Return to Sport, or technically return to your previous pre-injury activity level, is usually the goal for ACL folks. It's the reason why we keep doing rehab, to check off the required steps and make it back to the life we once knew. It's a whole rehab continuum. If I had not had such a pre-injury active lifestyle, then maybe the bar wouldn't be set so high. Maybe it wouldn't be such a mental battle. A 2014 paper from Arden et al. summarized over 7,000 male and female ACL patients (BPTB or HT) return to sport statistics. The graphic below is just a visual summary of Arden et al. findings created by Mark Roe, PhD of Ireland. Here are the stats for my case (3 years, female, recreational) and the likelihood of returning to my previous activity level:
Those aren't great odds! But I am so determined to be part of the numbers in the orange column! It may take several years! Desire just has to outlast the length of rehab! There are a variety of reasons people don't make it back to where they were. I think surgeons aren't very up front with these facts either. I like to break those that don't make it back into two different categories:
With the first group, rehab is simply insufficient. Of course you cannot make it back; you're not done with rehab or ready for RTS testing. Things that can cause rehab to be insufficient are pain, loss of motivation, social pressures (people telling you to give it up, family obligations, etc), fear of reinjury, poor rehab quality, poor guidance, etc. The second, RTS tests declare your knee is physically capable of handling your sport demands, so you can remove the "rehab is insufficient" factor from the first category. Still, you can make it that far and not actually return to your previous level for several reasons. They kind of look like the list above, but rehab is actually sufficient now. Fear of reinjury seems to be the biggest factor people don't get back to sport (Nwachukwu et al 2019). If you are still afraid of a retear after having a fully rehabbed knee, then perhaps some counseling, visualization, going back to sports drills in a controlled environment, gradual exposure to your sport, more time are all ways to get over that kinesiophobia with a fully rehabbed knee. So whenever I hear someone didn't make it back, I always think to myself, "Did they finish rehab and pass the tests?" But it's also OK to not go back your previous level if you don't want to. Go do something else with your knew bad-ass strong knee. That is OK too. I have been told that you can pass those full RTS sports testing criteria with a SORE KNEE. The idea is that we just get it so adapted that it can handle the demands but the soreness hasn't actually gone away yet. Kind of like how I got adapted to biking and hiking. Took many months, it's still sore, but I can do it. That is good news, because I thought my sore knee would actually hold me back, aka prevent me from getting to the fancy part of rehab (jumps, agility, etc). We can get things strong and adapted enough, but there can still be pain. At least hope to get to that level. Will it still be fun to ski with pain? Well I'll have to find out. Too soon to tell. On the flip side I am part of the black column! 79% make it back to some kind of sport after 3 years; 80% of sub-elite make it back to some kind of sport; and 75% of women make it back to some kind of sport after ACLR. So even with my delayed, drawn out case I am still in the black column.
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I jest about the easy part, but today is recovery day 1100 and I had the thought now I can sum up my last 100 days and add it on to my list of "steps." Amazing to think that 100 days ago I was walking through the bottom of Paria Canyon in Arizona on a 3 day backpacking trip walking 13 miles a day. That was my last big physical effort.
Hopefully all goes to plan (HA!) and by day 1200 I should already be a few weeks into the hop/skip reintroduction with running come up next. My 3 year ACL surgery ankneeversary was on Valentine's Day. As per tradition, I always take my knee out for a good time. This winter, due to the foot, winter fun has been VERY limited. I was wondering what kind of activity could I do to honor my ankneeversary. I was secretly hoping I could cross country ski for this ankneeverary "knee date" (back in November I was cleared to try it, but that is when the foot issue culminated). In the end, I chose to go on a fat bike ride! Now I have not biked outside in 11 months since starting my WristWidget recovery protocol for a TFCC tear. I am not actually approved to bike outside, but I chose it because I thought it would have the least amount of consequences. I sit on a stationary bike for an hour, so maybe this wouldn't jack up my arm and wrist too bad? Turns out it was pretty lovely, definitely needed a really good shoulder/arm stretch session after. The arm aftermath wasn't too bad. The sun was shining that Friday morning, there was no one at the trailhead when I arrived. The snow was pretty firm (great for riding), but yet the air temps felt pretty comfortable for a ride, might I say perfect for a fat bike ride? I took myself out to lunch and then got a chocolate, Valentine's themed acai bowl afterwards. Nice little ankneeversary date! Poor husband was not able to join me. He is dealing with pneumonia right now. Check out what I did for Year 1 and Year 2 ankneeversaries. The day before I had Skyped with my PT in Australia. It had been 3 months since our last Skype. The plan we laid out in the November Skype did not happen at all due to the foot issue becoming the limiting factor. He did not agree with the podiatrist's opinion on waiting until my foot is 0/10 pain before adding in any calf raises. The concerns are I already have a pretty deconditioned leg due to the moonboot, it already had about 7 weeks of "rest" while in the boot, and that didn't eliminate the pain, and waiting to be pain free could take weeks or months! This just makes daily function become even more challenging and the atrophy process get worse!
