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Crowdsourcing a DX - what's wrong with Nick's knee

Step right up ladies and gentleman. Step right up and see if you can win a prize. What you need to know:

  • Patient is a mid-30s male
  • 5'10'ish, 180lbs
  • Patient is athletic and in good shape despite his love handles.
  • Patient has prior history, both ACLs have been repaired for sports-related injuries
  • Patient presents resulting from injury on 7/25, states he heard and felt a pop when landing from box jumps in the gym
  • Patient reports little swelling, moderate pain and stiffness and mild instability
  • Patient does not report any joint locking
  • Patient prefers to be called Nick, not patient
  • I'm Nick, Hi!

MRI study: Here's your chance. For all the money (there is no money), and the grand prize (there may be a prize), what is Nick's diagnosis?

Leave your thoughts in the comments.

Once the official diagnosis is confirmed, I'll report back here and we can play the next round: "What treatment does Nick pursue?"


two knees, or not two knees

Editors note: yes, I went there on the title. Yes, I studied English in college and no I'm not ashamed of the cliche turn of phrase.... maybe a littleYou go in there My first reaction was to laugh, I think it caught my doctor off guard. "It's the ACL," he said shaking his head. The look on his face was earnest disappointment at the diagnosis. Maybe it was the eight weeks that had passed since the injury, or the fact that I skied out the rest of the season, but my only reaction was laughter. And, when you consider the circumstances, it is pretty funny.

Last April, we were out in Vail on the first day of a week long trip. My dad and I separated from my mother and my wife to go ski outer Mongolia in some soft but quite nice spring snow. Since he had the video camera, I had him go first with the intention of rocking through the bumps and getting some ego footage. I had a great run and took my time coming to a stop at the relatively flat bottom. As I was coasting slowly I lost my balance, the back of my ski dug in to some lose snow and I went over like a slinky. I heard a pop, shouted some choice words and lay there in pain for at least 10 minutes.I managed to ski down the front side of Vail, mostly on one ski (thanks years of race training for that useful trick!).

(I documented a lot of that process here and tagged posts as ACL) I had the reconstruction at home and this winter was back on the snow, skiing better than before the fall. It was a painful surgery and the rehab was hard - mostly because  it was boring and time consuming, not all together painful. On the one year anniversary, to the day, of that fall we were out in Steamboat. Same story- the old man and I hitting the back bowls. On our way back to the front, we came upon The Boat's section of double black diamonds. So I did the reasonable thing and sent my father ahead with the video camera. My thought was to get a video to send to my orthopedic doc to show him my full recovery. What would be a better testimonial than me flying down an impossably steep double black one year after my injury and reconstruction?

Right as I was taking off, Dire Straits' Espresso Love came on my iPod. For the whole year, I had avoided listening to that song. It was playing when I went down last year! But I was in mid turn, and off to a nice start and decided to ignore it. I skied a fairly iced out steep pitch nicely, although not as gracefully as I would I have liked. I took a pause and came to a gliding stop and thats when it happened.

The same, exact fall. Right knee this time. Same pop, but not nearly as much pain and no loss of range of motion (no swelling) I again skied off the mountain and even skied the rest of that week; followed by another two trips out west of some seriously hard skiing. In fact, I even bought two new pairs of skis this year because I was skiing so well. Unfortunately this right knee just has not changed. It is no worse, but no better either, there  is a constant dull pain. I've been in the gym pretty hard (squatting 360lbs often) and it feels stable when I run. Walking is another story, it does not totally slip out like my left did pre-surgery, but it locks up a bit with some significant pain at random times.

I broke down, had the MRI and consult. The diagnosis is a torn right ACL. Surgery seems imminent, and I am begining to make peace with that. My hope is, since I did not swell and do not have the resulting muscle loss, that I can do an abbreviated PT schedule and get back into the gym sooner. I'd rather not lose the ground on the weight loss and fitness while I convalesce for another 6 months.

So add this to the list of posts on this blog tagged with ACL... lets home this does not become an annual feature!

Hopping around - post op day 5

back to workJust a quick update - five days after surgery, things are on the mend. I think it is safe to say that I underestimated the recovery from the ACL reconstruction and meniscus repair. Thursday, Friday and Saturday (days 1, 2, and 3) were spent in bed with little or no mobility. It was during physical therapy on Monday that things seemed to round the corner. While the joint has started to calm down, I have also gotten better on crutches. Perhaps its taking a few more risks in the form of a hop or two. I have been able to get back to the office and am returning to a somewhat normal schedule.

