Ruptured Patellar Tendon Surgery

[boing]

Boing, I am guessing the tad bit of the patella alta you have doesnt bother you in terms of running?

So far I am still on baby steps, it does not bother me at all. I will update with you when I speed up in next month.

[SellaVee]

Tom, I know what you mean about the boredom, but reading all these posts fills a few hours  .

As I go through from 2003, if I find someone whose story encourages me I click on their name and this lets me read all their posts at once so I can find out how they got on, what worked for them, and what their timeline was.  I've even made notes.  There have been a few double RPT cases so it might be worth doing that with them.

Remember that these protocols we follow are guidelines.  Don't get discouraged if you don't get exactly the same ROM at the same time - but if you do better, feel great!

I had my first physiotherapy session this morning, before I read your post.  I expected some sort of treatment but I didn't get any.  I was told to walk around with my brace unlocked, and work on bending my knee.  I can sleep without the brace according to the physiotherapist.  I've to do heel slides and raise and lower my leg, supported by my other leg, while seated.  When pressed the therapist said I could do quad sets and leg raises (can't physically do those).

[carkeltom]

SellaVee, thanks for the kind words.  I too have found that checking out a former poster's entire post is quite helpful.  With mine being a rare double, I has been helpful.  There seemed to be a whole lot of action on this board in the past.  I feel like I know some of the earlier posters and their stories and the ones who have also torn both tendons are the one I really focus on, especially their PT updates.  According to my PT protocol, which follows the Univ of Wisconsin protocol given by John and one I found from UMass.  I think my OS and I will have to talk with the PT when it comes time for out of home PT.  I think I am a few weeks from that anyways, since I am only schedule to get to 90 degress of Passive ROM after 6 weeks, which is two weeks from now.  I wish I had the angle device to measure mine as the in-home PT always forgets to bring hers (even though as a former carpenter I know what a 90 degree angle looks like). 

I am also suppose to start a pool exercise program, so going to need to find a pool I guess.  There is a local hotel that will let you use their pool for 5 dollars a day, but there is also a local gym that gives my employer a discount and they have a pool, so might go for that and get the pool exercises from the PT.

I know my co-pay for PT is like $50 per visit and that is pretty steep compared to a monthly gym bill of $19.  As a former gym rat during my football (american football) I spent quite a bit of time in the gym and know my way around.  But until I am able to unlock the braces, I know I will not feel comfortable with any type of weight bearing activity without the braces. 

On another note, I received my electronic stimulator in the mail today and thanks to youtube I tried it out.  The company even sent me some extra pads for free for ordering online.  Tried it out and it is weird.  Hopefully I got the electrode pad placement right.  Another question for the PT next week.  She is going to be glad to get rid of me I think. 

I do have one question for anyone.  What does SLR stand for in terms of PT.  Stiff Leg Raises, standing leg raises, seated leg raises as the protocol calls for anti-gravity SLR flexion?  Any advice there JohnK?  DO you still volunteer at the hospital or was that a long time ago?

Have a good weekend everyone.  Going to take a car ride tomorrow and might stick my head out the window and wag my tongue like a dog all the way there.

Tom

[mxbigd17]

carkeltom, SLR stands for "Straight Leg Raises". You sit on your butt on the floor with your good leg bent at about 75/80 degrees, then you tighten your thigh muscle (don't tighten your butt muscles) then point your toes back towards you getting a good solid straight leg. Then lift your leg (without bending) up to about where your good legs knee is then slowly return it to the floor. Let the muscles relax for a second, then repeat. I do 3 sets of 10. I found this on the web, comes in handy http://www.permanente.net/homepage/kaiser/pdf/64676.pdf
Good luck with the SLR, they are very hard at first but you can do it.

