13 Months Post-Op

I am not as optimistic as I was at the end of last month.  I have stopped trying to run on the alter G.  I can't get much above 75% body weight.  I also felt my gait was off.  It felt like I was favoring my right leg and when my left leg would hit it felt awkward because I would unintentionally not bend it as much as when my right leg would hit.

Overall, I am disappointed in this surgery.  I really don't feel any difference.  I feel like I have been rehabbing the invasiveness of the surgery over the last year while my injury was never actually repaired.  I still have lots of cracking and popping and pain when I try to stand on one leg and bend.  Running without the alter G is still out of the question.

I emailed my surgeon to ask what the next step was.  I haven't seen him since 5 months post op and I feel I've given this surgery a long enough chance that I want an MRI to see what's going on.  My surgeon's response to my question was three-fold:

1.  He said the first thing I need to do is make sure my quad strength is back.  I feel like my quad strength is sufficient.  I don't think it will ever be the same as my right leg but i've made a lot of progress in this.  My PT said he didn't notice much difference between the strength in my right and left leg.  Additionally I workout 4-5 times a week so I've been very dedicated to rehab.

2.  The next thing he mentioned was getting an MRI to see if I am healing as expected.  Yes, I agree.  I want an MRI.

3.  The third thing he mentioned was steroid or hyaluronic acid injections.  There has been some success relieving knee pain with theses injections.  I wasn't that excited about this option because it is not fixing my problem and just treating the symptoms.  And it's also not a long term solution.  But I'm willing to give it a try after I get the results from the MRI.

I ended up getting an MRI.  This are my results below:

I sent the disk with he scans to my surgeon.  I am very interested to see what he says.  What's concerning is the report says I still have "Grade IV chondromalacia in the weight bearing part of the medial femoral condyle."  This is exactly what my MRI said before I had the surgery. So I'm wondering what the hell happened?  Is the graft even there?  I hope after discussing with my surgeon I will get some answers.

I have no idea what the next step is going to be but I'm not excited to have any more surgeries.  I would consider a diagnostic scope but that's about it.  For the next couple of months I'll continue my workout routine but I have little doubt that I'll experience much improvement as this point.

 

1 Year Post Op

Well, I've finally hit that 1 year point.  This past month has been interesting for my recovery.  I've really started to push my limits and see how much my knee can withstand at this point.  So for the past month I've been trying to work towards running, as suggested by my physical therapist.  I've spent some time in the alter G treadmill experimenting with running.  Here's a wrap-up of the alter G workouts I've done over the past month:

21 Jul:  Alternating 5 min walk/1 min run for 30 mins (45% body weight)
27 Jul:  Alternating 5 min walk/1 min run for 30 mins (50% body weight)
29 Jul:  Alternating 4 min walk/2 min run for 30 mins (55% body weight)
2 Aug:  Alternating 3 min walk/3 min run for 30 mins (55% body weight)
5 Aug:  Alternating 3 min walk/3 min run for 30 mins (60% body weight)
15 Aug:  Alternating 3 min walk/3 min run for 30 mins (65% body weight)
18 Aug:  Alternating 3 min walk/3 min run for 30 mins (70% body weight)

*walking pace = 4.0 (15:00 min/mile)
*running pace = 5.0 to 5.5 (12:00 min/mile to 10:55 min/mile)

21 Jul 2016 was the first time I've run in 677 days.  The last day I ran was 13 Sep 2014.  That day I had terrible pain in my knee and I knew something was wrong.  It would be another 11 months before I had my ACI surgery.

