Pre-op Rehab update #2

Thought I’d post a quick update! Had my last Physio session today before going back to Hospital for a consultation, my flexion is up to approximately 70 degrees which I’m relatively pleased with. My original target was 90 degrees to have my foot bend to underneath my knee while sat, however my progress slowed right down – I didn’t think I’d get past 50 odd but I have.

On Sunday I went and watched my Football team play, coincidently against the team I was injured playing against! After the game when I was sat down I noticed that my femur (thigh bone) wasn’t straight when placing my foot flat on the floor, in that it pointed inwards.

I mentioned this to the Physio today and he confirmed I have valgus knee which essentially means my leg bows outwards.

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This could be the result of the damage to the MCL (which would tighten up the joint on the inside of the knee) or that there is some meniscus damage (cartilage) in my knee and that it’s catching and holding my joint in this position. It’s something I’ll need to bring up with the Orthopaedic Surgeon which he’ll hopefully correct (as far as an OS is concerned his job is to fix the ligament aspect of my knee, once that’s done I’m gone and any other problems are for a Physio).

I’ve had a couple of people ask about recovery of my MCL. This can be done with no surgical intervention however in some severe Grade III cases a surgical repair may be appropiate. An MCL will take upto 8-10 weeks to heal for a Grade III (where possible), on that time scale my MCL should just be coming good again unless it’s so badly damaged it needs surgery (which I won’t know until exploratory keyhole surgery).

For those of you that don’t follow football this horror challenge happened a few weeks ago during a Premier League game. The player who got injured, Haidara, lucky sustained no bone or ligament damage – only soft tissue damage and bruising. Very lucky man! Just shows you how robust the knee can be (when it chooses to be!).

That’s it for today, bit of a boring post this one! Sorry. I’ve got nothing. Other than I have a new activity to keep me amused. Drawing eyebrows on dogs.

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Pre-op Rehab update

Thought I’d update you all on my latest escapades! I had my first Physio session on the 19th March, 5 days after my cast came off, to increase the range of motion of my knee and build up strength in my quadriceps. I opted to have Physio at the Doctors surgery near me rather than at the Hospital I was attending as 1) The surgery is pretty much just down the road 2) I’ve worked with a Physio there previously for a sciatica problem.

I was thankfully able to get an appointment with the Physio I had used previously – he’s switched on, knows what he’s talking about and will happily answer any questions/listen to suggestions. Having a good Physiotherapist makes a difference, there are some clowns out there – if you aren’t happy go with a different one.

That'll sort your knee right out!

That’ll sort your knee right out!

As I briefed the Physio on the injury and recovery I stated my wish/need for surgery for my ACL. He pointed out that an outrageous number (9+) of the All Blacks rugby squad who had played in a recent World Cup (2011?) had a missing ACL in one of their legs and played. While this is true they are built like brick shhh houses and the muscle mass in their upper leg allows the knee to be held together and still perform twisting/turning/pivoting without dislocation. The Physio went on to make this point to me but it could still be an option, I reiterated that I didn’t think this was an option for me. He then read the letter from my consultant Orthepaedic Surgeon to my Dr….

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On second thoughts…

He then agreed I’d need surgery. Because of the injury I have and the stage of recovery there is very little hands on Physio, I was given some basic exercises to do:

  • Leg raises sat on the edge of chair
  • Bending knee, sliding heel to bum (with/without using an aid)
  • Rolled up towel underneath knee, while on a bed, and pushing down into the towel with knee
  • Gently rock patella (kneecap) side to side with a thumb each side
  • And of course ice (20mins on/40 off), elevation, and Ibuprofen (NSAIDS) to keep down swelling

My knee flexion was measured at 20 degrees (a straight leg being 0 degrees) which is relatively little. Upon returning one week later I was up to 45 degrees flexion, initial improvements were big and then they dropped off considerably – this is likely to me feeling comfortable with beginning to bend my leg again and relaxing more. When I get to 45 degrees my knee feels similar to when a joint becomes tight before you crack it to release the ‘pressure’. My knee feels tighter and tighter except theres no ‘crack’, not nice. On the physiological side of things it could be that there’s actually damage to my meniscus (cartilage on end of shin/thigh bones) that the MRI didn’t pick up, a tear of the meniscus could prevent me from bending my knee past a certain point. More likely it’s just how tight my knee is at the moment and it doesn’t want to bend any further, however not knowing which it is, is unnerving!

