Rehab Diary for Patellar Tendon Lengthening Surgery - Month 2
Below is a summary of my second month in physical therapy after reconstruction of my patellar tendon by Dr. Noyes. Again, I would like to express my sincere gratitude to the staff at Cincinnati SportsMedicine (CSM) for the treatment that I received. Their dedication, patience, and endless words of encouragement were greatly appreciated.
8/16/07 - Day 29 post-op. Well it's been almost a week since I was released from the hospital following the MUA and epidural. The status is - pain increasing, pain meds increasing, range of motion stuck. If the steroids I'm taking don't kick in, the may do a nerve block next week. I'm not looking forward to more stuff that involves needles.
8/17/07 - Day 30 post-op. I have been able to feel changes in the knee over the last 24 to 48 hours. More pain in the knee cap itself when trying to bend, more numbness around the incision, and much more heat. Since my knee is being so difficult I work with Tim every day on knee mobs and ROM and keep telling him my tale of woe and symptoms. When talking with Tim this afternoon, he said he could feel it bogging down again and that doctor intervention is needed to progress further. The doctor is out next week, but we may do a nerve block if they feel the Medrol dose pack isn't working. Due to the recent pain, PT is trying to balance everything, so we are holding off on pushing it much more and are just working on keeping flexion at 90 to 100 on the ERMI. They prefer my flexion be in the 110 to 120 range since I got to 120 the day that I was released from the hospital after the epidural. I seem to be maintaining the extension, 3 to 5 degrees on the table, and they can easily push me to 0. I just can't get my quads to engage enough to keep it there. They offer Saturday clinics in the fall for the high school sports on Friday night, so Tim said we could do a session first thing in the morning. It's a bit early, but I dread weekends because I seem to loose some ROM. At this point, I'm pretty down and frustrated.
8/20/07 - Day 33 post-op. I'm sure everyone is tired of getting these cheerful updates by now. I'm getting tired of sending them. I'm not sure the Medrol pak is doing anything. I'm just glad that I'm in Cincinnati and can discuss all the changes as they happen, some times pretty major ones within 24 hours.Today was brutal at PT. Tim is on vacation and Al tends to take a more aggressive approach to things. I think they had me in tears 4 times and there was a scream with a Lidocaine injection. In addition to all the scar tissue in the soft tissue, there is a band or two of scar tissue on the outside of the knee cap and no matter how hard they wiggle the knee cap, it's not moving.
Tomorrow I get a nerve block to help let me work through the pain of stretching out the scar tissue. Tomorrow afternoon I will be officially diagnosed with a phobia of needles. I'm not sure how this will play out later this week. I seem to have some really gooey scar tissue that just stretches a little and then shrinks back into place. I got loaded up on pain meds again today, but they seem to be less effective as we get more aggressive. Hopefully with the nerve block and the meds I can make some progress this week. I was hoping to return home at the end of next week, but now I'm not sure. The doctor is out this week, so I will have to see what he has to say upon his return next week. My jaw hurts almost as much as my knee from clenching it all the time. The good news was that I got rid of one crutch and the brace today, which is weeks earlier than they were planning on doing.
8/21/07 - Day 34 post-op. I had the nerve block today. I don't think it was worth the effort. The doctor doing the procedure spent a lot of time poking me to find the nerve. The effects lasted for about 6 hours (should have lasted 24 to 48 hours). It wore off in the middle of the second PT session as Al was doing patella mobs. I was hoping that the block would at least last through the night so that I could get some sleep. I only sleep about 4 hours a night and it's not all at one time. I think that my body structure is just different from everyone else on the planet. So far I have been called an interesting case, an outlier, and an alien by various medical professionals in the last 5 weeks.
My biggest concern at this point is balancing aggressive PT with the heat, inflammation, and pain. Tim seems to back off at this point and Al seems to want to push through it. I'm getting pretty physically and mentally exhausted.
8/22/07 - Day 35 (5 weeks) post-op. I'm glad yesterday is over. I'm definitely walking a very fine line (no pun intended) in the rehab area. I think that we may have broken through a plateau today. I seem to be consistently getting to 110 with the overpressure and I feel that I can increase the weights in my strengthening routine tomorrow. I'm still in a lot of pain and feel that the active ROM is very limited, but Al is focusing in on that now. My knee now feels like it is full of silly putty instead of cement.