My first experience on the alter G was awful.  I felt pain in my graft area and my leg felt like it wasn't working correctly during the 1 min run portion.  Running was very awkward.  It's hard to describe but I felt like my leg didn't remember how to run.  I felt like my muscles weren't firing correctly and that I was just jarring my graft site.  I was pretty down after this experience because I felt like after a year of recovering from this surgery nothing had gotten better.  I talked with my physical therapist and he said to stick with it.  He said I wasn't going to do any damage trying to run at 50% my body weight and the graft should be strong enough to support this.  Amazingly within another week, I started to feel really good.  The pain didn't completely go away but I felt good enough to start upping my body weight and the amount of running during each session.  I can't believe the difference between the 19 Jul workout and the 18 Aug workout.  This is the first time since this surgery that I'm starting to feel really good and thinking that this might have worked for me.  I'm looking forward to increasing my body weight over the next couple months and get to the point were I can run normally on a treadmill.

In addition to the alter G, I've been continuing to work on strength training.  I still work on hip strength a lot along with leg press, squats and lunges.  This month I added large stepups to my routine.  Since I've been doing these I've noticed my ability to walk up stairs has improved.  I'm almost able to go up stairs completely normal now.  I do hear cracking and grinding going up stairs though.  It doesn't hurt but its somewhat disconcerting because it just sounds bad.

I do have some things I am still concerned about though.  Mainly, I worry about not being able to stand on my bad leg and do a squat.  I can do this so easily with my other leg.  It's quite painful when I try to do this.  Also, walking up a steep incline is difficult.  I really want to be able to do this so I can go hiking.  Other than that It's been a fairly positive month and it feels great to start running again.        

11 Months Post Op

This month I've been focusing on hip strength as recommended by my physical therapist.  I've been doing the exercises he recommended 3-4 times a week in addition to my normal workout routine.  I noticed my hip muscles were a little sore the first couple of days so the exercises were apparently working something.

I had another appointment with my physical therapist after doing the hip exercises for about a month.  He did some various strength tests and said my hip strength was pretty could and he couldn't tell the difference between my right and left leg.  So that was good news.  However, I still have a noticeable difference in quad strength between my right and left leg.  He suggested I start trying to run using the alter G treadmill to build confidence in my leg.  The alter G treadmill is a special treadmill that lifts you up to allow partial weight bearing.  I used this early on in my recovery to transition to walking.  I'm a little nervous about starting a running program.

With this machine, you zip yourself into special "shorts" that are
attached to the machine.  Then the machine calibrates after it's
turn on.  You can then set the percentage of body weight that
you want to exercise with and the machine lifts you up
accordingly.  Science...it's cool.

I'm not sure my leg is ready.  When I voiced this concern to my PT, he said it shouldn't hurt the graft at this point especially when starting in the alter G.  He suggested starting at 50% of my body weight then slowly working up to more of my body weight over the next month.  According to my protocol, the graft should be strong enough to withstand light jogging at this point.  So I'll give it try this next month and see how it goes.

Stairs are becoming easier.  I don't have any trouble going down stairs.  I still have a little trouble going up stairs.  But I can walk up stairs now without limping or using the handrail.  I just have to focus on flexing my quad and keeping my knee in correct alignment as I push off.

I'm still unable to hop on one leg or do a one leg squat.  I have been doing one leg squats using my arms to help but I really struggle with this still.
  

10 Months Post Op

As I sit to write this post I realize there's not been much difference in my knee between 9 and 10 months.  I am continuing to workout regularly to build my strength back and I am now on my 4th physical therapist.

I've started to see a new physical therapist.  I'm hoping a different set of eyes might help with some of the weakness issues I've been having.  Though he is not familiar with ACI I hope that he can still give me some good advice by relying on his overall expertise.  I've seen him once so far and he suggested I try some new exercises focusing on my hip strength.  My knee is still unstable going up stairs.  It sort of wobbles left and right.  He said this is because I have weak hips and strengthening them will help to keep my knee in alignment. So I've been adding his suggested exercises into my workout routine for the last 10 days now. For the first couple I days I had soreness in my hip area so I know the exercises are doing something. Here's a sample of some of the new exercises:

This one hurts and I can barely do 3x sets of 10 without
holding on to something

The side-stepping and lateral step downs really bother my knee.  I feel pain in the graft site when doing these exercises.  However, I'm going to continue doing them as long as it doesn't get worse.  I think at this point the graft should be strong enough to with stand the pressure from these exercises.  My protocol had me doing lateral steps downs at month 3.  I avoided doing them because they hurt and I was worried I was damaging something.  But at this point I'm going to work through it and hopefully find my pain will decrease as I get stronger.

