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Author Topic: Follow Jake’s LOA from start to finish  (Read 60117 times)

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Offline Jakem

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Follow Jake’s LOA from start to finish
« on: June 25, 2005, 09:09:19 PM »
Follow Jake’s LOA from start to finish

I had the LOA surgery on 6/24/05.  Here is the background that got me into this dreadful arthrofibritic condition (knee full of scar tissue).

From age 13 to 40 I led a life of vigorous health and fitness.  At age 40 I was averaging running more than 10 miles per day including long runs up 22 miles and I could squat 300 pound for rep and bench press 250.  On October 1, 2002 I was out on a 12 mile run and I was sky high.  The day before I had done my medium long 18 mile run at 6:58 per mile and it felt effortless.  I was setting all time personal strength records in every weightlifting exercise.  Then, as Steve Tyler sings in Aerosmith’s classic Same Old Song and Dance, “Fate came a knocking”.

I was running across a side street and a car came barreling through a stop sign.  I had to stop on a dime or get run over.  When I did this, I fractured a piece of medial femoral articular cartilage in my left knee.  The doctor said that 99% of the time what happened would have caused a slight meniscus tear.  I was the unfortunate 1%.  The meniscus didn’t tear, the articular cartilage tore.  It was 1 cm2 defect.  It was the beginning of a long downward spiral in my life that, if you are reading this, you are all too familiar.  When you get an articular defect you are faced with 4 options, all of them ugly.  Just live with it, microfracture, OATs or ACI.  All of them result in disappointing outcomes and wreak havoc in your life.  If you go for a surgical option, you will most likely have several surgeries over several years with lots of pain and suffering and dashed hopes.  If you are one of the lucky ones, you will end up with knee that you can’t do any real sports again but you just experience moderate pain in day to day activities.  The majority aren’t so lucky. 

Dr #1 advised resting for a year which was unsuccessful.  11/20/03 Dr #1 did microfracture surgery.  This surgery was unsuccessful.  5/20/04 Dr #2 did a cartilage harvest for future ACI if necessary.  Genzyme will store the cells until 5/08.  Dr # 2 was to do an OATs procedure but there was a long delay due to a quirky insurance issue.  I foolishly decided to go to Dr #3.  This would be the biggest mistake of my life.  9/8/04 Dr #3 got in there “didn’t feel comfortable with doing an OATs” and instead did another microfracture of the MFC and did a trochial microfracture and a Lateral Release none of which I wanted to have.  This surgery resulted in massive bleeding and swelling.  I was unable to get full extension back.  A massive hemotoma formed and he had do surgery again 3 weeks later on 10/1/04.  The trauma to the knee was too much and the resultant pain, heat and swelling lasted many months.  I never regained full extension nor flexion and my knee gradually became full of scar tissue (arthrofibrosis).  My range of motion was 10 to 110 cold and my life became the nightmare that many of you are all to familiar with.  I came back to Dr #2 at the recommendation of Dr Millett, who is leaving the Boston area and going back to Steadman in Colorado.  Dr #2 did the LOA yesterday on 6/24/05. 

Thanks to this wonderful message board and great information from so many of you especially Laurie, Heather, JaneB, Knicknack and many others I was able to educate myself on this horrible affliction and to try to find a way out.  I studied the literature of Shelbourne, Millett, Steadman and others.  From this I designed the ideal rehab protocol for myself.  Of course it is ideal and there will be many setbacks along the way.  Also, I won’t blindly follow it because any new activity that causes and increase in pain and heat or swelling will be discontinued and I will go back to the basics.  Here is the link to that protocol:


http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=17215.0



Offline Jakem

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Re: Follow Jake’s LOA from start to finish
« Reply #1 on: June 25, 2005, 09:10:19 PM »
Day one  6/24/05

Here is what ideal plan was:

