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Quadriceps Tendon Rupture Repair And Rehab
Idaho Guy's Rehab Diary
Introduction (January 31)
I am writing this to document my journey through a recent injury resulting from alpine skiing. I also want to be able to help others through the experience if (shudder - God forbid) this ever happens to them. Finally, I want to write this to hopefully, help me rehab my knee to the same or better condition it was in three short weeks ago.
46 y.o. male. 35 year skier. Former ski instructor at large Colorado resort for 8 years. Former ski racer. After children (2 - now young teens), moved to Idaho to get a "real job" - which involves sitting behind a desk and wishing I were out skiing most days.
Ski typically 30 to 40 days a year now - not even close to enough. Still love steeps, bumps, trees, terrain. Mostly ski at Bogus Basin near Boise, but take trips to Utah, California, Montana and Canada to ski steeps. I am a fanatic in the true sense of the word. I never, ever get enough. When I taught skiing, it was my goal to be the first person on the lift every morning of every season, and I very nearly succeeded. I would ski every day of my life if possible. In addition to alpine, I do a lot of nordic early season before terrain begins to open up.
Cycle all summer - both road and mountain. Long, long rides. I have a gang of guys my age and a little younger with whom I both cycle and ski - very fortunate that way. Also very fortunate that my wife (former ski instructor) loves the exact same activities as I. We both stay in shape, and in addition to cycling, I typically begin a lifting and conditioning program in early September to get my body in "ski shape."
Have had a previous torn left ACL approximately 5 years ago (repaired with a hamstring) from which I recovered well and have continued with my lifestyle ever since. I do have nearly constant patellar/femoral pain in both knees which I deal with through physical therapy, lifting, cycling, nordic skiing, etc.
The morning of Sunday, January 13, I was skiing with a friend at Bogus Basin. Having a great day - probably 4 inches of new. On about the 7th run or so, was following said friend down a steep face, making relatively high speed GS turns with a "must make" right hand turn down at the bottom onto a very narrow traverse out of an extremely steep sided, long, narrow, gully underneath a quad lift.
The "must make" turn at the bottom was perfect - beautiful, balanced, high speed . . . . until my left knee simply exploded in pain, and I went down screaming with my knee on fire. I ended up hanging upside down on my back, dangling from my left ski (which never came off), in incredible pain - looking up at the faces of numerous lift riders who were all staring back down at me (probably wide-eyed at the string of profanity I had just let loose with).
My friend came down, quickly assessed the situation, and helped me release the binding and get turned around with my good leg planted underneath me. My knee was extremely painful - absolutely on fire - and we quickly opened up the zipper on my shell pants and packed it in snow. Then, as we were in an extremely sketchy place for a rescue, attempted to get back up to the traverse (max two skis wide with a very steep drop off below) and as far down it as possible. My leg was simply unresponsive - dangling without any control at all. I hooded my pole strap into the bottom buckle of my boot, and was able to lift it and move it that way. Suffice it to say that the situation was somewhat desparate.
Patrol came and performed a rescue - while I appreciated their efforts, I was somewhat concerned for both their safety and mine. Despite a few bumps and problems, we all made it out without further injury to anybody else - I am sure it was quite a show for the fully loaded lift overhead!
Initially, as soon as I got down to town, we iced the knee and determined whether to go to the emergency room. As the pain was slowly subsiding, I determined to tough it out without paying the huge fee to have the ER doc tell me to go see the "Orthopod". Got into to see my Orthopod two days later. The knee was simply too swollen and too injured to make a proper diagnosis, although the doc suspected that the ACL hamstring graph had failed (he was really bummed as it would have been the first such repair he had done that had ever failed). He suggested that rather than getting an MRI, he should take several cylinders of blood out of the knee to get the swelling down and that I should spend money instead on PT - a suggestion that I think he later came to regret. We proceeded on the basis that we needed to get the swelling down and begin physical therapy to keep the leg as movable as possible. I agreed to come back in two weeks for further diagnosis and discussion of surgical options.
