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Author Topic: ACI 7 weeks ago takes turn for worse  (Read 11335 times)

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Offline mlashmar

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ACI 7 weeks ago takes turn for worse
« on: October 05, 2010, 07:32:36 PM »
Hi

I had (M)ACI nearly 7 weeks ago and it seems to have taken a turn for the worse.  :( :( :(

At 6 weeks the brace was removed (for good) and I started on strengthening exercises as directed by physio (wall slides, squats, sit to stand, calf raises and step up in ROM exercises).  All relatively low impact to get going.  No pain was felt during exercise, I found the exercises hard work, but not painful.  My knee gave way on one occasion, but again, no pain was felt at the time.

My knee, although swollen and uncomfortable before was pretty much improving slowly I believe.  It has now become noticeably more swollen, hot and uncomfortable (borderline painful).  Difficult to locate the pain, seems to be general although it could be attributed to the repair site, but also other parts of the knee.  Appearance-wise, it doesn't appear to have changed too much (other than swelling of course).

If you had a similar reaction to starting your strengthening exercises, I'd be interested to hear from you.  Likewise if you recognise these symptoms.  Is this a sign of failure or that I've overdone it and it is typical for the knee to get cross and swollen in this way or is it a case of me over-cooking things a little too far?

Thanks

Mike
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline ajschnelk

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Re: ACI 7 weeks ago takes turn for worse
« Reply #1 on: October 05, 2010, 09:50:22 PM »
I am not sure the location of your defect, but it's safe to say that you are doing way too much too early.  I had aci for a trochlea defect and i didn't even think about doing any of those things at 7wks other than the ROM and contraction type excercises.  I don't think i even attemped a partial squat until around 5months.  Where is your defect? 

Offline markld

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Re: ACI 7 weeks ago takes turn for worse
« Reply #2 on: October 05, 2010, 09:52:04 PM »
Are you insane? You are doing things that one shouldnt do until 6 months post op. I had ACI on both knees and really didnt start strengthening until around 6 months. The graft is still way too soft at 7 weeks to be doing wall slides/squats... etc. You need to slow way down and find a therapist who has some experience in rehabing ACI. The only thing you should be doing at this point is slowly riding a stationary bike.
April 2008 microfracture left knee trochlea
Jan 2009 ACI harvest from right knee
Mar 2009 ACI right knee trochlea
July 2009 Aci left knee
Nov 2009 left knee scope to check graft

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #3 on: October 05, 2010, 10:02:15 PM »
Hmmm, that's interesting.

I have a 1cm x 2cm full thickness defect on the trickles.

The rehab I am on is as prescribed by the national trial I am part of which indicates beginning strengthening exercises at 6 weeks to 12 weeks. That said, doing what I am doing is clearly too much for the knee, so if I recover, I'll scale down considerably.

The physio was telling me to get rid of the knee brace, start walking with one crutch (and hopefully without a crutch soon) and drastically increase range of movement exercise.

Thanks for your feedback, how are you guys getting on? Frustrating isn't it?
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #4 on: October 05, 2010, 10:05:08 PM »
Damn iPhone, trochlea not tickles!
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #5 on: October 06, 2010, 12:24:31 AM »
Hi Mike

Ditto what the others have said.  The only strengthening to be done at this stage is light strengthening comprising quad sets, ham sets, straight leg raises etc.  Some additional exercises that allow you to strengthen other parts of the body without stressing the knee is also recommended.  Bike is good for mobilisation as long as it is at zero resistance.

I find that some physios seem to expect you to follow a protocol like you're a robot.  But your knee is telling you its too much by the increased swelling and discomfort.  If in doubt get in touch with your OS to let them know how your knee is taking this.  In my book it's downright unethical to push anyone to jeopardise the outcome of an op if an alternative is possible.  In other words, the Hippocratic Oath and the Declaration of Helsinki that governs all work and research among human participants restricts activities to those that would not do anymore harm than you might experience normally (i.e. your rehab should not be accelerated without tight monitoring to ensure it is not harmful).

How experienced is your PT with MACI rehab?  I know I had one physio who was way too aggressive, so I ended up ignoring her.  Her approach seemed to consist of loading me up with lots of exercises I might do but without any guidance on suitability.  Luckily I knew more than her she's since proven herself to be excellent at talking to you and citing research but less capable of doing any therapy!

I did have another physio who has ACI experience who was excellent and modified everything according to to tests in clinic and outcomes since the last session.  If there were any questions at any point she would check it out with the OS.  I never had any problems with swelling etc. under her guidance.

