e
 
AUG 20, 2020 - present
 
Trip Report #: 449     

An (Ongoing) Trip Report
for

Recovery From a Knee Injury (Torn ACL + Torn Meniscus)


In August 2020, after a pretty amazing summer of climbing, I tore my ACL and meniscus in my right knee, while descending from a climb in Rocky Mountain National Park. The injury was bad enough and the terrain rugged enough that I had to be helicopter evacuated off the mountain. A couple of weeks later I got surgery to repair my ACL and meniscus. This page documents the recovery process.


INTRO

In August 2020, while jumping from one boulder to the next coming down from the summit of Arrowheadmy knee buckled underneath me and it sounded as if a small explosion went off in my knee....$#!&....

This page contains:
  1. Accident Report (copy/pasted from my Goldfinger trip report)
  2. The Injury (copy/pasted from my Goldfinger trip report)
  3. Recovery "Trip Report" 



Accident Report


I tried to stand up, but my knee buckled and a wave of excruciating pain shot through my leg. It was pretty clear that my knee would not support my weight. Nate and I had to make a decision: Do we try to self-rescue (which would involve me crawling a couple of miles of quite rugged terrain to the trail and then Nate piggy-backing me out from there) or do we call the Rocky Mountain National Park Search and Rescue team while we still had cell service? The summit of Arrowhead gets a bit of cell service (Verizon at least) and ever since my life-(or at least leg-)saving phone call for a serious tib/fib injury in 2010, I always bring my phone on a climb. Both Nate and I lean towards self-rescue if possible. I tried to stand up again, and again my leg buckled and and I yelped in pain. Okay, maybe I was less ambulatory than I thought. We decided to make the call to SAR. We wrapped my leg in my small climbing pack to attempt to stabilize it. I began to sideways crawl and butt-scoot along the summit ridge towards the rappel route while Nate passed on the necessary details to the SAR team (i.e. my status, our plan to self-rescue to upper McHenrys basin, and the approximate location of our bivy site there). What is normally a casual 10-15 minute romp from the summit to the top of the rap route became a rather butt-bruising 2 hour scoot. Once we arrived at the rappels, Nate lowered me while I used my good leg and two hands to keep my knee from hitting the rock. From the base of the two rappels Nate belayed me for another rope length while I butt-scooted down the steep granite slabs towards the bivy cave where we had stayed the night before. The entire descent from the summit, which typically would have taken under an hour, took just over 3 hours (which actually isn't too bad considering the circumstances). We re-established ourselves at our bivy site and waited for the SAR team to arrive. I wolfed down a handful of expired pain meds and tried to study some math and Nate tried to read a book. The 3-person ground SAR team arrived a few hours later. The medic assessed my condition and splinted my knee, and then the team assessed the best means to get me out. The main means of rescue in RMNP are foot, horse, helicopter land and load, and helicopter hoist. Due to the rugged location and my non-ambulatory status, the SAR team deemed it best to request assistance from a Colorado National Guard helicopter from Buckley Air Force Base to extricate me via a hoist operation, using a winch operated cable. It was too late in the day for the chopper to come that evening, so we all settled in for the night. The Blackhawk chopper arrived as scheduled the next morning at 8:00am for their first recon loop. They had to make two attempts to successfully lower a rescue personnel, who strapped me into a screamer suit, grabbed the swinging 100-foot cable, clipped us both in along with my pack, and signaled the chopper to begin winching us up as it flew off. Eight minutes later we touched down at Upper Beaver Meadows. Nate had hiked out early and was there to meet us. Part of the reason for this was to avoid the costly unnecessary ambulance ride, but the best part was seeing a familiar and friendly face. I made some calls to my insurance company to make sure the Estes Park Hospital was in-network, and after confirming it was, Nate dropped me off at the ER for the day, telling me to call him when I was ready to be picked up. I couldn't ask for a better friend and climbing partner.

Once more, I want to express my gratitude to the Rocky Mountain National Park Search and Rescue Team, the Colorado National Guard helicopter team, and most especially to Nate for executing this rescue with efficiency, precision, and compassion. 


ACCIDENT/RESCUE TIMELINE

Hurt knee near summit: 12:05 pm, Thursday, August 20
Phone call to SAR: 12:25 pm
Top of rappels: 2:03 pm
Back at Bivy: 3:20 pm
SAR arrives: 6:48 pm
Helicopter pick-up: 8:23 am, Friday, Au gust 21
Upper Beaver Meadows: 8:31 am
Estes Park Hospital: 11:20 am


PHOTOS

Photos from the successful evacuation below.