Here is my 12 week update. Leg is getting stronger and the PT measured my flexion at 105 degrees on Thursday the 22nd. PT is very hard and painful. I am having a lot of pain on my inner knee area, it's keeping me from getting any sleep at night and I am becoming very exhausted because of it. Does anyone else have this problem. It swells up and just hurts all the time. Also when I try and walk normal, heel to toe-heel to toe, it feels like something is catching my kneecap on the outside of my knee which causes me to limp bad. If I walk really slow, I can walk normal but if I try and walk a normal pace the kneecap feels like its going to pop out of its groove and it hurts pretty bad during the process. I know people say this is a painful injury and surgery, but 3 months into recovery isn't it supposed to get better. My PT looks at me like I'm a pussy. I can deal with pain but holy smokes does it hurt like hell sometimes. My girlfriend says I moan and gron in my sleep at night because it hurts so bad. I have wrecked my dirt bike and messed myself up enough to know how to deal with pain, so im a little concerned with my pain being where it's at 3 months into recovery. If you guys an gals say its normal, then it's normal. Any advice would be awesome. Even though my knee hurts, I do my home PT, and pool PT which is awesome. If you guys have access to a pool, I say take advantage of it. Take John K's advice and purchase a floor cycle also. It's worth it's weight in gold when in comes to helping getting ROM back.

I attached 2 pictures of myself. One is me enjoying riding my bike, the second is what happen to my knee after I fell off my bike.....lol.. Kneecap in thigh is a scary site. I hope it post correctly.

[SellaVee]

mxbigd17, that's some photo of you kneecap!

I'm interested in what you said about pain and swelling on your inner knee.  I woke up this morning after my first night without wearing a splint in bed.  I measured my knee (just curious and had a tape measure handy) had a bathroom trip (put on the splint) then back in bed stretched both legs out in front of me.  My injured knee was really swollen on the inner part.  It looked huge though it wasn't painful so I started my own exercise regime comprising some Pilates stretches and upper body work plus quad sets using a rolled towel, straight legs raises (didn't move and inch), then lay on my side and raised my leg to 45^o  (hip adductors?).  This last one was easy peasy on my good side.  Thought I wasn't going to make it on the injured side then suddenly up went the leg.  Not very far, but up.  Then I did another Pilates exercise called the saw, which showed me how out of balance my body is and I finished with a full body stretch.  When I looked at my legs again the swelling at the side had gone and the leg looked and felt much more normal, but when I quickly got the tape measure going it was still the same size, so the swelling hadn't gone down, the leg had just changed shape.  I'd really been trying to work my VMO so I don't know if that was what pulled the leg back into shape but I was amazed at the difference.  It still wasn't painful.  All of this was done one the bed, as I can't get up and down onto a floor mat yet.

I'm not pushing myself very far, and I'm not back at work, so that might be why I had the swelling but not the pain.  I'm 7 weeks post op and I still rest my leg a lot.  My PT isn't yet hard and painful, in fact all I did was sit in a chair and have a little walk on the corridor.  The therapist didn't even look at my leg out of the brace, far less do any work on me.  So it may be that the swelling is normal and the pain kicks in when you've been working harder.  Looks like I'll be doing that on my own.

Later I worked on my bend.  My brace was set at 30^o but I've increased it to 60^o.  Today, for the first time, I sat at the table for lunch without having my leg up on a chair.  OK, so it was on a biscuit tin, and my leg's still in the brace, but that's progress.

I'd love to start a pool programme.  When I mentioned this to the physiotherapist yesterday she said let's get the bend back first.  That's her main concern and I only get to see her every 2 weeks.  It's frustrating because I can swim for free in our local pool and I have a friend who is a former swimming instructor who is willing to take me and my husband would come too.  What do you guys do in the pool?

Another question concerns the incision site.  Mine is still covered with a dressing which at least keeps the brace from irritating it.  I wear a leg cover when I shower.  What happens when you go in the pool guys?

Tom, let us know how you get on with the electronic stimulator.

Is there anyone else having treatment in the UK at the moment?

