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.

Day 17

I’m told that somewhere along my journey back to health there will be a corner. And that this metaphorical corner, once turned, will mark the start of better days. Rehab will become easier. Pain will be minimized. Recovery will be accelerated. It is a belief in the existence of this corner that helps to motivate me, especially on those days when my own improvements are not readily evident.

As for my physical status, my resting pain is basically under control at this point but I am behind schedule on recovery. My range of motion was supposed to be 0-90 by the end of week 2. Now, well into week 3, I can barely reach zero in extension and I’m still max'd out at about 80 degrees of flexion. The unassisted walking (in reality, gross limping) that I had done late in the 1st week proved to be too much too early and actually ended up causing more pain and swelling. It turns out, the general rule in recovery is that walking is exclusively about form, not function. The goal is to walk with focused and exacting mechanics, even if accuracy requires crutches or other assistance. Hobbling awkwardly across the room without crutches may be emotionally rewarding but it's not physically beneficial.

It seems that there are two key interrelated elements involved in ACL surgery recovery – swelling and movement. The way they work together is that deliberate, controlled movement helps reduce swelling, and reduced swelling allows for more range of movement. Of course the converse is true as well. Swelling prevents range of movement and lack of movement prolongs swelling.

With regard to swelling, here’s another entirely unconfirmed medical theory based solely on my observation: it seems that there may be two types of swelling. The first is an immediate, fluid inflammation that is quite visible and increases when the knee is abused and held below the heart. This swelling can be greatly reduced by ice, elevation, and light, directional massage. The other category of swelling is a more solid, unyielding swelling of the bones and tissues. This swelling has a greater effect on stiffness and on limiting range of motion. It is this type of inflammation that seems to be somewhat improved by anti-inflammatory drugs and movement. And time. Lots of time.

This is our family room.

And, for now, my bedroom.

And my dining room.

And my rehab area.

And my office.

This is essentially where I have spent at least 20 hours of every day since I returned home after surgery. If I’m not in this very spot, I’m either at physical therapy, in the kitchen, or in the bathroom. These four locales have quite nearly made up the total of my existence over the past few weeks. I have been considering taking down the air-bed and getting back to real life – sleeping in the bedroom, eating at the dining table, working at a desk. But I don’t want to be wrong and then have to ask to have it all set up again. I guess the fact that I am even considering giving up my comfort zone is a promising sign.

I’ve been in physical therapy three days a week since surgery. For the most part it has been a steady struggle, but today I had a small breakthrough. With my leg very nearly reaching full extension, I stood up without crutches and slowly transferred my weight from my left side to equally balance myself over both feet. I could feel my right knee gradually settle into the type of centered, stable support that allows us to stand upright with relatively little effort. I slowly straightened my posture and looked directly ahead of me. I felt eight feet tall. I drifted into a vision of myself comfortably standing on the sidelines watching my daughter at her next soccer game. Standing solid like that on both feet was a minor, although much needed achievement. Shortly thereafter a man came into the PT clinic, his head held well forward on his rigid neck. He held a plastic cup into which he spit the accumulated saliva that he was apparently unable to swallow. His voice strained as he explained to the staff that he had been sitting up at home for nearly ten minutes at a time. By their responses it was clear that they were as pleased with his progress as they were impressed by his determination. And I was once again left with an adjusted perspective and a renewed appreciation for my own condition.

After physical therapy I returned home, cinched down the straps on my hinged leg brace, and with the prior approval of my physical therapist, I set off on a partial weight bearing walk around the block with my crutches and my two kids. There are ten houses on the inside of my block. The round trip took about 25 minutes. It was an exhausting trek but it was not unreasonably painful and I actually felt strong right up to the end. If I have a few more days like this one, I suspect I may be turning that corner I've been told about very soon.

Recovery Tips

Following are a few thoughts in case you or someone you know is about to have ACL surgery. I'm not a doctor and I don't play one on TV so clearly none of the following is intended to supersede any advice or direction provided by a medical professional. These are just a few things that I learned as I went through the initial post-op phase so I thought I'd include them here.

Get help
This is critical. Find someone who is willing to be at your beck and call 24/7 for at least the first few days. Talk to this person (or people) ahead of time and explain to them what will be required. Be explicit in your expectations so there are no misunderstandings. If you’re married, now would be a good time to tactfully remind your spouse of the “in sickness and in health” line that you both agreed to during the ceremony. Also, get creative and find a few tricks to help yourself. I wore a robe with big pockets so I could transport things while on crutches. I also hooked the foot of my good leg under the injured leg as necessary to help lift myself onto the couch or into bed.

Get comfortable
To suggest that the first week or so after surgery will be uncomfortable would be understating the situation by more than a little. Make an effort to help balance out the discomfort by increasing comfort in other areas. Get a stack of comfortable clothes. Get some nice socks or some fleece underwear. Whatever does it for you. I cut one leg off at the knee from a pair of sweats so I could stay warm while icing. Cook a meal or two ahead of time. Get some comfort foods at the ready. Keep them to a minimum, but an occasional fudge brownie or three might just be what you need to keep your heart in it.

Get situated
The first week is going to be a long one so get prepared. Create a space for your post-op experience well ahead of time. The space should have some method for leg elevation, and be somewhere that you can safely and easily sleep. Make sure all critical items are located within reach – food, water, crutches and meds in particular. I also had my laptop, tv remote, phone, magazines, ice pump, and a guitar all no more than 30 inches away once I got home.

Manage pain
This is the primary objective of the first few days. It seems like an obvious goal but for me, if the pain is severe enough for long enough I can actually begin to loose focus on trying to manage it. Certainly pain is subjective and post-op there is definitely going to be some of it but if things drift too far beyond your tolerance it will get miserable very quickly.

Transition slowly
The worst pain that I experienced came with the transition and aftermath of moving from a leg elevated position to standing up. The blood that rushed to my lower leg brought with it the most agonizing pain and teeth clenching pressure of the first week. I quickly learned that the key to limiting this pain was to transition in stages. Move the leg from elevated to flat, wait. Move the foot to the floor, wait some more. Slowly stand with crutches, then go on the move.

Do drugs
Understand how the different meds work, especially those that affect pain. I was given a narcotic (Percocet) and an NSAID (Toradol). The narcotics (at least for me) are primarily what I would consider “disassociative” drugs. They only reduce my association with the pain. It's still there but I don’t feel as connected to it. The NSAIDs are Non-Steroidal Anti-Inflammatory Drugs. These actually reduce pain by reducing the inflammation that is, in part, the cause of the pain. I was also taking an antacid and plenty of fiber to avoid any digestive issues caused by the surgery trauma and the various IV and post-op drugs. Last, if you end up on a course of anti-biotics like I did, consider following it with a probiotic of some sort to get your gut back in order.

