Author Topic: Super delayed ACL rehab 7 mo. in due to atypical pain anterior - so sad  (Read 248 times)

Offline mtngirl

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Hello, Im a 41 year old female in the US. I tore my ACL while backcountry skiing (aka not in a resort) late January 2017. It was an epic 3.5 hour ski out on one usable leg with the help of two friends on either side of me. I did not swell up, I did not have pain (unless I tried to use the leg), but while still wearing a boot and ski I could touch the ground for balance just not full body weight. I had surgery 16 days after my injury. No prehab surgeon felt it was unneeded due to quad muscle and ROM at the time.

I am nearly 7 months post ACL reconstruction (right knee, patellar tendon autograft). Surgery went well, new ACL is intact. My issue is I am having some major pain in the front of my knee so severe that all my rehab is pretty much at a standstill until the pain subsides. My last actual physical therapy (PT) visit was almost 4 months ago. I have good ROM full extension (maybe even some hyperextension) and flexion is about 146 last we checked months ago (non operative side is 155). Inside the joint feels OK with some clicking.

I was on course with normal rehab protocol up until month 3. While I have pain every day, I can say I felt the best at month 3.  When I said it was painful to do the exercises, they said push through to a certain degree. Lunges killed me especially when my operative leg was the back leg. Like someone just threw an ax into my knee and told me to lunge. My quad was not growing as they liked according to the Biodex dynamometer machines. Just after month 3, PT beefed up my rehab program with gym time and underwater treadmill time and really worked me. I think this just set off a case of severe inflammation that just has never calmed down enough, I'm in a vicious inflammation cycle. Maybe it was too much too soon.

Since the severe inflammation started at month 3+ we have tried a lot of things to calm it down: iontophoresis patches with dexamethasone, low lever laser therapy, steroids burst pack, a month on Celebrex COX2 inhibitor (Im anaphylactic to all NSAIDs but Celebrex that means ibuprofen, aspirin, naproxen), Action Release Technique A.R.T. massage, soft tissue massage, therapeutic ultrasound (current PT is not a fan of it, second opinion PT is a fan of it), FULL rest (2 months of it), just walking on the underwater treadmill. On the natural side, Ive tried turmeric and am on an anti-inflammatory diet. I still have to ice everyday. I have not had a SINGLE pain free day yet since the injury 1/29/2017. Today, Im so hobbled I could probably use a crutch.

The exercises that I manage to do daily are pretty much what weve all been doing at week 5 (clam shells, side leg lifts, quarter arc quad sets, hamstring curls, two legged bridges, etc). THAT IS IT. I cant progress past that or I am in such pain Im back on a crutch or couch bound for a few days. Ill try a squat now and then and then its a NOPE. I can do a 1/16th squat (not quite an 1/8th squat). I currently do 7 minutes of no-resistance stationary biking 2x a day if I can handle it. I break the biking up because 14 minutes total would leave me majorly limping for a few days. Yes, at nearly 7 months post op. The most insane part is that a move will be fine one day, but then on another day it will leave me sore and limping. There is not a lot of consistency so I don't know what to back off from.
 
I feel I am going absolutely nowhere, very slowly. My physical therapist, surgeon, physician assistant all say time is all I have now. Do whatever doesn't hurt/doesn't cause inflammation. I'm still trying to figure that out. They suggested possible PRP Platelet-Rich Plasma injections maybe at the 12 month mark. Otherwise, they have run out of ideas for me.

I had an MRI done at month 4.5 post op. Patellar tendon graft site was healing/thickening nicely - in inflammation. We did see my sutures very clearly. They should be dissolved. What was inflamed was the subcutaneous or superficial infrapatellar bursa in front of the patellar tendon. A little thin bursa sac that was on fire. The theory was maybe the sutures are aggravating it, or maybe my body is rejecting/allergic to the sutures. Just a theory, not a clear diagnosis.

