.  It was good to let the water run over the incision.  Once again the shower was exhausting and upped my pain level.  Sleeping has been difficult.  I am a side sleeper but I can only sleep on my back because it is too painful to try to lay on my side or move my leg.  I need Percocet to fall asleep.  Usually I wake up in the middle of the night and my knee is painfully throbbing.  The throbbing is due to the swelling which is significant.  My knee is twice the size of my other knee. 

  

ACI Surgery Part II

I had the second part of my ACI surgery on 20 Aug 2015.  The procedure required an incision over my knee and removal of the knee cap to gain access to the cartilage lesion on my femur.  The damaged cartilage was scraped away and a patch made of biological material was placed over the lesion.  The patch is held in place by sutures and glue to make a water tight seal.  My cartilage cells that had been growing in the lab over the last few months were injected underneath the patch.  My knee cap was reattached and the knee sewed up.  The surgery took about 2-3 hours.

                                                                                                                                                                                           

                                                                                      

One decision I had to make before the surgery was whether or not to have a femoral nerve block to help with post op pain.  The procedure involved an injection into the femoral nerve to numb it similar to an epidural.  I opted not to do this.  It was one more thing that could go wrong. Additionally I was going to only spend one night in the hospital and I didn't want to be at home when the nerve block wore off.    I would rather be in the hospital where I could receive intravenous pain medication rather than find out I couldn't handle the pain and have to come back to the hospital after it wore off.

I woke up from surgery in minimal pain.  I was already receiving intravenous pain meds through my IV before I woke up so I actually felt pretty good.  My pain was around a 4.  I was moved to a hospital room which I don't really remember getting there.  I slept most of the day and night.  At some point during the night I was weened off the intravenous pain meds and was given 2 Percocets every 4 hours for pain.  This worked fairly well.  Toward the end of the 4 hours my pain would climb up to a 6 or 7 but slowly subside as the pills took effect.  I was also put on antibiotics through an IV to prevent infection.

I left the hospital late afternoon the day after my surgery.  I could keep my pain under control with the Percocet so I was ready to go home.  The worst part about leaving the hospital was standing up on crutches to get in the wheelchair.  The blood began to rush to the bottom of my leg and the pain was intense. However once I got settled in the wheel chair the pain subsided a bit and I felt ok enough to leave.  

Preparing for ACI Surgery Part II

Since I am starting this blog at 6 weeks post op I have a couple of tips to help during the first few weeks:

1.  Someone will need to stay with you the first couple of nights:  You will need help with basic things such as showering, going to the bathroom and changing clothes.  My parents stayed with me.  I remember calling out to my Dad to help me get to the bathroom in the middle of the night.  I consider myself fairly tough but this surgery will humble you.  After a week or so you should be fine if someone comes over and checks on you a few times of day.

2.  Get a toilet seat riser and stool:  The hospital provided the toilet seat riser for me.  Your leg will be locked out straight so you will need the stool to prop it up when you go to the bathroom.  Also you will need to have a shower stool to sit on in the shower if you don't not have a bathtub.  Standing up to take a shower will not be possible for at least 2 months.  Here is my bathroom set up:

3.  Stock up on books and movies:  Boredom will set in and that has surprisingly been one of the most difficult things for me to deal with.

4.  Get in good shape before surgery:  If you need to lose some weight, lose it.  If you need to work on strength and conditioning, do it.  This will take a toll on your body and months of inactivity following the surgery will lead to atrophy.

5.  I recommend yoga prior to surgery:  You will be on crutches for at least 8 weeks. During this time it's essential not to fall or stumble on your bad leg since the graft is very fragile.  Having good balance is of the utmost importance.  It highly unlikely that you will never stumble or trip while on crutches so having the ability to balance will really help with this.  Also, practice with your crutches before surgery if you've never used them.  A fall in the early stages could damage the graft.

6.  Going back to work:  I will have had 2 months off from work.  During the first 6 weeks you will be in a constant passive motion (CPM) machine which will bend your knee to stimulate cartilage growth and prevent scar tissue.  My rehab protocol said I need to do this 8-10 hrs a day.  So with PT sessions and the CPM I didn't have time to go into work.  However, I physically felt like I could sit at a desk somewhat comfortably for a few hours a day at 3 weeks.

7.  Driving:  I would have felt comfortable driving after about 3 weeks.  However, you need to be off narcotics to drive.  Also my surgery was on my left leg.  As far as the right leg I would think it would be several weeks before you could drive.  I have a manual car so I will be buying a new car since it will be several months before I am able to safely push in clutch without damaging the graft.

8.  Pain medication:  Take at the first on set of pain.  Don't wait until it gets really bad.  It is much harder to get rid of pain when it is very uncomfortable because the pain meds take awhile to work.

