The SPECIALIST'S OFFICE => Ruptured patellar tendon or ruptured quadriceps tendon => Topic started by: NoGoodKnees on June 19, 2014, 04:24:29 PM

Title: Complex Patella Tendon Rupture
Post by: NoGoodKnees on June 19, 2014, 04:24:29 PM
Hi All, I am a 42 year old female from Australia and have just found out I have a complex patella tendon rupture. On Wednesday the 11th June I slipped on a wet floor and injured my knee. MRI tests showed that I have fracture a bit of bone off my patella. A piece of tendon was attached to the small segment of fractured bone, and as it has come away from the patella it has torn the patella tendon on a slight diagonal down the middle into two separate pieces but is still attached to the tibia. The other half of the tendon is attached to the patella, but has torn off at the tibia. Resulting in 3 tears. This knee has a pre existing history with patella dislocations and due to this had patella realignment surgery in 1988. X-rays also indicated chronic arthritis in this knee as well. Surgery is booked to repair the rupture for Friday June 27th.

The days following the injury I had severe bruising at the base of my knee cap, down the front of my leg and behind the knee. Is this common? Due to nerve damage sustained in my previous surgery I don't have a lot of feeling in my knee, so to date the knee is only painful when I move it (I have been in an immobilisation brace since I did it).

Is there anyone who has had a similar tear like this that could share their story/ journey with me? I am just starting to realise that this is a serious injury and that rehab is a long process. I work in an office that has stairs and was wondering what the time frames where that people started back at work and also when they could start driving. Also wondering if people who have had complex ruptures had to have a tendon graph at all.

I see my surgeon for a consult on the Tuesday before my surgery so will also fire these questions at him, but would live to hear from people who have had similar repairs and get any advice on things to watch out for or tips on how to get through this the best I can.

Starting to get very nervous at the seriousness of it all.

Thanks Heaps :-)
Title: Re: Complex Patella Tendon Rupture
Post by: Kaddydee on June 20, 2014, 09:28:27 AM

I'm sorry to hear about your injury.  I don't have any helpful advice but I would love to follow your journey as I'm a 36 year old Aussie also with a complex Patella tendon tear (not full rupture).  My tear occurred 18 months ago, due to a knee manipulation that was done in hospital.  For a couple of weeks I had bruising under my kneecap and my shin and lots of pain.  Unfortunately, because I had other knee issues (Complex Regional Pain Syndrome) the tear was overlooked.  I now have Patella Alta (kneecap sitting too high) which means that I can't bend my knee from 0-30 degrees when weight bearing - I can't walk up or down stairs or hills and can't run.  I also can't lift my leg into a straight position.  Thankfully, I'm not in pain and I can walk well.

My surgeon said he would have to use my hamstring to repair my tendon.  However, because it has been a long time since the initial injury he cannot guarantee any improvement.  My whole situation is complicated because I got complex regional pain syndrome after simple arthroscopic surgery  and surgeons are scared that I could get it again if I have more surgery. So, at the moment, I'm weighing up whether to attempt the surgery or be content with walking and having with no pain. 

A patella tendon reconstruction is a big operation but my suggestion for you is to get it fixed now so that you don't end up with further complications down the track.  I know it's scary to think how a big operation will impact your life but in the long run a few months of rehab is better that a life full of knee issues.  There are some positive stories on this site so hopefully you will find support and encouragement from others.  It will be interesting to hear what your surgeon has to say.

All the best,
Kath (Kaddydee)
Title: Re: Complex Patella Tendon Rupture
Post by: SellaVee on June 20, 2014, 02:54:13 PM
Hello ladies and welcome to the world of the ruptured patellar tendon.  It's a club that no one wants to join but we're here to help each other make the best of it.

I'm also female, aged 60 when I fell last year after I turned round too fast and my new shoes stuck to the carpet.  The turning motion added torque and so I also managed to pull a bit of bone from my patella while rupturing the tendon.  I don't have a complex tear but I think much of my recovery will fit with yours, NoGoodKnees.

I had tremendous bruising around my knee.  My youngest son was about to get married and I joked that I needed to buy a hat to match the bruising.  If I moved it at all my knee was painful but when the doctor doing the scan pressed on my knee it wasn't sore.  He looked very concerned about this so I was worried about nerve damage but apart from a small numb patch to the right of my scar I now have no problems.  I didn't have the scan until 21/2 weeks after my fall so some of the bruising had gone down.  I had the op a week later.  My knee is now held together with wire which they decided to leave in. Some surgeons use it, others don't.

