20 weeks after my breaking my knee cap

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Today is exactly 21 weeks after breaking my knee cap, so its worth looking back at my recovery so far.  I had originally intended to map out all my recovery but life got in the way.

My recovery was going very well until the 17th week of my recovery when I had a setback.  Before my setback, I felt I was well on the path to recovery and that the 6-9 months my physio had said it would take to make a full recovery was a very pessimistic.  By Easter (with Good Friday being the 16 week mark) I could:

  1. Walk at normal speed with (almost) no limp.  Walking speed is something I can quantify from my Garmin Vivosmart 3.  I could almost walk downstairs normally too.
  2. Bend my knee to about 120 degrees – far from perfect, but a big advance on when I first came out of plaster and was allowed to bend to 30 degrees but the knee would barely move.
  3. Do a straight leg raise (i.e. lie on my back and lift my leg up from the hips, holding the leg straight).  It took many weeks before I could finally do this but I was well past this stage.
  4. Cycle.  I had gradually built up from 10 minutes in the gym on 4 March to initially trying to cycle outdoors but finding my knee didn’t quite want to bend enough, more (very boring) indoor cycling, through to cycling to work for the first time on 23 March.

After all that progress, I may have overdone it.  I cycled to work and back for 2 days in a row and went for a long walk at lunchtime.  My knee swelled up again and got very painful.  I think going to my physio gym class made it worse.  After a few days I was walking very slowly and painfully and couldn’t even do a straight leg raise.

After a visit to A&E, I went back to fracture clinic on 16 April and I finally saw the consultant, or I should say a consultant, as A&E booked me in for the first available appointment, so it was a different day to usual and a different consultant. He thinks that the lump I had noticed when my knee worsened is one of the two pins sticking out and wants to get the metalwork out asap. This is good news as I’ve so far had conflicting opinions on taking it out, but come to the view myself that it probably should come out asap.

Over the last few weeks, my knee has got much better again.  It was getting better before I saw the consultant and has carried on improving  Psychologically, knowing that part of what I’m feeling is the top of the pin scraping against my flesh has actually made the pain easier to bear.  So last Friday (19 weeks after my accident) I went to the gym and did 15 minutes on the exercise bike (my first pedalling since the 5 April when my knee was getting swollen again). It tired my knee  but that gave me the confidence that I could get back on the bike.

I didn’t actually cycle until yesterday due to having a cold and rainy weather. I cycled to my physio gym session and going up The Bishop’s Avenue, which is a few minutes of steady climbing, was harder work on my overall fitness than my knee. The gym session itself also went well and I cycled on to work and then home today (alternating in this way was what one of the physios had advised).

The physios commented that my knee looked a lot more normal and less swollen. For reasons I don’t entirely I understand I had shaved my legs the previous day for the first time since my accident. Shaven knees make it a lot easier to see what’s going on and, while there is some swelling still, I think a lot of the extra size of the knee (it looks about 1.5 taller than it should) is actually due to the wire/pins rather than swelling. Somehow, seeing this and knowing that the bump above it is the top of one of the pins makes me feel a lot better about it.

I have a date for taking the metalwork out – 8 weeks to go, so the day after that 2nd operation will be 29 weeks after my initial accident. That will give me 4 weeks to train for Ride London!

Finally I have had the blood clot to deal with and am on anti-coagulants for 6 months. Apart from the knowledge of having it, the main effect has been that my calf gets very swollen over the day (big marks from socks!), sometimes very itchy (skin stretching I think) and that I am often conscious of it as I walk (again I think this is probably about the skin being sore). This week has been the first week where I’ve felt the swelling might be going down and I’m getting less conscious of it.

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Famous sportspeople who have come back after a broken patella

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This is probably even more obscure than a list of famous Belgians.  However, reading on might just give you the edge on your next pub quiz.  I have found it quite comforting as I recover to discover that breaking a knee cap is more common than you might think, and that it is possible to make a good recovery.