Arthroscopic surgery to remove scar tissue.  Use narcotics every 4 hours after surgery.  Also take non-steroidal anti-inflammatory such as ketorolac.  Also may take intravenous corticosteroid during surgery.  Drain will be installed.  Leave hospital that day.  Use crutches with no weight bearing.  Drive home in back seat with leg locked at zero and elevated with pillows and use Cryo/Cuff.  At home start CPM immediately set at -5 to 90 degrees for 2 hours.  Do 2 hours on and 2 hours off until midnight.  When not doing CPM keep knee locked at zero and elevated by lying on floor with heel on coffee table with pillow.  Do ankle pumps throughout the day.  Sleep on living room floor with heel on coffee table with pillow from Midnight to 600 AM with leg in Dynasplint extension brace.  Gradually increase tension each night from 1 the first night to 10 by day 10.  Use Cryo/Cuff continuously. 

Here is what actually happened:

The surgery started at 1200 and took 1.5 hours as the scar tissue was extensive.  A manipulation was not required as he said the knee went to 135 with just gravity.  He said the patella tendon was locked down hard and when if was freed, I went instantly to full extension.  The patella was  bound solidly down and now moved freely.  Also, my original mfc defect was completely filled in and solid looking.  This was the only good thing to come from the massive bleeding I had with double micro and LR that led to the scar tissue.  I firmly believe that the microfracture combined with taking glucosimine& condroitin results in more hyaline cartilage and less fibro cartilage.   Instead of having only 10% hyaline, maybe the glucosimine bumps that up to 30%.  That was the good news.  The bad news was that I was one of the 90% of people with arthrofibrosis that incurred additional patello-femoral damage from the 9 months the scar tissue was in there.  My patella had a defect on the inside part of it but not to the bone.  The trochial region had one tiny but deep defect going all the way to the bone.  The Dr said “I took a hit there”.  He did say it had a good shoulder on each side, so it remains to be seen how much trouble this defect will give me.

To knock out the swelling, the Dr. used a 4 prong attack.  He gave me an intravenous cortisteroid during surgery.  Think this is much better than waiting till a month after like most doctors because the swelling and heat are already established and the needle causes an inflammatory reaction in itself.  The doctor also gave me a 5 day supply of the oral steroid prednisone.  In addition he installed a drain and left it in after the surgery.  He also gave me an antibiotic during the surgery and I don’t think all doctors do that.  He had me do 1.5 hours of CPM in the recover room before I left the hospital.

I have nothing but praise for my doctor in his talent, professionalism, decision making, straightforwardness and compassion.  He does not BS you and is right to the point and always has time for you unlike most doctors.  He  also is supremely confident but without a trace of the arrogance that afflicts most doctors.  He is never threatened by any questions you may ask.  He is even coming in Sunday just for me to take out the drain and check on progress.

The ride home was awful.  I went with the pillows to elevate the leg and that worked out.  We got caught in rush hour and it took 2 hours instead of 1 hour, we got rear ended, my drain leaked and the check engine light came on.  Actually it wasn’t as bad as it sounds (laugh).  Some knee geeks have driven for 5 hours post surgery, one for 2 days in a snow storm and many have had the agony of plane flights so I won’t get much sympathy from them (laugh).  Luckily there was no damage to the car as it was more of a love tap.  Also the car didn’t break down.

As soon as I got home I got in the CPM and did two hours on and two hour off till midnight.  My CPM is set for -5 to 90.  I plan to increase it by 5 degrees a day till I get to 110 which is the maximum for this unit.  I also did patella mobes through the dressing as best I could several times.  I also prayed and I prayed for Jim Mac and Katrn who also just had surgery.  Hope you don’t mind Jim and Katrn!  I have a great set up at home.  I am all on one floor so no stairs.  I have a mattress on the living room floor with my CPM there.  I have my cyro cuff there, a coffee table with a mattress on there for elevating the leg and to use for prone hangs and a wall right there for wall slides.  I have a bed pan so I don’t have to leave the area (laugh).  I have a lap top right here too.  I have a home e-stim unit to reduce swelling (Rehabilicare GV II).  I have no need  to go see any poorly informed (on arthrofibrosis rehab) or overly aggressive PTs nor do I have to deal with the hassle of getting there and the stress that put on the knee.

