It’s been about 15 weeks since I had my left knee anterior cruciate ligament reconstructed with cadaver allograft. My recovery was initially steady and most observers say that I progressed more quickly than average. Truth be told, I didn’t comply completely with the typical rehabilitation time line. I did so not because I believe I’m some sort of unique snowflake but rather because the sensations I had along the way suggested to me an altered path. Pain, swelling and the return of muscle control all guide one’s progress. I adhered to these concepts without fail, testing the waters and then proceeding. The deal was that I did so two to three weeks faster than expected.
There are certain milestones that are commonly used to mark progress after surgery. These are based on the type of reconstruction performed along with the graft choice. In my case, since I have a cadaver graft, pain and swelling is reportedly less and that’s been the case with me. On the other hand, most investigators maintain that cadaver tissue incorporates more slowly than your own tissue so care must be taken in terms of activity choice and progression. Every surgeon has their rehab protocol based on their training and perhaps their own research into the topic and personal experience. In my own quest to understand the topic, I’ve read quite a bit and this information helps guide my choices. Additionally, I’m seeing a physical therapist informally once a week who also advises and adjusts my mostly self-directed program.
I realize that the accelerated program could cost me at some point along the way. This price could range anywhere from some additional swelling on any given day all the way to premature graft loosening or even failure. That would suck. On the other hand, by adhering strictly to the activity selection, I feel like I should be able to avoid the latter two. Time will tell.
Range of Motion
Early on, leaning on it HARDSome surgeons recommend proceeding slowly with restoring complete range of motion (ROM), particularly full and hyper extension. Certainly, a cranky knee does not tolerate a lot of force in this regard and pain limits one’s enthusiasm. But as the dust settles after the first couple of weeks, ROM can then be addressed. Certainly, in the early period, creating a significant flexion contracture by not aggressively extending (straightening) the knee can create long term problems as things scar in and tighten. However, some surgeons feel that being too aggressive can stretch out the graft. In my research, I found that this fear is not supported by the literature on the topic. Additionally, there is a large cohort of therapists and surgeons who feel that restoring full extension, including hyperextension, as soon as possible leads to the best result long term. Consequently, I’ve spent some time pushing the extension with a variety of techniques seen here.
Looking for that final 5* of hyperextensionMost experts feel that full flexion (bending) can come more slowly and mine has been progressing fine with just a little bit of prodding. By 3 months post-op, I expected to have recovered all of my original ROM as is typical but I’ve failed to see that. Full hyperextension has been difficult and I’m a little suspicious that I might not see it. My therapist likes to see its restoration in the first 4-6 weeks and a review of the literature suggests the same. Aside from some persistent fluid in my knee, I don’t have much pain inhibiting me from extending. I hate to even think of it but I suspect that my graft may have been placed too tight. Graft tension at the time of surgery is one of the variables. Too tight is possible just like too loose is. Time will tell.
Early flexion work. I'm nearly heel to ass nowThe biggest issue with my impaired extension is the delay in my return to walking normally. Gait mechanics get all screwed up at both the knee and the hip and I’ll have some work to do as time passes to restore these to normal.
The other big issue to address early on is the firing of the quadriceps, particularly the vastis medialis oblique (VMO). This is made more difficult with my lack of full extension. Any residual swelling in the knee joint, which can persist for 8 to 10 weeks, also impairs firing of this muscle. Electrical Stimulation can be used to encourage return of this important “electrical” connection. These same units seem to be popular with high level athletes, used for some sort of recovery augmentation. From what my therapist says, the VMO issue persists for many during the first year.
Activity
The MTB has been keyAs pain and swelling have subsided, my therapist has given me numerous exercises to do. These have various goals. ROM, balance, strength and proprioception all need to be restored. Protecting the integrity of the graft is the number one precaution. My biggest victory so far as been my return to riding a bike, first in the gym and now outside. With cycling I have the tool to stop the decline in my fitness and start my return back to where I was prior to my injury. It’s an exciting process. Initially, I went too long or put too much pressure on the pedals and paid for it that evening or the next day. The good news is that with seated riding there is little stress on my graft. I can now stand pretty normally and put full pressure with no pain. I’ve even done a few Zone 4 workouts. But mostly I’m trying to restore my Zone 1-2 base and aerobic fitness. It’s coming easily.
I’ve been back in the weight room formally. I started with bodyweight squats and have progressed to less than body weight. I’ve been coaxing out the ROM, going deeper as pain allows. Investigators have pointed out that with squats performed with at least 30 degrees of hip flexion and keeping the plane of the knees behind my toes, there is little stress on the graft. This has to do with the fact that higher degrees of hip flexion lead to increased posterior chain activation which is protective of the ACL. I think that weights have contributed to some of the persistent swelling so I’m not doing a ton of it right now.
I’ve done weighted, walking lunges which feel super productive. I’ve done some weighted step-ups onto a bench. Last week I started some very easy two-legged jumps up onto stairs, first one step and then two. This creates an explosive moment followed by a brief decelleration which will prepare me for descending and running.
So good to be in the AlpineI did my first real hike yesterday. Alyeska ski resort has a tram down their North face. I get a 2.2 mile hike up 2,000 feet of vertical and then a free ride down. It’s a perfect way to introduce hiking back into the schedule. Of course, I couldn’t help myself and did a second lap.
Emotions
If I’m truly honest with myself, it’s hard to deny the profound emotional cost of this sort of injury and its aftermath. In the grand scheme of things, an ACL rupture and reconstruction is a pretty light weight event compared to more profound trauma experienced by others in the mountain community. Thinking about what truly broken friends have gone through and looking at their experience through the lense of my own gives me great respect for their resiliency.
I try hard to shut out most of the negative feelings that come up during the process of recovery. I haven’t always been successful. The return of pain and swelling, even if it’s just for a day or two can be incredibly disheartening. But the good days tend to out weigh the bad ones and the darker moments resolve. But I occasionally find myself mourning the loss of what could have been. I’ve been lucky during my climbing and skiing career. Sure, I’ve got a funky ankle and hip but nothing that really holds me back. But this injury and surgery portends an uncertain future. That realization is something that I must learn to cope with and put into perspective. On the other hand, as I cross certain thresholds and meet various milestones, I feel the weight of uncertainty get lighter. And then I simply step back and look at all the great athletes who have come back from the same or much worse and I feel confident that I can do the same.