Sympathetic Calf Pain After An Acl Reconstruction? (Page 1)
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In the spring of 1993, I suffered a torn acl with additional damage to my meniscus during a collegiate lacrosse game.
After the swelling had gone down in about a month, I had arthroscopic surgery to replace the acl with a portion of my patellar tendon from the same knee, as well as to remove some of the torn portions of the meniscus.
I went to physical therapy religiously in order to regain full use of my knee as soon as possible as I wanted to play lacrosse again. After several months of rehab, it became apparent that something was not right about my knee. Even after all the work that myself and the physical therapy team had done, I was still unable to fully extend my knee without experiencing extreme pain and swelling along the joint line.
The athletic trainers at the physical therapy department with which I had contact all felt that the rehab had progressed as far as it could go from their standpoint. I had completed my therapy with a minimum of atrophying of the surrounding muscles, and had done a lot of plyometric training in order to strengthen the complimentary muscles around the injury. My knee was strong, and stable, but I did not have full extension and that made it difficult to run with a normal gait.
The collegeâs physical therapy team sent me to an orthopedic surgeon at the nearby hospital affiliated with the university. Since I had gotten the surgery done by a doctor at home during the summer, this doctor had the opportunity to take a fresh look at the situation.
My new doctor ordered an additional mri and, upon looking at it, came to two conclusions:
1. There was a portion of my meniscus that had been torn during the initial trauma, but had been missed during the surgery. This fragment was keeping my knee from being able to fully extend because it was lodged within the joint itself.
2. The graft from my patellar tendon appeared to have been implanted at the wrong angle.
The new doctor recommended an additional arthroscopy to correct both of these problems. I consulted with my physical therapists, who also agreed that this was the best option. My parents agreed, so I decided to have the surgery.
The second surgery was much worse than the first. I was not sufficiently prepared for what would take place. Upon waking up, I was horrified to discover that the surgeon had taken part of the hamstring from my good leg to replace the acl in my bad one. Now I had two legs bandaged up. Further, during the surgery, I apparently suffered some muscle spasms which resulted in the tearing of my quadriceps on the acl-reconstructed knee. As if the acl reconstruction itself werenât painful enough, I also had the quad problem to contend with.
Once I was lucid enough to actually have a dialogue, I spoke with my surgeon. He said that the damage was far more extensive than heâd at first predicted and this was the reason for the additional graft harvesting on my good knee. He assured me that heâd received permission from my parents while I was anesthetized to go forward with that part of the operation, which they later confirmed.
The rehab from this second acl reconstruction went far more slowly. As with the first, I worked very hard with my therapists to rebuild the strength in my knee because I wanted to play ball again. At the end, my knee still did not extend as far as it did previously, but it did do so without pain. There was simply too much scar tissue in and around the joint to allow it to do this. I eventually discovered that my left knee (the good one) actually hyperextends a bit. Thus, by comparison, the damaged knee looked that much more like it could not extend fully.
Happily, I did make a full recovery from the surgery and went on to play my last two seasons of lacrosse (without a brace) alongside my teammates, which was where iâd wanted to be all along.
That was over 10 years ago.
Now, iâm 30 years old, out of shape, overweight and my knee is a constant source of pain and annoyance. Itâs very sensitive to changes in barometric pressure as well as sudden temperature changes. It aches all the time, but the pain is exacerbated during atmospheric changes as iâve stated.
Iâm not sure if the weight thing is a chicken or the egg situation. Did I start putting on weight when my knee began hurting to the point where simple exercise became annoying, or does my knee hurt solely because of the additional strain it bears? Both explanations seem reasonable.
Thatâs not technically, what iâm asking about, though. I included all the additional (probably superfluous) information in case there is something specific that might explain the real source of annoyance, my calf.
When my reconstructed knee aches, I get excruciating sympathetic pain and cramping in my calf. The source of the pain is so deep within my calf that itâs nearly impossible to massage. My wifeâs hands get tired long before her hands can reach the source of the pain. I would almost say it feels like tendonitis in my calf, but I canât figure out what that has to do with my knee hurting.
I saw a doctor when the pain started becoming a real problem (keeping me up at night, etc) and he basically told me that I needed to lose weight. I informed him that the cramping started before I had to start limiting my activity and thus put on weight. In fact, it was one of the major reasons I had to stop mountain biking and rollerblading because my calf would cramp up so badly when I tried either activity. He recommended some stretching exercises, but the pain originates so deep within my calf muscle that none of them felt as though they were âgetting atâ the area that was in pain. After I told him this, he became very dismissive, and I got the impression that he believed I was some kind of painkiller junkie trying to scam drugs off of him. This infuriated me, and I did not return to him for additional consultation.
That was a year ago, and my calf is hurting more and more. Iâm trying to swim and do some other activities that donât impact the calf, but the kicking action from swimming makes my knee hurt, and thus the calf does as well. Itâs getting very frustrating.
Is this a common problem? Is there something iâm overlooking? Is there something I should specifically tell a doctor to look at when describing the problem?
After the swelling had gone down in about a month, I had arthroscopic surgery to replace the acl with a portion of my patellar tendon from the same knee, as well as to remove some of the torn portions of the meniscus.
I went to physical therapy religiously in order to regain full use of my knee as soon as possible as I wanted to play lacrosse again. After several months of rehab, it became apparent that something was not right about my knee. Even after all the work that myself and the physical therapy team had done, I was still unable to fully extend my knee without experiencing extreme pain and swelling along the joint line.
The athletic trainers at the physical therapy department with which I had contact all felt that the rehab had progressed as far as it could go from their standpoint. I had completed my therapy with a minimum of atrophying of the surrounding muscles, and had done a lot of plyometric training in order to strengthen the complimentary muscles around the injury. My knee was strong, and stable, but I did not have full extension and that made it difficult to run with a normal gait.
The collegeâs physical therapy team sent me to an orthopedic surgeon at the nearby hospital affiliated with the university. Since I had gotten the surgery done by a doctor at home during the summer, this doctor had the opportunity to take a fresh look at the situation.
My new doctor ordered an additional mri and, upon looking at it, came to two conclusions:
1. There was a portion of my meniscus that had been torn during the initial trauma, but had been missed during the surgery. This fragment was keeping my knee from being able to fully extend because it was lodged within the joint itself.
2. The graft from my patellar tendon appeared to have been implanted at the wrong angle.
The new doctor recommended an additional arthroscopy to correct both of these problems. I consulted with my physical therapists, who also agreed that this was the best option. My parents agreed, so I decided to have the surgery.
The second surgery was much worse than the first. I was not sufficiently prepared for what would take place. Upon waking up, I was horrified to discover that the surgeon had taken part of the hamstring from my good leg to replace the acl in my bad one. Now I had two legs bandaged up. Further, during the surgery, I apparently suffered some muscle spasms which resulted in the tearing of my quadriceps on the acl-reconstructed knee. As if the acl reconstruction itself werenât painful enough, I also had the quad problem to contend with.
Once I was lucid enough to actually have a dialogue, I spoke with my surgeon. He said that the damage was far more extensive than heâd at first predicted and this was the reason for the additional graft harvesting on my good knee. He assured me that heâd received permission from my parents while I was anesthetized to go forward with that part of the operation, which they later confirmed.
The rehab from this second acl reconstruction went far more slowly. As with the first, I worked very hard with my therapists to rebuild the strength in my knee because I wanted to play ball again. At the end, my knee still did not extend as far as it did previously, but it did do so without pain. There was simply too much scar tissue in and around the joint to allow it to do this. I eventually discovered that my left knee (the good one) actually hyperextends a bit. Thus, by comparison, the damaged knee looked that much more like it could not extend fully.
Happily, I did make a full recovery from the surgery and went on to play my last two seasons of lacrosse (without a brace) alongside my teammates, which was where iâd wanted to be all along.
That was over 10 years ago.
Now, iâm 30 years old, out of shape, overweight and my knee is a constant source of pain and annoyance. Itâs very sensitive to changes in barometric pressure as well as sudden temperature changes. It aches all the time, but the pain is exacerbated during atmospheric changes as iâve stated.
Iâm not sure if the weight thing is a chicken or the egg situation. Did I start putting on weight when my knee began hurting to the point where simple exercise became annoying, or does my knee hurt solely because of the additional strain it bears? Both explanations seem reasonable.
Thatâs not technically, what iâm asking about, though. I included all the additional (probably superfluous) information in case there is something specific that might explain the real source of annoyance, my calf.
When my reconstructed knee aches, I get excruciating sympathetic pain and cramping in my calf. The source of the pain is so deep within my calf that itâs nearly impossible to massage. My wifeâs hands get tired long before her hands can reach the source of the pain. I would almost say it feels like tendonitis in my calf, but I canât figure out what that has to do with my knee hurting.
I saw a doctor when the pain started becoming a real problem (keeping me up at night, etc) and he basically told me that I needed to lose weight. I informed him that the cramping started before I had to start limiting my activity and thus put on weight. In fact, it was one of the major reasons I had to stop mountain biking and rollerblading because my calf would cramp up so badly when I tried either activity. He recommended some stretching exercises, but the pain originates so deep within my calf muscle that none of them felt as though they were âgetting atâ the area that was in pain. After I told him this, he became very dismissive, and I got the impression that he believed I was some kind of painkiller junkie trying to scam drugs off of him. This infuriated me, and I did not return to him for additional consultation.
