Day 16 - Everybody has bad knees

As I limped home from physical therapy today, a guy stopped me on the street, saying, "How's your knee feeling?"

I was a little surprised since I didn't know the guy. But as I told him about my knee he explained he was going in for knee surgery himself and was a little apprehensive about it.

It's not uncommon to meet people who have torn their ACLs. Last week, a guy stopped me on the elevator to ask who had done the surgery on my knee because he was considering the operation himself. Last Saturday at a party --when I was still wearing my conversation-starting brace-- I met a girl who had torn her ACL in both knees. I know a family where the dad has torn his ACL and so has his son and daughter. Several other people I know have also told me their tales of knee woe.

It's not surprising that there are so many people with torn ACLs. According to the American Academy of Orthopedic Surgeons, 200,000 ACL ruptures and 100,000 reconstruction surgeries occur each year in the United States. Over time, that adds up to a lot of people.

And women are more at risk than men for reasons that are uncertain. Various hypotheses have been put forward, such as differences in pelvis angle and muscular strength, but no one is really sure what the culprit is.

Clearly, the human race is making their knees do things they just weren't designed to do. This 1938 paper in the Journal of Bone and Joint Surgery on the evolution of the knee might help explain why the joint is so often injured. We evolved from animals that either walked on 4 legs or brachiated. So we had to make do with materials that weren't up to the task of all the jobs we make our knees do. As the 1938 paper notes: "Man is the only animal to assume the completely erect posture, and the knee joint is completely extended while bearing the weight of the body."

But luckily for all of the minions who tear their ACLs each year, we have surgeons who have devised ways to patch us back together again.

Day 15 - What can you do with a brand new ACL?

What can you do with a brand new ACL? If you're Tiger Woods, apparently everything you could do before except better. He lost in his first tournament back since undergoing ACL reconstruction, but to hear it from him, he's better than he's been in a long time:

His mindset and his swing were no different, he said, except that now, following his rehab after the reconstruction of his left knee, he had “two legs stronger than they’ve ever been” and “a stability” he hadn’t enjoyed for years. All mercifully pain-free, too.

“I just didn’t think it would feel this good. To have it this solid and secure, man, it’s a great feeling.”

And it showed up on the course too:

His driving? He barely missed one fairway. The distance? As intimidating as ever. His accuracy? He made a couple of duff approaches but, on wildly sloping greens, still managed to command the ball to stop dead within a few feet of the pin time and again.

His putting? Immaculate. And the old magic? There it was when he splashed out into the hole from a greenside bunker. Even the giant Saguaro cacti shook, such was the cheer when the ball plopped in.

I'm not to that point yet. This week I'm just getting my walk back. But it's nice to see a clear example of what's at the end of this long road of rehab and recovery.

Steri-strips conundrum

After the nurse removed the sutures and applied the steri-strips, she warned me that I shouldn't take a bath and soak the steri-strips. I asked if that meant no showers too. She said I could take showers, but that I shouldn't "soak" the steri-strips. "But they'll get wet in the shower too," I helpfully reminded her since she didn't seem to be familiar with the concept of showers. Who knows, maybe she grew up in a bathtub-only culture or something.

"Showers are ok," she replied. "Just don't soak them, like don't get in the bathtub and just lay there."


I still didn't understand the difference. If the bandages weren't supposed to get wet, then it would seem that a little water was just as great a concern as a lot of water and/or soaking. I assumed she was worried about infection with bacteria and a little water would be just the type of environment bacteria would like. "So I should cover them when I'm in the shower?" I ventured, thinking I had figured out this riddle she was playing.

"No, that's not necessary."

"But they'll get wet otherwise." I was very perplexed.

But she was exasperated by this point. "Just don't soak them. Don't take a bath with them!" she said louder, as if the problem was just that I was hard of hearing and that this bath vs. shower logic actually made some sort of sense if I could just hear it correctly. She also seemed to be implying with her tone that I was the insane one.

Maybe I was, I thought. Maybe there's some sort of new shower system that doesn't wet your legs somehow. I'm usually not up to speed on the latest in bathroom fixtures, so maybe I had missed out on a whole trend that had been sweeping the nation. So I finally gave up asking the nurse any more questions.