Have you looked up the posts of JulianUK?  He's had two successful MACI grafts which have held up for years, so he's probably the Golden Boy from the UK (especially Stanmore) for this procedure.

Hope you can sort things out to get back on track soon!
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #6 on: October 06, 2010, 08:53:24 AM »
Thanks Renn, all of you have been really helpful  ;)

My physio is widely recognised as the best for knees in the area, that said, she hasn't too much experience in MACI. I'll have to wait until Monday for my first post op visit with the surgeon to see whether this is just a nasty reaction that'll settle or the end of the road for this MACI. A little nerve wracking as I'm meant to start a new job on 1 December! Utterly deflated at the minute  :'(

We seem to be pretty good at actually doing the operation in the UK but post op support and rehab is pretty poor!

I'll look up Julian, thanks for the info.
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #7 on: October 06, 2010, 12:18:04 PM »
Mike

It's probably a bit early to be writing off the MACI op, but if I were you, I'd stop the squats and any activity that increases the shear forces beyond that you'd have with walking - see article by Karen Hambly on PT post-ACI.  As far as I can tell, she is the expert physio in this area.

Where are you based?  I know of some physios out of my area who are familiar with MACI and if they match I can PM you the details.
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #8 on: October 06, 2010, 12:19:55 PM »
Thanks Renn, I'm based in Southampton, Hampshire
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #9 on: October 06, 2010, 12:22:47 PM »
PS where is the article?
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #10 on: October 06, 2010, 12:52:52 PM »
You can find all the articles for Karen Hambly within the Information hub just scroll down the page till you find Karen's name.

Sorry, my contacts are not in the Southampton area, so can't help out as I'd hoped.  If I hear of anyone I'll let you know.
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline barnee21

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Re: ACI 7 weeks ago takes turn for worse
« Reply #11 on: October 07, 2010, 05:57:58 PM »
Hi Mike,

Sorry to hear about your setback, I am due to have first stage ACI at stanmore on the 22nd oct under Mr Carrington, I am also in Southampton and would be really grateful if you find a decent Physio in the area if you could forward their name on to me, rehab is a huge part of the whole process and getting a physio with knowledge or previous experience of ACI or MACI would be a massive advantage. Hope the knee settles down and you get the correct information on what your limitations are, squats seem a little brutal this soon after the op.

Lee

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #12 on: October 08, 2010, 08:17:22 AM »
Hi Lee

There's good news and bad news.

Bad news
No one in the area has much if any experience of ACI. The op is comparatively rare still.  I was referred to someone who is widely recognised as the best physio for knees is Southampton.  The referral system for physio is very odd in Southampton, most likely you'll be referred to Moor Green, I'd recommend you resist this and push to get Southampton General.

Good news
Some of the responses on here suggest not doing the strength exercises until 5 months, but that doesn't seem to be protocol here and my physio was following it. The exercises were just a little too much and we should have eased into them a little more slowly, but it is tricky to judge.  Have a look at thinks like Chester Knee Clinic for rehab guides (which seems a little more aggressive than my programme) for an insight and when you do your rehab, your more than welcome to drop me a line, I would however suggest, scale back your exercise programme and build up very very slowly and see how your knee reacts,

Best of luck

Mike


Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #13 on: October 08, 2010, 09:59:15 AM »
oh, and by the way, if you can afford it, well worth investing in an Aircast Cryo Cuff device, I managed to get it (ice bucket and cuff) for about 100 all in and it is an absolute god send!  Fill up the ice and water in the morning and you feel the benefit for pretty much the entire working day.
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #14 on: October 08, 2010, 12:30:46 PM »
Mike

I've collected a variety of rehab protocols from all over and the ACTIVE protocol is by far the most aggressive and way out of line with all the others, including my OS's.

Karen Hambly has written an article on rehab protocols and gives the earliest time at which exercises may be introduced, but the physio needs to exercise judgement as to whether it is appropriate for a particular person.  The OS should also provide guidance.  I think that true strengthening work is normally restricted until the OS says whatever you can within the limits of pain etc.

If you want to find further protocols you can use Google to search for Dr Minas, Dr Cole, Carticel protocol, the Cartilage Repair Centre and the original Gothenburg protocol.  It takes a bit of time, but there's a lot of info out there.

