MICROFRACTURE REHAB DIARY

This is a recap of three months of Kevin's recovery and rehab from microfracture surgery performed on a knee.  The object is to give others who might be considering this surgery some idea of what to expect.  The caveat is that each microfracture procedure is different - size and location of the chondral defects play a major role in what limitations are imposed and how long healing will take.  The injuries in my knee were quite large, almost to the limit of the procedure.  That said, my experience seemed to follow what little I could find in the way of "specific" information.  Hope it helps.

DAY ONE

The procedure was scheduled for 8:30, so it was a reasonable start (for me - not for my driver, who considers 8:30 itself to be the crack of dawn).  We were at Davis Ambulatory Surgical Center at 7:00.  There was a little sitting around after check-in, but once back in the prep area, things moved quickly.  Working with seniors as I do, I had no shortage of clients and participants in my programs who had used Davis or taken someone there.   They universally said wonderful things about the center.  They are all true.  The center is designed for easy access and egress.  The staff was friendly, compassionate, and helpful without exception.  The people in the prep area were easy-going and conversational.  All seemed to understand the anxiety of the patients and adept at putting them at ease (as much as possible).

Dr. Almakinders came by to check in.  I have been bugging his staff with lots of questions, and clearly it had gotten back to him, as we talked about some of the issues I had raised.  We discussed the use of a Controlled Passive Movement (CPM) device for recovery/rehab.  During our initial visit as we had discussed options for treatment, Dr. Almakinders mentioned that the odds for successful regeneration of cartilage would be improved if I could "live in a CPM eight hours a day" - like the professional athletes apparently do.  Of course, most of us don't have that kind of time.  However, the rest of his staff didn't think I would be using a CPM.  His assistant said they were only available at the hospital, and his PA said she thought it might be overkill.  In my research on the procedure, I had found out that a CPM is an approved aspect of trreatment with my insurance (the most important factor).  His PA had said that if I contacted Blue Cross and they gave the go ahead, the practice (North Carolina Orthopedics) would be able to procure one for me.  But I hadn't had time since the pre-op to get that done.  Dr. Almakinders discussed more active range of motion activities that I could do, and when I should begin them (48-72 hours - to give the new tissue time to be laid down).  We decided that it would be my call on a CPM.  If I feel that I'm not getting enough active motion, then I'll try to track down approval, and they'll track down a machine.

The anesthesiologist dropped by.  I don't remember her name - I'll have to wait until I see a bill before I can add who it in here.  Then it was the anesthesia nurse (Mike Smith - not a tough one to recall) who wheeled me into the operating room and started the good stuff flowing.  

My next memory is of the recovery room.  Amnesia is one of the side effects of the anesthesia they used, so apparently a lot more happened than I can recall.  Perhaps Marian will post more.  She was chastised for laughing at my repetitive comments and questions (so she says, I don't remember).  She told me that Dr. Almakinders had dropped by and given her an overview of the procedure, and instructions on what to do at home (she later said that I asked her about that repeatedly).  I was surprisingly comfortable, and once the fog cleared, we were on our way home.  I think we were back in the house not long after 11:00.  Marian was surprised at how well I got about on the crutches.  While I have limited experience with them (a couple of sprained ankles for a couple of days), when you're around athletics for as long as I was, there is always someone around using them who's willing to let you play with them.  So getting from the car to the bathroom and then to bed was no problem.  At that point, even though I'd had a normal night's sleep, done no activity, and been unconscious for 90 minutes, I slept until 4:30 (one wake-up).  They had given me pain killer (die, pain, die!) in the recovery room and I took one when I woke up for good.  I read and dozed and ate.  I was feeling better than expected and very hungry.  I came out for dinner an hour later and spent the evening at the table and on the couch.  Another percoset (pain med) and it was back to sleep.  I think even the cats were impressed with my napping abilities.

 

DAY TWO

Woke up and my knee was "uncomfortable" - the value of the pain medicine is noted.  Today, I've gone 5 hours between pills.  About that point I'm feeling it.  After the pill the knee feels better and I get a nice mellow glow.  This is different from my previous experience with percoset (I realize now that I'm not sure about the spelling - and it's probably generic oxycodone anyway), which made me uncomfortably loopy.

The discomfort has been more in my leg than my knee.  My foot has felt numb and swollen, as if the bandage is too tight.  The back of my calf gets sore from resting the elevated leg at that point.  And my knee pain isn't so much "in" my knee as behind it - again like it's a problem with the dressing.  We're going to take a look at the bandage, but Marian says my foot is not cool to the touch and responds to being squeezed (changing colors) as she was told to look for.

I've moved the leg a little getting up and down with no pain.  I've been doing ankle exercises o help with the feeling in my foot.  Ankle circles, point and flex, writing the alphabet, and curling and spreading the toes.  I made the mistake of putting some weight on it this morning and felt it immediately.  It wasn't a horrible shooting pain, and I caught myself before I pressed very hard.  But it was enough to keep me from forgetting again.

The main problem today has been boredom.  I'm feeling well enough to want to do something.  I had all the reading, web surfing, and soccer watching I can stand from one couch.  I can't wait to lower this leg and begin to exercise it.  But I think I'd better have one more day of taking it easy.

 

DAY THREE

I have posted some pictures of my knee during the surgery to a new page on the website, labeled (as you might expect) Surgery Photos.  The quality of the photos I received was remarkable to me.  Much better than what you see here – the lines are from our scanner.

Figure 1 shows the damage to the medial femoral condyle.  This is the one I felt most when planting and turning.  Chondral (cartilage) defects are graded 1-4, with 1 being minimal damage and 4 being 50 to 100% loss.  This defect was a 4, and you can see the exposed bone in the middle.

Figure 2 is more damage.  I think these shots are from the trochlea – the groove on the femur for the articulation of the patella.  In the shot on the left,one of the surgical tools is pulling on the tissue.  Again, this was a grade 4 defect.