[copper44]

Hello Everyone.  Had my post-op followup yesterday (10 days) and my knee is healing well.  They removed all of my bandages and gave my leg some needed air.  Such a relief to release all of that wrapping pressure from my leg which immediately decreased my ankle swelling and associated pain.  I was also able to take my first "pseudo-shower" since having the surgery today.  I say pseudo because I was on a bench with my leg on a bath chair, but I'll take it!  My doctor also said that I had tears in the tissue on the sides of my knees so he repaired that as well.  He said once it heals, this should help make the knee even better than it was before the rupture which is nice to hear.  Not sure if that means I'll be able to run like I used to.

I am fully off pain medication and have minimal pain in the area.  The right side of the knee is numb as well, but from all I've read on this board, that seems normal at this stage.  My instructions are to continue to be non-weight bearing for another 2 weeks.  That also seems pretty consistent as that will put me at weight bearing around 4 weeks post-operation.  I can put my brace to 20 degrees extension next Monday (3 weeks) and then up to 40 degrees the following Monday. I can already see a little atrophy in my thigh muscle so PT will be put to good use when I'm finally able to start.

SellaVee, glad to hear that your exercises are going well.  Also, pillow under the ankle did the trick!  Thanks!

[SellaVee]

Glad to hear you're doing well copper44.  Do you have anything covering your incision now?  Mine has a big white stick on dressing (sort of giant bandaid) over it.  I don't think it needs to be there but it does stop the brace from catching on the scar.  I've got the numb spot too.

I had a shower the other day with just a plastic bag over my knee.  Whoopee I got my foot properly wet!  Put a fresh dressing on when I was done.  I don't stand up in the shower, I have a plank across the bath to sit on and another at the end to prop my foot on.  It's the little things that mean a lot!

Stuart, Tom, mx, fishy, Arran, Beasman et al, how are you all doing?

[fishy]

Hello everyone....I met my goal!! I danced at my girlfriends sons wedding....actually I think I danced with half of the female guests.  I busted a few moves...but I didn't bust my knee!  I am 14 weeks and counting.  ROM 130+ both legs (double RPT).  I didn't have PT last week but I did walk, over 7 miles one day....my legs ached at night but Advil and water helped...and I resorted to one of my favorite fruits from my running days....banana's.  Potassium supplements also helped. PT resumes tomorrow, but while I was away for the wedding my floor bike arrived, so I can sit, read this site, etc., while pedaling.  I think the fear of reinjury (for me, anyway) is greater than any pain I've had during my recovery....I can take a pill if the pain gets too severe, but reading this site has given me insight and knowledge is power...so my fear is abating and I continue to get better.  Thanks to all my extended family for your journey postings and I will continue to post mine.  I will keep you all in my prayers.

[carkeltom]

fishy, glad to hear that you met your goal.  Right now I can not imagine dancing, especially since I too have the double RPT.  I know what you mean about potassium though.  I have been a big believer for years since I always seem to have a cramp somewhere.  What ROM do you need for the floor cycle?  I purchased one several weeks ago in anticipation of the ability to use it with my legs, but have been using it with my arms right now for some cardiovascular although, I expend most of my energy on passively flexing my knees, using the muscle stimulator and standing and exercising.  Fishy, I would be very interested in knowing if the protocols that are in the information JohnK has posted are similar to the ones you and your PT used.  With having a double, I am wondering how to broach the subject of guarding when I will not have a good leg to catch myself or use to brace, like those who only have one RPT (not that they have it any better as this is just a horrible injury).  If you have the ability to email it to me, let me know.  Also, about how many sessions per week for how many months did you do PT.  I know that my co-pay is outrageous for PT, and if my math is correct, my out of pocket cost would be up to $600 per month if I go 3 times per week.

