Number 1 in age group – way to go Jeremy!

Do you know someone who has had an injury or surgery and has not fully recovered? Have they been unable to do what they could before, or do the things they want? Sadly, it is my experience that there are many people who are in this boat and have not found a solution. The reason for this is likely to be different in each case, with some assuming it is their lot, or worse being told that the lack of progress was a risk of their surgery.  I have seen many of these people and, with the freedom, my practice at PhysioWorks provides, have been able to step back, review the case holistically, and take a different approach. In many cases, this has helped them to progress further than they had previously, and in the best instances make a full recovery.

In this blog, you will get to hear the story of Jeremy, a 33-year-old who had an ACL tear, surgery, PT, a second surgery, more PT, yet was still unable to get back to the things he loved – running, cycling, hiking, and weight training. When I first saw Jeremy, he was part of the 20% of ACL reconstruction patients who had not returned to sport. Over the course of nine PT appointments, spread over a year, Jeremy has returned to doing all the things he loves, even placing 32nd and making the top of the podium in his age group in his first ever duathlon – the Heel and Crank in April 2017! He then went on to complete the Assault on Mount Mitchell, a 102 mile, 10,000ft ascent!

The video below shows Jeremy’s progression with running. You can really see how his biomechanics have improved over time, making him a stronger, faster runner, with less future injury risk.

As you read Jeremy’s story, you might wonder about an old injury that has bothered or restricted you – email me about it! I would be happy to listen to your story and explore whether my approach can help you.

A More Detailed History:

The Injury And Surgery:

Jeremy was an active 33 year old – he cycled, ran, hiked, and rode dirtbikes. Unfortunately, in January of 2014 he came off of his dirtbike and hurt his knee. Examination and MRI revealed an ACL rupture and meniscal tear. Shortly after, he had an ACL reconstruction (ACLR), using the central third of his own patella of the same knee (technical term: patella autograft). This patella tendon tissue over time turns into ligament tissue that very closely matches that of the original. The meniscus was torn in the outer third, in the so called red-zone, which meant it was repairable with two anchors. The red zone means there is good blood supply and it will heal, versus a tear in the white zone of the meniscus, which is considered irreparable and  is typically trimmed off. The surgeon must have also found an area of cartilage damage, where the bone was essentially bare, because a microfracture procedure was also performed. Microfracture involves small holes being drilled into the bone to stimulate bleeding, the release of stem cells and subsequent cartilage regrowth.

Post Surgery, a second surgery, and post surgery again!

Jeremy followed the typical ACL rehab protocol at another local PT clinic associated with his surgeon. He did well with respect to basic normal activity (i.e. walking, stairs, slopes) and felt good enough to try some hiking that same August. However, following the hike, his pain levels started to increase and he started to have issues getting his knee fully straight, had pain going from sitting to standing, and also pain when walking on slopes. Going hiking at this stage should have been ok if the strength and range of motion is available, so it is likely that one of these was not quite where it needed to be (but I cannot travel back in time and see!). A year after the initial surgery he continued to have issues, so he underwent a scope of the knee to remove scar tissue. He did therapy as recommended by the doctor, saw some improvement, but still could not return to running or sports – meaning at that time, he was part of the 20% of people who had not returned to some form of sport.

I’ve written before about ACL injuries (here and here) because we’ve seen such a dramatic increase in them in youth sports in recent years, and because the sad fact is that many athletes do not make a full recovery after ACL rupture. Typically, recovery back to normal activity (walking, stairs, etc) is fairly uneventful. This is normally as far as your insurance-covered PT treatment will take you. But return to sport after ACL reconstruction is challenging – even many professional athletes don’t make it back to their pre-injury performance. Statistics show that about 80% of ACLR patients return to some form of sport, 65% return to the same sporting level and only 55% return to sport at a competitive level within 1-2 YEARS post ACLR¹

Two Years Later – Jeremy’s Assessment at PhysioWorks

Jeremy was unwilling to accept this outcome, so in April 2016, he contacted me and came to the clinic for an evaluation. As I do with every patient, we began with me listening to Jeremy’s story and understanding his goals and frustrations with his current lack of progress. In fact, some of this process started before Jeremy walked into my clinic – my online paperwork system meant that I had already read about his history and goals before we met for his first appointment, and I could immediately zero in on the key issues, ask clarifying questions, and quickly develop an in-depth understanding of not only where Jeremy was at that moment, but the entire history of his injury and recovery to date. Sometimes patients can become frustrated as they move from provider to provider, having to tell their story again and again, and over time the accuracy of the story they tell may reduce. This can be a big problem in an on-going case like Jeremy’s, where small clues about what was going on even before an injury can really be helpful in understanding the big picture and the underlying issues that will need to be corrected for a full recovery to be possible. Taking the time to understand a patient’s issues and where they’re at in terms of processing and dealing with injury, pain, and loss of function is incredibly important. For this reason, it is not uncommon that half of my 45-minute examination time is spent talking to the patient. In many cases you can do most of your diagnosis by talking, and the physical examination is just a confirmation. I find that this approach is particularly helpful for people with complex problems, and they often tell me they have not really felt anyone has truly listened to them before. (As a healthcare professional, hearing this always makes me sad!)

