Nymeria soaks in the bacta tank - (ACL reconstruction and rehab log)

[Nymeria]

@Obax: yep. That's exactly it. I technically could do pull ups, but I'm afraid of doing anything at all that could possibly lead to any impact on the knee.

Some of the hardcore climbers, when recovering from this type of injury, will put on their harnesses, secure themselves to the pull up bar/campusing wall/etc and work the upper body that way. I'm not fully comfortable with that, so I'm going to use this as an opportunity to use the lat pulldown machine and work on the bar to chest part if the motion.

I may have to get a rice bucket to maintain my grip for the next two months, until I can do one legged toprope.

[Yuen]

Re: more isn't better-

I'm sure someone like Yuen could explain this much better, but I'll take a stab from my understanding of the whole process.

For ACL reconstruction, one of the factors is regaining muscle strength in all of the muscles that stabilize the knee, which would normally suggest that pushing things to strengthen those muscles would be a great thing. After all, the muscle strength is the thing that lets you feel more physically capable and ready to get back into normal activities.

But, there's also the healing of the graft itself to consider. For mine (hamstring autograft), the graft is attached by drilling holes in the bones, and then attaching the tendon with screws. So, it takes some time for the tendon to affix itself to the bone. Too much stress before the area is fully attached and healed could lead to detachment, which in turn leads to another surgery.

Also, the tendon is weak until your body regrows a network of blood vessels in the tendon. This takes about 12 weeks. Too much stress before then could lead to tearing or over stretching the new ACL.

So, the PT is largely a balancing act between letting you maximize your muscle gain while still protecting the graft from too much stress. I think the 12 week point is when I'll be cleared to return to a lot more activities.

 

You understand the ACL rehab concept really well Nymeria

 

It's been a while since I've examined or treated a knee (doing purely hand and wrist work now), but I remember the basic principles.

 

Like you said you want to regain muscle strength and ROM as soon as possible. But you don't want to detach, rupture or stretch out your graft so it becomes lax by doing things too early. Getting that balance right is the hard part

 

Pull out at the graft/bone interface is the less common mode of failure. The failure load of an normal intact ACL is  slightly greater than 2000N. Modern fixation methods start their pull out strength at slightly greater than 1000N. Depending on the fixation type it takes up to 12 weeks for the graft to incorporate to the bone.

 

Failure of the actual graft itself is the more common mode of failure. If you had the type of graft I think you did (ie a 4 bundle hamstring) the ultimate tensile load at day 0 is around 4000N. So it is actually stronger than your native ACL to start with (but the fixation in bone is weaker at day 0 so you still can't push it).

 

However the graft actually begins to die (central necrosis) from lack of blood supply when it gets ripped from your hamstrings (and all the blood supply) and shoved into your knee (which starts off with no blood supply). So it begins to lose strength from day 1. However it then begins to develop a new blood supply and remodel into a ligament (I think they actually break it into 3 stages of synovialisation, revascularisation and ligamentisation, well 4 stages if you count the initial necrosis stage).

 

Anyway what this means is that your graft is at its weakest at around about the 4-6 week mark (and not as you would expect at day 0). So that would be the only thing to consider. Don't get too confident and start pushing limits at 6 weeks because you feel 6 weeks of healing means your graft must be 6 times as strong now. It means that your graft has died a bit and lost strength, and you are waiting for new blood supply to begin to re-strengthen things. Just stick to to the regime your doctor and PT give you, and leave the pushing things until later. (Which I'm sure you were going to do anyway!)

 

In terms of what motions you are allowed to do, they of course start at things which stress your ACL less and gradually increase. Contact sports which require twisting and pivoting of the knee are the worst. Drills which require twisting and pivoting are second worst (unfortunately I believe climbing would put your knee in twisting/pivoting positions). Open kinetic chain exercises are worse than closed kinetic chain exercises. You of course don't have to worry about any of this, you just follow the program

 

---

 

I also don't know if I've said this clearly enough to you yet: From what you write, you are the ideal patient that a surgeon would want to have. And if you continue putting as much thought and effort into you rehab as you are right now, you are going to have an excellent long term functional result. Most doctors would be overjoyed to have a compliant, motivated, intelligent person such as yourself as a patient. I bet your doctor is happy every time he sees your name on the follow up appointment list

[cobaltsword]

i gotta catch up on everyone, including you Xo but so far as I can see you're doing just great i'm so glad to see your knee is healing so well ^^

[Nymeria]

Yuen, thanks for that wonderful explanation! I am trying very hard to be both diligent and compliant with my rehab. I think sometimes that being slightly older is working to my advantage. If I had gone through this 10 years ago, I'd be one of the people pushing too hard and returning to climbing before I should. But now, I'm old enough and wise enough to realize that the climbing walls, hiking routes, weight training, etc will all still be there for me when I'm finished with rehab, and the best way to enjoy them for many years to come is to do all that I can to ensure that my knee ends up being as healthy as possible. I'm trying really hard to view this as an opportunity to try out the things I'm actually allowed to do rather than dwell on what I can't do.

