Week 2, ACL Recovery

I started off the week with a milestone by going back to work (a desk job in web development). To my chagrin, there was already a message when I got in from my physical therapist cancelling my appointment that morning.   Now, my next appointment was Wednesday, just two days away.  But I had to have my  PT fix, so I quickly got a new appointment for Tuesday, leaving me with two days in a row of PT.   For the most part this was a good thing, but the Tuesday workout left me so sore and tight that I’d actually lost a degree of flexion by Wednesday.  Horrors!  On Friday things were much better, but we forgot to measure my flexion, and there was no way I was going to report a negative progress until I had better numbers, which I got today (see below).

Overall, the PT was once again fun and challenging, with a lot new exercises for balance, proprioception, and gait, all stuff where my background in karate really helps.  However, there were two exercises—introduced to me on Tuesday (Day 11)—that were a bit more challenging. The first had me sit on a stool and pull myself forward using my heels.  I just couldn’t do it with my injured leg at first.   I kept trying until my calf muscles cramped and my hamstring graft started hissing at me.  I probably worked it more than I should have and pretty much did myself in for the PT session the next day.  But I got some more time on my beloved NuStep and a nice calf massage as a consolation prize.

The Atomic Wedgie StretchThe second exercise is a flexion stretch that has me lying on my stomach and pulling my foot back towards my butt using a rope (a leash works great, too).  I call this one the Atomic Wedgie Stretch because it reminds me of how my friend’s older brother would ratchet up the intensity of wedgies he gave us when we were in middle school by pulling back our calves and hooking our underwear over our feet.   While less painful (and certainly less demeaning) than those old wedgies, this is the most difficult of my exercises.  It doesn’t really hurt.  But pulling against the tightness in my knee requires concentration, relaxation, and deep breathing.   I love doing it because I can feel it stretching my knee.  I dislike it for the same reason.

By Friday, things were back on track (despite missing the flexion measure) and I was psyched enough by how things were Poor man\'s stationary bike.going to pull out an old piece of equipment that we bought in the early 90s and have neglected ever since. It’s a stand that turns my wife’s ancient Nishiki ten-speed into a sort of poor man’s stationary bike for days when I can’t get to the gym.  The bike’s tires are flat, and the whole thing looks a little rickety.  But it’s stable enough to hold me, and the crossbar is low enough to let me get my injured leg over.  My physical therapist explained that the motion is key to pumping synovial fluid—the main source of nutrients for the knee joint—in and out of the knee, helping with swelling and healing. Kind of fun to find such great use for what has essentially been garage filler for the past decade.

All in all, another good week with measurable progess and new and interesting things to work on.  So without further ado, here’s the week in stats.

Week 2 Benchmarks

Exercises

  • Leg raises (slow descent), 4 sets of 10, 1-3 times per day; added 1lb weight on day 11.
  • Balance on injured leg for 15 seconds (sometimes extending good leg forward, to side, and backward), 2 sets of 10, 1-3 times per day.  Started on day 11.
  • Treadmill, 10-minute session, walking forward — and starting on day 17 — walking backwards.
  • Steps (real ones!), ascending with no brace, day 14.
  • Step down from 4″-block, 2 sets of 10 at PT sessions.
  • Balance board, side-to-side balance with 15 squats and front-to-back balance, day 14
  • Still doing most of the exercises from Week 1.

Flexion

  • 115 degrees on day 11.
  • 114 degrees on day 12 :-(
  • 124 degrees flexion on day 17.

Walking

  • Brace most of the time, days 8-17.
  • No brace, mostly in the house, days 8-17.

Pain and Meds

  • Some Muscle pain, usually around hamstring graft.
  • Ibuprofen as needed, but I often forget it.
  • R.I.C.E. – continuing to rest when I can, ice 3-5 times a day, wrap with an ace bandage at night, and elevate when resting and sleeping.

Week 1, ACL Recovery

Some guy enjoying the NuStep reclining step machineMeet my new love.  No, not the guy.  The machine.  It’s called a NuStep.  We met at Physical Therapy, on my second visit, and I want to move in together.   Well, I’d at least like to have one at home for a few weeks.  It’s a reclining step machine.  And, it’s great for getting that knee moving in a controlled way. Unlike a bike, the pedals just go back and forth. No rotation.   You can sit back and take it nice and slow.  Very relaxing and rewarding.  I can feel that knee stretching oh so nicely.

To be honest, I kind of feel that way about a lot of my physical therapy.  So far, the exercises haven’t been painful (except maybe pushing the flexion), and usually feel quite good. I enjoy being able to impress the therapists with some of the things I can do and appreciate getting encouragement and feedback.   The only hard part has been trusting the leg when working on weight bearing.  It’s the ‘couples therapy’ part of the process. So far, the knee hasn’t let me down, and I haven’t pushed it too far. We’re starting to build up trust again.