  1. Penny Coomes.  No, I hadn’t heard of her either until the Winter Olympics.  In June 2016, she was practicing her ice dancing routine with her partner and jumped a little bit too high and fell onto her knee.  Her patella shattered in 8 places.  By January 2017 she was skating again, but the wires were irritating her tendons so she had a second operation to remove them.  Another 3 months off.  By September, she was skating well enough to win a competition and qualify for the Olympics.  Eleventh place in the Olympics might not win a medal but its a pretty impressive recovery.
  2. Alejandro Valverde.  I remember his awful crash on the rainy first day of the 2017 Tour de France.  He skidded towards the end of the time trial and went straight into the barriers.  With such an awful crash at the age of 37 commentators thought that might bring his career to an end.  Seeing him in contention for Strade Bianchi a few weeks ago where he eventually finished 4th made me check what his injury was.  I vaguely remembered his knee being mentioned but it didn’t have any particular significance for me at the time.  I now know that he broke his knee cap and was cycling again within 6 weeks.  By the end of February, he had actually achieved 8 victories in just 14 days of competition in 2018.
  3. Another cyclist and a Belgian too.  Johan Museeuw will always be associated with Paris-Roubaix. Some of the most iconic pictures in cycling show Museeuw riding in a break away with his 3 Mapei team-mates before himself winning the 1996 Paris-Roubaix.  No doubt they prepared better than the other teams.  I knew that he then suffered a horrific crash (1998) in the Arenberg sector and subsequently nearly had his leg amputated because of the gangrene infection before coming back to win in 2000 and 2002.  I now know that he actually shattered his knee cap in that horrific crash.

So a full recovery is possible and, with that in mind, I have exercises to do.

Healing knees

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The knee is an amazing joint.  Think about how much weight goes through it when you walk, more when you run, or go down the stairs and what about running down the stairs.  I broke my knee cap 13 weeks ago and I meant to write about my recovery on this blog but I haven’t written as much as intended.  I emailed someone last week with some advice on knees and I thought I would turn that email into a post.

I have spent half a century abusing and then repairing my knees.  Most of the damage has been caused by running, hill walking and skiing.  However, in the last year, I have hurt both of my knees cycling.  

A brief history of my knee problems from the age of 25 onwards

  • Initially caused by running – probably because I increased my training load too quickly (I went from 0 to 80 miles a week in very little time), then pushed through some knee pain when I came back after a break  and didn’t wear the right sort of shoes or change them frequently enough.
  • I carried on getting knee pain when hillwalking especially descending, probably made worse by a more sedentary lifestyle, as I went from being a student to working in London.
  • In my early 30s I was diagnosed with slight tears in the cartilage (this was after an  MRI scan and exploratory keyhole surgery on one knee).
  • After extensive Physiotherapy, a podiatrist making custom insoles and stopping running my knees were as good as new.  I think doing more frequent exercise, initially going to the gym and then rediscovering cycling in my early 40s really helped.
  • My only knee pain cycling was from badly adjusted cleats when I first started going on longer rides.
  • Last summer I was hit by a car on my right knee and it swelled up horribly.  After a few weeks on crutches, it was still swollen but I was able to walk fairly normally (including in the alps) and when I started cycling again I had no pain and the swelling went down totally.
  • Thankfully my right knee was fully recovered before I broke my left knee cap and only time will tell if I make a complete recovery.  Initial signs are good, especially now that I am no longer using crutches and have started (indoor) cycling.

The things that I have found most helpful are:

  • Podiatrist prescribed orthotics.  This made a big difference to me as I have high arches, leading to my feet leaning inwards and effectively making me knock kneed.  I have walked with orthotics for about 20 years now and also ski and sometimes cycle with them.
  • Leg length discrepancy.  It was only a second podiatrist, a few years after the first, who noticed that one leg is 1cm longer than the other (possibly due to breaking one of my legs when I was about 20) and she added a rise to the orthotic for my shorter leg.  Again I now use this for walking, skiing and cycling longer distances.
  • I have greatly benefited from numerous physios over the years.  I would really recommend https://www.amazon.co.uk/Sports-Injuries-Self-Help-Vivian-Grisogono/dp/1905367287/ref=dp_ob_title_bk both for helping to diagnose and understand what is wrong and also for providing exercises to help strengthen the right muscles.
  • Glucosamine/Chondroitin/MSM – the evidence is weak but it seems to help me and many other people, especially as we get older.  A friend of mine said that the thing that convinced him of the benefits was seeing the improvement in an arthritic dog, who obviously wouldn’t know it was meant to help.

The thing that you might find hardest to believe is that cycling can actually help your knee recover from an injury.  As I have been told recently you have to “let pain be your guide”.  Cycling has the advantage of being non weight-bearing.  The movement is also meant to help lubricate the cartilage and help the swelling go down. My current physio has told me that studies show that even 5ml of excess fluid in the joint can reduce the quadriceps’ function by 40%.  So its easy to get into a vicious cycle where swelling stops you moving the knee and the muscles become weaker so you can’t move it and are more likely to injure it (one of the reasons a brace, which I wore 24/7 for 6 weeks after breaking my knee cap, is so important).  So cycling can help break this pattern, by getting the knee moving without tiring it by putting weight through it and thereby strengthen the muscles and also reduce the swelling.