Figure 3 are pieces of cartilage that have broken free.  That lost cartilage has to go somewhere, and here it is floating around.  You can see from the shot on the right how such a loose body can get pinched and cause pain as the knee moves.  For all my running buddies who seem to enjoy taunting me about catching up to me, I ran a sub-36 5 miler with that thing in the way.  For you serious runners out there I realize that’s not setting any world records, but it was my personal best at that distance.

Figure 4 is a shot of what most of my knee looks like – thankfully.  According to the MRI report, all of the other connective tissue is in good shape as well.  Not bad for someone who jumped up and down on that joint several million times playing volleyball.  I attribute the relative good health of my joint to the regimen of strength training I’ve kept up for over 25 years.  (I attribute the damage we see here to stupidity – running much faster than I should have over very uneven and unstable terrain.)

This last shot of damage (Figure 5) is unknown (by us) tissue.  Dr. Almakinders told Marian what it was, but she doesn’t remember.  I’ll be sure to ask during our next conversation.  To me, this looks nastier than anything else – red and ragged and in a position to be easily pinched.

This final shot is of the microfractures in one of the defects.  You can clearly see the holes that have been punched into the bone.  These should secrete (bleed) new tissue to fill in the damage.  If I rehab it well, the signal to the tissue will be to form cartilage.  Keeping our fingers crossed.


DAY FOUR

First, a delicate subject - going to the bathroom.  One of the side effects of the pain medication is constipation, and sure enough I had yet to poop the first three days despite eating plenty and taking medicine to help.  However, by last night I was beginning to think that it might be the toilet and not my bowels.  Sitting on the toilet has been the most painful thing for my leg.  It hurts my hamstrings, my calf, and my foot.  I think it is the position on the seat, with so much weight on my leg and none on my left foot.  So today I switched to the other bathroom.  The seat is a different shape.  I hadn't been using it because the other bathroom is much easier to maneuver.  But sure enough, it hurt much less and things went much more smoothly, so to speak.  We have set up a frame around the second toilet that will make it much easier to access.

Took off the dressing today.  There had been very little oozing and bleeding.  A very tiny hole on each side of the patellar tendon, well healed.  There was nothing done on the back side of the knee, so the cause of my discomfort in that area remains unknown.  Got a check-in call from the surgical center.  Very brief.  They were satisfied I wasn't dead and hung up.

Went to the office today to shower and shave.  The handicapped accessible locker room and shower are enormously beneficial.  Rolled the wheelchair right up to the sink for shaving, and hopped easily into the shower on my crutches and sat on the bench.

Spent some time focusing on moving the knee.  There is surprisingly little pain on movement.  The discomfort is mostly when the swelling gets "squeezed," just like the injury.  From a supine position (lying on the bed), I was able to do heel slides to about 60 degrees of flexion.  I did 5 sets of 10 repetitions, not wanting to push it too much.  In between those sets I did ankle exercises: flexing the ankle, foot circles, inversion/eversion, and lots of flexing the toes.  At the end I did two sets of what I call quad presses.  Wth the leg lying sightly flexed on a pillow, you flatten the pillow by straightening your leg (contracting the quadriceips).  I held each contraction for 5 seconds.  10 reps each set.  I repeated the exercises (same volume) in the evening.

I had gone the whole morning without any pain medication.  I wanted to be able to see how the leg felt during all the general activity and then through the exercises.  No problems.  By 12:30, it was sore, so I took a pill with lunch.  I have decided that most of my pain is in my lower leg, especially the gastrocnemius muscle (calf).  I wonder if they had the leg stretched out in some extreme position while performing the procedure.  The leg gets sore almost immediately upon lowering it, and it feels tight on dorsiflexion (flexing the foot up toward the knee, which stretches the gastroc).  After the second bout of exercises, I finished by massaging that calf with a roller. 


DAY FIVE

Got more serious about rehab today.  Did the same routine as yesterday in the supine positiion.  Twice - once late morning and once late afternoon.  Added two reps to each set of the heel slides, otherwise exactly the same.  Added other passive movements at other times.  From a chair I did sets of 100 knee extension/flexion, using the right leg to move the left.  I did this three times throughout the day.  The first time I did it from the wheelchair, but that limits the amount of flexion I can achieve because the floor gets in teh way.  So the second two sets were done from a counter stool, and I was able to flex all the way to 90 degrees.

The knee feels good, me not so much.  Battling an upset stomach and headache.  Wonder if I'm getting a little cold?  Did manage to cut back on medication, one in morning and one before bed.  Also spent less time in the ice machine, with no noticable change in swelling.  Sent e-mail to doc to ask why my calf hurts.

 

DAY SIX

Not as much rehab today.  Did the supine routine 1 time.  Upped the heel slides to 15 on the last 3 sets.  Later did 250 passive flex/extends in sets of 20.  Less exercise today because I just didn't feel well - like a cold coming on most of the day.  Was up and about more:  went to the office for a shower and some paperwork; got coffee with a friend; and watched Justin's baseball game.  Before the game, took a couple of tylenol to get rid of the headachy feeling and that helped.  But, went the whole day without oxycodone.  Leg is pretty sore now (late), so I've given in and taken one before bed.

 

DAY SEVEN

Long day home alone.  Felt well enough to spend lots of time n the wheelchair doing little "chores."  Thank goodness we have no steps in this house.  The one step we do have is into the laundry room, so I'll be no help there.

Rehab went well: did the supine routine twice, with all sets of heel slides at 15.  Also did 2x100 passive ROM twice, and one set of 25 chair rolls.  By the end of the day, my foot was swollen, probably from being in the chair more than all the exercise.

As I continue to search online for rehab protocols, I find the entire range from virtually complete immobilization to an almost immediate return to normal activity.  There is very little "professional" discussion.  Most of it comes from patient reports.  It is my guess that much of the activity prescription is dependent on the extent of the repair.  A small lesion with one microfracture applied is going to require less time and restriction than multiple large lesions with multiple holes punched in each one.  In my case, they weren't even sure if the microfracture procedure would be appropriate until they actually got into the knee to see the size of the defects.

