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Sports Medicine

ACL 6 mo post-op

07/20/2009

Question:

I am 6 months post-op from ACL reconstruction with autograph from patellar-tendon. Injury occured 2 and a half years before surgery. I have the same pain that I had pre-op. I had 40 visits of PT. 6 visits of work conditioning that lasted for 2.5 hours per session. When I saw my Dr. two months ago, I had 2 cm of atrophy. My visit a month later, I had 2.5 cm of atrophy. Then, a week or so later when I started work conditioning, I had 3 cm of atrophy. My knee "buckles" more than it ever did before surgery. I also have a tearing sensation on the lateral aspect of the proximal tibia whenever I carry something, or step on uneven groud. I have reached the maximum amount of PT visits for a worker`s comp case, so more PT is not an option. My Dr. tells me that it should get better, that the ACL is stable, and he can feel no laxity at all. He seems satisfied with his work, but I am very concerned. My quality of life has been drastically reduced. This problem has persisted for three years now, and I am ready to feel better. Is it normal to have increased buckling post-op? When should I start to have pain relief? And, why am I experiencing an increase in atrophy as I get further from my surgery date? Is there anything that I can suggest to my Dr? Should I seek a second opinion?

Answer:

Making an unstable knee more stable - surgically or nonsurgically - doesn't necessarily make it any less painful. That is, there's often not a direct relationship between pain and instability... an unstable knee may be minimally painful, whereas a stable knee can have severe pain.

One possible reason for pain persisting despite surgical correction of its initial cause is that when pain has become chronic, it may then become "ingrained" into your nervous system, such that the neural circuits/pathways - which have conveyed these pain impulses from your knee, up to and through your spinal cord, then up to your brain resulting in pain perception - have done so for so long that as a result they have become "primed" or "reverberate, and continue to do so even if the original cause is no longer present. This is a proposed reason why anti-seizure medicines can sometimes help "tone down" pain severity/frequency.

An alternative or additional possibility is there may be another source of pain besides the ACL tear, including, among other possible causes, osteoarthritis, patellofemoral pain, iliotibial band friction syndrome, and pain from the proximal tibio-fibular joint.

Atrophy can result from reduced use (disuse), and muscle strength and tone are reflexively inhibited (reduced) by pain in the joint that muscle crosses (e.g., quadriceps and hamstrings for knee pain).

Although ideally the cause for your symptoms is diagnosed and treated, certain measures may help reduce your knee pain symptoms, such as non-steroidal anti-inflammatory medications (if you're able to take them), ice application for 15-20 mins., trying on a number of different designs of knee braces/sleeves to see if one helps more than another, cross-training (aquatic exercise, cross-country ski machine, etc.) with an activity which doesn't flare your symptoms, "cross-over training" - meaning heavy resistance training for the other leg to achieve strengthening benefits which can "cross-over" to the painful side, and knee steroid injection (or if steroid injections have been tried/not helpful and osteoarthritis is present, knee viscosupplement injections).

If your orthopedist has nothing further to offer to help your persisting pain, it is reasonable to consider obtaining a second opinion.

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Response by:

Brian L Bowyer, MD Brian L Bowyer, MD
Clinical Associate Professor
Physical Medicine & Rehabilitation
College of Medicine
The Ohio State University