AZOPT Follow Up: Rehabbing Major Knee Injuries

AZOPT Follow Up: Rehabbing Major Knee Injuries

ACL injuries are a scary thing to see when they happen to athletes on television.  We see them writhing in pain, clutching their leg with tears rolling down their face.  An ACL injury to an athlete is season ending, potentially even career ending.  The rehabilitation is gruesome, tedious, and long.  But professional athletes have teams of doctors, physical therapists, trainers, and coaches to help them get back to 100 percent.  Not to mention their rehabilitation becomes a full time job.  That’s why, over time, most athletes bounce back from major ACL injuries. 

What about the common, middle-aged, weekend athlete?  In February, we posted an article Everyday People: Rehabbing Major Knee Injuries with AZOPT.  In that blog we met Josh, who suffered a grade 3 tear of his ACL and MCL, along with torn meniscus and bone bruising while practicing Judo with another adult in his son’s class.  A 35 year old father of three, Josh was an active person who participated in CrossFit, Judo, bike riding, and golf.  Josh had successful surgery on January 14, 2013 to repair his torn ACL, and he began physical therapy at AZOPT on January 23, 2013 with Ryann Roberts, DPT and Owner.

We interviewed Josh upon completion of his physical therapy March 8, 2013:

Your first appointment following surgery was January 23, your last March 8.  What was the focus of your rehabilitation during that time?

I attended physical therapy three times per week during that time.  We focused on strengthening, stretching, and balancing.  Strengthening exercises included squats, first with both legs, and then one leg at a time.  I also did various lunges and calf raises.  Stretching exercises were aimed at regaining range of motion with physical manipulations, static holds, and soft tissue massages.  The balancing exercises helped improve coordination by standing on one leg and throwing objects, or rocking on a tilted surface.  With going to physical therapy three times each week, I was pretty sore.  At home I tried to get good rest and kept up with stretching exercises Ryann had given me.

How helpful was physical therapy?

Physical therapy was very helpful as the first part of my recovery process.  Physical therapy took me from barely being able to walk to now (May 1) re-entering CrossFit and engaging in fairly rigorous physical activity.

On March 8, at your last physical therapy appointment, how far along were you in your complete rehab?

My rehab was progressing along nicely.  I had just been cleared to return to jogging and strengthening exercises, but not athletic type movements.  At the time, I felt I was ready to go off on my own and continue to rehab.  Ryann had given me a thorough home exercise program that included strengthening, stretching, and balance exercises. 

As of today, how far along are you in your rehab process?

My doctor has just cleared me to gradually return to sport-like activities.  I am participating in a form of modified CrossFit.  My doctor has just cautioned me to proceed slowly as my strength and coordination return.

What do you feel, if any, is the difference in rehabbing your knee with Ryann as oppose to anywhere else?

Ryann was an excellent fit for me.  His own athletic background gave him a unique perspective to appreciate my goals.  His more than capable oversight helped me achieve my best recovery possible.  My doctor has told me my knee represents their hope in all patients and is a best-case scenario. 

In our first article, we talked about your mental state and how faith has played an important role in accepting this injury and moving forward.  Having gone through the rehab now, what can you tell others about your experience?

The last seven months have been an unexpected sequence of events beginning with my injury then dealing with the consequences of the injury including doctor's appointments, rest, rehab, surgery, more rehab, etc.  Each of these has been accompanied with frustration, inconvenience, monetary expenditure, and physical pain and discomfort.   That is the honest reality of getting your leg snapped in two.  However, with that said, the thing that stands out most clearly is how fortunate I am.  God has been good to me.  I have received constant love, care, and encouragement from my family.  I was blessed to receive exceptional medical care from my doctor and the team over at AZOPT, and I have been blessed by the time and place I live so that I now have a reconstructed knee.  Think about how incredible this is.  Doctors used a portion of my hamstring muscle to recreate ligaments in my knee and because there were only minor incisions paired with modern medical techniques I will have a knee capable of returning to play in the NFL--pretty good for a middle-aged guy who is just trying to keep in shape and have an active life with my kids!  I have a lot of which to be thankful.