That said, I have been less than impressed with the communcation from surgical team.  Sent an e-mail with basic questions two days ago and no response.  I'd like to think that they have confidence in my experience and knowledge to handle things on my own, but I doubt that's really the case.

Oh, almost forgot - no pain medicine today.  Hopefully, I'm all done with it.


WEEK TWO, DAY 1

A good day all around.

Upped the passive ROM to 400 reps total (2 x 200).  Also did 2 x 25 of chair rolls, and one set of the supine routine.  Got out and about more, and figured the extra movement in and out of cars, chairs, etc. counts for something.  

Second day in a row without pain medication.

Went back to work for one appointment, and also went out to dinner.  Swelling is increasing in my foot.  When out to dinner, wore a shoe just to keep some compression on it.  Hard to put a shoe on without putting weight on the foot.

Got a call from the Dr.'s office.  They confirmed that the pain in the calf was from the stretched position the leg was in for the procedure.  Also cleared me to drive again, and said that swelling can be an issue for up to six weeks.  They want me to try to elevate the entire leg (foot highest) when possible, to offset the time that I'll be out and about with it down in a normal posture.  I'm grateful to Pamela, my friend who got me not only a chair for the office, but also a foot rest that will allow me to elevate my leg while in it.


WEEK TWO, DAY 2

Saw clients in the morning.  I'm getting adept at moving around the office while in the chair.  Afterwards, used the leg extension machine to sit in while I did a set 500 passive flex/extends.  The hardest part about that is keeping an accurate count.  The knee really feels good while I'm moving it.  I've had clients who have said the only thing that relieved pain after their knee replacements was the CPM machine.  I can see why.  Although I'm not in pain, all that movement really gets the synovial fluid going and loosens up the joint.  Did another 500 reps twice at home (this is the Steadmen clinic prescription of 500 reps 3x daily), along with the usual supine routine. also twice, and a bunch of chair rolls.  Upped the reps on each set of the heel slides to 20.

Foot continues to be swollen, although I've yet to dedicate any time elevating it.  Marian went out and got a pair of compression socks.  It was a workout for her trying to get the sock onto my swollen foot.  I think I'll need to keep it on till the next shower to keep her from doing it again.  The worst part about the socks is the style.  Black, and knee high.  One looks really odd, but if I wore both I'd be nine tenths of the way to geezerhood.


WEEK TWO, DAY 3

Here is an excellent synopsis of the microfracture procedure, written by Matt Harpring - the former Georgia Tech forward and NBA standout.  Either he spent time doing more than playing basketball while in school, or he had help from a good writer/editor on this article.  I suspect the former, as he was always annoyingly clever when playing against UNC.


http://www.nba.com/2009/news/features/12/09/harpring.micro/index.html

After more than 12 hours in the compression sock, and with lots of leg elevation, the swelling is down in my foot.  It feels and looks better.  Looks like I need to go out and find some white ones, as I don't relish wearing one (or worse - two) black knee sock in public.

Got in another 3 sets of 500 reps on the passive flexion/extension.  Did a bunch of chair rolls, did the supine routine twice, and added some new exercises: prone leg flexion (like lying on a leg curl machine - only without weights).  Did 1 set of 15, twice during the day.  The only problem was that my knee was uncomfortable with the kneecap pressed into the bed during the movment.  So I moved to the end of the bed so that my leg from the knee down was over the edge.  Also addded two standing exercises: hip abduction and hip extension.  Fifteen reps for each, affected leg only (obviously).


WEEK TWO, DAY 4

My first full day at work, and it was a normal Monday - 8:00 a.m. to 7:00 p.m.  No problems, other than those caused by limited mobility.  Decided to go with a compromise on the compression sock.  Wore it, but rolled the leg down to the ankle and covered it with another sock.  Folks later said the one black knee sock would be styling, but I know a setup when I hear one.

An added benefit of my line of work is the opportunity to squeeze in some exercise.  So while I led leg exercises in the senior programs, I did flex/extends from my chair.  Don't know how many, but it was 10-15 minutes in both programs.  Also had time to do the full 500 at work and at Justin's baseball game.  The ones at work were completed in the leg extension machine, and they were more fatiguing for the right (active) leg than other times.  I think that is because the set is slanted back and there is more work against gravity.  Also did the supine routine at work, along with the prone flexions, and standing hip exercises.


WEEK TWO, DAY 5

Broke down and wore a compression sock all the way to the knee today.  With the ace bandage covering part of it, it doesn't look too dorky (unconfirmed opinion).  The leg is not swollen and felt comfortable even when sitting this evening without being elevated.

Added more exercises today.  While standing, I did hip flexion, diagonal hip 1 (angled out) and diagonal hip 2 (angled across, like a soccer pass).  While lying down, I did straight leg raises in all four directions (supine, prone, and side-lying both ways).  My leg felt heavy during all of those done on the floor.  Pretty sure it doesn't weigh any more, so it's a sign of the weakness of those muscles.  And while you'd think that the atrophy has occurred in the past 11 days, in truth it started before that, as I'd stopped doing much strength training with that leg first when it hurt, and then more so when I knew of the damage.

I can "feel" the medial condyle when I'm lying with the leg straight and rotate the entire leg internally.  Not sure if that's an aspect of growing tissue or something else.  Don't feel it on any other movements.


WEEK TWO, DAY 6

Do you know how hard it is to count to 500?  For me, very hard.  Somewhere in the 200s or 300s, I'll find I'm not really sure whether I'm at 49 or 66 or 82.  So, after a week of struggling with numbers, it finally hit me.  Time it.  Sure enough, 500 reps takes about 13:30.  So now I'm flexing for time - 15 minutes.  That puts me at slghtly more than 500.  And, I can do things like watch TV, read, or just have a conversation.  Today's work schedule set up nicely, with breaks every several hours that allowed me to get the movment in.  After "feeling it" on active hip rotation yesterday, decided to limit the exercise to the passive stuff until I check in with the surgical team tomorrow.