Make a schedule
For your meds, make a written schedule of some sort that allows you to check off or otherwise record when you have taken something. You cannot afford to wonder if you just took a Percocet ten minutes ago. Missing a dose might make for an unnecessarily rough day and doubling up could be worse.

Feed the body
Eat eat eat. But try to eat as healthy as possible. Your body will be trying to recover from a major assault. This is not the time to fill it with pepsi and cheetos. Make sure you keep your digestive system as happy as possible by regularly tossing good food down the hatch. You can burn off the extra calories in a few months but if you go hungry and your stomach turns on you in the first few days, it will make things far more difficult and uncomfortable than they’re already going to be.

Be the potty
Females can skip this trick because honestly I don’t know how to help you here, but for guys, consider keeping a large empty plastic bottle handy. You really do need to stay well hydrated, but at least for me in the first two or three days, getting up just to get to the bathroom was by far the most painful part of the whole ordeal. Consider at least giving yourself the option of shortening those trips down to just a simple roll onto your side. Maybe getting up to go won’t be an issue for you, but a simple plastic bottle is cheap insurance in case it is.

Keep clean
As a guy I am genetically able to go for many days without bathing but doing so can eventually drive away anyone who had previously committed to provide post-op help. ACL surgery makes bathing difficult in part because of the pain and immobility and in part because the sutures cannot get wet for at least the first few days. Here are a couple of ideas –
1.) Face it. Skip the shower and just wash your face. Or even easier, go with a swipe of witch-hazel. You’ll feel cleaner even if the rest of you has begun to smell like the inside of a city dumpster.
2.) Sit down. Get a chair that can go in the shower. I used a milk crate but it was not very comfortable and eventually I got tired of the waffle marks on my butt.
3.) Hose off. Get a removable shower head with a hose. If you have to sit down to shower, this is a must have feature.
4.) Wrap up. I used saran wrap to keep my sutures dry. This method is not waterproof by any stretch but it's plenty splash proof enough. You can also get a shower bag from most medical supply stores.

Take off
Obviously you’ll be off work for some period of time but I’ve talked to some people who tried to go back to work the week after surgery. While this might be physically possible, depending on the severity of the procedure and the physical demands of your job, 2 weeks to a month may be more reasonable. For my surgery (ACL BPB allograft and meniscus repair) I had difficulty even working from home during the second week because I couldn’t sit in a chair for any length of time without my knee blowing up like a balloon.

Keep smiling
Even if you have to fake it, and you probably will, smile as much as possible. It's a simple and powerfully self-fulfilling gesture. Make a list of all the things you can do while you’re temporarily stuck with a bum leg. Find a project, learn a language, read a novel. Most importantly, be positive, be strong. And remember that the worst of the recovery is short and it will all soon enough be behind you.

Day 7

Today was quite uneventful. This was a much needed development – or lack thereof. It has been a very long week. The idea that surgery was just seven days ago is incomprehendible. It feels like nothing short of a month at least.

I am actually getting good at being injured again. Surprisingly it takes some practice, some time to adapt. But I am also ready to be over the steep initial section of this recovery and back into the more incremental stuff – like doing fifteen mini-squats instead of just twelve. For now, I suppose the keys to success are patience and diligence. I cannot rush my progress and I cannot get overly anxious for improvement. And I have to keep doing all of the things that help. Now residing amongst the normal daily requirements of work and family are the elevating, the icing, the medications, the stretches, the exercises, and the regular pushing well into the pain in order to improve and maintain range of motion. Already there have been days, I assure you, when I have felt like just skipping it all. People typically talk about physical therapy in terms of the number of days of scheduled PT per week. But recovery requires a daily engagement. When I first met with Dr. Stone I told him I understood that PT would be a substantial commitment of 3 days per week for 3 months. He laughed through a single breath and said, “Oh no. I want you doing physical therapy every day for the rest of your life.”

Of course I was talking about actually going to the PT clinic and although I have pretty good insurance there is no way in hell they are going to help cover that schedule. But he was talking about life. And in alignment with at least one other doctor I talked to, he was essentially saying that once the ACL is torn, the luxury of being able to neglect the health of the knee is lost forever.

I took a shower today. The second one since surgery. For the first shower I just sat outside the tub and leaned into it, resulting in an only half satisfying rinse of my upper body. This time I got a plastic milk crate from the garage and set it upside down in the tub on a non-slip pad. Safety first. Then I went a couple of times around my leg with plastic wrap from the kitchen to keep the sutured areas of my knee dry. It looked a bit like a leftover ham. Our shower head is removable and attached to a long hose – a nice feature in general when you want to direct some focused shower action to specific areas and critical for any sit down affair such as this when one leg is propped up on the side of the tub. My seated posture on the crate made me feel like a geriatric patient and had the unfortunate side effect of accentuating the developing roll around my midsection. Getting rid of that will surely be my next project after this ACL business is sorted out. When I was finished I carefully removed the protective plastic wrap. A strange feeling came over me as I studied my badly beaten bare knee which has been typically covered by a compression sock. Disturbingly swollen and stitched up, it didn’t look familiar at all. The size, the shape, the color, it was entirely all wrong. It was as though it belonged to someone else. At that point I even began to get a bit uncomfortable as I became more aware of my own nakedness in the company of this stranger’s knee. It was quite an odd experience. And no, it wasn't the result of a mild Percocet overdose.

In fact, since I mentioned it, I haven’t taken more than one Percocet in any of the last three days. Today I didn’t even take any. Personally, I don’t feel like it does me much good. It certainly has little or no therapeutic effect unlike the Toradol, which actually contains an anti-inflammatory. Percocet (and all of the morphine derivative drugs for that matter) seem to be good not for reducing pain, but only for reducing my desire to care about pain.

In general though, my knee is getting better. It's taking its sweet time about it but it is getting better. Every day I can stand up a little longer. Every day I can take a few more unaided steps. And although there were hours today when I was certain that the pain would spike into new agonizing territory, eventually it eased up and overall I’d say it was still a bit better than yesterday.

From here I will probably post weekly or monthly as I think of additional things to include. I’ve been considering a consolidated list of recovery tips for others headed for ACL surgery, so I’ll start working on that.

In the meantime, I know I only have a few dedicated current readers (hi mom), but this blog has already helped me to this point by giving me an outlet for my thoughts. As such I give my sincere thanks to those of you who encouraged me to start it in the first place. You know who you are.

