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Offline kathleenj

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A little setback
« on: July 20, 2004, 07:18:51 PM »
Thursday marks 6 weeks since my second Oats.  Things have been going great...started weight bearing and it felt great up until a few days ago.  I started having some stabbing pains in the medial area and got really concerned.  I had been to my OS last week for an xray and he said things looked good so I couldnt understand what this could be.  I went to PT today and explained the pains and the occasional snapping feeling.  She said that my kneecap is really constricted and this pain could possibily be either scar tissue or plica syndrome.  I feel pretty confidant that it is not the graft because it doesnt seem like that deep bone pain.  Either way, my PT said to go back to the 2 crutches and pull back up on the weight bearing to see if it calms down.    This stinks!!!!  I know I need to go slow with this but I was up in cloud nine last week and here is am back to 2 crutches with limited weight bearing again.  
Anyway,  does anyone know what kinds of problems I could have with this scar tissue thingy or the plica?  How much is this going to hold me back?   I have been really patient the past year with this knee but I am beginning to lose my patience, and my mind a little bit too.
Any words of advise would be greatly appreciated.
Kathy
right knee oats 12/03 scope autograft
right knee revision oats 6/04 open autograft
loa, plica excision, chondroplasty 12/04
synvisc 5/05
patellofemoral OA
patella baja

Offline JessToni

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Re: A little setback
« Reply #1 on: July 20, 2004, 09:34:38 PM »
I am in a similar situation.  I had an osteotomy and OATS procedure done about two months ago.  After about 7 weeks my doc said i could start weight bearing and get rid of the crutches when i felt comfortable.  It was so nice to finally be rid of them!  then last week at physical therapy they put me back on the crutches with limited weight bearing.  The main reason being I have practically no quad muscle strength so my knee was rotating inward and collapsing while i was walking.  I have also had a lot of medial pain and was told that my xrays look fine.  They suggested scar tissue and said hopefully when the swelling goes down, i get more range of motion and i get some quad strength pack the scar tissue would soften up and not be a problem.  I am keeping my fingers crossed.
I can definitely sympathize with you on having to be back on crutches though..i have been cranky ever since i got back on them.

Jess

Offline kathleenj

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Re: A little setback
« Reply #2 on: July 20, 2004, 10:05:21 PM »
Jess,
There is nothing like getting that little taste of freedom only to have it ripped away from you.  I can understand the quad weakness thing you are having.  I had that with my 1st Oats in Dec.  I didnt realize how quickly muscles can waste and mine wasted to nothing.  It took me almost 3 months to get completely off the crutches last time.  After this surgery I was on top of the muscle issue.  There was no way I was going to let my muscles waste like last time.  I was doing slr's a few days after my surgery.  It hurt like hell but I wasnt going to let my leg turn to mush.  It has paid off alot as I can physically walk without the crutches now.  The only problem I'm having is the scar tissue. I never realized how much scar tissue hurts.   My PT is doing lots of knee cap mobs and massage and ultrasound so hopefully it can be controlled.
Good luck with your rehab...I know its frustrating but its safer for you to be on crutches right now with such quad weakness.
Kathy
right knee oats 12/03 scope autograft
right knee revision oats 6/04 open autograft
loa, plica excision, chondroplasty 12/04
synvisc 5/05
patellofemoral OA
patella baja

Offline mj/usa

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Re: A little setback
« Reply #3 on: July 20, 2004, 10:06:48 PM »
Kathy---

I had  many similar things happen during pt after my oats---my therapist was calling my os often, but it really turned out to be the weak quad muscle and the virtually non-existant vmo that kept my knee from feeling so great.  I was on crutches for 6 weeks and then it took me another 2 on one crutch to feel really comfortable without them.  Pt was a long slow haul, sometimes I had the feeling one step forward, two steps back.  But the knee will get better as the quad gets stronger! It is early days yet.  And if the x-ray was perfect last week, the graft is still probably right where it should be.  Just go slower on the pt.
Good luck and a continued good recovery!
Mary Jane

ps/ my therapist also did quite a bit of scar tissue massage and some kind of ultrasound to help speed things along.
« Last Edit: July 20, 2004, 10:08:43 PM by violin1 »
plica excision 05/01,  followed by OATS 09/02

Offline kathleenj

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Re: A little setback
« Reply #4 on: July 20, 2004, 10:21:37 PM »
MJ,

The only thing that has me concerned is that my strength is great.  My vmo has been firing since the 1st week after surgery and the quads are looking good too. I know they are not totally up to par but they are not too far behind the good leg.  My PT says that considering my kneecap is so restricted she is actually really suprised at how well I am tracking.  It is all so confusing.  She thinks that maybe too much scar tissue is growing and getting stuck under the edge of the knee cap at extension.  If that makes sense.  The pain I am feeling is with weight bearing and non weight bearing and is beginning to get quite painful.  
I dont know...very frustrating. Hopefully the ultrasound and massage will help break it up.
Thanks for responding.
right knee oats 12/03 scope autograft
right knee revision oats 6/04 open autograft
loa, plica excision, chondroplasty 12/04
synvisc 5/05
patellofemoral OA
patella baja

Offline Heather M.

