Getting the Bends

Day 12

Don't fret, I haven't given myself the bends in the hyperbaric oxygen chamber (i.e  the torture tube) but I am working on getting my knee to bend a bit more...

After getting my staples out on Tuesday (Day 9), it was back to the Southern General to see the physio. This wasn't as bad as I was expecting, as we didn't do any forceful range-of-motion (ROM) exercises. I could only just get 30* of flexion, which was a bit worrying at first but after doing a bit of research on the very useful KneeGeeks website: http://www.kneeguru.co.uk/KNEEtalk/index.php it turns out that there is often quite a limited ROM for quite a while after getting the popliteofibular ligament reconstructed. They also don't like to do too much, too soon, to prevent too much stress on the new ligament graft.

I have been doing isometric (static) quadriceps contractions 4 times a day, 3 sets of 7 reps. I'm using a similar method that climbers use doing finger strength training called repeaters. This basically involves contracting the quad as hard as possible for 7 seconds, then relax for 3 seconds. This is repeated 7 times, then a couple of minutes rest, followed by a further 2 sets of 7 reps with rest in between. By the third set it's getting quite tiring, so must be doing some good. I'll up the reps as I get strength back.

On top of that, I'm doing hip abduction and adduction exercises (i.e. lateral leg raises lying on my side, then on my other side), plus normal leg raises lying on my back (although, I'm doing both legs at the same time time to give my abs a workout too, and finally, I'm doing patella mobilisation (i.e. wobbling my kneecap about).

So, plenty to keep my busy. I'm still going in the "torture tube" once a day. It seems that the swelling around my knee is reducing quickly, which is what the treatment is meant to do. Obviously it would be reducing without  the treatment so it's difficult to determine how much good it's doing.

Here is my knee:

Looking around the Internet, it seems that my knee is similar in size to people at about day 30! We all heal at different rates, but it seems like my swelling is going down fairly quickly.

On top of all the exercises, I'm doing passive range of motion exercises, using my left leg to support my right. At the physio I could only get 30* but today I managed to get between 35* and 40*, small progress, but it's going the right way!

I've been told not to push it too hard in the early days to make sure I don't over-stress the grafts.

That's all for today.

Day 8 & Hyberbaric Oxygen Treatment

Day 8

It has to be said, the last 8 days have drifted by much quicker than I was expecting. I've not even been particularly bored. I guess it's not so bad to be waited on hand and foot by the parents...

I've got through 3 books:

1. 9 out of 10 climbers make the same mistakes. Dve Macleod
2. Revelations. Jerry Moffatt & Niall Grimes
3. The Meaning of Sport. Simon Barnes.

I might even write some mini-reviews if I get bored.

Tomorrow I get my staples and stitches out, and get to see the physio to get my hinged knee brace fitted. I'm quite happy with the progress so far. The swelling on my calve and ankle have come down by 3.5cm and 2.5cm respectively. I'm off the painkillers and considering stopping the diclofenac tomorrow. I've been using some fairly experimental treatment: Hyperbaric Oxygen Therapy.

Hyperbaric Oxygen Treatment

Once a day, for about 60 minutes a session, I've been getting zipped into one of the only home hyperbaric oxygen treatment devices in the UK. Basically, the "tube" gets pressurised up to 1.5 bar (i.e. 1.5 x atmospheric pressure) and the inhabitant breathes ~95% oxygen through a mask.

 If this all sounds a bit strange, well, it is!

The aim of the treatment is to reduce inflammation and stimulate the regrowth of the damaged tissue in my knee. The second process is the promotion of growth of new bone, collagen and blood supply to the ligament grafts and bone tunnels.

The reason we have one in our house is because my dad has serious rheumatoid arthritis and has tried every damn treatment under the sun, none of which worked and some of which made his health significantly worse! Rheumatoid arthritis can cause debilitating lung damage (whether or not it's the illness or the drugs that are the cause is debatable, anyway, I digress...) and his lungs currently function at about 42% and he is on supplemental oxygen 24 hours a day.