Yes, this is a serious operation and you're right to feel nervous.  Yes, there is a long rehab.  The good news is that you can get through it.

Ask your surgeon to talk you through the op and the recovery period afterwards.  I mentioned that my son was getting married exactly 1 week after my surgery.  I'd been told I'd be in plaster from hip to ankle but instead I was heavily bandaged and put into a cricket splint (sometimes called a Zimmer splint).  When the registrar came to see me on the ward afterwards he told me that the repair had been successful and that on the painkillers I was taking I'd be able to have a glass of champagne at the wedding.

I was confined to bed for 24 hours.  The hospital physiotherapists had me weight bearing and walking with crutches the next day but wouldn't let me go home until I could manage stairs.  I managed that the following day, 5 days before the wedding.  I didn't think I was going to make it as it was taking place a 2 hour drive away.

Don't underestimate the "fun" you will have with your leg in a splint/brace.  You can either be lying down, standing up, or sitting with your leg stuck straight out in front of you.  I had to travel home on the back seat of the car.  Going to the bathroom becomes an art form.

My husband managed to hire a wheelchair with a right leg extension which was eventually to transform my summer as I could go out in it.  With my car adapted I was able to get to the wedding and I even managed to "dance" the Macarena at the reception.  I did the arm movements and my eldest son spun me on the turns.  I wore a long dress to cover my splint and the photographer would put me into position with everyone else around me then a friend would whip away my crutches while I held on to the person next to me then it was back into the wheelchair.  I even managed to walk slowly up the aisle beside the father of the bride.

The day before the wedding, 6 days post op, I did the church flowers with the help of my other daughter-in-law and that evening I did bouquets for the bride and her bridesmaids from the "comfort" of my wheelchair.  I think I was being carried along on adrenalin and enthusiasm.

To be continued if you'd like to hear more.


Title: Re: Complex Patella Tendon Rupture
Post by: NoGoodKnees on June 20, 2014, 02:55:57 PM
Hi Kath, and thanks for your reply to my post. Seems like you have had quite a journey yourself with your knee. I will certainly keep you up to date on how I am going and would love to hear how your journey continues..  :)
Title: Re: Complex Patella Tendon Rupture
Post by: NoGoodKnees on June 20, 2014, 03:06:01 PM
Hi Stella, thank you for sharing with me. Would love to hear more of your story and journey. Glad you mentioned the wheel chair as a friend has offered me one and I wasn't sure if I would need it. I have a list of questions for my Dr and am trying to stay very positive. (Hey my kids have learnt how to use the washing machine in the last few days so that's a big positive! Lol) One of my biggest worries is the amount of time I will need to take off work, as I am a single mum and the sole income earner for my little family. But I'm sure I will work something out.

Sounds like your timing couldn't have been worse with your injury. I'm sure it must have been a huge relief to be able to go to the wedding, have a 'dance' and most importantly a glass of champagne!

Keep sharing as it will be people such as yourself and Kathy that inspire me along the way  :)
Title: Re: Complex Patella Tendon Rupture
Post by: SellaVee on June 20, 2014, 04:16:45 PM
OK, here's the next instalment, but first, be aware that you will need a wheelchair with a leg extension to support the injured knee.  Because your leg is in a fixed position you cannot bend it at all, so you have to sit with one leg bent and one straight out.  Without  an extension you're relying on your thigh muscles to hold your leg up.  I suffered tremendous muscle atrophy through being in a splint for so long and I couldn't have managed without the extension.  Secondly you will need someone to push the wheelchair! 

A lot of the guys on here don't bother with a wheelchair but it was just so much faster than being on crutches.  My (fortunately early-retired) husband could push me up the road to the local pub garden and there was no palaver about getting me into a seated position with my leg propped up.  He could also take me out for long "walks".

One of the things you will have to really work at is staying positive.  Mentally this injury is a bummer.  With the wedding and all I stayed in a big bubble of happiness for 2 whole weeks.  Then the tears of frustration kicked in and I spent a weekend sobbing.  Then I got over myself!  So be prepared.  I was worried about whether I'd walk normally or dance ever again.  Don't worry, if you work at it you will.