The guys in the US have a super-duper system which pumps the water regularly.  I think Donjoy UK may be able to supply something like these, but they're not mentioned on their website.  It may be worth investing in to ensure the icing happens as thoroughly as possible.
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #15 on: October 10, 2010, 09:07:11 PM »
Well it's off to see Mr Carrington tomorrow at the Royal National Orthopaedic Hospital (he's the consultant / OS). A real sense of trepidation about it all.

The knee has settled down a bit from what it was, but still not great. I have pretty much done nothing for the entire week, very occasional leg bend to 90 degrees and some SLRs.  Still swollen and uncomfortable in as much as it 'doesn't feel right' if you all know why I mean. That said, I don't feel any clunking, grinding and general bad sensations when I hold the palm of my hand over my knee as I bend it, I certainly did before, so maybe not all bad.

Anyways, fingers crossed all is good and whatever happens, I'll post tomorrow and let you know how I get on, and whatever happens, I'll keep you updated.

Mike
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #16 on: October 12, 2010, 08:31:03 AM »
OK, so I had my visit yesterday to the consultant (or OS if you're in The States).  Overall it seems to be pretty good news, if a little confusing.

First off, a physical examination, a little brief but the consultant was adamant and very confident that there were no signs of failure and all was ok (good).

Secondly, he said that he would have wanted me to be much more aggressive with the range of movement exercises. The Royal National Orthopaedic don't use CPM machines (regarded as old fashioned, movement using own muscle power is much preferred). I explained that I'd followed the protocol, sowing thy is up for revision.

Lastly, he explained that my strong reaction to exercise was due to 'adhesions' in the knee as a result of the op and the length of time I have been immobile. This is entirely normal and I should cope with it with ice and pain relief as appropriate. I was not expecting that response, my physio suggested that I calm down exercises if I get that reaction, so will challenge my physio on my next appointment (on Friday) as now I don't know when I'm pushing exercise too far (what is a natural reaction and what is as a result of pushing things too far).

So, overall good I think, I just have to be prepared to have periods of severe pain and swelling. Back to working hard again!
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #17 on: October 12, 2010, 01:00:06 PM »
Hi Mike

It's good to hear that your surgeon was happy the graft was intact.

If you have adhesions, then you may like to visit the 'Soft Tissue Healing Problems - Arthrofibrosis' section.  The general approach to managing adhesions is to stretch but without getting into pain and swelling.  Those two factors will simply encourage further formation of adhesions and you could then find yourself needing more surgery.

Ask your physio about ultrasound for the adhesions.

As far as being aggressive with range of movement exercises I'd caution against going into pain and swelling, but work to 'massage the limits' using prolonged low load exercises.  Dirk Kokmeyer has written some info on rehab from adhesions which is good useful reading.

Thanks for keeping us updated, and good luck with the continuing rehab.
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #18 on: October 12, 2010, 05:16:05 PM »
Cheers Renn, thanks for that, really helpful (as ever), I'll look into it.

Hopefully others reading this will benefit and not feel too much doom and gloom when they get pain and swelling.
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #19 on: October 13, 2010, 10:09:21 AM »
I've been using an exercise for a few days now (I'm now 8 weeks in) and it seems to be a great help in improving joint mobility.  I have been doing the basic range of movement exercises in any case (albeit for a break when my knee for very swollen and sore), but bike seems to have a really good effect.

Settings wise, I have the seat slightly higher than I would normally, so my leg is quite straight at the bottom of the pedalling motion.  That allowed me to bend my knee (just about) at the top of the cycle motion.  I had to get my (long suffering) girl friend to adjust the seating position initially and make sure I could get on and off the bike OK (a little tricky, but you soon pick up a few tricks to allow you to do it safely).  The bike is set on minimal resistance and I started by just doing 1-2 minutes 2-3 times a day, I've upped it to 3 mins now.  I'll keep it on minimal resistance for the time being, I may increase the range of movement slightly by lowering the seat by the smallest amount).

Initially the cycling motion was really awkward, but not painful.  I was cycling in slow motion, perhaps about 20 rpm, but this morning, I improved significantly, perhaps about double. Interestingly, I'm not 'pushing' it, it just kind of happened, my leg just went at the pace my knee felt comfortable. 

The bike is set at minimal resistance and I'll keep it as such until the physio tells me.
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #20 on: October 15, 2010, 09:25:55 AM »
I had my physio at 0730 this morning and all went really well, my physio was really pleased and it seems the problems I had a week ago were just the breakdown of adhesions and nothing more sinister!  Great stuff!