At the rheumatology clinic he attends, he is the only patient who has not got significantly worse year on year since the start of the hyperbaric treatment. In some tests he has actually improved, which is practically unheard off. Oh, and he's not using any of the usual anti-inflammatories or immuno-suppressants that are normally prescribed and has cut down to a near homeopathic dose of 5mg/day of steroids. (He was previously on 30mg/day).

So, the upshot of all this is, I have access to the treatment at home. Unfortunately there has not been a great deal of research on the use, partly due to the fact "Big Pharma" (the massively wealthy and influential drug companies) pay for most of the UK's fundamental research and they have no intention of financing it.

Anyway, one recent piece of research, Effects of hyperbaric oxygen treatment on tendon graft and tendon-bone integration in bone tunnel: Biochemical and histological analysis in rabbits, concluded:

Experimental results demonstrated that a higher number of Sharpey's fibers bridged the newly formed fibrocartilage and graft in the HBO group than in the control group. In addition, HBO treatment increased neovascularization and enhanced the incorporation of the progressive interface between tendon graft and bone. Biomechanical analysis showed that the HBO group achieved higher maximal pullout strength than the control group. Examination by EM showed that HBO treatment resulted in regenerated collagen fibers with increased compaction and regularity. Based on experimental results, HBO treatment is a treatment modality that potentially improves outcome following ACL reconstruction.

I really hope more research is done in this area, as it seems very promising, is very safe and, if implemented properly around the UK could help lots of people, and save the NHS a whack of money on drugs.

Here's the link to the paper:

http://www3.interscience.wiley.com/journal/114110845/abstract?CRETRY=1&SRETRY=0

Andy, if that doesn't work...  http://lmgtfy.com/?q=effects+of+hyperbaric+oxygen+treatment+on+rabbits+acl+wiley&l=1

Day 2 to 4

Day 4

Four days since the surgery and all seems to be going well. Yesterday I only took painkillers in the morning and before bed - slept from 11 till 6 then dozed till 8. Today I'm avoiding them altogether but I'll put some by my bed in case I can't sleep. Swelling doesn't seem too bad, but it's under about 4 layers of bandage, so hard to tell! I really hope BBC Radio 6 doesn' get axed as it's definitely helping to keep me sane! Cutting 10% of the wages of the top DJs would pay for it...

Posterolateral Corner

As I've said before, I tore both my Posterior Cruciate Ligament (PCL) and my one of the ligaments in the Posterolateral Corner (I tore the often missed Popliteofibular Ligament - PFL).

Surprisingly, the tiny, insignificant looking PFL is anatomically more important than the PCL. The PCL stops the shin bone translating rearwards under the knee and anyone with reasonably strong Quadriceps can live a normal life without one. Many sports can be played with a knee that has no PCL.

The PFL on the other hand stops the lower leg moving outwards (varus translation, or more commonly "bowlegged") and it stops the lower leg rotating in a toe-out direction. For me, the most important aspect of this repair is the varus translation, as I was finding that my knee was giving way in this manner, especially when outside edging in my climbing shoes.

For anyone who's interested, and not squeamish, here's a video of the procedure of reconstructing the PFL:

http://www.youtube.com/watch?v=Zz_U2CWES3s

My PFL was replaced with a tendon graft harvested form my hamstring and my PCL was replaced with a ligament from a donor, called an Allograft. The allografts are usually taken from the Achilles. I recently read a decent article on the various aspects to think about if you are considering a PCL Allograft:

http://www.kneeguru.co.uk/KNEEnotes/node/2125

Four more days till I get my staples and stitches out. Then I can get into my locked, but releasable, knee brace and out of this monstrosity: 

Happy days!

The Surgery

Surgery

They never tell you about the pain. They tell you about everything else: the rehab, the risks, the outlook, but they never tell you about the pain. Morphine, Co-Codamol and Voltarol don't make a dent on sliced skin and drilled bones. OUCH!