I went to get a second opinion physical therapist opinion last week out of desperation. I drew my MRI from memory. She said shes never seen anyone this delayed or in pain so long after surgery in all her 35 years of practice. Her theory was it was the Hoffas Pad / infrapatellar fat pad. She said to use shoe orthotics (I have some somewhere), tape the knee, do only hip exercises for now (I have some bone misalignment on this surgery knee that is natural to me). Her theory was that my bone misalignment along with atrophied muscles are putting undo pressure on my fat pad.  So I let her ultrasound, soft tissue massage, and tape me. I left quite crippled, in tears, and blew up like a stuffed sausage and had to remove the tape within an hour. Normally I am sore even to touch the knee. I couldn't do my exercises the next morning due to pain.

Her theory is contradictory to the MRI. The item that was inflamed was in FRONT of the patellar tendon (aka subcutaneous infrapatellar bursa) just under the skin. The Hoffas fat pad is behind the patellar tendon deeper into the knee. I reiterated thats not what was inflamed on the MRI. I ran it by my current PT and he disagrees with her theory. What to believe!

I have another post op visit with the physician assistant in a few days for 30 weeks post op. I want to revisit the MRI with the doctor, discuss Hoffas Pad idea (because it has remedies, the infrapatellar doesn't seem to!), discuss what suture options there are if any. Maybe cortisone shots to the bursa? Dry needling?

What do you think? Heard of something like this? Should I get another opinion from a knee surgeon? My progress feels like at a standstill for 4 months, but to someone else there have been tiny improvements (like I can add a theraband or an ankle weight to some moves). I fear I will never be pain free, or maybe it will take years. I was so active. I've done a good job at distracting myself, finding new hobbies, but I'm getting really tapped out and struggling emotionally.

PS I do have a history of healing very slowly from other injuries, and they like to point the blame on that Im just slow.
« Last Edit: September 07, 2017, 10:13:31 PM by mtngirl »
Backcountry skiing injury 1/29/2017
ACL recon (R, patellar autograft) 2/14/2017

Offline jackson7

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Re: Super delayed ACL rehab 7 mo. in due to atypical pain anterior - so sad
« Reply #1 on: September 10, 2017, 12:17:11 AM »
I'm having similar problems...and I also heal slowly.   After my first injury, took me a year to be able to walk more than a block, pain free, and my knee was bluish-red and blotchy almost the entire year. 

After eventually getting the surgery, I tried pt for two months , but was getting nowhere and it was actually just irritating and inflaming my knee.  Unlike you, i know where my main pain is originating (defect on my femoral chondyl scraping against the edge of the resected meniscus + really bad tendonosis), but there seems to be nothing i can do about it...ortho hasnt suggested anything.

If your sure you dont have any cartilage lesions/defects, you might have tendinosis from too much pt and/or a milder version of CRPS...or maybe all that in combination with some osteoarthritis or calcification.  There's just so many possibilities...many of which just take time to work themselves out as good as possible.  If you have to rest, then do it...but at least try to walk some every day and keep doing the pt exercises that dont cause pain.  Good luck.



« Last Edit: September 10, 2017, 12:20:50 AM by jackson7 »
Dec 2015: slow speed bicycle crash (wet leaves)
Jan 2016: a zillion x-rays & 2 MRIs only showed tendinosis
Mar 2016: bone scan showed "uptake" in all compartments
Aug 2016: cortisone shot (did nothing)
Mar 2017: diag scope (partial med meniscus resection, med fem chondroplasty, synovectomy)

Offline mtngirl

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Re: Super delayed ACL rehab 7 mo. in due to atypical pain anterior - so sad
« Reply #2 on: September 11, 2017, 09:58:55 PM »
Thanks Jackson for reading and replying! So sorry it took a year to walk around the block. Is this post surgery or post injury?

My 7 month post op visit was today. We got Xrays and looked again at my MRI from June. There was no calcification or OA  he said. All my cartilages and menisci look good he confirmed. I have the scans now in my possession on DVD (in case I get a specialist's opinion).