That was a year ago, and my calf is hurting more and more. Iâm trying to swim and do some other activities that donât impact the calf, but the kicking action from swimming makes my knee hurt, and thus the calf does as well. Itâs getting very frustrating.
Is this a common problem? Is there something iâm overlooking? Is there something I should specifically tell a doctor to look at when describing the problem?
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First Helper Crosscheck42
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I can't offer any advice or help. My problem is different, but I hope someone with information will reply to your questions. Your summary is very well written, and informative. I often wonder if doctors ever take the time to review this forum. It would be nice if someone with the knowledge and experience could offer a little hope. Good luck.
Youngatheart
Youngatheart
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I Can Relate.....
To most,if not all of the things you have written here.I used to weight 505 lbs,had gastric bypass,now im down to 240 lbs.My knees are still an issue,every friggen day of my life,and now im sick of it.I have posted on here about total knee replacement,and thats where im at.So oct 10th is when im gettin'r dun.Am I scared? Hell yes!! But if I wait any longer,my hips are gone,ankles gone...Then what? Not to mention the pain every moment of every day.Im sick of it!! Two total knees cannot amount to the pain I have right now with the knees I have.We all come from different walks of life and we choose the paths we are on,right now.Im at the end of my rope(right now)with my knees.If things stay the same course(in your life)as they are today...You will be feeling the exact same way as I am right now.
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Calf Pain
I have had 3 acl replacements at this time. The frist 2 failed for reason such as the doc messed it up. I have now had the 3 acl and I am also experiencing calf pain and cramps. I don't remember it being so serve after the frist 2 surgeries. I told the doctor about it but they became offensive and told me the calf pain was coming from my back. I do have degenerative disk disease but take medicine already for the leg problems. The cramping in the calf of the leg is different and deeper. I have not experience this pain before and it is only in the leg with the acl replacements. How do you make you doctors believe you. I feel they think I am lying.
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Hi there! Your stories sound pretty much familiar, they think we are druggies until they have an accident then they understand what pain is and also at 1st, no, it's in your head will at 1st mine was carpal tunnel then neck, after the carpal tunnel surgeries, both left and right and two neck fusions, then back to leg and then I fell leaving me with reflex sympathetic dystrophy also known as complex regional pain syndrome and I also have degenerative disk disease and digenerative joint disease and ms, optical neuritis I seriosly doubt that I will have another surgery because of the scar tissue and arthritis unless it is a pain pump because their is just too many problems later. I lost weight due to stress and I have also heard that a gastric by-pass comes with a lot of problems but I want to wish you the best of luck with yours as their are some that do have good luck. I know that I keep trying but keep falling because I am not ready for my electric wheel chair yet but I do use a cain and a electric sit-down scooter when hubby and I and our dogs go out.
All the best to all of you!
All the best to all of you!
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Deep calf pain
I know exactly what you're talking about in regards to the very deep calf pain. It's at the upper, medial part, of the back of the calf, right? I have no idea what it is. I am now 10 months post surgery and NO ONE has been able to give me an answer. My surgeon is very dismissive about the whole thing, my pt is sick of hearing about it and just tells me at this point I just need to work through the pain. Can somebody please explain what's going on. I've seen online that many ppl have complained about it, but nobody has an answer. What's going on??
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excruciatingcalfpain,
Unfortunately doctors of 2011 don't have a Tricorder like the doctors on Star Trek. However, calf pain is very common after almost all knee injuries/surgeries of any significance. Some of the muscles that cross the knee joint posteriorly, actually move two joints. Getting their actions and interactions back in sync after injury (surgery is controlled trauma) is sometimes a problem. And sometimes, that delicate coordination is never regained fully.
The gastrocnemius muscle originates on the back of the femur and inserts on the calcaneous. Thus, it acts to flex the knee and to plantarflex the ankle. The hamstrings (though not calf muscles) insert on the back of the tibia (behind the knee) and also have two actions; hip extension and knee flexion. Other muscles that plantarflex the ankle, or aid in that action (to stand on your toes) are the soleus, plantaris, the peroneals, and the toes flexors.
One source of deep proximal calf pain, that most surgeons forget about till someone brings it up, is an injury to the plantaris. This is a very small muscle with a long tendon, which is really not needed now that we don't live in trees. It is commonly used for tendon grafts. However, I have seen it rupture, usually when the person is trying to push an extremely heavy object (like a refrigerator or a car). This can cause extreme pain in the calf, sometimes with swelling and bruising for a little while. After the initial injury, the symptoms subside and most people get back to their usual activities (most are not collegiate or elite athletes) without too much trouble. However, there are some that continue to have cramping and pain from the scar tissue that was formed when the muscle healed. Unfortunately, except for stretching, deep friction massage, and other such techniques, there is not much you can do about the scar tissue.
Also, anytime the knee is operated on, it is very important to get full extension as soon as possible. I'm sure your surgeon or therapist told you not to drape the knee over a pillow, but to elevate it straight. Your PT should also have emphasized extension right off the bat. The posterior capsule of the knee and the pesky posterior muscles can shorten and scar very quickly. If they do, you end up walking on your toes, which puts more stress on the calf muscles. Unfortunately, this can get to be a vicious cycle.
One, very rare cause of calf cramping after arthroscopic or arthroscopically assisted knee surgery is a compartment syndrome (even a subclinical one). The fluids that are used during surgery are pumped into the knee under pressure. This keeps the picture clear and the joint cavity clean of debris. This fluid can get pushed down into the calf, which is a tight fascial compartment. It's sort of like a hot dog, it can't take much fluid in it till the structures within it start to get squashed. In a full blown compartment syndrome, the muscles die due to lack of oxygen and the leg is useless. So, if you had a fairly good outcome, this did not happen to you, but, I have seen some subclinical cases where there was some substantial swelling in the calf that did cause some scar tissue. And as you probably realize, scar doesn't stretch and contract like normal muscle, and it can cause cramps easily. Unfortunately, there is not much you can do about it.
So, trying to determine exactly what is going on, is not as easy as just opening an anatomy book. It is probably a combination of things and a different combination in each patient. You can try to prevent the big problems and treat the symptoms, but medicine is not an exact science. Most people do well. Unfortunately, when you are in the 1 to 5 % that don't, well, ...
The previous people who posted will probably not answer you, since it's been over 4 years since they wrote. But, I hope you find the answer to your particular problem, or at least find a way to live with it.
Good luck.
Unfortunately doctors of 2011 don't have a Tricorder like the doctors on Star Trek. However, calf pain is very common after almost all knee injuries/surgeries of any significance. Some of the muscles that cross the knee joint posteriorly, actually move two joints. Getting their actions and interactions back in sync after injury (surgery is controlled trauma) is sometimes a problem. And sometimes, that delicate coordination is never regained fully.
The gastrocnemius muscle originates on the back of the femur and inserts on the calcaneous. Thus, it acts to flex the knee and to plantarflex the ankle. The hamstrings (though not calf muscles) insert on the back of the tibia (behind the knee) and also have two actions; hip extension and knee flexion. Other muscles that plantarflex the ankle, or aid in that action (to stand on your toes) are the soleus, plantaris, the peroneals, and the toes flexors.
One source of deep proximal calf pain, that most surgeons forget about till someone brings it up, is an injury to the plantaris. This is a very small muscle with a long tendon, which is really not needed now that we don't live in trees. It is commonly used for tendon grafts. However, I have seen it rupture, usually when the person is trying to push an extremely heavy object (like a refrigerator or a car). This can cause extreme pain in the calf, sometimes with swelling and bruising for a little while. After the initial injury, the symptoms subside and most people get back to their usual activities (most are not collegiate or elite athletes) without too much trouble. However, there are some that continue to have cramping and pain from the scar tissue that was formed when the muscle healed. Unfortunately, except for stretching, deep friction massage, and other such techniques, there is not much you can do about the scar tissue.
Also, anytime the knee is operated on, it is very important to get full extension as soon as possible. I'm sure your surgeon or therapist told you not to drape the knee over a pillow, but to elevate it straight. Your PT should also have emphasized extension right off the bat. The posterior capsule of the knee and the pesky posterior muscles can shorten and scar very quickly. If they do, you end up walking on your toes, which puts more stress on the calf muscles. Unfortunately, this can get to be a vicious cycle.
One, very rare cause of calf cramping after arthroscopic or arthroscopically assisted knee surgery is a compartment syndrome (even a subclinical one). The fluids that are used during surgery are pumped into the knee under pressure. This keeps the picture clear and the joint cavity clean of debris. This fluid can get pushed down into the calf, which is a tight fascial compartment. It's sort of like a hot dog, it can't take much fluid in it till the structures within it start to get squashed. In a full blown compartment syndrome, the muscles die due to lack of oxygen and the leg is useless. So, if you had a fairly good outcome, this did not happen to you, but, I have seen some subclinical cases where there was some substantial swelling in the calf that did cause some scar tissue. And as you probably realize, scar doesn't stretch and contract like normal muscle, and it can cause cramps easily. Unfortunately, there is not much you can do about it.
So, trying to determine exactly what is going on, is not as easy as just opening an anatomy book. It is probably a combination of things and a different combination in each patient. You can try to prevent the big problems and treat the symptoms, but medicine is not an exact science. Most people do well. Unfortunately, when you are in the 1 to 5 % that don't, well, ...