Instead, much like my tendon expert PT would say, we need to add load to the tendon despite my 2-4 pain level (which is an acceptable level of pain). We are not going to rupture the tendon with these moves. The key point here is that despite poking into pain a little bit, we are in no way doing any tissue damage. Now I have a 4 month tendon loading plan. These are to be done 3-4 times a week. On top of that 2x heavy lifting sessions, and 4-5x week of cardio (biking, walking, swimming, elliptical are all OK).
Hard to believe I used to single leg calf raise 1.2x my body weight. All this before any running is attempted. Yes, this is a bit of a bummer and a setback. However, I feel this is the right action plan. Also no snowshoeing, xc skiing, snow walking - need to stick to pretty flat hard surfaces or else that tendon will be irritated in this stage. This tendon issue has been around for many months and I want to build it up right. I don't envision running again until mid-June. I am shaking my head in disbelief that my very first run was late May 2019, and then my next run may be June 2020. In that entire year process I have never made it past 2 minutes of running! (2 min run/2 min walk, repeat for 32 minutes to be exact). My last consistent week of running was October 21 (3 weeks after the costochondritis episode.) Good lord! How am I going to get anywhere at this rate!?!? *Phew Big Breath* It won't be like this forever, I have to not ruminate on stuff. I have to catch myself and stop it when I dwell on this too long. What I do know is that I do have a new capacity to do things that I once could not before, however I may go a bit overboard and my body may not be resilient enough to bounce back from these random big events. While I am encouraged to do normal things and live like a normal non-rehabbing person, I also need to know when to stop an activity early. It's the DOSAGE of normal fun that I am not getting quite right, which leads to these other issues. Still need to get rehab more consistent to build up my resiliency. I had my follow podiatry appointment today. Thanks to the MRI, the doctor came up with a new diagnosis: Insertional Posterior Tibial Tendonitis. He showed me the evidence which was bright white inflamed spots on the tendon sheath on several MRI slides. When he was pressing on my navicular bone and I said it hurt, he now says that was the insertion point of the tendon on the navicular bone. My current still lingering achy pain is tendonitis. The stabbing top of foot pain I did have was probably a mild arthritis flare up. Most people over 40 already have some kind of mild arthritic changes as seen on an MRI, so he wasn't too worried about that.
I often thought I felt plantar fasciits in my arch, but maybe I was feeling more tendonitis? I passed the clinical foot resistance tests for this tendonitis, it was only pain upon palpation. Hopefully, it's a one time thing that we need to settle down. Instructions are: ice the area and apply an NSAID gel to hopefully get it to settle. Pain must be a 0/10 before we do running tests or calf raises (wonder what my PT will say now, as before this he thought 3/10 pain was acceptable, but we didn't know it was tendonitis then). Should I get stabbing pains again or I find the tendonitis pain is creeping up, he gave me a lace up ankle brace to wear. While at the PT clinic getting the brace fitted, I spoke with a former physical therapist of mine. He remembered me and wanted an ACL update, even though he was not part of my full rehab, he did sub in a few days on occasion. He as the one who actually got me to do a leg lift finally thanks to a neuro hack he made up. I told him about the last 3 years, who had helped me, what a long journey it's been. I asked him if he would test me on the Biodex when I'm ready as my current PT will need it, even though I'm not technically anyone's client at this clinic. He said he would, said book a session with a certain PTA, and make sure to do it on a day he is in so he can explain me the results. One of the front desk ladies remembered me and couldn't believe it has been 3 years already. She asked if it seemed fast. I said no it's been dragging on forever, I'm still rehabbing! Turns out my original PT I saw for the ACL no longer deals with clients directly, he does more managerial stuff in an office behind a desk. |
AuthorA 45 year old active female who tore her ACL in January 2017 (at the age of 40). Reconstructive surgery in February 2017 with bone-patellar tendon-bone autograft. Archives
November 2022
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