 

 

 

After 12 weeks a broken bone is broken no more: X-rays of a broken knee cap healing

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Day 0 – one displaced fracture and one smaller fracture

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2 weeks later (right hand image) pinned, wired and still obviously broken and 6 weeks later (left hand image) – largely healed but not hardened

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12 weeks later – the miracle of nature, with a little help from some skilled surgeons and its pretty much back to normal

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Recovering from a broken knee cap: Part 1 and the meaning of ORIF

Having broken my knee cap, I’ve spent a lot of time surfing about what to expect and do so I thought it might be useful to write up my experience as a guide to others, though I wouldn’t wish a broken knee cap on my worst enemy. I have generally been very impressed with the quality of care I received at the Whittington Hospital, though one criticism I would have is that I wasn’t given any sort of leaflet on what to do or what to expect at any stage (except by the physiotherapists, who clearly understand that patients do not have perfect memory).  Even if medical professionals give you all the right advice, which they probably don’t because they are busy and fallible, I don’t think you can really expect a patient, who at various times is shocked, drugged, tired, depressed or scared to remember everything that they are told.  So I would have found it helpful to have something in writing for clarity.

I hope this might help others, though it does of course come with the caveats that it is only based on one person’s experiences, different cases will be different and I am not a medical professional.

Now, six weeks after my operation, and the day after I have been given the all clear to put my weight through the affected leg, seems a good time to write this, as I move to the next phase.

Day 0 (Friday 8 December) hitting the pavement can break a bone

Breaking a knee cap is painful.  Falling over as an adult is generally a shock and I always want to get straight up but I didn’t feel I could.  One passerby told me I was making a fuss.  Another, who claimed to be a first aider (though she must have done her course a long time ago) told me to try standing up.  I thought I would try standing up after a few minutes when the shock had worn off a bit but I really didn’t want to move.  I think my lycra cycling tights probably masked the swelling.  I remember yelping as I hopped up the steps into the ambulance.  I felt slightly sick when I took my lycra off lying on a stretcher in the ambulance and the knee seemed to pop up a few centimetres.  Even then, I thought taking me to hospital for an  x-ray was precautionary and was quite surprised to be told that my knee cap was in 3 pieces.  So I would draw the lesson that if it really hurts (and I am sure there are far more painful things) it’s worth getting it checked and that if you have the misfortune to have a hard blow to your knee cap, it may well break.

So I went from being surprised that I had a broken bone to being told that I would have an operation the following day to signing a consent form about all the things that might possibly go wrong in a few minutes. A few hours later, I was wheeled on a trolley into a ward for my first overnight stay in hospital since I was born. Apart from being really bored until my family visited later on, I don’t think much of note happened until it was time to go to sleep. The night nurse then told me that I shouldn’t hobble to go to the toilet as I might make the swelling worse and they wouldn’t be able to operate if my knee was too swollen. I still don’t know if this was true but it really worried me, particularly as I had read by then about the importance of having a broken knee cap fixed into position quickly.

So it was not only my first night in hospital but my first night of weeing into a bottle with four other patients in close proximity.  My first attempt was totally unproductive after a long wait but I soon got into the swing of things

Day 1 (Saturday 9 December) Patella ORIF

Most contacts with professionals involve learning a new language.  I just about knew that doctors call a knee cap a patella though I still have to check that it’s not a patellar.  However, ORIF was an unexpected new acquaintance.  ORIF means Open Reduction Internal Fixation, so the surgeon cuts your knee open and then internally fixes the broken bits together.  If you are lucky a simple fracture might not need this, but my knee cap was split in two with a significant gap and one of the halves had a further fracture.  The surgeon told me that when they put the big pieces together the little piece came into line.  In my case the fixation was two stainless steel pins to hold the knee cap in place, and then some wire wrapped around it to stop the bone slipping on the pins.

I woke up a bit confused after 2 hours under general anaesthetic to find that my affected leg was totally wrapped in bandages and it was only a few hours later that I realised there was also a plaster cast on the back of the leg, from half way up my thigh to covering most of my foot so that my ankle as well as my knee were immobilised.  In fact the plaster went so far up my thigh that I had to sit forward in a chair with several cushions behind me to stop the top of the plaster sitting uncomfortably underneath me.

Day 2 (Sunday 10 December) discharge him before he turns into a heroin addict

One of my first memories of the morning was being told to take a diamorphine tablet.  I was quite surprised when google told me it was heroin. I was slightly disappointed not to be discharged with any, though that’s probably a good thing since google also told me how highly addictive it is.  I was discharged with 3 different pain killers but I barely took any after the first night back home.