My number one problem the first day is pain and this is not surprising.  Most patients stay over night and some even several days.  This allows the use of a spinal catheter for great pain control so they can do the CPM and PT.  I was discharged with just percoset.  When the anestisia wore off about 8 PM I was hurting pretty bad.  I upped the pecoset to 3 tablets every 3 hours.  I couldn’t sleep at all, but then suddenly at about 5 AM the pain was gone.  So I am now glad with the way we did it.  I am happy to be at home with my nice set up.  I hate hospitals and I am already over the big pain part so it worked out well.  Yet another great decision by this doctor.

As predicted by some knee geeks I am already off my schedule.  The Dr. said he did a lot of work so he told me to just do the CPM and mobes and put off the prone hangs and wall slides till day 3.  I was also unable to use the dynasplint brace at night.   I was in too much pain especially in the back of the knee, I think because my those tendons are not use to full extension after being so tight for so long.  I am getting a little blood from the drain 75 ml in the first 2 hours then about 20 ml every 3 hours after that.  I am glad that is draining out than swelling in my knee.

I am cautiously optimistic at this point.  However, I know it is a long tough road ahead.  I remember several from Vail feeling so great immediately after surgery then things went down hill, one started losing ROM, another got infected, others can’t get off crutches etc.  I think I am doing everything right, but I am guarded in that I know things could suddenly go down hill.   I hope this information helps some of you and I will provide daily updates.  Thank you all for your support and kind words.

Offline Jakem

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Re: Follow Jake’s LOA from start to finish
« Reply #2 on: June 25, 2005, 09:30:46 PM »
Day 2  6/25/05

Here was the plan:

Walk partial weight bearing with crutches.  Start with just feather touch weight bearing and gradually increase weight bearing with crutches as the week progresses.  CPM set at -5 to 90 degrees for 2 hours, 4 times a day 600 AM, 1100 AM, 5 PM, 10 PM.  Do PT 4 times 915 AM, 215 PM, 345 PM, 815 PM for 20 minutes in between CPM.  Do Patella Mobilization an additional 2 times at 600 AM and 12 midnight.  When not doing PT or CPM keep knee locked at zero and elevated by lying on floor with heel on coffee table with pillow.  Do ankle pumps throughout the day.  Sleep on living room floor with heel on coffee table with pillow from Midnight to 600 AM with leg in Dynasplint extension brace.  Gradually increase tension each night from 1 the first night to 10 by day 10.  PT consists of passive ROM including Patella Mobilization (5 min), wall slides (5 min), prone hangs (5 min, add ankle wt as necessary and as tolerated) and extension stretching.   Also do quad sets (1 x 10), straight leg raises (1 x 10).  Use cryo cuff continuously all day.  Continue to take narcotics every 4 hours round the clock and anti-inflammatory.

Here is what actually happened:

The day is going very well.  CPM 2 hours on and 2 hours off starting at 600 am and patella mobes thoughout the day.  No prone hangs or wall slides for now per doctor’s direction till Sunday.  ROM seems great.  Full extension and CPM now at 95 and a piece of cake.  Even better, I am in no pain.  Zero. Feels like I haven’t even had surgery.  Of course it is very early and I haven’t tried to do anything yet (laugh).  I cut back to one Percoset every 3 hours.  It is hard to tell though the dressing but I appear to have minimal swelling due to the doctor’s 4 pronged attack of cortisteroid during surgery and 5 day oral steroid prednisone, CPM and drain installed.  I am still draining about 20 ml of blood every 3 hours.  I don’t know if this is a concern or not.  I will find out when I see the Dr. tomorrow.  I am elevating and locking knee in full extension when not in CPM or doing mobes.  I will try the dynasplint brace for an hour tonight.  I started out icing in Cryo cuff around the clock but the knee has absolutely no heat at all (for the first time in 9 months!) so I have cut back to the standard 20 minutes on, 40 minutes off sooner than I expected.

I am also focusing on diet.  Before this surgery, I worked out hard building up muscle and burning fat.  I even worked the bad leg with one leg presses, curls, extensions and calf raises.  I came in at 5’11” 175 pounds and 5% body fat.  I believe this will help my recovery.  I am eating a high protein, low fat, low sugar diet with fruit and veggies so I minimize the inevitable muscle loss and fat gain during recovery. 