I can get my braces off in about 5 minutes, but it takes me about 10 minutes to get them back on properly as I have become very, very particular on how they feel and fit my legs.  I return to the OS on 9/3, next Tuesday, and per the protocol, he is going to unhinge the legs to 30 degrees locked, which will at least allow me to have some bend.  The in-home PT has decided that she is going to pass me along to a facility based PT and they actually called me today to set up an appointment.  I asked to meet with them next week, after I have seen the OS and can discuss some of my concerns with the double RPT.  The PT measured my passive ROM at 78 for the left and 80 for the right, which I think is astounding, since the rt knee had other damage besides the RPT since that was the one I tried and failed to stand on three times.  I am shooting for 90 degrees by the OS visit next visit and with doing the ROM exercises 3-4 times per day, I know I can get there.  My protocol calls for 90 to 30 leg lifts, but we decided to hold off till the visit since I have not been ok'd too actively flex yet.

cooper44, glad to hear that you are doing well.  yeah, I have the numbness on the outside and below the knees also.  My ortho said that during the vertical incision on top of the knee and below the knee, they have to cut thru some small nerves, and they hope that they will regenerate/and or find a new path.  My mother had one knee replaced three years ago, and she still has some numbness.  For my scar, I had what they called a boarded guazed strip, which was a gauze pad with adhesive around it which covered my scar.  After the suture removal and when the steri strips were there, I applied neosporin/triple anti-biotic ointment to the scars and used cocoa butter lotion and vitamin E lotion to the skin around the scar to keep it loose and stretchy. 

The damage to the sides of the knees, the lateral retinaculum is normal also.  Although I had torn the tendon off of the bottom of the patella very cleanly, the connective tissue on both sides of the tendon were torn and not as cleanly ripped.  So the OS had to put them back together.  After my first set of steri strips came off, I cleaned the area each day and applied the ointment.  It felt good to leave the area open to the air.  If I am going outside or on a trip, I wrap ace bandages around the scars and leg, and that also helps my brace from slipping. 

Being almost 6 weeks post injury and post surgery, I can almost total weight bear, when I am in my house and have things to hold onto as I go about some normal activities, but there is no way I am going anywhere for too long without my crutches, another topic to discuss with the OS, since the protocols all suggest switching to one crutch or no crutch after 6 weeks, but with a double, I just dont trust my knees to hold me up and dont expect them too yet.

sellave, jealous about the shower.  6 weeks and counting without a proper shower or bath.  I just dont feel safe enough yet to transfer both legs into and out of the tub.  Still thinking about buying some cheapo immobilizers on line to use in the tub or shower, but just can not pull the trigger.  My wife and PT couldnt believe I paid for the muscle stimulator, but it is awesome and will get my money's worth out of it. 

mxbigd, yup, that is about what my knees looked like also.  Wish i had had the forethought to take pictures in the ER, but was somewhat drugged up.  Have not had a narcotic in over two weeks, so that has been a plus, but have a full script filled for the psycho PT who wants to make a name for themself or show that they are smarter than I.  This website has been a blessing to say the least.

OK, that is my update.  Hoping the doctor will unhinge the braces so I can return to work and drive a little by myself.  That is all I am hoping for.  Need some neuro stimulation.

Good luck everyone and will keep you updated.

Tom

[carkeltom]

OK, here goes.  Going to try out my typing skills and post my orthopedic surgeons' protocol for MY injury.  From following JohnK's links, it matches, to an extent the Univ of Wisconsin and UMass protocols.  Even though I suffered a bilateral rupture of the patellar tendon (both knees) at the same time, this is what he gave me.  I plan on working with him and the PT to develop something tailored to my situation and experiences, since the protocol is geared to someone who only hurt one tendon and is able to guard with their non-injured knee or use it to brace themselves.  Like JohnK has told me and from what I have found, there are only 5-6 doubles on this board and we all seem to have had different protocols and outcomes.

I.  Immediate Post-Operative Phase (Days 1-7)

Precautions:  Sleeps and walks in a locked brace, full extension for 6 weeks
                      Flexion ROM limits see below

Goal:  Restore full passive knee extension
           Diminish pain and joint swelling
           Restore patellar mobility
           Initiate early controlled motion
           Controlled foces on the repair site

Post-op Days 1-4

Brace:  Drop locked brace locked at 0 degree extension with compression wrap.  Sleep in brace.
Weight bearing:  Toe Touch with WB with two crutches or walker
ROM:  Passive ROM 0-30 degrees
Exercises:  Ankle Pumps 10 times per foot/ankle per hour
                  Quad Sets  3 sets of ten per day,  flex and hold for 5-ten seconds
                  Patellar Mobilization  (moving the kneecap slowly and with slight pressure in each direction
                  Standing Hip Abduction/Adduction
Ice and Elevation:  20 minutes of each hour at elevate

