6-12 week "danger period"

[Alla]

Hi there

I have had several people tell me that the 6-12 week period is the most crucial time after an ACL reconstruction because during this period the graft is regaining a blood supply.  I've been told take it easy during this period, but I wondered what exactly that means. Today marks 6 eweks since my reco. I thought that so far I had been extremely careful already.... even to the point of being told by my OS that I am too careful (at 3 weeks after I had a fall at day 10).  

With the issues I currently have with lack of muscle strength I dont want to reduce my exercising... I want to gradually increase it as I have a 9 cm difference between my quad muscles and feel that I really need to focus on reducing that difference.  I am struggling to walk unaided because I havent the strength.

Can anyone suggest what constitutes "taking it easy" during this period,  especially in light of continuing a strengthening program??? Any ideas on strengthening would be appreciated to!!

Alla

[raquetball1]

Pretty much all my PTs told me during that period, as at all periods, regarding strengthening is that if it actually causes pain to the knee, as opposed to "good" muscle pain, nix it until you can do it without knee pain.  Do all the leg lifts you can tolerate as they are not knee stressers and help build up upper leg muscles.  Hope this is of some help.

[Gab]

Taking it easy in the sense of avoiding activities which put unecessary stress on the reconstructed ACL. Examples: Jogging and stopping suddenly (your tibia will want to move forward), avoiding twisting the knee like when you get in a car, open chain exercices like short-arc extensions/straight leg raises with weights (you should be fine without weights) and over all, just be careful not to fall as your reflex will be to avoid the fall at any cost and any cost can mean your graft.

Closed chain exercices like squats, single leg dips etc should not put stress on your new ACL.

[Alla]

Thanks....

I have an issue with the straight leg raises... I cant do them at will.  I have to do some first thing in the morning because my muscle is too weak later in the day.  I've actually only been able to do them since last saturday.... and I cant do many before the muscle is totally fatigued.  My Pt and I have been watching the lag reduce over the last 3-4 weeks (from 20 degrees to 15, then 10 then 5).... On my last visit we had it nearly 0 but I couldnt quite lift.... I've not been able to see him for over a week (hes on holiday) so his missed all my excitement at being able to do them unassisted.  I've been doing them in the pool too to try and add some strength and remind my muscles what to do.... that's been one of the real issues.... my muscles dont seem t remember how to contract and stay contracted.  I certainly have to make a concious effort to tell my knee cap to lift when I straighten to walk, it seems to forget (needless to say that I dont think Im at too much risk of injuring myself while running.... I still cant walk really well unaided). 

So Im a little frustrated at my weakness I guess..... I've gone from having two very muscular legs for a girl (apparently), to having one that is nothing but skin and bone... the other that has had to develop even more muscle to compensate....   and I am unfair to the recovering leg.... I keep comparing it to its bigger stronger sister (the good leg).

Like I said.... any suggestions for strengthening are appreciated... and I'll try those that I already have been given.

Alla

[Gab]

Hey just a question: Did you do any PT prior to your recon? How bad was your weakness/atrophy at that time?

I seriously did no PT whatsoever for the two months between the injury and surgery. My quads were but totally gone, I could only see the bone and a bit of flesh. I was partial weight-bearing in crutches as my muscles were too weak and the instability was out of this world. But 2 weeks after surgery I could do straight leg raises (with difficulty but when I concentrated hard enough on keeping my leg sraight, I could do it). I thought my situation was bad but yours sound like you have even more weakness.

Just curious.

In any event, don't give up! Those exercices really help getting that strenght and mass back.

[Gab]

Other exercices that really helped getting my strenght back were wall slides and squats. At first I thought I was going to fall all the time because my bad leg was shaking so bad from the effort but eventually I got it strong enough to the point of being able to do these exercices on one leg, then on one leg leg-press.

However, don't attempt these exercices before getting the green light from your PT. But it's just to give you hope that there is a gradually increasing set of exercices that WILL get your strenght back.

Take care. 

[Alla]

thanks heaps Gab.

I had muscle wastage apparently before the surgery, but I couldnt tell myself.  When the SPorts GP first saw me he said he knew I'd done something to my knee because of the quad wastage.  The OS said the same thing.  I asked about building up before the surgery but was told not to waste my time "save it for after surgery" was his exact words.  Since I had surgery 10 days after my OS consutation I can see why I was wasting time at such a late stage.  I still maintained my cycling.... which I'd done as soon as I was able to after the injury.  I ride 8 kms to work and back when Im able. 