So far so good but I am very guarded as I am well aware things can rapidly go downhill.

Offline Heather M.

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Re: Follow Jake’s LOA from start to finish
« Reply #3 on: June 26, 2005, 02:28:13 AM »
Good luck and keep an eagle eye on things.  Arthrofibrosis patients, regardless of their doctors or protocol, are famous for doing well for 1-2 weeks, then declining.  That happened the first time with me (had an insufflation at 2.5 weeks post-op), but so far I've avoided it. 

And the reason Dr. S. waits to start the steroids is to reduce risk of infection or delayed wound closure.  So watch your ports and monitor for signs of infection.  Prednisone was a miracle drug for me in that it knocked back the inflammation in a way that was amazing--but it came at a price with my knee, which was two post-op infections and ruptured incisions.

Anyway, it's great that the pain is minimal--last time is the first that I've had that, as well.  I was sitting up eating a burger & fries about 12 hours post op!  It was amazing.  Of course, once I started weight-bearing more fully that pesky pain-free thing was taken care of, but I sure enjoyed it while it lasted.   ;D

Hang in there and keep us updated.  This, too, shall pass.

Heather
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline TracyS

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Re: Follow Jake’s LOA from start to finish
« Reply #4 on: June 26, 2005, 05:24:44 PM »
Hi Jake,

I'm glad to hear you're doing well and letting your knee dictate what adjustments it wants to make to your protocol.

I remember the tendons in the back of my knee as being rather sore also after I suddenly regained extension.  The first few days after surgery I got twice a day massages back there from the PTs.  Perhaps you've someone there at home who can give you a gentle massage or two.

Looking forward to more posts on your continuing saga.  Hopefully they will be as encouraging as these.

Tracy

PS:  Loved hearing about your trip home.  I can only imagine what those people thought after rear ending your car and then seeing they've hit someone going home from surgery!!
left knee: '90-ACL recon, '91-tibial screw removal
right knee: 12/00-ACL recon, lateral meniscus repair, 3/01-LOA, 10/02-patella tendon LOA, bone spur removal, tibial screw removal, 4/04-joint, patella tendon, pes anserinus tendon LOAs, 5/05-LOA, AIR, synovectomy, chondroplasty, loose body removal

Offline Jakem

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Re: Follow Jake’s LOA from start to finish
« Reply #5 on: June 27, 2005, 02:41:49 AM »
Day 3 6/26

I had a mixed day.  The positive was I walked partial weight bearing and I could have easily walked with no crutches and with a normal gait for the first time in 3 years.  I have almost no pain.  Now the negative news.  My drain was removed and since then then swelling has increased from minimal to what I would call typical now.  Also my incisions are healing slowly.  This is requiring the dressing to stay on which makes it hard to do the critical mobes and also tougher to have ice work better to reduce swelling.  I started prone hangs, wall slides, SLR and quad sets and extension work.  The dr says I need to work to get more extension so I can get full hyperextension.  The stuggle begins.

Offline Jakem

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Re: Follow Jake’s LOA from start to finish
« Reply #6 on: June 27, 2005, 03:24:38 PM »
Day 4 6/27/05

Here was the plan:

Walk partial weight bearing with crutches.  CPM set at -5 to 100 degrees for 2 hours, 4 times a day 600 AM, 1100 AM, 5 PM, 10 PM.  Do PT 4 times 915 AM, 215 PM, 345 PM, 815 PM for 20 minutes in between CPM.  Do Patella Mobilization an additional 2 times at 600 AM and 12 midnight.  When not doing PT or CPM keep knee locked at zero and elevated by lying on floor with heel on coffee table with pillow.  Do ankle pumps throughout the day.  Sleep on living room floor with heel on coffee table with pillow from Midnight to 600 AM with leg in Dynasplint extension brace.  Gradually increase tension each night from 1 the first night to 10 by day 10.    Stop using Cryo Cuff continuously and instead use cryo cuff 20 minutes on, 40 minutes off all day.  Continue to take narcotics every 4 hours round the clock and anti-inflammatory.

