Healing knees


, , , , , , , , , , ,

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


, , ,

Day 0 – one displaced fracture and one smaller fracture


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


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


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


, ,

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


, , ,

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


, , ,


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.

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.



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.


Wrap up visit with GP


, , , , , , , ,

Having been discharged and given the all clear by both the neurologist and cardiologist I went for a final visit to my GP. I think we’re back to what the A&E Dr said to me hours after my accident “Everyone’s allowed to faint once”.  There’s  nothing wrong with me and no obvious cause of my faint.

I may have been slightly dehydrated, though given the hassle of stopping for a comfort break on a short ride, I’m not really inclined to drink much more.  I may have been slightly stressed, and I think that’s under control now.  I had thought that paying more attention to my heart rate might be relevant but the first cardiologist I saw said not to worry, and my heart rate has been higher since my accident without ill effects so I think that’s a blind alley.

There may be something in monitoring resting heart rate.  I have recently been checking mine with an optical sensor and it seems all over the place: the average is around 45bpm with a variation from 42bpm to 50bpm.  The cardiologist told me that the 24hr ECG measured it at 39bpm which is lower than the optical sensor generally measure it.  So room for further investigation!

One possible contributory factor to my resting heart rate being variable is that I still find it uncomfortable to sleep on my injured shoulder.  The joint is taking far longer to get back to normal than the bone took to heal.  It actually seemed to get significantly worse over Christmas so the GP referred me back to physiotherapy.  I don’t yet have an appointment but it of course feels much better now I have a referral.

The GP also thought it worth getting an annual blood test which I will do.  I also continue to take (non-prescribed) Vitamin D.  The number of times I have been asked how much alcohol I consume has also made me try to drink less alcohol and I almost managed a “dry January” (from just after midnight on the first until the evening of the 31st).


Final visit to the Cardiologist

Two months after my first visit to the cardiologist, I went back for a follow up visit.  In the meantime I had been for an ECHO Cardiogram (Heart Ultrasound) and had also been fitted with a 24 hour ECG.  The 24 hour ECG was another lesson in how the NHS doesn’t really consider the patient experience.  I wasn’t warned in advance that I would have to come back to the hospital the following day to have it taken off, and when I did go back I was asked to take it off myself as the technician wasn’t around.  I also wasn’t warned in advance that I couldn’t shower with it.  I cycled back home with the ECG attached and made a point of cycling hard to take it back, into a headwind, as I wanted to make sure I pushed my heart as much as possible while wearing it.

When I returned to see the Cardiologist, I was disappointed to find that I was seeing a different Doctor as I had liked the first one.  The nurse took my blood pressure while I was waiting.  She told me I had the blood pressure of a teenager (120/70), which is presumably a good thing, perhaps unlike the blood pressure of a teenager’s parents.

The cardiologist basically said that I was absolutely fine. The ECHO Cardiogram showed a normal thickness heart wall.  It was slightly thicker than average due to the amount of exercise I do, but well within the expected range.  The 24 hour ECG also didn’t show any abnormalities.  I asked if it would be worth having a treadmill test, but he thought that this wasn’t worth doing given how fit I was: he said the point of the test was to provoke symptoms but I was clearly pushing my heart without showing any symptoms.  He thought the most likely cause of my faint was morning dehydration.  He made the point that over an 8 hour sleep one would drink nothing, i.e. a lot less than over an 8 hour period awake, so having a single cup of tea in the morning wouldn’t really compensate.

So that’s it and I’m not really any wiser though at least I know that there is nothing definite wrong with me.  Having read about some of the heart and brain problems that can manifest themselves in sport, I’m glad not to have any of them, though I think they usually show up well before the age of 50.