I went to PT, began building up the quad muscles through isometric and other exercises, began spending time on the bike and walking in the pool. I also used an "Iceman" (thanks John!) all night every night. However, I could never fire the quads enough to straighten out the leg, and it would simply collapse on me at any time - causing extreme agony. The PT suggested a partial tear of the patellar tendon below the kneecap.
On the second visit to the Orthopod - two days ago, he diagnosed a complete tear of the Quadriceps tendon (above the kneecap) and sent me to get an MRI to determine whether any further problems existed. There is some torn and loose cartilage floating beneath the kneecap.
He explained to me that the tendon simply "peeled" off of the kneecap under the extreme force exerted by my quads in the turn I was executing at the time. I now understood why the pain had been so incredible - 'twas nothing like the ACL injury I had experienced a few years previous.
The Proposed Surgery
The surgery is somewhat gruesome, so if you don't like blood, you may want to skip this part. First, they must open an approximately 8 - 10 slit in the leg immediately on top of the kneecap (no arthroscopic surgery for this procedure). Next, they drill four holes through the kneecap lengthwise, from the top near the femur to the bottom near the tibia. Then, he stitches a couple of pieces of permanent material into the quadriceps muscle and tendon using what he calls a "baseball stitch". These pieces of material have several "tails" each, which are then run through the holes in the patella and anchored with knots at the bottom. For a view of the surgery and a better description of the injury, see this link: http://www.arthroscopy.net/quadrep.htm
So, this will happen to me tomorrow morning. Hopefully I can quickly recover and begin rehab. I have a great feeling about this one - I know it will take awhile for rehab (6 months), but have done rehab before, and can do it again. Now, I can't wait until cycling season here in Idaho! I have many good friends, a great family, and am very fortunate in many other ways. The thing I keep remembering is that many, many people my age would never have this injury because they are not active enough to ever get hurt this bad. Between athleticism with an occasional injury, and couch riding without ever getting hurt, I'll take athleticism any day.
Post-Surgery (February 5)
Well, I obviously made it through surgery as I am sitting in front of the computer sweating profusely trying to get this written and off. The first thing I would advise anybody with respect to this injury is DO NOT DO IT at all costs. I woke up out of surgery with my leg in a straight splint (in which it must remain for at least four weeks). Then, it seemed like they were just hurrying my wife and I out of there. They gave me one (count em - ONE!) hydrocodone "for the pain" - which of course didn't even touch the raging pain storm in my knee at the time. Despite my pain, "so sorry, very sorry, but you must move" they put me in a wheel chair and dumped me into our car for my wife to drive me home. We did stop on the way to pick up some more pain meds - more hydrocodone, oxycodone, and valium. Took those as soon as I got home.
Then, I don't mind telling you I was wracked in agony and sobbing for about two hours until the meds finally and blessedly kicked in. I was hoping to be back at the office by today - yeah, right. Now, I'm just hoping to be back at the office by next week. Went to PT for the first time yesterday - they unwrapped my poor pitiful knee (what I used to call a raging steel piston) and had to help me move it to even 30 degrees of flexion.
Ufortunately, this appears to be a worse injury than I had originally anticipated. Does'nt mean I won't be back on skis again, it just means it will be harder to get there than I had assumed. I'll update again soon. 'Til then, keeping making some beautiful turns - and make each of 'em count!
Update: Rehab (February 7)
Back to the Therapist again today. She tells me I am doing well on my isometric quad sets, but do NOT at any costs, attempt to flex my leg myself - passive flexion with help only - tomorrow we can go to 45 degrees.
Drugs: I've stopped taking the oxycodone and valium - they were simply making me feel "fuzzy" and forcing me to sleep all day. I'd rather trade away some pain for a little more function in the brain.
Bored today - watched the film "The Devil Came On Horseback" online from Netflix while wife was at work and kids at school - wow - disturbing commentary on the genocide in the Sudan. Wanted to go back to work tomorrow to at least feel like I am doing SOMETHING, but the PT sided with the wife and said probably best to wait 'til Monday. So, another weekend of checking snow reports and watching my family run off to some early morning freshies. Ah well - better that someone I know and love gets 'em.