Photos:
Photo descriptions:

DAYS
1&2
AUG 20&21
2020

ACCIDENT
&
RESCUE



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1. We wrapped my leg in a pack and I crawled from the summit to the first rappel anchor.
2. We set my hot pink rope on a boulder to help the Search and Rescue Team find us.
3. I tried to study a bit as we waited for SAR to arrive.
4. The ground SAR team.
5. Split and rope.
6. The ground SAR team.
7. Making radio contact with the helicopter.
8. The view of Chiefs Head must be amazing.
9. Blackhawk helicopter.
10-22. The hoist.
23. Safe in the chopper.
24. In the hospital filling out some paperwork....getting ready for some bad news....




The Injury


The ER at the Estes Park Hospital was characteristically empty when I arrived, and a nurse rushed to meet me with a wheelchair as soon as she saw me hop out of Nate's truck. I spent the next several hours filling out forms, being prodded, getting x-rays and an MRI, talking with the attending ER doctor, scheduling some surgeries, and texting my parents in the interim periods. The news was not good (red highlights are the main ones requiring surgery and long-term recovery):
  1. Fracture of the posterior aspect of the lateral tibial plateau, predominantly a nonarticular cortical depression fracture, but there is also an osterchondral component involving the posterior articular surface.
  2. Cartilage defect (approximately 12x4 mm) within the posterior lateral tibial plateau at the osterochondral fracture site.
  3. Torn proximal ACL.
  4. MCL and FCL sprains. No high-grade tear identified.
  5. Large, displaced bucket-handle tear of the lateral meniscus with the handle displaced into the intercondylar notch, slightly greater anteriorly.
  6. Vertical longitudinal tear of the peripheral posterior horn of the medial meniscus (ramp lesion).
  7. Large hemarthrosis with posterior capsular tear and extensive hemorrhage and edema within the popliteal fossa.
  8. Bone contusion of the anterior aspect o the tibial plateau involving the medial and lateral aspect and a smaller bone contusion of the posterior medial tibial plateau. Small osterochondral impaction fracture of the anterolateral femoral condyle at the condylopatellar sulcus and bone contusion of the upper peripheral lateral femoral condyle.
  9. High-grade partial thickness tear of the mid substance of the quadriceps tendon at its patellar insertion measuring approximately 13 mm in length. The peripheral fibers, lateral greater than medial, are intact. (Note: This quadriceps tendon damage was likely a pre-existing and healing overuse injury I had developed the previous year from too much running.)
Well, that why I couldn't walk. Seems like my knee basically exploded inside me. I'm pretty appalled at the level of damage from what had seemed to be a benign jump from one boulder to another, but it seems most likely to me that I had a torn ACL already, from 7 years previous when I had popped through into a crevasse, torqued my knee into such an unnatural position and heard/felt a pop, and proceeded to pay an ortho specialist $300 to tell me I just had a sprain; it was the (probably already torn) ACL that gave out first and then as my weight continued to come down on my knee the rest was just a cascade of snaps and tears. Needless to say, I am in for a long haul recovery....again...



Recovery
(will be updated as needed)


 RECOVERY TIMELINE (WITH PHOTOS)

Key:
Days from injury
Days from surgery

|_Injury/
Helicopter/
Hospital/ Surgeries
|_Appoint./
Tests
|_Physio related |_Other
DAY
0
12:05 pm, Thu,
Aug 20
Injury. Hurt knee near summit of Arrowhead.

1.  

1. We wrapped my leg in a pack and I crawled from the summit to the first rappel anchor.

DAY
1
Fri,
Aug 21
Helicopter Evacuation

2.   

2. The hoist.

DAY
1
Fri,
Aug 21
Hospital. Estes Park Hospital.

3.    

3. In the hospital filling out some paperwork....getting ready for some bad news....

DAY
2
Sat,
Aug 22



Nate and Scott drive me and my car to Boulder.
DAY
2
Sat,
Aug 22


• Thigh circumference 36-49 cm, Calf 32 cm.
• Knee pretty swollen.
DAY
4
Mon,
Aug 24



Classes start at CU Boulder (thanks to Covid, all of my courses are online via Zoom).
DAY
4
Mon, 
Aug 24

Consult. With Dr. Khemarin Seng at Boulder Center for Orthopedics and Spine. Scheduled surgery for 10 days later. Given the go-ahead to hobble around. Goal is to get the swelling down and some mobility before surgery. 