The previous people who posted will probably not answer you, since it's been over 4 years since they wrote. But, I hope you find the answer to your particular problem, or at least find a way to live with it.
Good luck.
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You're an angel
Thank you so much for your response. Everything you said makes perfect sense. I do know that my muscles are not syncing properly because I have had a constant, deep aching sensation in my left hip (left knee was operated on) that has not subsided since the surgery 10 months ago. It (hip) has been relentless and is uncomfortable to sit or lay down. I suspect that something is not right with my gait, but have tried everything in the world to fix it and get rid of the hip (or calf pain). The calf pain is constant, not on and off. And it's more like a deep ache (feels like a pulled muscle, but I can never reach it when I stretch or massage.
I have also suspected that this pain was coming from the plantaris muscle as I've spent endless hours pouring over different diagrams of the posterior calf and knee trying to pinpoint where the pain is, and each time I would end up pointing at the plantaris area.
When I had the initial injury, I was tumbling (gymnastics)and landed from about 5 ft high. As soon as I landed I heard two pops (which sounded much like a bone breaking)and immediately sat down. For the next 6 weeks I could not even walk because the pain was so unbearable. I had ACL reconstruction and meniscus repair exactly 6 weeks after the injury (which I never walked again from the injury to the surgery). Then it was 3 months until I finally was able to ween myself off the crutches and walk on my own (with a very heavy limp). I know it sounds like I was being a baby, but the pain was excruciating. I have broken many bones in my athletic career and have an extremely high tolerance for pain. I am a collegiate/elite athlete and have even placed 2nd in the JR Olympics.
I am going to explore the different possibilities that you mentioned that could be the source of the pain. I am determined to beat this injury and make a full recovery as I have done many times in the past, but as I approach the one year mark and I am still in pain every single day, it's quite discouraging.
Thank you again for your help. You have sparked a bit of faith in me and have given me hope that there is someone in this world who understand the mechanics of the leg and may be able to help me find some answers. It's terribly frustrating when the doctor ignores me and just says I don't know. Especially since I've paid over $10,000 out of pocket for this failed surgery. (There is now so much laxity during the Lachman's test that the doctor will not clear me to play sports.) The whole experience has been the worst nightmare of my life.
I have also suspected that this pain was coming from the plantaris muscle as I've spent endless hours pouring over different diagrams of the posterior calf and knee trying to pinpoint where the pain is, and each time I would end up pointing at the plantaris area.
When I had the initial injury, I was tumbling (gymnastics)and landed from about 5 ft high. As soon as I landed I heard two pops (which sounded much like a bone breaking)and immediately sat down. For the next 6 weeks I could not even walk because the pain was so unbearable. I had ACL reconstruction and meniscus repair exactly 6 weeks after the injury (which I never walked again from the injury to the surgery). Then it was 3 months until I finally was able to ween myself off the crutches and walk on my own (with a very heavy limp). I know it sounds like I was being a baby, but the pain was excruciating. I have broken many bones in my athletic career and have an extremely high tolerance for pain. I am a collegiate/elite athlete and have even placed 2nd in the JR Olympics.
I am going to explore the different possibilities that you mentioned that could be the source of the pain. I am determined to beat this injury and make a full recovery as I have done many times in the past, but as I approach the one year mark and I am still in pain every single day, it's quite discouraging.
Thank you again for your help. You have sparked a bit of faith in me and have given me hope that there is someone in this world who understand the mechanics of the leg and may be able to help me find some answers. It's terribly frustrating when the doctor ignores me and just says I don't know. Especially since I've paid over $10,000 out of pocket for this failed surgery. (There is now so much laxity during the Lachman's test that the doctor will not clear me to play sports.) The whole experience has been the worst nightmare of my life.
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Dear Gaelic,
As a doctor, I must commend you on your articulate and clear answers to people. You are doing a lot of good. I wonder if you would consider answering a question for me. I hurt my knee as a 14 year old and that was a long time ago and they put me in a cast for 6 months. I remember thinking the cast was a little too valgus, and when they took me out I was too valgus. And the tibia was rotated out a little. Almost as if I had an injury to the lateral condyle and it didn't grow as much or the mesial condyle overgrew. The knee has become steadily less stable over the years and now it is pretty bad, despite having had an ACL repair to try to give it some stability despite the capsule being pretty stretched. I think the valgus has led to the lateral meniscus taking the brunt, and now I'm bone on bone laterally but the lateral joint space still opens up when I lie down. Not as much pain as you might think, but I'm a surgeon and do pretty long surgeries, and my plantaris is getting a workout as I swivel and stand my 6' 5" frame around. Over the years I've also started to get some scoliosis due to the dynamic leg length discrepancy.
I can't play most sports or even run, but my work is my life and so that is really kind of OK, although I can't keep myself in shape except by biking. I'm 48 so maybe a little young for a total joint. My question is whether to get a resurfacing graft laterally instead of a total joint. Maybe small particle disease is less likely? Maybe there could be multiple tries to get it right without losing all my tibial plateau? If the bone wasn't ground down too much before the metal was somehow fixed to it, this might build up the lateral compartment and put me back into normal alignment. I'd like to rotate the tibia a little inward too, by placing the grafts sort of anterior on the femur and posteriorly on the tibia, althought that might change tendon lengths in the knee and mate the mesial articular surfeces differently. It might require a big violation of the capsule, and so I am worried about whether I would get a lot of fibrosis. What do you think? Anybody do this type of surgery?
As a doctor, I must commend you on your articulate and clear answers to people. You are doing a lot of good. I wonder if you would consider answering a question for me. I hurt my knee as a 14 year old and that was a long time ago and they put me in a cast for 6 months. I remember thinking the cast was a little too valgus, and when they took me out I was too valgus. And the tibia was rotated out a little. Almost as if I had an injury to the lateral condyle and it didn't grow as much or the mesial condyle overgrew. The knee has become steadily less stable over the years and now it is pretty bad, despite having had an ACL repair to try to give it some stability despite the capsule being pretty stretched. I think the valgus has led to the lateral meniscus taking the brunt, and now I'm bone on bone laterally but the lateral joint space still opens up when I lie down. Not as much pain as you might think, but I'm a surgeon and do pretty long surgeries, and my plantaris is getting a workout as I swivel and stand my 6' 5" frame around. Over the years I've also started to get some scoliosis due to the dynamic leg length discrepancy.
I can't play most sports or even run, but my work is my life and so that is really kind of OK, although I can't keep myself in shape except by biking. I'm 48 so maybe a little young for a total joint. My question is whether to get a resurfacing graft laterally instead of a total joint. Maybe small particle disease is less likely? Maybe there could be multiple tries to get it right without losing all my tibial plateau? If the bone wasn't ground down too much before the metal was somehow fixed to it, this might build up the lateral compartment and put me back into normal alignment. I'd like to rotate the tibia a little inward too, by placing the grafts sort of anterior on the femur and posteriorly on the tibia, althought that might change tendon lengths in the knee and mate the mesial articular surfeces differently. It might require a big violation of the capsule, and so I am worried about whether I would get a lot of fibrosis. What do you think? Anybody do this type of surgery?
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I answer this a while ago, but the answer was put on at the end of the thread, so I do not know if you got it or not. So, I thought I would copy it up here, under your note:
noh,
Thank you for the kind comments. I know all too well, how those long cases, especially if you have to wear lead, can take a toll on the back and lower extremities.
You have certainly had a long tough time with your knee. Valgus deformities can really take a toll on a joint. The 11th Commandment of orthopedics is "Thou shalt not valgus!"
The femoral condyles can also have a type of dysplasia, or underdevelopment, of just one condyle. It is not common, but has been noted in the literature as a cause of instability and abnormal wear patterns of the articular and meniscal cartilages. But, that is what you have to work with.
You are not actually too young for a total, as the age is tending downwards. Patients are not wanting to wait anymore and are really putting pressure on the surgeons to do the totals at younger and younger ages.
However, as you know, the prosthetic implants only last for about 15 years, give or take a few years. That is why orthopedic surgeons like for the patients to wait as long as possible, so that the joint put in will last the rest of the patient's lifetime. And, patients tend to be more sedentary later in life. Many younger patients do not want to give up their active lifestyle, and that can significantly impact the life of the prosthesis. But, if you are careful, you could probably have a total last the rest of your life.
Patients also don't always understand the ramifications of having to have a replacement redone. They really don't see the problems that can arise from the scar tissue and loss of bone stock. Every time the replacement has to be redone, the procedure is harder and the risks/complications are higher. However, as you are well aware, it is hard for patients to get the abstract concepts of something happening down the road, when all they can think about is the pain in their joint. But, anyways...I digress.
Resurfacing techniques have been done for quite a while in the hip, and now, are also done in the shoulder. These procedures are truly resurfacing, as they replace only the articular cartilage and subchondral bone on one side and leave the other side of the joint alone.
In the knee, "resurfacing" techniques are actually unicompartmental replacements. These are great procedures for patients who have unicompartmental disease. They require a lot less dissection and can many times be done through a key hole incision. The recovery is usually a lot easier and much quicker.
To have a uni done, the patient has to have normal, or nearly normal, articular cartilage in the other compartments. Often, a patient only has to have the uni done, and that takes care of the problem. But, the procedure does not burn any bridges, so if one has to have a total joint in the future, it can be converted.
