Day 50

Here’s a bit of recovery wisdom that I've recently derived: One of the main reasons that you want to rehab as soon as possible after ACL (or any other immobilizing) surgery is that the longer you remain bio-mechanically altered, the more likely you are to injure something else.

Last week’s diagnosis of my recently instigated knee pain:
Sciatic nerve damage.

The determination was based on a quick exam and a few physical tests administered by Thor, comic book legend and trusted PT guru. I know nerve damage sounds nasty but given the alternatives the nerve is by far the best choice. If not the nerve, then the source of pain would have probably been one of the repaired elements of my knee (the ACL graft or sutured meniscus). If either of those had been compromised, it would be highly unlikely for the situation to somehow self-resolve. As such, I was more than happy to buy the nerve damage story. In general, you know things are a bit desperate when you are rooting for nerve damage.

It's now just ten days later and while the pain is not gone, it is already quite a lot better. The relatively quick improvement matches the initial diagnosis and is a good indication that the source was not the graft or the meniscus. Definitely good news.

So how did this happen? Well in my case the theory goes like this:

3 Easy Steps to Sciatic Nerve Damage
1.) Do not straighten or fully use the knee for a few months. This will help to make the nerve shorter and less flexible.
2.) Ice the knee into a deep freeze.
3.) Stand up and fully straighten the knee into hyper-extension – be sure to bend forward at the waist to induce maximum stress on the nerve.

Although it was enough to force me back onto crutches, I’m off them again now and as mentioned, the pain is definitely better. This is especially promising given the fact that I recently gave up Advil, the last of my pain medications.

I had been taking 200 mg of ibuprophin (via Advil) every 4 hours for nearly 5 weeks (beginning the day my supply of Toradol ran out). For the first few days after the nerve diagnosis, however, I doubled the doses to 400 mg every 4 hours. Into the third day of elevated doses I was opening my mail when my eyes suddenly obtained free-agency status. Within seconds my left eye was looking at the ceiling and my right was angled toward the floor. I stumbled to the couch and squeezed my forehead between my hands trying to correct the internal corkscrew effect until it finally subsided after a few very long minutes. By then I had sworn off everything from Advil to fast-food, squinting, nail-biting, illegal u-turns, littering, loitering, loud music, internet porn, new episodes of LOST, and anything else I could think of that might have caused the disorientation. I haven't touched the Advil since.

Going off pain medication is a bit like jumping into a mountain lake. It might be ok or it might be bone-chillingly cold. But you won’t really know until it’s too late to undo what you’ve done to find out. Thankfully, the post-Advil period has so far been quite tolerable. I just have to keep reminding myself that the newly identified aches and pains at this point are not likely an indication of lost progress, but rather the result of once again accurately feeling everything as it really is.

Yesterday I was back on a Stone Clinic PT table where I confessed to Thor that my lower back was still not entirely right. He worked my back a bit and then targeted a new area, the Psoas, a hip flexor muscle that you never even knew you had. Thor calls it the “Filet Mignon of the human body” and in accordance with what is apparently a strict personal policy of full-disclosure, he said that if we were ever stranded after a plane crash in the Andes, that’s the part he would take first. A distracting bit of information I now wish I could manage to forget. In any case, digging into my abdomen to “relieve” the tension in the psoas was a none too pleasant endeavor in itself but it definitely did seem to help afterwards.

The PT session focused primarily on the sciatic, the aforementioned filet, and on obtaining full extension (the latter of which I had been successfully getting to at home for the past couple of days with the help of my wife who is understandably somewhat hesitant to push on my knee). Afterwards I asked Thor about the sports brace that he had previously suggested. The bottom line was that he highly recommends one if I am going to engage in sports during the first year post-op. A quick internet search when I got home led me to this excerpt from about.com regarding ACL knee braces…
“The problem with knee braces? While they may help support the knee when low forces are applied, these forces would not be expected to cause injury to the reconstructed ACL. However, a force that is high enough to disrupt the reconstructed ACL would not be effectively stabilized by the knee brace.”
Similar comments can be found here on the ACL Solutions website: http://www.aclsolutions.com/faq_07.php

Given the opposing opinions, the fact that I already have the bulky post-surgery issued brace, and my general lack of intention to join a pro sports team this year, I think I may have a difficult time justifying a sports brace.