If I haven't mentioned it before, I'll say it here: I'm really glad we set the office up to make it easy for my wheelchair clients.  There is plenty of room to maneuver while helping.  The handicapped facilities in the locker room mean I don't have to struggle in our little, non-accessible bathrooms at home, and if I ever get around to it, it will be very easy to get into the machines for upper body exercise (and leg exercise, once I'm cleared for it).

Got a comment on my "look" with the one black knee sock, so now it's off for some e-shopping to see if they make mid-length compression hose...


WEEK TWO, DAY 7

Had my follow-up with the doctor today.  More specifically, had the consult with his physician's assistant.  Once it appeared that everything was going okay, she spent more time explaining the theory behind the repair.  Nothing that hasn't already been covered in these posts: hopefully, my leg is continuing to lay down more tissue in the defects and will eventually fill them in.  Moving the knee is good, standing on it is bad.  She gave me a referral to physical therapy that I can't start until a month out, and reinforced the idea that I had to stay off the leg.  She said I can put my toe down for balance, if necessary, and could put up to 25% of my weight on that leg.  At 4-5 weeks, I can start to put more weight on it, and see how it feels.

I gave her the exercise record of what I'd been doing.  She glanced at it, but wasn't impressed and failed to put it into their file on me.  I did review what I've been doing and she nixed the leg lifts and the hip rotation.  She wants me to avoid anything that would put torque on the joint.  The open chain exercises and rotations both fall into that category.  She did okay the standing hip movements, and (thanks be to God) cycling with no resistance.  She recommended the upright bike over the recumbent, as it will be easier to keep the foot stable when I'm directly over the pedals.  I mentioned that I had found ways to secure clients' feet to the pedals if they didn't have good function in one leg, and she said it would be a good idea to do that.  In fact, she mentioned being "clipped in," and it may be possible to put one of my old pedals and use my old left shoe to stay on that pedal better without using weight.  I didn't bother discussing getting in a pool, as that was an activity that hurt enough before the surgery to make me see a doctor, and the variable force of the water definitely adds to the torque on the joint.  So despite the fact that we've had four hundred days in a row in the 90s, I won't be getting wet anytime soon.
I contacted a physical therapist that I'm familiar with (and who is familia with me) to set up an appointment in mid-July.  Hopefully, it will be easy to establish a relationship that will allow me to do most stuff on my own and contact him for advice, rather than visit the office for actual therapy.  The PA said that using a therapist can be beneficial to help with the passive stuff (as in we're going to bend your leg until you scream like a baby) that you might not do as well on your own.

Only did the 500 flex/extends twice today, but did lots of chair rolls during the senior program.  I'm looking forward to replacing sitting in a chair with riding a bike.  Also decided to forego using an ace wrap on the knee to see if it swells.  Of course, that means the knee-high black sock stands alone...


WEEK THREE, DAY 1

New week, new exercise.  Rode the exercise bike for 15 minutes.  Following he PA's advice, I stopped at that point, even though I felt like I could pedal forever with no resistance.  And besides that, it felt great to be doing something that was a normal activity.  Usually, when I'm on an erg bike, I'm ready to get off after 5 minutes (as opposed to my real bikes, which I can ride for hours without wanting to stop).  But today, the 15 minutes flew by.

Also did 15 minutes of flex/extend.

If you've ever been around a chairbound person, or someone with limited mobility, you might have noticed how they operate with a sense of order to their routines.  I'm figuring out that this is a necessity.  When in a chair, or on crutches, if there are 5 steps to completing an activity or chore, you HAVE to do them in order - step 1 through step 5.  If you pick up your crutches before you put on your backpack, you'll have to put your crutches down, sit back down, and then put on the backpack before grabbing the crutches again.  It requires patience and attention to detail.  Patience is my strong suit, and it has helped tremendously.  However, I'm too scatterbrained to do things with ordered steps efficiently.  So I'm spending lots of time starting over from square one as I try to do any number of things - from just leaving the house, to getting into the car, to showering, etc.  So it's all putting my patience to the test.  Maybe if I'm lucky, I'll be more organized by the time this is all done.

I went without an ace wrap on the knee, or a compression sock on the leg, all day.  By the end of the day I had some swelling, but it wasn't terrible.  The knee was a little sore and I don't know if it was because of the swelling or the cycling.  I'll plan to wrap tomorrow, but still ride, and see if that makes a difference.

 

WEEK THREE, DAY 2

This may be the last day-by-day post for a while.  Things have settled pretty much into a routine.  I do not anticipate making any changes to the rehab routine until I meet with the PT.  Flex/extend, exercise bike, chair rolls, and heel slides for ROM.  Standing hip exercises a couple of days a week, and quad sets to try to maintain some amount of strength in that quad.

I'm finding that time at work is easier than time at home.  Besides the open space that makes tooling around in the chair easy, there's also more to do: helping clients, office work, and exercise.  Home is just a lot of sitting around - not my strong suit.  Today, I found myself heading back to the office late in the day to try to rig the exercise bike with a real bike pedal.  No luck, because the existing pedal is on the crank too tight.  Will try taking a pedal crank to it next time, and also have the next level of weapon - Winston the football player.  But if the clipless pedal and cleated shoe don't work, I'll try to switch to other exercise bike pedals that will take straps.


WEEK THREE, LATE

I had gotten away from doing the quad sets, and I noticed today that my ROM was more limited in extension, so it was difficult to press the knee into the towel.  When I did hamstrings stretches with a strap, I felt a little discomfort on that medial condyle.  I'm going to change to stretching from a seated position on the floor so that the heel is stabilized that way instead of with the strap (and pulling the leg up while lying down).

At the office, it's easy to do sitting exercise but harder lying down.  At home, I can do the supine work from the bed, but we don't have a table or elevated mat in the office, so I have to get on the floor.  Meanwhile, it's easy to hop on the leg extension machine or exercise bike and start moving.  So I need to do a better job of doing the lying exercises when at home, even if it means being less social for 15-20 minutes.