Everyday People: Rehabbing Major Knee Injuries with AZOPT

Everyday People: Rehabbing Major Knee Injuries with AZOPT

Minnesota Vikings running back Adrian Peterson. Chicago Bulls point guard Derrick Rose. Washington Redskins quarterback RG3. Most recently, snowboarder Lindsey Vonn. What do these professional athletes have in common? They have all had surgery to repair a torn ACL. If you are a sports fan, you will read about an athlete tearing their ACL almost too frequently. Not to downplay this horrific injury, but ACL injuries have become so commonplace, that we expect an athlete to recover quickly from ACL surgery, and in some cases, perform even better. Just look at what Adrian Peterson accomplished this season in Minnesota, winning the NFL’s MVP award. Athletes are privy to top doctors, top physical therapists, and top rehabilitation equipment, right?

 

But what happens when a young, otherwise healthy, person tears his ACL? Can they expect the same doctors, same level of physical therapy, and ultimately, the same return to normal activity? To answer these questions, we will examine Arizona Orthopedic Physical Therapy’s patient Josh H., who is in the mist of rehabbing his left knee after surgery from suffering a grade 3 tear of his ACL and MCL, along with torn meniscus and bone bruising.

 

On November 7, 2012, Josh was enjoying a Judo class with his son. While practicing with another adult, their legs became entangled, and the sparring partner fell onto Josh’s fully extended left knee. It was one of those fluke injuries that could happen during any activity. Josh knew it was bad right away. He heard a loud, audible snap that sounded like celery when you break it in half. His leg felt like a peg, there was total instability. Josh immediately called his primary care physician, who referred him to an orthopedic surgeon. There, Josh was given a physical exam and an MRI, which revealed the tears.

 

A ligament is a tough band of fibrous tissue connecting two bones. The ACL (anterior cruciate ligament) and PCL (posterior cruciate ligament) are inside the knee joint connecting the femur (thigh bone) to the tibia (large bone of the lower leg). The ACL and PCL form an “X” inside the knee that stabilizes the knee against front-to-back and back-to-front forces.

 

ACL injuries are sprains, in which the ligament is torn or stretched beyond its normal range. Almost always, when the ACL is torn, it’s due to a sudden stop, twist, pivot or change in direction at the knee joint (like a running back, point guard, or skier), extreme hypertension of the knee (like Josh’s injury or a gymnast landing a vault), or through direct contact to the outside of the knee or lower leg. A grade III ACL injury is the most severe form of injury in which the ACL is completely torn through and the knee feels very unstable.

 

According to Health A-Z, a Harvard Health Publication, “most ACL injuries are severe Grade IIIs, with only 10% to 28% being either Grade I or Grade II. Currently, between 100,000 and 250,000 ACL injuries occur each year in the United States, affecting approximately one out of every 3,000 Americans. Although most of these injuries are related to athletic activities, especially contact sports, about 75% occur without any direct contact with another player.”

 

Prior to this injury, Josh was a generally active person. As a 35 year old, Josh participated in CrossFit 3 or 4 times per week, and also enjoyed Judo, bike riding, and golf. He had intended to participate in the Toughmudder run this February. This father of 3 was not prepared for the substantial change in lifestyle caused by this injury – not being able to carry his kids or even tie his shoes. Initially, Josh felt a sense of loss from doing the activities he once enjoyed, but his faith (Josh is a Pastor) guided him through this difficult period.

 

Immediately following the injury, Josh was placed on crutches and told to rest and heal, allowing the swelling to go down in the knee. This is common practice in Grade III tears known as RICE - Rest the joint, Ice to reduce swelling, Compress the swelling with an elastic bandage, and Elevate the injured area. Josh followed this regimen through the month of November.