Actual:

I am pretty much on schedule with the following exceptions.  I have the CPM at 105 so I am a little ahead there.  It only goes up to 110 which pisses me off, but I will have to live with that and work on wall slides to get full flexion back.  Of course extension is far more important than flexion, especially early.  I am stuck at about 0 degrees right now.  I have till day 14 to get to full hyperextension (-5).  After day 14 you are stuck with what you got.  This is going to be a real challenge.  I did the dyna splint brace last night for 4 hours and it sucked of course and hurt.  I also did my prone hangs with a 5 pound wt strapped on my ankle.  I am also doing the push down on the knee with the ankle on a book routine.  I think I improved a little from yesterday but not positive.  For good news, I can walk fine, but I am going to be cautious and stick to my schedule of staying partial wt bearing with crutches for a full week.  I also have minimal pain and I am going off the narcotic pain killer percoset, much earlier than planned.  The negative is I have more swelling that I would like and I am starting to get a little heat.  I am having to ice almost continuously as opposed to the 20 min on/40 min off I would have liked to be doing by now.  I am still taking the steroid anti-inflammatory prednisone until wed.  I see the doctor then and he was talking ibuprofen after that for inflammation.  I also don’t have my rental e-stim unit yet.  I need to get that shipped to me asap because that can help inflammation.  You got to beat down the inflammation or else the scar tissue will grow back.  The battle is on!

I am also taking Keflex to prevent infection at the suggestion of the doctor.  That gives me a lot of peace of mind.  I feared he wouldn’t do that so I ordered my own supply of Keflex from an Online Indian company last week.  That was a waste of 35 dollars!  Oh well!

Offline JaneB

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Re: Follow Jake’s LOA from start to finish
« Reply #7 on: June 27, 2005, 07:01:28 PM »
Hi Jake,
Congratulations on making it through the surgery.  I've been thinking about you and hoped all went well.  Take it easy on yourself and don't lock yourself into expectations that are too rigid; I've found that I had to titrate the rehab program many times. It's tried my somewhat limited patience alot!

 I had virtually no swelling/heat for a month and then it came back with a vengence, causing me to halt entirely with strength training, etc.  It's a very slow process overall but it's great that the pain has improved so much so quickly.  I hope it stays that way.  I am very glad I had the LOA 6 months ago and although I wouldn't call my knee normal at this point I am inching toward my former activities every day.  Stay patient if possible.

All best wishes,

JaneB
ACL repair 3/04
arthrofibrosis developed ROM 125/-10
LOA \anterior interval release/chondroplasty 12/04

Offline John1

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Re: Follow Jake’s LOA from start to finish
« Reply #8 on: June 27, 2005, 10:31:36 PM »
Hi Jake,

Thanks for the updates. Are you taking any vitamins or other supplements? Also, I found with the CPM machine on the mattress, my butt would sink in a little then the angle reading on the machine wasn't accurate. For example, the machine said 0 degrees, but the leg was actually only going to 5 degrees.

Good luck,
John
4/12/05 Arthroscopy: plica removal and medial femoral condyle microfracture (2 cm^2)
11/9/05 Arthroscopy: complete removal of plica, removal of scar tissue on fat pad behind patella tendon and on medial side.

Offline Jakem

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Re: Follow Jake’s LOA from start to finish
« Reply #9 on: June 28, 2005, 12:14:03 AM »
Based on what everyone is telling me, this is the calm before the storm and that the real fight is to come.  I will have to remain patient and cautious.

John,

I stopped taking vitamins because they cause bleeding and swelling.  I stopped taking them 10 days before surgery and won't start taking them again for a few weeks.

I am taking glucosimine condroitin and MSN.   There is strong anecdotal evidence this stuff works for articular cartilage.  There is no solid scientific evidence they work but some minor studies showing they work.  If you take it in conjucntion with an ACI or microfracture you get better results.  My first micro was your typical failure.  The second one I took massive quantities of the stuff.  That combined with the massive bleeding from the LR and micro may have given the good result.  When the dr went in to do the LOA, he said the original defect was filled in solidly and in excellent condition.