Physio had told me to pretty much carry on as I am, no real changes to the exercise regime, just carrying in building quads, calf and range of movement exercises.  Small changes are to practice moving leg through a step up motion to help make walking more fluid and to either lower the seat or increase resistance on the bike (only one or the other and only by a small amount).

All seeming to go pretty well at the moment, improvements on a daily basis, just need to ensure the progress is steady (and not get ahead of myself)
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #21 on: October 18, 2010, 07:47:44 AM »
A touch of tenderness on the patella tendon (tendonitis?) but otherwise all seems to be going ok.

By Wednesday it will be week 9 and the knee is still swollen (albeit much reduced) and stiff. Range of movement is up to 120 degrees, but not a fluid movement yet, cycling seems to be a benefit.  Down to one crutch now, nut certainly need that for walking, although there are times when I feel that I don't.

At night, still most comfortable to lie in my back (I miss lying on my front!). Lying on my side with the scar side down is fine at first bit the gets uncomfortable. Whilst my knee isn't uncomfortable as such, I am aware of it most of the time, I suppose it is on the verge of discomfort.
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Youthist

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Re: ACI 7 weeks ago takes turn for worse
« Reply #22 on: October 18, 2010, 09:06:05 AM »
I am a permanent lie-on-front sleeper too, always have done, so after two nights I am struggling ! I hope I get used to it  - i see you are still on your back at week 9 - gulp!

How much movement / bend did you have in the first week or two? can you remember?

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #23 on: October 18, 2010, 10:28:18 AM »
Not much movement, albeit this was on purpose to protect the graft, the protocol limited movement such that there were no range of movement exercises in the first week and then 0-30 degrees from weeks 1-4.  I'm sure I could have done more, but the priority is protecting the graft, not range of movement in that period.  Moving the knee over the 0-30 degree range wasn't too difficult from memory, it soon became relatively easy, just important not to try and do any more than that.

You will get used to sleeping on your back, or at least enough that you can get to sleep like it.  I kept the brace on at night for the first 4 weeks to keep it all protected.  I still wake up when I go over on my side!  I will deffo post when I first sleep on my front, it will be a momentous day!
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Youthist

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Re: ACI 7 weeks ago takes turn for worse
« Reply #24 on: October 18, 2010, 11:10:53 AM »
Good stuff. I am two days post op now, and my brace has been set by Dr Skinner and the physio team at max 45 degrees, and I can just about get there at the moment. He also wants me to put weight on it ("as much as pain will allow") as the compression onto the lesion and patella he said will compact it and encourage growth.

I can now see how every single of these treatments varies based on the location of the trauma, the operation, plus many other factors!

I am going home later today, dreading it a bit to be honest, I am getting used to all this care and attention :-)

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #25 on: October 18, 2010, 12:45:26 PM »
haha - yes I bet, try and make sure you have plenty of people coming in to visit you, prob need to get the ice topped up mid-afternoon (depending on when you get up) and have dvds pre-loaded into the player.
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #26 on: October 28, 2010, 03:29:09 PM »
Seems like ages since I was last on here, but it's been just over a week.  I've now reached 10 weeks post op, so thought I'd write a few lines to update on progress.

I have begun walking without crutches, only a little bit around the house.  Not quite normal fluid steps, particularly after I have rested for a while, but beginning to improve and become more fluid in my walking.  Feels a little like waddling at the moment and still a little stiff through the knee joint as my leg moves through the walking motion.  I'm surprised the motion is not very fluid (still) as my range of movement exercises are taking me well beyond 120 degrees, albeit they are not that fluid either.  It sometimes feels as though parts of my knee get a little stuck in range of movement, but not the repair site.

Pain-wise, the pain I had in my patella tendon no longer seems to be present, or at least no where near as much.  That said, the knee is still a little stiff and swollen and I get the odd pain here and there.  I haven't used the ice or pain killers for a while now (at many times I thought I would take them for ever more!). 

I am doing wall slides, sit to stand, moving my leg through a step up motion, calf raises and exercise bike at the moment.  I use the good leg a little to assist in wall slides and sit to stands.  I've been doing these exercises for nearly 4 weeks now, so have increased the reps but feel like I could do more.