I also awoke to snow, which was even more unwelcome when I eventually left hospital in the dark of night.

I was visited by two physiotherapists in the middle of the morning who said they would teach me how to walk again.  This seemed a bit over the top, since I had last walked about 36 hours previously. I realised what they meant when they started me off on a zimmerframe before moving me on to crutches.  It was less than 24 hours since my ORIF and hobbling a few steps on the zimmerframe was hard work.  I was really grateful that they taught me to go up and down stairs and spent the next few days at home carrying their leaflet around with me. I eventually learnt that going up stairs means leading with your good leg, and that your bad leg goes down first, with the crutches staying with the bad leg.  Simple, but it does take some learning, and painful and confusing when you get it wrong.

This has turned into a much longer post than expected, so I will continue in another part.  For the next few weeks, I found this useful as a rough guide to my recovery protocol though I inevitably didn’t follow it exactly

Sometimes swelling is more serious

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I wrote a week ago about the wonders of ibuprofen making my swelling feel better. That is still true a week later. Unfortunately, despite feeling better, the swelling hasn’t gone down and today I found out why.

Unfortunately I have a DVT. The doctor in fracture clinic suspected this as soon as I mentioned the swelling and he saw the leg. An ultrasound a few hours later confirmed this suspicion. So I now have the pleasure of injecting myself with anti coagulant daily, until I go to a blood clinic where I’ll probably be put into tablets for at least 3 months.

On the positive side, my bone is healing well, and I can now fully weight bear. So, within reason (certainly no squats for a while) I can use my leg, rebuild muscle, work on mobilising it etc.

The before (on the right hand side, and this is actually 2 weeks after the fracture) and after x-rays show the repairing bone very clearly.

Even clearer are the two stainless steel pins and tension wire. I had previously been told that they might take the wire out after a year if it bothered me. Today’s doctor said that they would probably take them out in four months in a simple day procedure.

Restarting this blog

I originally started this blog because I had fainted while cycling and broken my collarbone and wanted to record my journey of finding out why I had fainted.  I never really find out why I had fainted.

Once I was able to cycle again, I didn’t really have the time or inclination to keep the blog up to date so it petered out.  I did actually refer a few people to it for advice when they broke their collarbones.

So, in that spirit, now that I have broken my knee cap, I thought it might be useful to record some of my experiences of recovery in the hope that it might help others in a similar situation.  I have certainly found googling on various themes around “broken patella recovery” useful and would rather there was more out there.

So my first new substantial post will be about managing swelling.

Using ibuprofen to manage swelling

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I woke up in the recovery room at the Whittington Hospital and immediately burst into tears of relief that I had actually woken up from my general anaesthetic.  There ended two hours of my life that I hadn’t experienced, while surgeons used 2 stainless steel pins and some wire to pull the three broken parts of my knee cap into one, so that it could heal properly.

One of the things I remember from the recovery room is the nurse saying he would give me some “morphine”.  The next morning, as I woke up to snow, the nurse gave me “diamorphine” which my phone told me was heroin.  Pretty strong painkillers and I was sent home that evening with a fortnight’s supply of three different painkillers. After the first night, I barely took any painkillers as I wasn’t really in pain.  I also read that there was some evidence that ibuprofen (one of my three prescribed painkillers) might actually interfere with bone healing. This seemed a big deal at the time so I stopped totally.

I had my first physiotherapy session three and a half weeks after the accident.  I knew my foot was swollen before I saw her but I think she made me realise just how swollen it was.  So since then I have been elevating and icing my knee a lot more.  I also found that a few days of foot pumping really got the swelling of the foot down.

However, approaching five weeks since the operation, my calf has remained stubbornly swollen.  It then got more and more uncomfortable and I have been fiddling with my knee brace.  Too tight and it hurts.  Too loose and it slips down.  The knee brace which I loved as a replacement for the heavy and rigid plaster cast suddenly became a great source of irritation and discomfort.

More googling made me realise that I might not get the calf swelling down until I could properly weight bear on the affected leg.  This is at least another week away (my next visit to fracture clinic). So I started wondering about taking ibuprofen again.  It’s a member of a family of drugs known as NSAIDs – Nonsteroidal Anti-Inflammatory Drugs – a pretty strong clue that it might help. Five weeks after the accident, knowing that my last x-ray three weeks ago showed the bone looked fine and that I haven’t done anything dramatic to it since, I am less worried about a possible impact on bone healing.  I also looked at a review on NSAIDs and bone healing and concluded that the risk was probably less than I had thought.

