Managing Complex Knee Issues After ACL Reconstruction: Pain and Solutions

How to address complex knee issues?

Hello, doctor.
I underwent a posterior cruciate ligament (PCL) reconstruction surgery last October, which was my second reconstruction.
The first surgery resulted in ligament laxity after a year, leading to the need for a second operation.
Initially, an autograft was used, but later it was replaced with an artificial ligament.
I have been undergoing rehabilitation post-surgery, but due to multiple knee surgeries, including adhesions, infections, and meniscus issues, my knee flexion recovery has not been ideal.
After a year, I can only bend my knee to about 120-125 degrees at most, and my doctor has given up on improving the angle.
Currently, my knee has more than just an angle issue; I am also experiencing significant pain, unusual sounds, and a grinding sensation.
Recently, I have noticed that the ligament from the second reconstruction has also become somewhat lax (the tibia can move back and forth), and considering my previous meniscus injury, where at least half of the lateral meniscus was removed, I am uncertain about the factors causing my knee pain and what can be done to address it.
My questions are as follows:
1.
After standing or walking for more than 30 minutes, I experience pain on the lateral and posterior sides of my knee, with the posterior pain becoming more pronounced during flexion.
Initially, I could bend to 120 degrees, but now I can only bend to 100 degrees due to a feeling of compression accompanied by intense pain that prevents me from applying pressure.
Sometimes, the pain radiates down to my calf and thigh, resembling a cramp.
2.
When sitting with my knee bent at about 90 degrees, I experience lateral pain similar to the cramping and weakness described above.
Interestingly, walking or straightening my leg does not trigger this pain.
It is particularly noticeable when sitting or riding a motorcycle, with symptoms appearing intermittently (but about 80% of the time).
When these symptoms occur, my entire leg feels very uncomfortable, including after prolonged bending when I try to straighten it.
The knee issues cause me pain while walking, and even when I am not walking, I still experience pain, which intensifies during flexion.
I often feel uncomfortable about where to position my leg.
However, during follow-up visits, my doctor only mentions that the imaging appears normal and that the pain should be due to temporary inflammation, suggesting observation or continued rehabilitation.
The therapist indicated that my issues stem from ligament laxity causing joint instability, leading to posterior tibial displacement during flexion, resulting in pain or a feeling of compression.
The lateral pain is attributed to meniscus or cartilage wear.
When I asked if there are ways to improve my condition, the therapist said that it may not be possible until my thigh strength improves.
This implies that I am currently stuck in a cycle of pain and discomfort, training, and waiting for recovery.
Doctor, given my current situation, is there truly no way to resolve this? If I were to try prolotherapy targeting ligament laxity and meniscus wear, could it potentially alleviate the pain? Thank you for your response.

Niming, 20~29 year old female. Ask Date: 2020/11/27

Dr. Chen Bochen reply Orthopedics

Hello, your issue is indeed complex and requires a meticulous and skilled physician along with a good rehabilitation team to assist you long-term.
I recommend you consult with Dr.
Luo Jian-Sheng, the orthopedic specialist at Chung Shan Medical University Hospital.
He is an expert in this field, so be patient and follow his guidance without frequently changing doctors.
Wishing you a speedy recovery.

Reply Date: 2020/11/27

More Info

Managing complex knee issues after ACL reconstruction can be quite challenging, especially when multiple surgeries and complications have occurred. Your situation, involving a second reconstruction with artificial ligaments, persistent pain, and limited range of motion, is not uncommon among patients who have undergone multiple knee surgeries. Let's address your concerns systematically.

Understanding Your Symptoms
1. Pain After Prolonged Standing or Walking: The pain you experience after standing or walking for more than 30 minutes, particularly in the outer and posterior aspects of your knee, could be attributed to several factors. Given your history of ACL reconstruction and meniscus surgery, it is possible that you are experiencing patellofemoral pain syndrome, which is common after knee surgeries. This condition arises from the improper tracking of the kneecap over the femur, leading to pain during activities that involve bending the knee.

2. Pain While Sitting or Bending: The discomfort you feel when sitting with your knee bent at 90 degrees may be related to the altered biomechanics of your knee joint due to the previous surgeries. The sensation of "tightness" or "cramping" could indicate that the surrounding muscles and tendons are not functioning optimally, possibly due to weakness or tightness. This can lead to increased stress on the joint structures, including the ligaments and cartilage.

Potential Causes of Your Pain
- Ligamentous Laxity: The looseness of the reconstructed ligament can lead to joint instability, which may cause pain during movement. When the tibia shifts excessively, it can create a sensation of pressure or discomfort, especially during flexion.

- Meniscal and Cartilage Damage: Since you mentioned having a partial meniscectomy, the loss of meniscal tissue can lead to increased stress on the articular cartilage, potentially resulting in osteoarthritis over time. This can manifest as pain and a grinding sensation during movement.

- Inflammation: Post-operative inflammation can persist for an extended period, contributing to pain and discomfort. This inflammation may not always correlate with visible damage on imaging studies, making it challenging to diagnose.

Management Strategies
1. Physical Therapy: Continuing with a structured physical therapy program is crucial. Focus on strengthening the quadriceps, hamstrings, and calf muscles to provide better support for the knee joint. A strong musculature can help compensate for ligamentous laxity and improve overall stability.

2. Activity Modification: While it is important to stay active, modifying your activities to avoid prolonged standing or walking can help manage pain. Incorporating low-impact exercises, such as swimming or cycling, can maintain fitness without exacerbating knee pain.

3. Pain Management: Over-the-counter anti-inflammatory medications (like ibuprofen) can help manage pain and inflammation. However, consult with your physician before starting any medication regimen.

4. Injections: Considering your ongoing pain, you might explore options like corticosteroid injections or hyaluronic acid injections. These can provide temporary relief from inflammation and improve joint lubrication.

5. Regenerative Medicine: You mentioned the possibility of trying regenerative therapies, such as platelet-rich plasma (PRP) or stem cell injections. These treatments aim to promote healing and reduce inflammation in the knee joint. While results can vary, some patients report improvement in pain and function.

6. Surgical Options: If conservative measures fail, revisiting your orthopedic surgeon to discuss potential surgical interventions may be necessary. This could include ligament reconstruction, meniscal repair, or even cartilage restoration techniques, depending on the specific issues identified.

Conclusion
Your situation is complex, and while it may feel discouraging, there are various avenues to explore for pain management and functional improvement. Collaboration with your healthcare team, including orthopedic surgeons and physical therapists, will be essential in developing a tailored approach to your rehabilitation. Remember, recovery from knee surgeries can be a lengthy process, and patience, alongside consistent effort in rehabilitation, is key to achieving better outcomes.

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