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.
Physical Therapy
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 Vastus Medialis Oblique (VMO)
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!
This is a sensible review of an interesting product:
I think everyone writing on this blog is a big foam roller user, and I know that in St Louis we generally graduate up to using harder rollers and things like softballs to get into the hip rotators. But this looks like it would be a useful intensifier too.
On August 16th, 2010, I tore my right anterior cruciate ligament – the main ligament in the knee – at a fight training class. This is part 1 of the story of how it happened, the reconstructive surgery, the 5 months of physical therapy that followed the surgery, and my gradual return to full participation in fight training.
The Injury
The ACL (anterior cruciate ligament) is the most important of the four ligaments which stabilise your knee. It is is a strip of connective tissue which inserts at the front of the bony plateau at the top of your tibia, in your lower leg, and crosses to the back of the distal part of the femur, in your upper leg. Its major function is to resist your lower leg being drawn forward and/or twisted in relation to your upper leg.
The major ligaments of the knee.
The other three ligaments in the knee are the PCL, LCL and MCL. The PCL (posterior cruciate ligament) inserts towards the back of the tibial plateau and runs forward to the front part of the femur. It forms a cross with the ACL, hence the name “cruciate” and the “anterior/posterior” part comes from where the ligament attaches to the tibia. The other two ligaments are the LCL, or Lateral Collateral Ligament, on the outside of the knee, and MCL or Medial Collateral Ligament, on the inside of the knee.
ACL tears are common sports injuries, especially in sports that involve a lot of cutting and landing, such as football and basketball. One man I met at physical therapy had torn an ACL on five separate occasions – getting it reconstructed in between, of course, he only had the two legs.) Women are more likely to tear an ACL than men, but at the time of my injury, the only ACL incident I had heard about was that of football legend Michael Owen, who tore his ACL in 2006 World Cup against Sweden. You can actually watch him do it here:
You will see that Owen isn’t touching anyone. Non-contact tears like this are very common; you don’t need to be tackled or kicked to tear your ACL.
Unlike many, mine was not a non-contact tear though. I was doing stand-up randori with a friend. We were the only two people in the class at the time, so our instructor, Robert Miller, was watching closely. We were outside on grass, and wearing athletic shoes. My friend is a fair bit bigger than I am, so was really putting my all into my attempts to throw him. We were in the last few seconds of the round and I managed to line everything up for a good o-soto-gari leg sweep with my right leg. I didn’t get it cleanly and he didn’t go down right away. So I did what you do to force it: I planted my sweeping leg, and attempted to use every atom in my body to force him back over it. He bore down to resist. I pushed hard…but instead of him going back, there was a pop from my right knee and I found myself on the ground, yelling and clutching my knee, with a very worried looking practice partner looking down at me and wondering what the hell had happened.
The intense pain didn’t last long, and within two minutes I was able to get to my feet and limp away. We ended the class then. The back of my calf felt tight at the top, near my knee (I now know that was because when your ACL isn’t there to resist anterior draw of the tibia relative to the femur, your gastroc muscle tries to do that job instead. The tightness was my gastroc freaking out at all the new work it was going to have to do.) But I was ok, I thought, I had just strained my knee or my calf in some way, and a little ice and elevation would have me fixed up in a couple of days. Deep down I knew that the popping sound I’d heard was a bad sign—that people reported hearing such noises when their ACLs went but, honestly, it just didn’t hurt that much any more. I iced, I elevated. I walked funny. But I didn’t think I I’d done anything that wouldn’t heal itself in couple of days. But I was wrong.
The next night I was teaching karate at Washington University. I was demonstrating a technique, shifting forward in stance to block before grabbing and pulling my uke into my punch. And as I shifted forwards there was another crack from my forward knee—this time it felt like the noise was from the femur slipping against the tibia—and I found myself back on the ground, with more yelling, this time with a few more alarmed people looking down at me. Everyone had heard the crack. And my knee had just collapsed on me.
Diagnosis
That collapse was surprising and unexpected enough that I called my GP the next morning. Robert Miller came with me when I went to see her. She asked me what had happened and performed a few tests for knee stability, including one with which I am now very familiar— the Lachman test—the standard clinical test for ACL function. Then she said: “I’m not totally sure, but going from what you’ve said, the way you are holding your leg when you stand, and from manipulating it, I think you might have torn your ACL. Anyway, I’m going to send you to an orthopedist, so we can find out for sure.”
And honestly, I thought—naah. What does she know? She isn’t even sure and she’s probably just being careful. My leg is fine. I’ll go and see the orthopedist and they’ll tell me it’s just a strain. Looking back I find it easy to recognise the element of denial— a commonly reported response in the sports psychology literature—in my own responses. But I went to see the orthopedist. He repeated the Lachman test, immediately diagnosed an ACL tear and scheduled me for an MRI to try to find out what other damage I might have done. He also gave me a brace for my leg in order to minimise any extra damage I might do to the soft tissues until we figured out just how stable my leg was (at this point there was some question about whether I might have damaged the LCL at the same time as the ACL.)
One of the sad things about the injury and brace was that it took me out of the FSRI demo at the 2010 MoBot Japanese Festival. Here I am mic'd up to present while Chris looks sad about having no-one to demonstrate with.