And so it ends. My first week in the ACL reconstruction club. I’d like to ride off into the sunset now, but I’m still about 30 degrees short of being able to pedal so I’ll just keep my leg propped up here on the couch. I’ll post with more details as they occur…

Day 6

Baby steps. That’s what I’m back to in a very literal sense. Yesterday I took my first unaided post-op steps. About forty in total, in three separate events. At one point I just got up off the air-bed and forgot my crutches. I took a step toward the kitchen and realized “Hey, I’m walkin’ here” (sans New York accent). It was definitely painful but rather than any sharp pains there was just an overall pressure that actually seemed to counterbalance the strain caused by standing upright in the first place. So I took a few more steps, very slow, very calculated, and very ready to bail over if I felt anything bad. A dozen or so steps later and I was back to the family room. No crutches needed.

It occurred to me later that if you spent a week elevating, icing, and avoiding putting any pressure on even a completely healthy leg, those first few steps would be damn uncomfortable. With that in mind, I wonder which aspects of my current discomfort are due to a complete lack of use and which are from the injury and surgery. Regardless, the knee actually feels better when I put weight on it now. For sake of accurate record, ok, the term "walking" may be just a bit on the exaggerative side. Let’s call it “maintaining balance while awkwardly moving forward”. In any case, at this point it's as close to walking as I’ve been since last Tuesday morning and it does feel unreasonably satisfying.

Unfortunately, with the primal joy of my recent walking accomplishment still fresh in my consciousness, I was reminded of my most fundamental limitation. As if some bitter, buzz killing part of the universe felt the need to provide some balance to my newly developed sense of optimism and achievement, my 7-year old ran toward me in the family room hysterically screaming that her 3-year old sister had just hit her head “real bad”. With my wife just out of reach in the front yard I started heading toward the bedrooms and the sound of the crying when I realized that had left the starting line with no brace and without my crutches. Do I take the six steps back to the crutches or just push for sixteen more in the direction of the 3-year old? I slammed my teeth together as I chose the latter without ever really considering going back. “HURRY!”, my 7-year old pleaded, urging me down the hallway as she realized how long it was taking me to travel the last 25 feet. I was already going as fast as I could and it was clearly not fast enough for either of us. A wave of helplessness had turned to anger for my condition by the time I made the last few steps into the bedroom. She had fallen while standing on the bed and had hit a bookshelf on the way down. Her body was still lying where it landed. She is unusually prone to this type of random accident but thankfully she is also somehow nearly immune from real injury. Within a few minutes the tears finally ran dry and she was fine.

Helpless, inadequate, incapable... Just a few of the things as a parent that I absolutely cannot tolerate feeling. Another good time to remind myself that the current situation is temporary and improving every day.


Today I had my first local physical therapy appointment. It was nice to be back but the session was terrible. After all of the walking yesterday I woke up with some renewed levels of pain and pressure in the knee and down the shin – which has now begun to display dull shades of purple and yellow. I took a single dose of Toradol with breakfast but then I got caught up in work related issues as the day wore on (working from my air-bed) and I forgot to take the afternoon dose. I didn’t ice during the day and I never had a chance to get my leg elevated. All noteworthy mistakes. Everything I did at the PT session was more painful and thoroughly distressing than it should have been. Range of motion was back down to 10-60 degrees. Just a day and a half prior I was achieving 0-85. I’m not sure what the unit of measure is (µA I suppose), but for the electrical current testing my left quad sets showed a 126 average, the average on my right side was just less than 5. By the time I got home I had concluded that the session was my worst to date, and that quite possibly I should have gotten a ride to the appointment rather than driven myself.

Next PT session is Wednesday. Two days to ice and elevate and prepare.

Next time will be better.

Day 5

Everything happens for a reason. Things have a way of working out. What you truly need will somehow be provided for you. None of these generalized well-wishing statements hold much value in my beliefs about the way life works. I do believe strongly in the mind-body connection and I believe that the events of our lives can to some extent be affected by a positive and welcoming approach. But I also know that bad things quite often happen to good people and vice-versa and typically no amount of focused spiritual karmic voodoo makes any difference.

That said, as if she were somehow listening in on my self-generated psychosis last night regarding the strength of the graft attachments, Dr. Stone’s assistant surgeon called at about 1pm today “just to check up on me”. Yep, on Sunday afternoon. She is a wonderfully positive and engaging person and based on the things she has said is also a strong believer in the interaction between mind and body. I explained to her what had happened but to my relief she did not at all share my concerns. She assured me that the graft and its attachments are strong and that at this point it would basically require a force similar to that which caused the original injury in order to create new damage. The same was true of the repaired meniscus. Apparently re-injury fear, even heaping irrational levels of the stuff, is very common in recovery. “Stay positive” was the closing bit of advice she left me.

At 4pm, perhaps, I wondered, at the request of the assistant surgeon, Dr. Stone himself called. He too assured me that the ACL was fine. “It’s locked in there”, he said. Well alrighty then.

I’m really not one to question good news, but I have to say that for the most part this “ACL is safe” theory does not make sense to me. To make matters worse, I naively believe that there are few physical concepts that I cannot comprehend if they are just explained to me. Surely, everything is relative and with enough force, anything can and will fail eventually. But given that I applied very little force to my knee and given that my two doctors believe the reconstructed ACL is reasonably difficult to harm, eventually I have to abandon my own terribly underinformed, logic-based thought processes and just go with what I am told.

It is at this point that I also have to begin to admit that I am carrying around a rather generous load of ignorance. Despite my research efforts on the ACL over the past two months and my typical lack of difficulty understanding the basics of bio-mechanics, I still cannot quite get my arms around the function of the ACL. I can almost get a general feel for its hyperextension support by studying the ACL in diagrams, but I don’t at all see how it provides rotational stability. I also have nearly no awareness of how to protect or even favor the meniscus or any of the other major components. In fact there is only one thing about the knee that I have determined for certain. As simple as it looks from the outside, the internal elements make up one exceptionally complicated system.

A quick update on pain levels. My digestive system has finally registered an official complaint over the working conditions of the past week. I’m not nauseous but everything I’ve eaten since this morning has been in a rather big hurry to leave the building. It could be the antibiotics (which are now finished) or the pain meds, or just something I ate. Regardless, the result is that I decided to skip my 2pm feeding of Toradol and now, nearly four hours later, pains that have been gone for days have begun to reappear with renewed intensity. The most severe ache is coming from the upper two-thirds of my shin, likely inflammation of the periosteum (the thin outer layer of the bone). Nothing catastrophic, thankfully, but overall it is considerably worse than yesterday. If nothing else, it's a good measure of where I really am in terms of unfiltered pain. Apparently there is still plenty to go around.