This time the physician assistant went back to the "patellar tendon harvest site still healing" theory - essentially patellar tendonitis. Last visit he was more on the superficial infrapatellar bursitis, but not so much this time.

Basically he said it's probably a multitude of things from having been sliced open in surgery, plus a little Reflex sympathetic dystrophy possibly (same as CRPS it sounds like?). He doesn't really know. Even said they are at a loss as to what to suggest for me. My case is unique and no one has seen it yet (surgeon, PA, PT1, PT2). So I'm about to find a specialist to go over. Something knew to research at least!

I had a situation a few years ago when a hip overuse injury that they called a tendinopathy issue. It went on for over a year. They ran of out of ideas and the doctor even gave me Lyrica (nerve drug) which did not work. I wonder if that was a CRPS issue going on.

PA was going to suggest Lyrica but then I told of my last time I tried it.

On the patellar tendonitis side (or even tendonopathy like you've said), I've read a couple journal articles about the healing rates of the patellar tendon after harvesting for ACL. At month 6, 59-76% of patients were healed on their graft.  100% were healed at month 12. So I could also just ride it out until month 12. Painful patellar tendonitis (not from overuse but from surgery) can hinder rehab up to a year.

I hope I know more in 5 months at least!
Backcountry skiing injury 1/29/2017
ACL recon (R, patellar autograft) 2/14/2017

Offline jackson7

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Re: Super delayed ACL rehab 7 mo. in due to atypical pain anterior - so sad
« Reply #3 on: September 12, 2017, 04:59:49 AM »
I couldn't walk for a year post injury (although, due to relatively aggressive PT, I'm having even worse problems/pain post surgery).  I saw several GPs in the "free" network and they all told me nothing was wrong and I should be using my knee more to get it back working properly (not one of them ever suggested an ortho).  Something in my knee seemed excessively wrong, but I naively trusted the GPs and, already a good 6 weeks after my injury, I slowly started walking more and more every day.

One day, I was walking down this steep little hill and it felt good and I could see my quads (especially atrophied VMO) really working...so I kept walking up and down that hill for about an hour.  That night, my knee blew up with pain and turned a sick pale shade of purple.  For a year after that day, I couldn't walk without horribly sharp pains all around and underneath my kneecap, so basically just laid around in bed for months.  This helped reduce the pain, but also made both legs atrophy a lot and, according to x-rays, caused de-mineralization of my leg bones.  Since the heat in my knee decreased so much, I did not use any NSAIDs or ice in those last 5 months.

I finally had about a month before my surgery that I was able to walk, pain-free, for several blocks (only in a straight line, though, as any sideways movement was still extremely painful due to the torn meniscus and chondyl defect).

BTW, before my injury, I was a big snowboarder ("pow hound" - driving up the sierra nevada mtns immediately after every winter storm to get first tracks in the glades).  I also surfed every weekend from spring through fall.  My knee has now been too painful for almost 2 years to do any of that...it's like being in prison.

Anyway, it does sound like you, at least, have tendinitis (which, depending on it's severity, can be extremely debilitating even without other issues).  With sensible rest, I do think you will improve in the next several months.
« Last Edit: September 12, 2017, 05:39:34 AM by jackson7 »
Dec 2015: slow speed bicycle crash (wet leaves)
Jan 2016: a zillion x-rays & 2 MRIs only showed tendinosis
Mar 2016: bone scan showed "uptake" in all compartments
Aug 2016: cortisone shot (did nothing)
Mar 2017: diag scope (partial med meniscus resection, med fem chondroplasty, synovectomy)

Offline Brandon123

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Re: Super delayed ACL rehab 7 mo. in due to atypical pain anterior - so sad
« Reply #4 on: September 12, 2017, 08:39:43 AM »
BTW, before my injury, I was a big snowboarder ("pow hound" - driving up the sierra nevada mtns immediately after every winter storm to get first tracks in the glades).  I also surfed every weekend from spring through fall.  My knee has now been too painful for almost 2 years to do any of that...it's like being in prison.