Encounter Notes:

History of Present Illness

Stephanie is a pleasant 37 yo female, presenting today for evaluation of her right knee after she was hiking out from climbing on friday 8/21/2020, missed a step, felt a pop in her knee and the "knee blew out," and the national guard had to come pick her up, went to estes park ED, had x-rays/mri's, and has been non-weight bearing in straight leg knee immobilizer.

pain is okay and taking no pain medications as long as she doesn't move it or weight bear,

hasn't been icing much due to the lack of pain, has been elevating a little bit,

hx of left tib/fib fracture

has pre-lim stats exam on friday for her PHD.

denies numbness/tingling, denies chest pain, denies sob, denies difficulty of breathing

Review of Systems None recorded
Physical Exam
Patient is a 37-year-old female.

RLE: moderate edema, no erythema/ecchymosis, ttp posterior/lateral tibial plateau, ttp superior patella/quad tendon insertion, nttp med/lat joint line, intact pain free straight leg raise w/ 5 degree extensor lag, flexion 0-80 w/ pain at end range, +lachman, guarded +pivot shift, unable to assess mcmurray's due to rom limitations, grossly nvid

Procedure Documentation None recorded
Results/Interpretations None recorded
Assessment and Plan

Assessment: right knee pain/injury s/p hiking fall, right knee mri review (acl tear, bone bruises of tibia/femur, lateral meniscus tear w/ bucket handle tear, medial meniscus tear ramp lesion, mcl strain, fcl strain, hemarthrosis), dr. seng recommended discontinue straight leg knee immobilzer, dr. seng recommended RLE WBAT & PT/hep/"prehab" for rom (rx sent to PT @ BCO), follow up with dr. seng on 9/1/2020 for rom recheck, or sooner w/ issues/concerns

Plan: I discussed the pertinent anatomy, etiology, and pathology of the patients issue with stephanie, advanced imaging was reviewed and discussed with the patient. Images and reports reviewed with patient within the context of their musculoskeletal issues. All pertinent questions were answered.

right knee mri impression:

1) fracture of the posterior aspect of the lateral tibial plateau, predominantly a nonarticular cortical depression fracture, but there also is an osteochondral component involving the posterior articular surface

2) approximately 12 x 4mm cartilage defect within the posterior lateral tibial plateau at the osteochondral fracture site.

3) torn proximal acl

4) mcl and fcl sprains, no high-grade tear identified

5) large, displaced bucket handle tear of the lateral meniscus with the handle displaced into the intercondylar notch, slightly greater anteriorly.

6) vertical longitudinal tear of the peripheral posterior horn of the medial meniscus (ramp lesion)

7) large hemarthrosis with posterior capsular tear and extensive hemorrhage and edema within the popliteal fossa

8) bone contusion of the anterior aspect of the tibial plateau involving the medial and lateral aspect and a smaller bone contusion of the posterior medial tibial plateau. small osteochondral impaction fracture of the anterolateral femoral condyle at the condylopatellar sulcus and bone contusion of the upper peripheral lateral femoral condyle

9) high-grade partial thickness tear of the mid substance of the quadriceps tendon at its patellar insertion measuring approximately 13mm in length. the peripheral fibers lateral greater than medial, are intact

- dr. robert leibold

dr. seng counseled that surgery is highly recommended for the meniscal injuries, and recommended for the acl tear, but we need to wait for the swelling/inflammation to decrease, and work on her range of motion.

dr. seng recommended cycling program/range of motion/heel slide & leg extension exercises, and obtain good strength/rom of the right knee, to allow inflammation/swelling to decrease and increase her range of motion

dr. seng counseled stephanie may wean from brace and crutches as tolerable, and that stephanie be wbat rle, all to allow her to start pt/rom/prehab

recommended ice every day, warm epsom salt soaks,

dr. seng counseled no cutting/pivoting/twisting, no bouldering,

dr seng recommended acl repair with hamstring autograft and med/lat menisectomy vs repair tentatively planned for 9/3/2020, and in office recheck with dr seng on 9/1/2020

follow up with dr. seng on 9/1/2020 for rom recheck, or sooner w/ issues/concerns


I discussed the risks, benefits, and alternatives to the treatment plan, answered all questions satisfactorily, the patient agreed with plan. Patient will call if anything worsens or if they have any concerns.

F/u: follow up with dr. seng on 9/1/2020 for rom recheck, or sooner w/ issues/concerns

60 minutes was spent in face to face contact, greater than 50% of which was spent discussing in coordination and care.

Case discussed with Dr. Seng who agreed with assessment and plan.