In the end my surgeon replaced my posterior cruciate ligement with a donor achillies tendon and replaced my popliteo-fubular ligament (shown as PFL below) with a hamstring graft.

My knee is apparently in good shape with no signs of wear or cartiledge damage. My LCL is a little slack but he wasn't too worried about that. It's pretty amazing what they can do these days.

REHAB

Today is the first day of long period of rehab. Best estimates are 12 months before I'll be back climbing and I'm stuck in a fixed knee brace for 6 weeks or so during which time I can only do passive exercises. A long road ahead, I'm hoping for a good outcome...

Motivation Boost

Today is a good day. Well, it started bad - bit hungover because of the one too many three too many beers last night. But my flatmate was heading down to Dumby for a spot of bouldering and since the weather was stunning, I thought I'd tag along. Brought my shoes to do some very easy climbing.

Like I said in my last post, I've been struggling a bit for motivation recently. The thought of a year out from climbing and various other things have been playing on my mind. Losing all the hard fought fitness and finger strength was a worry. My copy of Dave MacLeod's 9 out of 10 climbers dropped through the door today.

A few things today have really lifted my mood and taken a weight of my mind:

1. Ross Henighen doing Silverback, a Font 7C at Dumby and the first hard problem he's done since his return from 2 years out of climbing.
2. Speaking to Mark McGowan who, after a 15 year lay-off is back in the game and already getting near to doing some hard routes.
3. Top roping a Fr7b route I did last year and finding the crux easier! Also nearly getting Slap Happy, a benchmark 7A boulder problem. This is all after 3 months of not climbing, in fact, not doing very much at all.
4. A quote from Dave's book about reversibility maintenance:

"It turns out much less training stimulus is needed to maintain a given level of fitness than to increase it ... in the region of one session a week"

These events and ideas have really upped my psyche. If I can manage a reasonable fingerboard session once or twice a week for the next year, I should come back to climbing without having lost too much.

Today also gave me a reminder as to why I'm getting the surgery. Quite often it feels like my knee is fine -day to day it doesn't bother me and I was seriously starting to question if I need the surgery or not. If I had onyll torn my PCL, I think I would maybe get by without it, as many people do but it's the pesky wee PLC (posterolater corner) that's causing me the most grief. If I'm outside edging, doing drop knees and eqyptions my knee just gives way. I quite positive about the surgery. If my knee is this good now, a bit of improvement should really make a difference to my sporting life.

Only one more day until the operation!

Summoning Motivation

This week has been a bit weird. Went sailing on the west coast on the weekend, but due to other people's commitments, we had to be back on Monday. Got lucky(ish) with the weather and had a blast.

I'm off work this week, using up holidays as I'll be struggling to use all mine this year - never said that before. Just been pottering around the flat, trying to summon the motivation to do something. Anything. I've been doing a lot of cooking, just making stuff for the freezer so life's a bit simpler once I'm out of the operation. Beef Rendang yesterday, Venison Casserole today. Rick Stein's Beef Rendang might be one of my favourite dishes, I urge you to try it, or gimme a shout and I'll make it for you.

Get Strong

Lots of folk have said I should spend the next year getting super strong on the fingerboard. Good in theory, difficult in practise. I bought a pull-up bar and have been doing pull-ups every couple of days, seem to be getting a bit stronger at them...might break the 15 rep barrier soon, pretty gash for a climber...

Today I managed to get on the fingerboard (beastmaker) and man, have I got weak. I used to be able to hang the small monos and the 45s, but now, 30s are a struggle. Still, feels nice to be able to put some effort in. Need to get in to a rhythm and hopefully once I'm back to climbing I'll not have lost too much. It'll be a miracle if I come back stronger, but who knows!

Check the size of them weedy forearms, and the new HTC Desire/stopwatch in the background. Repeaters are much harder when you actually time the 7/3 second cycle. Stop that cheating!