Same thing here, after 2 years of not being able to do anything remotely active (due to patella cartilage damage), I'll second that prison feeling...

But hey, mtngirl, like Jackson said, I also think you will start to improve soon (albeit maybe slowly).

Offline mtngirl

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Re: Super delayed ACL rehab 7 mo. in due to atypical pain anterior - so sad
« Reply #5 on: September 12, 2017, 05:58:17 PM »
I was a big skier. I tore my ACL on ski day #30 of my 58 day season this past winter. That's 30 backcountry days. I had even competed in a ski mountaineering race the day before my fall (could have attributed to being tired). When I fell, I was alone at first at the bottom of a huge avalanche chute. I was on my way to the car to call it a day, while my group continued on further on the ridge. I just knew I had to get out of the chute so I skied on my own (only to the right, left didn't work), crossed a creek, through bushes - all with no ACL. Then when I made contact with my husband (an amazing text that should not have worked) we did an epic self-rescue where I skied out on one leg for 3.5 hours with his help into the dark. Slept on it, then saw the ortho the next day.

If it is tendonitis, then the studies I've read say 100% of people were healed up at month 12 (unless I'm that 0.0001% weirdo patient). If it this, then I just wait another 5 months, try not to flare it up and do the simple/low level exercises that I am able to, hoping for some kind of slow progress. I did two months of full rest and nothing changed, but I atrophied more and it made normal walking pretty cumbersome so I feel like I have to so a little bit of something, not full rest. I mean it was sliced open and things were removed 7 months ago. That doesn't seem to long ago, but then again other people who had this surgery are already returning to sports right now and running.

The physician assistant said the term "Reflex Sympathetic Dystrophy" (actually he spaced the last word even) aka CRPS which I had never heard of until Jackson's post above the day of my appt. Just starting my research, but you want to jump on that now and get it under control asap as it progresses. I don't think I know enough yet to feel I need to find a doctor in this field yet. This is pretty scary. I don't want to go down an rabbit hole, but I also don't want to miss this investigation if it's time sensitive. We'll see.

Even if we don't have the same exact issue, it is a little comforting to hear others have been on the 2+ year boat. I was feeling like the only one with issues. I had to unsub from all my ACL Facebook groups. I couldn't stand to see the milestones while I struggle with daily things.
Backcountry skiing injury 1/29/2017
ACL recon (R, patellar autograft) 2/14/2017

Offline mtngirl

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Re: Super delayed ACL rehab 7 mo. in due to atypical pain anterior - so sad
« Reply #6 on: September 17, 2017, 09:54:14 PM »
CRPS - I don't think I have enough of the symptoms to go down that road yet. My knee is not stiff actually, I have full ROM now.

What I am exploring now is patellar tendinopathy from surgery. In the papers, it says that there is no presence of inflammatory cell which is why an MRI can look fine (like mine did). Also another reason why Celebrex, iontophoresis and steroid pills did nothing (there was no inflammation to treat). The collagen make up of the tendon is in disarray or messed up (slicing it open?). It's more chronic too. Reading some papers on that now. Eccentric decline squats are something I haven't tried yet. Starting with my feet on the wall and my back on an exercise ball right now.

 I shared my story on a popular ACL instagram account. There was one popular opinion from a couple PTs: I be actively working with a PT and have a structure program outlined (probably geared towards tendiopathy).

I should find a physical therapist trained in complex ACL rehab situations and pain science/management. Right now I'm not actively working with my PT. He kind of set me free to "find whatever you can do that doesn't hurt" and then I was to rejoin the clinic once I could perform squats like a normal person I presume. Every time I email him, he tells me he doesn't know what else to tell me. It's hard to tell if he really wants to work with me - seems too hands off given the rarity and complexty of my situation.
Backcountry skiing injury 1/29/2017
ACL recon (R, patellar autograft) 2/14/2017

 

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