After the surgery I had lots of swelling which my PT said was inhibiting my ability to contract my muscles.  It was some time before I could get the quad muscle to fire on command (I think it was almost a week after before I saw a contraction at all).  I also had a fall down some stairs that had me really worried that I'd done some damage so I had a period of about 4-5 days where I really didnt do much in the way of exercising properly because I was scared of doing damage.  I saw the OS not long after that and he said I was being way to careful.  So since then I've been going flat out (as flat out as I can any way), but I'd already lost a lot of muscle andgetting them working again has been tough. I have a lot of fast twitch muscles which aparently waste quite quickly...  It is getting better, but it is very slow.

Alla

 

[Orava]

Just to say thanks all - a great thread and some good points which I will bear in mind as I approach the "danger period".
Still on crutches but managing exercises I've been given well. Have a long way to go with weak quads too.
Orava

[tiggs]

Have you tried going to the swimming pool ?

I was non weight bearing for the 1st 4 weeks and then only partial for 3 weeks so my muscles were really weak but what I found reaaly helped was going to the pool every day just for 1/2 hour and did all my usual exercises in the pool. Particulary trying to walk with out the aid of my crutches! I found I was more confident in trying to walk well as if you cant do it or your knee gives ,you cant hurt yourself or twist your knee as you just drop down in the water no harm done and less stress ! I used this alot for practising my balance from one knee to the other.

Tiggs

[colin]

Hi there,
I had a hamstring ACL recon 3 months after stopping sport with significant muscle wastage.
Post-op I could not get any visibility of muscle in the recovering leg, nor could I get the muscle (for me the medial quad was the problem) to move consciously. The PT, to intially resolve this, gave me a black box with electrodes that you strapped to the thigh, and got me to carry out 15 mins of electro therapy every 2 hours (bit like a TENS machine if anyone has used it). In these 10 mins, I had to spend half the time letting the machine work the muscle and the other actively concentrating on trying to mentally tell the muscle to contract. (15 seconds alternating)
I did this for about 5 days and this gave me the initial ability to contract (ever so slightly) at will. From then on I focused on doing the contractions every few hours, but unaided by machine (still do a bit now - 5 months post op).
Other exercises that my PT gave me were:
1) stepping slowly down off a small phone book (from recovering leg onto good leg) - then building up phone book.
2) the old faithful wall slide (squatting with back to wall and sliding up and down)
3) the leg press at the gym.
I have focussed loads on this and although it felt painful in the knee itself, the pain has reduced and the muscle significantly increased. In fact my "bad" leg now has better defintion than my good leg if not quite yet the same bulk, but real close. I now have to concentrate majorly on my ham-strings.
With regards to injuries, I have had the odd fall, muscle tweak etc, but have found it best to get back to very light stretches and exercises as soon as possible, as long as I am not hurting the knee itself.
Hope this helps.

[Alla]

Thanks guys for continued support and suggestions.  Keep em coming!

I have been going to the pool...it is great.... although I live in a rural area so getting to the pool isnt possible everyday.... I go about 3 times a week and fnd it great... the only place I can do all my exercises

Colin.... thanks for all those suggestions... I'll ask my PT about the electo thing you sugested... although I think I am past that a bit now.. I can contract the muscle now.. it is just weak.  The Phone book is a great idea... I havent got a step to try step ups and downs... so I'll be trying that...With the wall slide.. I do try them.. but I find I unconciously make the good leg do the work... still working out how to make the other work a bit harder....

Alla

[raquetball1]

Alla

re the wall slides:  check with your physio or pt and see if they'll let you do one leg wall slide/squats.  Have to be very careful to make sure foot placement is correct, but you'll feel when it is.  Don't take them too low, just to where comfortable and do twenty at a stretch without touching down other leg.  This will eliminate the good leg taking on the burden.

Another good twist on the step-ups/step-downs is "dipping". And for this you don't need an isolated step:  stand on one step facing a wall or some piece of equipment you can catch yourself on and squat your bad leg on step to just touch heel of good leg to floor then back up twenty times catching any unbalance only with your hands...ie never fully putting down your good leg.  Start on whatever height step is doable for you.  I would urge you to try to find a board/step for step-ups/step-downs though.  They have a plastic/rubber model with square bases that you can add to or subtract from to get a comfortable height at most gyms.  Step-ups and downs, particularly backwards step-up on bad leg really seemed to help me turn a corner in strength and confidence and loosen up the stiffness and pain in knee for me.

Does your facility have a "sports cord"?  Just walk it out five times in each direction (1. walking forward 2. walking backward 3. walking side step from one side 4. walking side step from other side).  When completed, walk the cord backwards, ie cord is in front of you, to a reasonable distance and carefully do the two-legged squats under that tension.  If you have someone around to help you, then walk the cord out a distance, stand on operative leg and toss a weighted ball back and forth to someone else.  Have them bring in the toss from different angles. 

Back to leg lifts:  even after working with so many weighted machines for seven months, I do these on days I don't go to gym and still find them challenging when done in a slow, controlled manner. 