Once I found this site I became much more positive.  John42 on the main thread has a wealth of information which I know he has shared.  He has been on this site for 10+ years and always welcomes newbies.  I got in touch with him before I first posted.  I think he would agree that the progress we're making nowadays is so much better than what was achieved when he had his fall in 2003.  I continue to make progress almost a year after my surgery.  I'm talking about fine tuning here, not leaps and bounds.  I have had full flexion back for quite some time, even though I was a slow starter.

Good to hear the kids have learned to work the washing machine!  See if you can organise grocery deliveries or someone to shop for you.  That way you can teach the kids to cook too.  From the hips up you will be fine, but you must keep taking the pain relief tablets at regular intervals.  Do not wait until you're in pain before you take them.  You can wean yourself off them quite quickly but don't go too fast.  It's a balance.  It will be painful straight afterwards so keep taking the tablets.

Start working on your arms now, even if it's only lifting baked bean tins.  Try and keep your upper body strong.

Before I talk about going back to work, what do you do, how do you get there, and how old are your kids?

Keep smiling,

Title: Re: Complex Patella Tendon Rupture
Post by: Kaddydee on June 21, 2014, 04:08:39 AM
Hi again ladies,
Thanks for your reply Sella.  It's always good to hear people's stories and little bits of wisdom!
Even though I haven't had a patella tendon reconstruction, I did live with a straight leg for 2 months so I have some idea of what it will be like with a splint/brace.  I had many physios and OT's work with me at hospital and at home to make my life a little easier.  Here are some bits of advice that helped me:

To get in and out of the car - put the seat back  as far as it will go and put a plastic bag on the seat.  Sit on the edge of seat, lift your straight leg with your good leg or a towel (wrap it under your leg and pull up with your arms) and then swivel around on the slippery bag.  Then put your leg on cushions.  Have a go at it before your op!  It made such a difference for me.  Also, you need to have your car door fully open to get in and out so you can't park too close to other cars - I learnt that the hard way!

I had a bench stool in the kitchen - I could sit on the edge of the stool and keep my leg straight.  It meant I could cook some meals and eat some meals for short periods of time.

To carry things around the house, I found a long handled bag that I wore around my neck.  When your hands are on the crutches it can be difficult to carry things around the house.  I'd keep the phone, a book and a drink bottle and a couple of snacks in here all the time.

I also had a wheelchair for three weeks - I mainly used it to go on family walks.  The kids enjoyed pushing me and it meant that I wasn't stuck at home.

Make and freeze meals now.

Set mini goals with your family - when I can bend my knee to 90 degrees, let's go to the movies (I couldn't sit in a cinema for many weeks!), when I can walk without crutches let's go out for lunch etc It's a team effort so it's nice for everyone to feel rewarded.  I told my family that we could get a dog when I could walk again - it took 18 months but it kept the family focussed on the positives rather than dwelling on things I couldn't do!

And stay connected to other kneegeeks!  Like Sella, I felt really supported through my toughest times.  It's just nice to know other people understand what you are going through!

Anyway, I hope some of this helps. 
Have a great weekend,
Title: Re: Complex Patella Tendon Rupture
Post by: SellaVee on June 22, 2014, 05:17:15 PM
Excellent post, Kath.  I'd forgotten about the plastic bag trick.

One of the best pieces of kit I had was a leg lifter.  The hospital physiotherapist was unhappy with my towel wielding technique for some reason - I used to hook it under my foot and pull my leg up.  She got me a leg lifter and being rigid it was much easier to use.  You can find out about it by "Googling".

I got very fed up with being on crutches because although I could go to the kitchen to make a cup of tea, I couldn't carry it back to the sitting room to drink it.  In the end I bought a mobility trolley from ebay.  Now that I no longer need it for carrying cups of tea I use it for nail polishes etc. so I have my own manicure station!


Title: Re: Complex Patella Tendon Rupture
Post by: NoGoodKnees on June 23, 2014, 11:04:43 AM
Thank you both for your wealth if information. No doubt it will come in handy and I will be re reading your posts. 3 days and counting nervously until my surgery. Am getting quiet scared, main worry is about the pain afterwards and being able to function at home with just my sons and me. (13 and 17 years). Sella to answer your question I am a Kindergarten teacher. I work with the children 3 days a week and in the office 2 days a week. Due to the office being in a two story building my emoter does not want me to come back till I  off crutches. So just wondering what yours and Kaths and anyone else who wants to answer, at what stage did you forgo your crutches .