My hope is with the glucosimine combined with all the bleeding from the LOA and the 6 weeks of CPM will improve the condition of the patella and trochilal defects caused by the 9 months of scar tissue.  It may not mean anything, but walking now I feel the best I have in the 3 years since the original injury.

My mattress is firm and new and on a solid floor so there is not much reflex, so my CPM is probably pretty accurate.

Offline Janet

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Re: Follow Jake’s LOA from start to finish
« Reply #10 on: June 28, 2005, 12:23:43 AM »
Jake:

It's great to hear you've gained so much flexion. Keep working on that extension! But don't push too much. You know, "your knee will only do what it will do," not necessarily what you want it to do. I'm glad you're not in pain, but the swelling is another indicator that you may need to back off some. I know you are analyzing constantly and making the needed adjustments, but when you don't have pain, it's easy to get too "enthusiastic." Keep up the good work!

Janet
Torn quad tendon repair & VMO advancement 4/99, MUA with LOA 10/99, Patella baja and arthrofibrosis, LR & medial release & LOA 5/01, LOA & chondroplasty 6/03,TKR on 11/06, MUA 12/06. From perfect knees to a TKR in 7 years, all from a fall on a wet floor...and early undiagnosed scar tissue.

Offline Jakem

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Re: Follow Jake’s LOA from start to finish
« Reply #11 on: June 28, 2005, 12:28:29 AM »
Excellent advice Janet.

I have two weeks to get beyond 0 degrees extension after that it is impossible in most cases.  However, if I push too hard I can set off a new wave of scar tissue formation.  It is a very delicate path.  I may have to settle for 0 degrees.  We shall see.

Offline favouritesearcher

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Re: Follow Jake’s LOA from start to finish
« Reply #12 on: June 28, 2005, 04:00:10 AM »
A massage works wonders with the pain down the back of the leg.  You can get away without it for a while but although you don't realise it, the pain will affect your gait. A massage might even help get you into hyper-extension.

John
Mar 04 - Tibial spine avulsion fracture (skiing). Open surgery to fix, 1 screw.  Max passive ROM 20-75, active ROM 30-45
Aug 04 - Diag. severe arthro. Scar tissue clean up (LOA, removal of scar tissue).
Feb 05 - Discharged from surgeon's care. ROM 3-125.
Apr 05 - Discharged from physio. Same ROM

Offline Laurie

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Re: Follow Jake’s LOA from start to finish
« Reply #13 on: June 28, 2005, 04:29:47 AM »
Jake,

I was 8 weeks before I got all my extension back - 0 degrees then, but I can actually hyper extend now.  I was at 3 degrees for 4 weeks.  So don't freak at the 14 day mark if you are not there, especially if you have swelling.  The swelling can stop your extension.

Massaging the swelling up towards your butt helps dramatically.

Good luck,

Laurie
Laurie :)

Offline jim mac

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Re: Follow Jake’s LOA from start to finish
« Reply #14 on: June 28, 2005, 05:42:22 PM »
Jake,
Glad to hear of your progress.  I have lots of pain (couldn't walk without crutches if I wanted) and the pain meds are the only thing keeping me working at ROM exercises.  My patella is gliding like new and I have 0 extension.  Extension has never really been an issue for me . . . flexion on the other hand is really painful!  I have sooo much pain in my upper thigh that stretching beyond about 80 HURTS.  I am going at things really easy but I am being persistent.  CPM all the time.  In fact I'm headed to get back at it for an hour before PT at 2:00.  Talk later.  Good luck

Jim Mac
2005 - 3/4 arthroscopy meniscus repair + plica removal, 3/9 staph infection 2nd scope (lavage), 3/12 open incision (lavage), 3/13 cauterize vein + lavage, 3/17 lavage and incision closure, -  Arthrofibrosis -  6/24 debridement, LR, MUA - 10/12 LOA + synovectomy 2006 . . .















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