(during this phase, I was in both the surgical hospital and rehab hospital and was using the CPM machine as tolerated 30 minutes per leg every two hours.  I started at 0-30 degrees)

Post OP days 4-7

Continue the use of brace at all times (sleep in locked brace)
Weight bearing:  Locked brace and two crutches or walker, Weight bearing as tolerated (WBAT)
Range of Motion:  Passive 0-45 degrees
                             CPM 0-75 degrees as tolerated (30 min per leg per two hour period, including
                             while sleeping)  I planned it so that I could try to get the whole hour done     
                             consecutively and try to get some sleep and have like one hour off the machine.
Exercises:  Continue all exercises above plus:
                  Initiate gravity eliminated SLR Flexion (assisted)  This consisted of me standing using the             walker or crutches and bringing each of my legs forward one at a time (think of it like              standing on one leg and kicking your toe forward, without flexing your quad.)  3 sets of ten per day.
Continue Ice and elevation

II.  Maximum Protection Phase (Weeks 2 to 6)

Goals:  Control forces on the healing tendon(s)
            Gradually increase passive knee flexion
            Restore full passive knee extension (placing heel on pillow and allowing knee to               extend                 downward
             Restore Patellar mobility (not letting the kneecap get stuck in the tracks and to reduce formation of scar tissue)
             Inhibit muscular atrophy (quad sets only for the flexion motion)

Week 2:

Brace:  Continue use of locked brace for 6 weeks
            Sleep in locked braces 6 weeks
Weight Bearing:  WBAT (usually 50-75% of body weight)
Range of Motion:  Passive ROM (PROM) knee flexion only to 60%
                             Full passive knee extension
                             Patellar mobilization
Exercises:  All previous exercises
                  Electrical muscle stimulation to quads
                  Quad Sets
                  Ankle Pumps
                  Hip abductions/adductions
                  Gravity Eliminated SLR Flexion (my doc and PT did not do this being a double RPT)
Continue Ice and Elevation

WEEK 3: 

Continue above mentioned exercises
Passive ROM 0-75%
Continue the use of walker or two crutches  75%-80% of body weight

WEEK 4:

Continue all exercises listed above
Weight bearing:  Progress to one crutch at 28 days (Not to easy with a double patellar tendon rupture
Passive ROM 0-75%
Exercises:  Initiate Mini-squats (0-45) (also not done with my double)
                  Initiate weight shifts ( I did this while standing at my kitchen counter)
                  Initiate Proprioception Drills (standing at the counter and closing my eyes)  also I used
                  a pillow and stood on it since the body has to adjust to the weight shifts


WEEKS 5 and 6

Discontinue use of crutch at 5 weeks post op
Unlock braces for ambulation at 6 weeks
Passive ROM:  Week 5 0-80 degrees
                        Week 6 0-90 degrees
Exercises:  Initiate pool exercise program
                  Active knee extension 90-30 (sitting on chair and actively flexing knee to 30 degrees)
                  Multi-angle isometrics knee extension (subnex)  ( I have no idea)
                  Continue all above exercises from weeks 1-4
                  Initiate anti-gravity SLR flexion
Continue Ice, compression and elevation as needed

OK, that is my weeks 1-6.  If yours was any different or if the PT or physio added something, let me know and I would like to see if it appropriate or needed for myself.  I know that I am different being a double, but just trying to get back to normal as we all are.

Thanks and best wishes

Tom

[SellaVee]

Fishy, well done!  Glad to hear you enjoyed the wedding.

I agree about the fear of re-injury as I worry about getting over that too, in fact I'm quite scared.