I also have pain with this one

As I look back on the rehab protocol I was given after surgery, I believe it was way too optimistic.  In my case, I haven't been able to meet most of the pre-set goals on-time.  Here is a list of the goals for my rehab protocol and how I've fared at each juncture:

Goal at 2 weeks:  Pain/effusion control; Good quad control

I would say I met this goal.  By 2 weeks my pain was under control and I was able to do a quad set so my quad was firing.  I still couldn't really lift my leg but at least the muscle was working.

Goal at 4 weeks:  Range of Motion 0-40 degrees

Doesn't hurt at all!

I believe I met this goal as well.  I was doing 40 degrees fairly easily in the CPM after the first month.

Goal at 6 weeks:  Range of Motion 0-90 degrees

I also met this goal but I really struggled to do 90 degrees on the CPM.  After 6 weeks I discontinued the CPM and found my range of motion came back quicker when I manually bent my leg by trying to sit back on my heels.

Goal at 8 weeks:  Range of Motion 0-120 degrees; No effusion

I definitely didn't meet this goal.  I was only around 100-110 degrees after 2 months.  I was

Doesn't hurt at all!

also still very swollen so I think it's totally unrealistic to say no effusion at 8 weeks.  I had swelling for about 5 months.

Goal at 10 weeks:  Full Range of Motion

Nope.  It took me about 3 months to achieve full range of motion and I had stiffness for another 3 months after that.

Goal at 12 weeks:  Normal Gait

I suppose I did meet this one but my walking was pretty slow.  I really didn't feel totally comfortable walking around until 4 months.

Goal at 6 months:  Thigh girth equal bilaterally

Nope.  My thighs are still uneven though I've noticed a slow increase in definition.

Goal at 9 months:  Walk 2 miles at 15 min/mile pace

Nope:  I was doing around 17:00 min/mile pace at this point.

Goal at 12 months:  Run 2 miles on treadmill at comfortable pace

Hell no.  Though I'm only at month 10 there's no way I can  foresee being able to do this at 12 months.

It is somewhat frustrating not being able to run when my rehab protocol says I should be able to.  However, I've learned to take it with a grain of salt and realize the protocol I was given is generic and people have different success rates.  Most of the people I've interacted with on the blog say it takes 18 months to really feel "normal."  If that's the case, I'm a little over half way then.  

Over the next two months I plan to keep working on my strength and walking faster on the treadmill. I also want to see my surgeon at 12 months and hopefully get an MRI.  I'm hoping an MRI can tell me if the graft is healthy.  

9 Months Post Op

First of all, let me apologize for not doing an 8 month post.  Life tends to get in the way of things.  But at least that means my knee is not holding me back from living it.  I'm at 9 months now and I'll try to catch you up.

In the 2 months since my last post, I have not noticed much improvement or difference in my recovery.  I've found myself asking the questions "is this as good as it gets?  Am I still going to see improvements down the road?"

To sum things up, here are the things I still cannot do:
- Run
- Jump
- One leg squats
- Climb stairs without discomfort or weakness

Here is what I can do now:
- Walk 2 miles at 1730 min mile pace on the treadmill
- Front squats with 20 lbs
- Lunges with 5 lbs in each hand
- Descend stairs normally
- Unrestricted biking and elliptical
- Rowing machine
- Any weight machines in the gym expect leg extension (I heard this puts a lot of stress on the knee so I don't do it)

Issues I'm Still Having:

Weakness:  My operated leg is still much weaker than the right leg though I workout 5 times a week.  I can still see lack of definition in my quads when I compare it to my right leg.  Sometimes when I walk it locks and gives out, then I stumble.  This usually happens after I've had a tough workout.  I think it's due to muscle fatigue.  It usually takes me by surprise and scares me a little but I have no additional pain when it happens.