Day 16: did my morning PT, and then went to the gym. I kept things light and easy, with 10 minutes of slow, tensionless cycling for knee ROM followed by 3 sets on a lat cable pulldown machine, the incline press machine, and some side pulldown machine where your arms start up and your elbows pull down to your sides.

Since I've mostly been doing body weight stuff, I had to make rough guesses as to the weight. Unsurprisingly, I grossly underestimated the necessary weight for the pull machines and overestimated for the push one. It was pretty easy to use all of these machines without having any involvement at all from my injured leg.

I did have a few very minor twinges in my knee from the cycling. I think I was twisting my leg slightly upon occasion. I doubt this is a huge problem, but I think I'll wait until my next PT session before I try cycling again, just to make sure everything is okay.

[Nymeria]

People who have been through ACL rehab often say the process is filled with ups and downs. I've really been feeling that for the last two days.

The ups:

-I can channel my desire to "push it" into upper body work. I actually gave myself upper body DOMS for the first time in the last 6 weeks.

-I weighed in at 147 lbs, fully clothed and with my 3 lb leg brace. So I probably weigh about 142 naked. Granted, most of that weight loss is leg muscle (which I knew I'd lose), but at least losing anything is better than putting on fat.

-I've been consistent with my PT exercises.

The downs:

-while I'm completely off of crutches in the house, I'm nervous about walking around outdoors without them.

-I will randomly have painful twinges in my knee, stiffness, tightness, and cramping.

-I'm still paranoid about somehow tearing or stretching the graft.

-the road ahead seems so incredibly long.

[KB Girl]

You're doing so well. Im impressed with how positive you are!

Good to hear that you could challenge yourself with upper body work, sometimes doms can be a very nice feeling

 

Are you sleeping better? Better able to take care of yourself and your family again?

 

The explanation of how this reconstruction + recovery works is actually really interesting. Sad to know you're living that right now, but still very interesting. I can imagine you're really paraoid about damaging things somehow.. Hopefully you'll get more and more confident as you go along!

[cobaltsword]

seems you're still doing better though i can imagine the paranoia, i would be too ^^

still progress seems to be made and that's what you should focus on

[sammiejune29]

So glad to hear that the surgery went well!

 

When I was going through everything with my back surgery, I was definitely frustrated at not being able to do all the things that I wanted to do, but I like to find the silver linings in things. So for me the silver lining was that for two months, the only thing that was expected of me was to take care of myself and get better. I tend to push myself super hard at everything that I do and after pushing that hard for so many years, I took the break that life gave me and actually relaxed. Don't get me wrong, I was still frustrated a lot, but after all was said and done, I felt more at peace than I had been in years. I also took the opportunity to do things that I had been meaning to do for years and had never found the time to do.

 

Here's to the silver linings *cheers*

[Nymeria]

@KB: still hit or miss on the sleeping. I had a couple good days in there, but the last two have been pretty bad. It's tough to get comfortable in the first place, and I can usually only sleep for a few hours at a time before stiffness or muscle cramps will wake me up.

@cobaltsword: I'm definitely making progress, but it's so slow. I've never been particularly good at being patient with things like this.

@sammiejune: I really wish I had gone through something like this before having kids, rather than while actively trying to parent them. It would be a lot easier, both physically and psychologically, if I truly felt that my only duty right now is to heal. I'd normally enjoy the extra reading and video game time, since I typically don't get much, if I didn't feel guilty about shirking my duty toward my kids.

[Nymeria]

2 weeks + 5 day update:

I slept poorly, my muscles were stiff, and I felt like my ROM was poorer today than it had been. Still, at PT, I measured at 115 degrees, which is an improvement of 5 degrees over last time. I'm still not quite at full extension, which is slightly concerning. I mean, the leg will fully extend under pressure, but it needs to be there while relaxed.

I at least got a couple new exercises, which will alleviate the boredom somewhat. I really hope that I get a good night of sleep. Being sleep deprived makes me much more moody and depressed.

[Nymeria]

Nothing new to report. Things chug onward.

I'm a huge football fan, and lately, I've become more keenly aware of knee injuries to NFL players. So good luck to Gronkowski (1 week ahead of me) and Navarro Bowman (2.5 weeks behind me) with their recoveries from basically the same injury and surgery I had (untreated grade 3 mcl and reconstructed acl).

When I'm getting frustrated with my rehab and PT, it helps somewhat to picture big pro football players having to endure the same crap I am. It'll be interesting to see how they're doing next fall, when the 2014 season starts.

Just for fun, here's a link with a picture of Bowman's injury. http://www.usatoday.com/story/sports/nfl/niners/2014/01/20/navorro-bowman-49ers-knee-injury/4654855/

That must be what my leg looked like when I was snagged and hanging upside down.

[KB Girl]

Shit, that looks horrible :/ 

 

Hope you got a good nights sleep!

