So I’m going to wear a knee brace whenever I do sports activities that are likely to put rotational stress on the knee. That includes ice skating, rollerblading, kicking around a soccer ball, and playing tennis. The brace is way cool, by the way. It’s the official brace of the U.S. Ski Team, and it’s manufactured by Donjoy and was custom-fitted for me by Gotham Surgical and Brace on 39th Street. I had my choice of colors, but chose a respectable dark blue.

I know it’s hard to believe seeing just the pictures, but the brace is actually remarkably comfortable, indeed, much more so than the smaller fabric covered brace I was wearing a couple of months after the surgery. What’s great about the brace is that there’s no fabric on it, so it’s cool and there’s nothing to rub against the area where the plate was screwed onto the bone.

The knee feels strong. Here’s what I can do now that I couldn’t do before the surgery: run for the bus. I can go from standing still to running without a second thought and without pain afterward. The arthritis is still there on the medial side of the knee, but with the weight shifted to the outside of the knee, I’m rarely aware of it. Oh, there’s a minor twinge every now and then just to keep me honest, but it’s night and day from a year ago.

And the area where the plate was inserted has almost all of the feeling back. In fact, I think there’s less numbness than there was after the first surgery twenty years ago.

To celebrate the anniversary, I bought myself a new set of CCM hockey skates, my first new pair in about fifteen years. My first time on the ice after the surgery was last weekend at Wollman Rink, though it was so crowded that it was hard to really get in good skating rhythm. So tomorrow morning, weather permitting, I’m off to the “The Pond at Bryant Park” first thing in the morning to put the knee through its paces. Bryant Park on a weekday generally has the advantage of being less crowded than Wollman and — even better — much less expensive: in fact, it’s free.

Don’t worry, Dr. Feldman, I’ll be conservative!

I had my last visit with my surgeon, Andrew Feldman, two months ago. At that time, he was very pleased with my progress, saying that I was ahead of where most patients would be after four months. He told me that there were four areas in which things might go wrong: the healing of the tibia, the stability of the ACL repair, the flexibility of the knee and joint, and the overall alignment of the leg. In my case, everything was working out perfectly.

He was particularly pleased with the alignment of the leg.The picture at right shows a recent picture of my knees. You can see that my “good knee” (the one at the right of the picture) is naturally a little bow-legged. The repaired knee, at left, is much straighter. In fact, Dr. Feldman over-corrected just a little, meaning that my right leg is actually a little knock-kneed. This assures that the weight is borne through the outer part of the knee, away from the damaged medial area.

For the last two months, I’ve been working out steadily on the elliptical trainer in the gym, trying to build up strength in my quad and hamstring. Last month, I began rollerblading again, which also gives those muscles a nice workout. I’m currently wearing a brace whale blading, to avoid wrenching the knee in the event of a collision or fall.

I’m still not supposed to be subjecting the knee to any significant impact, but I have been experimenting with a few minutes on a treadmill a couple of times a week, just to see what it feels like to run. It’s feeling better and better. Clearly, I’m not going to be running a marathon at any point in the future, but I do hope to return to tennis and squash and to be able to play soccer and baseball with my sons. That seems like it’ll be possible. Right now, I can kick a soccer ball pretty well, but I have more work to do before I can run after it gracefully.

The last four months have been a process of learning how to walk comfortably on the realigned knee. I still walk a little stiffly, and I limp a little if I’ve given the knee a real work out. My flexibility is good, though I can’t yet bend my right leg all the way up to my buttock. The knee is a little stiff when I get up after sitting for a while. And there is a little numbness and an occasionally prickly sensation around the area where the plate has been attached to my bone (beneath the diagonal scar in the picture) and in the muscle lining my tibia (tibialis anterior). From my experience after my previous ACL-repair, I expect that I’ll always have some odd sensations below the knee.

On rare occasions, I’ll feel an arthritic twinge from the medial side of the knee, but it’s nothing like the nearly constant pain I had before the operation. Indeed, for the most part I don’t experience the knee as “painful.”

So I’m pleased with my progress thus far, though I realize I still have a a lot more work ahead. Progress now occurs at a slower rate than it did during my intial rehabilitation. But all the time spent at the gym for the past four months is paying dividends beyond a stronger knee. My next visit with Dr. Feldman is sometime in September. I’m hoping for an equally positive evaluation then.