Pain:  While I don't have a lot of discomfort, I still feel pain in the area of the graft.  I wonder if this will ever go away. I feel it when I try to do a one leg squat or do step ups.  Running is still out of the question because of this.  One of my big questions is why am I still feeling this?  Is it because the graft is still hardening or is it because the graft has worn away?  I saw my surgeon last at 5 months post op.  He said I didn't need to come back unless I was having issues after a year.  At that point I could get an MRI to see what's going on.  I will definitely be going back to see what he says if I feel the same 3 months from now.

Popping/Cracking:  So this has gotten significantly better.  I still feel popping but it's almost like a release and it feels good.  But my PT said she's never heard someone's knee make noises like that post op so that was discouraging.  But then again, she has never heard of ACI until me.

Things That Have Gotten Better:

Stability:  My leg feels much more stable and I'm confident when I'm doing squats and lunges.  I think this is a result of building my strength back.

Stairs:  I am now to the point where I can go down stairs normally without hanging onto the handrail for dear life.  Going up stairs I don't need to use the handrail but I have to concentrate and make sure my quad is flexed and my knee is tracking straight.

Walking:  I'm really starting to pick up the pace on the treadmill.  My PT says we should try to work toward fast walking and hopefully be able to transition to run at some point.  So I'm working toward walking 2 miles at 15 min mile pace over the next 2 months.

Overall Impressions at this Point:
I had no idea at 9 months I'd still be struggling with pain in the graft area and muscle weakness.  It is also still surprising to me how slow and incremental the recovery is.  For instance, my experience with stairs has been characterized as slow but gradual improvement since 3 months post op.  I am wondering when I will reach my "peak" of recovery and when I will stop seeing improvements.  I hope that it is not now because I would be disappointed at the results of the surgery if this is as good as it gets.  In hindsight,  I wish I had a PT who had experience working with ACI patients because she can't answer my questions so we're sort of figuring this out together.

*On another note, thank you everyone for all the comments and encouragement.  It helps to hear how others are fairing after this surgery.  I wish you all the best and will continue to post and look forward to reading about your experiences.

7 Months Post Op

At 7 months post op my biggest issue is weakness.  I don't really have much pain anymore but every once in a while I'll get a twinge in the graft area where I had my injury.  However, getting strength back is a SLOW process.  Even though I work out 4-5 times a week, it is still painstakingly slow and I have seen incremental progress over the last month.  

A note on the VMO:  The Vastus Medialis Oblique (VMO) muscle is the part of the quad on the lower inner leg right above the knee. This little muscle provides stability for the knee and can cause knee pain if it is weak.  A weak VMO will cause the knee cap to track incorrectly and cause pain.  Strengthening the VMO is critical after knee surgery because it is the muscle to atrophy the most and the hardest to build back up.  Mine is weak!  To build up the VMO, you need to focus on exercises that strengthen the quad. Physical therapists and surgeons have different opinions on if you can actually target the VMO with specific exercises or you need to work on just strengthening the entire quad.  The ability to "spot train" is controversial but you can't go wrong if you do exercises to target the entire quad such as squats, lunges, step downs and step ups.  So that's what I've been focusing on the past couple of weeks.

Here's a video of me doing some of these quad strengthening exercises:

Stairs:  Stairs are slowly getting easier.  I can go down stairs now without having to hold the handrail but I still do just because I feel more stable.  Going up stairs I still have to hold on the hand rail pretty tight.

Cracking and Popping:  I've noticed this has gotten better over the last month and my knee doesn't do this as much anymore.  I guess the scar tissue is breaking up.

Overall:  I think the most important thing that I learned this month is that regaining strength is a slow process.  It just doesn't happen quickly no matter what I do.  It took 2 months of doing lunges in parallel bars to get to the point where I could do them without holding onto anything like in the video.  The definition in my VMO when compared with my non-operated leg is significantly different.  I think this is why I have such trouble with stairs.  This muscle is important when doing the step up motion.  When I look at where I was 3 months ago, I have gained significant strength back so remembering this is how I stay positive.    