I will get through this and still quite can't believe the seriousness of what damage a little slip on wet tiles has done. Appointment with the surgeon tomorrow so will know more then.
Title: Re: Complex Patella Tendon Rupture
Post by: SellaVee on June 23, 2014, 06:41:03 PM
You're very welcome to all the hints and tips we have on this site :)!  If you are interested in any one individual's journey you can log in then click on that user's name.  This will give you the option to see all that user's posts right from the beginning.  Click on "show posts".

Don't worry at all about the pain - you've had 2 children!  Potentially the pain is bad but hospitals are skilled at managing it.  I had a pain block injection and a general anaesthetic then I went on to liquid morphine and paracetamol when the block wore off.  Ask questions about the best way to take your pain relief and keep taking the tablets.  It's manageable.  I wasn't allowed to take supplies of morphine out of the hospital so the nurse and pharmacist worked out an alternative plan that saw me through the wedding.

Your sons are young men now so you should manage fine.  Am I right in thinking they are on school holidays or soon will be?  If that's the case they'll be around to help.  Years later their wives will be grateful for the opportunity you've had to train them.  Your big problem will be standing up and sitting down but you'll literally get into the swing of that. 

Once vertical I could get around quite well on crutches but I was very slow.  I was so worried about falling again.  My consultant told me to ditch the brace and go down to 1 crutch at 11 weeks, but he admitted he'd kept me in the brace too long.  Have you been told about the hinged brace?

Some guys have ditched their crutches quite early on and just kept the brace on.  A lot of it is to do with balance and confidence.  You don't necessarily have to keep the weight off your leg so the crutches are for stability.  I continued to use a stick for a while when I was out in crowded places, just to let people know to take care.   Some folks are so wrapped up in their own affairs they'd knock you over and not even notice! 

You can go up and down stairs slowly on crutches - I guess your employer is worried about fire evacuation.  I'm my opinion you'd be able to go back to office work much sooner than the classroom.  You won't be able to crouch down or sit at low tables for a while and you daren't trip over a little one.

I teach part time in a high school and I went back after 4 months but on reduced hours.  Your most important practitioner will be your physiotherapist.  Find a good one and keep doing the exercises.  You will get better.

I couldn't believe the damage I'd done either.

Keep smiling and keep posting,

Title: Re: Complex Patella Tendon Rupture
Post by: Stuart Rulka on June 23, 2014, 07:49:18 PM
NoGoodKnees, just so this doesn't turn in to an all Woman thread let me say that due to arthritic wrists I dumped my crutches at 5 days, with no ill effects. I was fortunate to have suffered absolutely no pain post-op so you too may be lucky!
  Every one of us has had a different experience., some of us  easier than others; I was one of the lucky ones, resuming my regular hiking after 6 weeks, so don't get too down. A positive attitude goes a long way. As you will hear interminably, "listen to your own body"!
  Good luck on your journey - it will have a successful conclusion.
Title: Re: Complex Patella Tendon Rupture
Post by: NoGoodKnees on June 24, 2014, 09:47:19 PM
Hi All, appointment yesterday with the OS. Was great at answering my questions. However, I have read numerous times on here and also during my online reading with 'Dr Google' lol that is seems to be the norm to go into a hinged brace that can have your ROM adjusted at certain stages.

The OS said I don't need one just the standard brace they gave me in the Emergency department when I first presented with my injury. (I will add that the brace I have continually slips down my leg no matter how tight I pull it) I did go out and purchase a new brace today and had it properly fitted by a PT. It is hinged, but that is only because the PT suggested it was the best type of brace to get as she could mould it to my leg. The new brace doesn't slip down which is awesome. 

OS also said no PT for 6 weeks to give my tendon time to repair. Staying positive and doing as much forward planning as I can. Still in no pain, unless I try to bend my knee (which I don't do as it is in the brace. Am currently walking around without crutches but have been told this will change after the operation. 