Now if only I could finish writing that book manuscript …

It’s now been ten weeks since my knee surgery, and everything is going beautifully. The x-rays pictured above were taken three weeks ago during my third post-op visit to my surgeon, Dr. Andrew Feldman. (At the left is a side view, at right a frontal view.) He was very pleased with the way that they looked, pointing out that the line where he made his cut (just to the left of the plate and equidistant between the screws on the righthand x-ray) was barely visible, indicating that the bone was healing perfectly. He said that the realignment of the leg was exactly what he wanted it to be and that the reconstructed ligament felt strong.

He cleared me to begin bearing weight on the leg, suggesting that I move to one crutch, then to a cane, and then to unassisted walking as I felt ready. My target was to be able to put 50% of normal weight on the leg after a week, and full weight a week after. I was able to shed the full-length brace at the beginning of week eight in favor of a much smaller brace, which I dont’ have to wear at night. Lately, I’ve only been wearing it when I go outside.

As it turns out, I was able to progress more quickly, putting full weight on the leg with a week and moving to a cane shortly thereafter. I’m now walking around without the cane, and I try to minimize the limp as much as possible.

My physical therapy sessions have become more demanding, lasting between 1.5 and 2 hours. We’ve added riding on the stationary bicycle at low resistance for 10 minutes, isometric exercises for the quads, and some weight-training for the quads. Russian stim is no longer necessary.  When I’m at the gym by myself, I’ll usually start with 30 minutes of bike riding, followed by the complete leg routine and whatever upper-body exercises I still have the energy for.

Because it’s being used now, the leg is sore much of the time — not painful, just sore, with the occasional twinge around the area where the plate was affixed. My therapists started massaging the scar area a few weeks ago to keep the skin from adhering unnaturally to the tissue below, and it’s made a difference. There’s less discomfort in the area now, and the numbness has decreased.

I’m not due to see Dr. Feldman for another five weeks if all keeps going well. My goal is to be able to walk into his office without limping at all. Walking on the leg does feel a little strange, because I feel conscious that the outside of my knee is bearing more weight than it used to and that I’m a little knock-kneed. Whether I can actually feel that, or whether I think I’m feeling it because I know that’s what the surgery was supposed to do, I can’t say. It does feel, however, as if I’m re-learning how to walk properly.

Click on the continuation link, if you’d like to compare the present x-ray to the one that was taken before the surgery.

The picture on the left was taken late last year. Part of the reason that the surgery lasted so long was that the hardware below the knee was precisely in the place where the cut into the tibia had to be made. That clip had to be removed first. The clip above was, I believe, left in place. I’m not sure that you can see the hardware for the new ACL graft in the x-ray on the left, but you sure can see my new hardware, the plate and screws that kept the allograft bone in place. And you can get a sense of the new angle of my leg. The correction was 10 degrees.

Below is a picture of the knee from the side.

This morning I opened the brace up to 90 degrees of flexion. I can bend the knee 80 degrees without too much difficulty and will be working on those last 10 degrees this week. I have two physical therapy sessions a week. I begin with Russian stim –  ten seconds of electrical stimulus, ten seconds of rest — for 20 minutes During the stimulus, I work to contract my quadriceps as tightly as possible. Then, with the brace on, I work on bending the knee as much as possible, 30 reps on the table, 30 reps standing up. I then work the right leg on the hip machine in four directions with weights, followed by ankle flexes using a rubber band. Then electrostimulus and ice for 10 minutes. I do some version all of this, with the exception of the electrostimulus, each day. When I’m at the gym using the hip machine, I try to throw in some upper body exercises and a few exercises for the left leg.

Despite all the exercise, I’ve still loss muscle mass and tone in my right quad and thigh.

The incision is practically all healed, and the brusing on the inner part of the knee, above the site of the microfracture, is almost all gone. There’s little pain during the day, though I think I’ve felt a few arthritic twinges on the medial side in the last couple of days.

I see Dr. Feldman again two weeks from tomorrow. There’s the possibility that I’ll be able to begin putting weight on the right leg, if the X-rays show that the tibia has knitted properly.

I’m much stronger on my crutches than I was three weeks ago, but I’m really eager for this particular phase of the rehab to end.