6 Months Post Op

Well, here I am at 6 months and life is slowly returning to normal.  After my last Dr. appointment, I learned I could add some additional exercises to my workouts including lunges and squats.  I also learned I can go to 90 degrees flexion when doing these exercises.

Physical Therapy:  I still go to PT twice a week.  Mostly I still go to touch base with my physical therapist and to get ideas for different exercises.  But I think I know enough now to do my own workouts at the gym.  Plus I prefer to go to the gym on my own because I can get a better workout.  Here are the exercises I do now:

Cardio:
Elliptical Trainer
Stationary bike
Swimming
Treadmill backwards walking at a high incline

Strength Training:
Squats (only body weight)
Lunges (only body weight)
Calf raises
Leg Press
Hip weight machine
Hamstring curl weight machine

I feel comfortable doing pretty much any weight machines except leg extensions.  I've read that this exercise causes sheering forces on the knee and I feel pain in my knee cap when I try to do this.  So I think it might be a little soon for this.

I also started going to yoga class again.  This has been challenging.  Any balancing poses on my left side are difficult and I'm highly unstable due to weakness around my knee.  But It feels really good to start doing this again and I think this will help a lot with building up my strength.

I don't have any pain in the area of the graft when I do any of these exercises.  The only issue I noticed was during lunges. When I lunged forward on my non-operated leg I felt a twinge in my operated leg near the graft site.  So I only do forward lunges with my operated leg for now.

Pain/Swelling/Stiffness/Weakness:  Now that I've added some new exercises and started to work my leg a little harder I noticed some pain around my kneecap near the incision.  The area around my incision is still a little tender and I'm getting used to some of these new exercises.  I don't have much swelling or stiffness anymore so I feel back to normal when I'm sitting on the couch or laying in bed.  My knee makes a lot of cracking and popping sounds when I do my exercises.  It doesn't hurt but I'm surprised how much cracking there is.  According to my surgeon, it's normal so I'm not bothered by it.  My biggest issue is weakness right now.  Going up and down stairs is still very difficult.  I can go up and down alternating legs now but I hold onto the handrail pretty tight.

Overall:  I'm still about 3 months out from beginning a running progression program according to my rehab protocol.  I'm not sure I will ever get to the point where I can run.  I still have some pain in my femoral condyle where I had the graft when I walk or go up stairs but it's minor.  I can't imagine trying to run right now.  Hopefully over the next 3 months I will continue to get stronger and the graft will continue to harder and fix my injury.     

5 Months Post Op Dr Appointment

I went back to see my surgeon to see how I was progressing.  Here are some of the questions I asked him and the answers (in red) and my reactions (in blue).

1.  Why do I still have pain in the same area as before the surgery?  Is this normal?

It is normal to still have pain until you get your quad strength back.  Cartilage injuries are difficult and it's sometimes difficult to see what is causing the pain.  However, it's too soon to think about other options because the graft is still hardening and adhering to the bone (I'm definitely NOT having another surgery for this.  At this point I'll live with what I got if this is as good as it gets).  The pain should slowly decrease over the next couple of months as your quad becomes more functional.

2.  It's hard to strengthen my quad when my rehab protocol is so restrictive.  When can I start doing more intense exercises such as lunges and squats?  Do you have any recommendations of exercises I can do now to strengthen the quad?  What about stairs?  Are those ok?

At this point you are okay to start doing squats and lunges (Well this is good to know!  Apparently my rehab protocol is very generic and fits worst case scenario for this surgery.  I'm excited to try out some new exercises over the next few months).  Your lesion is in a location that those exercises should not put excessive pressure on the graft.  But you'll need to start slow since your quad is very weak.  The leg extension weight machine is a good way to build the quad.  You'll have a lot of trouble dong stairs right now so you might want to avoid that until later down the road (Too bad my house has stairs.  But I just go up one leg at a time).