8/23/07 - Day 36 post-op. I think things are definitely starting to improve and yesterday wasn't a fluke. I'm easily getting to 110 on the ERMI and with a lot of force I got to 115 today. That is the best that I have done since this whole mess started. My functional range of motion is now 5 to 85, which is a big difference from Saturday. I increased the weights in the strengthening routine today and have even managed to ride the bike with full revolutions and no hiking of the hip. However, I'm trying to balance all of this with the pain and heat. I still sleep with the Iceman cooling system on to keep the thing as cool as possible. Tim is back on Monday and I can't wait for his gentle touch. I thought I would be on the crutches and in the brace for at least three more weeks, but Al threw that stuff out the window this week. The last crutch went today. He told me not to walk in to therapy with it tomorrow.
I'm scheduled to return home at the end of next week, but I'm not sure that is a good idea at this point. I'm at the ROM and muscle strength points that I haven't been able to get through before, so I will discuss with Tim on Monday.
8/27/07 - Day 40 post-op. After a very brutal week of PT I may have passed a slight curve in the road. I can now reach 110 degrees flexion (with overpressure) without huffing, puffing, and tears. I'm still struggling with the active range of motion, but gaining every day on strength. Unfortunately, I'm still in excruciating pain and the knee is very warm to the touch. I did manage to walk about a quarter of a mile today without the brace or crutches and will pay for that dearly in a couple of hours. Tim and Dr. Noyes are back this week, so we will see what they have to say. Our plans are to return to Knoxville on Friday, but Mom and I both have concerns about this because of the heat and pain and also this is the farthest I have gotten in rehab in four attempts and don't want to blow it now.
8/30/07 - 6 weeks post-op. I continue to maintain on the ERMI and consistently hit 110 on the ERMI and usually push to 115. I don't think Al is going to let me slide backwards. Tuesday, I saw Dr. Noyes during a PT fly by. They took x-rays and the patella has dropped 5 mm. It's not critical yet, but he will continue to monitor it's position. I spiked a temperature of 100.5 Monday evening, so the doctor tried to pull some fluid from my knee to test for infection, but there was none to be found. I was sent across the street for blood work and that came back negative. I'm back on the Medrol Dose pak for the inflammation. In general the doctor seems pleased with progress in PT and is not surprised about the pain levels. He thinks the pain will persist at this level for another month or two. The wire should remain intact for another 10 to 14 weeks.
I'm getting through PT pretty well. Both sessions focus on ROM, with strength emphasized in the morning and balance in the afternoon. The problem is the evenings as soon as I start to relax or try and engage in what used to be my life, the pain hits like a brick. I'm still in a significant amount of pain. They are doing the best that they can to manage the pain. I have had a historically high tolerance to pain medication. The constant deep penetrating pain is always just there and I have learned to deal with that, but when you pile on the pain from walking or therapy it just gets out of control at times. I think most of the spike in pain is due to the patella mobs and the PT attempts to break the scar tissue from around the patella tendon. They are not gentle about this and sometimes I have to remind them to breathe. I don't have much swelling, it's about as low as has been since the initial accident or about 2 cm larger than my good knee. I just keep generating the heat and can't get that to go away. We don't want to pull back on the strengthening because I have to get the quad and hamstring muscles used to working again and we don't want to let up on the ROM, because the tissue has to get stretched. I just seem to be caught in a catch-22 situation. I don't notice much effect from the dose pak, but it may reduce the heat a little.
I plan on staying up here for another couple of weeks or so, especially since he seems to adjust my treatment plan every week depending on how I'm doing. He will be taking another set of x-rays in a couple of weeks.
9/6/07 - 7 weeks post-op. I continue to maintain my flexion. I got to 120 on the ERMI in both the morning and afternoon sessions yesterday. This is where they think I will max out at. My active flexion was at 105, so I'm really focused on strength to get another 10 degrees or so. In the last week I have developed a hypersensitivity to light touch and fabric. This makes sleeping difficult since I can't stand the sheets and blanket on my knee. Dr. Noyes has prescribed some meds that hopefully will help with this. I hope this resolves itself in a few weeks, before it starts getting cooler and I have to wear pants.