So, as you know, you need to find a total joint surgeon who is well versed in unicompartmental procedures. You need someone who is very experienced, as experience is key in these procedures. You want someone who does a lot of these, not someone who does one a month or less. Then sit down and discuss your options. You have had some significant problems and surgeries in your knee, so it is definitely not "normal". It may take some extra pre-op planning and maybe even a custom prosthesis. But, the consulting surgeon should be able to give you all your options after reviewing your studies (plain x-rays, MRI (for evaluation of the cartilage in the knee), and full length weight bearing films of the lower extremities for evaluation of overall limb alignment) and examining your knee.
Good luck. I hope you find a good solution to your knee problems. Surgery isn't as fun, when your back and knees hurt. Again, good luck.
noh,
Thank you for the kind comments. I know all too well, how those long cases, especially if you have to wear lead, can take a toll on the back and lower extremities.
You have certainly had a long tough time with your knee. Valgus deformities can really take a toll on a joint. The 11th Commandment of orthopedics is "Thou shalt not valgus!"
The femoral condyles can also have a type of dysplasia, or underdevelopment, of just one condyle. It is not common, but has been noted in the literature as a cause of instability and abnormal wear patterns of the articular and meniscal cartilages. But, that is what you have to work with.
You are not actually too young for a total, as the age is tending downwards. Patients are not wanting to wait anymore and are really putting pressure on the surgeons to do the totals at younger and younger ages.
However, as you know, the prosthetic implants only last for about 15 years, give or take a few years. That is why orthopedic surgeons like for the patients to wait as long as possible, so that the joint put in will last the rest of the patient's lifetime. And, patients tend to be more sedentary later in life. Many younger patients do not want to give up their active lifestyle, and that can significantly impact the life of the prosthesis. But, if you are careful, you could probably have a total last the rest of your life.
Patients also don't always understand the ramifications of having to have a replacement redone. They really don't see the problems that can arise from the scar tissue and loss of bone stock. Every time the replacement has to be redone, the procedure is harder and the risks/complications are higher. However, as you are well aware, it is hard for patients to get the abstract concepts of something happening down the road, when all they can think about is the pain in their joint. But, anyways...I digress.
Resurfacing techniques have been done for quite a while in the hip, and now, are also done in the shoulder. These procedures are truly resurfacing, as they replace only the articular cartilage and subchondral bone on one side and leave the other side of the joint alone.
In the knee, "resurfacing" techniques are actually unicompartmental replacements. These are great procedures for patients who have unicompartmental disease. They require a lot less dissection and can many times be done through a key hole incision. The recovery is usually a lot easier and much quicker.
To have a uni done, the patient has to have normal, or nearly normal, articular cartilage in the other compartments. Often, a patient only has to have the uni done, and that takes care of the problem. But, the procedure does not burn any bridges, so if one has to have a total joint in the future, it can be converted.
So, as you know, you need to find a total joint surgeon who is well versed in unicompartmental procedures. You need someone who is very experienced, as experience is key in these procedures. You want someone who does a lot of these, not someone who does one a month or less. Then sit down and discuss your options. You have had some significant problems and surgeries in your knee, so it is definitely not "normal". It may take some extra pre-op planning and maybe even a custom prosthesis. But, the consulting surgeon should be able to give you all your options after reviewing your studies (plain x-rays, MRI (for evaluation of the cartilage in the knee), and full length weight bearing films of the lower extremities for evaluation of overall limb alignment) and examining your knee.
Good luck. I hope you find a good solution to your knee problems. Surgery isn't as fun, when your back and knees hurt. Again, good luck.
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excruciatingcalfpain,
Sorry about your troubles. We often get a skewed idea of how ACL surgeries actually do. We all hear about the pro athlete who gets back to playing within a year. But, the press doesn't mention the staff of therapist he has or that the knee is shot up with marcaine and cortisone before each game. (I do remember that Edgerin James of the Indy Colts tore his ACL, but just could not get back for two seasons. I was impressed that he wasn't pushed to stress the knee when he didn't feel safe yet.) When one makes hundreds of thousands of dollars a game, the rules are different. Unfortunately, many college and elite athletes are rushed to reconstruction. It has been shown that if the patient rehabilitates the knee first, to where there is no swelling, minimal pain, and the strength is at least 90% of the uninjured leg, he/she does the best. But, because of schedules and other restraints the athlete is often pushed to surgery way before he/she is ready. This is also a set up for a disaster call arthrofibrosis.
It's too bad that your knee is still unstable. Hopefully, your current surgeon has determined what's the underlying cause: improper graft placement, too long of a graft, torn/stretched graft, etc. If you are going to have it redone, be sure that you have rehabbed it to the max before surgery.
Unfortunately, schedules get so busy, that surgeons forget that every patient is different and don't follow the guidelines in the books we study for boards. For some reason, they get irritated at patients that aren't "on track". They even take it as an affront, personally, as if the patient was doing it to say they were a bad surgeon. Yea, it's easier to take care of the patient that was "read the textbook" and has no problems. But, these are also the doctors that have made the profession a "business", so what do they expect?
Hope you find a surgeon and therapist that are good "fits" for you. You have a long life ahead of you, even if you do not get back to competitive athletics, you will want to play with your kids and grandkids. Good luck.
Sorry about your troubles. We often get a skewed idea of how ACL surgeries actually do. We all hear about the pro athlete who gets back to playing within a year. But, the press doesn't mention the staff of therapist he has or that the knee is shot up with marcaine and cortisone before each game. (I do remember that Edgerin James of the Indy Colts tore his ACL, but just could not get back for two seasons. I was impressed that he wasn't pushed to stress the knee when he didn't feel safe yet.) When one makes hundreds of thousands of dollars a game, the rules are different. Unfortunately, many college and elite athletes are rushed to reconstruction. It has been shown that if the patient rehabilitates the knee first, to where there is no swelling, minimal pain, and the strength is at least 90% of the uninjured leg, he/she does the best. But, because of schedules and other restraints the athlete is often pushed to surgery way before he/she is ready. This is also a set up for a disaster call arthrofibrosis.
It's too bad that your knee is still unstable. Hopefully, your current surgeon has determined what's the underlying cause: improper graft placement, too long of a graft, torn/stretched graft, etc. If you are going to have it redone, be sure that you have rehabbed it to the max before surgery.
Unfortunately, schedules get so busy, that surgeons forget that every patient is different and don't follow the guidelines in the books we study for boards. For some reason, they get irritated at patients that aren't "on track". They even take it as an affront, personally, as if the patient was doing it to say they were a bad surgeon. Yea, it's easier to take care of the patient that was "read the textbook" and has no problems. But, these are also the doctors that have made the profession a "business", so what do they expect?
Hope you find a surgeon and therapist that are good "fits" for you. You have a long life ahead of you, even if you do not get back to competitive athletics, you will want to play with your kids and grandkids. Good luck.
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A Miracle happened yesterday
Hi,
So today and yesterday have been the happiest days of my life. Yesterday I saw a new OS and he gave me a shot (cortisone I think) in my knee and it was like MAGIC! Within 10 minutes I felt instant relief from the pain. It's the most incredible thing I've ever experienced. My knee feels fantastic! There is NO PAIN!! My knee seriously feels brand new, and the calf pain subsided too. I am in total shock of how I went from being in so much pain constantly to having no pain at all. I know it won't last forever but I pray it does. Should I be at all worried about causing more damage to the knee because I don't feel the pain? Hmm...
I would like to start jogging and doing my physical therapy again to help rebuild the muscles. I hadn't been doing it because the pain has been so unbearable (though I regularly lift girls up in stunts 3-4 times a week. I instruct competitive cheerleading. I"m just hoping that when the shot does wear off that I'm not in 10X more pain than I was before.
Thank you again for your help. You have been amazing and I am so thankful for your posts.
So today and yesterday have been the happiest days of my life. Yesterday I saw a new OS and he gave me a shot (cortisone I think) in my knee and it was like MAGIC! Within 10 minutes I felt instant relief from the pain. It's the most incredible thing I've ever experienced. My knee feels fantastic! There is NO PAIN!! My knee seriously feels brand new, and the calf pain subsided too. I am in total shock of how I went from being in so much pain constantly to having no pain at all. I know it won't last forever but I pray it does. Should I be at all worried about causing more damage to the knee because I don't feel the pain? Hmm...
I would like to start jogging and doing my physical therapy again to help rebuild the muscles. I hadn't been doing it because the pain has been so unbearable (though I regularly lift girls up in stunts 3-4 times a week. I instruct competitive cheerleading. I"m just hoping that when the shot does wear off that I'm not in 10X more pain than I was before.
Thank you again for your help. You have been amazing and I am so thankful for your posts.
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excruciatingcalfpain,
So glad to hear about the relief you have obtained. I'm also glad it lasted more than a few hours. Often, the local anesthetic (usually marcaine, that is injected with the cortisone) takes the pain away, while it is working, but the cortisone doesn't kick in, so the pain comes back in a few hours.
Another area that can cause pain behind the knee, in the proximal calf, is the posterior capsule. It attaches just below the posterior lip of the tibial plateau. Often after surgery, swelling and distension causes inflammation of the capsule and it can contract some. Then, when extending (or slightly hyperextending) the knee, its attachment gets pulled, setting up sort of an enthesopathy. The cortisone should help that.