9.  Have a social network:  Invite friends/family over.  Although you may feel bad and think you look terrible (I didn't shower much in the beginning) don't turn down social visits.  They will help overcome feelings of depression and loneliness.  I had my surgery and first 2 months of recovery out of town from where I lived but my parents were there to help out and keep me company.  Communicating with friends over the phone was very helpful in keeping my spirits up.

10.  A wheelchair is handy:  See if your insurance will cover a rental.  I had a wheelchair with a trough that allowed my leg to rest in an extended position.  The wheel chair allowed my to get out and do a few things.

11.  Stairs:  If you have stairs in your house I recommend moving to one floor.  Stairs are doable on crutches but if you can avoid them, it's better.  It's not worth risking a fall and damaging the graft.  

ACI Surgery Part 1

Those familiar with ACI surgery know there are 2 surgeries required to complete the procedure.  Part 1 involves a minimally invasive procedure to harvest healthy cartilage cells from the patient's own knee and an analysis of the knee to determine if the patient is a good candidate.  The cells are then cultured in a lab for 4-6 weeks then implanted into the cartilage defect during open knee surgery.

I had my scope on 7 May 2015.  I was nervous because I still did not know if I was a good candidate for ACI.  An MRI only shows so much and a surgeon really needs to look inside the knee with a scope to determine to overall health of the knee.  Things I was concerned about included:

1.  Was there enough healthy cartilage surrounding the defect to do the procedure?
2.  Was my defect too large to do ACI?
3.  Was my defect not bad enough to warrant an invasive surgery such as ACI?
4.  Were there more cartilage defects that didn't show up on an MRI?

As it turns out I was a good candidate for ACI.  My knee was very healthy with only a "pothole" of damaged cartilage on the end of my femur which could be fixed by ACI. My cartilage defect was measured at about 1.5 cm.

My recovery after the scope wasn't bad.  I was on Percocet the first and second day after surgery with minimal pain on day 3.  I was walking normally after about 7 days and used crutches for about 5 days.  I had full range of motion after a month.  But it took 3 months to feel the same as before the surgery.  By this I mean I could bend my leg exactly as I could before the surgery.  I do a lot of yoga which requires significant bending of my knees.  Therefore, after 3 months I felt my knee was back to normal.  And by normal I mean I still had the same pain from the cartilage injury but I felt no worse off after the scope.  In fact I did feel a little better.  My surgeon cleaned out some of the debris caused by the damaged cartilage.

Although my cartilage cells would be ready for implantation in 4-6 weeks I opted to have Part II ACI done on 20 Aug 2015 due to work commitments.

My Decision to Have ACI

There are not a lot of options to fix articular cartilage injuries to the knee.  Articular cartilage surrounds the end of bones and protects them during load bearing activities.  My cartilage injury is on the end of my femur where it fits into the inner knee.  Articular cartilage tends to wear away in older people resulting in arthritis. However it is possible to injure the articular cartilage in a young person due to an acute injury or wear and tear on a certain location.

ACI does not fix widespread arthritis but is a good option for people with an small area of cartilage damage surrounded by healthy cartilage.  This is what I have and it's most likely due to wear and tear in a small area.  So when I learned I didn't necessarily have arthritis but an actual injury that could be fixed I was relieved. However, the options for fixing this type of injury are invasive with 12-18 month recovery periods.

My decision to have ACI was easy for me.  My injury prevented me from running and doing most of the athletic activities I like to do such as snowboarding and hiking.  Day to day my pain was minor.  Just walking around I could feel a twinge in my knee but it was just more of an irritant than anything.  However, when I would try to run I could only get a few steps with shooting pain.  Many people who undergo this surgery are debilitated in daily life due to pain.  I do not fall in this group but I felt a successful ACI recovery would let me get back to the life that I wanted. Additionally since cartilage doesn't repair itself, a knee replacement would be the only other option for me down the road.  A knee replacement wouldn't allow me to be as active as I want so I will only consider that as a last resort.

Diagnosis

Getting a diagnosis of my knee problem turned out to be a long frustrating process.  The biggest lesson I learned was you know when something is "definitely wrong" and keep pressing until you get an answer you are satisfied with.  You are your own best advocate.

My knee pain started in May 2014 after I ran a half marathon.  The pain started as a vague slight discomfort on the inside bottom portion of my knee  After the half marathon I took a little time off then I began doing higher intensity sprint work on a track.  Mostly I was doing this because it was a great workout and a great way to stay in shape and get a little faster.  Also I had a friend come with me to the track and we would come up with different exercises and workouts to do that were challenging.  Working out together kept us from getting bored and we were able to push ourselves by coming up with creative workouts involving different types of sprints and body weight training.