But later I asked my physical therapist about this. And, I'm not making this up, she gave me the same schpiel about not soaking and bath vs. shower. Maybe I really am the insane one.

But I just googled steri-strips and here's the recommendations I found on one health website: "Steri strips should be treated as stitches (they should remain dry)." Notice, it does not say "no soaking" or "showers are ok." It clearly says keep 'em dry. I'm still confused though.

Day 14 - They had me in stitches

I got the stitches removed today. This was an experience I'd like never to repeat. They tie the sutures pretty tight, especially around the knee, because the skin there tends to move and stretch a lot. So I think they want to make sure they don't tear loose. But this makes taking them out a little tricky. The nurse tried to be gentle, but it was a little painful on a few of these incisions, especially the big one under the knee, just because the sutures were so deep into the skin and the wounds are still a bit sore. To be honest, the actual pain was not that bad. It was more the anticipation of pain and concern that here she was digging into still sensitive wounds with sharp scissors. I was sweating by the end of it, but thankfully it was over before I actually passed out. Phew. I can't believe we're still using something as primitive as sutures. Seems like somebody would have come up with something better by now.

Anyway, here are some pics of my leg post-sutures (the white bands are steri-strips that I have to keep on until they fall off on their own in about a week):


And here's a close-up:


I also went to physical therapy and was able to do complete pedal revolutions by moving the seat back a bit. So by next week I might be able to get back in the saddle. Unfortunately, my bike still looks like this:


Actually, you probably can't tell from this picture but I've made a lot of progress in the overhaul of my bike in the past couple of days. With any luck, it should be ready to go when my knee is.

Day 13 - Return to biking

My first brace-free walk was down to the bookstore to buy this:



So I can turn this:



Into this:



They say I can return to biking at 3 weeks after the surgery. That gives me another week to finish overhauling my bike and get my knee to the point where I can make it all the way around the pedal stroke. Right now, I can't bend my knee in far enough to make a complete pedal stroke. And I still walk with a bit of a limp, primarily because my knee is still stiff and it's difficult to bend it after taking a stride.

But hopefully in another week or so, I'll be able to bike no problem. My bike will probably be my close companion for the next few months, while I gradually ease back to running and agility exercises. It'll give me the freedom to move fast, something I can't do on leg power alone just yet. And it'll keep me in shape for the big trip I'm planning. It's good to have goals, particularly when they involve warm, beautiful beaches.

Day 12 - Look ma, no brace!

Last week, I had been gingerly walking about my apartment for several days without wearing the brace. But I kept putting the brace on whenever I left and when I slept. On Saturday, I finally threw caution to the wind and left my apartment without wearing the brace. I stepped gingerly, carefully and slowly. The warnings from everybody from my doctor to my physical therapist to my mom had instilled in me a strong fear that without the brace, my leg would snap in two at any second. But to my surprise, my leg held up. Here's a photo (Notice that my leg is not crumbling):


And here's one from the side, lest you think I'm being propped up on poles:


It turns out that despite all the hoopla and urgent warnings to wear the brace, even while sleeping, it actually doesn't make a difference in recovery. Several studies have looked at those who adhere to the brace recommendation and those who don't. They haven't found any difference. The brace provides support, but after the surgery, your leg is so beat up and swollen and sore, you're taking it easy on it anyway. So the brace doesn't provide any actual protection that you're not already giving yourself.

By the way, the same goes for the cryocuff and the CPM machine. Studies have looked at both and neither of those have been shown to do much at all. So use 'em if you want to, but don't feel bad if you don't.

So I've been brace-free since Saturday. And so far, so good. They say it takes about 6 weeks for the bones and other tissue to fully heal and incorporate the new ACL, but as long as you're taking it easy, you won't rip out the surgical anchors, which generally consist of screws and bone.

Supposedly, I can return to cycling in 3 weeks after the surgery. But I'll save that for tomorrow's post.