As it turned out, I only had to wear the brace for a week, but that week was miserable. You wouldn’t think it would be such a big deal—the brace only weighs a few pounds and since I was injured anyway, it’s not as if I was walking normally before I started wearing it. So let me break down the ways in which wearing it was bad. First, it locked my leg in extension, making it impossible to bend my knee. I couldn’t ride my bike, and I couldn’t walk normally—a major disruption to my lifestyle, though since classes hadn’t yet started at the University where I teach, I didn’t need to get to work each day, and so didn’t need to ride my bike as much. But you only have to go without bending your knee for a few hours to really, really develop a serious yen to bend your knee. When I took the brace off to shower I would attempt to bend it but the hours of extension had shortened the quadriceps around it to such a degree that bending it was slow torture. The additional weight of the brace puts extra strain on your hip flexors as you walk (you end up walking as if your braced leg was a pendulum—something you have to swing forward as one piece, like a crutch) tightening them on the side with the brace. This in turn puts extra pressure on your lower back, leading to much achey-ness. I also to sleep in the brace, which is not so easy, and meant that I was getting less sleep, and with it less recovery.
I haven’t mentioned the worst part yet, which is that in the week of wearing the brace the muscle melted off my right leg like warm butter. All those years of training and building up quad and hamstring strength were undone in a few days, leaving my right leg about half the size of the left. It was this, I think, that really brought it home to me that I had to take this seriously. I couldn’t look at my shrivelled right leg next to the as-yet still muscular left one in the mirror and not realise that something had gone very, very wrong.
The results of the MRI came back, confirming that I had a complete ACL tear, but no other serious problems, except for the fact that I was as incapable of lying completely still for 40 minutes as a 2 year old on Red Bull. Doctors from then on would frown and shake their heads over the “movement artefact” on my MRI. I was allowed to take the brace off, and proscribed physical therapy for a few weeks while the inflammation from the initial injury went down, and while we considered options for surgery—the topic of a future instalment of this account.
Posted onMay 23, 2011|Comments Off on Statement from FSRI
We were recently shocked to learn that that our martial arts colleague and friend in the UK, Mr Harry Cook, has been convicted of sexual assault. Whilst we are still struggling to process our personal feelings about the news, we would like to take this opportunity as an organisation to condemn these serious crimes and express our anguish for the victim and her family. Our thoughts are also with Harry’s wife and children, and with the others whose lives and relationships have been affected. The history of martial arts is littered with examples of people who used their mystique as a teacher to exploit their students – criminally or otherwise. Here at FSRI we’ve worked hard to create a culture in which things are different, and we liked to think that the teachers at clubs we associated with were different too. It is with deep anger and sadness that we realise we were wrong about this.
If you are working out, you need to replenish fluids regularly for optimum performance. Water is great for this, but if you’re working out longer than 45 minutes to an hour, there’s good reason to drink gatorade, for the salts, for the performance-enhancing carbs, and because that slightly troubling fruity sweat flavour somehow transforms into the elixir of the gods once you’ve worked up a sweat.
But gatorade comes in suspiciously gummy colours, is expensive, and is usually bought in a new plastic bottle every time. And if you read the ingredients you’ll quickly see that Michael Pollan wouldn’t approve. What if you are the kind of karate-ka who likes to “eat clean” and fill your water bottle with tap water?
Then you are the kind who might appreciate this homemade “gatorade” recipe. It’s so easy that I blush to call it a “recipe” and the ingredients are things you’ll likely have lying around anyway, or be able to get in your dorm’s dining hall on the way to training:
Homemade “gatorade”
1/2 cup orange juice
Then fill your bottle up with water.
3/4 teaspoon salt
That’s it.
Don’t think you’ll make some kind of super-gatorade by doubling or trebling the salt content – I tried that, not good. Ideally you want both sodium and potassium, so check and see what kind of salt you have. There’s potassium in orange and lemon juice, so if you have ordinary sodium chloride for salt you’re good.
Alternatively:
Fill your waterbottle with tea, add a little lemon juice and 4-6 teaspoons of sugar (or honey)
3/4 of a teaspoon of salt
Reducing the sugar gives you low-calorie “gatorade” but how useful that is depends on your goals, how much you’re drinking etc. The carbohydrate is an integral part of sports drinks and if you’re not using fruit juice you’ll need to get it from somewhere else.
You know, people say Americans don’t care to learn about the world outside their borders, but some bright spark at the Tuscaloosa News in 1981 thought that the people of Alabama needed to know what was going on with karate in Soviet Russia.
I was a little alarmed by this news story about Darren Day being on trial for carrying a kubotan.
I used to use a kubotan as a keyring, which I carried pretty much everywhere, including past the TSA checkpoints at airports. It looked like this, except that mine was pink:
It didn’t get past the TSA every time. On my way back from the Fitness for the Fighting Arts seminar in Virginia this year, they searched my bag after it went through the x-ray and dug it out. Then they confiscated it, checked my record, filled out some paperwork, and told me stories about their mate who was really good with the kubotan and could “just put yer on the floor, just like that.” (Oddly enough it was one of the more pleasant interactions I’ve had with the TSA. It was certainly better than watching them yell at some old lady for not getting her shoes off fast enough.) And then just before the flight took off, one of the stewards came up and said “they just wanted me to check – was this your assigned seat?”
Reading the Darren Day story, it looks like I got off lightly. One of the people quoted says about the kubotan: “the worst-case scenario it could kill somebody.” I think that’s probably right, but then, so could the floor, or a t-shirt, or a walking stick. Safety is hard. Both for me, and for the TSA.
This is a curious short film. Its subject is clearly a proponent of the “more is better” and “more crazy is more better” schools of training. I by no means recommend spending several years attempting to hang from a tree as a way of improving your harai goshi throw, indeed, I recommend against it, on the basis that harai goshi doesn’t involve prolonged isometric holding of the position in question, and is easier if you haven’t destroyed your knees and elbows. But this is sort of interesting anyway.
Also, John Wang seems to have invented the “right-click” mouse button. Who knew?
are available here.
Fight Sciences Research Institute blog 