1. Pain in right knee
M25.561: Pain in right knee
  • PHYSICAL THERAPY REFERRAL -
          Schedule Within: provider's discretion
    Evaluate & Treat: RT knee pain & acl tear, RT knee rehab, stretching/strengtheing, quad/hamstring/glute strengthening Visits per Week: 1-2
    Total # of Visits: 16 Exercises: RT knee pain & acl tear, RT knee rehab, stretching/strengtheing, quad/hamstring/glute strengthening
    Modalities: deep tissue massage, dry needling, ultrasound, kineseo taping, heat/ice therapy, e-stim Knee Rehabilitation?: Y
    Lower Extremity Stretching Program?: Y Protocols: acl injury/acl reconstruction in future possibly

DAY
4
Mon, 
Aug 24


• Hobbling slowly around the house in knee brace, 100% weight-bearing.
• Not too much pain.
• Swelling decreasing. Mobility increasing a bit.
• Icing on occasion and propping leg up while sitting down.

• Able to drive my car.

4. 

4. 
Life is always better when you have a cat in your lap. 
DAY
5
Tue, 
Aug 25



Numerical Analysis Preliminary Exam.
DAY
8
Fri, 
Aug 28



Probability & Statistics Preliminary Exam. 
DAY
11
Mon, 
Aug 31

Pre-operative COVID Test. No COVID!
DAY
12
Tue, 
Sept 1

Pre-operative Consult. With Dr. Khemarin Seng at Boulder Center for Orthopedics and Spine.
Encounter Notes:
History of Present Illness None recorded
Review of Systems Patient reports no fever, no night sweats, no significant weight gain, no significant weight loss, and no exercise intolerance. She reports no dry eyes, no irritation, and no vision change. She reports no difficulty hearing and no ear pain. She reports no frequent nosebleeds and no nose/sinus problems. She reports no sore throat, no bleeding gums, no snoring, no dry mouth, no mouth ulcers, no oral abnormalities, and no teeth problems. She reports no chest pain, no arm pain on exertion, no shortness of breath when walking, no shortness of breath when lying down, no palpitations, and no known heart murmur. She reports no cough, no wheezing, no shortness of breath, and no coughing up blood. She reports no abdominal pain, no vomiting, normal appetite, no diarrhea, and not vomiting blood. She reports no incontinence, no difficulty urinating, no hematuria, and no increased frequency. She reports no abnormal mole, no jaundice, and no rashes. She reports no loss of consciousness, no weakness, no numbness, no seizures, no dizziness, and no headaches. She reports no depression, no sleep disturbances, feeling safe in relationship, and no alcohol abuse. She reports no fatigue. She reports no swollen glands and no bruising. She reports no runny nose, no sinus pressure, no itching, no hives, and no frequent sneezing.
Physical Exam
Patient is a 37-year-old female.

Procedure Documentation None recorded
Results/Interpretations None recorded
Assessment and Plan

ACL tear, lateral meniscus tear, medial meniscus tear ramp lesion, mcl strain, fcl strain, hemarthrosis-- proceed with r knee scope. ACL recon ALLOGRAFT, bilat menisectomies v. repairs. Work on stretching, begin PT post-op. FU post-operatively.

M presents to the clinic today for further discussion of R knee scope. ACL recon bilat menisectomies v. repairs. BSC. ROM check. She has some mild swelling and tightness in her hamstrings. She has some questions. She likes to hike and climb. She is inquiring about ALLOGRAFT

M's past right knee radiographs appear to indicate chondrocalcinosis.

exam with 3-95

mild effusion

+Lachman

better exam than last week.

R knee past MRI: acl tear, bone bruises of tibia/femur, lateral meniscus tear w/ bucket handle tear, medial meniscus tear ramp lesion, mcl strain, fcl strain, hemarthrosis

M's range of motion is better than previous visit, but still limited within its range. Her comfort with her knee appears better. I recommended waiting a couple more weeks in order to continue to improve her ROM, she would like to proceed sooner with treatment and risks with arthrofibrosis. . As stated previously I think she is a good surgical candidate for r knee scope. ACL recon, bilat menisectomies v. repairs. I explained the risks of surgery to M based on her limited ROM, because rehab and PT will be much harder if she lacks ROM. We discussed allograft vs. autograft. She elected to proceed with allograft. I answered all questions. She should continue stretching, stationary bike, FU post-op, begin PT post-op.

ACL recon

Allograft

meniscal treatment

25 minutes was spent in face to face contact, greater than 50% of which was spent discussing and coordinating patient care.