And thanks for sharing Stuart and adding a 'male' presence to this thread  :)
Title: Re: Complex Patella Tendon Rupture
Post by: Kaddydee on June 25, 2014, 05:10:13 AM
Hi Nogoodknees,

I'm glad you got lots of answers to your questions.  You seem quite relaxed which is great!
Can you tell me a bit more about what will happen in the operation - will they repair your existing tendon or make a new one from another tendon? 

If I don't hear from you again, all the best for Friday! And make sure those boys of yours are under strict instructions to look after you - lots of chocolates, movies and magazines!

Title: Re: Complex Patella Tendon Rupture
Post by: SellaVee on June 25, 2014, 10:17:35 AM
Morning NoGoodKnees,

I was also told about no exercises until the tendon is healed.  That's why it's important to keep moving, and working you upper body.  I was told I also needed to protect the repair to my kneecap.  My first physiotherapist appointment was delayed so I started at 7 weeks, and then very gently, but most importantly I got there in the end!  The early stages of no exercise are frustrating and boring.  I worked on my skin - playing with all the sample creams I'd acquired from magazines etc and opened the fancy soaps I'd been given as gifts so at least I smelt nice!  ;D

I don't know if you are sleeping in you brace, but I found the hinged brace very uncomfortable to sleep in especially since I am short and the brace went very high up my leg.  I used to swop it for my splint at bedtime and put the hinged brace back on before I stood up in the morning.

Keep polishing you positive mental attitude, and good luck with the op,

Title: Re: Complex Patella Tendon Rupture
Post by: NoGoodKnees on June 25, 2014, 12:57:07 PM
Hi Kathy and Sella,

Kathy the Dr only gave me a general idea what would happen as he said until he opens me up he won't know the extent of the damage, or what other factors may impact on the repair due to my prior surgery and wear and tear.

I gave him the go ahead to not only fix the rupture, but if he finds anything else (either pre existing or as a result of my last injury, to fix it up. He said he would go through the procedure thoroughly afterwards to let me know what he has found and what action he took. He did mention that he would be hoping to be able to stitch the tendon together, then may use wire and thread or through my tibia and also through my kneecap and ties it off, just to act as a support the tendon and restrict movement while it heals.

I am fortunate enough to have had previous dealings with the surgeon as by coincidence he operated on my daughter last year. (A different GP referred me to him telling me he was one of the best). So I have confidence in him.

A friend dropped off a wheelchair tonight (which my son hasn't bee out of since it arrived lol).

Sella I sleep in the brace they have me in the Emergency department, it's a bit softer, and like you change into my hinged brace when I get up.

I purchased a second hand rowing machine today and some hand weights. So with all the spare time on my hands I will do some upper body work out.

Two days and counting. Staying positive and controlling what I can and letting go the things I can't. Will keep you posted how I go on Friday.

Thanks again for your support.

Nikki (No Good Knees)
Title: Re: Complex Patella Tendon Rupture
Post by: Kaddydee on July 02, 2014, 04:59:05 AM
Hi NoGoodKnees,

Just checking in to see how you are going after your op?  I hope everything went smoothly and that you are on your way to a full recovery!  With the cold weather that has hit Australia, it's not a bad time to be rugged up inside.

Take Care,
Title: Re: Complex Patella Tendon Rupture
Post by: NoGoodKnees on August 15, 2014, 05:55:38 AM
Hi just wanted to give an update on my progress. Today is 10 and a half weeks since rupture occurred. And exactly 8 weeks post surgery. The 2 and a half weeks from when I did the injury till surgery I experienced no pain what so ever. Very extensive bruising and my leg was immobilised in a brace.

Surgery went well and after an overnight stay in hospital was sent home with endone, anti-inflammatories and other pain killers. Once again I was so lucky and didn't need to take any of them as I experienced no pain what so ever. Was surprised at the length of my scar (approx 25cm). Had my first review by the surgeon at 3 weeks post op. As my patella tendon was split vertically and one half remained attached to the tibia but detached from the patella and the other half was attached at the patella but not the tibia, the Dr drilled through both bones and sewed the tendon back on and also sewed down to middle to rejoin that tear. The bit of bone from the avulsion fracture of my patella was not viable to re attach so the piece of fractured bone was removed.

I had been walking around at home without crutches from approx 2.5 weeks Post surgery, so the surgeon was ok with me to not use them anymore. He was surprised at the Rom I had in my knee and how well it was heeling. I was still unable to get a clearance to go back to work or a clearance to drive, but was ecstatic to get rid of the crutches. Surgeon keeps reminding me of the complex and serious nature of my injury which at times is hard to process the amount of damage I did.