Day 4

Pain levels toward the end of last night and this morning continued to improve. The swelling does not seem to have decreased but another change of the dressing shows that the stitched wounds – and now that I take closer note I see that there are at least eight of them – are mostly dry under the protective pieces of first-aid tape. With the reduced pain levels I began today to work on range of motion.

When I woke up this morning I had an approximate range of motion of about 10-25 degrees, or about 15 degrees total. I iced around 10am and again at 1pm and at 2pm I took my scheduled dose of Toradol and added a Percocet, the latter of which I have been skipping on at least half of the available 6 hour doses. At that point I started sliding my foot back and forth on a ramped piece of melamine. I can push my foot up toward the top of the board and toward full extension and then I use a piece of rope looped around the bottom of my heel to gently coax my foot back down the ramp towards flexion. I did this for a couple of hours and eventually worked my way to nearly full extension and about 60 degrees in flexion. I was quite pleased with the progress.

Afterwards, to minimize any resultant swelling, I iced again, this time for nearly an hour. During that time the heel of my foot was resting toward the top of the ramp, my butt on the bed, and my knee, unbraced for the ice wraps, was just barely off the ramp and therefore essentially unsupported in the middle. As I removed the ice wrap I saw that my knee had settled to about zero degrees. Or was it farther? I suddenly worried if the swelling in my knee was causing it to appear more bent than it really was. My stomach turned and I could sense my lunch beginning to reappear in the back of my throat. I tried desperately to determine if I had fallen into hyperextension. Although I have been told that my knee is “solid” and that I should not worry about re-injury, my own mechanical perspective suggests to me that I do not want to be pulling on the ACL at all at this point. The soft tissue of the graft is strong, I understand, but the bone plugs at the ends of the graft have surely not had time to heal into my bones and so are still relying entirely on the interference screws for their attachment. I sat flat on the floor and fully extended both of my legs. The right leg is tight in extension but it gets there far too easily for my taste. I am now nauseous and disgustingly unnerved.

According to the Stone Clinic guidelines my range of motion goal within the first phase of recovery (1-2 weeks) is as such:

"Passive range of motion should be 0 degrees or hyperextension to 90 degrees flexion, minimal pain and edema, unassisted good quality gait before moving onto Phase II."

Certainly my right leg was not far into hyperextension, if at all, and obviously there was very little downward force on the joint but the fact that I even potentially endangered the new graft (or even just the intended tension of the graft) is absolutely sickening me. It is mentally devastating. What is apparent at this point is that since Christmas this ordeal has generated plenty enough pain and emotional disturbance for me to develop an exceptional level of obsessive paranoia around anything that threatens a successful recovery. I may have a difficult time getting to sleep tonight.

Day 3

I am now on a blow-up bed in the middle of the family room, resting ironically at the precise location of the original injury. My leg is constantly elevated as it has been every day since surgery and I'm icing for twenty minutes every other hour or so. Last night I slept without the brace for the first time and thankfully I kept reasonably still. I have been sleeping with a brace for most nights since Christmas because if I happen to have a dream that causes me to flinch or stir, I am quickly and violently reminded that my knee is not available for such random movement.

Here are some of the movements that I am engaged in at this point (in case any of my PT friends are reading along)…

Foot Pumps – This is a repeated forward and backward motion of the foot moving at the ankle. It doesn’t sound like much, but it stretches and pulls on areas of the knee that I never knew existed.
Circles – Big ones and then little ones, to the right, to the left. Another ankle exercise to help the lower leg remain engaged.
Alphabet – The final foot related feat, drawing the alphabet in the air with the big toe using the available movement of the foot and ankle.
Quad Sets – Isometric contraction of the quads. I’m not quite there yet so I’m doing “flicks”, which is a repeated instantaneous firing of the quads.
Glute Sets – Isometric contraction of the glutes. This also tends to work some of the upper hamstring.
Range of Motion – Extension and flexion. Honestly, I haven’t done any of this work yet because it's been too painful and as a result I am down from about 30 degrees on the day after surgery to now less than 5 degrees of available motion. Will need to get started on this soon.

The pain is actually a lot better today, right on schedule. As long as my leg is up, the discomfort is completely tolerable. And, when moving from “leg elevated” to “leg down” to crutch my way around the house, the redirected flow and pressure in the knee, although still very apparent, is far from the excruciating levels of the past few days. This is a particularly welcomed development, I assure you.

For some reason it just occurred to me last night that this injury (likely to be known from this point forward as "The Christmas Day Incident") was the most severe injury I had ever experienced of any kind. Ever. I've had plenty of bike crashes, car accidents, and I even once opened up three of the fingers on my right hand in a mishap with a viciously sharp wood chisel. The misguided chisel assult resulted in an impressive distribution of blood across the garage and a few bits of unfinished pine lost forever in the fleshy parts of the fingers. But after a couple packages of gauze and a few feet of first-aid tape, the injury was under control and everything healed within a month or so. The knee though, this was different. This was a new degree of injury. And then I realized that this new “worst ever” injury honor had been quickly reassigned to the surgery itself, which although immensely more controlled, was far more damaging than the event that caused it to be necessary in the first place. I've noticed that in the language of physical therapy, the cleverly designed reference to this operative induced injury is “physical insult”.


One aspect of this journey that I somehow did not anticipate is the underlying disappointment of the surgical re-injury. For every one of the forty-two days between Christmas and surgery I worked hard at improving mobility and function and healing and although I was never 100% I was quite able to get around on my own with limited discomfort by the time I stepped into the OR. Now I am debilitatingly injured once again. And to some degree, even more so than before. I never used the crutches pre-surgery, and now I am absolutely dependant on them. I never needed pain medication pre-surgery, but for the past few days it has been critical. Alone in the house I just now spent twenty minutes getting myself into the kitchen to make something for lunch. As my stomach has begun to tire of the medication schedule, I have needed to be even more diligent about keeping myself regularly fed. Turns out, although I was able to empty the contents of the can and heat it up, there is just no good way to get a bowl of soup from the microwave to the table while relying entirely on crutches for your own movement. Even if I could somehow manage to get the soup to the table, I would still not be able to sit in a chair for long enough to eat it.

Obviously the reconstruction surgery was not unplanned nor the consequences entirely unforeseen, and I am still quite optimistic about my recovery. But I must admit it is still far more frustrating than I had expected to be so “physically insulted” and so very dependant once again.

When Dr. Stone asked, “Are you ready?”, clearly this is the challenge to which he was actually referring.