Mostly, it’s just been mental.  It’s been beautiful out, and I’m starting to get a bit of cabin fever.   I miss not being physically active.  I miss karate.  I miss being able to pick up my sons and tickle them to the floor.  I’m sick of sleeping on my back with my leg elevated.  I miss being able to check out the karate-induced callouses on the bottom of my left foot. (Yeah, I know. Yuck.) Thank god for books, blogs, the rest of the Internet, and DVDs.

It’s been tough on the family. My wife’s been pulling a lot of extra bedtime and morning duty.  I’ve been doing most things for myself, but I am kind of in the middle of everything down here on our first floor. It’s probably been hardest on our two sons, neither of whom is used to having a father who doesn’t run around with them having pillow fights or playing with foam swords and armor.  The only member of the family who still seems to be enjoying this is our cat Josephine, who has yet to cease her furry ministrations.

Still, it hasn’t been as bad as I might have thought.  The phantom leg stuff seems to have stopped.  The knee seems good and strong.  It’s still tight, but  it seems to be getting a bit looser and less swollen every day.  A good start.

So with all that said, here’s the week in stats:

Week 1 Benchmarks

Exercises

  • Hamstring and calf stretches, 4 each for 30 seconds, at least 3 times per day.
  • Ankle rotations, 20 each way, at least 3 times per day.
  • Ankle pumps, 20, at least 3 times per day.
  • Leg raises (slow descent), 2 sets of 10, 1-3 times per day.
  • Heel slides, 2 sets of 10, 1-3 times per day.
  • Weight shift, 1 set of 10, 1-3 times  per day.  (Standing on one leg on day 7).
  • Step and lean, 1 set of 10, 1-3 times per day.
  • NuStep, 10 minute sessions at PT, days 5 and 7.
  • Incline squats (80% weight bearing), 20, days 5 and 7.
  • Bike machine, 10 minute session, full rotations(!), day 7

Flexion

  • 90 degrees on day 3.
  • 100 degrees on day 5.
  • 105 degrees flexion on day 7.

Walking

  • Two crutches, days 1-3.
  • One crutch, days 4-7.
  • No crutch, day 7.
  • Brace, days 1-7 (and continuing).
  • No brace, occasionally in the house, days 5-7.

Pain and Meds

  • Pain worst around stitches the first few days.  Some aching and tightness from swelling.
  • Brace, which wasn’t fitted correctly, caused my calf and hamstring to tighten when I first started trying to walk properly.  Very counterproductive. Make sure to ask your physical therapist for help!
  • Percocet, days 1-2, 5mg every 4 or so hours. 
  • Vicodin, days 3, 5, and 7 before physical therapy.
  • Tylenol, days 3-7 (ibuprophen prohibited by my surgeon until post-op visit).
  • R.I.C.E. – days 1-7.  As much as possible! Ice before exercises has been especially helpful. 

My Phantom Leg

A strange, kind of cool thing has been happening since my surgery.  I’ve been having an “out of leg” experience.

“Huh?” you may ask. Well, what I mean is that often, when I close my eyes or can’t see my injured leg (like when I’m typing on my laptop), I get the distinct sensation that the leg is not where it should be—that it’s in the wrong position. Not by much, mind you. But enough to make me look.

And when I do look, I am invariably surprised to see that it’s still up on the pillows, where I’ve been keeping it elevated, and not down level with my other leg, where I had just been sure it was. But what’s really weird is that I feel it momentarily in both postions and, for a split-second, I have three legs.

So, why? Why should this be happening? My best guess is the post-op swelling (and maybe some lingering effects of the nerve block) is interfering with the proprioceptor nerves in my knee, greatly reducing the number of signals they send to my brain.

The job of these specialized nerves is to send information about where the various parts of the body are in relation to each other. And when the brain stops receiving signals from them, strange things can happen, such as feeling a phantom limb in place of one that was lost.

But of course my leg is still there, and I can still feel it when I touch it or wriggle my toes. Which is why this only happens when I’m not paying attention to it, when I’m just letting it sit there and not looking at it. I think my brain just kind of loses track of it and slips into a default mode, placing my leg in a kind of at-rest position.

Cover of The Body Has a Mind of Its OwnNow, this all theory, I know. Some of it comes from talking with my physical therapists and with a researcher at the local university who’s looking at how better to revive the muscles surrounding injured and swollen joints. And some comes from a book called The Body Has a Mind of Its Own by Sandra and Michael Blakeslee about proprioception and ‘body maps’. But whatever the cause, I’m hoping it goes away soon. As helpful as a third leg might be in karate, I’ve already had more than my share of trouble with the two I had before.

And so, back to exorcising this phantom through R.I.C.E.


