Challenges After ACL Reconstruction: Knee Stiffness and Pain Management

Knee issues after posterior cruciate ligament reconstruction?

Hello Doctor: I underwent a second anterior cruciate ligament (ACL) reconstruction surgery last October because the autograft used in the first surgery had loosened.
This time, an artificial ligament was used, but I have always had an issue with knee adhesions, which prevent me from achieving full range of motion after each surgery.
Before the second reconstruction, I could bend my knee to a maximum of 135 degrees, which I achieved after one anesthesia session, two arthroscopic debridements, and over a year of rehabilitation.
Although I couldn't fully flex or squat, it was still acceptable.
However, after the second surgery last year, my knee's range of motion improved even more slowly than before, despite starting rehabilitation immediately post-surgery.
In January, I underwent another anesthesia session for knee flexion, and the doctor used a needle to help clear the adhesions, but under anesthesia, I could only bend to 120 degrees.
The doctor was unsure why I couldn't achieve more flexion.
I would like to ask: since I can only achieve 120 degrees even under anesthesia, will continuing rehabilitation help improve my range of motion (currently still at 120 degrees)? What other methods, aside from surgery, could help increase my flexion? Would another anesthesia session for knee flexion be beneficial? (This time, I was stuck at 95 degrees during the procedure.) Additionally, since my last surgery, my knee has been making very loud noises.
Unlike before, which sounded like crumpling paper, now every degree of flexion produces a loud "pop" sound that is easily audible.
This is particularly noticeable when fully extending and then bending my knee, and I can see the tibia shifting slightly with each pop.
The follow-up doctor suggested that this noise might be due to the friction between proliferative tissue and bone.
Although it is not painful, it is quite bothersome, and my knee feels very stiff.
For instance, when trying to go down stairs, my knee makes a series of loud pops, which is quite alarming.
If this issue needs to be resolved, is surgery the only option? During each follow-up, the doctor seems unable to do much, only suggesting that if surgery is needed, I should return to see him or continue rehabilitation.
However, surgery is only considered as a last resort, and the doctor mentioned that the range of motion may not necessarily improve, which is quite frustrating, leaving me unsure of what to do.
Am I destined to continue rehabilitation indefinitely?
Lastly, I have another question.
The doctor mentioned that there was significant adhesion on the inner side of my knee, which he cleared during surgery.
I wonder if this is the reason why I experience extreme pain whenever I apply pressure inward on my knee or perform movements similar to kicking a shuttlecock, where my ankle pushes against something.
The pain is excruciating, akin to bending a finger in the opposite direction to its limit.
Strangely, even though the pressure is applied at the ankle, the pain radiates up to the inner side of my knee, and this has persisted for a long time.
When I asked the doctor, he said it could be due to tearing from the adhesion removal or inflammation of the tendons, and there seems to be no solution.
This is quite troubling for me because sometimes my knee unconsciously turns inward while I sleep, and after a while, when I turn or extend it, the inner side feels extremely painful, almost as if it cannot fully extend.
Therefore, I would like to ask: what could be causing this issue? I have also had my meniscus repaired, and although the doctor said it looked fine during surgery, could it be related to the meniscus? What tests can be done to confirm if there is an issue on the inner side? Or is it simply a result of the previous adhesion removal? What treatment options are available? Thank you for your response!

Niming, 20~29 year old female. Ask Date: 2020/05/04

Dr. Shi Guozheng reply Orthopedics

Joint adhesions are inevitable after multiple surgeries.
Under anesthesia, performing knee surgery can improve some conditions, but it is impossible to return to the pre-injury state.
Achieving a range of motion of 120 or 135 degrees is already considered good.
To determine whether there are any structural issues within the joint, it is essential to consult the surgeon, as they can directly observe the problems within the joint during the procedure.

Reply Date: 2020/05/04

More Info

After undergoing ACL reconstruction, particularly with the complications you've described, it's not uncommon to experience challenges such as knee stiffness, pain, and the presence of audible sounds during movement. These issues can stem from various factors, including surgical technique, rehabilitation protocols, and individual healing responses.

Knee Stiffness and Pain Management
Knee stiffness is a frequent complication following ACL reconstruction. It can result from scar tissue formation, which may lead to adhesions that restrict the normal range of motion. The fact that you have a history of adhesions and have undergone multiple procedures to address this issue suggests that your knee is particularly susceptible to these complications.
1. Adhesions and Scar Tissue: The formation of scar tissue is a natural part of the healing process, but in some cases, it can become excessive, leading to stiffness and pain. This is often exacerbated by prolonged immobilization or inadequate rehabilitation. The sound you hear during movement, described as a "crack" or "pop," could be due to the friction between the scar tissue and the underlying structures of the knee, such as the bones or the remaining soft tissues.

2. Rehabilitation: Continuing rehabilitation is crucial. While it may feel discouraging that your range of motion is limited to 120 degrees, consistent and targeted physical therapy can help. Techniques such as manual therapy, stretching, and strengthening exercises for the quadriceps and hamstrings can be beneficial. It's essential to work closely with a physical therapist who understands your history and can tailor a program to address your specific needs.

3. Pain Management: For pain management, consider modalities such as ice therapy, ultrasound, or electrical stimulation, which can help reduce inflammation and pain. Non-steroidal anti-inflammatory drugs (NSAIDs) may also be recommended by your physician to manage pain and swelling.

Further Interventions
1. Anesthesia and Manipulation: You mentioned undergoing manipulation under anesthesia (MUA) to improve your range of motion. This can be effective in breaking up adhesions, but it may not always yield the desired results. If you find that MUA has not significantly improved your range of motion, it may be worth discussing alternative approaches with your orthopedic surgeon.

2. Surgical Options: If conservative measures fail and your quality of life is significantly impacted, further surgical intervention may be necessary. This could involve arthroscopic surgery to remove adhesions or to address any structural issues within the knee. However, as your surgeon mentioned, surgery should be considered a last resort, and outcomes can be unpredictable.

Inner Knee Pain
The pain you experience on the inner side of your knee, especially during specific movements, could be attributed to several factors:
1. Residual Adhesions: The pain may be related to residual adhesions from your previous surgeries. These adhesions can cause discomfort when the knee is subjected to certain movements or pressures.

2. Meniscal Issues: Although your meniscus was reportedly intact during surgery, it’s possible that there could be minor tears or degeneration that were not evident at the time of the procedure. Meniscal injuries can cause pain, particularly during twisting motions or when pressure is applied.

3. Nerve or Tendon Involvement: The pain radiating from the ankle to the inner knee could also indicate involvement of the tendons or nerves in that area. This could be due to inflammation or irritation from the surgical site.

Recommendations
1. Consultation: It would be beneficial to consult with your orthopedic surgeon or a sports medicine specialist who can perform a thorough evaluation, including imaging studies like an MRI, to assess the current state of your knee and any underlying issues.

2. Physical Therapy: Continue with physical therapy, focusing on both strengthening and flexibility. Your therapist can provide specific exercises to address the inner knee pain and help improve your overall knee function.

3. Pain Management Strategies: Discuss pain management strategies with your healthcare provider, including the potential use of corticosteroid injections if inflammation is significant.

In conclusion, while the journey to recovery after ACL reconstruction can be fraught with challenges, a comprehensive approach involving rehabilitation, pain management, and possibly further evaluation or intervention can help you regain function and reduce discomfort. It's essential to maintain open communication with your healthcare team to ensure that all aspects of your recovery are addressed.

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