Update (February 12)
Thank you to those who have wished me a good recovery. I note that some of you have your own health problems - I also wish the best for each of you.
Today is my second day back at work. I have had my office set up with a Lazy Boy type chair - with a footrest - and a wireless keyboard and mouse (the mouse is set upon an Integrity Designs platform attached to my chair, so I don't have to reach far at all to do any work.) Yesterday I went to PT where they worked me over pretty hard - I explained to them how interested I am in being able to ski at the same level again - they believe that there is no reason that cannot happen - maybe not next year, but certainly the year after. So, I am working extremely hard on PT everyday - I can feel it making a difference in the leg. Called the Orthopod today and found out that I can put 50% weight on the leg in about three more weeks, so might be able to walk (with a brace) without crutches by then.
"Scar manipulation" - there is a term for you. The PT put a piece of theraband rubber over the scar yesterday and moved it around for awhile - excruciating.
That sounds like "cross friction massage." It is supposed to keep the skin from adhering to the fascia overlying the muscle. When the scar heals it starts laying down fibers in a random pattern. The fibers can heal downward to the fascia and adhere. This can make the skin pucker and limit movement. The cross friction helps break up adhesions and helps the fibers lay down along the lines of stress. Makes the scar more mobile and stronger. Why they used a piece of T-band is beyond me. I usually stack my middle finger over my index finger and rub perpendicular to the scar.
Yep, you are right, except that this scar is too new to be rubbed perpendicularly. Instead of that, he is using rubber to grab a "large area" and prevent actual reopening of the 11 day old scar. Regardless, all I've got to say is "OUCH!"
Update (February 22)
My wife has been incredible through this, and I am so grateful to her for her help and her refusal to judge my continued high-risk athletic endeavors.
On another note, if you want to read about somebody who has had the same injury and had more problems than any of us, go read this guy's blog: http://www.crazyguyonabike.com/doc/?...c_id=2732&v=59
Saw the orthopod this week. He tells me four more weeks in a straight leg brace - only passive range of motion for that time - he knows me a little too well - without specific instructions, I will push and do more than I should. After the straight leg brace, it'll be a hinged brace for at least some time. He says I can go to 50% weight bearing with crutches immediately, and 75% in two more weeks.
Range of motion - up to 90 degrees this week, and 120 within three more weeks.
When I asked him about getting on a bike, he said we will talk about that the next time he sees me in four weeks.
PT continues to go OK - lot of pain yesterday to even get the leg to 75 degrees. Muscles in my thigh are going into spasms a lot as well - causing me to grunt in pain and grab my leg (and causing a look of great concern with whomever is in my presence at the time).
Not much to say today . . . a little down . . . wishing for some physical activity.
Update (February 26)
My PT bent me to 90 degrees yesterday - I came to work looking and feeling kind of haggard after that. Too bad this had to happen this year - it has been an absolutely epic year in Idaho. Traveled to McCall this weekend where the family nordic skiied and I hung around the room wishing I was skiing. The wife is skiing into a yurt this weekend with some friends - the kids and I were originally planning on heading up to the Masters World XC Championships in McCall at the same time to watch some of the best racers in the world, but it is just too hard to hobble around and get to good locations for watching. Hopefully I can get the kids up to the local hill with their friends so they don't miss too much skiing on account of their Dad.
Still, all in all - I think we are all lucky. We can all be fixed - unlike some years ago - we are fortunate to live when we do. Another of the good things about being injured is you have a little time to reflect on your life and make changes where necessary - a luxury not always available at other times. Also, I don't know about the rest of you, but as news of the injury spread, I heard from very dear friends that I hadn't touched base with for years - joyful to hear from them, even at this time. People really DO care - it affirms my faith in the basic goodness and optimism of humans.
Explanation:"Passive" Range of Motion
"Passive" means I am not supposed to bend the knee using the muscles one would normally use to bend it. So, my PT does it for me, my kids do it for me, and my wife does it for me - I just let it flop there, and they bend it (now past 90 degrees).