P.S. If you’re studying a martial art (or really engaged in any kind of sport), I especially recommend The Body Has a Mind of Its Own, which includes some intriguing research on things like how, when you pick a tool like a sword, the brain actually appears to start mapping it as if it is an extension of your hands, a part of your body. It took me a good while to find a copy in my area, but here are a couple of podcasts about the book and a link to a short article by book’s authors.

Nurse Kitty

Nurse Josephine on the job.

Do you have one of these at home? Ever since I got back home from surgery, our cat Josephine has made herself my constant companion, my cat nurse. She’s been near to, next to, or right on top of me nearly every one of the past 96 hours. With her rolling little purr, nice body heat, and sandpaper tongue, she’s served as sedative, bed warmer, and hygenist, subjecting my limbs on more than one occasion to furious little baths that leave me gritting my teeth. She’s only gotten up to stretch, make short visits to the great outdoors, eat, use the litterbox, or — as happened a couple nights ago to the detriment of my sleep — join a multi-cat, multi-floor, multi-hour ‘mousecapade’ that only ended when the Rodent Rescue Patrol (my frazzled wife) safely escorted one severely harried mouse out to the front yard.

I’m the first to admit that Josephine’s behavior may be more self-serving than maternal. After all, I am a captive lap. And she’s certainly gotten more than her usual share of petting and chin scratches in return for her attentions. But time and again, she’s behaved this way whenever one of us gets sick or laid up for a few days. She’s almost diagnostic in that regard.

I must say, though, that as good a nurse as she is, she’s actually a pretty bad physical therapist. She can’t seem to resist crawling on me when I’m doing my exercises. Leg lifts? Time settle on the pelvis. Quad sets? Time to walk on the injured knee. Ankle rotations? Let’s see if we can’t get some fur in his mouth. Puh!

But whatever her motives or shortcomings, she’s been excellent company and great medicine. If you’re going through something like me, I highly recommend getting a cat nurse. If you have trouble finding one, let me know. Josephine’s not very particular. I’m sure she’d make a house call.

Surgery Recap

When I first started reading the blogs of other ACL ‘survivors’, I found myself focusing on the entries about the surgery itself. I was struck by the variations on the theme. Inpatient vs. oupatient. Autograft vs. allograft. General vs. block. So, rather than delve into a narrative of my day at the clinic, I thought a simple list with some comments might be enough for others who are probably mostly curious about how these things might go.

Symptoms: Torn ACL in left knee and torn lateral meniscus as determined by physical exam and MRI. (During operation, the meniscus tear turned out to be minor and some free-floating material was found and removed.)

Surgery: Outpatient on April 11. Arrived at the clinic at noon and was back home (and monstrously hungry) by 6:30 p.m. About 2 hours of this was actual surgery.

Anesthesia: Femoral and sciatic nerve blocks just prior to the operation and general for the procedure itself. My experience with the blocks was very good. The tough part was getting in the house with a numb limb, but it dealt with the pain well. And the timing was pretty good, too. The afternoon surgery meant that the femoral block didn’t wear off until the middle of the night, so I slept well for a few hours.

To Hack Shaft who got a spinal block and watched his procedure: better you than me.

Replacement tissue: Autograft from the hamstring. This was my surgeon’s preference, and mine too. Patellar grafts seem to be less favored these days and probably not as desirable for us kneeling martial artists. An allograft from a cadaver, which Hack Shaft got, was never really mentioned as an option by the surgeon, and I didn’t really pursue it. Not sure why because the results are known to be very good.

Incision pattern: Three small arthroscopic incisions around the knee and a longer incision a little off center just below the knee for the replacement tissue harvest.

Pain and pain meds: When it comes to pain, I think I got lucky. It hasn’t been that bad. The worst, for me, was the burning sensation around the incisions when I first started with the crutches. I think the nerve blocks blunted most of the early pain. I did get a little fentanyl post-op, which was probably the nicest thing that happened to me that day.

When I got home I immediately started taking Percocet in order to be ready for when the femoral nerve block stopped working. Percocet’s a nice little wonder. But usually, after I’ve taken it for a few days, it starts to destroy my sleep, filling it with disturbing dreams in which I’m often being hunted (seriously!). So by the second morning I decided to just go with Rapid Release Extra-Strength Tylenol and take a Vicodin just before my PT sessions.

Surgical team: My lead surgeon is a star. He’s got a great reputation. One of my friends, who is himself a surgeon, asked around on my behalf and got only good reports. Plus, a few days before surgery I was on my way up to the surgeon’s office to pick up some paperwork, when who should get on the elevator with me but a former, All-Pro, NFL Hall-of-Fame defensive lineman who now lives in my area. He was obviously on very familiar terms with the staff in the office and announced he had a 9:15 appointment with my surgeon. Now there’s an endorsement.

