This is Part 2. (Here’s a link to Part 1):
Deciding on Treatment
The MRI scan confirmed that I had a complete ACL tear, but little other damage, which meant that I could stop wearing the (awful, awful, awful) brace and begin to consider treatment options. Complete ACL tears don’t heal on their own, and the remaining tatters of the ligament atrophy quickly. It isn’t feasible to sew the ends back together, which leaves two main options: i) go on without an ACL or ii) have surgery to replace it.
It is possible to have a more or less normal life without an ACL. You can even do some sports such as running, cycling, and weightlifting. Surgery has significant costs—both financial ones (I’m in the US, I have health-insurance through my work but, as I discovered, that doesn’t mean it is free or cheap to get surgery here) and costs in time, inconvenience and pain during the recovery period. More about those in a bit. Generally, the older you are, and the less active, the slower and less complete your recovery from the surgery is likely to be, and the less need you are likely to have for a functional ACL anyway. The case for having reconstructive surgery gets stronger as the patient’s age decreases and their activity level increases. If the activities one wants to pursue include a lot of cutting or landing, as in football, basketball and yes, fighting, then an ACL might be required to keep the knee stable under the sorts of stresses such activities produce.
I’m 35, female and the martial arts are a huge part of my life, meaning that that I was very keen to get back to participating fully. I was actually rather worried that my age, gender, and profession would make doctors and therapists underestimate the extent of my physical activity. How many 35 year old female college professors consider it extremely important to be able to engage in physical activity that goes beyond well-controlled activities like running, cycling, and lifting-weights? Many—maybe even most—of my colleagues either run, bike or lift; we practically need our own departmental bike rack. But colleagues who are still playing soccer, rugby or basketball regularly are few and far between, and among the women it’s even rarer.
So I took it upon myself to convince any and all doctors and physical therapists that I was in need of a very, very good ACL reconstruction. There were three main strategies that I employed here: first, I always portrayed myself as an athlete, to the point where I made sure I was wearing sports gear whenever I had an appointment. Orthopaedic departments seem to have two kinds of clientele in the waiting room: young athletes who got hurt doing sports and old people who need joint replacements. The athletes are often teenagers in athletic shorts and school t-shirts, the old people are in shirts and trousers. There’s no way I look like a teenager, but I made sure I always wore shorts and a karate t-shirt to appointments. Second, I told all and sundry that I was worried that people would underestimate my activity level because I’m female and older. That put the disparity between me and the typical old college professor firmly in their minds. And lastly, I sought out the most athletic-oriented physical therapy center I could find.
The doctor who had diagnosed my injury recommended that I get six weeks or so of physical therapy before surgery, on the grounds that prehab and just taking the time to let the swelling go down had been shown to lead to better results after surgery. They gave me a choice of physical therapists, so I went home to look them up on the web before I made a decision, and in doing so I discovered this place. I checked with my doctor’s office, and yes, it would be fine if I went there, so I called and made my first appointment. My physical therapist was Ryan Noirfalise. You can see him in action in this video (although I should mention that Ryan hated this video because they only asked him to do it about 2 minutes before they started filming, so he didn’t get any time to prepare what he was going to say.)
Ryan had me do various exercises, both in my sessions at the SEG and at home. Doing 2-3 lots of 20 minutes of PT at home every day takes a lot out of your schedule. When you think about it that’s about 7 hours a week – plus whatever time you’re spending with the therapist – and whilst it’s sort of interesting and you’re pretty motivated to do it at the beginning, it quickly becomes routine drudgery. Especially the wall-sits. But Bob’s training in corrective exercise had convinced him i) that physical therapists are amazing and ii) that something done regularly and correctly for a finite period of time (like 8 weeks) can make a huge difference long term, iii) that trainers and physical therapists often have a hard time persuading their clients to stick with a programme long enough for them to start seeing results and iv) that often it’s much more important that you do the exercises than that you fully understand the rationale for doing them. So despite the fact that I’m a naturally argumentative, theory orientated person who won’t normally do what she’s told without 6 weeks of research and a book’s worth of reasons for doing so, I settled down to do whatever Ryan damn well told me. Including getting up half an hour earlier so that I could fit my at-home PT in before work, and sleepily struggling through my routine when I got home at 2am, even if I just really really wanted to go to bed. I did it in airport departure lounges, on the side of the mat in karate, and in my office. But it got done.
The objectives of that pre-surgery PT included i) improving the strength of my VMO (see the picture above) ii) improving my control over my VMO iii) improving my hamstring strength and iv) improving my balance and my ability to make my toes track forward over my knee when I bent it. One of the first exercises I ever had to do (and which is likely to be familiar to anyone who’s torn an ACL) was this one:
I discovered it was pretty difficult to activate my quad muscles on command whilst simply lying down—though within a couple of weeks I’d had enough practice that I could control those muscles pretty well.
Meanwhile, I was trying to find a surgeon. Or rather, I was trying to find the best possible surgeon. When I first tore my ACL I mentioned this on facebook and was amazed to discover how many of my friends had done so too. None of them were martial artists mind. The people who’d torn their ACLs were generally skiers, footballers and basketball players. I emailed a couple of them to ask for advice (thanks Fabrizio and Jose!) and one thing I heard many times was that you want to find a surgeon who has done the surgery hundreds of times—that experience with the particular surgery you were having done was key. I have no complaints at all about the surgeon who’d diagnosed my ACL tear, but he was very young and not all that experienced (though no doubt in 30 years he will have the experience.) I asked at the Sports Enhancement Group, where they see hundreds of ACL reconstructions a year, and they recommended Michael Milne with the phrase “he’s turning out the best knees in St Louis these days.” So I made an appointment and it quickly became clear that he’d done the surgery, in its many variations, hundreds and hundreds of times, and so I decided to go with him. The decision then was what to put in place of my old ACL and the three main choices are i) part of your own patella tendon, ii) part of your own hamstring and iii) an allograft from a cadaver. There are various reasons for or against each version, but Doctor Milne made it clear that he’d be prepared to do any of them. I was keen on the allograft from the start, reasoning that the less of me that had to get cut up the better. One reason people sometimes avoid the allograft is the risk of rejection or infection, but it turned out that this risk was so low as to not really be a concern for me. I got the impression from the physician’s assistant that people sometime refused the cadaver ligament just because of the “ick”-factor. But that wasn’t a big consideration for me—though I can imagine a crazy horror movie where a cadaver implant somehow allows a necromancer to take control of your knee… Reasons against the patellar tendon and hamstring homografts include increased recovery time (especially if you are older, like me) anterior knee pain (in the patellar case) and some problems with fixing the material to the bone (in the hamstring case) which Doctor Milne told me had largely been solved. Anyway, I heard a lot of different things from a lot of different people on this topic, and the technology is steadily improving, so you’d want to talk to your surgeon and get the most up-to-date advice. I went with the allograft and allowed Dr Milne to choose the particular type (it was a hamstring allograft.) And we booked the surgery for 7 and a half weeks after the initial injury, which allowed me to fit in a trip to a conference in Scotland. (The physical therapists at the SEG warned me that my knee would swell up on the flight and gave me a compression bandage to help control it. They were totally right, as usual.) I was allowed back on my bike, allowed to drive and allowed to do some basic conditioning, though I quickly discovered that I my knee wasn’t really stable enough for everything I was allowed to do (like side planks.) In the next instalment I’ll talk about the surgery itself and maybe I’ll even be able to find the photos that the doctor took from inside my knee!