Left: Lightweight state of the art custom fitted brace available in a dozen colors.
Right: Brace worn by Joe Namath in the 1968 season prior to Superbowl III.

At this point I’ve abandoned the regularly scheduled formal PT sessions, although I’m working daily at home and will continue to follow up at the Stone Clinic as needed over the rest of the year. I’m spinning 30 minutes every night on the bike (mounted in a trainer, and at a blazing 40 rpm, but hey, it’s something). I’m still not getting to full extension when I walk but I am getting closer. Overall, I’m quite thankful and pleased to report that despite the recent setbacks, things do seem to be back on track once again.

Day 41

Something has gone wrong. And it has done so rather suddenly and severely.

As of yesterday I was doing reasonably well, albeit behind relative to the published recovery schedules. Over the past week I had been seeing improvements with strength and flexion. Last night, I wrapped, elevated, and iced my knee. Afterwards I slowly pressed it into full extension and as I stood, partially supported by the edge of the couch, I was pleased to see that the slightly hyper-extended angle of my left leg was finally matched by my right. I carefully felt for and found the solid stop of the new ACL. Encouraging progress to say the least.

But early today the light at the end of the tunnel quickly faded as sharp pains began shooting through my leg. The origin was difficult to determine although it seemed to be firing from a nerve running across the back of my hip and landing somewhere inside my knee. I took a hot shower, which helped some, and an hour later I was back at the chiropractor. The adjustments helped with the upper element of the pain but left me with a new awareness of the problem in my knee. I had to stop six times over the 30-yard walk through the parking lot back to my truck. When I got home I was on my way from the driveway to the front door when I finally summoned for my recently retired crutches as my wife and 3-year old by chance saw me standing outside on the sidewalk.

I ran through yesterday's events in my head in search of some possible indication of cause as I surfed the internet for "ACL reconstruction failure". Over the course of the next few hours, filled with intermittent, sharp pains shooting from within my knee, I began to suspect that the more likely source was not the ACL, but rather the newly sutured meniscus. I tore the meniscus in my other knee a few years ago, the result of an unscheduled road bike dismount. That tear thankfully healed without surgery but I still have some well seared memories of the pain. It was very much like this now feels - sharp, specific, and plenty severe enough to stop me in my tracks.

Obviously I don't yet know what this all means. My recovery is at the very least on hold. Tomorrow I head back to the Stone Clinic for previously scheduled physical therapy. Hopefully I can find some answers there. I suspect that they will tell me to just wait this out for a while to see if it somehow begins to resolve on its own. If it doesn't, there will probably be another MRI in my future.

To suggest that I was not emotionally prepared for this recovery detour would be a tremendous understatement. I realize that I have an excess of what would in smaller doses be a healthy paranoia about this injury and I am trying to maintain an accurate perspective here. Still, I find that I am becoming somewhat overwhelmed with the uncertainty of this entire ordeal once again.

Day 34

An update on my rehab situation…

I've been diligently heading off to physical therapy three times per week since early January. Stone has a PT room in his facility but since he's an hour away and out of my insurance network, the vast majority of my pre and post op therapy has been at an in-network clinic closer to my house. They are all very nice there, have all the necessary equipment, and they seem reasonably competent. The therapists at Stone on the other hand are some of the best in the business and today I had PT with one of them in conjunction with a post surgery check up appointment. Given the Stone motto (Fitter, Faster, Stronger) and the undeniable fact that I was nearing the start of week 5 but still only barely meeting week 2 recovery expectations, I knew full well that I was stepping into a possible shit storm by seeing a Stone therapist but I also knew it had to be done. When I arrived, Dr. Stone gave me a quick once over and said he was pleased with how solid my new ACL was. He smiled in a way that made it clear that he was genuinely proud of his work, like a kid admiring his recently completed model airplane. He also pointed out that my range of motion was lacking and he told me to check with him on my way out after therapy.

The Stone therapist that I saw today has no shortage of size and muscle to adequately deliver “therapy” and as all good physical therapists do, he probably harbors some well developed sadistic tendencies beneath his pleasant and professional exterior.