Day 11 - Rehab is my life

I've now settled into a routine that begins with my rehab exercises in the morning, followed by more quad strengthening throughout the day whenever I have a free moment and then ending with another set of rehab exercises at night. The rehab routine right now consists of quad contractions, then heel slides (bending my knee and using a band to pull my heel as close to my butt as possible), leg raises, and then more leg raises while laying on my side and back. Then I do hamstring stretches, followed by calf raises while standing on one leg. The whole routine takes about 20-30 minutes. That's at least an hour per day and probably more when you factor in the exercises I'm squeezing in throughout the day. That's actually down from the time I put in during the first week or so after surgery, where I spent at least 3 hours per day just in the CPM machine. So it really is true that if you're not prepared to commit yourself to the rehab exercises, you should probably not go through with the ACL reconstruction surgery in the first place.

Day 10 - I kick physical therapy's ass and drink a beer

I actually had my second physical therapy session yesterday. And I kicked its ass, primarily because I've been doing the exercises on my own and building up my knee strength and flexibility. My knee flexion is up to 110 degrees and I think that's even gotten slightly better today. All the other exercises --leg lifts in different directions to strengthen the quads, hamstrings, abductors and adductor muscles-- were a cinch. I couldn't go all the way around on the bicycle pedals yet. The stiffness of my knee only allows me to go about 3/4 of the way around, but that'll be there soon enough, especially as the swelling subsides and the fluid around the knee drains. Standing on one leg and the calf raises were no challenge at all. Based on my stunningly, impressive leg strength (well, relatively speaking anyway), my physical therapist told me I'd be out of the brace next week.

I told her I'd already tried walking without the brace and my leg felt ok. She chastised me a bit for that, but not too much. Apparently, all or at least most guys who go through ACL reconstruction surgery try to get out of the brace sooner than recommended. But girls don't and do exactly as ordered. Not sure which way is better. But it seems near impossible to get back all the leg strength you need for walking without actually walking. The main concern with returning to walking too soon is that the muscles won't be strong enough and the knee will buckle. But my leg is pretty stable and there's no chance of it giving way on me.

To reward myself for the physical therapy ass-kicking, I cracked open a bottle of the much revered Bell's HopSlam Ale, which looks like this:


This was my first beer since the operation, and it was magically delicious. Notice the guy on the label who's pinned underneath a gigantic hop bud. That says it all about the taste of this beer. Hopped through the roof, but yet smooth and drinkable, even at 10% ABV.

Tonight, I'm headed to a Mardi Gras party. I'll definitely strap on the brace for that.

Day 9 - The Zone of Ouch

The pain hasn't been all that bad for the most part and it has been much, much less than I anticipated. But there's an area around the incision below my knee that has remained painful and tender. I've started referring to it as the zone of ouch. Here's a pic that graphically illustrates what I'm talking about:


I don't know if the actual incision is painful. I'm too scared to touch it. But the area surrounding it towards the inside of the leg is tender and fluid-filled. That's where they drilled into my tibia to anchor the new ACL so it's not surprising that's it's such a tender site. The pain is slowly resolving, but if I've been laying down for a long time and then get up, it's very, very, motherf*&king sensitive when I put my weight on that leg.

Day 8 - Pain is my friend

If you've ever seen --even accidentally-- a Steven Segal film, you'll be completely flummoxed to learn that they might contain a nugget of wisdom. In "Out of Reach," the villain Faisal says, "Pain is your friend. Learn to love pain and it will set you free." I don't think he was referring to recovering from ACL reconstruction, but if he was, he was right on the mark. (By the way, if you've never seen a Steven Segal film, consider yourself blessed. I'm pretty sure I'm at least 2 IQ points lower just for having seen snippets of his movies). The surgery, the swelling, the cutting, it has all left my knee painful and tender and not wanting to do the rehab exercises. Most are not actually that bad, but bending the knee in as far as it will go is agonizing. When I do it, I usually wind up cursing, begging for death and making faces that look like this:


Here's a sideview, so you can see how far I'm bending my knee:


But when it's over, when I put my knee back down, the pain goes away and I feel sweet relief. And on the next painful, agonizing bend, I'm able to get it just a little further. And that's progress towards a full recovery. So maybe Faisal is right. Loving the pain will set me free.

Day 7 - Where be my muscles?

Having a new ACL really messes up your biomechanics, especially if you've lived without one for about a year like I did. The muscles in your legs are wonderful at adapting without you even being aware of it to whatever weaknesses you have. In my case, they were compensating for the lack of an ACL and probably also the torn meniscus to provide me with stability. So even though I was doing a lot of pre-hab exercises prior to surgery to strengthen my quads, it's a whole different ball game now that I have an ACL because it provides a lot of tension and support that the muscles must now re-adapt to. My quad strength is improving already, even from yesterday, but they are very weak.

