ROM and Progress on Rehab after MUA and MFX - lots of questions

[PonyExpress]

Hi there

I've got a few questions regarding rehab and wondered if anyone would be able to offer some thoughts, comments, suggestions.

Background to my injury/surgery: 19th February fell off pony and hit the outside of my left tibia and femur on the pole of the jump, it REALLY hurt at the time  but just felt like a hard knock. Went to walk and it was painful to put my weight on my knee. Everyone insisted I 'got back on' - as horsey people do! which I did, with the help of a very high mounting block. Rising trot was just far too painful and it was the end of the lesson anyway, so got off and took pony home. Spent next 2 weeks resting, icing, compression and elevating, very poor ROM, doctor sent me for an x-ray 29th February -  nothing showing.

At this point I carried on with my life, working and riding etc with a significant limp, but could at least function, not in any particular pain, just could not bend my knee.

I'm in UK with private health care, so was finally referred for an MRI mid April, this showed significant bone bruising (8wks after impact) - OS was quite impressed that I hadn't broken anything! plus some minor indications that he wanted to explore further - but nothing major on the MRI except the huge white areas of bone bruising on the femur and tibia, he booked me in for an exploratory and clean up arthroscopy on 30th April.

I am now 3 weeks down the line from the surgery, the following is copied from the letter from my OS to my Dr:

The arthroscopy revealed an area of Grade III chondral damage in the weight bearing part of the medial femoral condyle measuring about 1.5cm x 1.5cm. The loose chondral flaps from the edges were shaved followed by microfracture technique for the damaged chondral surface. The lateral tibial plateau itself was slightly irregular and on probing it was clear that the articular surface over the lateral tibial plateau was mobile indicating delamination between the articular surface and underlying subchondral bone. OS said this was not a good prognostic sign. The anterior fat pad itself was quite prominent and this is often the cause for stiffness of the knee and hence this was debulked using a shaver.

The OS also performed EUA and regained full range of movements from 5o of hyperextension to about 130o of flexion, apparently the knee was quite stable.

PT had me weight bearing as soon as I'd had my first cup of tea and biscuits!!! and I was discharged the same day.

I've since had 2 PT sessions and my ROM has gone from 105 on day 9 to 125 on day 17.

My queries are regarding the pain and ability to achieve the ROM.  Everytime I begin my exercise regime my ROM is poor, it takes several minutes stretching, massaging and manipulating to get it all moving again. I can use a static bike with the seat on the highest setting, although getting that first revolution takes a while and hurts for the first few.

Although I can 'force' the ROM, I can't make my leg do it by itself, my brain tells it to bend and my leg just seems to ignore it. I am doing quad exercises as well as many others.

I do between 4 and 5 PT sessions a day and am up to 10-15 mins static bike with some resistance during each session.

I have always been very active, am 48yrs old and miss my horseriding, especially as the sun has recently come out and I could get a ride in after work. If only I wasn't worried about twisting my knee and damaging the microfracture area, and if it wasn't so painful to put my foot in the stirrup to mount.

Should the ROM go back to 'poor' within half an hour of a PT session? Is there a way to avoid this? I'm not convinced all of the swelling has gone down, would this be causing the pain and lack of 'natural' ROM?

I also still walk with a significant limp is there a way to rectify this? I'm not due for my next PT session for about 10 days.

I know in comparison to many on this forum my 'issues' are pretty insignificant, however, I would really appreciate any thoughts, comments, suggestions and of course your time for having got this far.

Many thanks 

[Maverick]

Pony Express, can you tell me more about your MFX?  When did you start weight bearing?  MFX typically don't allow for weight bearing for 6 to 8 weeks and you started immediately? 

Here is my background:  I am a 48 year old very active female, former MMA black belt, rock climber, cyclist, etc.  I am accustomed to working out 8-10 hours a week.  Last September I had a Lateral femoral condyle (LFC) microfracture (grade 4) in my left knee along with a lateral meniscectomy.  Surgery included 7-8 microfractures.  I am in my 8th month of recovery and it is going very slow.  I spent 2.5 months non-weight bearing and did not get off crutched completely until 5 months.  Waiting this long ended up with significant atrophy in my leg.   I have an unloading brace that I just recently set to no-loading (0 setting) but still wear when my knee starts getting painful.  I work out at the gym 3-4 days a week with 30 minutes cycling (90 cadence) and using weight machines for leg press, leg extension, leg curls and abductor exercises using a cable and ankle cuff. I still have significant knee pain in the microfracture area 2-4 days a week, mostly at night.  My surgeon did a bone scan and MRI at 5 months to determine if there were any issues with the knee.  Nothing showed up other than thinning cartilage in the original injury area.  Although my recovery is slower than I would like, I am better than I was pre-surgery.

Hang in there!

[PonyExpress]

Thanks for your reply Maverick and your encouragement. I've read some of your other posts elsewhere on the forum and must say your journey does seem to have been very long and painful.

In answer to your question, the Physiotherapist had me weight bearing as soon as I'd had my first cup of tea after the operation. I had brought crutches to the hospital with me, but was told I did not need to use them.

I returned to work today (4weeks on from op) and spoke to a colleague who has had 16 knee operations, including MFX, and he also expressed surprise regarding me weight bearing immediately. I've done alot of reading since the op and everything suggests non weight bearing for at least 2 months.

I have a follow up with the OS in July, so if things haven't improved by then, will ask him why I had MFX followed by immediate weight bearing.  Obviously I have avoided any atrophy, but can't quite get my head round MFX if it is not protected so that it forms 'cartilege'.

Since my original post I have been able to lower the seat on the static bike and have found my old V-fit Stepper.  I've only been using the stepper for 2 days now, but I seem to have got the best results from this.  After 5 minutes my knee really loosens up and I walk so much better. The effect doesn't take long to wear off, but it has helped me to remember how to walk without swinging my hip.

Do you find that you loosen up after your gym sessions, but then stiffen up soon after?

[Maverick]

PonyExpress, I do have to say that my knee feels best after my workout but it does stiffen up pretty soon afterwards.  Icing immediately after my PT or workout helps alot.

To loosen up before my workout, I ride a spinning bike or my road bike that is on a trainer.  I start out slow and then increase the rpm's but not necessarily the resistence.  Resistence puts extra pressure on the knee, which I don't need.  I just need to lossen it up and build my quads and hamstrings back up which riding at faster RPM's for a longer period of time does for me.

If you don't mind, please let me know how your journey progresses.

[PonyExpress]

Interesting that you use the bike to loosen up before your exercises, I use the exercises to loosen up before using the bike and stepper.

I saw my PT yesterday and he measured my ROM at 125 deg again, although this time he measured it with me laying on my back, whereas previously he measured it with my legs hanging over the edge of the table. He felt I had made progress.

I discussed the weight bearing on the MFX with him, he said there were 2 schools of thought and the one I'm following is that a little light stress will irritate the MFX to continue to produce cartilege - so long as I don't over do it. He was happy that I only went as far as a little pain, but stopped before it was too harsh.

He suggested another month or two would see real progress, and I have to say that the past few days do seem to have felt like I'm making progress. Maybe it's because I'm back at work and only doing 1/2 days, so that's more exercise without overdoing it. I exercise as soon as I get home and it's great to get my legs up on the settee straight afterwards