I have had no problem adding 5 minutes a day to my cycling - today it was 30 minutes.  I'll keep it there (and keep it to once a day) for a while to avoid overdoing it.  Have started a dialogue with the physical therapist who I'll be seeing once I'm allowed to actually start PT (July 15).  He commented that he was looking forward to learning and figuring things out together.  Encouraging!


WEEK FOUR, 1ST HALF

The exercise continues to go well.  When I'm in a wheelchair, I'm trying to be diligent about doing chair rolls.  Noticed that I can flex farther this way without feeling anything.  The cycling goes well - it's easy to pop on the recumbent with a book and get in a half hour.  A couple of days ago, I had some discomfort on the medial condyle, so yesterday I backed off to 25 minutes (the day before had been 30, with two bouts of flex/extends as well).

Went to a Durham Bulls game.  Decided to get some advantage of my handicapped status and purchased "barrier-free seating" on a night that would have otherwise been hard to get tickets.  You have to be a dedicated baseball fan to go see a game if you're in a wheelchair.  The ballpark has some handicapped parking, but it is at least a quarter of a mile from the entrance.  Worse (at least at the end), the parking is uphill all the way after the game.  Between the downill grade and the fact that the sidewalk slopes sideways as well, my hands were burning by the time we got there from braking and steering.  But the real challenge was the return.  Don't think I could have done it if I didn't have someone helping push from behind.  And I don't think they could have done it if I wasn't helping on the wheels.  Marian and Justin had to take turns-  Marian taking the steeper parts.  Next time, I'll wear cycling gloves to give my hands a break.


WEEK FOUR, END

End of week 4 - that means 2 more weeks, hopefully, off the leg.  This week I got up the courage to get into the pool.  It has allowed me to do different exercises.  At shoulder depth, I weigh virtually nothing.  So that has enabled me to do partial knee bends and heel raises with both legs.  I've also done some (very) slow walking -but I've avoided lateral movement that would put torque on the knee.  Additionally, I've done something like a water massage.  It seems to have helped improve circulation in my lower leg and foot and reduced the swelling.  The toughest part is getting out of the pool.  (Getting into the pool is really no problem - anybody can fall into a pool).  However, using a chair or the ladder gives me enough leverage with my arms to stand back up once I'm sitting on the side.

Besides an obvious atrophy in that left thigh, I've noticed that my hamstrings get pretty tight.  So I'm making an effort to do some extended stretching on that leg a couple of times a day.  So far I'm only stretching the hamstrings and gastrocs (calf).  I don't have the courage to bend the knee far enough to stretch the quads - that and I'm not sure there's enough of them left to stretch.

I've also noticed that the left (affected) leg is much cooler than the right.  Since it does no work, circulation is minimal and there's no heat whatsoever generated from muscle work.

Getting in time (30 min) on the bike every day, and some days still doing other stuff like passive flex/extend, heel slides, or chair rolls if I'm not doing the ROM stuff in the water.

Funny story:  Yesterday I was picking my son up from camp at the same time as a storm rolled in.  As we neared the car it started to rain and a big bolt of lightning cracked nearby.  He started running for it and shouted at me: "Crutch for your life!"


WEEK FIVE, MIDDLE

Had an appointment with a physical therapist.  During the initial interview as I explained the procedure and the rationale behind the exercise I had been doing to this point, he asked "so why are you here?"  I took that to mean that he agreed with my choice of exercises and the progression, such as it is.  I told him that I wanted to be able to bounce ideas off of a professional, and to get other ideas.  By the end of the appointment, I was extremely happy that I had scheduled the session.  They had evaluated strength and range of motion and found subtle discrepancies and given me excellent suggestions for working on them.  In some cases it was stuff I was aware of (hamstrings flexibility), but they had ideas for addressing the issue that was both different than what I have been doing and also adds to helping to returning the leg to normal function.  In this instance, one of the suggestions for helping get that leg into full extension was to start walking on the leg with partial weight bearing (still using crutches) and making sure that I straighten the leg completely on each step.  They want me to start strength training by pressing a theraband - again making sure I hold the full extension at the end of each repetition.

Today was also the first day that I put some resistance on the exercise bike - 35 to 50 watts.  For reference, when the bike is not turned on, it probably still takes 20-25 watts to turn the pedals.  I figure that if I'm allowed to put a little weight on the leg that it's also okay to add some resistance to the pedal.  The knee was a little sore by the end of the day, and in hindsight it might have been better to hold on changing the bike resistance on a day that I was put through some paces at the PT office.  The therapist, like the surgical team, felt that I should be using discomfort as a guide for the amount and intensity of my exercise.  His quote:  "This is not a case where no pain, no gain applies."  

I have to say that I was pleasantly surprised by how well the evaluation went.  I have a better range of motion and more strength in that leg than I would have guessed - given the noticeable atrophy in that quadriceps (noticed by others, not just me).  They did measure continued swelling in the knee itself.  In all I've read, swelling is an issue for quite a while with this procedure.  But they did prescribe icing it at least once a day - something I had not been doing because of the expectation that swelling would occur anyway.


WEEK SIX, EARLY

've gotten into the routine of the rehab exercises prescribed by the PT.  More counting.  (It's nice to have the Tour de France to watch while doing these at times.)  I've already noticed a better contraction in my quadriceps using the tension band.  Rehab, like other exercise, can be easy to put off.  You have to make sure that when you have 15-20 minutes that you get it done - especially if you're supposed to do things two or three times a day.  The toughest exercises are the standing ones.  The hip abduction is harder on the standing leg which gets a little crampy by the end of the slow repetitions (holding each one for 10 seconds).  And the calf stretch is difficult because it's hard to keep most of the weight off the stretching leg.  It is clear that the flexibility in that calf has been reduced, and that means I have to shift more weight onto it to get it to stretch out.