As an aside, while I realize that those in the PT trade may be meeting the clinical definition of “therapy”, until the start of this whole experience I always thought the word had a wonderfully serene and peaceful feel to it. Like aqua therapy or aroma therapy. It is supposed to be after all, therapeutic. Turns out though, physical therapy is much more closely related to electro-shock therapy. And perhaps a close cousin to running-naked-through-a-hail-storm therapy.

In any case, my therapist today, let’s call him Thor, is clearly dedicated to his craft and is a fountain of catch phrases. He asked how things were going on the bike. I explained that I had tried a few days ago but still could not get over the top of the pedal stroke. “Well, we’ll fix that”, he said, as if he was talking about squirting some 3-in-1 on a stuck hinge. “Motion is lotion you know and you should be on the bike by now. You’re a bit behind the curve.” “Yes, I know”, I replied. Thor went on to explain that a big part of the reason for my limited range of motion was the swelling around the kneecap. When the leg is straight and the quads are flexed, the patella should move toward the hip. Mine, as he pointed out, looked like it was set in cement. Thor said that the swelling in my knee was “old and cold” and that it never should have gotten to this point. “But don’t worry”, he said with a quick grin, “we’ll fix that too”.

As the therapeutic part of the session began, Thor hit me with another catch phrase that had something to do with eating shit and essentially was meant to explain that in physical therapy, if you don’t pay frequently with a little pain each time, then you have to make a few larger payments of pain to catch up. Today, he warned me, would probably get expensive.

All of my physical therapy sessions have had some associated pain. I mean, my knee has already been hurt, so to do anything to it or with it just hurts more. Sometimes a little, sometimes quite a lot. But today was an entirely new level of demandingly ferocious pain. It started with what seemed like days of increasingly hostile, insistent gouging and squeezing and digging around the patella. Thor used his fully double jointed muscle-bound thumbs to “get the junk out” from within the tissues around my knee. This attack nearly sent me diving off the table numerous times for the relative safety of the floor. I was told to verbally refer to my leg as someone else’s, as though we were both observing this violent work being done to some other poor sap. But this only served to confuse me – why the hell does that guy’s knee hurt me so much? Between each attempt to force the knee beyond its recently self-imposed limits, there was more targeted grinding and smashing of the tissues. Lying on my back I desperately focused on random holes in the ceiling tiles. To gain extension, my knee was firmly held down to the table while my foot was pulled upward. To force flexion my leg was bent farther and farther in short pain filled bursts. Eventually I just gave up on trying to achieve the requisite Zen master concentration and I resorted to yelling my way through the previous limits. By the end of the session I had pushed into nearly 5 degrees of hyper-extension and gained an extra 17 degrees of flexion. Significant and exhausting progress.

Afterwards my knee was iced for 20 minutes or so and I actually felt pretty good, my euphoria fueled by a combination of lingering endorphins and the relief that the session was over. Thor said it was time to burn the crutches and the brace - metaphorically, I assumed. Then he gave me a neoprene sleeve to wear to help keep the swelling down and told me not to panic if by tomorrow my knee turns a little purple. “It’s just temporary”, he assured me.

On the way home I thought about how reserved and cautious my usual PT clinic had been and although I really like the people there I tried to honestly assess their value in my recovery going forward. I wondered how much of today’s “make-up” work should have been done in their facility, the easier way – a little at a time. Later I stopped at my local clinic, paid off my existing co-pay tab (3 sessions at $25 each) and cancelled my future appointments. I have an evaluation session with another local clinic this Thursday. It’s time for a change of PT scenery.

Day 30

The corner, the one that they told me I would turn at some point during my recovery, the one that would be the start of easier rehab and accelerated improvement, the one that I had been looking forward to for weeks, yes that corner, it turns out, is a myth.

Like any good myth, it sounds plausible enough, maybe even likely. But the truth is, there is no corner to turn. It just doesn’t exist. Recovery, if it must be described in comparative terms, is like hiking up a long, tedious trail. Progress sometimes comes easily and other times it is very difficult. Overall, ground is gained only gradually. Those who have been through ACL injury, surgery, and recovery often refer to the experience as a journey. It's now more clear than ever that the vast majority of time and dedicated effort required over the course of that journey is spent in recovery.