But I’m grateful: there have been no setbacks or complications so far. I did fall on my ass the other night getting out of a cab in front of my building the other night: lost my balance trying to transfer one crutch from my right side to my left. I’m attributing that to the icy conditions at the time (rather than to the two martinis and glass of sake that I’d had at a friend’s house earlier.) About four people jumped to my aid and hauled me up. I think I must have looked quite picturesque. Luckily, nothing worse than a sore rump and a bit of wouned pride.

We took another X-ray, and Dr. Feldman said it looked great: the tibia seems to be knitting together nicely, with no sign of any slippage. (Slippage? Who knew that was even possible?)

The leg brace has been set to allow 40 degrees of flexion. I can do 30 comfortably; 40 feels a little tight for now, but should become easier as I exercise the knee. I’ll be increasing the flexion by a notch each week, which should take me to 90 degrees in two weeks and completely open in three. My next post-op visit will be in four weeks. If all goes well, I may be able to start putting a little bit of weight on the leg after that.

I’m still taking aspirin every day to help avoid clots, but I haven’t been on any antibiotics at all, and there’s been no sign of any infection at the surgical site. The arthroscope wounds have healed and the incision looks pretty good. Click here if you want to take a look at the current external state of the knee: View image.

I’ve been very sparing in my use of pain-killers, and for the past week I haven’t been taking anything at all during the day, not even extra-strength Tylenol! I have been waking up in the middle of the night with the leg throbbing, which has led me to take one Percocet tab in order to get back to sleep. Benny, the doctor’s aide, was impressed that I didn’t need more pain medicine and said that the nighttime throbbing was to be expected. Blood and lymph circulate differently when you’re asleep, he said. They’ve prescribed Vicodin for use when the Percocets run out, but I’m hoping not to need anything before too long.

Meanwhile, Mike, the office’s brace specialist, snorted when he heard about Empire’s denial of benefits for the EBIce cold therapy unit: “It absolutely is not experimental.” He gave me a “statement of medical necessity,” which reads: “This cold unit, used in conjunction with a pump and sterile circulating pad, allows cold therapy around the injury site immediately after surgery. A sterile pad allows close contact with the surgery site and can be applied under sterile dressing. It is used to prevent or reduce post-operative swelling and edema. Without cold therapy, the patient risks increased inflammation and pain.”

We’ll see what they say.

Electrotherapy is intended to stimulate motor nerves and is thought to be beneficial for pain relief. The exact mechanism through which it might relieve pain seems still to be unknown: it may block transmission of pain signals along nerves; it may also promote the release of endorphins.

I’d experienced electro-stimulation before, when I dislocated my shoulder while skiing in late 1988. During physical therapy, electrodes were hooked up to my right deltoid, which had been weakened by the dislocation; the elecrical pulses stimulated the deltoid to contract and, together with exercises, allowed me to regain use of the muscle.

“Russian stim” is a variety of electro-stimulation that makes use of “a symmetrical biphasic square waveform,” which is produced by dividing a 2500 Hz carrier frequency into 50 Hz packets. Its name comes from the fact that it was originally developed by the Russian Olympic team to help its athletes gain muscle mass. Physical therapists use it now to help strengthen muscles and to treat muscle spasms. Like regular electro-therapy, it stimulates motor nerves, but its relatively high frequency of 2500 Hz is thought to enable stronger and more complete contraction of muscle fibers.

So today we had a few minutes of Russian stim for my right quad, combined with isometric exercise: during 10 seconds of electro-stimulus, I would contract the quad as strongly as I could; then rest for 15 seconds; then repeat. We did this for a little under 10 minutes. Then some regular electro-stimulus for 10 minutes under an ice pack. And then leg lifts while in the brace: 3 sets of 10 in each direction (lying on my back, left side, stomach, and then right side).

Given the current restrictions on my leg movements, that’s all we could do. The therapists thought that the muscle strength in my right leg seemed pretty good, so they suggested that we save my visits until we can do more. I’m going to do the leg lifts and isometric exercises at home. I’m seeing Dr, Feldman again on Tuesday, at which point the prescription for physical therapy might be revised.

The knee, with dressings removed for the first time after surgery, about to be x-rayed:

And a close-up of the incision, before the staples were removed.

Appearances to the contrary, the wound hasn’t been that painful. And even the removal of the staples was only “uncomfortable.” And according to both Dr. Feldman and his physician’s aide, Benny, the knee looks very good, all things considered!