Thread: Healing response ACL failure - what to do now

I just tore my ACL and MCL the other day. I had torn the same leg ACL (grade 3) 6 years ago in Vail and had the "healing response" done there. 4 weeks of a straight leg brace pre-op plus six weeks post. I had chondromalacia from running, so the surgeon cleaned up. Long, long story short is i ended up with a ton of atrophy (despite diligent rehab) and a lot of anterior pain where they cleaned up. The patellofemoral pain complicated rehab tremendously. The pain never went away (moguls were very painful as were stairs for two years post op), and as a result, i could never get the muscle to get back to normal. However, the leg was stable (no giving way and KT1000 less than 1 mm difference). I do have patellar tendonitis on my good leg. Before just blowing it again, I was set to have Synvisc to help alleviate the pain.

I am a 40 year old double black, aggressive skier. I also play tennis. I was all set to do an allograft before reading all of Dr. Mark's comments. Given that I have significant anterior knee pain in the affected knee already, and some patellar pain in the other, that would seem to point to hamstring.

My doctor is one of the best orthopedists in Chicago (my dad is a doctor, reputation of patients, reputation of PTs, etc). However, I am not sure he does a lot of hamstrings.

Dr. Mark, what is your view on what to do? Any surgeons you particularly like in Chicago? Given that you say many non-experienced surgeons choose the allograft because it is cheaper and more profitable, are they skewing the data? Is an allograft in a great surgeon ok?

Allografts seem to work ok for many folks, but autografts seem to have the upper hand when the results are reviewed in metanalysis. (The means many studies are combined together) and when serious athletes are the study group. Since I only treat active serious athletes, it may be that my experience is biased towards autografts. My first choice is always the patella tendon from the opposite side. In well over 1000 opposite patella tendon harvests, I have never had anyone with lasting issues on the donor knee. I am sorry, I don't know anyone in Chicago.

Thanks for the quick reply, Dr. Mark. What is your general view of the microfracture healing response surgery for ACLs?

Does the fact i have long standing patellofemoral pain from the last surgery influence what type of graft to do this time?

Lastly, with a grade 3 mcl/acl from this week, should i be on crutches/brace or not?

My unwashed undiplomatic view is that the healing response stuff is as useless as titties on a boar hog.
I have only seen failures of this procedure, and there is nothing that doesnt' work in labratory animals that works in people, (while the converse is always true. Stuff that works in the lab, often farts out in live humans, but don't get me started on this)

Patellofemoral pain syndrome doest not al all influence my primary choice of ACL graft

When you say grade 3 MCL, it sounds like that came off an MRI scan. Many of these reads can go straight to the garbage because the MRI regular over calls MCL injuries. My practical approach is that if the MCL is torn off the tibia, it needs surgical repair. If its torn in the middle or off the femur, a locked brace or cylinder cast is best for four to six weeks to allow it to heal without surgery and before the ACLR is done. But most MRI generated diagnoses are overcalled, and no specific attention is directed to the MCL which is usually only mild to moderately sprained. That is why fancy tests are no substitue for a careful physical examination.

I haven't had an MRI yet (scheduled for Monday). The orthopedist who did the physical exam 1 hour post injury made the comment. My knee did feel like it was bending inward and hitting my ski brace (which was obviously useless) on the way to the clinic. The orthopedist told me just to keep wearing my hinged CTI brace and do touch done crutch walking. However, i have known others who were told, as you said, to have a straight leg brace with no weight bearing for a period of time. Thoughts? How do you know where the tear occurred? From the MRI?

other question: if I do have some sort of "high grade" MCL sprain that is 5 days old, can I bike to rehab right now or just rest it?

Without looking at it, I couldn't begin to tell you because the MRI regular over diagnoses the MCL injury.

Previously, I have told my patients who get hurt on vacation, to keep the ER brace on tightly, don't bend the knee at all, and weight bear to tolerance with the brace on. That is typically the most reasonable thing to do when one isn't quite sure what is going on. Like when a patient calls me in Hoston from their hotel in Whistler.

looking on the issue of sports injuries.bold and so active approach are given by u,its just amazing.well i keep looking on ACL,pcl,it sounds dat if i will b train by u,i will b the next dr mark.its mentioned abt patelofemoral pain,so even using contra graft there is this pain still n if so fr hw long?plus i do have a question peopel wd ACL deficient knee can do static cycling?dr mark do u oftenly repair meniscus or straight away menisectomy is done?and while during th arthroscopy,do u use some instrument to find the strength that after reconstruction menis will not be torned.plz do enlight urs views.

I'm sure you've reviewed the other acl threads. I'm 9 weeks post-op to repair a fully blown acl/mcl. I feel great and have been riding my road bike for several weeks, though at a very easy pace (75% max hr) to get back aerobic capacity.

My surgeon recommended a hamstring autograft. After a lot of research I agreed and added the opposite leg harvest. I'm 51 and a strong skier, climber, cyclist, etc. I'm very happy with the results so far, as are my doc and pt. I really think the opposite leg harvest makes sense and has, I think, been a significant reason for the relatively easy recovery. The damage really isn't that bad and especially early on you can focus the pt on the repaired leg without straining the hammy. Having a less hammered repaired leg allows quicker healing for that leg and allows you to get the most out of pt. The worst part with regard to the harvest leg is immediately post-surgery getting from the wheelchair to the car to your bed at home.

Reading dr mark's comments about mcl mri's is interesting. The emergency room doc very quickly diagnosed a full acl/mcl. Based on my mri weeks later, my doc diagnosed a grade II tear. During surgery my doc found it totally detached and fixed it. By the way, the mcl part of the recovery has been the most difficult: locked brace for a week, then wearing the brace for two months, the most pain, the stiffest, the most in need of being careful, etc. Early on I envied the acl only people. Now it's all good.

Originally Posted by ordjac

I just tore my ACL and MCL the other day. I had torn the same leg ACL (grade 3) 6 years ago in Vail and had the "healing response" done there. 4 weeks of a straight leg brace pre-op plus six weeks post. I had chondromalacia from running, so the surgeon cleaned up. Long, long story short is i ended up with a ton of atrophy (despite diligent rehab) and a lot of anterior pain where they cleaned up. The patellofemoral pain complicated rehab tremendously. The pain never went away (moguls were very painful as were stairs for two years post op), and as a result, i could never get the muscle to get back to normal. However, the leg was stable (no giving way and KT1000 less than 1 mm difference). I do have patellar tendonitis on my good leg. Before just blowing it again, I was set to have Synvisc to help alleviate the pain.

I am a 40 year old double black, aggressive skier. I also play tennis. I was all set to do an allograft before reading all of Dr. Mark's comments. Given that I have significant anterior knee pain in the affected knee already, and some patellar pain in the other, that would seem to point to hamstring.

My doctor is one of the best orthopedists in Chicago (my dad is a doctor, reputation of patients, reputation of PTs, etc). However, I am not sure he does a lot of hamstrings.

Dr. Mark, what is your view on what to do? Any surgeons you particularly like in Chicago? Given that you say many non-experienced surgeons choose the allograft because it is cheaper and more profitable, are they skewing the data? Is an allograft in a great surgeon ok?

I am having a very similar issue as I just recently tore my ACL again. Now looking at a second ACL recon.