Typically when people ask me how I am doing, I invariably say, “I'm better”. And then, as if accuracy was an important element in responses to polite, largely rhetorical questions, I sometimes clarify that I don’t mean ‘all better’, just better than I was last week. And that last week I was better than I was the week before. And so on. For the most part, as long as I can keep giving that answer, I don’t really need the mythical corner after all.

The reality is that I have made some significant improvements over the past few weeks, the most dramatic of which is a welcome reduction in pain levels. In fact, overall the pain has steadily decreased every week since surgery, with the exception of a few days in week 3 wherein I began to get the disturbingly consistent sensation that that someone was pouring acid down my shin as the nerves began to regrow. But now, just beyond week 4, other than a random twinge or ache, my knee really only hurts when I am engaging it – trying to extend the leg or plant my heel when I walk, trying to extend or flex beyond my still limited range of motion, or doing something stupid that results in banging, bumping, or otherwise annoying the area.

The swelling hasn’t gone down at all in the last few weeks, partly, I suppose, because as my symptoms improve I am increasing my activity level. It’s not dramatic, but compared to the other knee, the swelling it is very obvious. "Oh, it's supposed to look like that one.", I frequently get from people when they see how thin my healthy knee is. Based on my previous thoughts on the two types of inflammation it’s pretty clear that I’m down to the more stable type of tissue swelling that will not be going away any time soon.

Range of motion has not increased by any significant measure and I have to admit that it is beginning to concern me. I am now a full two weeks behind any published recovery schedule I have found. On a really good day I can push through the pain and eventually force the knee down near or even at a full zero degree extension – still a far cry from my natural range which has nearly ten degrees of hyper-extension. Then again, it’s been pointed out to me that there is no functional advantage to achieving hyper-extension, so maybe zero will be enough. In flexion I can now get to 100 degrees, but I'm hopeful that with another day or two of consistent icing, pulling, and stretching, and a few R rated outbursts of profanity I will be able to achieve the additional ten degrees I need to spin bike cranks again. Getting there will be my goal for this weekend.

In general things are definitely getting “better”. Last week I spent a day at work, in the brace and on crutches for the most part, but by the end of the day there was little question that it was just too much too soon. The next day I was back down to about 30 degrees of total motion and I could barely stand. But this week I spent two consecutive days at work offsites, again in the brace and with the crutches, and I did much better. If nothing else, it feels good to be able to leave the house and be out like an ordinary, healthy person again.

Also contributing to my renewed sense of normalcy, I packed up the airbed a couple of weeks ago and I’m back to a more normal existence - sleeping in my own bed (although with a large flat pillow between my legs to keep my knees from banging into each other), showering standing up, working at a desk, and eating at the dinner table again. Small things individually, but in aggregate, they make up a large part of why I now feel like a healthy person recovering from an injury rather than a helpless immobile invalid. Although having the perception of health does not in itself make you healthy, I do believe that getting trapped in the perspective of pain and disability can definitely delay recovery.

As I go back and look through my earlier posts, I run across the bits of well-intentioned, Hallmark-ready recovery advice I had about staying strong and maintaining a positive outlook and continuing to focus on improvement. I’ve now come to realize that this advice is much easier to give than to follow. I’ve also realized recently that although I had previously seen plenty of people recovering from injury either on crutches, or in knee braces, or casts, or slings, or the like, I had always considered only the practical effects of the physical limitations they were faced with. No riding for twelve weeks, or no stairs for six months, no mosh pits for a year, or some similar consequence. Never, not once did it cross my mind that these people were almost certainly in the middle of a lengthy excursion into physical discomfort that at times was likely quite physically and emotionally demanding. The bottom line is that until you actually go through it there is no way to fully understand what it takes to remain diligently positive and strong throughout an extended period of even moderate pain and disability. Those who can do it, and I am not one of them, have an inner strength that the rest of us will never truly know.

Certainly, my knee injury is not catastrophic. But as I have said before, neither is it at all insignificant. It lies somewhere in the middle. And thankfully, I have a bit of a short memory for personal details. So when I look back on this a year from now, I will have only a vague recollection of how uncomfortable and difficult it really was. I will have gladly forgotten the true extent of the trauma. I may even have forgotten about the myth of the corner that was promised to me. What I will know by then is only that despite a few very long days, various confidence draining setbacks, and countless hours spent pleading with my knee to heal itself, eventually, I still made it through.