Hopefully, the cortisone shot will be a one time event. Cortisone was used very willy-nilly in the past and it has been found to be very hard on the hyaline (or articular) cartilage. It's one of those substances that really puts the whammy on inflammation, but sometimes doesn't know when to stop. Therefore, currently, it should be used judiciously in joints that have essentially normal articular cartilage. In the elderly, who have basically bone on bone arthritis, cortisone can be used as much as wanted, usually till the person has a TKR.
Glad you have gotten back to something you love.
Good luck.
So glad to hear about the relief you have obtained. I'm also glad it lasted more than a few hours. Often, the local anesthetic (usually marcaine, that is injected with the cortisone) takes the pain away, while it is working, but the cortisone doesn't kick in, so the pain comes back in a few hours.
Another area that can cause pain behind the knee, in the proximal calf, is the posterior capsule. It attaches just below the posterior lip of the tibial plateau. Often after surgery, swelling and distension causes inflammation of the capsule and it can contract some. Then, when extending (or slightly hyperextending) the knee, its attachment gets pulled, setting up sort of an enthesopathy. The cortisone should help that.
Hopefully, the cortisone shot will be a one time event. Cortisone was used very willy-nilly in the past and it has been found to be very hard on the hyaline (or articular) cartilage. It's one of those substances that really puts the whammy on inflammation, but sometimes doesn't know when to stop. Therefore, currently, it should be used judiciously in joints that have essentially normal articular cartilage. In the elderly, who have basically bone on bone arthritis, cortisone can be used as much as wanted, usually till the person has a TKR.
Glad you have gotten back to something you love.
Good luck.
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Gaelic, I had an ACL reconstruction using an allograft 4 weeks ago. I am feeling pretty good and can straighten my leg completely and at 3 weeks could bend it 125 degrees. The swelling has gone down considerably in the last 4 days. Since then, I am noticing a strange restriction or misalignment of the joint if I extend it fully and leave it that way for a minute or so. When I bend it its as though it is not properly together. I also notice it as I walk. Sometimes when I straighten my leg out to take a step, it feels like something moves and then pops into place. Sorry for the horrible description but I don't know how else to describe it. Is this normal?
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450dakota,
I'm trying to picture it in my mind's eye. There are a lot of things that could possibly cause your symptoms.
It could be from something as simple as some swollen synovial tissue getting caught in between the patella (kneecap) and the femur (thighbone). The patella would then snap as it goes into extension, into its groove on the femur.
There is a little "play" in the normal knee joint. There is also a movement called the "screw home mechanism" when the knee goes into full extension, the tibia rotates slightly on the femur. If there is a little soft tissue interposed, it may pop when the knee fully extends. This may be excentuated by the weakness of the muscles around the joint after surgery.
Then there are more serious problems also. Your graft may not have been put in quite correctly, or it could have stretched, and now that the swelling has gone down, the residual instability is showing up. Or, one of the menisci has a tear in it and it is catching in the joint.
The only way to know for sure, is to have the knee examined by your surgeon. In most cases it is just a phase the knee goes through while healing. But, if it is something more significant, the surgeon will want to know about it also.
Good luck in your future rehab.
I'm trying to picture it in my mind's eye. There are a lot of things that could possibly cause your symptoms.
It could be from something as simple as some swollen synovial tissue getting caught in between the patella (kneecap) and the femur (thighbone). The patella would then snap as it goes into extension, into its groove on the femur.
There is a little "play" in the normal knee joint. There is also a movement called the "screw home mechanism" when the knee goes into full extension, the tibia rotates slightly on the femur. If there is a little soft tissue interposed, it may pop when the knee fully extends. This may be excentuated by the weakness of the muscles around the joint after surgery.
Then there are more serious problems also. Your graft may not have been put in quite correctly, or it could have stretched, and now that the swelling has gone down, the residual instability is showing up. Or, one of the menisci has a tear in it and it is catching in the joint.
The only way to know for sure, is to have the knee examined by your surgeon. In most cases it is just a phase the knee goes through while healing. But, if it is something more significant, the surgeon will want to know about it also.
Good luck in your future rehab.
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I hope it is more of your first description than the graft problems you describe. I don't really want to go through that again. I did have some of my meniscus trimmed. I am in physio 2 days a week and do exercises everyday based on what the therapist tells me to do. I am scheduled to see my surgeon in about a month.
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450dakota,
Most of the time it is something simple. Continue with your therapy and get your knee as strong as possible. Often, as your strength increases, some of these little snaps and pops go away.
If it continues, just be sure you can describe it or show it to your surgeon. It's a whole heck of a lot easier to figure out that way!
Keep up the hard work. Good luck.
Most of the time it is something simple. Continue with your therapy and get your knee as strong as possible. Often, as your strength increases, some of these little snaps and pops go away.
If it continues, just be sure you can describe it or show it to your surgeon. It's a whole heck of a lot easier to figure out that way!
Keep up the hard work. Good luck.
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Orthovisc shots
Gaelic,
Ok, so I wanted to share a few things with you. Well, the miracle injection that I had was not cortisone like I initially thought. It was actually Orthovisc and it has been incredible! Unfortunately, as expected, it did not last forever. After 4 days the pain slowly started coming back (first in the uppercalf behind the tibia, then under the patella, then the incision site, etc) By 7 days, it was pretty much back to normal (but still better than before the shot).
Two weeks later, I had my second injection. While it did relieve the pain under the patella, it was nothing like the first shot and did not help at all with the calf thing or the pain in the medial part of my knee. (Which btw, I had an MRI done recently and they found that there is a longitudinal tear in the meniscus that was not fixed during surgery. While they did repair one tear in my meniscus, they apparently missed or didn't see the other one). I was a little discouraged after the second shot because it was nowhere near as good as the first.
Then I had the third shot a week ago, and this time it was great again. I feel excellent, very little pain except when I really push it hard. This one was much more similar to the relief I felt after the first shot. I will finish out the injections (two more spaced two weeks apart) and they are supposed to last up to 6 months so we'll see.
The doctor told me that he aimed the second injection to target the pain under the knee cap so that's why I didn't feel relief in the calf and medial area. He didn't go deep enough. Before the third injection, I told him to go all the way so that we target that calf area and medial section. I guess he did, because I felt relief. I am just ecstatic about this whole thing. I wonder why they didn't try this before, instead they had me on a daily high dose of oxycodone for 6 months straight!
In the last month, I have been able to run, cut, jump, and land aggressively with barely any pain. I do have to take it easy though because one out of every 10 jumps I will feel movement going on in my knee when I land.
Ok, so I wanted to share a few things with you. Well, the miracle injection that I had was not cortisone like I initially thought. It was actually Orthovisc and it has been incredible! Unfortunately, as expected, it did not last forever. After 4 days the pain slowly started coming back (first in the uppercalf behind the tibia, then under the patella, then the incision site, etc) By 7 days, it was pretty much back to normal (but still better than before the shot).
Two weeks later, I had my second injection. While it did relieve the pain under the patella, it was nothing like the first shot and did not help at all with the calf thing or the pain in the medial part of my knee. (Which btw, I had an MRI done recently and they found that there is a longitudinal tear in the meniscus that was not fixed during surgery. While they did repair one tear in my meniscus, they apparently missed or didn't see the other one). I was a little discouraged after the second shot because it was nowhere near as good as the first.
Then I had the third shot a week ago, and this time it was great again. I feel excellent, very little pain except when I really push it hard. This one was much more similar to the relief I felt after the first shot. I will finish out the injections (two more spaced two weeks apart) and they are supposed to last up to 6 months so we'll see.
The doctor told me that he aimed the second injection to target the pain under the knee cap so that's why I didn't feel relief in the calf and medial area. He didn't go deep enough. Before the third injection, I told him to go all the way so that we target that calf area and medial section. I guess he did, because I felt relief. I am just ecstatic about this whole thing. I wonder why they didn't try this before, instead they had me on a daily high dose of oxycodone for 6 months straight!
In the last month, I have been able to run, cut, jump, and land aggressively with barely any pain. I do have to take it easy though because one out of every 10 jumps I will feel movement going on in my knee when I land.
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excruciating,
Yea, it's too bad that some surgeons get their practices so busy that they don't have time to sit down and listen to the patient. If they would just remember back to medical school, in the first examination class, they are always told that 90% of the diagnosis is the history, listen to the patient. The history will almost always tell you what's wrong. The exam should just confirm what the history told you.
Hopefully the longitudinal tear won't cause you any problems, as they rarely flip into the joint like radial (or parrot beak) tears do. If you did sustain a severe twisting injury, the longitudinal tear could theoretically get squeezed and pushed so that it becomes a buckethandle tear. But, that severe of a twist would probably get your ACL too.
The Orthovisc (or Synvisc or Hyalgan) is supposed to work for 6 months. Of course, the research was done in elderly osteoarthritic patients. So, how it relates to young active patients is still not too well known. Hopefully, you will get the 6 months or more of relief. While the knee is feeling well is a good time to build up strength. A strong knee is vital in an ACL reconstruction (especially if it has a little play in it). You can strengthen the muscles without abusing the joint, just ask your PT for some ideas.
Good luck.
Yea, it's too bad that some surgeons get their practices so busy that they don't have time to sit down and listen to the patient. If they would just remember back to medical school, in the first examination class, they are always told that 90% of the diagnosis is the history, listen to the patient. The history will almost always tell you what's wrong. The exam should just confirm what the history told you.
