All things ACL: Diagnosis, Graft Selection & Prehab

My ACL Journal

So you may have torn your ACL. What now?

At the ER, I was diagnosed with a right knee injury and a mild concussion. My right knee's differential included an ACL tear, but x-ray results would not have been able to confirm that diagnosis. 

On Day 3, I started meeting with orthopedic surgeons. I also received a prescription to get an MRI, which would confirm my diagnosis two days later. 

ACL Tears appear to be so common, but I still felt very much alone.

We have amazing friends who referred us to their orthopedic surgeons, who also shared what they could remember about their experiences with their own ACL injuries. 

But I still couldn't help feeling very alone, perhaps even more alone as I began to meet with orthopedic surgeons and experienced certain levels of desensitization during my care. I guess I should know better: my background is in healthcare, and I'm just as desensitized about certain pathological cases due to the nature of my work. But that's a debate for another day...

If you're at this stage of your ACL injury, please know that you are not alone. Read on for my day-to-day entries during my diagnosis and pre-surgery work-up.

Day 5: Complete ACL rupture...
On Day 5, my MRI confirmed the diagnosis. (I would post a picture of my MRI, except that I do not have a Windows operating system with a CD drive...)

While I knew that this diagnosis was inevitable, my visit with the first orthopedic surgeon wasn't great. I was treated like I was a number, and I was asked to schedule my surgery and all of my appointments before receiving my MRI results. The system was designed to maximize the number of cases seen, and I felt that decisions were being made for me just by the nature of ACL cases commonly seen at the practice.

Tip #1
​Get multiple opinions, and select a team that best fits your values

Day 8: ACL Graft Options...
I decided to get a second opinion with another orthopedic surgeon who was highly recommended by a friend, a fellow martial artist and female member of the same sparring team. My friend had just experienced an ACL tear about 6+ months earlier than me. Yes, that's right: She also experienced it as a non-contact event during martial arts training.

Maybe it's due to my first experience, that I truly did not know anything about my circumstance. Maybe it's also because I now knew what type of care I did not want. I came prepared to this appointment, fully armed with questions and also (sadly) expecting the same amount of desensitization as the first. My experience at this second opinion was phenomenal from check-in to check-out.

My surgeon assessed me fully, explained what he was looking for, and then gave me his "usual speech" on what type of ACL tear I had, my options, and what rehab would look like for each. It was then and there when I had selected my surgeon.

It's also important to select the appropriate team for your physical therapy. I'll reveal my decision in the "prehab" section.

Tip #2
Get to know your ACL graft options: Autograft vs. Allograft?

One of my first inspirations towards mobility and prehab work is The Prehab Guys. This video is from their library exploring ACL Reconstruction Graft Options.
You can also read the full article written by The Prehab Guys on ACL Graft Options and Prehab (more on my prehab later).

A quick review on terminologies:
Autograft means that you are harvesting a tendon from your own body, and transplanting it to replace another.

Allograft means that you are harvesting a tendon from a cadaver, and transplanting it to replace yours.

My undergraduate study is in medical laboratory science, and I was familiar with potential complications of tissue grafts. These were my questions in regards to graft handling and processing, and the answers to my questions:

1. Histocompatibility testing for cadaver allografts? Not applicable.
2. Do we need to obtain the cadaver allograft from a tissue bank source? Not applicable to the patient, but hospitals work with certain tissue banks/distributors for certain tissue or bone grafts. 
3. Other testing or criteria checks for graft selection? Not applicable, but again, these are likely performed by the distributor, and hospitals have policies to ensure that they are handled per recommendations.
4. Is there an additional chemical or radiation processing for sterilization of the graft? As with any surgery, complications can occur due to less-than-sterile conditions. These grafts are Fresh Frozen. Here's a PubMed article on Fresh Frozen patellar tendon used for ACL reconstruction.
5. How is the graft (autograft or allograft) secured to the knee? I personally can't remember this discussion, but bone plugs were used that did not require an additional visit to remove. The Slideshare presentation shows these graft fixation options in more detail.

Acl graft fixation options from orthoprinciples

Due to my age (I was in my 30s), the nature of my recreational activities (active but not professionally competitive), and the desire to decrease the amount of recovery time post-surgery, I selected the patellar tendon allograft.

Tip #3
Reduce inflammation and Prehab:
​Actively control full knee extension and flexion before surgery

Day 10: 1st Day of Prehab...
There are two risks for sub-optimal outcomes post-surgery: inflammation and poor mobility.

Many who have experienced an ACL tear were shocked to learn that my surgery was scheduled within 2 weeks of diagnosis. That most had to wait a month or more for their surgery. During my assessment, my surgeon did compliment me on my ability to significantly reduce inflammation after injury, which gave him the confidence to schedule my surgery faster than most.

PEACE & LOVE is the new RICE
We were originally taught to apply RICE after injury:
R - Rest
I - Ice
C - Compression
E - Elevation

However, this is now antiquated. Check out this article from The Prehab Guys​. 
​I didn't know this at the time, but I did keep my right leg elevated and reasonably compressed throughout the day. I did not leave the compression on overnight during sleep, and I did not ice for more than 15 minutes, twice a day each session. I'm pretty sure that I did not take non-steroidal anti-inflammatory (NSAID) medications beyond the first two days after onset of injury. I have a relatively high pain tolerance since childhood.

My surgeon also recommended that I work with a physical therapist to perform prehab exercises so that I can actively control my knee's current full range of motion. I selected the same physical therapy group who helped me recover from my grade 2/grade 3 ankle sprain years before. They were familiar with my history, and they specialized in athletes.
​
Day 1 Measurements:
Left knee extension = -1 degrees
Right knee extension (injured knee) = 2 degrees

Yes, that's correct. Both of my knees can hyperextend, but with the injury, my brain limited that range of motion for protective measure.

I unfortunately did not record my knee flexion measurements.

HEP from Day 10:
1. Heel slides with towel
2. Knee extension mob/push
3. Leg raises
4. Glute/Hip rear extensions
5. Sit to stand squats using chair

HEP from Day 12:
Same as #1 thru #5 plus
6. Hip flexor side raises
7. TKE (Terminal Knee Extensions) pressing ball to wall
8. Glute bridges

Surgery Day: May 15, 2017
Tip #4
Don't be a hero. Accept that last pain medication at discharge.

Warning: I will be sharing the arthroscopic images from my surgery at the end of this section.

After reaching milestones post-op, I was ready to be discharged from day surgery. My nurse asked if I wanted to receive one more dose of pain medication before hitting the road, and my ego got the best of me. I felt great at the time, I wasn't in pain, and home was only less than 15 minutes away, and so I thought I could tolerate the transition towards home.

I was wrong.

The pain medication started to wear off while I was in the car. We also have a split-level home, and we planned to have me shimmy my butt up two staircases (each with 4 to 5 steps) while my husband held up my braced leg. 

The pain was unbelievable. I had to take breaks going up these stairs.

About some time later, my brother-in-law underwent ACL reconstruction surgery. The same question came up right before his discharge, and I pleaded with him to take the final dose, most especially that he lived an hour north from the surgi-center. He fared better on his way home.

Stay tuned for my next post on All Things ACL!