For more "normal" exercise, I've begun to put a little resistance on the exercise bike.  If I can use partial weight while standing, it's time to make that leg push a little bit against the pedal.  And little is the operative word.  Right now it's between 35 and 50 watts.  And bigger news was that I did actual swimming.  I borrowed someone's pull buoy so that I wouldn't have to kick.  It worked great, and I immediately went out and got my own.  I wish I had tried that earlier, as it would be a way to get some real aerobic exercise.  It will be a nice change of pace coming up, as the forecast is for high 90s most of the week.  Even once I'm cleared to start regular activity, the climate won't be favorable for reconditioning by walking or cycling outside.

I've been walking on the leg while crutching, as suggested.  This turns out to be even slower than regular crutching.  It's hard to go very fast when you're trying to evaluate how much weight you're putting on each step.  So I'm "walking" when I'm not trying to get anywhere on time.

 

WEEK SIX, END

Met with Dr. Almakinders for my six week follow-up and he cleared me to move to full weight bearing by the end of next week ("wean off the crutches" he called it).  He said to start with a limited time of full weight bearing and increase it every day.  So I experimented almost immediately and found that I can stand with weight evenly distributed on both feet with no problems.  From that standing position, I can easily do a pretty deep squat with no discomfort - something I could not do before the surgery.  However, when I have tried to put all of my weight on the left leg (i.e. take a step) the knee gives way.  I can feel it at the repair site, but I think the problem is the complete lack of quad strength.  When the femur drops onto the tibia it presses the repair.  I don't think it's a problem with the repair itself.  At Dr. Almakinders' suggestion, I have switched to just one crutch, using it on the left step with the right arm.  It's hard to imagine, but this makes me even slower.  But I'm going to stick with it and shelve the other crutch, no matter how long it takes me to get places.  By the end of the day, I think I can tell that the quad function is improving.  Stay tuned.

The conversation with Dr. Almakinders was a good one.  I got to ask lots of questions, and he gave thoughtful answers.  He mentioned that it's too bad there's no easy way to take a peek into the knee and see exactly what the repair looks like.  Instead we're stuck with my interpretation of how it's feeling.  When reading discussions online by people who have had this done, it seems like many of them are triathletes.  I asked him if there had been a study to see if there is some mechanism happening on the transition from bike to run (as in very tired quads and then the knee is suddenly stressed in a different way at the start of the hard run).  He said he was n't aware of anything.  And from his experience, he saw many more cases from "weekend warrior" basketball players than endurance athletes.  He also talked about which activities to attempt first.  His feeling is that cycling is easiest, but to take it easy on hills and cadence.  With swimming, be very gradual about adding kicking, and avoid breast stroke with its "whip kick."  Running is usually the last thing you should attempt.  He suggested getting on the eliptical by the end of this next six-week segment - which is full weight bearing, but non-impact.  Running is never suggested before three months, and after his procedure he waited four.  I asked if waiting longer (six or more) would be even better and he said yes.  That would be the holidays for me - a time when it's getting cold enough with short days that running is my easiest choice.  Of course, as I've said before, I can live with no problems if they tell me never to run again and just live on my bike.


SOMEWHAT OFF TOPIC

This week I celebrated my 50th birthday.  I've been pretty pragmatic about repairing and rehabbing my knee, but this was one time I felt "bothered" by the whole process.  For quite some time, it has been my tradition to ride my age in miles on my birthday, and for almost the past 10 years, a friend (born 4 days after me) and I ride one year for each of our ages, or "the double birthday."  This year we had hoped to do more than just head out our doors in the morning - instead doing a century in the mountains or something more special.  Obviously, that didn't happen.  Perhaps by the end of the year - I think we have until next summer before we hit the statute of limitations.  Still, I felt like I needed to do 50 of something.  And I was able to come up with it.  Despite not being able to kick, I've learned I can use a pull buoy the get some actual swimming in.  And so I swam 50 laps (2500 yards).  It was an appropriate challenge, since I've never done more than 1500 at a time before.  With the go ahead to start working toward normal activity again, I look forward to the goal of getting in 50, and then 100, miles on my bike again.

And now for my rant (which I've taken pains to avoid on this page so far).  All of my birthday wishes were more like condolences.  Seems many folks look at changing a decade as a sign of decline.  I don't feel that way at all.  First of all, going from 49 to 50 is really no different than 48 to 49.  Second, if anything, I've looked forward to turning 50 to get the previous year over with.  It was filled with injuries and scheming business partners and economic challenges that I'd just as soon move on with.  Third, as an endurance athlete (sort of), aging up means I'm one of the young ones in the category instead of the oldest.  Of course, in the one event I participated in, I finished even lower (toward the bottom) than before (in the middle), despite finishing 22nd overall.  So apparently the other 50+ guys are all ex-pros...  And finally, I see no reason to be depressed about a new decade.  Every decade I've experienced so far has been better than the last.  I won't go through the whole timeline, but the last decade saw me open an office, enhance my professional reputation, reach new goals (running a marathon), and spend a hell of a lot of time having fun as a parent.  Seems to me the folks who lament getting older spend a lot of time looking into the past.  I'm too busy planning for the future to have that perspective.  And besides, how can I set the record for being the oldest person to ever ride cross-country unless I keep adding numbers to my age.  As usual, it took a day running my senior program to get it right.  When I mentioned the birthday there, one of the program participants remarked, "What a great age!  I had so much fun when I was fifty!"  There you go.


MIDDLE OF FIRST WEEK OF WEIGHT-BEARING (7TH OVERALL)

The weight bearing is going slower than I expected.  As good as the knee felt while not using it (or moving it through a good range of motion without weight), I really figured I'd just hop back on to it and go.  But Ispent the weekend hobbling around the house with extremely affected gaits - the family was calling me Gabby Hayes.  I've been able to stand at work, but the leg tires considerably as the day goes on, and I'm still spending time in the wheelchiar observing sessions late in the day.  If I have any distance at all to walk, I need the crutch.  At this point, I'm not using it for a lot of support, and I can walk at normal speed with it.  While walking is hard and the knee is sore on most steps, I can squat through a full range of motion with my weight evenly distributed without pain  - something that was impossible before surgery.  That's a very good sign.
I have begun to crank up the resistance a little on the exercise bike.  It doesn't hurt, but limited wattage produces a much higher heart rate than it used to.