My first physio was at 5 weeks post surgery and I had ROM of 70%. This week my ROM is almost 100%. Have been a bit naughty and walk around without my brace at home. Gosh it feels great though!

Mild discomfort when doing physio exercises but still no pain. Dr unsure why I haven't had any pain. The injury hurt for about half an hour after I did it then no pain since. If anyone can shed some light on why this is so please do. Although I am not complaining.

My knee has buckled on me at times, when my brace has been loose and once when I wasn't wearing my brace. But not to the point where I fell.

All up doing well. Can feel a real weakness in my knee, but can't wait to get back to the gym when I can drive. This site has been so helpful and I appreciate all of the information from it.
Title: Re: Complex Patella Tendon Rupture
Post by: Kaddydee on August 15, 2014, 08:11:39 AM
Wow!  What a great recovery!  I'm so happy for you.
You've given me hope - I've decided to have my surgery at the end of Oct so it's uplifting to hear a positive story.
Keep us updated and continue to stay positive!
Title: Re: Complex Patella Tendon Rupture
Post by: Stuart Rulka on August 16, 2014, 05:21:44 AM
NoGoodKnees. I differed in having a complete rupture of the Quad rather than Patellar tendon  but I too suffered no pain, either at the time of injury or post op. My surgeon actually kept me in hospital an extra night , feeling I would need IV painkillers! I did not. No one can explain this. I was actually back at work 3 days post op, and driving after 2 weeks. Back hiking Vancouver's Grouse Grind at 6 weeks.( One of the world's 10 most dangerous hikes).
   Each of us is different, but financial necessity is a great incentive!
Title: Re: Complex Patella Tendon Rupture
Post by: NoGoodKnees on October 12, 2014, 12:47:20 PM
Hi All,

As per the story at the beginning of this post it is now 4 months since I ruptured my patella tendon  (half of the tendon ruptured off the patella, then tore down the middle of the tendon to the tibia, and then  the other half of the tendon ruptured off at the tibia.) Operation went well, very minimal pain post op. About 9 weeks post op I did notice a hole like indent at the base of my patella in the middle where the tendon had torn down to the tibia. The surgeon called it a 'deminished' part if tendon and said he would keep an eye on it as it may heal itself.

.Four weeks ago my knee gave way twice in one weekend. Both times I fell back, no impact on knee. Slight soreness and moderate swelling. Didn't think too much of it until 5 days later when my knee  turned yellowish like an old bruise. There was also a lump on it when I did verticals leg lifts from a sitting position or whenever I tensed my knee cap. Went to the GP who ordered a scan. Had the scan last week and the scanning Dr was concerned as from what he saw his diagnosis was that I have re ruptured the part of the tendon that I had ruptured off the patella initially (repair of rupture at the tibia still intact).

Very surprised as like all the way through have had very little pain. I have noticed I can't straighten my leg or lift it very high when laying down. Frustrated as  prior to surgery the surgeon mention putting an ancor in to keep the repair in tact then take it out at a later date. Post op he told me he didn't need to put one in as he thought it should hold.

Surgeon visit next week, but just wondering if anyone else has experienced a similar complication and if follow up surgery was required and time frames for walking, driving etc.

Thanks in advance :-)
Title: Re: Complex Patella Tendon Rupture
Post by: Thomas99 on November 15, 2014, 08:21:13 AM
Hi NoGoodKnees,

Unfortunately my story and outcomes are almost the same as yours. I ruptured my left patellar tendon on the 10th June 2014 (one day before your injury) tripping on an unsafe angled tile. I am also from Australia.

I have stairs with no lift at my workplace office as well and have not been in my office since the injury due to the stairs, although I have been able to do some work remotely from home.

5 months post surgery, I was still experiencing significant pain and was unable to do a vertical left lift at all. Doctor ordered a MRI and I saw a new Orthopaedic Surgeon who advised that I had partially re-ruptured the patellar tendon again. I will need to have the surgery redone all over again in early December and to start my rehab/recovery from scratch again. They will use my right hamstring for the graft this time as they used the left hamstring for the last graft.

Not looking forward to starting all over again and going through the incapacity and pain, but the one thing I have learned from this site, is that patience is required.