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Re: A little setback
« Reply #5 on: July 20, 2004, 11:33:11 PM »
For those of you who are having scar tissue problems, now is the time to take care of it!  Two PT appointments a week aren't going to magically soften the stuff, though of course it will help and is better than nothing.  But to aggressively treat the scar tissue, you should be doing stuff at home throughout the day along with formal PT.  Trust me...I have a lot of problems related to arthrofibrosis (excess scar tissue) that was not adequately treated.  It is best to deal with the scar tissue early, as it hardens and turns fibrous and rope-like as it matures.  It can attach to structures it shouldn't, push things out of the way, fill up spaces that should remain empty, and literally cripple you.  Now that is a worst case scenario, and one that usually happens in people like me who have a genetic predisposition to forming too much scar tissue.  No one understands why, it's just an immune system that's gone out of control and doesn't turn off the inflammatory response after the acute phase of the injury/surgery.  You guys are actually LUCKY, believe it or not, because your scar tissue is likely the result of the traumatic procedure you had and the subsequent immobilization.  Arthrofibrosis is the number one complication of cartilage restoration procedures, so your surgeons should have some experience dealing with this.

There are some current methods for dealing with scar tissue that might be helpful for you, and should be discussed with your doctor...these methods are actually counter-intuitive, in that they go against the standard knee rehab protocol.  The three most important things are with scar tissue patient are 1)  to achieve full ROM (including full extension!) 2) keep the swelling down as much as possible and 3) keep the kneecap mobile through massage, ultrasound, and patellar mobilizations done by the PT and the patient at home.  I did mine hourly for awhile....

Strength training is usually delayed until the patient has full ROM and the knee swelling has gone down.  This can take anywhere from several weeks to months--because once the scar tissue is present in the knee, it can actually become a self-sustaining thing; it causes irritation, the body dials up the immune response which leads to swelling, and this inflammation leads to the production of more scar tissue.  It's critical to not push the knee too hard when there is swelling going on.  It is not helpful to push through the pain and do activities that irritate the knee, because that can actually make things worse.  It's a slow recovery--one knee patient was stuck for 7 months doing quad sets, straight leg raises, patellar mobes, and bike without resistance as the sum total of her rehab, because her knee was still inflamed.  

Inflammation and swelling are the mother of scar tissue, so they have to be stamped out.  It's a slow and frustrating process.  You should definitely talk to your OS, as he/she may want to change your current protocol to address the scar tissue problems that are popping up.  Scar tissue is the way our bodies heal, so it is a normal result of surgery.  But if your body makes too much of it, or if the scar tissue gets into the wrong place, wraps around nerves, or gets into this feedback loop of irritation-inflammation-scar tissue formation, the patient can be in a world of hurt.  My scar tissue was dealt with aggressively, but not appropriately.  Now I have permanent mechanical changes and very serious osteochondral lesions on the back of my kneecap.  My condition is called infrapatellar contracture syndrome and patella baja.  This is one of the worse complications you can have in orthopedic surgery, so it's definitely something you want to avoid!  

The good news is that your arthrofibrosis/scar tissue is easily explained by the invasive procedure you had.  Mine is a mystery case that developed after an arthroscopy.  Still, arthrofibrosis is a very rare condition, and it needs to be treated early and appropriately.  Studies show that as long as the adhesions are adequately addressed within six months of the surgery that caused them, the patient can expect a full recovery of function.  At 6-12 months post-op, the results of scar tissue treatments are less promising, as mechanical and articular cartilage changes are permanent and irreversible.  

I urge you to learn from my rotten experience and ask your doctor what YOU can do each and every day to:  keep your kneecap mobile, maintain the suppleness and elasticity of your patellar tendon/IT band, get back full ROM, and keep the inflammation at bay.  I do want to stress that my situation is truly a worst-case scenario.  But it could have been avoided.  So I'm hopeful that by telling others and encouraging them to do research on their own scar tissue problems that you guys can avoid following my example!  When I was on this board and first heard the term arthrofibrosis, there was only one other person with the condition posting.  But in the last few years we've built up quite a knowledge base on the condition, and hopefully you can read through this and make a difference in your own rehab and care.  If I'd known then what I know now, I'm confident that I'd be back hiking, backpacking, and working out.

Heather

PS you should look through the Soft Tissue Healing Problems section above, that's where the scar tissue folks hang out.
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
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Offline kathleenj

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Re: A little setback
« Reply #6 on: July 21, 2004, 12:02:32 AM »
Heather,

Thank you for your input.  It is always appreciated.  I have read alot of your posts and do appreciate your knowledge of scar tissue issues.  I am not too sure that I need to be too alarmed at this point.  I have a great OS that has been on top of my rehab more than most OS's I read about.  At one point you even told me to "kiss him because he is on the cutting edge of scar tissue issues".  (or something like that, but definately to kiss him;)  )  My PT is wonderful too.  I am currently going 2 days a week and doing a lot more at home. I will move to 3 days as soon as we can start with strengthening exercises. Although, I havent really lost too much strength.  I do patellar mobs almost hourly and scar massage.  I am icing regularly.  My active ROM today was -5 to 122.  Not too bad if I do say so.  Pt can push me to 0-127.   I understand that scar tissue can still cause problems even though I have good ROM, I believe you said that you have full ROM.  
I have had problems with scar tissue with my 1st surgery.  My surgeon went thru my patellar tendon to do the 1st OATS because I wanted to avoid an open procedure.  I had and still have some scarring down of the tendon but nothing that is not functional.  I know that I do form a little too much scar tissue but I am confidant that my OS and PT are on top of it and that we can beat it.  It's just a bummer to have to go backwards when I was making such great progress.  
As much as I hate the fact that I need to go back to 2 crutches, I realize that not doing that would hinder my recovery.  I need to cut back a little and get the swelling and heat under control.  
Thanks again for your input.  I really do appreciate your knowledge in regard to scar tissue and I do understand your concern for others to stay on top of it.  
Kathy
right knee oats 12/03 scope autograft
right knee revision oats 6/04 open autograft
loa, plica excision, chondroplasty 12/04
synvisc 5/05
patellofemoral OA
patella baja