On returning to Hospital on 11th April I want to be bending my knee to at least 90 degrees – I don’t know how much my consultant is expecting me to be able to bend it by then but I’ll be pleased with that. The annoying thing is I’m going to gain my range of motion back and then once I have surgery my knee won’t bend again!! Additionally I’ve noticed that my patellar ligament is numb, this could be down to damage or a trapped nerve – if it’s damage it rules out a patellar autograft :/

And to finish of this entry, a couple of vidoes showing just how easy it is to tear your ACL…

 

The cast comes off… 4.5 weeks muscle atrophy

Owing to the multiple injuries I received my leg was placed into a full leg cast 4.5 weeks to allow these to heal before addressing my ACL. As mentioned in my ACL post the delayed surgicial ACL intervention will not affect the final outcome of my knee recovery (early vs short term delayed surgery).

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However… obviously having been sat or laying down for the last 5 weeks there has been significant muscle atrophy (loss) as it is. My ‘good’ leg is noticeably smaller than what it was previously, my leg casted leg now looks like a twiglet from complete immobilisation. The pictures do not do it justice, I can nearly fit my hands around my right quad.

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My knee still hasn’t got it’s shape back, I think this is primarily due to effusion (fluid on knee). When I lift my right leg into the air my leg/knee/calf are all one, there’s no variation in width…. actually makes me feel uneasy to look at :/

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My knee flexion is approximately 20 degrees (straight leg being 0 degrees), I will need to gain the range of motion (ROM) back in my knee before surgery is on the table, full ROM is required to ensure I can rehabilitate my knee post-op.

So here’s to 4 weeks of Physio!

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Chin Up

Just had to speak to my Doctor and asked him to confirm my injury: MCL grade III tear, ACL complete tear, ruptured patellar femoral ligament with possible damage to my patellar ligament.

Every time I think of my knee injury I think of sitting in Nando’s and pulling a wing apart with the joint cracking and snapping :/

My second consultation tomorrow, my cast is coming off!

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I have no doubt I won’t be able to bend my knee , I’ll need to regain mobility of it before surgery. I think I was given a cast rather than a leg brace/nothing owing to my multiple injuries, I had done too much damage for surgery to be carried out as soon as the swelling had gone down. Additionally the initial diagnosis may have been a Grade II tear of my MCL rather than Grade III, and that a preference was made to allow that to heal first (which as I now know won’t as it’s Grade III). Hopefully more will become clear tomorrow…

With all that said it does get me down, as this kind of injury will to any player/athlete. Although not applicable directly to my situation I came across this video that motivated me, strong words.

This guy overcame challenges bigger than I will ever have to face.

Then this. It never fails to make me smile! Must just be my immaturity ahaha!

Coming to terms with my injury

So I’d been dealt my cards and I couldn’t change them, my ACL and MCL were gone. Upon being told of my injury by the consultant I just wanted to know how long would my recovery be and would my knee recover 100%. No it wouldn’t. Apparently 90% (clearly a vague guess). I told myself it could be worse.

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Taking this onboard I wanted to know what this meant in real terms, would I be able to play Football again like I had been? Would my performances drop? It started to get to me so I began using everyones favourite research tool and searched the web for some real stories and inspiration.

Not this time Lionel.

Not this time Lionel.

Unfortunately a lot of stories seemed to suggest that performance did decrease on return. Not what I wanted to hear! I wanted to steer away from professionals owing to their access to top surgeons/doctors/physios/facilities. One annoying aspect was that people often began to write about their experience (pre-op, start/mid rehab) but never update their entries with their return and the impact on their sprinting! There’s plenty of stuff floating around about joggers successful comebacks but very few on sprinters.