They way it has been explained to me is that the injury requires a conservative approach because they really are just sticking a chopped-off tendon onto a piece of bone (the patella), and hoping it re-establishes a connection - the contraption of strings and stitches they have created to keep it there for the meantime really isn't worth a sh#t when it comes down to your quad firing away and creating tremendous stress while skiing. Is that the understanding that you guys all have? What do your docs say about why they want to take a conservative approach?
So, this morning, I was puttering around the kitchen with the straight-legged brace on, but without the crutches. I caught the foot on something and stumbled a little, and felt the knee completely collapse as I unexpectedly put weight on it - was more appreciative of the Orthopod's insistence that I wear it after that - although I am not wearing it in bed anymore.
Spent some time in the pool this weekend. In 4-5 feet of water. I walked 800 yards yesterday and 1200 yards today. Then just did some standing leg raises in every direction while in the pool. I was absolutely thrashed last night, but it felt great - It is awesome to finally be able to do something - ANYthing! The leg can easily be moved to 90 degrees now. Rehab is progressing . . . . Life is good.
Update (March 6)
Surgical repair for this injury is complicated because the remaining 'tendon' must be stretched out and fixated.This effectively shortens the quadriceps and makes it difficult to contract the muscle. It also places a good deal more force on the lower portion of the patellar 'tendon' and the patella itself. The patellar tendon is unusual because it has a bone (patella) floating within it. So, this area is prone to reinjury.
I wouldn't count on Mach, light speed, hip dragging turns any time soon. Even if you can.
I once had a guy slip on ice, whipping his knee into extension in mid air. His patella spontaneously exploded. This was after the quad tendon was repaired.
Further progress on my front - the PT got me to 105* today - she believes I'll be able to ride a bike (indoors only) as soon as I see the Orthopod again - 1 1/2 weeks from today - says you need to be able to flex to 110* to ride a bike. The pool really is incredible - I'm doing the squats that Sinrider does in the water, walking, leg extensions, high leg raises, etc. (all against Dr's orders, I might add - but I am starting to feel a little bit more like myself again - plus its nice to be with other athletes again). Still in a straight-legged brace, but taking it off for longer and longer periods and doing more and more without it.
Vermont Soldier - get in the pool with or without your Orthopod's ok - at about chest level, all of your weight is born by the water - you are risking nothing by doing it -but be careful getting in and out! Have somebody there help you until you are comfortable doing it.
Update (March 10)
My PT bent my leg to 114* this morning. I keep the full range, even though it is stiff and sore, because I'll go walk in the pool tonight, and have my family bend it just as far as it goes afterwards. My PT seems to think the orthopod will release me to ride a stationary bike next Tuesday when I visit him. If so, I plan on spending HOURS on it every week.
Update (March 14)
A quick update. Saw the PT yesterday. She bent my knee to 121* - some stiffness and pain, but not too much. I am close to running in the pool now - did 1400 yards last night - interesting pool - it is 25 yards long, saltwater, and ranges in depth from 3' at both ends to 5' in the middle. It is perfect for walking. While in the pool, I am doing increasing amounts of squats (w/increasing flexion added in), calf raises, leg extensions, and straight-legged hip strengthening exercises. At home, I do at least two sets of 40 isometric quad sets each day, straight-legged hip exercises, and attempt to increase my passive ROM as much as possible. I plan on trying to ride my bike on a trainer with my right leg only this weekend. I see the orthopod on Tuesday, and hopefully he releases me to at least ride a stationary bike.
Update (March 18)
Visited the Orthopod for 6 1/2 Week followup today. As I suspected, he did scold me for doing so much. He was happy that I am getting stronger and feeling ok, but he told me to hold back on weight-bearing ROM because the repair is very delicate and requires babying further. He gave me a hinged brace at 30* for 2 weeks, then 40* the week after and 70* the week after that (I intend to immediately go to 40* and then 70* and then 90* fairly quickly thereafter). He told me to stay on at least one crutch another 2 - 3 weeks. I can ride a stationary bike with no resistance in another week and a half (I'm going home to get on my own bike on a trainer tonight). He took a lot of time to show me the knee on x-ray and explain why the repair is delicate - I believe him, but I also know what I have been doing, and what I am capable of - and it is more than he is suggesting is permissible. Basically, what he is telling me is "Don't hurt yourself". I'll be careful, but I am going to push to be riding again very soon - have a goal of doing a "metric century" road race on June 14 - and I don't intend to miss it!