Day 2

Today has been better, although still a significant challenge. The fifteen foot 8am trek to the bathroom, essentially at the expired end of my 2am pain meds, was by far the most distressing and difficult ten minutes of the day. I went back to the Stone Clinic one last time (for this week) and had my dressings checked and changed. They were mostly clean and with the help of a Toradol injection in the backside I cringed my way through another PT session.

Interestingly, the advice from the clinical side of the house in terms of meds is to try to get by with as little as possible. “As needed” is the default prescription frequency and they are clear in their opinion that less is better, both for your liver and your mind. It is an approach that, in general, I fully support. On the PT side of the clinic, however, there is a different viewpoint. When I first met with the therapist today I said, “Great to see you, don’t touch me.” With this greeting he concluded that likely I had “fallen behind on my meds”. In PT, they seem to prefer a well medicated patient with which to work. If you flinch and jump and yelp every time they try to get your limbs working again, then obviously they cannot do their job. This scenario is bad for the patient as well as this delay in initiating movement is potentially damaging to the tissue and can have long term consequences. I have no problem working through pain, but there is a clear subjective difference in my mind between good pain and bad pain. Good pain is stretching and straining and forcing out the bad stuff. Bad pain is injurious and damaging. At this point, pretty much everything feels like damage, even though I am told that my knee is solid and, short of a hyper-extension or other forceful trauma, I cannot easily re-injure the knee. Well, certainly if I was able to bend it, eventually I would begin to blow out the stitches from the five holes they left behind, but otherwise, I am apparently safe from further damage. At least for now, I am not willing to find out.

Finally, I am home again. Back with my little girls and familiar surroundings. Without the ability to stay in the city during the last four days, this simply would not have been possible. Staying at my brother-in-laws with his wife, my wife, and the ferrets made this entire event as convenient and comfortable as it could have possibly been, despite the fact that the eighteen foot walls in my “recovery room” were painted semi-gloss blood red and featured the stuffed and mounted heads of a multi-point buck and a zebra. It was a long few days. But I’ve made it through what I am told is the worst of it and now it is nice to be home.

I will of course do my exercises and get focused on recovery just as soon as my every waking thought is not of finding some way to better manage the pain. I have high hopes for improvement in this area over the next few days. For now, I am so tired I can barely type. It is nearly 7:30pm. 30 minutes to the next med consumption. I’ll probably need to set my alarm or I will surely sleep through it.

Thank you to everyone who has called and emailed and otherwise sent wishes for a strong and speedy recovery.

Your thoughts have been greatly appreciated.

Day 1

Success and optimism turned to disaster early this morning. I got up at 1:30 am to go to the bathroom and the pain pump fell to the floor, shearing off the tiny plastic connector to the tubing that was attached to my knee. I frantically tried to reconnect it but it was clearly broken beyond simple repair. I huffed and swore and growled my seething disappointment. I was filled with panic. I called the doctor out of desperation and spoke with the on-call assistant surgeon. She talked me through the fear and reminded me that plenty of people have survived this surgery without the aid of the pain pump. True enough and after a bit I managed to put the event just far enough behind me to be able to get back to sleep.

It seems, however, that my mind was still busy processing the incident while I slept because at 3 am I awoke to the realization that I had now likely contaminated a previously sterile line of fluid that ran directly into my knee. I tied a knot in the plastic line where it entered the dressing and spent the rest of the night worrying about what may have happened and what we would likely have to do about it.

Back at the doctor’s office this morning, everyone was in clear agreement – the pain pump line would have to come out immediately, and I would go on a preventative course of antibiotics to combat any potential infection. The $475 investment that was certain to make the next few days tolerable was now nothing more than a paper weight aimlessly oozing priceless pain killer.

The nurse changed my dressings and after revealing the surface of the knee she calmly suggested that I lay back and take some deep breaths. Apparently my face had turned a nice shade of white at the sight of my badly violated knee and soon there were additional people in the exam room giving me water and placing cold, wet towels on my forehead. My wife was instructed to hold my left leg up above my heart to help redirect some blood back up to my face. I was beginning to fall apart just a bit.

With the new dressings applied I crutched my way down the hall for some follow up x-rays and then underwent some mild PT, including massage, passive motion, and riding a stationary bike using only my good leg. By the time I returned home I had definitely begun to miss the effects of the pain pump and as of now, 8:30 pm, the pain is beginning to show its full potential. It is now a significant struggle to get off the bed to get to the bathroom. The pain causes me to shake and chatter my teeth and moderately hyperventilate. I have gotten very serious about creating and maintaining a strict schedule of medication but it is clearly not going to be enough to control the pain to the degree that I would prefer. For the record, here is my med list:
· Aspirin (81mg) – 1 / day, blood clot prevention
· Percocet (7.5mg) – every 6 hours, pain reducer
· Toradol (30mg) – every 6 hours, anti-inflammatory and pain reducer
· Cephalexin (Keflex, 500mg) – every 6 hours for 3 days, antibiotic
· Pepcid Complete (1 tablet) – every 12 hours, antacid
· Triflex (500 mg Glucosamine) – 3 / day, joint lubricant
· Ambien – 1 / day, sleep aid

I am running the ice machine for 20 minutes every 2 hours as directed and doing quad sets and ankle movements including writing the alphabet in the air with my big toe. I have aligned all meds onto 8-2-8-2 schedules and have set an alarm to cover the 2 am requirement.

If the pain continues to get worse tomorrow I will certainly have trouble getting out of the house for my PT appointment. I had heard plenty of stories about the depth of discomfort during the first few days of post-op recovery and now that I am stuck in the middle of it, I can confirm that the accounts are every bit as true as stated. It is quite difficult. More tomorrow…

Day Zero

Surgery.

I slept well last night thanks to the Ambien and I woke at 5:57, three minutes prior to the three different alarms I had set for 6 am. I showered and shaved my knee one last time. My wife, who has become the core of my support system, drove me to the surgery center and stayed with me until I went into the OR. In pre-op we met with the nurse, the assistant surgeon, Dr. Stone, and finally, the anesthesiologist. All of them were overwhelmingly compassionate and positive, just as everyone associated with Dr. Stone has been. After meeting with everyone I decided to have them install a “pain pump”, a device that feeds a constant dose of marcain and zylocaine directly into the knee for four days after surgery. It seems like an ideal supplement, even possibly an alternative to the oral narcotic options that are otherwise sure to make a temporary mess of my mind and my stomach.