Here's my leg at rest:


Here's my leg at full contraction (notice the awe-inspiring, rippling muscles):


And just so you can see how weak the muscles still are, here's a comparison to my other leg (notice how high the right foot is off the ground compared to the left (I didn't lift my leg, this is just purely from contracting the quadriceps):

I watch bad TV

One of the good things about going through ACL reconstruction is that it gives you plenty of time to broaden your horizons. Take this morning, for example. While laying in the CPM machine for an hour, I scrolled through the TV channels to keep my mind entertained. I had the good fortune to stumble onto an episode of Jerry Springer titled "Hot-headed hillbillies." In this episode, two self-described "trailer park trash" girls were fighting over a guy who looked like this:


I have no idea how the human race did not die off long ago.

I'll post an update on my knee later today.

Day 6 - Bandages be gone

I saw the surgeon today and he removed the bandages. Lots of little incisions from the surgery. One was still bleeding a bit but it soon stopped after a band-aid was put on it. It's swollen and ugly, but the X-rays showed the new ACL was doing fine:


I wrote the "YES" on my leg prior to surgery to indicate that "yes" it was the left knee they were to operate on. You can also see the surgeon's initials "SB" in the middle of my knee cap, indicating that he had checked with me and I agreed the left knee was the one to operate on.

Here's a comparison with my other, fully-haired knee so you can get an idea of how much swelling there is. (Too many shadows in this pic, I'll try to post a better one later)


I started physical therapy after the doc's appointment. I have good extension (ability to straighten the leg), so I'm mainly focusing on improving flexion. I got to about 78 degrees unassisted and 90 degrees when the physical therapist assisted me. My other knee went to 135 degrees, so I've got a way to go.

So for now, it's a lot of quad tightening, stretching the calf and hamstring and a few other exercises to improve flexibility and strength. The main goal is to build up the quad strength so I can take off this damn, annoying brace. But it's good to see my knee again and allow it to breathe.

Photos of cartilage tear and ACL

This might not be big enough to see, but here's a photo of the tear in my medial meniscus. The two pictures in the second row show the tear. The photo on the right in the 3rd row and the photo on the left in the 4th row show the cartilage after the surgeon has snipped out the bit where the tear was.



And this photo shows the new ACL. I'm not really sure where it is, but you might be able to spot it in the last few photos (the ones that are more red (not for the squeamish!):

Day 5

I've achieved 120 degrees of flexion (that's as far as the machine will go) and here's what it looks like:


I think I'm ahead of schedule, but I have a post-surgical visit with my surgeon tomorrow so I'll find out more then. They also take off the bandages, so I'll get the first glimpses of how swollen my knee is as well as the surgical incisions. After that, I go straight to my first physical therapy appointment.

I stopped the Vicodin yesterday. All I had most of the day yesterday was Extra-strength Tylenol. I took two this morning around 9 am and didn't really need anything else until about 4 pm. It's not much pain, just a little aching, which feels like it's mostly in my hamstring where it attaches to the back of the knee. Not sure if that's where the pain is really coming from but that's where it feels like it. I have some other aches that are only activated when I move my knee. I'm not moving the knee that much, aside from the CPM machine, which doesn't cause any pain at all, so most of these aches are avoidable and ignorable.

More tomorrow after seeing the doc and physical therapy.

ACL overview

For anybody who doesn't know, the ACL is a ligament that runs cross-ways through the knee. It attaches on the lower leg bone, the tibia, and the upper leg bone, the femur. It stabilizes the knee by holding the tibia and preventing it from sliding forward. So if it snaps, the knee can be unstable and the bones will grind on the cartilage. Here's a couple of photos to show you what it looks like in the body:




In the reconstruction surgery, my surgeon put in an allograft that consisted of achilles heel from a donor. He also snipped out a piece of my medial meniscus cartilage where it was torn to help smooth it out and relieve any pain the torn flap was causing. Here's a diagram showing what surgeons do during ACL reconstruction:

Day 4

I tried to ditch the Vicodin last night because it seemed like the pain was tapering off. All was well until about 4 in the morning. I woke up with moderate pain in the back of my leg, I think where they snipped out a bit of cartilage but not really sure. I took a Vicodin and everything was soon ok again. I've been trying to space out the Vicodin today to see how long I can go without it. I'd like to get off the stuff. They make me feel kind of brain-fogged.

