PFJR post op activity

[RGB]

Dave33 and I will probably continue our discussion on patellofemoral arthritis and PFJRs in this thread to avoid taking over Mr F's!

[Dave33]

Thanks RGB.

For those who may be following in the future- RGB has had a PFJR and I am scheduled to have one in a few months. Perhaps due to the relatively rare incidence of this type of resurfacing, there is not a lot of information available to those considering it in regards to sporting activities post, particularly in the younger subset of arthritis sufferers in the patellafemoral joint. - and RGB's experience has been invaluable.

My intention is to return to hockey and semi competitive cycling post implant.

I've been somewhat outspoken of my failures to address the arthritis with biologics, which I don't think is uncommon. I'd be happy to answer any questions pre and post op, and I'm sure RGB will do the same.

RGB - glad you're back in the saddle! A 2 hour ride is a very decent workout. Yes, i understand the new dual suspension bikes are the way to go now.. the advantages outweigh the extra weight in a lot of cases..

Could you do a 2 hr ride on consecutive days without pain?

[RGB]

The 2 hour mountain bike was after a 1 hour hardish road ride session the previous day, with a 10 minute out of the seat hill at the end. I had no symptoms of pushing it too hard. I probably wouldn't have done a second mountain bike session the next day though. So that gives you some idea. Post the PFJR there's not really any pain - the signs that I've overdone it are general swelling and a mild feeling of pressure in the medial tibiofemoral area. The latter is probably more a consequence of my missing meniscus than the PFJR. Bear in mind that I've only just started to increase activity after the ankle break so I expect to ramp up slowly rather than hit it hard straightaway. I'm currently on a program of mini one legged squats with 20kg weight plus a Swiss ball against the wall 'phantom chair' - 90 degrees without weights and about 50 degrees with 20 kilos. That happens 3-4 times a week and the idea is to strengthen the knee before skiing but I haven't left myself much time. I tried something similar at about the 6 month post-op point but it was too soon and didn't go well. However, it's all good this time.


I'll search back through my emails and try to document my rehab program from just after the op to the present - in case it's useful. However you really need a good physio who specialises in knees, immediately after the op and, ideally, beforehand. Once the prosthesis is in, strong muscles are going to have some value.
 

[Dave33]

Thanks rgb- your physical therapy regimen would be helpful to know. I'm especially curious about the days immediately post surgery. My surgeon said he'll have me up walking as soon as I'm out of recovery, but I'm curious how that will translate to day to day living. Were you using crutches or a walker up front? Is it better to move as much as pain will bear, or elevate/ice/rest?

[Dave33]

In a way, I'm trying to compare the expected rehab and pain to that of the tibial osteotomies I've had, which were largely "wait out bone healing" endeavours.

[RGB]

I haven't yet gone back and consulted my physio's rehab program but here's what I remember:
1.  Immediately after the op I felt remarkably good. No swelling. I could bend my knee a little and bear weight. So I walked down the corridor a couple of times (very slowly) and was able to go to the bathroom without crutches or a walking frame. I did leglifts and some mild bending on a set of 'portable bicycle pedals' which I could position near my chair. It sounds like I was very active but it was only for short bursts. Ice and elevation were important. The swelling kicked in sometime on the second day.

2.  I probably could have gone home after a couple of days but I didn't. Australian private healthcare has a system where you can be referred to an inpatient rehab program at a specialist unit and that's where I went (at no cost to me!). I probably could have done just as well at home but it was nice to have someone take care of the medication and enforce the 2 physio sessions per day. The other big plus was a 'cryocuff' automatic icing wrap. This was on most of the time that I was lying down, including overnight. In addition to the 2 supervised physio sessions per day I did more leglifts and some mild heel slides. I did a daily gentle walk around the block - maybe 500m - 1km. Medication was endone, paracetamol, anti-inflammatory and a blood thinning injection. Pain was minimal and I had no trouble sleeping. The only pain was trying to walk up and down steps. Towards the end of my stay I did a few of these just to be sure I could but I didn't push too hard. I was there 10 days.


3.  After the rehab unit I went to my Airbnb accommodation for the next 4 weeks (I was away from home and couldn't easily fly back). That was pretty tedious. Lots of lying around, icing, physio exercises (I'll provide more detail of these in another post), low/no resistence cycling and walking. I used a step counter and aimed for about 4,000 steps a day. I did a bit of work on my PC but I wouldn't have wanted to travel far or have my leg lowered for too long. Medication was just slow release paracetamol and maybe an anti-inflammatory. The swelling gradually decreased and so the flexion increased. I would have been well past a 90 degree flex by the end of that time.


That's enough for now - more later. I now wish I'd kept some notes as my memory is a bit hazy. Let me know if this is too much detail or generally not useful!