I consider myself a fairly well informed patient. A few weeks ago I wrote about the process of finding a surgeon. I attributed a good deal of that research to working in and being connected with the healthcare industry. I thought I had asked the right questions, made the right calls and done my homework. And frankly, for the decisions I had to make, I was well informed. However, I was not fully prepared for the recovery and post-op recovery.

Since then, I have rediscovered the Mayo Clinic's online health library. Mayo has made a name with its health library, licensing the content to other providers and sites (which is how I had first come across the site). It is a wonderful resource for anyone doing research on a health-related issue.

As the pain lessons, I am pushing through with physicial therapy. I am in good hands and expect to be walking again in a few weeks.

day 2 - let the rehab begin

Not a lot to report today except for some reduction in the pain. I have discovered that 'keeping in front of the pain' means taking the meds before you need them. As long as I set some reminders, then it seems to be much more manageable. Physical therapy - electro shock

Yesterday was my first dose of physical therapy. Given my limited understanding of whats to come, yesterday's PT was rather mild. The best part was getting the bulky dressings off. Besides just being able to flex and breath a bit, it means that the pad from the ice machine is closer to the joint and considerably more effective. We covered a few basic exercises including quad flexing, heal pushes and ankle pumps. Its remarkable how much you muscles atrophy in a short period of time - at this point I cannot lift my leg without help. Two weeks ago I was squatting 400lbs at the gym... pretty stark juxtaposition.

As the pain gets better and movement gets easier, I am looking forward to what the next 24 hours will bring. I've been cleared to bend my knee to 90 degrees which means I may be able to sit up and spend some time somewhere other than the bed.

On a sad note, I am bummed to be missing Susan's marathon this weekend. Be sure to follow her progress on twitter.

A leg up - one day after surgery

Recovery Room

Fans of the TV show Top Chef know that contestants are often admonished for not tasting their food before it goes to the diners. Sampling your wears is the tenet of any service industry. That said I would wager that most healthcare professionals have not volunteered to go under the knife just to see what its like (and who would fault them?). There are times however when some of us get a chance to experience our service from the patient perspective - yesterday was one of those times for me.

As a result of my ACL injury, yesterday I underwent a surgical procedure to start the road to recovery. I wrote about my decision to to return to Richmond verses having the surgery at a world-renown clinic. What I did not not mention, something that was a major factor for me, is that I work for a top notch health system with four hospitals in Richmond. As part of my role I am focused on our 'service excellence' initiative. Indeed it is something we empower all of our team members to lead; a path towards world class patient experiences. The goal is simple, in every move we make, every interaction, we seek to exceed every patient's expectation, every time. In practice it is not so easy a thing.

So what did I observe from my day as a patient? For starters I confirmed what I had hoped for, that we do have team members committed to first class treatment. We have some things to fine tune but overall there is no doubt that my decision to come home for care was the right one.

The procedure went well, or so I am told. Once inside, they found a considerable amount of damage beyond the ACL rupture. From the MRI, we had suspected a tear in the meniscus (a cushion of tissue that forms a cup between the thigh and leg bones. The surgical team found multiple rips in the meniscus and were fortunately able to repair them. That repair will hopefully save me from a knee replacement in the future but it comes with a price tag. To let the meniscus heal, I have to keep my weight off the knee for three weeks - crutches, blurg! The ACL repair is a very interesting procedure in itself. When they tear, anterior cruciate ligaments literally explode, leaving nothing behind. I had a choice, they could remove a portion of a ligament from elsewhere in my leg or use a donor ligament. For various reasons, I chose the donor tissue. In either case, the procedure is really a bone graft. Since ligaments cannot be directly attached to bones, the replacement ligament still as a portion of bone attached to either end, and that bone segment is grafted into the knee joint.

And the patient? I'm in a fair amount of pain and rather immobilized. But I have a wonderful care taker and will start physical therapy today which should help. I also want to say a very heartfelt thank you to friends and family who have checked in.

Throughout my convelesence, I will continue to update this site with notes and observations. In particular, I am looking forward into detailing the clinical procedure and the physician who performed the work. For those interested, check back soon!