I occasionally hold my hand over my knee cap when I bend my knee, the old crunchy grinding sensation no longer seems to be present, so I hope things are still going well.   :)

I decided to invest in an automatic car, the old one had nearly had enough of me anyway!
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #27 on: November 01, 2010, 12:20:47 PM »
Whoops

Over did the physio this morning, perhaps a little carried away on the bike, quite sore at the minute and a little warm and swollen.  I wonder when the knee starts to feel normal again, I certainly look forward to the day when I don't think about my knee and just get on with a normal day!  Seems like it will be a little way off for now.....
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Dennis BadKnee

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Re: ACI 7 weeks ago takes turn for worse
« Reply #28 on: November 02, 2010, 12:54:40 AM »
Mike,

I bet you did not hurt anything at the physio.  I would get a hot knee or slightly painful at your stage.  I feel the painful is something to avoid, but heat can be reduced by icing (at least I was told it is ok).  I still ice regularly.  I have an IR thermometer (industrial) and still see something like a 3 degree C difference from the same spots on my good knee all the time, but higher after a workout. 

I also found that increasing distance/time was more forgiving than increasing intensity.  I still do things at a rather low intensity albeit for a long duration.  Yesterday I went for a 7 mile hike (just under 3 hours).  It is not that I cannot go faster, but it seems to hurt after if I do.  And I do not think pain is good.  At your stage, you just are not sure what is ok and what pain is bad.  Good that the crunch feeling is gone.  Sounds like you've got a smooth knee.

I also shopped for an automatic car, but never did get one.  Now it no longer matters.

Keep us posted.  You seem to be doing well.

Dennis

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #29 on: November 02, 2010, 12:12:41 PM »
Wow - 7 mile hike sounds good!  Well done, keep adding little bits at a time.  How does your knee feel after doing the walk?

Incidentally, I read the links you mentioned and saw a lot more of your history, wow, sounds like a really rocky road, so no wonder your confidence in physios and the knee itself has been knocked.  Little by little, I hope you get it back.

Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Dennis BadKnee

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Re: ACI 7 weeks ago takes turn for worse
« Reply #30 on: November 04, 2010, 12:27:50 AM »
That was about my 3rd 7 mile hike. I say 'about', because I went on a few less structured hikes in mountains that might have been about this or more, and one 3 day kayak trip where I walked a bunch. I can walk 5 miles every other day, perhaps every day, and not have any pain or swelling, but I can feel I did something and it is time to stop - no tiredness, but some other awareness about the knee.

On the 7 miles, the knee swells just a little and feels ever so slightly sore at night. The next day it is back to normal. I think it is good to give the ACI the message that we plan to do such things. But I don't think it would be good to do more at this point.

I do probe every now and then to see if my limits are increasing - especially when I feel very confident and complacent. Those 7 miles are now about it, I think.

Oh, BTW - when I two-man carry the kayak, with my end being 30+ pounds, it feels (for days) like someone hit my kneecap lightly with a rubber mallet. Can't be good. Yet, I can lift weights and carry 70 pounds for a few feet at the gym, no ill affect.  I think this makes a good case for my friends bringing in my firewood this winter.

Keep up the good work and stick with it. This is not something where we can let down the guard or get complacent.

Dennis

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #31 on: November 08, 2010, 11:20:37 AM »
Feeling a little down over the last few days  :(

I guess it must be par for the course with MACI to feel like this at times, the odd bad week here and there.  In fact, that's how this thread started when on weeks I was convinced things had gone badly wrong (in fact, it was just my reaction to breaking down the adhesions in my knee, thankfully).  So, why am I feeling down, especially as I have been walking without crutches for a couple of weeks now?

My knee seems to be playing up, I think.  It might be fine, but I just don't feel confident in saying that and I feel utterly deflated at the minute and Friday's physio session (where I can chat it through with the physio) can't come soon enough. 

Symptoms wise:
- the knee seems to be acting up a bit, the days of discomfort, pain and swelling have returned, especially by the end of the day and with a vengeance. 
- specifically, I'm getting pain at the patella tendon and to the side of the knee
- when cycling, I get a clunking type sensation in the knee (I can feel this when placing my hand over my knee), but interestingly, I can feel that on my other knee too! 

It all seemed to start when I was doing some wall slide exercises, difficult to describe the feeling, but it was like the knee got stuck as I was moving through the exercise, it was painful and a bit of a shock.  Perhaps it was just part and parcel of rehab, these things happen, but I wonder if I have done some damage.

Roll on Friday......
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #32 on: November 08, 2010, 11:51:33 AM »
Mike,

I'm sure you'll discuss your symptoms with your PT, but I'd guess that the increase in symptoms are a guide to that fact that you're currently stressing your knee to the limit.  It may be worthwhile just cutting back a little in the forces you put your knee under, whilst maintaining motion and mobiity.