[cooperd70]

Going to keep my eye on this thread, so keep up supplying all the fantastic info RGB/Dave33 

Male/48/5'10"/101kg
I was knocked from my cycle by a car two years ago.  The patellar must have been bashed against the femur during the collision.  At the time it only caused swelling and heavy bruising that was gone within 3 weeks or so and then I was pain free.  I had no medical intervention.  I then started getting pain at approx. the 1 1/4 year mark after the accident, but only when climbing stairs.  The pain got a lot worse very quickly over a two week period.  I stopped climbing stairs with the knee (just used the good one to get up stairs) and also stopped commuting to work by cycle (10% hill on the way into the office).  I iced the knee each evening to reduce swelling and just did non-weight bearing exercises on the bad knee until I was given an MRI (6 weeks later - UK NHS).  This showed two full thinkness and two half thickness fissures on both the medial/lateral condyles of the femur as well as one each side retro-patellar, plus some early quadriceps tendinopathy.  I started a lower limb physio class to strengthen muscle groups.  At the same time as starting physio I started to commute to work via cycle again - I'd had a 3 month rest-up at this point).  This was when I actually noticed muscle loss in my quads on the bad side.  I can get up most of the hill, but I get off and walk when it kicks up to the 10% part of the climb (which thankfully isn't a long distance).  I no longer have swelling in the joint and at the end of the 6 week physio class do seem to have less pain.  I now only get it when climbing stairs and I 'skip' up the step on the bad knee to ensure that I don't get any pain.

I assume that I will need to re-address this as/when my situation gets worse.

Will I have to accept the loss of muscle in my left leg or are there any good exercises that you guys can recommend?

[RGB]

I hesitate to offer advice because I'm not a medical professional but more so because I think what seems OK for one knee will not be so for another. However.... for my knee pre-PFJR, the best compromise of strengthening and non-pain/irritation was a range of static squats at different angles. Usually I would do this with a Swiss ball behind me against a wall at a range of angles from 30-90 degrees. Something like a 2 minute hold, one minute rest, 2 minute hold, then move onto the next angle. The reason was that I found anything that involved movement and load was no good. That included cycling. However, I could row on a machine and that's what I used for a good cardio workout. Hope this helps but don't do anything that hurts or causes more swelling. Another tip - I always found my knee reacted slowly. If I pushed it too hard, I couldn't tell straightaway. It took me a while to figure that out. I kept thinking that because the knee reacted well initially to exercise then I was all good. However, I'd pay in pain and swelling two days later.

[Dave33]

Another tip - I always found my knee reacted slowly. If I pushed it too hard, I couldn't tell straightaway. It took me a while to figure that out. I kept thinking that because the knee reacted well initially to exercise then I was all good. However, I'd pay in pain and swelling two days later.

I can second this many, many times over. I've countless left a short workout thinking "wow, my knee is not nearly as bad as I thought" and then two days later, I'm on the couch with ice bags for the rest of the week. My understanding is that the inflammation in the synovium is a delayed response to pain receptors.

Regarding my pending PFJR - I've been formally given a surgery date of end of Aug, so I'm starting to feel the reality of this setting in. The one thing that is a bit troublesome is that the other left patella has been even worse than the one they plan to resurface first... so much so that I've considered going back and begging for them to do a bilateral procedure.

After thinking it through, however, I've had so many surgeries that didn't end up the way I'd hoped - so it makes more sense to do this one side only, and confirm that it is the magic bullet I'm hoping for, before going "all in" on a 2 for 1 deal .

How goes the skiing prep, RGB? I see the tour de france started the other day (froome took a spill early), and was wondering how you were doing.

[Dave33]

Going to keep my eye on this thread, so keep up supplying all the fantastic info RGB/Dave33 

Male/48/5'10"/101kg
This showed two full thinkness and two half thickness fissures on both the medial/lateral condyles of the femur as well as one each side retro-patellar, plus some early quadriceps tendinopathy.  I started a lower limb physio class to strengthen muscle groups.  At the same time as starting physio I started to commute to work via cycle again - I'd had a 3 month rest-up at this point).  This was when I actually noticed muscle loss in my quads on the bad side.  I can get up most of the hill, but I get off and walk when it kicks up to the 10% part of the climb (which thankfully isn't a long distance).  I no longer have swelling in the joint and at the end of the 6 week physio class do seem to have less pain.  I now only get it when climbing stairs and I 'skip' up the step on the bad knee to ensure that I don't get any pain.

I assume that I will need to re-address this as/when my situation gets worse.

Will I have to accept the loss of muscle in my left leg or are there any good exercises that you guys can recommend?

There's lots of good quadricep excercises out there, and RGB mentions a good one with the swiss ball, and of course the disclaimer of not being a medical professional (applies to my ramblings as well) . One thing I'd caution you on is that you need to be hyper sensitive about "good pain" vs "bad pain" when it comes to cartilage damage. You need to establish what your envelope of function is, and stay within it and very, very gradually increase - and you may very well get to a point where you can't increase any further, and have to live with what you have. At 48 (we're close to the same age) - we simply don't regenerate articular cartilage any more to offset full thickness damage. It's about protecting what's left.