 

Once the swelling and pain subsided, Josh began seeing AZOPT’s Ryann Roberts, DPT, on December 5, 2012. Throughout the next few weeks, Josh and Ryann worked on basic strength, flexibility, and range of motion. Physical therapy consisted of range of motion stretching, hamstring stretching, quadriceps strengthening, balance training and knee stability training – all with the purpose of preparing for surgery and the rehabilitation that will follow. In three weeks, Josh met all of his pre-surgery goals.

 

Post Surgical Photograph of Josh's Knee

The next step in Josh’s recovery was surgery. On January 14, 2013, Josh underwent a surgical procedure known as auto graft to repair the torn ACL. Dr. Douglas Hartzler performed the surgery, in which he uses a section of tendon taken from Josh’s hamstring to replace the torn ACL. Dr. Hartzler also shaved down the torn meniscus. The MCL healed on its own during Josh’s pre-surgical physical therapy. Currently, almost all knee reconstructions are done using arthroscopic surgery, which uses smaller incisions and causes less scarring than traditional open surgery of the past that left large scars.

 

As Josh said, “after surgery is when the real work comes in play.”

 

Two weeks after surgery, January 23, Josh was back at AZOPT with Ryann to begin the long and tedious process of rehabbing the knee allowing Josh to get back to regular life and exercise, but more importantly, reducing the risk of reinjuring the knee or injuring the other knee. At the time, Josh was icing the knee and resting. Dr. Hartsler had given the green light for easy isometric exercises with the goal of returning to light jogging in three weeks.

 

To track progress, Ryann recording these initial measurements:

 

Active Knee Flexion – 85° (normal is 120-125°)

 

Passive Knee Flexion – 98° (normal is 130-135°)

 

Passive Knee Extension: -6° from full extension

Inability to maintain full knee extension during straight leg raise

Girth measurements (circumference of knee):

• Mid patellar - R: 39.1 cm L: 44 cm


• 5 cm below patella - R: 35.7 cm L: 40.8 cm


• 5 cm above patella - R: 44.9 cm L: 46 cm

 

In his first physical therapy session with Ryann after surgery, Josh received manual therapy on a table to increase his range of motion. The plan was to begin no resistance bike pedaling at the next session if his range of motion allowed. Josh was instructed to continue using ice at home and to elevate his leg for several hours each day.

 

In the short term, 2 to 6 weeks, Josh will look to improve his range of motion to within normal limits. The goal over the next 12 weeks is for Josh to be able to walk with some light jogging while reducing the swelling by 90% and returning to light fitness activity. At physical therapy, Ryann will supervise therapeutic exercises geared to correct specific strength deficits. Ryann will also administer manual therapy including joint mobilizations and soft tissue treatments. Josh will have physical therapy two or three times each week for the next 12 weeks.

 

Josh has reasonable expectations for his recovery. He understands that each individual is on a continuum and heals differently. While there is not a general timeline for recovery, Josh fully expects to get back into all the activities he loves – CrossFit, bike riding, golf, etc. – except Judo. Josh is finished with Judo. When asked what kind of advice he would give someone in his situation, Josh said “be pragmatic. It may take a while to rehab – a month, 8 weeks, sometimes longer – to significantly heal, so be patient. And remember, suffering is good for us, it perfects our character, teaches us how to be useful and content, and helps us remember to be thankful for what we do have.”

 

We will check back on Josh in March to report his progress. In the meantime, let us know what questions you have about your injuries or rehab process. The team at AZOPT is available to answer your general or specific questions. You can ask your questions in the comments section below, or live tweet with a therapist @AZOPTTherapy.

When Should I See a Physical Therapist, and Will it Help?

As most of you know, Ryann and I are very involved in CrossFit Fury.  This blog was written for their blog, but we are posting it here, too, as it applies to all athletes and people exercising.  Whether you are involved with CrossFit, a local gym, or your own workouts in home, pain is pain, and AZOPT is here to help, regardless.  I hope you find this blog helpful, and if you have questions about specific problems you are having, leave us a comment or contact us directly.

When Should I See a Physical Therapist, and Will it Help?