Hopefully the longitudinal tear won't cause you any problems, as they rarely flip into the joint like radial (or parrot beak) tears do. If you did sustain a severe twisting injury, the longitudinal tear could theoretically get squeezed and pushed so that it becomes a buckethandle tear. But, that severe of a twist would probably get your ACL too.
The Orthovisc (or Synvisc or Hyalgan) is supposed to work for 6 months. Of course, the research was done in elderly osteoarthritic patients. So, how it relates to young active patients is still not too well known. Hopefully, you will get the 6 months or more of relief. While the knee is feeling well is a good time to build up strength. A strong knee is vital in an ACL reconstruction (especially if it has a little play in it). You can strengthen the muscles without abusing the joint, just ask your PT for some ideas.
Good luck.
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Agreed! I have been taking full advantage of the reduction in pain and doing much strengthening that I was unable to do before because the pain was so severe. The hamstring exercises definitely cause the most pain (in that calf area behind the tibia). Even with the shot, the hamstring exercises really aggravate that area and once that happens it usually will not go away until the next shot.
My quads have filled out and feel very strong, and the knee itself feels strong, but I know my hamstrings are weak in that leg. I get very nervous about that bc I worry about hyper extending the knee again (that's how I tore the ACL). There's barely any resistance when I extend my leg all the way (my hamstrings are way overstretched bc of the flexibility required in my sport), and there's almost no resistance even in a full left leg split.
Thanks for all of your support. I will keep updating the progress.
My quads have filled out and feel very strong, and the knee itself feels strong, but I know my hamstrings are weak in that leg. I get very nervous about that bc I worry about hyper extending the knee again (that's how I tore the ACL). There's barely any resistance when I extend my leg all the way (my hamstrings are way overstretched bc of the flexibility required in my sport), and there's almost no resistance even in a full left leg split.
Thanks for all of your support. I will keep updating the progress.
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Calf Cramps
I had ACL replacement via allograft and partial meniscus removal at the end of February. By the end of April I was doing pretty good except for the swelling in my ankle. We gave it some time , but it only grew and became painful. I received a cortisone injection a month ago. I have had calf cramps since the beginning of June. Blood work show I'm not lacking in anything. the ankle swelling never went away and has preceded down my foot. The leg cramps have also become worse. An MRI of my ankle is scheduled for next week. Anyone hear of any issues resultsing in calf cramping and ankle swelling as a result of ACL surgery 5 months post op?
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calf pain from the knee
It is important to remember that the problem is not always where the pain is! (For example, a heart attack may cause arm pain - there is nothing wrong with the arm.) This is called referred pain. Knee problems can cause calf pain - the calf itself is entirely OK.
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Well I'm releved that I'm not the only one suffering after surgery. I am 18 months post op and the cramps in my calf are horrendous! I wish I could offer you a solution, but I'm looking got one too.
Good Luck!
Good Luck!
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noh,
Thank you for the kind comments. I know all too well, how those long cases, especially if you have to wear lead, can take a toll on the back and lower extremities.
You have certainly had a long tough time with your knee. Valgus deformities can really take a toll on a joint. The 11th Commandment of orthopedics is "Thou shalt not valgus!"
The femoral condyles can also have a type of dysplasia, or underdevelopment, of just one condyle. It is not common, but has been noted in the literature as a cause of instability and abnormal wear patterns of the articular and meniscal cartilages. But, that is what you have to work with.
You are not actually too young for a total, as the age is tending downwards. Patients are not wanting to wait anymore and are really putting pressure on the surgeons to do the totals at younger and younger ages.
However, as you know, the prosthetic implants only last for about 15 years, give or take a few years. That is why orthopedic surgeons like for the patients to wait as long as possible, so that the joint put in will last the rest of the patient's lifetime. And, patients tend to be more sedentary later in life. Many younger patients do not want to give up their active lifestyle, and that can significantly impact the life of the prosthesis. But, if you are careful, you could probably have a total last the rest of your life.
Patients also don't always understand the ramifications of having to have a replacement redone. They really don't see the problems that can arise from the scar tissue and loss of bone stock. Every time the replacement has to be redone, the procedure is harder and the risks/complications are higher. However, as you are well aware, it is hard for patients to get the abstract concepts of something happening down the road, when all they can think about is the pain in their joint. But, anyways...I digress.
Resurfacing techniques have been done for quite a while in the hip, and now, are also done in the shoulder. These procedures are truly resurfacing, as they replace only the articular cartilage and subchondral bone on one side and leave the other side of the joint alone.
In the knee, "resurfacing" techniques are actually unicompartmental replacements. These are great procedures for patients who have unicompartmental disease. They require a lot less dissection and can many times be done through a key hole incision. The recovery is usually a lot easier and much quicker.
To have a uni done, the patient has to have normal, or nearly normal, articular cartilage in the other compartments. Often, a patient only has to have the uni done, and that takes care of the problem. But, the procedure does not burn any bridges, so if one has to have a total joint in the future, it can be converted.
So, as you know, you need to find a total joint surgeon who is well versed in unicompartmental procedures. You need someone who is very experienced, as experience is key in these procedures. You want someone who does a lot of these, not someone who does one a month or less. Then sit down and discuss your options. You have had some significant problems and surgeries in your knee, so it is definitely not "normal". It may take some extra pre-op planning and maybe even a custom prosthesis. But, the consulting surgeon should be able to give you all your options after reviewing your studies (plain x-rays, MRI (for evaluation of the cartilage in the knee), and full length weight bearing films of the lower extremities for evaluation of overall limb alignment) and examining your knee.
Good luck. I hope you find a good solution to your knee problems. Surgery isn't as fun, when your back and knees hurt. Again, good luck.
Thank you for the kind comments. I know all too well, how those long cases, especially if you have to wear lead, can take a toll on the back and lower extremities.
You have certainly had a long tough time with your knee. Valgus deformities can really take a toll on a joint. The 11th Commandment of orthopedics is "Thou shalt not valgus!"
The femoral condyles can also have a type of dysplasia, or underdevelopment, of just one condyle. It is not common, but has been noted in the literature as a cause of instability and abnormal wear patterns of the articular and meniscal cartilages. But, that is what you have to work with.
You are not actually too young for a total, as the age is tending downwards. Patients are not wanting to wait anymore and are really putting pressure on the surgeons to do the totals at younger and younger ages.
However, as you know, the prosthetic implants only last for about 15 years, give or take a few years. That is why orthopedic surgeons like for the patients to wait as long as possible, so that the joint put in will last the rest of the patient's lifetime. And, patients tend to be more sedentary later in life. Many younger patients do not want to give up their active lifestyle, and that can significantly impact the life of the prosthesis. But, if you are careful, you could probably have a total last the rest of your life.
Patients also don't always understand the ramifications of having to have a replacement redone. They really don't see the problems that can arise from the scar tissue and loss of bone stock. Every time the replacement has to be redone, the procedure is harder and the risks/complications are higher. However, as you are well aware, it is hard for patients to get the abstract concepts of something happening down the road, when all they can think about is the pain in their joint. But, anyways...I digress.
Resurfacing techniques have been done for quite a while in the hip, and now, are also done in the shoulder. These procedures are truly resurfacing, as they replace only the articular cartilage and subchondral bone on one side and leave the other side of the joint alone.
In the knee, "resurfacing" techniques are actually unicompartmental replacements. These are great procedures for patients who have unicompartmental disease. They require a lot less dissection and can many times be done through a key hole incision. The recovery is usually a lot easier and much quicker.
To have a uni done, the patient has to have normal, or nearly normal, articular cartilage in the other compartments. Often, a patient only has to have the uni done, and that takes care of the problem. But, the procedure does not burn any bridges, so if one has to have a total joint in the future, it can be converted.
So, as you know, you need to find a total joint surgeon who is well versed in unicompartmental procedures. You need someone who is very experienced, as experience is key in these procedures. You want someone who does a lot of these, not someone who does one a month or less. Then sit down and discuss your options. You have had some significant problems and surgeries in your knee, so it is definitely not "normal". It may take some extra pre-op planning and maybe even a custom prosthesis. But, the consulting surgeon should be able to give you all your options after reviewing your studies (plain x-rays, MRI (for evaluation of the cartilage in the knee), and full length weight bearing films of the lower extremities for evaluation of overall limb alignment) and examining your knee.
Good luck. I hope you find a good solution to your knee problems. Surgery isn't as fun, when your back and knees hurt. Again, good luck.
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knee cramping
I am a massage therapist with a client who presents the same deep cramping after acl surgery. So far my stretching hasn't been enough for him. I am also working on cross-fibre friction to break up the significant scar tissue behind his medial knee. I worry about this because for us, it's an endangerment site, but the tissue is so very hard that I doubt I could do any damage. Does this also mean I won't be doing any good? What is the best thing for me to do or to advise him to do?
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stronghands,
This is a very difficult problem to deal with after an ACL reconstruction. And, it is not that well known. I don't think I have ever heard a sportsmedicine orthopedic surgeon talk about it, or heard any lectures given on it at any conventions. I did a literature search on the topic on the internet, and found a couple of article that state that a flexion contracture can cause muscle cramps in the calf, but I also found several messages and several different forums, all from ACL patients with calf cramping. I'm beginning to wonder if this is something that the surgeons need to study. I'm not sure of the actual incidence for this problem. But, it might be a good study for a surgeon and therapist.