1. Complete tear, knee, anterior cruciate ligament - Right
S83.511D: Sprain of anterior cruciate ligament of right knee, subsequent encounter
  • PHYSICAL THERAPY REFERRAL -
          Schedule Within: provider's discretion
    Evaluate & Treat: post r knee scope. ACL recon ham auto, bilat menisectomies v. repairs, work on swelling and ROM

2. Bucket handle tear of lateral meniscus of knee - Right
S83.251D: Bucket-handle tear of lateral meniscus, current injury, right knee, subsequent encounter

3. Tear of medial meniscus of knee - Right
S83.231D: Complex tear of medial meniscus, current injury, right knee, subsequent encounter

4. Sprain of medial collateral ligament of knee - Right
S83.411D: Sprain of medial collateral ligament of right knee, subsequent encounter
  • MEDIAL COLLATERAL LIGAMENT INJURY: CARE INSTRUCTIONS

5. Hemarthrosis of right knee
M25.061: Hemarthrosis, right knee

6. Chondrocalcinosis of joint of right knee
M11.261: Other chondrocalcinosis, right knee
DAY
14 / 0
(2 weeks from injury)
Thu, 
Sept 3
Knee Surgery. ACL repair via allograph + double meniscus repair.



5.    
6.    
7.    
8.    

5. Covid-style waiting room. 6. Taken less than a day after surgery, working on some homework. 7. My pharmacy improved thanks to thoughtful friends Cassie and Taylor. As for pain meds, I ended up being able to keep the pain tolerable with just Tylenol and ibuprofen and hazelnut snickers. I'll save the two bottles of narcotics for my first aid kit. 8. It's great to have friends that understand.

DAY
16 / 2
(2.3 weeks)
Sat, 
Sept 5


• Allowed full weight bearing and bending leg 60° down from fully extended (bending limited due to meniscus repair).
• Hobbling slowly around the house in knee brace without crutch support, 100% weight-bearing. Apparently typical ACL repair recovery timeline is to be on crutches for about a week after surgery, so already I am ahead of schedule, despite the meniscus repair to boot. That's a good sign!
• Munching Tylenol and ibuprofen and avoiding the narcotics.
• Icing on occasion and propping leg up while sitting down.

9.    
10.  

9. I was curious to see how the incisions were looking. 10. The fancy knee brace they gave me can be set to lock off at any angle. It's set to 60° for awhile.
DAY
21 / 7
(3 weeks from injury)
(1 week from surgery)
Thu, 
Sept 10

Post-operative Follow-up. With Dr. Khemarin Seng at Boulder Center for Orthopedics and Spine. Stitches removed.
Encounter Notes:
Assessment and Plan

1 week s/p R knee scope. ACL recon ham allo, bilat menisectomies v. repairs. 9/3-- making good progress. Brace readjusted. Initiate PT at MedX with Dr. Scrivner. WBAT 0-60. Progress 5-6 degrees per week. FU 4 weeks

Stephanie presents to the clinic today for routine post-op evaluation for R knee scope ACL reconstruction ham allo, bilateral menisectomies v. repairs 9/3. She reports that she is doing well. The brace feels a little loose, but with the cooler weather coming she will be wearing pants more and doesn't necessarily mind.

Right knee:

There is a good resting attitude of the knee

skin looks clean, dry, healthy,

sutures removed

3-60

Intra-operative arthroscopic images reviewed

I am limiting her range of motion to 60 today. Increase 5-6 degrees per week. In 1 month she should be near 90 degrees ROM. She will begin therapy in Estes at MedX with Dr. Scrivner, ACL and meniscal repair protocol. WBAT. She should do heel slides daily. Can do upper body workouts now. May remove brace at night if she is a calm sleeper, if she is waking herself up with pain or wakes up in pain, wear brace to bed. From 6-12 weeks we can push past 90 degrees. FU in 4 weeks.

25 minutes was spent in face to face contact, greater than 50% of which was spent discussing and coordinating patient care.


11.    
12.   

11. Got the stitches removed 7 days after surgery. 12. Still some swelling. And calf is experiencing some atrophy (-1.5 cm of circumference so far).
DAY
21 / 7
(3 weeks)
(1 week)
Thu, 
Sept 10


• Hobbling around doing errands (not just my apartment any more) in knee brace without crutch support, 100% weight-bearing.
• Still only allowed to bend leg 60°from horizontal and increase this by 5° per week.
• No pain medications needed. I don't really have any pain.
• Icing on occasion and propping leg up while sitting down.
• Swelling decreasing.
• Driving again. My knee feels fine to do so.
• Thigh circumference 36-46 cm (-3 cm), Calf 30.5 cm (-1.5 cm).
DAY
24 / 10
(3.4 weeks)
(1.4 weeks)
Sun, 
Sept 13


• Walked about 3.5 miles, with crutches to absorb about 20% of my weight on my injured knee. For short distances, I don't use crutches.
• Walking carefully around my apartment without the brace. Gotta be careful not to trip but it feels nice to have the brace off and knee actually feels pretty stable for just walking around my apartment. This might have something to do with the fact that - unbeknownst to me - I had a pre-existing ACL tear for the last 7 years that caused my knee muscles to have to strengthen a bit.