By Teri Roberts, DPT

Sore? “Who Cares!”  Achy?  “No problem.”  Stiff?  “No big deal.” 

We…are Crossfitters.  If we did not like to “feel the burn,” we would still be working out at a local gym using elliptical machines and machine weights.  But when the feeling goes beyond the burn and enters into pain, or even worse – injury, how do you know if physical therapy can help?

First, let’s define physical therapy.  Physical Therapists are trained to find the biomechanical dysfunctions that cause pain and assess physical movements to make sure pain never occurs.  In other words, as highly trained healthcare professionals (most have a Doctoral degree), physical therapists will examine you and make a treatment plan that will help you with flexibility, strength, endurance, coordination, and/or balance.  First, this will help you “feel better” by reducing pain and swelling.  Then, and more importantly, physical therapy will work to increase your flexibility, strength, and endurance to ensure the injury never happens again.

Pain may be caused by weakness, tightness, or a muscular imbalance.  Sometimes pain is caused by a combination of all three.  These elements may cause inefficiencies within your workout, even if pain never occurs.  Here are a few key points to help determine your physical therapy needs:

You have no idea why something hurts

If the WOD is a 1,000 meter row and 300 air squats, we can expect your hamstrings and quadriceps to be sore.  Similarly, if the WOD is 50 kettle-ball swings and 25 pull-ups, your upper traps and lats will likely burn.  However, if the WOD is snatch and toes-to-bar, you should not feel pain in your lower back.  If you are feeling pain in a muscle group that should not be affected by the exercise, physical therapy can help determine the imbalance that may be causing that pain, and introduce you to stretches and exercises designed to eliminate the imbalance, thus ending the pain.

Pain persists longer than three days following a workout

Normally, the average person takes two or three days for sore muscles to start feeling better, especially if this person continues to stretch and workout.  Pain, or soreness, for any longer can mean an injury.  After completing a push-press workout, I felt intense pain in my lower back (an example of having no idea why something hurts).  After three days of moving, stretching, and stabilizing exercises, my pain was not subsiding.  I knew it was time to get scheduled for physical therapy, and yes, I will schedule time with my husband, Ryann, when needed.  With three days of manual physical therapy, I was feeling much better and able to complete my clean and jerk PR without an ounce of pain!

The same body part is injured twice over a few week time period

This is really a no-brainer.  By injuring the same body part twice, you are showing there is an imbalance or weakness that is causing your body to not exercise properly.  Let’s say you have hamstring stiffness a few days following tire pulls, but it goes away.  That’s great – this is what should happen.  But if the next couple times after tire pulls you have that same hamstring pain, you would be smart to have a physical therapist help identify and address the issue.  Soreness is good, it means you are working.  Pain is not, it means you are doing something wrong.  Do you really want to be in pain any longer?

The pain travels (i.e. lower back pain moves down your leg)

Pain should not travel.  If you had shoulder soreness after the rope climb and then wake up with soreness traveling down your arm, manual therapy may be warranted.  Same goes with lower back pain, it should not travel down your leg.  If this is the case, you are a great candidate for physical therapy.

You swear you are doing everything right, but changes are just not occurring

Maybe you are just not pushing yourself with weights or reps due to the fear of injuring or re-injuring yourself.  You could be compensating during lifts or technical movements because you are off-balance and unable to stabilize or move through your needed range of motion.  Physical therapy can assess these areas as well.  Physical Therapists are experts in motion who treat patients of all ages to reduce pain and improve or restore mobility and improve stability. 

While CrossFit is a physically demanding workout, it should not cause any more soreness or pain than a regular man’s workout.  Making sure you are CrossFit safe and CrossFit pain-free is a passion of Arizona Orthopedic Physical Therapy.  Let us know what you struggle with and we can perform a full body screen to see if your body is limiting your success.  Ryann is also available to meet you at the gym and observe you in action to help diagnose the issue or help develop a plan or progression to allow you to improve. 

Call us at (623) 242-6908 to schedule your FREE screen today!