By July my knee pain got a little worse and I decided to rest until it went away.  I got to the point that running was uncomfortable and I knew I had an injury.  So I would take a week or 2 off at a time then test the knee by jogging.  The pain was still there so I would stop and try to wait it out.  During this time I focused on stretching and low impact exercises such as biking and swimming.  This went on for months and the knee pain never resolved. In fact it got worse to the point I couldn't even run a few steps without a shooting pain on the inside of my knee and a giving out sensation.

I finally went to the doctor.  He did several tests and didn't find anything blatantly wrong.  I told him the pain felt like a stress fracture (something I was familiar with since I had had a few over the years).  Since the pain was on the inside of the lower part of my knee, I thought it might be an upper tibial stress fracture.  My doctor ordered x-rays which showed a potential stress fracture where the pain was.  However, he ordered a bone scan to confirm the diagnosis.  The bone scan showed a "hot spot" on my medial femoral condyle but was inconclusive for a stress fracture or any other diagnosis.  The calcification of bone on the x-ray was mostly likely a healed stress fracture that I had high school.  But there was something going on in the femoral condyle so my doctor sent me to a sports medicine doctor for further care.

The sports medicine doctor diagnosed me with runner's knee which is a common running injury due to improper tracking of the kneecap.  He sent me to physical therapy and said I'd probably be fine in a month or two after doing some strengthening exercises.  This was frustrating because I knew my pain had not gotten any better during months of rest.  Stress injuries such as runners knee typically get better when you stop doing the activity which caused it.

I reported to physical therapy and my PT said he didn't think I had runner's knee since I've had the same level of pain for months without running.  My PT ordered an MRI right away.  In the meantime he gave me several exercises to do to strengthen my abductors.  I did these exercises religiously over the next month and they did not help with my knee pain.  The MRI showed a "full fissure cartilage defect on my medial femoral condyle."  I went back to my doctor to discuss the results and the way forward.

My doctor said I basically had arthritis in my knee and there was nothing that could be done about it.  I didn't like that diagnosis at all.  I felt a healthy 33 year old should not have debilitating arthritis at this point in life.  I pushed for an orthopedic referral and was granted one although I was told there wasn't anything that could be done surgically.

The first orthopedic surgeon I saw looked at my MRI and recommended ACI surgery to fix the cartilage defect.  That night I googled all about ACI surgery.  After reading about the requirement for the procedure to be open knee rather that a less invasive arthroscope and a year long recovery I opted for a 2nd opinion. Additionally, I wanted to find a surgeon that had experience with this surgery since it is not one of the more common knee surgeries.

I decided to see a surgeon at a top orthopedic center in San Antonio.  This surgeon also recommended ACI pending a diagnostic arthroscope of the knee to determine if I was a good candidate and to harvest the cells for the procedure.  I decided to have this surgeon do the surgery and scheduled the scope for 7 May 2015, a year after the onset of the pain.

My Background

People that have ACI surgery come from all sorts of different backgrounds and athletic abilities so I thought I'd share a little about myself.

Fitness has always been an important part of my life.  I've been an avid runner since high school.  My running mostly has consisted of 20-30 miles a week to stay in shape and the occasional race.  I took up marathon running a few years ago and have completed 3 marathons and several half marathons.  Other than running I swim, lift weights and do yoga to stay in shape.

My Dad and I at the Pensacola Half Marathon

My BFF Nicole and I after our first marathon

 

My BFF's Jess, Tarah and I after the Shamrock Marathon in Virginia Beach

I've always been very healthy and fit.  Until ACI I've never had a surgery (other than minor stuff like wisdom teeth), broken bone, or major injury.  The only running injuries I've had have been a few stress fractures in my foot and tibia.  Those healed normally and have never given me problems.  My knees have always been great so I was surprised to find out I had a knee injury which would not heal unless I underwent major open knee surgery.

Thus begins the saga to figure out exactly what was wrong with my knee...

Blog Purpose

Hello, my name is Megan.  I'm a 34 year old female who used to be an avid runner.  I am 6 weeks into recovery from autologous chondrocyte implantation (ACI) surgery for a cartilage defect on my medial femoral condyle.

I started this blog to spread awareness for people considering this surgery and to document what to expect during recovery.  I've spent hours googling blogs and information on ACI recovery.  I was disappointed at how few blogs there were that discussed the recovery after ACI.  The few blogs I did come across were quite helpful for reassuring me that what I was going through was normal and to give me perspective that this recovery is a MARATHON, NOT A SPRINT!

Let's face it, surgeons like to cut and are not necessarily the best at chronicling what comes after surgery. It's especially difficult for surgeons to convey the emotional rollercoaster that happens during a long and difficult recovery.  As you read this I hope it will provide a roadmap as to what ACI recovery is like and if this surgery is for you.  I'd like my readers to keep in mind that everyone heals differently and at different rates, especially when it comes to knee surgeries.  So with that, let's start at the beginning....