Tom, I'll tell you what's different about my protocol.  I haven't got one.  No information at all about wound care, massage, scar tissue.  Fitted with a locked brace but not told if I should sleep in it or not.  Physiotherapist at 7 weeks (first session) said "work on the bend, that's what we need to concentrate on", and "walk about with your brace unlocked" followed by "come back in 2 weeks".  That's my protocol.

For those in the UK:  "What do you think of it so far?"

[carkeltom]

SellaVee, I would say if you can copy and paste either Tendon Tim's protocol or mine, do it and take it to the next physio/PT appointment.  I know that the English health care system is much different than ours here in the US, but knowledge is good.  Find out where you are at on the timeline and see what the physio will let you do.  Have them show you and make them give specifics.  If need be, take printout with you.  I will work on entering the rest of the protocol also.  That took me about an hour, but I was wearing the stim machine and cant tell you how many times I had to backspace a misspelled word.  Plus, I am no typing expert.  Maybe JohnK would have some advice on how to approach your health system.   

My wife is a nurse and she did most of my wound care.  The PT told me how to massage the scar and surrounding tissue, to keep the patella mobile.  Take thumb and forefinger and move them along the scar, on each side.  I use the staple holes as a guide and slowly rub it up and down the scar site.  There is tissue under the skin and it keeps the blood flow going.  I know that you have the wire in place, so caution might be to take it easy.  Not sure though.  Have you had the date set yet for wire removal.  I have read on this site that the wire can inhibit ROM.  I read that the surgeon is supposed to manipulate your knee and tendons during wire with the surgery to make sure that the wire can withstand the flexion of your knee.  If I am correct, there was a younger girl on this site, 20ish, who's doctor actually ruptured her tendon during surgery during a procedure, but I am not sure if she had the wire implanted or not. 

But back to wound care.  That bandage should be changed every two days or so, especially if there is drainage.  I am not sure if you are having any or not.  Since your sutures are out, do you have the little strips over the incision or not?  Keeping the area clean is important.  Massaging your quad tendon is also easy to do.  You take your five fingers and place them on your quad and pull them back toward the top of your thigh.  I also move my hands to both the inside and outside of the knee and start at the top of my calf muscle and move them over the sides of my knees. 

Well, enough unwarranted advice and I will post the rest of my protocol for you, since I know you are further along than I.  If you want my email let me know.

Tom

[carkeltom]

SellaVee, this is the University of Mass protocol.  It is very informative.  Similar to mine for my OS except nothing on the double rupture.

http://www.massgeneral.org/ortho/services/sports/rehab/Quadriceps%20and%20Patellar%20tendon%20repair%20rehabilitation.pdf

Tom

Anyone heard from Oscarsan or Hages lately?  We need to exchange emails.

[carkeltom]

http://orthodoc.aaos.org/mdprice/Quad%20Patella%20Tendon.pdf

Another good resource for patellar tendon repair.

Tom

[fishy]

Hey Carkeltom;  Hey buddy, I am a 66yo Viet Nam Vet so I had my surgery and PT at the VA facility located at JBER, Anchorage, Alaska.  My PT protocol is basically the same as a single RPT....just being cautious not to reinjure.  My formal PT started at week 12 and I have had 4 PT sessions.  I was in braces for 9 weeks (hated every minute, by the way).  Baths were terrifying for me cuz I couldn't get my legs into the bathtub (very little ROM)....slowly I gained confidence and showering became easier.  I walked with a walker, cane with claw foot, cane until I felt secure enough to walk without any support. My 9 week visit to my OS...he said I could start weaning off the braces...so I took them off and left them off.  I walked with a cane (fear of falling) for a week, then ditched it and never looked back.  My girlfriend says I walk like Forest Gump....RUN Forrest, RUN....but now, at week 14 my walking is more normal, but still kind of floppy, especially if I have been walking much on a particular day.  Being a double has its own set of complications.  My suggestion would be to enjoy the ride, PATIENCE, laughter and read all the posting for the week you are at in recovery (a great time waster or a great source of information....or both)..... The most important thing to remember is you will recover.  PS....a sense of humor will carry you a long way.... and the braces give you a great advantage for parking, restaurant reservations, etc.....