I successfully fought off my nerves during the nearly two hours between arrival and surgery by reading through the random assortment of available magazines. In particular, I read the Sports Illustrated article on Kevin Everett, the former Buffalo Bills football player who was paralyzed early in the 2007 season on defense during a kickoff return. He was immediately treated with a new and controversial deep freeze approach to reduce the effects of his spinal cord injury. Today he is learning to walk again. It is an amazing story of physical triumph and yet another strong bit of perspective adjustment for my own situation.

When I had been sufficiently scrubbed, prep’d, and hooked up to the IV, the nurse wrote “YES” on my right leg and led me into the operating room. Before I even got through the door I could tell that the OR was significantly colder than in the rest of the surgery center. I got up onto the table and took a deep breath. Most of the crew was already there awaiting my arrival – two nurses, the assistant surgeon, and the anesthesiologist, the last of which wasted no time in hooking up something to my IV that he said would “mellow” me out a bit. The last thing I remember was him saying, “Ok, now you should start to feel that a bit”, while I thought to myself, “That’s strange, I don’t think I feel anything at all”…


In the next instant I was waking up in post-op. My “nap” had felt extremely restful and although I was aware that there was of a lot of vibrant dream activity, I was surprised by the fact that I had immediately forgotten any of the content. My leg was fully wrapped and a thin line of plastic tubing from the pain pump snaked its way around the new brace and under the dressings. Dr. Stone came in to explain that the surgery went well and in addition to the ACL reconstruction, there was in fact a substantial tear in the lateral meniscus that he sutured together with high hopes of successfully repairing. After about twenty minutes the nurses came back to get me dressed and on my way. They sat me up on the table and gingerly swung my feet to the floor to get my shoes on. “I’m not ready”, I said with certainty as the room started spinning around me, so they let me lay down again for another hour or so before we tried again. The second time went better and I was dressed and then carefully wheeled to the elevator and down to the car. I was in pain, for certain, but it was entirely tolerable. The twenty blocks across the city were about as much as I could take and I was happy to crutch my way into the house and onto the hide-a-bed. For the next few hours the ache fluctuated from moderate to severe before it settled back into a very tolerable range. The ice machine ran constantly, keeping my knee cold, and the pain pump did its job wonderfully, keeping the pain mostly down to a dull ache.

And so it is done. I have traded nervousness for discomfort, and especially given the reasonable pain levels, it is a very welcomed exchange. I have spent the afternoon between naps calling people to let them know I am alive and well and I feel very good about the way things have gone. The assistant surgeon and Dr. Stone have both called to check up on me tonight and to re-emphasize how well the surgery went. I know the next few days will be challenging, but it is quite relieving to have the surgical aspect of this journey finally behind me. I have been very lucky to have been surrounded by wonderfully positive and capable people for the past few days now – my wife, who has made me laugh a dozen times today, my brother-in-law and his wife, everyone on the medical staffs, all of the people who have called to wish me well, even the guys in the valet parking garage at the surgery center. And I am more than thankful to everyone for their part in getting me through this. I am truly fortunate to be in such company.

Day [-1]

Just a few quick thoughts from pre-op.

The appointment went well today. Dr. Stone greeted me by saying, “So you’re ready?". “You tell me”, I responded, and then I proceeded to give him a rundown of all of what I thought to be the relevant data. “I’m still a couple of degrees from full extension, about 5-10 short in flexion, and my quad sets are good, not great, but especially with a bit of a bend in my knee I think…” “No”, he calmly interrupted, “I mean are you mentally ready.” Oh that. “Yes”, I said. “I’m ready”.

A surprisingly uninvolved physical exam and some x-rays followed and then I was given multiple lists of instructions. Don’t eat or drink anything after midnight tonight. Fill all of the post-op prescriptions. Get extra ice. Wash the knee with antibacterial soap tomorrow morning. Wear baggy pants. And a dozen other details. The only instruction Dr. Stone gave me directly, and the only one not on a written list, was “Just chill out”. Oh, and he wants me to start by taking a sleeping pill tonight. Apparently, relaxed patients do better.

Thing is, the harder you try to relax, the less relaxed you really are.

An interesting side note, one of the people whose support I could have really used through all of this has been, oh, let’s just say, less supportive than I had hoped. I’ve talked with this person a couple of times and the person has asked some questions that I had already answered in the blog. “Have you read the blog?”, I asked. “I’m pretty busy. I don’t have time to be reading someone’s ACL blog” was the answer. This person went on to say that they know lots of people who have had knee surgery and they just go in and get it done and that’s it. The clear implication being that I am making far too big a deal about all of this.

I do realize that some people are in fact very busy, and that perhaps this blog is not the most intriguing reading available. Surely it’s not destined for the best seller list. But ignoring that self-evident fact, the entirely legitimate question on the table is this: Am I making too big a deal of this whole thing? Should I just go and get it done and finish rehab and then bring it up, if at all, in an “Oh, by the way, I had to have knee surgery earlier this year” kind of way? Over the past week I really have tried to honestly re-evaluate my perspective on this (yet again) to determine the actual severity of the situation. Here are a few objective details that I came up with:
1.) Hyperextension of the knee is extremely painful and can be catastrophically destructive.
2.) Reconstructive surgery is even more painful and destructive, and although it is reasonably successful most of the time, just like any surgery there is a long list of potential complications.
3.) Rehab is challenging at the very least and full function and strength, if obtained at all, are at least twelve months from surgery. I have read that full strength of the allograft is obtained in 12-18 months.
So there is it. Seems pretty serious to me. Even in the best case scenario, I’ll be limping to some degree for the better part of a goddamn year. I never would have imagined how physically demanding it is to limp everywhere you go, but I can assure you, it is exhausting. Maybe the blog is a bit self-indulgent but there are still some people seem to appreciate it. I know that the ACL diary I found (included in the ACL links section) has been very helpful for me. And maybe in some small way this blog will be helpful for someone else some day.

In the meantime, here’s a thought if you do tear your ACL… It’s a big fucking deal and no one will be able to convince you otherwise. Some people may try, but consider that it may just be their backwards way of supporting you by downplaying the significance of the whole mess. Be optimistic and be positive and be strong. But do not do so by trying to underestimate the impact that the injury, the surgery, and the rehabilitation process will have on your life and the lives of those around you. That approach would be painfully counterproductive. There are quite a few ACL diary websites on the 'net, and one that I read weeks ago finished something like this: “And so I was finally approaching normal again and finally I was getting beyond the injury that consumed and defined much of my life for the last twelve months.”

And so shall it be for me someday soon as well.

Final Approach

It is now 37 days since the injury occurred and just 5 more days until surgery. I have to admit that deep down I am still very worried about the long term prognosis for my knee. And although I have the highest possible level of confidence in Dr. Stone, there is still a small part of me that is scared senseless of the surgery itself. Committed optimism is just not that easy to come by right now.