13.   

13. 3-mile walk. The red material is to cushion the crutch handles. Crutches aren't too comfortable after an hour straight....my fingers are going a bit numb from pinching of some nerve in my armpit....
DAY
26 / 12
(3.7 weeks)
(1.7 weeks)
Tue, 
Sept 15


• Physio Appointment #1. With Rob Scrivner at MedX of Estes.  Rob Schrivner is a fellow climber and physiotherapist in Estes Park. He understands my goals of getting back to boulder-hopping, scree-sliding, drop-knees, and offwidths. 
• Prescribed daily physio (Forward Ts, Planks, Step Downs and Step Ups, Leg Raises, Single Leg Stance, Passive and Prone Knee Extensions, Patellar Glides). I plan to do physio+walking for at least 2 hours every day, as I see it as my ticket to getting back to climbing by the spring.
• Some soreness after physio exercises. Lots of tightness trying to bend knee past about 70°. Main focus at the moment is straightening the leg fully and even hyperextend slightly. The fact that I am able to fully straighten (albeit with a bit of discomfort and difficulty) is apparently ahead of schedule for most ACL/meniscus recovery timelines. That's a good sign.
• Walking 3 miles (1 hour) a day in brace without crutches. I limp a bit in the brace, but I don't feel much pain or weakness in the knee. 
• Haven't felt the need to ice the knee due to not much swelling or pain.
• Have developed a seroma on one of my incisionsAbout a week after surgery, I noticed that one of my four incisions had a growing bump underneath. Google tells me this is called a seroma. A seroma is a collection of fluid that builds up under the surface of your skin. Seromas may develop after a surgical procedure, most often at the site of the surgical incision or where tissue was removed. The swelling and fluid may start right away, or may start collecting several weeks after surgery as it did in my case. Minor, small seromas like mine don’t always need medical treatment. That’s because the body may naturally reabsorb the fluid in a few weeks or months. So I guess I will just wait and see. I have bigger priorities at the moment. See photo below. (Update: It took about 6 weeks for the seroma to dissipate to the point where it was barely noticeable.)

14.    
15.    
16.    
17.    

14. Awesome to have a physiotherapist as psyched as me to get me back to climbing as soon as possible. 15. Doing "passive knee extensions" with weight as I watch a lecture to try to get my leg fully straight. 16. Daily 3 mile walk. No crutch support now. 17. Seroma.
DAY
32 / 18
(4.6 weeks)
(2.6 weeks)
Mon, 
Sept 21


• Physio Appointment #2. With Rob Scrivner at MedX of Estes.
• Rob was pleased with my improvement over the last week. He recommended continuing the same exercises for another week, but adding in some 70° squats and making the balance exercises more challenging by using a foam pad or closing my eyes. He also recommended massaging the seroma to try to get it to break up and get re-absorbed by my body. I did this for a day or two before getting bored of that exercise (my diligence on physio is clearly a bit selective.)
• The 3 mile walk and going up and down stairs is getting easier by the day. The progress gives me hope and motivation.
• No issues (pain, stiffness, etc.) straightening and even hyperextending the leg.
• Thigh circumference 36-47 cm (-2 cm from normal but +1 cm from 2 weeks previous), Calf 31 cm (-1 cm from normal but +0.5 cm from 2 weeks previous). Looks like atrophy has been pretty minimal due to the fact I got back to weight-bearing quickly.
• I officially stopped wearing the brace 3 weeks after surgery. This would be a bit too soon by most protocols (some protocols suggest wearing a brace up to 2 months following an ACL+meniscus repair) but my knee feels stable and strong, isn't swollen or painful, and my walking has a much more comfortable and normal gait without the brace. The main reason for the brace is to protect my vulnerable ACL graft and meniscus repair against an unexpected trip or biker careening into me on the walking path. Given how stable my knee feels and how nice it feels to walk without the brace, I've decided to take my chances. I hope I don't regret this decision.


18.    
19.    
20.    
21.    