Anyways, to your problem. If the patient is still in the early post-op period you have a better chance of helping with the problem. If the patient does not have full extension of the knee, that needs to be corrected.
But, besides the stretching and friction massage, there is not a whole lot that can be done for the problem. It can take quite a while for scar to mature and soft.
If it can be shown that the posterior capsule has contracted and is the main problem, then arthroscopic lysis of adhesions, with immediate post-op CPM or ROM might help.
Another option, if the cramping is really significant in interfering with the rehab, would be the use of a tiny amount of Botox. But, it cannot be a lot, or it will interfere with the regaining of strength.
Also, heating up the tissues before stretching (warm tissues are more pliable) may help.
If the patient has full knee extension, and you have max'ed out the stretching and friction massage, then you may need to speak with the patient's surgeon about the problem. Especially if it is interfering with the rehab program.
Wishing you the best. Good luck.
This is a very difficult problem to deal with after an ACL reconstruction. And, it is not that well known. I don't think I have ever heard a sportsmedicine orthopedic surgeon talk about it, or heard any lectures given on it at any conventions. I did a literature search on the topic on the internet, and found a couple of article that state that a flexion contracture can cause muscle cramps in the calf, but I also found several messages and several different forums, all from ACL patients with calf cramping. I'm beginning to wonder if this is something that the surgeons need to study. I'm not sure of the actual incidence for this problem. But, it might be a good study for a surgeon and therapist.
Anyways, to your problem. If the patient is still in the early post-op period you have a better chance of helping with the problem. If the patient does not have full extension of the knee, that needs to be corrected.
But, besides the stretching and friction massage, there is not a whole lot that can be done for the problem. It can take quite a while for scar to mature and soft.
If it can be shown that the posterior capsule has contracted and is the main problem, then arthroscopic lysis of adhesions, with immediate post-op CPM or ROM might help.
Another option, if the cramping is really significant in interfering with the rehab, would be the use of a tiny amount of Botox. But, it cannot be a lot, or it will interfere with the regaining of strength.
Also, heating up the tissues before stretching (warm tissues are more pliable) may help.
If the patient has full knee extension, and you have max'ed out the stretching and friction massage, then you may need to speak with the patient's surgeon about the problem. Especially if it is interfering with the rehab program.
Wishing you the best. Good luck.
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Pain 1.5 yrs after ACL Surgery
Hello,
I am new to this forum, but after reading the posts by “excruciatingcalfpain” and gaelic, I feel I have finally found someone who understands my pain (literally and figuratively!).
I had an ACL repair (patellar tendon) and lateral meniscus clean up after a tennis injury in 2010. No complications after surgery, and I did 4 months of PT. I have relatively normal flexion and extension. I have recently (in the past 6 months) been experiencing pain in my leg. The pain is a strong throbbing ache, and I cannot pinpoint exactly where it is coming from. The pain seems to be worst when I have my knee fully extended in a resting position. I feel the pain from my lower calf, behind my knee and up into my hip.
I was cleared to return to full activity 9 months after surgery and have returned to playing tennis (with a brace). I have sharp pains on the lateral side of my knee when I stop quickly or bear weight stretching for a ball.
Personally, I am more worried about the aching pain felt throughout my leg, as opposed to the acute pain on the lateral side. I have been back to my OS, but he dismissed my concerns and said that it is normal to have pain after this type of surgery, often for the rest of your life. I have an appointment with another doctor in a week, but wanted to know if anyone had any thoughts on what it might be. Any help would be greatly appreciated!
Thanks!
I am new to this forum, but after reading the posts by “excruciatingcalfpain” and gaelic, I feel I have finally found someone who understands my pain (literally and figuratively!).
I had an ACL repair (patellar tendon) and lateral meniscus clean up after a tennis injury in 2010. No complications after surgery, and I did 4 months of PT. I have relatively normal flexion and extension. I have recently (in the past 6 months) been experiencing pain in my leg. The pain is a strong throbbing ache, and I cannot pinpoint exactly where it is coming from. The pain seems to be worst when I have my knee fully extended in a resting position. I feel the pain from my lower calf, behind my knee and up into my hip.
I was cleared to return to full activity 9 months after surgery and have returned to playing tennis (with a brace). I have sharp pains on the lateral side of my knee when I stop quickly or bear weight stretching for a ball.
Personally, I am more worried about the aching pain felt throughout my leg, as opposed to the acute pain on the lateral side. I have been back to my OS, but he dismissed my concerns and said that it is normal to have pain after this type of surgery, often for the rest of your life. I have an appointment with another doctor in a week, but wanted to know if anyone had any thoughts on what it might be. Any help would be greatly appreciated!
Thanks!
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Calf pain!
Hello,
I just tore the ACL and meniscus two weeks ago, and am still a couple weeks out from the surgery to repair them. My knee is still fairly swollen, I can only bend it about halfway, but most excruciatingly I am experiencing a constant strong deep aching pain inside my calf, radiating downwards. It is constant, and almost impossible to ignore. It is much more painful than the knee itself, and is making it difficult to walk normally, or at sometimes all. Has anyone else out there had this kind of experience? And if so, do you know why this is happening? And can I expect some relief soon, or will I just have to tough it out until the surgery? I don’t have any major swelling in the calf, so I don’t think it’s a clot or anything like that… (Of course I went online to try to figure out what was going on and scared myself silly with deep vein thrombosis etc). I called my ortho but he thinks it’s just generalized pain from swelling… Thoughts?
I just tore the ACL and meniscus two weeks ago, and am still a couple weeks out from the surgery to repair them. My knee is still fairly swollen, I can only bend it about halfway, but most excruciatingly I am experiencing a constant strong deep aching pain inside my calf, radiating downwards. It is constant, and almost impossible to ignore. It is much more painful than the knee itself, and is making it difficult to walk normally, or at sometimes all. Has anyone else out there had this kind of experience? And if so, do you know why this is happening? And can I expect some relief soon, or will I just have to tough it out until the surgery? I don’t have any major swelling in the calf, so I don’t think it’s a clot or anything like that… (Of course I went online to try to figure out what was going on and scared myself silly with deep vein thrombosis etc). I called my ortho but he thinks it’s just generalized pain from swelling… Thoughts?
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paininthecalf,
It could be from several things.
One is the effusion you are having in the knee joint (swelling inside the joint capsule). The knee joint capsule is actually connected to one of the bursa in the posterior aspect of the knee, located between the tendons. It is not uncommon, when there is a lot of swelling within the knee, for this bursa to become filled, and actually rupture. Then the fluid that was within the knee leaks down into the calf. The body will resorb the fluid over time, but it can cause the patient some discomfort in the calf. It is not uncommon for this to be confused with a DVT.
You could have injured (strained) some of your calf muscles in the injury. It is difficult to injure just one or two structures. So, it is not uncommon for patients to have some significant muscle pulls (strains) with a significant knee ligament injury.
You could be having referred pain from the knee joint.
You could be using the muscles differently after the injury.
It could be a DVT (unlikely). (But, if you are really, really, concerned about this possibility, contact your physician for an evaluation.)
Keep working on your rehab. It is very important to have full extension (and as much flexion as you can) before the surgery. Also, you would like to have the knee without any swelling. The less inflamed the knee is at the time of surgery, the better the outcome. This is why a lot of surgeons will do an arthroscopy to address any meniscal pathology soon after the injury, but will delay the actual reconstruction of the ACL until the knee is totally calmed down and the patient has full range of motion.
Wishing you the best. Good luck.
It could be from several things.
One is the effusion you are having in the knee joint (swelling inside the joint capsule). The knee joint capsule is actually connected to one of the bursa in the posterior aspect of the knee, located between the tendons. It is not uncommon, when there is a lot of swelling within the knee, for this bursa to become filled, and actually rupture. Then the fluid that was within the knee leaks down into the calf. The body will resorb the fluid over time, but it can cause the patient some discomfort in the calf. It is not uncommon for this to be confused with a DVT.
You could have injured (strained) some of your calf muscles in the injury. It is difficult to injure just one or two structures. So, it is not uncommon for patients to have some significant muscle pulls (strains) with a significant knee ligament injury.
You could be having referred pain from the knee joint.
You could be using the muscles differently after the injury.
It could be a DVT (unlikely). (But, if you are really, really, concerned about this possibility, contact your physician for an evaluation.)
Keep working on your rehab. It is very important to have full extension (and as much flexion as you can) before the surgery. Also, you would like to have the knee without any swelling. The less inflamed the knee is at the time of surgery, the better the outcome. This is why a lot of surgeons will do an arthroscopy to address any meniscal pathology soon after the injury, but will delay the actual reconstruction of the ACL until the knee is totally calmed down and the patient has full range of motion.
Wishing you the best. Good luck.
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Thank you so much for the help. And I start "pre-hab" on Monday with the goal of getting the swelling down and achieving full rom. Hopefuly that will help with the calf too!
Since you've been so helpful, may I ask you another couple questions? I've been reading up a ton on acl repair and meniscus surgery, but I was curious if my recovery would be significantly impacted by doing both at once? Will my recovery time be about the same? And after how long can I expect/hope to be 1)off crutches and 2)able to drive? (Bot required for me to return to work). I can only secure just over 2 weeks of from work, and I'm wondering how realistic this is - I am a retail manager and am on my feet for 10-12 hours at a time. I appreciate any thoughts you have on this.