I’ve been through nine physical therapy appointments and I’ll have one final pre-op session tomorrow. My physical therapist has been exceedingly helpful and considerate, not at all the sadistic tyrannical stereotype I had heard about from others. That said, I’ve been told that pre-op PT is just a dry run. Post-op is where the real work is required. We'll see. When I started PT three weeks ago I was still in quite a lot of pain and I was well short of being able to pedal through an entire stroke on a stationary bike. By my third appointment, I had gained a bit of range so I set the seat as high as I could reach and after a few warm-up swings I slowly forced the pedal over the top of the stroke by rotating my hips in the opposite direction. Tears came pouring out of my eyes with the gush of pain and the release of the wide range of emotions I had been diligently covering up since Christmas night. It wasn't until that moment that I realized how much it would mean to me to be able to pedal a bike again, if even just barely.

At this point, the pain in my knee, although constant, is mostly quite tolerable except in the area of the MCL. The mild visible swelling has improved to the point where the right knee now looks nearly like the left knee, except that I have shaved bare the general vicinity of the right knee to enable the placement and painless removal of the electrodes during PT. My range of motion has gradually increased, at least in part a result of the reduction of swelling. I can now extend my leg to within 3 degrees of straight and I can bend it to within about 10 degrees of full flexion. Walking is getting better, although I’m still quite obviously limping and occasionally I get sharp shooting pains through different parts of my knee if I don’t step just right. I’ve been using the hinged brace but it doesn’t seem to really help – other than to protect me from an accidental hyper-extension. As the non-specific pain in my knee begins to subside, the pain from the sprained MCL is becoming more prominent and I am beginning to worry that the damage to the MCL may be much more severe than initially suspected. I am reasonably strong in extension (leg presses from about 45 degrees to straight), but flexion exercises cause a debilitating level of pain on the medial side of my knee. Again, probably the MCL. Advil, even in over the counter doses, provides a noticeable improvement in most of my symptoms but the surgery center has suggested that I avoid ibuprophen and the rest of the NSAID family for the week leading up to surgery to help reduce bleeding. I’ve already lost an inch from around my thigh and yet somehow I’ve gained five pounds. I suppose those two unwelcome trends are likely to continue in the short term.

I will try to post every day next week. I’ll be staying in the city at my brother-in-law’s where they have two ferrets that roam the house in search of weak and injured prey. I’m going to bring a long stick and take my chances. My surgery schedule, in case you’re following along, goes a little something like this:

Monday – Pre-Op, 11:15 am
Tuesday – Surgery, 7:15 am
Wednesday – Post-Op, 10 am
Thursday –PT, 11:30 am

After that I’ll come home and start PT sessions locally with follow-up visits to the Stone Clinic scattered throughout the calendar for the rest of the year.

I have never had any kind of surgery before and there is no way to describe how I feel right now. “Anxious” just doesn’t quite capture it. I’m trying desperately to focus on looking forward to the recovery process so that I don’t fall back and bury myself in the negative aspects of this injury and the many unpleasant 'what if’s' of next week. Dr. Stone’s assistant surgeon emailed me yesterday and gave me perhaps the best advice I’ve had yet. “Just think of it as a day off”, she said, “with a really good nap”. Geez, she makes it sound almost pleasant.

Surgeons

There is an important link between ACL surgical options and orthopedic surgeons, and it is this – while they may be competent with multiple techniques, each doctor has his or her own surgical preferences. These preferences can be determined by many factors including personal experience, initial and ongoing education, medical study results, associations with medical distributors, insurance company requirements and limitations, group practices, and the specifics of the patient and their injury. I believe that all doctors are inherently good people but it is worth noting that not all of the aforementioned factors are necessarily based on the best interest of the patient. The doctors I met with all said something like, “typically in a case like yours I use…” and then they went on to describe their recommended surgical specifics.

Choosing a surgeon is a very difficult and personal thing. I sent a request for ACL surgeon recommendations to the cycling email aliases at work and within two days I had a list of 27 names. Some were known for treating high profile pro-sports athletes. One had performed numerous surgical repairs to Barry Bonds and was now under investigation for potential ties to the steroid mess. Some were in private practice, some belonged to groups. I sorted and evaluated them based on duplicate recommendations and the quality of their websites. Not exactly ideal criteria. In the end, I identified a small number of comparible details, most requiring entirely subjective assessment, and from there I made a list of five doctors.

It took about three weeks to get out to see all five doctors. Based on their collective comments, it seemed that I had a pretty typical ACL case, although there was a higher degree of collateral damage than they normally see. They all performed essentially the same physical exam and all agreed with the MRI Findings Report, the complete summary of which is as follows:
1.) Complete tear of the ACL near the femoral attachment
2.) Grade II MCL sprain, Grade I/II LCL sprain
3.) Sprain of the short head bicep muscle and vastrus lateralis muscle
4.) Suspect tear of the lateral patellar retinaculum
5.) Joint effusion with superomedial patella plica

Each of the doctors I saw had their own specific method and approach. The breakdown was as follows:
Graft Source: Allograft (5)
Tissue Type: Tibialis tendon (4), Patellar tendon (1)
Attachment Method: Transverse suspension (3), Endobutton (1), Interference screw (for use with bone-patellar-bone graft) (1)
Hardware: Bioresorbable (5) [note: the endobutton itself is titanium]

All of the doctors wanted nearly full range of motion in the knee and little or no swelling prior to surgery. They all would perform the surgery as outpatient (no overnight) either in a local hospital or surgery center. Only two required x-rays, and only two recommended pre-op physical therapy (PT). My feelings on those last two items helped me narrow the field. If there were another six ways to image the knee, I’d want them all. And if PT helps get the knee prepared for the surgery and subsequent recovery, then why would you not do it?

The last doctor I saw was Kevin Stone in San Francisco. Initially I was drawn to him because he was performing repairs of the native ACL, but after talking with him about it I decided against that approach. His extensive involvement in orthopedic research and the dozens of patents he holds for surgical tools and methods are convincing indications of his overwhelming commitment and competency. Finally, I was so impressed by the level of professionalism and compassion that he and the entire staff displayed that I could hardly imagine going anywhere else. He was geographically inconvenient, but still well within reach. He was “out of network” as they say in the insurance game, but I could cover the additional cost.

And so surgery was scheduled. February 5th.