Then I came across this post. Alec Cranford, a US teen entering his senior year at High School (due to my ignorance to crap TV and therefore Glee or High School Musical, I’m not fimilar with US school years, although I’m guessing this is probably around 17 years old?). He tore is MCL and ACL like me, and like me he was a sprinter. Although he only runs track now (400m) as opposed to 100m and 200m, he has cut considerable time off of his 400m PB post injury. While these improvements could be a contributed in part to age-related developments or greater specificity in his training, he still improved on his return.

English Gardner (I’m not having you on) is an American athlete who tore her MCL and ACL in High School. She has returned to take national championships, 60m indoor and 100m outdoor since her injury.

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Leeroy Burrell was yet another American athlete who competed in triple jump and 100m. At the age of 19 (1986) he tore his ACL, returning 18 months later he started competing again and soon was breaking records. He beat Carl Lewis in 100m and broke the 100m world record twice. While he would have been a relatively high-end athlete on injuring himself, and therefore access to better doctors/physios/equipment, his injury was back in the late 80’s – surgery and rehab programs for the average joe have improved vastly since and surpassed what Leeroy would have received.

There have been plenty of professional Footballers who have torn their ACL’s and returned to play:

  • Robert Pires (Right ACL; 2002, left ACL; 2006)
  • Ruud van Nistelrooy (2000)
  • Roy Keane (2001)
  • Michael Owen (2004)
  • Alessandro Del Piero (1998)

The above players all returned to the level they were playing at pre-injury (with the possible exception of Owen). Ruud van Nistelrooy was injured prior to his arrival at Manchster United and Real Madrid where he had huge success, additionally Del Piero also injured himself early in his successful career (he’s still playing now at 38).

For those interested in football I was able to talk to the Head of Medical Services at a top Premier League club recently. Professional footballers often have surgery as soon as the initial swelling has settled (providing there is no collateral damage) and quadricep rehab also begins pre-surgery. While very good results have been achieved through both patellar and hamstring grafts (probably owing to their 500k salary Surgeon), preference is made towards the patellar autograft (I shall cover the Patellar vs Hamstring graft in a seperate entry). Secondary problems faced are often hamstring issues and back pains but this can be avoided with well planned rehab. He couldn’t stress enough the mentality and motivation of the patient is VITAL. If you don’t want this enough, you won’t get it.

What I have learnt through reading all the stories I have come across is the following.

  • ALWAYS follow the advice of your Doctor and Physio.
  • Stick to your rehab program religiously
  • It is a long process, do not force anything

I believe that I will return to play how I was previously although I might be consigned to lose a yard or so on my sprinting. But I’m going to do everything I knee’d to come back and not lose that yard.

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You and your ACL – Everything you need to know…

The knee has four major ligaments, the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the lateral collateral ligament (LCL) and the medial collateral ligament (MCL). The lateral meniscus and medial meniscus act as shock absorbers and gliding surfaces between your femur (thigh bone) and tibia (shin bone).

Right knee, front view

Right knee, front view

This post aims to cover everything you need to know about your ACL

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While among fellow atheletes the seriousness of the dreaded three lettered abbreviation is understood it’s often not fully comprehended, more so with those who have little or no participation in sport.

What’s the function of the ACL?

The ACL is the most important ligament in the knee providing stability to the knee in dynamic movements, such as pivoting, stopping and turning. It consists of two bundles of fibre rooted deep in the femur connecting to two sites on the tibia.

It’s primary function? It stops anterior translation and medial rotation of your tibia in relation to your femur. What does this mean? Without your ACL your shin bone can slide foward and in front of your knee, or when rotating on your foot (rotating to the outside of your leg) your thigh bone will rotate with your hips but your shin bone might not. The knee becomes unstable and dislocation is likely.

With all this instable movement in the knee your meniscus will take additional stress and becomes damaged – don’t be surprised of an early onset of athritis.

I tore my ACL – How long will it take to repair? Do I need surgery?

I’m going to cut straight to the chase here – unfortunately your ACL will not heal, and you will need surgery.