The problem with many people, especially those from athletic backgrounds, is that they're mentally conditioned to see results by "pushing past" thresholds - and even get mental satisfaction from it. This is not how recovering from cartilage damage works -and you can seriously damage your lifestyle further by pursuing it in this fashion (I'm exhibit "A" ).

[RGB]

Hi Dave. Brief response from the ski slopes. We are only here for 6 days and the field was closed for the first 3 due to bad weather. So the first opportunity was yesterday. I ended up skiing about half a day spread over the whole day. It was great fun obviously but I assume that's not of much interest  . From a knee point of view, here's what's relevant:
1.  I was a pretty good skier years ago. Double blacks etc were no problem. Yesterday I was skiing intermediate and advanced runs but nothing more than that. My turns were OK but I would have struggled off piste or on the steep. It's hard to know if that's just time away (I've only skied a couple of times in the last 20 years) or the knee.
2.  There was no real pain but the knee was working pretty hard so took it easy, with a few rests, and finished early. I took a couple of Voltaren overnight as a precaution. There was some minor swelling but nothing more than I would get after a 2-3 hour mountain biking session.
3.  The interesting thing from my point of view is that my hip flexors on the bad leg were sore both during skiing and afterwards. They were clearly working much harder than they have for a long time. I do rehab exercises aimed at strengthening them (mostly the crab walk with a black Theraband) but I must be cheating in some way because those muscles are not strong! I'll need to address this in some way and when I do so it might improve my functionality in other areas.
4.  I've elected to have the day off today, to give my knee a chance to recover and also to see if there's more swelling to come - I've learned previously to my cost that waiting one day is not enough to understand the effect of new or hard exercise on the knee (both before and after the PFJR). So I'll start gradually and build up - there will be more opportunities later in the season.

I see Froome is on his way back. I feel conflicted about him and cycling generally. It would be nice to assume that it's all completely clean but I suspect most, if not all, of them push the medical boundaries. Is he an outlier and deserving of the negative publicity he's getting? I'm not sure - the case is not so clear as for others in the past.

[MasterForte]

Hi RGB,

How long did your swelling last post-op? Do you still get any with activities or has that pretty much cleared up?

[cooperd70]

I hesitate to offer advice because I'm not a medical professional but more so because I think what seems OK for one knee will not be so for another.

No worries on that.  The situation is often unique for each individual.  However I only ever use information that is relevant to my situation (pick and choose).  Just trying to manage what damage I have and minimize it from worsening.  I, like most want to maximize the time up unto the point where I will require surgery.  I won't be having an op anytime soon and will hold back on that until I have no further options.

DC

[cooperd70]

I can second this many, many times over. I've countless left a short workout thinking "wow, my knee is not nearly as bad as I thought" and then two days later, I'm on the couch with ice bags for the rest of the week. My understanding is that the inflammation in the synovium is a delayed response to pain receptors.

Regarding my pending PFJR - I've been formally given a surgery date of end of Aug, so I'm starting to feel the reality of this setting in. The one thing that is a bit troublesome is that the other left patella has been even worse than the one they plan to resurface first... so much so that I've considered going back and begging for them to do a bilateral procedure.

After thinking it through, however, I've had so many surgeries that didn't end up the way I'd hoped - so it makes more sense to do this one side only, and confirm that it is the magic bullet I'm hoping for, before going "all in" on a 2 for 1 deal .

How goes the skiing prep, RGB? I see the tour de france started the other day (froome took a spill early), and was wondering how you were doing.

I'm by no means athletic, but I have been commuting in/out of London ([amended, sorry] 15 miles each way, 5 days week) for the past 9 years or so.  I love cycling and I'd hate to have to jack it in.  I have been learning where my threshold is and as its mostly uphill to work (low % though except for a short sharp 10%) I've learnt to keep on the inner chainring and spin, rather than mash on the outer.  Then as a reward the outer on the way home) 
I too agree with both of you in that pushing it too far is a no go that just sets you back a few days.  If my situ were to change and I have to have an op, then here in the UK I have heard of a surgeon by the name of Jonathan Eldridge, Bristol or Bath way who specializes in knees.

I manage to get home in time for the TdF highlights at 7pm for an hour...its been put pack until 10pm this eve due to the Word Cup {not a fan}...boo 

[cooperd70]

I see Froome is on his way back. I feel conflicted about him and cycling generally. It would be nice to assume that it's all completely clean but I suspect most, if not all, of them push the medical boundaries. Is he an outlier and deserving of the negative publicity he's getting? I'm not sure - the case is not so clear as for others in the past.

I read an excellent book by Tony Hewson some years ago called 'In pursuit of stardom' and think along the same lines as TH (rode pro in Europe in his day).  Its a grueling 3 week cycle race with 2 days rest...they've been taking anything that may give them the edge or dull the pain that their body is going through since its inception.  In the early days it was whatever they could get their hands on (sometimes having a negative impact on their performance).  As the years have gone by they've {the sport} got smart as to what does/doesn't work.  I'd like to think that present day guys race clean, but how much further can an athlete push their body for even more impressive wins, year on year.