The clunking may also be due to deconditioning of the muscles at the moment.  Once you can get back to strengthening then this should decrease.

I don't know what type of wall slides you're doing, but if they are painful could you go through the same motion without stress the joint in the same way?

My understanding is that if the graft fails you definitely know suggests it's very painful.

Hope you pick up through the day!  :)
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #33 on: November 09, 2010, 04:17:01 PM »
Cheers Renn

Scaling back exercises now, but still giving me hassle after by mid-afternoon.  PT can't come quickly enough, guess I'm going through a low period at the moment (seems to go in cycles, but thought I'd finished them!).  Rubbish.
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Youthist

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Re: ACI 7 weeks ago takes turn for worse
« Reply #34 on: November 09, 2010, 05:56:50 PM »
Hang in there mate - I am sure things are fine.  I had a bad patch two weeks ago, and it passed (which you really helped with, iirc). Remember how patient we all have to be to get where we want to get to.  Like my physio says all the time to me - this operation is  not about 5 minutes, or 5 months, its all about 5 years. 

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #35 on: November 16, 2010, 08:03:28 AM »
Cheers You

Well, I went to the physio on Friday and offloaded.  Physio still seems positive and did some basic checks and thinks things are OK.  Pleased with my progress and has added stepping up and down from a step to the routine, which I have progressed with really well since.

Nagging doubts still persist as does the clunking in my knee (to be fair, it is present in my good knee too, so who knows).  Walking is getting a little more fluid now and I am getting less conscious of it.  I am still 'aware' of my knee the whole time and it still gets swollen and sore by the end of the day (had a few days where I thought that was subsiding, but not convinced yet).

If anything, the knee seems to stiffen during the night and I have to 'get it going' again in the morning!  Still not sleeping on my front (preferred), but am able to sleep on my side for some time (gets uncomfortable after a while).

Noticed some lumps underneath the scarring on my knee, give me sharp pain sometimes when doing ROM exercises.  Physio thought they could be residual stitch material, seems odd after 3 months, but I guess the surgeon will tell me.

My exercise regime is:
- wall slides
- sit to stand
- step up and down using bad knee
- cycling (now up to 8 minutes per session, low to moderate resistance)
- single leg squats (less than 90 degree bend, prob about 60 degrees) and using chair for balance
- leg bend exercises to full ROM

Next off to visit surgeon on 22 Nov and start my new job on 1 December, so fingers crossed for both of those!
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #36 on: November 16, 2010, 01:36:57 PM »
Hi Mike

I'm really surprised to hear that you are doing wall slides, sit to stand, steps and 1 leg squats.  For me those exercises were banned for at least 3 months.  Clearly, our constraints are dictated by our defect sizes and locations.

If I were you, I'd refer back to the info provided by Karen Hambly and at http://www.cartilage-repair.co.uk/ and also check with the surgeon that they are happy for the exercises to be done.  As Dennis has said, so PTs can do more harm than good because of not knowing what they don't know.  However, you are the one who has to live with the consequences.

The lumps under your scarring are probably adhesions.  They do tend to hurt with ROM because they are being stretched and don't have the same elasticity as your normal tissue.  Has your physio advised you about massaging these?
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #37 on: November 16, 2010, 05:49:30 PM »
Hi Renn

I'll double check, but they appear to be included in the Stanmore protocol.  I am walking around unaided now, and the protocol seeks to build up quads through a variety of exercises from relatively early (week 6) and a milestone for week 12 is to be able to dynamically stabilise the knee during single leg stand/squat.

I'll check out the lumps with the surgeon when I see him, not too convinced by the explanation, but the physio isn't sure as does not have detailed op notes (as to how wound was closed).  Sounds like adhesions is more likely, thankfully they are quite small. 
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #38 on: November 23, 2010, 08:04:16 AM »
Saw the consultant yesterday (Mr Carrington) for my 3 month check up, so thought I'd add another update.

This last weekend I went away for the weekend, the first little holiday this year.  Stayed in a nice little village and decided to have a walk around the town.  Quite apprehensive about it (the walking) at first, but gave it a go.  Probably walked about 1.5 miles in all, with some steep inclines included, various stops on the way to see how things were progressing.  It went really well, in fact, I actually felt really good afterwards.  I rested my knee before we went out for dinner that night, but probably didn't need to, felt great!!!   :D ;D :D ;D

I went to London for the outpatient visit as I mentioned above.  Initially I worked in our London office for the morning, taking the overground train (1.5 hours) and underground when in London.  Travelling was fine and I am now able to bend my knee for relatively long periods comfortably.  I spent the morning in the London office without my usual leg rest, seemed to go OK (kept moving my knee to keep comfortable but otherwise OK).  Then I headed out for the appointment, I decided to walk from the office to the appointment, about 1 mile.  A slow walk and my knee puffed up afterwards a little, but it seemed to go OK.