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Why will it not heal? Your knee has a synovial membrane inside which contains synovial fluid, basically a small water balloon around the centre of the knee with a fluid inside to keep everything lubricated. To the bane of every ACL victims life, the ACL is located inside of this balloon. The body’s response to a torn ligament is to bleed, when bleeding occurs a blood clot will form to stop the bleeding and allow repair of the damaged ligament. However the fluid found inside the synovial membrane does not allow blood to clot and therefore the body is unable to repair your ACL.

“I can’t believe it, I’ve a Grade I ACL injury, I’m done for!!!”

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You’ll hear your Doctor talk about Grade I, II or III injuries – these are classifications as to how bad your injury is. The higher the grade the worse it is (although it seems the illogical way around for me!).

  • Grade I – Microscopic tears, your ACL may be stretched out of shape but still functions. If your injury is Grade I you’re lucky. Unlucky Rating: 0/5
  • Grade II – Partial tear, increased knee instability and susceptibility to further knee injury. Unlucky Rating: You should have broke your leg instead.
  • Grade III – Complete tear, your ACL is in two parts and your knee will be very unstable. Unlucky Rating: Or broken both legs.

Grade II and III injuries will require surgery to return your knee to normal functionality however surgery is optional.

In my opinion surgery should not be a choice but a necessity where there aren’t other health issues (old age). Anyone who participates in high-level sport where running and changing direction is involved (Football, Rugby, Basketball, Tennis) will not be able to continue without surgery. Those who do not participate can elect not to have surgery, but I question why people would choose to live the rest of their lives often with the feeling that their knee is going to give out, suffer numerous knee dislocations, deal with their knee locking and increase their chance of athritis.

ACL Surgery/Reconstruction

Straight off the bat I want to put your mind at ease with surgery – you’ll be under general anaesthetic and won’t feel a thing. Speaking as someone who has had general anaesthetic twice previously I actually quite like it, what’s better than falling asleep instantly! It’ll be administered through an IV already in your hand and you’ll be fast asleep within 5-10 seconds, you’ll wake up instantly in post-op with a brand new ACL in your knee.

Your ACL will be reconstructed in one of three ways:

  • Patellar autograft – Fibres are taken from the patellar ligament found between the patellar (kneecap) and tibia (shin), it is common practice that the middle 1/3 of the ligament is removed with bone fragments still attached either end.
  • Hamstring autograft – Fibres are taken from an accessory hamstring (semitendinosus) leaving the primary part intact. Fibres are also taken from an accessory adductor (gracilis) again leaving the primary part intact. The resulting two fibres are often folded in half and braided together to produce a strand four times as thick as a single fibre.
  • Allograft – The same as above, however the fibres are taken from a donor.

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Grafts are threaded through a hole made in the femur and tibia before being screwed into place, et voila! A new ACL.

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With the patellar grafts over time the bone fragments will fuse with the bone at the anchor points, giving a stronger fibre/bone attachment (as the fibres were removed in situ).

Ultimately which graft is used is down to your Surgeon although there are advantages and disadvantages to each one. I will cover this in a seperate entry in detail.

Surgery – When?

It has been a long standing view that surgery should be delayed for at least 21 days however this view has been disputed. In one study (Bottoni, C.R., 2005) that compared early surgery (9 days post) with delayed surgery (6wks post), results showed there were no differences in final functionality of the knee. Although those who had early surgery prevented potential additional damage to the meniscus and quicker recovery. The cause of longer recovery in delayed surgery is that the body has to recovery from trauma twice, from the initial injury and then again from the surgery. Early surgery means the body has to recovery essentially from one trauma. Sports professionals will have surgery as soon as the swelling has gone to reduce recovery time, however for the average Joe early or delayed surgery has no effect on the final outcome. What is important is the condition of the knee pre-op, in that it needs to be in good physical condition with a good range of motion – this will prove beneficial in post-op recovery.

Recovery and Rehabilitation

Recovery will be a long road. While some patients may be able to weight-bear or even walk on the same day as their surgery, their full recovery (participation in sport) will not be obtained until approximately 9 months post-op with some patients often taking upto, and even beyond, 12 months. The reconstructed ACL will be fixated taught which causes the decrease in the range of motion of the knee (alongside the swelling). This is so that when the knee is conditioned again the reconstructed ACL will stretch to its required length, rather than fixate it with less tension in and it becomes slack in time.