The morning PT routine consists of the following: hamstring and calf stretching, utlrasound around the patella and also the quad, patella mobs (this has been the key for me and brutally painfull, but worth every minute), calf raises holding 30 lbs, mini squats holding 30 lbs, leg press (single leg 80 lbs), leg curl (single leg 30 lbs), cable column (all 4 directions, 5 plates), rocker board, step ups (like single leg mini squats), band behind the knee (bend and straighten), but just changed to using weights on the cable column, patella mobs, quad stretching (prone position and they raise the upper portion of the table for 10 min), overpressure with the ERMI for 15 minutes, bike (10 min), stepping down with the good leg on a 6 inch step, and ice with hanging 20 lbs to maintain extension.
The afternoon PT routine consists of the following: hamstring and calf stretching, patella mobs, calf raises holding 30 lbs, mini squats holding 30 lbs, quad stretching (prone position and they raise the upper portion of the table for 10 min), overpressure with the ERMI for 15 minutes, sitting on a stool applying over pressure (5 to 10 min), bike (10 min), biodex machine for balance, stepping down with the good leg on a 6 inch step, and ice with hanging 20 lbs to maintain extension.
The morning PT session takes about 3 hours and the afternoon is about 2 hours depending on the availability of the individuals that have the ability to move my patella. I'm pretty wiped out by the time I get back to the apartment, so I rest until dinner. Then in the evening I try to get two 15 minute sessions on the ERMI, 2 or 3 e-stim sessions, I go out for a walk (up to half a mile now), and quad sets every time I get a chance. Also there is lots of icing in between everything. I also still sleep with the cooling system, unless it's just too cold on my knee (even with several layers of fabric in between). Without the cooling system on my knee at night, it just pulses with pain that keeps me from sleeping.
I tend to take it a little easier on the weekends. Several sessions a day on the ERMI, e-stem, walking. Whenever I'm sitting in a chair, I make sure there is constant over pressure. Quad sets whenever I'm just hanging out in front of the TV.
The first 5 weeks were very frustrating for me since very little progress was being made. But in the last couple of weeks, I have improved significantly. If only there wasn't constant pain. They think that the pain will eventually diminish, but as you can see by the PT routine, we are being pretty aggressive with the knee and just constantly working on it. I don't feel the wires. I think there is just too much scare tissue around the knee to feel them.
I will get another set of x-rays next Tuesday and if all looks good, I'm going to give up my table at PT and come home the end of next week. I haven't seen much of Cincinnati in my time here, but I did manage to go to the store and a movie over the weekend. For me this was a pretty big deal since I haven't felt like going out and about since the surgery.
9/12/07 - 8 weeks post-op. Great news - the x-rays yesterday looked good (the patella is in the same spot as last time, so I will not need an adjustment) and another week has gone by with no needles. I get to make a break for home on Friday. Today, I hit 130 passively and 120 actively. The goal set by PT was 120 passively. I haven't seen these kinds of numbers since my accident 10 months ago and never thought I would see them again. I have been taking Neurotin for the hypersensitivity to light touch/fabric and it seems to be helping. It also seems to be helping with some other pain in my knee that wasn't in the area where the patellar tendon was lengthened. In order to sleep at night, I would always put the compression stocking on so that the sheets didn't touch my knee (that is when I didn't sleep with the cooling system). But last night I slept without it and the sheets didn't seem to bother me.
There has been more pain and tears in the last 8 weeks, but the work has finally paid off. There is still a lot of hard work ahead to reduce the stiffness and work on stretching the new areas that I'm just now getting to. I have definitely made it over a couple of hurdles in the past couple of weeks. Now that I have made these gains in strength and ROM, I feel much better about the outcome of the next surgery to remove the wires. There is no definite date for this, but Dr. Noyes wants the wire to stay in as long as possible. So this has to be managed with the possibility of the wire breaking somewhere between 16 to 20 weeks post op. I can't wait to sleep in my own bed and see my pets. 8 weeks is a long time.
To be continued.....