3.  I have cracking and popping in my knee now.  Is this ok?  Should I be worried?

No, this is nothing to be worried about.  This is normal after open knee surgery.  To access the cartilage lesion the tendon attaching your knee cap was cut so the kneecap could be flipped up.  The tendon was then glued back together.  The cracking and popping is the scar tissue releasing and breaking up.  This should go away in a couple of months (This was a relief.  I thought these sensations were my messed up cartilage).

4.  Would an MRI show how the graft is doing at this point?

No, an MRI would not show much at this point.  If you still have pain a year post op then is would be appropriate to get another MRI to see what's going on.  Right now there is no reason to think anything is wrong with the graft as you seem to be healing well.  

5 Months Post Op

No swelling at 5 months

Pain, Swelling, and Stiffness:  At 5 months I finally have no swelling!   My knee looks like the other one except for the scar.  I still ice after I go to physical therapy but I don't feel the need to ice after I do workouts on my own.  I still have stiffness in the morning when I get out of bed but I don't notice it throughout the day.  As far as pain goes, I still have minor pain in my femoral condyle similar to before I had the surgery.  Over the last month, this pain has come and gone.  I have good weeks where I don't notice it at all and think the surgery worked.  Then the next week I feel it again.  This is the most frustrating part of this surgery.  I'm not sure why the pain comes and goes.  Sometimes I think it's my body reacting to upping my workout routine or trying a new exercise.  Interestingly though, I find that I feel better after I increase the weight or reps of any exercise involving my operated leg as long as I don't overdo it.  So maybe strengthening the muscles helps relieve the pain, I really don't know.  Additionally, I still have slight warmness when I touch my knee. It's not hot, just slightly warmer than the other one.  Everyone I've asked about this says it's ok and normal.  It just means there's still healing going on, which makes sense.

Physical Therapy:  The exercises I'm allowed to do hasn't changed since month 3.  However, I've been increasing the resistance, time, and reps of each exercise.  The exercises I do include:

Stationary bike (up to 45 minutes with varying degrees of resistance)
Elliptical (up to 15 minutes)
Treadmill walking (forwards/backwards for 15 minutes)
Swimming (up to 45 mins freestyle stroke)
Leg Press
Hamstring Curl
SLRs
Heel raises

Here's a short clip of me doing leg press.  I'm still limited to 45 degrees of flexion so it's hard to really  gain much strength doing this.  In this video I'm lifting 35 lbs which is difficult.  Note how skinny my leg is and how hard it is to see much definition as the muscles contract (I call it my baby deer leg).  My surgeon told me at one point I'll probably lose 30-40% muscle strength during the first 2 months of recovery.

Here is another clip of me doing straight leg raises (SLR) working the abductor muscle of the thigh.  I started doing these a week after surgery and I'm still doing them.  This is a good way to work the four major muscles of the thigh:  quads, hamstrings, abductors, and adductors.

A Note on Backwards Walking:  One exercise I recently started is backwards walking on the treadmill.  Backwards walking is good for people recovering from knee surgery because it primarily works the quadriceps and calves unlike normal walking which works the hamstrings and glutes.  Additionally, backwards walking produces less of a sheering force on the knee joint as opposed to forward walking so it is a good exercise to strengthen the muscles without causing too much stress.  So I'll be doing this a lot and trying to increase speed and endurance over time.

Other Thoughts:  Stairs are still difficult, especially going up.  Going down is much easier and I can almost do this normally as long as I'm holding onto the handrail.  I am still very careful not to overdo it with my knee.  I had a giant snow storm this month and was forced to shovel snow to get out of my driveway.  I was very careful to avoid putting too much weight on my operated knee or do much bending with it.  However, the next day I felt more sore than usual and was worried I overdid it.  But I felt ok a few days later.  So what this taught me is that even though I'm feeling a lot better and stronger, I need to not rush the recovery and stick to the exercises I know I can do safely.