Allison's ACL Update (20 weeks later)... Please help!

by Allison Fontana
(Plantation, Florida)

I'll try to keep it short. I injured my right knee on March 28th, 2009. I had surgery on April 14th to reconstruct my ACL (with my pateller tendon) and repair my meniscus. Progress in therapy soon stalled, I couldn't fully extend or flex my knee, my knee cap was immobile, and I was experiencing a lot of pain. An MRI showed scar tissue under and around my kneecap. A second surgery to relieve the scar tissue and manipulate my knee was done on July 7th. It is now August 13th (5 1/2 weeks after the 2nd surgery)and I'm having problems again. Although I don't have as much pain as before, I'm constantly aware of my knee and am uncomfortable. I would describe my daily pain as a 2 or 3. My knee feels very hard and large and movement is slow. I can push my kneecap side-to-side but up-and-down is extremely difficult. I have what looks like a very large band of scar tissue running laterally across the front of my knee over my patellar tendon. You can see it under the skin by just looking at my flexed knee. My doctor told me he made cuts in that tissue during the 2nd surgery to relieve the pulling. I feel that same pulling again plus pain everytime I flex more than 90 degrees. Once I flex, my knee adjusts to the flexion, stretches and feels better. I believe that band of scar tissue might be what is making my knee immobile. My therapist has pushed my flexion to 150 degrees (on a good day) but my extension is lacking. I usually start my therapy session at negative 3-4 degrees. With much work by my therapist, we can get the extension to positive 2-3. I feel good walking at that number although the extension on my good leg is positve 4-5 degrees. However, as soon as I sit flexed or I wake up in the morning the progress is gone and I'm back to negative 3-4. Why , after 5 weeks, can't I maintain any of the progress I achieve in therapy? I suspect scar tissue problems again. My knee cap feels "stuck" and my knee mechanics feel just "wrong". Are there any other options for scar tissue besides surgery? How do I keep the scar tissue from returning again? Please help, Bart (or anyone else), I'm at my wit's end. I'm very depressed, it's been 5 months since my accident and I'm not recovering. I just want to return to my job as a firefighter and to my very active lifestyle. Most of my day is spent rehabbing, stretching, icing, massaging or thinking about my knee. I just don't know what else to do. I'll be out of town for the next 2 weeks and my next doctor's appt. is on Sept. 2nd. Do you have any experience with this or any advice for me?

Thanks.

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Sorry to hear about your difficulties Allision. I agree with Bart regarding friction massage. As a former professional ballet dancer I have had my share of "career-ending" injuries and I can attest to the power of this sort of albeit painful massage. Likewise, my own clients have found that using Tei-Fu and Cinnamon essential oil before the rehab massages has helped to increase circulation to the area, alleviating some of the initial pain and improving the ROM immediately following. Likewise, for my own knee injuries and post rehab difficulties (specifically concerning the knee) I found that keeping my hip flexors, glutes and lower back/SI area mobile (through flexibility and stretching exercises) helped immensely. Doing some friction massage on the ITB might be to your benefit- it won't solve the scar tissue concern but it might help to improve circulation by opening up the other joints which are probably suffering by proxy as well as help the muscles that act on the knee to function better.

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scar tissue
by: Bart - SII

It does sound like you may be dealing with scar tissue issues again. Since you already had scarring issues to begin with, it could very well be what you are up against. Unfortunately, there isn't much that I know of to stop the scar tissue from forming.

I have had patients with similar problems - it was an uphill battle most of the time, however, with a dedicated therapist, it is possible to get better - just much slower than anyone wants it to be.

Friction massage over the patellar tendon and just below the patella over the scar tissue can help. The fact that your patella does not move up and down is likely contributing to your lack of flexion and extension. Assisted soft tissue mobilization or deep friction massage can sometimes loosen this tissue and allow for more motion - but it is painful and can be hard to bear.

I have also had good success with joint mobilization to help with extension. This is where the clinician glides the femur and tibia against each other to try to improve their gliding. It too can be uncomfortable, but if done correctly should not be painful. Lots and lots of patellar mobilization can also help. Pushing the patella side to side and up and down, holding each position to stretch for several seconds, and doing this as much as possible throughout the day can help. If you compare your uninjured patella's movement to your injured, I am sure you will find a significant difference.

Most scar issues will lessen over time if you continue to manage them with the above mentioned interventions. But, it takes what seems like forever for it to get better, and is so frustating in the meantime.

Talk to your PT and see if they can implement any other manual therapy techniques that may help.

Good luck!

Bart

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