My consultant was happy with the progress, range of movement had significantly improved (probably back to pre-operative range and has been for a good 3 weeks or more).  Need to work on quads, which is in hand.  Interestingly, he said that it is common for people to be disappointed with progress at 3 months, as the cartilage and quads have not fully developed at that stage, at 6 months, all being well, I should be feeling really good about it all.  I mentioned the clunking in my knee, he said not to worry about that, this should improve as the muscles develop, which in turn will allow me better control of the patella and how it tracks in the knee joint (i.e. poor control of the patella at present meaning it is bumping around in the knee a little).

So overall, a positive appointment, still some nagging doubts about it all, but perhaps that is an overhang from my failed microfracture and the fact that the MACI hasn't proven itself to be effective yet, so time will tell.  Off to do some exercises today and to sign up at a gym so I can do some more exercises!
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #39 on: November 23, 2010, 10:37:07 AM »
Hi Mike

Fantastic news!  It sounds like you're doing really well and getting back into life again (although with constraints).

I hope this carries one for you.  Remember not to overdo things at this stage you won't get any feedback on the stresses on the cartilage.  But there's plenty of advice from those who have gone before you.

Take care!
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #40 on: November 25, 2010, 04:58:37 PM »
Cheers Renn, sage advice

How are you getting on?  Things improving?
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #41 on: November 25, 2010, 06:05:20 PM »
Things are slower than I'd like, but that seems to be the case with everyone.

I'm at that stage where I can walk without crutches, but not for very far and I get discomfort behind the knee.  I'd like to work out how to increase my walking range without having the kick back pain I've had in the past.

I have almost full ROM, which tightens up overnight.  Still warm and swelling increases through the day.  Still doing three long home PT sessions a day, so it's life-consuming.  It feels like that same old stuff each day. :(

My pain is mostly under control although it does act up with activity.  Can bike at zero resistance comfortably but rower is quite demanding.

Pain meds were adjusted at my meeting in pain clinic on Tuesday so I'm now on slow release tramadol which may make it easier for me to come off the tramadol.  I'll then be in a position to reduce my fentanyl dosage but I've been told to expect to do this over 6 months, so no hurry.

I guess I'm not bad but like most people here struggle to see any difference from day to day.  Feeling sluggish as well.  Just want to wave a magic wand to get better.  8)

Good to hear your news. ;)

1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #42 on: November 26, 2010, 11:47:22 AM »
Renn

Sounds like you are making progress though, so hopefully things continue to progress.  I know what you mean about the rate of progress, it is difficult to see the difference day to day.  Maybe worth keeping a diary of progress (when you first up resistance on bike etc) which may help inform you of the progress you are making.  Many of your symptoms are identical to mine a month or so ago, so don't lose heart, keep being positive and carry on with the hard work.  It does feel like that in the last month things have picked up more quickly and hopefully as I head to 6 months that trend will continue, so hopefully you'll be the same once ROM is fully established and you start building those quads.

Have you tried lowering the bike a slot at a time, I found that helped get my leg going and make the leg feel smoother through ROM and generally.  Still stiffens in the morning, almost needs some exercise to get going, but I gather it will be like that for a few months still.
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #43 on: November 27, 2010, 12:15:01 AM »
Hi Mike

I keep a mind-blowingly tedious diary of everything I do and all the meds I take as well as a day-by-day diary of pain, heat and swelling with some indicator of ROM.  Sadly my pedometer is highly inaccurate mainly because I walk too slow for the set-up.  This recording helps me to work out whether or not I can increase the level of any particular activity, e.g. ankle weights, number of reps etc.  It provides a good intellectual level of feedback, but emotions seem to weigh more and that isn't necessarily tied to logic.

I probably won't be lowering the bike.  I have usually used the static bike with a high seat anyway.  It puts less stress on my patellofemoral joint, which is where I have my defects, it enables me to work on power output better and it allows my leg to go to almost full extension which simulates what I would be trying to do in competition although after all this time a return to competition is very low on my priorities.  I've found that I can do endless bike on zero resistance, the problems arise when I start to go to higher resistances.  On reflection, that may be due to trying to do my normal interval workout of fast and slow rpm.  I've now decided to forget the power work and just focus on the strength component until I can walk better.