He would use the bone-patellar-bone allograft. A slight donor source variation on the “gold standard” of ACL reconstruction methods. This is not to say that newer soft tissue graft methods are less successful, in fact there are plenty of studies that show that they have equivalent results. The BPB method, however, is the most common and in many respects the most straight forward approach. It seemed to me that having doctor Stone perform this operation would be a bit like getting Michelangelo to draw me a happy face. But then, why not. At least I was confident it would be a good one.

Choices

I'm a bit of an obsessive research junkie so naturally I spent every waking moment for two weeks drowning myself in the details of every available source of ACL related information on the internet. My objective was certainly not to become an ACL expert, but rather to become aware enough to be able to ask good questions. The fact is, doctors are the single best source for the latest and most accurate information on ACL injury (if you don’t believe me, ask any doctor). But conversations with doctors are typically much more productive if the patient already has a basic foundational understanding of the problem and the available treatment options. There are hundreds of ACL related sites on the internet and many of them contain marginal or outdated information. The key to doing internet research on the ACL is to find and stick to a few, good sources. ACLSolutions.com and the Orthopedics Associates of Portland for example both have excellent comprehensive sites.

If you are for some reason more inclined to break your leg than your ACL, then essentially the only thing you will need to decide is which color cast goes best with your shoes. ACL injury treatment, on the other hand, is much more complicated and requires some decisions to be made. The first and most basic is whether or not to have surgery at all. A torn ACL alone is far from life threatening. Although physical activity sans ACL has to be limited, the knee can be strengthened to compensate to some degree for the retired ligament. Some studies have apparently shown accelerated degeneration in knees without a functioning ACL due to increased play in the joint, but clearly the effect would depend on activity level. For me, surgery was a relatively easy choice because I want to remain active in ways that do require the stability that the ACL provides.

The second decision is to repair the existing ACL or reconstruct with new tissue. At least for now, this is almost a non-option as repair is very rare, with a short track record, and it requires near perfect injury conditions. There are also only a handful of doctors performing ACL repair. I happened to find one of these doctors, and I spoke to him about it. Although I was a reasonably good candidate for possible repair, after considering the possibility for a day I decided that I really needed to go with the surest option.

Within reconstruction, there are various treatment details to consider and all have their own risks and benefits. The four key options are as follows:
Graft Source: Graft tissue is either “harvested” from another part of the patient’s body (autograft) or graciously donated by a dead person who no longer needs it (allograft). The main concern with allograft tissue is the risk of disease transmission, extremely rare and potentially fatal. Donors are carefully screened and grafts are cleaned to the best extent possible, but complete sterilization by any current method does too much damage to the tissue.
Tissue Type: This is somewhat dependant on graft source. The most common autografts are patellar tendon and hamstring tendon. Allografts can come from various tendons including patellar, achilles, and tibialis.
Attachment: This is somewhat dependant on tissue type, but generally, holes are drilled through the tibia and the femur and the graft tendon is attached at the tibia with an interference screw. At the femur end, the graft can be attached in various ways including an interference screw, routed over a horizontal press fit pin, or run through a rope with a button on the end.
Hardware: Titanium used to be the standard for screws and pins, but it seems that new bioresorbable plastic screws have become more popular.

There are other details to consider but in general, I found that even the most personable surgeons will begin to tire of any discussion with a patient that goes much beyond the four listed above. Placement of the femoral tunnel is critical to the function of the knee, but the conversations I initiated with doctors regarding this topic were not very productive.

I formed some opinions on these different options before I went out to visit as many surgeons as my insurance company would tolerate. Thoughts from that tour next…

Perspective

And so it was that I had somehow managed to survive for four decades including the typical reckless stupidity of male adolescence, ten seasons of youth soccer, years of skateboarding, road biking, mountain biking, skiing, snowboarding, countless drunken stunts and dares, and a half dozen car accidents, two of which were severe enough to require ambulance transport to the hospital. And through it all, I had a handful of sprains, cuts, and bruises, two broken bones and a couple of degenerative cervical discs to show for it – nothing more. Not once in forty years had I ever managed to bend either of my knees in any directions other than those in which they were intended to bend. How truly amazing that particular statistic now seemed, given, in hindsight, my inability to avoid the recent violation of my knee’s design limitations.

Now for the first time I had an injury with permanent consequences. The one constant among people I have talked to with a reconstructed ACL is that their knee was never the same again. Some talked about functional instability and some described lingering pain that comes with too much activity or changes in the weather. A couple ACL vets told me about follow-up surgeries that were required to “clean up” debris and degenerative damage caused by the body’s response to the original injury. One doctor I saw said that he tells all of his ACL patients that their days of neglecting their knees or taking them for granted are over. “You will have to think about your knee every day for the rest of your life. How to exercise it, how to protect it, which activities it can withstand.”

After the ACL diagnosis was confirmed, I was emotionally all over the map. I tried to maintain stability on the outside, but internally I was hopeful, worried, angry, disappointed, frustrated, and deeply depressed, and often all within the same hour. It was very much as though a part of me had died – the part of me that was the healthy, naturally functioning knee. I spent hours dwelling on the details of the incident, and the surgery, and on all of the potential limitations and changes this could have on my life. I confided in close friends and, although I appreciated their words, no amount of well intentioned “you’ll get through this” support was enough to help me regain my usual sense of optimism and confidence. For weeks after the diagnosis I awoke every morning to the feeling of a bomb going off in my gut with the renewed realization of the injury. If I woke up during the night, there was little chance of going back to sleep. Worst of all, I felt in some way that I had let down my kids. I have always believed in the importance of being physically active with kids. This has consistently been one of my favorite parts of being a parent, and one of the ways that my kids and I have always been able to connect. Certainly I would now be falling well short of that kind of engagement for the next year at least, and to some extent, maybe long term as well.

It was only as I got into the fourth week that I really began to find what I needed to deal with the injury. Perspective. “It could be worse”, although true, is not at all effective unless and until you really begin to realize that for a lot of people, it already is. I began to consider, and I mean really personally consider what it must be like for people who are wheelchair bound, or slowly going blind, or for the people who will go to their doctor today and be told that some part of their precious body is full of cancer. Sources of perspective are easy to find, the key is be affected by them. For me, in order to be affected by someone else’s situation due to injury, or disease, or poverty, or disaster, or war, I first had to personalize their condition. I found that in just five minutes of genuine focused thought I could begin to feel enough of what someone else might be experiencing to significantly alter my own perspective, even if I was still only able to be barely aware of the full reality of that person’s daily life. It has been uniquely empowering for me to be able to adjust my outlook and create an objective appreciation for my own situation and for the opportunities that I have to improve it. Of course none of this changes the reality of my injury, but it has definitely helped to prevent it from destroying my attitude.