18. My daily 3 mile walk. If I am going to take the risk of not wearing a brace, I am at least going to make the terrain as flat and predictable as I can. 19. I've added stairs to my daily routine. I was able to start going down stairs (with difficulty) at about 2 weeks after surgery, and by 3 weeks after surgery it is getting pretty easy although there is tightness in the injured (right) knee when I step down with my good leg and my right knee has to bend. 20. Walking without the brace, 3 weeks after surgery. Besides for a slight limp, the knee behaves fairly normally for walking on a flat path at just over 3 mph.
DAY
40 / 26
(5.7 weeks)
(3.7 weeks)
Tue, 
Sept 29


• Physio Appointment #3. With Rob Scrivner at MedX of Estes.
• Rob was pleased with my progress, and gave me a couple of additional exercises to do and the go-ahead to start using some weight machines, as long as I continued to not bend the leg past 90° (again, not wanting to overload the meniscus repair is the reason for this, rather than the ACL repair).  
• Rob is going on a climbing trip for a few weeks, but I can continue with my daily physio routine and weights and hopefully be ready to start bending past 90° by next appointment with him in a few weeks. I loaned him my Needles (California) guidebook and hope to hear of some awesome climbing he did on his trip.
• After a week in the gym, thigh circumference 36-49 cm (back to normal), Calf 31 cm (-1 cm from normal still). So I've seemed to have beat the atrophy. I'll maintain the gym workout sessions to keep my body and knee strong, so all I am waiting for is the ACL graft and meniscus repair to become strong enough to get back to more enjoyable and calorie-burning activities. And a good way to prevent re-injury in the future will be keeping everything else around the knee strong. 
• I devote about 3 hours a day to physio: 1.5 hours of weights (arm, core, and legs), 20 minutes of stretching and balance, and 1 hour dedicated to a walk on a paved path. All without a brace, which I stopped wearing 3 weeks from surgery. I know 3 hours per day of physio sounds a bit excessive, but without climbing I need to focus my non-school energies on something, and one of those somethings has become physio so I can get back to climbing as soon as physically possible. How fast can I get back? Let's see! (is my motto every day) I feel I am staying ahead of the recovery timeline, so it seems my rehab efforts have been beneficial so far.
• Still feeling far from being able to jog down scree slopes, hop from one boulder to another, drop knee my way through a climbing move, or thrutch up an offwidth, but those are the goals....

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22. Leg press (quads, hamstrings, glutes).  23. Knee extensions (quads).  24. Recumbent bike (I cannot use a normal upright stationary bike quite yet since I cannot bend knee more than 90°). 25. Stairmaster!  26. The weekend. Wish I was climbing, life is a bit more boring and sedentary these days, but still pretty pleasant.  27. I was going to caption this photo with something like "drinking my knee injury days away" but the true story is I ended up with a tooth abscess/infection, and the few days leading up to a fast-tracked root canal put pain into perspective and caused me buy my first bottle of whiskey. I actually quite liked it, but kept the rest of the bottle for the next root canal.
DAY
61 / 47
(8.7 weeks)
(6.7 weeks)
Tue, 
Oct 20


• Physio Appointment #4. With Rob Scrivner at MedX of Estes.
• For the last few weeks I had been gradually increasing the bending of my knee up to 90° (not wanting to stress the meniscus repair is the main reason I haven't focused on bending much). My knee is pretty stiff once I try to bend past 90°, but Rob instructed me to bend it as far as I could and I was able to bend to 115°. 
• It seems that 90-100° is about what you need to be able to bend to make a full pedal circle on a stationary bike. Yay, progress and another way to exercise and work on getting rid of the stiffness in my knee.
• Rob added hamstring stretches as well as a terminal knee extension resistance band exercise to my physio regime to strengthen the hamstrings to be able to more easily lock off (slightly hyperextend) my leg.
• I'd also started to notice a bit of clicking of my knee-cap as I've been pushing my mobility. In fact, when Rob was bending my knee we could actually see the knee-cap shifting during the clicking noise. It's likely due to tightness of the patella's side stabilizing ligaments, so Rob also have added patella mobilization massages to my daily regime. At least this one I can do as I attend my Zoom lectures. In fact, I spend many of my lectures stretching and massaging my knee, something that has been made much easier due to the fact that school has gone online this semester (due to COVID-19).
• The seroma I had developed about a week after surgery has become much smaller and will probably be completely gone within a couple of weeks.