I don't know if I'm stiff in the mornings or not it doesn't feel like how I imagined stiffness would feel.  I constantly feel as if the back of my leg has strapping on it, but the physio said I was not visibly swollen behind the knee.  Maybe it is just tight soft tissue despite my stretches.

You sound really cheerful at the moment after a few stutters in the first few months.  I hope that you feel the path is a bit smoother from now on, but I imagine you will still feel some things are tricky at times.  Don't forget that people here will be happy to help support you through all this.

Take care!
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.

Offline mlashmar

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Re: ACI 7 weeks ago takes turn for worse
« Reply #44 on: December 17, 2010, 06:22:44 PM »
Well, tomorrow marks the 4 month post operation milestone, so I thought it was time to post an update!

I started my new job on 1 December, which for me was the first time I had properly gone back to work (I was previously on gardening leave, which suited my rehabilitation).  I was initially quite nervous about starting work because I still had a severe limp at times and keeping my knee comfortable would be an issue. 

The week before I started my new job, I joined a local gym and started on the X-Trainer, Exercise Bike (albeit I have one at home which I had been using) and the leg press and hamstring curl, all under advice of my consultant and physio.

So, as to how it is going, a bit of a mixed bag really.  I still walk with a noticeable limp, although at times (particularly in the morning) it is not very noticeable.  I still get quite uncomfortable most days at work (despite a good leg rest I managed to wrestle away from my former employer).  I quite often get clunky sensations in my knee (I'm sorry this is a rubbish description), it tends to happen when my knee goes through flexion/extension and both my physio and consultant explained it as most likely being the muscles around the knee not being strong enough to guide the patella correctly.  My thoughts (for what they are worth) are that neither has been able to confirm the explanation, so if I'm still worried next time I visit the consultant (at 6 months) I will push for an MRI scan (it's on the NHS, so I guess there is a reluctance to scan me - if anyone has managed to get a scan on the NHS after having an ACI, please let me know the factors that led to you obtaining one).

I am religiously going to the gym every morning before work, doing a combination of cardio and weights as directed. Certainly my strength is improving and my new colleagues have noticed the difference in my gait in the three weeks I've been at work, so it is certainly paying off.  I'm not doing my physio at home, which is a shame, but after the day is out, I tend to want to rest.  Walking down stairs is still a struggle (generally one step), but I am keen to improve on this.

Anyway, I have waffled on a bit, hope you are all getting on well in ACI land, Season Greetings!
Left knee
Full thickness defect (20mm x 20mm), Trochlea
Arthroscopy x 3 (1997 - 2006 NHS) - lose body removal, lavage and debridement
Microfracture 2008 Spire Southampton - diagnosis of trochlea defect
MACI Stanmore 2010

Offline Rennschnecke

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Re: ACI 7 weeks ago takes turn for worse
« Reply #45 on: December 17, 2010, 07:51:50 PM »
Hi Mike

I got an MRI at 14 months.  This was a standard part of the review process the NHS perform.  I don't know that you'd get much joy pushing for one in advance.  With the waiting list that may exist it could take some time to get your MRI and the timing may simply coincide with the normal one anyway.  Still, it can't hurt to ask.  Don't ask, don't get!  BTW you may find that appointments are restricted because you'll need a specialized radiologist to review your case.  I know I was put in with the top person at my hospital so it was a choice of one unearthly time on one day or an equivalent another day when they were in next.

The clunking in the knee could be due to imbalances in the muscles around the knee, especially if not accompanied by pain.  Your physio should be able to run your through a few diagnostic tests to identify where the problem might be.  Well, my first physio (lead physio at the EIS) did such tests.  You then need to sort out a programme to regain muscle balance.  Not all physios seem to do this, targeting major muscles rather than the smaller stabilizers.  Changes should be seen within 6 months, but depending on the degree of loss it may take longer to get back to normal.

Sounds like you're good though.  Have a good Christmas and don't get too drunk and fall down the stairs!
1/05 Ski accident: 5/05 ACLr LK; 10/06 Scope debridement, trochlear cartilage lesion (Gr4); 12/08 Scope chondroplasty, hematoma; 5 & 6/09 MACI patella & trochlea 'kissing lesions', ROM 0 to 80; 9/09 Scope LOA, IPCS & patella infera; 9/10 Scope AIR & LR.