In Jeremy’s case, this approach led not only to understanding the history of his injury, but also of his history of chronic low back pain since 2003 that could have some connection to his poor recovery. The persistence of back pain had been diagnosed as coming from his sacroiliac joint (SIJ). He would have flare ups from time to time, which were significant and disabling, even affecting his confidence in exercising and doing what he wanted to do in the gym or in rehab.

During our initial conversation, I told Jeremy the findings from a couple of questionnaires I had him complete. These questionnaires are validated to help understand the full effects that ACL injury can place on an individual, and both showed that there was a significant affect on not only his sporting interest, but his life in general. One showed that instead of what should be a normal 0%, he had a 44% on the emotion score. This does not mean he was a blubbering wreck! Instead in the ACL literature, emotional aspects of ACL injury can include feelings of loss, physical dependency on others, fear of re-injury, lack of self-confidence, and mood swings². Often people are unaware of the impact that such an injury and surgery can have. Thankfully, Jeremy was not willing to accept where he was at; he realized the issues it could have for his lifestyle and he wanted to make progress.

Only once I had a clear understanding of Jeremy’s history and goals did we move on to physical examination. My primary findings were gluteal (butt) weakness, quad tightness on the injured side, and persistent loss of muscle mass and control/balance in the leg that was injured. He also still had soreness at the patella tendon incision, indicating that there was a tendonapathy, even two years past the surgery!

All of these issues could be successfully addressed through a tailored home exercise program. When possible, this is always my preference, as it requires the patient to be an active participant in their recovery, as opposed to potentially becoming dependent on passive “hands-on” therapy treatments like mobilizations, manipulations, stimulation, etc. Creating a situation of dependence is not something we wish for and is particularly harmful when there is a persisting problem where the individual is desperate for a solution. Also, I knew that with a case like Jeremy’s, the recovery would likely stretch over months, even a year, rather than weeks. Prescribing the right therapeutic exercises would allow his therapy appointments to be spaced out rather than every few days, keeping the treatment affordable and not overly intrusive into his time and life. I expected each session would consist of progression of exercises and tapering of visits. Jeremy and I discussed that in order to be successful, he would have to work hard and be committed. This may sound like a no-brainer, but to commit to changing how you do things for an extended period and changing habits can be difficult! During the last 15-minutes of our hour-long evaluation, I walked Jeremy through about half a dozen exercises. I explained how to progress them over the next couple of weeks and to contact me if he had concerns. Instructions for the exercises were given via an online portal which had videos, photographs, and suggested ranges of repetitions and sets. (Click this link to see what this looks like!) This form of delivery has proven to be popular and helpful as many patients have told me about their frustration of being given stick figure drawings or simple picture print-out that they then lose or do not understand.

Jeremy’s progress:

I will not detail each of the follow ups, but Jeremy saw me a further eight visits through March of 2017. The chart below gives some highlights of the visits:

At this point Jeremy was very happy with the progress and decided to write us a review! However, he had more goals he wanted to meet, including comfort on century bike rides and running. Our rehab continued along the original plan.

The Final Result!

As you can see, at his last appointment (March 2017) Jeremy had made excellent progress. He had met all of his goals and has a very good approach for continuing to move forward. He is also very pleased that his back pain has not flared up recently which he would have expected it to do so. None of his sporting interests require a significant change in his plan, but I feel confident given his strength and previous hop testing that he should be able to do these as long as they are approached sensibly (i.e. the way all people should approach a new sport – gradually!)

As we already showed in the summary Jeremy was able to place 32nd out of 295 people in his first ever duathlon and then was able to make a a 102 mile, 10,000ft mountain ascent on a bike! He does not feel any particular restriction in his activity and is able to pick and chose what he wants to do rather than having his life dictated by an old injury.

Have you been struggling with an injury, or from a surgery that you cannot get over? Do you need a different and more tailored approach? Send me an email if you have questions about your problem; I would love to help you!

References:

1. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543-52.
2. Olofsson L, Fjellman-Wiklund A, & Soderman K. From loss towards restoration: Experiences from anterior cruciate ligament injury. Advances in Physiotherapy. 2010; 12: 50- 57.

1. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543-52.
2. Olofsson L, Fjellman-Wiklund A, & Soderman K. From loss towards restoration: Experiences from anterior cruciate ligament injury. Advances in Physiotherapy. 2010; 12: 50- 57.