I will take his advice and directions to heart -I'll obey their "spirit", but frankly, like the rest of you, I need some activity - I'm getting fat and cycling season is coming up fast here in the high desert, and I am not going to miss it. Moreover, cycling a lot this summer is going to help me next winter while skiing.
My orthopedic surgeon told me that my injury simply was not preventable, other than that I simply can't be as dynamic on skis anymore - he also tells me that I should expect to get almost 100% back to the same level of skier I was before. As to prevention, I already do everything right - I bicycle a tremendous amount until the weather gets too icy, then I head indoors to spin class. I do a program starting in early September that is ski specific: lots of weightlifting that is leg specific, a lot of core work, and literally thousands of lunges. I could lose 15 lbs to get back down to my age 22 weight - I am going to work on that this summer. Finally, I could do more core work year round. But, I think the real key for me is that I am going to have to become a little bit more of a short-turn, slice and dice skier, and less of a GS mode skier through steep, difficult terrain - I believe that is what got me into trouble.
Update (March 27)
My PT pointed out to me that 10 weeks ago when she first saw me after the injury, I could not even move my leg in any appreciable way - so, in perspective, I feel as if we have all come a long way since injury and surgery.
Went to the PT this morning and GOT ON A BIKE!!! WOOOOHOOOOO! I'm going home tonight to spend some time on my trainer. She also gave me a bunch of new exercises (Active ROM), and told me the next time she sees me not to bother with the crutch. She believes I am progressing much faster than expected by the orthopod - but again, she counseled that I should exercise caution as nobody has seen too many of these. (I think we all collectively have as much information about how this injury occurs, and how it is treated and rehabilitated as anyone).
Update (April 1)
Advice to fellow sufferers: Look into an "Iceman."
I am still using mine every single night, and I believe keeping the knee on ice 6 - 7 hours a day has been one of the true keys to recovery.
To recap, I started PT three days after surgery. Started with the PT passively bending my leg to 30* and doing isometrics, and gradually increased both ROM and activity levels since then. I am still in a brace - set at 40*, but I walk around the house without it most of the time (one level, no stairs). I have been walking in the pool since the scar was healed - I think this is the activity that has helped me the most. Started with 800 yards, and am still doing 1500 yards three times a week. I would recommend that every single person with this injury do the same - so would my PT. Am also on a bike 30 minutes or so a day - hoping to progress outside in another week or so. In the pool I do lots of weighted squats, calf raises, leg lifts, and stretches. Also do unweighted leg lifts and extensions at home out of the pool. Am now easily actively bending my leg to 125*, and I expect will soon be back to full ROM.
Update (April 10)
I was very optimistic after the last week I had until I went to PT this morning and she brought me back down to earth. I had thought that I would be able to get out of the brace and onto a bike for real after the Doc saw me next week.
She had me do some bosu ball work and some theraband work this morning - the theraband was literally excruciating. Afterwards, she said she didn't see any way that the doc would let me out of a brace, because the theraband work was similar to stairs, and that the bike was simply too chancey (lots of big, steep hills here in Boise - that I can't resist riding up when I'm on a bike). Well, so it is - I'll just keep after it - we all know there are setbacks emotionally with this injury, we just have to pull through it.
One other thing: my PT told me that she wonders if my propensity to be balanced on the outside of my foot while walking contributed to this injury - she is having me do a lot of inside foot work on the bosu ball as a result. Also, she is going to have me jump into a year-round weight training program instead of just the "pre-ski season" and "pre-cycling season" programs I typically do each year.