Rehabilitation will involve plenty of Physio sessions, the early months will aim to regain full mobility of the knee, before regaining and increasing strength of the quadricep, hamstring and calf. The most dangerous phase is the 3-7 month period, this is the time patients gain full mobility of their knee and begin to eagerly exercise again and sometimes overdoing it.

If you have anyquestions or would like to see something covered please leave a comment and I’ll get to it!

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Living with a torn ACL/MCL…

Having a full leg cast isn’t the best of situations, I’ve come across several issues having had my right leg turn into a peg leg for the best part of 4 weeks now. While few may have casts pre-op ACL surgery, post-op will be a very similar story with a knee brace.

1) Itches

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My knee dislocation was caused by significant trauma and I was getting muscle spasms and twitches around my knee initially, these subsided and the itches replaced them for my entire leg. There’s nothing more agonising than a non-itchable itch. Doctors will advise you NOT to put anything down your cast but when you’ve got to itch, you’ve got to itch. Get some of these:

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Job done.

2) Is Number 2

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This guy has bigger issues.

Underwear, for me, is the hardest part of this quest. Stopping just short of removing everything, I will drop everything to my ankles and I will hop one leg out using my crutches keeping my shorts and underwear amast on my casted leg. The reason for this is when it comes to putting your finest silks back on, reaching down to a foot on a fully extended casted leg is a chore and an impossibility for some.

By the time it comes to going to the toilet you’re going to have got up and down from your resting pit multiple times to have your own technique of getting up and down. Approach the toilet in exactly the same way…

While I have quads strong enough to crack walnuts leg press 4000kg and can lower/lift myself unaided, I still use a fixture and one crutch to lower myself. Due to how high my leg cast reaches I have to place my leg facing out to one side. Failing this you can also have something to place your leg onto in front of you that’s the same height as your toilet.

3) Supplies

Common sense does not come easy for some, supply your pit. If you have someone on hand to help you it’s not as bad, make sure you’re prepared! Have a couple of large bottles of drink next to you alongside a few snacks. Again, Dr says don’t carry anything with crutches. Unless you’re a complete reta idiot you’ll be competent of using them with a carrier bag hanging on one handle. The plastic shopping bag has become my trusty supply vessel, helping me carry multiple items from the kitchen back to my pit – just be sure not to put anything too heavy in there!!

4) Boredom

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I have a hell of a lot of time on my hands and essentially bed bound. Thankfully we live in a digital age and the internet has provided me with many a TV series and film to watch, but theres only so much you can watch wrapped up in your quilt. Sods law has it my PS3 broke the day after my injury too. However use this time to your advantage, take that course you’ve been thinking of doing, learn something. There’s plenty of stuff you can learn or courses you can take for free on the internet – not only will this take away your boredom and pass time, but it will create a positivity which will in turn help you get through the bad times.

My biggest qualm with having a full leg cast is I can’t have a bath or shower. You can buy plastic covers for your cast so you can fulfill this basic human necessity however I can’t find one that covers my entire cast. For this reason I have had to result to washing like a tramp at a service station in the sink.

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No tramps washing in sinks on google funnily enough…

The Day I Obliterated My Knee – 10/02/2013

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Hi I’m Tom! 25 years young, I have a white tie and friends that like to touch me.

I also have a full leg cast.

That’s me with my friend Kyle. The date is Sunday 10th February 2013 at 1300hrs. An hour previously I was running around playing Football like any other Sunday, why was I now in Hospital?

I play RB, for those of you not Football savy thats right-back or on the right side of defence. The ball had been played over the top of me and I was sprinting back towards my own goal, and the ball, to nullify the impending danger. Speed and explosive strength have always been my best attributes so I was off like a whipper snapper and was shifting up through the gears….

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The CB (centre-back, the player who players next to me in the centre of defence) has also started to run towards the ball, accompanied by an attacker. Now I can’t be entirely honest with you what happened next, there have been contradictory stories, but I think it’s clear.