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28. Now that I can bend my knee to 90° I have incorporated the stationary bike into my daily exercise/physio routine.  29. This is as far as I can bend it just under 7 weeks from surgery, around 115°. 30. Terminal knee extension resistance band exercise.  31. Doing patella mobilization as I study.  32-33. Estes Park traffic jam! (As seen from my morning walk after a physio appointment with Rob.)  34-35. Even Fred and the campus mascot are wearing face masks these days.
DAY
68 / 54
(9.7 weeks)
(7.7 weeks)
Tue, 
Oct 27

Follow-up Appointment. With Dr. Khemarin Seng at Boulder Center for Orthopedics and Spine. "Keep doing whatever you've been doing!" was the main advice Dr. Seng had for me. 
Encounter Notes:
Assessment and Plan

7.5 week s/p R knee scope. ACL recon ham allo, bilat menisectomies v. repairs. 9-3-2020-- Continue regaining full ROM, use stationary bike daily, massage/foam roll scar tissue, consider BFR. Progress 5 degrees flexion per week. FU in 5 weeks.

Stephanie presents to the clinic today for routine post-op evaluation for R knee scope ACL reconstruction ham allo, bilateral menisectomies v. repairs 9/3. She reports that she is doing well and has been doing physical therapy once per week in Estes with her climbing friend. The knee feels stable, she has not been wearing the brace for a couple of weeks. She reports that she puts in 3 hours of physio per day. She can flex her knee slightly past 90 degrees without loading it.

Right knee:

Teardrop crease VMO looks good

no swelling

full extension

120 flexion

negative Lachmann's

neg pivot shift

I informed Stephanie that she has made significant progress since her previous visit and is doing very well. Stephanie will focus on regaining full ROM, use a stationary bike, do banded exercises (monster crab walks, single leg lifts), and perform isometric exercises. By 12 weeks my goal for Stephanie is that she will have significant ROM, muscle activation, and that she will be ready to load the knee in squats. I informed her that she will have to wait until approx. 12 weeks for tissue to scar in appropriately. I informed her that the clicking that she has been feeling is a result of the beginning of the scar tissue formation. She will continue massaging scar tissue area, will work on progressing 5 degrees in flexion per week, and will continue to do daily heel slides. We discussed BFR, I explained the activity, risks, benefits, and expected outcomes. She was given a BFR script today. I informed her that at the next visit we will discuss if she can begin to run, hike, snowshoe, and/or in-door climb. Patient understands and agrees with plan. All questions were answered thoroughly. Follow up in 5 weeks for recheck at the 3 month mark.

doing well

progress PT

consider BFR

fu in december to discuss light indoor climbing

25 minutes was spent in face to face contact, greater than 50% of which was spent discussing and coordinating patient care.

DAY
75 / 61
(10.7 weeks)
(8.7 weeks)
Tue, 
Nov 3


• Physio Appointment #5. With Rob Scrivner at MedX of Estes. 8am
• I am religious to my daily 3-hour exercise+physio routine. I wake up most mornings at around 5 am to get it all done before school and other life events. At this point, my routine involves (1) 30 minutes on the stationary bike, (2) 20 minutes on a stairmaster, (3) 1 hour 20 minutes of weights for both legs and arms, (4) 20 minutes of stretching/massaging/balancing, and (5) 30 minute walk. Dedication to this daily routine is easy when getting back to climbing is the prize. 
(in future)
DAY
82 / 68
(11.7 weeks)
(9.7 weeks)
Tue, 
Nov 10


• Physio Appointment #6. With Rob Scrivner at MedX of Estes. 9am
(in future)
DAY
89 / 75
(12.7 weeks)
(10.7 weeks)
Tue, 
Nov 17


• Physio Appointment #7. With Rob Scrivner at MedX of Estes. 9am
(in future)
DAY
112 / 98
(16 weeks)
(14 weeks)
Thu, 
Dec 10

Follow-up Appointment. With Dr. Khemarin Seng at Boulder Center for Orthopedics and Spine. 11:35 am
(in future)

Encounter Notes:




MEDICAL BILLS (APPROXIMATE TOTALS BEFORE INSURANCE)

Helicopter Rescue, Colorado National Guard  $ 0
Hospital Emergency Room Visit $ 6,203.01
Covid-19 Test $ 100.00
Knee Surgery (ACL + meniscus) $ 13,293.00
Pre-op and Follow-up Appointments (5 x $40 co-pay so far) $ pending
Physiotherapy (___ x $___ per session) $ pending
Prescriptions Drugs & Vitamin I $ 100 (approx.)
Miscellaneous (crutches, scooter, knee braces, ice packs, etc.) $ 1000 (approx.)
TOTAL