I also had to stop taking the Naproxen, an anti-inflammatory I was to take twice a day. I think it was eating a hole in my intestines yesterday, or at least that's what it felt like. Hopefully, I'll be ok without it.


I'm already up to 100 degrees flexion on the CPM machine and hope to do more than that later today. I'm also hobbling around on my braced knee like a post and continuing to keep up with the quad contracting exercises. Nothing too exciting, but so far so good.

This is my dog, Darwin. She's been instrumental in my rehab. About twice a day, I limp outside and throw the ball for her. It keeps my spirits up and is probably good exercise for my knee. She also ate a pack of fig newtons when I wasn't looking. That didn't help with my recovery at all, but it was funny and it seemed to make her happy.

Day 3 - Off the crutches

Once the nerve block wore off, I ditched the crutches last night to limp over to the neighbors' house for dinner and I haven't used them since. The leg feels pretty stable in the brace and I'm supposed to walk on it as much as I can tolerate. I can feel a little soreness on the outside of the knee, but it's manageable. I can also feel some slight pins and needles at what I think is the site of one of the small arthroscopy incisions on the outside of the knee when I'm moving it a bit in the CPM machine. Hard to tell exactly what it's from because my knee is still buried under mounds of ace bandage and cryocuff. But that's not too bad either.

I was getting a little pain last night that made me fear it might get much worse. But I popped a Vicodin and turned on the cryocuff and it never amounted to much.

I'll do more of the CPM machine today and see if I can do more quadriceps strengthening exercises. It's hard to tell how hard I should flex the quads at this point because I'm fearful too much force will make the knee hurt. So I'm just doing it slowly and working my way up gradually.

Day 2 - Crutchward Bound

Welcome to Day 2. The nerve block is just now wearing off at 2 pm, more than 24 hours after I first got it. It hasn't worn off completely yet, so there's still a lot of numbness in my leg. Not much pain yet, but I've been keeping up with the Vicodin and naproxen.

I'm hopping around on the crutches pretty good, meaning it takes me 10 minutes to hobble over to a chair only to realize I've left the remote control across the room which takes another 10 minutes to hobble over to and back only to realize I've forgotten something else. The one-legged shuffle is a slow, slow dance.



I've also used the CPM machine for the first time this morning. It slowly moves the leg, bending it to about 30 degrees to start out with and then going back to straight. The idea is to get up to 120 degrees of flexion (bending). This is supposed to help with recovery.



I'm also starting leg raises and may try some quadriceps contractions later on depending on how everything feels once this nerve block wears off.

Day 1 continued

Here's a photo of my knee after the surgery. The brace, which has metal brackets running down either side, can lock so that it can't bend, which allows you to walk on your leg like a post. Supposedly. I haven't been able to put any weight on it yet because the nerve block they gave me in my upper thigh still hasn't worn off yet. So my leg is completely numb. It's an odd feeling. Touching my thigh feels like I'm poking a water balloon. And sometimes I feel itches on my legs that needs to be scratched, but when I go to scratch them, it's just all numb, so it doesn't really do much good. I'm not sure how I'm feeling the itches.



Underneath the brace is a load of ace bandages and a cryocuff, a bladder-like thing that surrounds my knee. Those two white tubes pump ice water from a cooler into the cryocuff to help keep the swelling down. But I stumbled upon a review from 1999 online last night that looked at several studies and concluded that the cryocuff didn't provide any benefit. I'm still using it though because it's not like I have anything better to do.

Here's another photo of the brace

Day of Surgery

So this is me just before surgery, nervous and anxious and fearing the worst. Also, I was slightly embarrassed by my fashion choice. I was told the paparazzi would not be there, so I just threw on the oversized gown and hairnet that I usually wear when nobody is around. But man, those paparazzi always get you when you least expect it.



And this is me at home after the surgery. The slight smile is a combination of the lingering effects of anesthesia, the Oxycontin I had popped not too long ago, and sheer relief.