We collided. Two of us or the three of us, the right side of my body taking the brunt of it. No big deal, it’s common. One point of impact was the outside of my right knee, the knee of the leg I was standing on. My knee collapsed. As I hit the grass I let out an almighty man scream drawing the attention of everyone within a 1 mile radius, polluting the previously peaceful rural landscape into one of murder scene. I have played Football continuously since I was 5 at several different levels, I have received my fair share of injuries but this is my first serious leg injury and boy did I hit the jackpot!!

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I’d never felt pain like it and could tell straight away I was in serious trouble. I continued to man scream for what seemed minutes (in reality about 30 seconds) before I was able to begin to gain some control over the pain. The game was immediately stopped and an audience assembled to gain clarity as to what possessed me to sound like a psychopath fox having sex. In this moment of torment I still raised a laugh by asking a photo to be taken as I couldn’t bring myself to look at what mess my leg was in.

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While it looks pretty innoncent, at first I thought that my kneecap had gone for a trip to the inside of my leg. Turns out that the big lump is actually the bottom of my femur (thigh bone), and the little lump coming coming from left of the big lump is one of my ligaments.

At this point I had a 20st (280lbs) referee squatted on his heels next to me, presenting his loins unto my face 60 minutes into a game, which pissed me off before he decided to give me a pearl of wisdom that I’d broken my leg. I now demanded to see the picture and knew this wasn’t the case, believeing it was my kneecap. I looked down at my leg and could see that my tibia (lower leg) was misaligned with my femur, with my lower leg being closer to the floor than my upper leg.

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I daren’t attempt to move my leg because of the pain it had caused and from seeing that the bottom half of my leg was clearly not connected to the rest of my leg correctly. The paramedics shortly arrived and gave me gas and air, what a wonderful creation! Within a minute or two I was high as a kite and talking absolute rubbish as I gave my consent for my boots to be cut through. After securing my knee and putting me into the Ambulance I was on my way to Accident & Emergency at the local Hospital. On arrival I received a shot of morphine and sank into the bed as the Dr took my foot (which was still pointing outwards) and rotated it in towards my left leg. I thought morphine was supposed to block pain?! With one final agonising moment my knee popped back together with instant pain cessation before I was rushed off for an X-Ray to make sure there were no breaks/fractures. The Dr told me two people were waiting to come in and see me and could they come in, expecting to see my manager and his wife I was totally taken a back to find two of my best friends, Curt and Kyle, walk in who had found out I had ended up going to Hospital.

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I was told that I had dislocated my knee with a sublaxted (dislocated) kneecap. I’d need a MRI (magnetic resonance image) scan within the next couple of days and return within the week for a consultation.

I attended my consultation and briefied the consultant what had happened before sitting in silence for the next 10 minutes as he looked at the MRI images in front of me as I occasionally caught a glimpses of the preliminary comments. I didn’t care particularly what I had done to my knee so long as my anterior cruciate ligament (ACL) was ok. The preliminary comments said it wasn’t clear but there appeared to be some damage to my ACL. Finally the consultant spoke after examining the images some more. And my heart sank.

“You’ve a grade II or III tear of your ACL…”

I was told I’d also torn my medial collateral ligament (MCL) alongside damaging other parts of my knee. I can’t tell you specifically what as I wasn’t really listening from “ACL” onwards. I know however that my lateral collateral ligament (LCL) and posterior cruciate ligament (PCL) are intact. My attention was quickly shifted when I was giving the fun task of picking my replacement cast colour!

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(I chose Blue)

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My second consultation is on 14th March 2013, 4.5 weeks post injury. The consultant wanted to completely immobilise my knee to allow for everything to tighten up around the joint before keyhole surgery to assess recovery and then surgery to repair my ACL. I’ll update more about this approach and my injury detail following my second consultation as literature advises otherwise.

Oh, and to top it off I was gingerly told by my manager that the opposition player wasn’t near the collision, and that it was with my own player whose foot struck my knee. Talk about friendly fire!