So I took my first 400mg tablet of ibuprofen two nights ago.  I woke up yesterday morning feeling that my leg was much more comfortable. As a sample of one, I can’t do a double blind trial or claim any statistical significance.  It may just be that I had a better night’s sleep.  In fact it wasn’t until I saw the box of ibuprofen on the kitchen table and took my second dose with breakfast that I associated my more positive feeling with taking ibuprofen but it seems to have worked.  Also, the NHS advise that the anti-inflammatory effect can take up to three weeks to get the best results, so overnight seems pretty good going.  Two days on, six does of ibuprofen on, all seems much better.

So, it seems to be working for me, so I will take it at least until my next visit to fracture clinic in a week unless I get any side effects.

Discovering Time Trialling

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Time trialling, or the “race of truth” as it is known, occupies a special place in cycling, particularly British cycling.  A time trial tends to mean cyclists setting off at regular intervals and being timed over a set course.  This can make it very boring for the spectator, especially if, for example, you see a succession of cyclists doing a couple of laps of the track as part of the Omnium.  Unlike a sprint event, there is no sense of seeing who crosses the line first, or the build to an exciting finish.  On the other hand, there is the purity of it being a test of pure athletic skill, rather than tactics, and there is no possibility of being sheltered by a team mate.  Hence, it really is a race of truth.  Events do, or course, intervene, and the size of the field in a professional race, with most riders setting off at 1 minute intervals and the higher placed at 3 minute intervals means that the weather, especially wind and rain, can change decisively over the course of the race.  In the 2010 Tour de France prologue time trial, Team Sky were too clever by half and opted for Bradley Wiggins to do the time trial early in the day.  He then raced through the worse of the rain and finished 77th in an event he might have expected to win, and certainly do no worse than finish in the top 10.  And time trials are not always boring, with the American Greg LeMond famously edging the 1989 Tour by 8 seconds by using aerodynamics to beat Laurent Fignon, resplendent in his flowing locks and professorial spectacles, on the final day’s time trial.

Time trials form the backbone of British cycle racing, dating back to early compromises between cyclists and motorists.  Unlike mass start races time trials can be raced without closing roads to other road users and almost in secret.  Traditional time trial courses in the UK are given obscure codes like F15/10 which denotes a particular route.  Distances may range from 10 miles to 100 miles and beyond and cycling clubs up and down the country hold many events over the summer.

Yesterday I entered my first time trial – a 10 mile event organised by Islington Cycling Club. I had always thought that I wouldn’t enter unless I was confident of cycling 10 miles in 30 minutes or less, the nice round number of 20 miles per hour. As a physicist, 20 mph also has the significance of being the speed where air resistance becomes the dominant brake on the speed of a cyclist, so going faster becomes progressively harder. Thankfully, particularly given how things turned out, I was persuaded that a time trial is an opportunity to set a time, which you can then try to beat.
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I rode the course a couple of times in the weeks leading up to the big day to familiarise myself with it. My first attempt, when l started off casually but I soon knuckled down and it took just over 31 minutes so I was pretty confident that I would beat the half hour mark. Especially, since my 31 minutes was on a windy day.

Yesterday was a gorgeous sunny, calm, cold morning and I rode out to the time trial course feeling confident. I had a slightly nervous start. I know that the drill would be for someone to hold me so that I could start off clipped in to both pedals and give me a helping push. However, I wasn’t sure quite how this would work and the starter, Pete, suggested that I could just start myself off, which I did. I then pressed the wrong button on my Garmin so I didn’t start recording the ride properly. Nevertheless I was soon in my stride. I realised my heart rate was too high, so I eased off marginally and settled into a steady effort that I sustained all the way round. I felt I had given my all at the finish.

When the results were read out I was disappointed to be last, and worse to record a time of 30:47. Not that much faster than my first attempt, but it felt much harder work. Not what I wanted, or even expected, but the race of truth lived up to its name. And no excuses as there was barely any wind, nor did I have to stop for any cars. The only obvious learning would be to start fresher and not do a hard 60 mile ride 2 days beforehand. Another chance to seek the truth in 4 weeks time.

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Yet more on Vitamin D

After my previous posts on Vitamin D, there seem to be more and more articles, both saying that Vitamin D supplementation is necessary, and also that it can be linked to athletic performance.  John Post has written about the impact on muscular performance.  I also found a helpful, work-in-progress summary of the evidence for the benefits.  In short, most people seem to show benefits from Vitamin D supplementation and there doesn’t seem to be any downside, as long as you don’t take too much.