END OF 7TH WEEK (1ST WEIGHT-BEARING)

Had a second therapy appointment on Thursday.  They re-evaluated the leg and found improvement in both strength and range of motion (in both the knee and ankle).  They weren't happy with the way I was limping around, and encouraged me to work through the discomfort and use a normal gait.  The PT said that modifying my walking to avoid pressure on the medial repair (where I'm feeling it) would cause more problems long-term than the stress on the new tissue when walking normally.  We found that using a cane allows me to stride normally without discomfort, much better than the cane.  So I've been using a cane since then.  Not only do I walk better, but it adds to an air of sophistication to my presence.  Began limited strength training.  Did one set of leg press with the affected left leg at 50 pounds and had no problem.  When I reported that, the PT said I can give up on the rehab exercises they had prescribed and begin regular strength exercises - starting with that 50 pounds and increasing 10% a week.  On Friday, I did a routine of strength exercises.  Had to keep the resistance lower than expected on some moves, but got through it with no soreness afterwards.  I used machines for everything - no bodyweight or unstable moves yet, except for heel raises off a step/block.

Went for my first real bike ride this weekend.  20 miles on a greenway - so it was about as flat and straight as it gets.  A group of friends was nice enough to plod along with me, and it felt great to be out there.  Unlike the walking, on which I feel every step, pedaling was pain free.  I may buy a unicycle for the office...

 

WEEK 8 (2ND WEIGHT-BEARING)

Got a couple of bike rides in this week, and I've also begun to swim with leg kicks.  I had been using a pull buoy to keep my legs afloat while using only arms.  My first attempts without the buoy consisted of the legs floating freely and only light kicks with the right (good) leg.  But I've progressed to light kicking with both legs and there is no discomfort.  This is a marked improvement, as swimming hurt that knee like crazy before the surgery.  As for the bike, I ventured out on my road bike with cleated shoes and pedals.  Did two very short (18K, 32K) rides - again with no problems.  I think if I really cranked it, I would feel it, but easier pedaling and high cadence is fine.  The short distances were about all I could handle.  Climbing even easy grades really brought me to a crawl.

Strength rehab went well.  Did the basic routine (single leg press, bilateral leg curl, terminal knee extension - left only, hip abduction and adduction on machines, calf work on a block and machine, and hip extensions from a low cable - left only because of consideration of standing on that leg), every other day.  The leg curl movement bothers the medial repair site at full extension, so I've limited the range of motion on that one.  This week, I had added 10 percent only to the original leg press weight for the left leg, butI I think next week I'll bump up the weight a little on everything.

I still "feel" the knee on almost every step, but I'm getting many comments that I'm moving better.  I finally shelved the cane mid-week.  The toughest movements are in the office, where I don't do much normal striding, but lots of little twisting steps around machines and people.  It's been variable when it feels the best - sometimes early in the day, sometimes at night.  It seems to feel better after the strength work, I think because the muscles, despite the fatigue, are firing fully and supporting the knee well.
The knee continues to swell.  Today seemed worse than usual, but the cycling seemed to alleviate it.


WEEK 9 – EARLY

A very good weekend.  Another short ride on Friday evening.  Saturday I walked farther (and longer) than any time previously.  The walking was all for running errands, but I covered some long distances.  Sunday was a long bike ride - 55 miles.  In hindsight, it was about 10 miles longer than it should have been - but at the end it was fatigue and not knee pain.  Like any other time you ride beyond your conditioning, it was soreness from being on the bike (hands, neck, seat) and the fact that my legs were running out of gas.  I had planned to keep the pace very reasonable and take a few breaks, and I did.  Once I tired, I really crawled the last 15K or so.  It was a great route around Franklin County.  It was pretty flat (except at the end, but that may just have been my legs), and very scenic.  And every road surface was smooth.  

I got to the pool both days, too.  On Saturday, I swam laps, and did more yards while kicking.  After the bike ride, as well as after the lap swim, I did rehab.  Some squats, but more water walking.  At this point, I do about 500 feet at a time.  After the walking and range of motion activities, the knee always feels better when I get out of the pool.  For that matter, my legs were pretty stiff getting off the bike, but the knee felt good.  Overall, I'm feeling the repair site less each day, but I still have a noticeable limp.


END OF WEEK 9

This week (M-F) was a consistent one for rehab.  I got strength exercises every other day.  Increased the work in various ways (weight, ROM, reps) throughout the sessions.  Also got water rehab in each day.  At this point the water exercises are usually walking in waist deep water, lateral steps in slightly deeper water, and one-legged squats on the affected leg.  I had been walking 500 feet - this week increased to 600.  Likewise went from 100 to 200 feet of lateral movement.
For regular exercise, I swam or rode all five days, and on a couple was fortunate enough to do a little of both.  The one ride on the road was the hilliest to date.  Didn't push it much, but felt the knee more than any of the other rides.  On Friday tried the training fins (flippers).  No actual pain, but I could feel more pressure on the knee while using them, so I gave up on them after just a couple of laps.

As far as the knee goes, it feels a little better every day.  Movement comes easier.  The exception to that was Wednesday, when it was much more sore than usual.  Still did the scheduled strength exercises with no issues.  Then, on Thursday, the knee felt much improved - no only better than Wednesday, but better than what I would have expected from the normal rate of progress.  Thursday felt like it should be Saturday, if that makes sense.

The aspect least improved is the swelling.  There are still times when it's quite puffy - especially if I've been standing on it for a while.  Unfortunately, that's most of my work day.


EARLY WEEK 10

Tried something new in the water rehab - running.  It was deeper water than I walk in - shoulder depth, or five feet.  I had tried this once before and felt the landing, so I abandoned it quickly.  This time I was able to do 300 feet with no problem.  Might do this more often, as it's easier to go back and forth in the deeper part of the pool than the 3.5 foot area, where all the little kids hang out near the wall.  The purpose of these exercises isn't so much for conditioning as it is for practice walking (or running) with a normal gait.  After I get out of the water, the knee always feels better. 