[Nymeria]

3 weeks post-op today! I'm at full extension, 120 degrees flexion, and the leg is continuing to get stronger. I was even allowed to walk a bit without the leg brace at PT. Everything seems to be on track.

One of the things I haven't talked about yet is the time required on a daily basis for rehab. A home PT session takes about 25 minutes with another 20 minutes of icing after. I have to do 2 if these each day. PT sessions happen 2-3 times per week and take 90 minutes including icing. The PT session only replaces one of the home sessions.

So, 4-5 days per week, I have 90 minutes of PT related stuff. 2-3 days, I have 135 minutes. For me right now, it's mostly ROM work. I bet the time demands will increase when I'm cleared to do more strength work.

[Nymeria]

It's kind of a rehab milestone. Today, I'm taking care of my 3 year old by myself all day. I'm finally stable and comfortable enough with the standing and walking to handle routine household stuff.

It's going to be tricky to work in my 2 PT sessions today. I'm not comfortable with taking off my brace and having my leg in an especially vulnerable position when my son is in my space. And he has been too clingy lately for me to ask him to play in another room. Hopefully, he will take a nap in the early afternoon.

[KB Girl]

That's good, great even! How is it going? Reading how much time the PT takes you helps understand how that would be difficult with a 3 year old around.. 

[MasterOfCows]

Good luck!  I can't imagine adding kid(s) into the mix.  

Let us know how it goes.

[Nymeria]

Yeah. The whole experience would be much easier without small kids. I constantly have to be aware of my son, what he's doing, and how vulnerable my knee would be if he gets too close or too wild.

I'm still being very good with following the PT, but i am getting a bit bored. I'm definitely going to have to get more of a timeframe for when I'll be able to cycle, swim, or do light yoga.

I'm also starting to think about going on a light cut, since I'm not allowed to really strength train my legs much, and then bulking when I start doing much more hardcore strength building (at 12 weeks post op?)

[cobaltsword]

so so so happy to see you're leg is doing great i'm behind on everyone but your doing awesome, so glad to see you can walk about again ^^

keep it up

[KB Girl]

Are you in control of all meals/cooking again? If so then it might be worth considering a cut. But only if it doesn't affect your happyness too much- you've already got enough to deal with without adding the sometimes emotional/grumpyness of a cut. 

[sammiejune29]

@sammiejune: I really wish I had gone through something like this before having kids, rather than while actively trying to parent them. It would be a lot easier, both physically and psychologically, if I truly felt that my only duty right now is to heal. I'd normally enjoy the extra reading and video game time, since I typically don't get much, if I didn't feel guilty about shirking my duty toward my kids.

 

I hope you know I wasn't suggesting you ignore your kids! I understand how much more difficult that would make it but I think all in all you are handling it really well

[Nymeria]

3.5 week update:

Today, I'm having random leg pain. So, my ROM for morning PT was pretty bad. From what I've heard, it's pretty typical to have good days and bad days when rehabbing an acl.

Gym workout: 3 sets of lat pulldowns, rows, overhead press, and bench press. All of these were on cable machines.

I'm starting to consider joining the next 6 week challenge. My goals will be somewhat lame, but I miss the community aspect. If I do, I'll probably have a diet/cut goal, some sort of upper body strength goal, and a grip training (grip putty or rice bucket) goal.

[obax]

There are no lame goals. Grinding out the basics might not be glamorous, but considering what else you've got going on, the basics certainly aren't lame. You're doing what you can now so that when the knee is all better, you're ready to burst back into the epic goal level like it never happened.

 

And I'm sure you know, all the Assassin's would be very happy to see you back in the challenges, regardless of what you're doing.

 

P.S. I answered your rice bucket question on my thread. I'm not sure it's helpful, but it's there...

[Nymeria]

I'm just happy that I've reached a point where setting some goals is even feasible. I considered trying to participate in the current challenge, but there were so many unknowns surrounding the surgery and early stages of recovery.

I asked some of my climber buddies about the rice bucket, and their view was that it was more of an injury prevention tool than a grip trainer. It really works the antagonist muscles, which helps maintain balance for climbers who overwork their grip. I'm going to try to combine rice bucket workouts with some sort of actual grip trainer, like maybe grip putty.

[obax]

That actually makes sense, re: the rice bucket, which is why it's probably a good idea for me to stick with it. I wonder if it's different for more experienced climbers too, whose grip strength is really well developed to begin with, versus someone like me who's still got a way to go.

[Nymeria]

Bleh. My knee is sore and stiff, I'm having poor ROM, I'm paranoid that I've somehow torn the graft, and I feel like my leg is never going to feel normal again.

I have to keep reminding myself that I'm only 3.5 weeks post-op, the process is slow, random pains are normal, and I will experience "bad days" as I rehab. I'm glad I have PT tomorrow, since the therapist will most likely reassure me that everything feels correct when she manipulates my knee.