Since you've been so helpful, may I ask you another couple questions? I've been reading up a ton on acl repair and meniscus surgery, but I was curious if my recovery would be significantly impacted by doing both at once? Will my recovery time be about the same? And after how long can I expect/hope to be 1)off crutches and 2)able to drive? (Bot required for me to return to work). I can only secure just over 2 weeks of from work, and I'm wondering how realistic this is - I am a retail manager and am on my feet for 10-12 hours at a time. I appreciate any thoughts you have on this.
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paininthecalf,
As to doing the meniscal procedure and the ACL reconstruction at the same time, and if they impact on the rehab of each other, depends upon what exactly is done with the meniscus.
If the meniscus is just debrided (the torn portion removed and the edges smoothed down), then it is fine, they can both be done together. However, if the meniscus is actually repaired, then often the surgeon will elect to do the repair of the meniscus first and rehab it, then do the ACL reconstruction at a later setting. But, meniscal repairs are not very common. The debridement is much more common.
The reason for the repair not being very common is that the tear has to be at the very periphery of the meniscus (in the so called red-red zone). This is the only part of the meniscus that has any blood supply. So, it is the only part that can heal a repair. Tears in any other part of the meniscus can’t heal, so that portion of the meniscus is just removed. Which is fine, as long as the outer rim of the meniscus is left intact, that is all that is needed for the meniscus to function properly.
As to the expected progression after the ACL reconstruction, ask your physical therapist for the post-op protocol that your surgeon uses. Most of the time, the use of crutches is up to the patient (how sore he/she is). However, the surgeon and therapist do not like for a patient to limp, as that puts abnormal stresses on the limb. They would much prefer the patient walk with the crutches or a cane, than limp.
Again, ask for the protocol. It should tell you exactly what exercises you are expected to do each day, and what “milestones” you are expected to achieve (and when). Usually, at first the goals are pain reduction, swelling reduction, and regaining full extension of the knee. Extension is very important and as such is worked on first.
As to driving, that is a very personal thing. There are quadriplegics who can drive a modified car, but there are other people who cannot drive with a hangnail. The surgeon will usually give you a general idea of when you will be allowed to start driving again. But, the surgeon cannot tell you whether you are safe or not. That is something that you will have to determine yourself. We usually tell patients, that if they are married and have kids, would they feel safe putting their kids in the car and driving? Remember, that you are not only jeopardizing your own safety (by driving too soon), but the safety of everyone else on the road.
You should note, that research has been done on patients with lower extremity injuries/surgery and their reaction times in braking. If has been found that ankle injury patients will have a slower braking time for up to almost a year after their injury/surgery. It is statistically significant, but in actual driving it is something that the patient can adjust for (not tailgating, allowing more room between cars, not driving as fast, etc). The same was done for knee patients and very similar results were found.
It also depends upon whether you have an automatic or a stick shift. And which knee is being operated upon. If it is your left knee and you have an automatic, then you can probably return to driving very soon (as long as you are not taking sedating medication). But, if it is your right knee or you have a stick shift, then it is going to take longer.
You just have to be careful. If you are involved in an accident, and you are wearing a brace, limping, using crutches/cane, etc you may be cited for unsafe driving (not saying it is right, but it occurs). So, again, everyone is different, and each returns to driving at their own time. Just make sure that you are very comfortable and feel safe on the road.
As to returning to work, two weeks is pushing it a little. But, some people can do it. Since ACL reconstructions are done mostly through the ‘scope now days, the rehab is faster than it used to be (when they were done completely open). But, this is a major orthopedic surgery. And tissues only heal at their own rate.
One thing you do not want to do is compromise your outcome. You will have to control your swelling, and being on your feet for 12 hours a day, that is going to be hard. You will need to elevate your leg whenever you get a break. So, it will probably behoove you to get some thigh high TED hose to wear when you are up on your feet all say. TED hose are usually used in the hospital, to help reduce the chances of getting a DVT. They provide concentric compression on the whole leg and are a thousand times better than ace wraps. Ask the nurse who takes care of you in the hospital about getting a couple of TED hose. You may be fitted with them anyways, but if not ask about getting some. The nurse will know what TED hose are. (TED is a brand name; I think they are made by the Kendall Corporation. There are other brands of Gradient Compression Stockings.)
You will also have to make time to do your therapy. The post-op therapy is as important, if not more important, than the surgical procedure. If the post-op rehab is not done, then the surgery is for naught. So, you do not want to be so tired out, that you cannot do your exercises.
We usually recommend that patients return to half days, if at all possible, for the first month or so. But, you do have to work. You should probably speak with your surgeon about you returning to 12 hour days, just two weeks after surgery. You may be able to do it. But, do speak with your therapist and surgeon about it.
So, work hard on getting your swelling down and on your range of motion. Again, it is very important to have full extension, work on that exceptionally hard.
Good luck on your upcoming surgery. Wishing you the best.
As to doing the meniscal procedure and the ACL reconstruction at the same time, and if they impact on the rehab of each other, depends upon what exactly is done with the meniscus.
If the meniscus is just debrided (the torn portion removed and the edges smoothed down), then it is fine, they can both be done together. However, if the meniscus is actually repaired, then often the surgeon will elect to do the repair of the meniscus first and rehab it, then do the ACL reconstruction at a later setting. But, meniscal repairs are not very common. The debridement is much more common.
The reason for the repair not being very common is that the tear has to be at the very periphery of the meniscus (in the so called red-red zone). This is the only part of the meniscus that has any blood supply. So, it is the only part that can heal a repair. Tears in any other part of the meniscus can’t heal, so that portion of the meniscus is just removed. Which is fine, as long as the outer rim of the meniscus is left intact, that is all that is needed for the meniscus to function properly.
As to the expected progression after the ACL reconstruction, ask your physical therapist for the post-op protocol that your surgeon uses. Most of the time, the use of crutches is up to the patient (how sore he/she is). However, the surgeon and therapist do not like for a patient to limp, as that puts abnormal stresses on the limb. They would much prefer the patient walk with the crutches or a cane, than limp.
Again, ask for the protocol. It should tell you exactly what exercises you are expected to do each day, and what “milestones” you are expected to achieve (and when). Usually, at first the goals are pain reduction, swelling reduction, and regaining full extension of the knee. Extension is very important and as such is worked on first.
As to driving, that is a very personal thing. There are quadriplegics who can drive a modified car, but there are other people who cannot drive with a hangnail. The surgeon will usually give you a general idea of when you will be allowed to start driving again. But, the surgeon cannot tell you whether you are safe or not. That is something that you will have to determine yourself. We usually tell patients, that if they are married and have kids, would they feel safe putting their kids in the car and driving? Remember, that you are not only jeopardizing your own safety (by driving too soon), but the safety of everyone else on the road.
You should note, that research has been done on patients with lower extremity injuries/surgery and their reaction times in braking. If has been found that ankle injury patients will have a slower braking time for up to almost a year after their injury/surgery. It is statistically significant, but in actual driving it is something that the patient can adjust for (not tailgating, allowing more room between cars, not driving as fast, etc). The same was done for knee patients and very similar results were found.
It also depends upon whether you have an automatic or a stick shift. And which knee is being operated upon. If it is your left knee and you have an automatic, then you can probably return to driving very soon (as long as you are not taking sedating medication). But, if it is your right knee or you have a stick shift, then it is going to take longer.
You just have to be careful. If you are involved in an accident, and you are wearing a brace, limping, using crutches/cane, etc you may be cited for unsafe driving (not saying it is right, but it occurs). So, again, everyone is different, and each returns to driving at their own time. Just make sure that you are very comfortable and feel safe on the road.
As to returning to work, two weeks is pushing it a little. But, some people can do it. Since ACL reconstructions are done mostly through the ‘scope now days, the rehab is faster than it used to be (when they were done completely open). But, this is a major orthopedic surgery. And tissues only heal at their own rate.
One thing you do not want to do is compromise your outcome. You will have to control your swelling, and being on your feet for 12 hours a day, that is going to be hard. You will need to elevate your leg whenever you get a break. So, it will probably behoove you to get some thigh high TED hose to wear when you are up on your feet all say. TED hose are usually used in the hospital, to help reduce the chances of getting a DVT. They provide concentric compression on the whole leg and are a thousand times better than ace wraps. Ask the nurse who takes care of you in the hospital about getting a couple of TED hose. You may be fitted with them anyways, but if not ask about getting some. The nurse will know what TED hose are. (TED is a brand name; I think they are made by the Kendall Corporation. There are other brands of Gradient Compression Stockings.)
You will also have to make time to do your therapy. The post-op therapy is as important, if not more important, than the surgical procedure. If the post-op rehab is not done, then the surgery is for naught. So, you do not want to be so tired out, that you cannot do your exercises.
We usually recommend that patients return to half days, if at all possible, for the first month or so. But, you do have to work. You should probably speak with your surgeon about you returning to 12 hour days, just two weeks after surgery. You may be able to do it. But, do speak with your therapist and surgeon about it.
So, work hard on getting your swelling down and on your range of motion. Again, it is very important to have full extension, work on that exceptionally hard.
Good luck on your upcoming surgery. Wishing you the best.
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