More to the point, my surgeon and his team do a lot of knee and shoulder work. They are old hands at it. There’s a great section in the book Complications by Atul Gawande where he profiles a surgical center that does only hernia surgeries. Sounds like a factory, but the results are clear: an extremely high success rate and less pain for the patient. If you haven’t read the book, I highly recommend it. You’ll come away with a more sobered, yet all the more respectful view of the medical profession.

If someone reading this thinks I’ve left out some important aspect, let me know and I’ll amend the post. I’ve also got pictures from inside my knee, so if anyone is curious I can post them separately. Otherswise, I won’t force them on the unwilling.

How about a nice Myoclonic jerk?

Ever been drifting off to sleep only to be rudely yanked awake by a violent twitch of your legs? If so, you’ve experienced what’s known as a Myoclonic jerk.

Generally, I’ve always find these odd twitches to be as amusing as their name, accompanied as they often are by a sensation of failing. A sensation that I suspect the brain manufactures simply to account for unaccountable muscle twitch. It doesn’t always happen that way. Sometimes you just twitch. But sometimes it happens just when you’re hitting that drifty, dreamy state where consciousness really does start to stream and “Whammo” you find yourself awake with maybe a touch of adrenaline coursing through you.

Usually, this is not enough to keep me from falling back asleep fairly quickly. But, when it happens the first few nights after surgery . . . well, it’s not pleasant at all. You get pretty good muscle contraction, and boy does that make your stitches burn. Ouch! It’s already hard enough to fall and then stay asleep on my back with my leg raised without these wicked little intrusions. Suddenly, the Myoclonic jerk has lost its charm.

Then again, maybe there’s some benefit. I’m barely able to contract my left quardrecips on my own. Maybe this is just my subconscious jumping in to help me with my physical therapy. Or just getting me ready for what’s to come, since I don’t have my first phyiscal torture, um, I mean therapy session until tomorrow.

“Blech” Thursday

“Blech.” That was the comment I’d received in response to one of the techniques I was demonstrating during my rank exam. And to be honest, that’s how I was feeling about the evening. “Blech.”

As performances go, it wasn’t really that bad. It just wasn’t that great, either. At least, not for someone looking to reach the next level of brown.

But the worst was yet to come. During a series of self-defenses, some of which were “blech” and few right on, it happened. I was trying to execute a relatively simple hip throw. I’d been having trouble with it recently, though I’d done it once so perfectly a few nights before that I literally swore out loud. I was just so easy and I’d been making it so hard. (Raise your hand if that sounds familiar.)

So during the exam, when I came up short on the technique the first time, I clenched my abs as I done those few nights before and rotated my hips. Only, it went wrong. Badly wrong. There were loud pops, and I went down.

“Did you hear that?” I asked my partner.

“Your knee?” he inquired back.

“Yep,” I said. And I knew it almost immediately. I’d torn my ACL. This Thursday had just earned an honorific. I suppose I could call it a “Black” Thursday. But it was the “Blech” that did me in. It was a black “Blech” Thursday.

So, here I am now — six weeks later — my first day after surgery, laying leg up with a laptop, a stack of books and DVDs, my iPod, and a couple of bottles of pain killers. It’s a little vacation, right?

To be honest, it hasn’t been too, too bad for me. The injury was nearly painless. The worst part was watching a video of the injury (yep, it’s on film) and seeing my knees drooping inward in the poor excuse for a horse stance that allowed my hips to go one way and my left knee the other. I wince whenever I think of it. Such a spectacular result for such a “blech” cause.

Even so, I feel lucky. Lucky to have done this nowadays, when the surgery is so routine and the ultimate result so positive. Lucky also to be living in a college town with a hefty athletics program and one of the best arthroscopic surgeons in the country. And lucky to have been studying martial arts for the past few years. I can’t imagine having to do this without the leg and core strength, flexibility, and balance that I’ve built up. Yes, I did this in karate, but I do believe that it’ll be karate that gets me through.

Today is day two of my recovery. On Monday, I start physical therapy, which I’ve been forewarned will be the hardest part. At one point, I was joking with one of our blackbelt instructors that I’ll need another kind of therapy with my knee: couples therapy. My knee and I are going to need to learn to trust each other again. It’s going to want me to not put it in jeopardy, and I’ll need to know that I can trust it to keep me stable. It’s going to be a long haul.

So, this is therapy, too. This blog. I can’t begin to say how helpful it was to discover the blogs of those martial artists in my position, HackShaft, Middle-aged Martial Artist, Michelle, and especially Black Belt Mama, and to follow their stories, each at different stages, of recovery.

So, I’m adding my voice to the small chorus of martial artists making their comebacks from this all too common injury. Hopefully, it’ll help someone else, too. And maybe, it’ll evolve into something bigger, a look beyond this momentary period of blues on the way to a black belt and beyond.