I'll need to start posting some aims and achievements - that might help the motivation and track the +/- progress.

The Diagnosis

It's a strange feeling to regain consciousness in the middle of this mess:

Next stop, Perth Royal Infirmary for a neck-check, pee test and seven x-rays. At one point I had to sit up for the chest x-ray and was on the verge of passing out again. Got some stitches for me knee and glass removed from everywhere it had got stuck, which was just about everywhere.

I wish my Mum had taken photos of me leaving the hospital. No shoes, jeans and t-shirt cut to shreds and hanging off me and I nearly passed out again, twice. Down jacket all covered in blood, fortunately in one piece as I'd made sure the paramedics didn't cut it off!! Rank.

Woke up the next day, well, to wake up you need sleep, so, waking up may be a loose term for what happened the next day. Anyway, pain was the order of the day, no, sorry, I mean PAIN was the order of the day. Knees, wrists, neck, stomach, ribs, calf muscles, ankles, and left shoulder. Getting out a chair was verging on comical, rock back and forth until momentum is on your side and brace for the pain.

Anyway, enough winging about the pain. The A&E doctors thought I had done no permanent damage to anything, but my right knee felt very unstable. After a quick google, everything was pointing to a torn Posterior Cruciate Ligament, so I went back to A&E to get a second, and third opinion. Verdict: Nothing Wrong, any persistent issues, go to your doc in 6 weeks.

To cut a long, and frankly quite boring story short, lots of doctors got it wrong but I finally got seen by a specialist orthopaedic knee surgeon and had an MRI:

Now, this doesn't mean a lot to me, but apparently there should be a PCL in the circled region, and mine is missing. Not good.

Here is the full report from the MRI specialist:

Complex picture.
1.  High grade PCL tear confirmed.  ACL intact.
2.  Areas of bone bruising as described.
3. With reference to posterolateral corner: definite
posterolateral corner injury involving biceps femoris, LCL,
popliteus tendon and popliteofibular ligament. However most
of these structures appear to have partial tears rather than
complete disruption. Posterolateral corner capsular rupture
with soft tissue oedema.

The outcome of all of this is I need my Posterior Cruciate Ligament and some of the ligaments in the Posterolateral Corner replaced. More on this in the next post.

The Cause

I've been meaning to start this thing for a while, well, since the accident really. Unfortunately, and maybe unsurprisingly, motivation has been low. I suppose I should start at the start.

On 31st of January this year, on the way home from a couple of awesome day's climbing, I was in a car crash. Pretty bad one too.

Me and Neil had gone gone up to the Lost Valley in Glencoe to have a look at Neanderthal, classic steep mixed route that we'd wanted to do far a while - no luck on this occasion, too black was the verdict, so we did Barbarian instead. Nice route.

After quickly nipping up Minor Issue, we started back down to the car, on the way we came across a gaggle of folk around a female casualty. She must have slipped on the icy snowpack and looked like she had a few injuries. Since there were plenty of people on the scene, it was decided that we'd be more useful as runners, so run we did. Well, run Neil did, as I gave up about half way as my knee was packing in. Again.

So, Neil got in touch with the mountain rescue to make sure they new about the accident, which they did and that was that. After some food in the Clachaig Neil headed home and I went to Fort William to catch up with Andy.

On Sunday we went up to Creag Meagaidh as there were rumours of classic routes in good condition. We guessed it would be busy so headed up the hill early, second team on the hill. As we practically had pick of the routes, we went for Smith's Gully, apparently one of the hardest of the Scottish gullies. It all went well and we got off the hill pretty early, just after lunch. Maybe not one of the hardest in the condition we found it, but certainly one of the finest.

Three routes in the bag and the season is only looking better and better, until it gets worse. A lot worse.

On the way home I was involved in a pretty brutal crash. Some of you know what happened, unfortunately, I can't post any details at the moment but all will become clear in time.

Next post, the (mis?) diagnosis.