END OF WEEK 10

Not much to report.  Things continue to improve.  Did increased resistance on the strength exercises and increased distance on the water rehab with no problems.  Added a couple of bilateral moves to the strength routine that challenge balance more than strength - standing on both two balance disks and the Bosu (upside down) and doing squats.  
The water routine at this point consists of walking (600 ft.) in shallow water (belly button), lateral walking (200 ft) in deeper water, and a set of one-legged squats (15-20x), also in deeper water like the lat steps.  I gave up on the running in deep water, because I could feel it at the repair site if I lost a little balance.  Depending on the schedule, I may do the routine a second time if I can.  The tough part is avoiding all the other pool users while a go back and forth.


END OF WEEK 11

This week my walking felt normal for the first time.  People commented on the improvement, but they always do.  However, I felt more discomfort than previously.  It took me most of the week, but my theory is that the swelling has diminished considerably, and that extra fluid may have been creating a little more space between the articulating surfaces.  This week also saw far less time in the water, as Justin has returned to school and scheduling made it difficult to get there.  Still got daily pedalling in, be it on an exercise bike or the real thing.

Increased the resistance on the strength exercises, as scheduled.  I considered backing off, but I felt no discomfort while doing them (and felt better afterwards, as usual).  The only one that was a problem was the leg curl, and I found that restricting the range of motion (back to where I had started) took care of that.
With the swelling subsiding, I notice more of a difference in size between the legs.


END OF WEEK 12

This has been the best week, by far.  Several people commented on the lack of a limp, and walking certainly felt normal.  And after the previous week's soreness, the knee felt the best it has to date (since I've resumed standing on it).  I was supposed to have my final followup with the surgeon, but they postponed it till next week.  Too bad, as this week has seemed as if all is returning to normal.

Tried two new activities: deep water running and the elliptical trainer.  The deep water running was interesting, but I'm not sure it really works as a lead-in to regular running.  The motion felt more like cycling, and is of course non-impact like riding a bike.  The elliptical trainer mimics the running movement more.  I put it on medium grade and resistance, and just did a few minutes (10) - moving both forward and backward.  No problems, so I'll probably try to use the elliptical instead of the stationary bike. 

As it continues to be about a million degrees here, still got several days of water walking (and swimming).  My cycling fitness is increasing, and I'm able to push faster uphill.  Because of the soreness I had last week, I increased the weights on the strength exercises less than usual (less than 10%).  Also limited the range of motion a little.


90 DAYS OUT

That's what the nurse said on my last follow-up with the surgeon this week.  I’ve been off crutches for 6-7 weeks, but it seems like a lot longer.  The doc’s compliment to me was that I have "done everything you could to make this procedure successful."  Now, only time will tell.  He outlined a plan to return to running, which I'm in no hurry to implement.  He also said he didn't see a need to schedule another appointment, but asked that I drop him a line several months out to let him know how things are going.  Obviously, should I have problems, he wants to see me.  I told him of my plan to have the left knee catch up to the right knee on strength exercises before I attempted running.  He said that their experience had found that the legs failed to get all the way to 100% strength until the athlete started running again.  Of course there's a difference in what I'm proposing.  He was referring to testing the leg for maximum strength.  I'm not worried about true maximums, but only in "functional" strength - the weight I use for exercising.  At this point, I've been increasing 10% a week with no issues.  If that continues to be the case, I'll be even in five to six more weeks.

A day after that appointment, I tried walking farther than I have previously.  I've spent lots of time cycling for short periods (and long) and swimming, but no real conditioning on my feet.  I walked about a mile and a half, and was surprised how tired my knee was by the end - specifically the quad close to the knee.  Also walked another 3/4 mile later in the day.  The knee was a little sore after that.  Dr. A. said that at this point, it is okay to push things far enough to be sore.

The soreness might actually have come from the strength workout the day before.  I added several more advanced hip movements that required standing on on one leg.  A couple of the diagonal movements put quite a bit of torque on the standing knee.  So when I did strength work again (today) I left those movements out.


SIX MONTHS

The rehabbing has continued to go smoothly.  As can be seen in the log, I've been diligent about doing strength exercises three times a week, with steady increase in the resistance each week.  My goal is to being able to press my own weight (185) with the leg, and I'm close.  Other leg exercises are back to the level of resistance I was using before the injury.  What isn't shown in the log is an almost daily regimen of cycling.  At about the four and half month point, I had regained my conditioning level to be able to ride a century (100 miles).  In fact, my cycling fitness is higher than it has been for several years - mostly because of the daily work.

At this point I am ready to try running.  The plan is to ease into it very gradually.  The first day (12/2 in the log) was only five minutes total running, one minute at a time in between 2 minutes of walking.  The second was 2 minutes of running and 2 walking with a total of 8 running.  However, the third attempt increased to 3 minute intervals of running, totalling 15, and my knee was sore after that.  That emphasized the importance of patience and adding to the workouts VERY slowly.  I've got no goal set for running, so it can be as gradual as necessary.

 

NINE MONTHS

This corresponds to the end of the exercise log.  As you can see, running has been reintegrated into my exercise routine.  The distance has continued to gradually increase, up to 10K.  The main limitation  with running is speed.  There are no problems during or after running if the pace is kept relatively easy (for me).  However, "pushing it" leads almost immediately to discomfort with soreness afterwards.  My theory on this is that the longer stride with a quicker pace mimics the movement/stride of the run which led to injury (which was fast).  This means the joint is articulating  on foot strike in a fashion similar to that run, so there is more pressure on the defects.  This is not a problem for me, as I have no plans to be a competitive runner.  But it should be a viable option for fitness.  On other exercises, the leg is back to full strength, and the variety of movements appears to be unlimited.  For all intents and purposes, rehab is over and I'm back to normal exercise and activity.