Good luck and keep up the good work.

[Alla]

Gee thanks for all those suggestions Raquetball1.... I'l lbe having a shot at those.... the reverse step ups sound good.... 

It seems that physio here is a bit different.... I dont seem t oget to use any gym equipment... most physios dont seem to have it... we have to join the local gym is we want to have ago at that sort of thing... my OS suggests that after week 8 I can do that.   When I go to Physio my physio basically checks my leg exetension to make sure that I can sill do that....if it isnt good then we work on that... then we work on the flexion.... he manually bends my leg to the point where I get pain and I have to work my knee to get the best flex possible for that visit.  He does have a step and has asked me to do step ups for him, but at the time I was too weak and unsure of my knee to do any more then a pathetic quarter of a step and I used the shelf to help (hee hee).  It exhusted my knee so much that we had to end the session.  his suggesion was to got to the hydro pool and try them there.... which I hve done.    I've gotten a lot more stronger since then.  So I reckon that I'll be able to do them for him at the next visit.   He also does make me to the other squats, SLRs and stuff as well.... to check my technique.

Alla

[libertynm]

Hi Alla,

There are a lot of good suggestions on this thread.  Another thing I found useful was a biofeedback device.  It was a small thing that would be strapped to my VMO and it would "sing" when I elicited a strong enough contraction.  I used this only a few times after I was able to elicit a relatively weak contraction on my own and it really changed the way I did my exercises (leg press and squats) so that they were more effective.  I also used electrical stim early on in the process (that helped a bunch).

Another thing to think about is whether or not you still have pain. . .that can inhibit contraction quite effectively.  If you can reduce/prevent pain (ie work just below the level you have pain, and use exercise modification, taping, anti-inflammatories, etc), even if it means backing off on some of your exercises, it may get you further in the long run.

Hang in there. . things will get better!  This is coming from someone who had an infection at 2 weeks, didn't start pt until almost 5 weeks, had massive muscle wastage, was on crutches through week 7, limped heavily at 3 months and wondered if she would ever walk normally again.  At 6+ months, I'm walking normally, my muscle mass while not fully back is about 3/4 there, I will get my activities brace in about a week, and plan on dancing shortly after.  It may seem an impossible recovery at times, but keep at it!

Much Aloha,
N

[Alla]

Thanks libertynm

I havent had much pain but I've had heaps of swelling at the beginning.  My PT said that was inhibiting my ability to contract the muscle (he said both pain and swelling did that).  It has been thwe weird thing about this whole experience is that I havent had a lot of pain.  I guess I have more now then I did at the start and really that has only been the screw settling in as everything starts to vascularise.  And that hasnt been anything too bad.  The swelling was particularly bad thou,..... at one stage I wanted to slit open my calves and let out all the fluid.  I do wonder thou if Im getting pain but arent aware of it??  I dont know if that is possible.. but even after the initial injury I wasnt really in pain.... I took one panadol the night that I hurt it and that was it (incidentally I had no swelling then).  My PT was digging his fingers into the joint 2 days after and I hardly noticed it.... that combined with the lack of swelling meant that he mis diagnosed.... but so did heaps of Drs I saw about it.

Anyhow..... Im feeling a bit beter about the whole thing at the moment.... I have just about dumped the last crutch..... tomorrow is week 7.  I really only take it on long trips now.  And I am able to do up to 20 SLR's as long as I do them first thing in the morning.... too much walking around and the muscles are too tired.  Although I do try to do them later in the day now.... should be starting to be able to do them soon.  I'm noticing that it takes longer for my knee to feel tired too.... at one stage I was only getting to 10:00 in the morning before I'd had enough.... yesterday I noticed that it was about 3:30 - 4:00 before I started to feel the knee tiring.  So that has to be good.  the Hydro pool is fantasitc.  I spent nearly a whole hour in there on saturday... which is good for me... I hate swimming.  most of the time just doing my exercises, but also chatting to another lady in there... who got the whole knee reco and knee replacement thing a bit mixed up... but anyway.... It was nice....and I think my knee appreciated the pool time... I thought I might have done too much, but it was all ok the next day. 

I tell you Im learning a lot about myself... I didnt realise how impatient I was.  Or how I really struggle with disciplining myself to do lamo exercises.  Most of my athleticism and fitness came from the fact that I play so much sport (several times a week) and not from repeated gym type exercises.... I even hate jogging... how bad am I!?!?!??!  I think Im more in favour of team sports... but anyhow... what that has meant is that I find it difficult to motivate. So I've been telling myself that the team sports wont happen if I dont do this stuff.... It is working ok at the moment... but I am so frustrated I cant play the other stuff..... I guess that I just have to wait.... this is the first netball season I've missed in 21 years.

Alla