Update (April 15)
At almost 11 weeks, I am still in a brace set at 90* flexion. I don't use it at all at home anymore, and walked 1/2 mile on Sunday morning without it. Still walking in the pool 1500 yards a pop as often as possible (although my two teenage sons' track, soccer and school schedules is making it very difficult to conduct rehab - but they are only this age once). Cycle at least 1/2 hour most days. Lots of leg lifts, short-arc extensions, balance work, isometric quad work, rolling on a foam roller to loosen up the IT Band and sutured area (ouch!), working with a theraband, doing deep knee wall sits. In short, I am ready to move on.
Seeing the OS on Friday and desperately hoping he lets me get on the road bike - I'll promise not to climb any hills, and will promise not to get on a mountain bike if that is what it takes (I'd have already done it like SinRider, but my wife has expressed her extreme frustration with my refusal to follow Dr.'s orders - she doesn't want to go through another one of these - Soooooo . . . I've not yet got on a road bike to preserve peace in the home). Also desperately hoping he lets me out of this brace - I am done with it and it is not helpful anymore. I really feel and believe that I need to get out and be active in order to fully rehab this thing.
Update (April 18)
Hi guys. 11 weeks out today. Went to see the OS this afternoon. He has a broken ankle from skiing Squaw Valley three weeks ago - bummed, but also is a very good patient.
But the good news is, he told me to ditch my brace, and start riding a road bike (although take it slow)! I am so excited to get home, I can hardly wait! It's like Christmas all over again! But, he did tell me no mountain biking for 2 months (Sidenote: the mountain biking in Boise goes primarily like this: ride out of your house to the north a few blocks. The hill tips to at least 10*. Climb at a powerful but slow rate for at least 3,000* up hills tipping up to 20* in some places. Go down. Repeat). Still, looking forward to lots of easy road biking for awhile.
Update (April 22)
It seems like the better recoveries are those which move forward a little more quickly. Looking back about 11 1/2 weeks ago, I did not expect to be where I am - everybody keep plugging away, and we'll all get there.
Did a couple of rides this weekend. The first day, just did about 10 miles on a flat road with very gentle rolls in it. Felt great, so the next day did about 18 miles with a stiff headwind and a couple of hills up to about 7% grade thrown in. The NEXT day, I was thrashed - both the leg and the body - that's what not cycling for three months 'll get ya'! So, yesterday, went back to a mellow ride - today will do the same. My PT has me working on a bosu ball - very painful to try and stand on just the hurt leg.
I expect to be doing some work with weights by the end of the week - still doing lots of isometric quad sets, and work with a theraband, along with wall sits and cycling.
Update (April 24)
I spoke with my PT this morning about this forum. She has checked it out, and really likes it. She says that she thinks it is helpful to have all the information we have in one place. She also believes that the primary reason for the drastically different protocols is because the injury is relatively rare and not seen often by PTs and OSs. She says with respect to a torn ACL - you would not see the diverse rehab protocols - everybody does them, and everybody knows how best to rehab them. She also stated that she believes the single best thing a person can do is to get in the pool and try walking as soon as the scar has healed - I can vouch for that!
She has me starting weightlifting now. Boy, am I ever WEAK!! Even when I did my ACL five years ago, I had some ability left to lift weights - now nothing. She says it will come back very fast, though. She also says that by far the most important type of lifting to do is "eccentric" rather than "concentric". Eccentric occurs when you are letting a weight back down (the muscle lengthens during this contraction) - concentric occurs when you are pushing it up (the muscle shortens during this contraction). Most all injuries (and I'll bet this includes all of ours) occur during an eccentric muscle contraction. Thus, it makes sense to work that particular movement to ensure it doesn't happen again. So, she says to really, really work the weights slowly as they come down - as slow and steady as possible - over and over and over and over. She says the concentric strength will naturally come, but eccentric must really be worked on.
The thread from which this story is excerpted is now 36 pages long and contains 1067 posts as of 4/20/09. For a relatively rare injury, the thread has attracted many sufferers who support one another in their difficult recovery.
I'm glad that this thread has helped others - it has certainly served its purpose for me - helped me to find others with the same injury and gain as much information as possible. Thanks to all who post.
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