My gaze jumped nervously around the exam room. I tried to occupy myself by skimming through a magazine. After reading the same paragraph four times and not being able to recall what it was about, I put it down. Breathe, just breathe I tried to remind myself. The medical assistant pulled up my MRI on the computer and said Dr. Yau would be in shortly. I couldn’t help but stare blankly at the screen. Part of me still hoped this was all a bad dream. Maybe they mixed up my results with another patient? Maybe the radiologist that interpreted my MRI made a mistake? Yeah, probably not.
“Christine, it’s good to see you,” announced Dr. Yau as he entered. “Were you as surprised as I was by the results?”
“You have no idea,” I replied.
“This was definitely not what I was expecting for you. I can imagine how hard it must have been to receive this news. Let’s talk about your options. You’ve been able to keep up with your activities without major limitations except for impact sports. You’re the anomaly in comparison to most patients with your diagnosis. We could go the conservative route, hold off on surgery and see how you do. I’d recommend significantly limiting if not completely avoiding all impact activities due to the increased risk for further injury to the surrounding structures of your knee, as you are already aware. That’s option one. Or, we can go down the surgery route. That’s option two.”
“Dr. Yau, I appreciate you considering the big picture. I love the thought of the conservative option. Heck, I am the conservative option being a PT. I wish I could say no to surgery, but I don’t think that’s the best fit for me. I need to be able to return to the activities I love doing, that I miss doing. I’m not ready to sideline myself from impact activities at this point in my life in order to avoid surgery. Running and running-related activities are a huge part of my life. I want to get back to that. I need to get back to that.”
“I completely understand. You’re young, healthy and have a great prognosis for a full recovery post ACL reconstruction. You obviously know the rehab part. Let’s talk about surgery and your graft options.”
We spent the next 20 minutes discussing the research: cadaver vs. patellar tendon vs. hamstring grafts (aka what would later become my new ACL). None are without their pros and cons. There are a variety of reasons why certain grafts are a better fit for certain patient populations. Age, prior knee injury history, activities the patient would like to return to, surgeon preference, etc… all play a role in the decision making process. Based on the medical research available, I was the perfect candidate for a patellar tendon or hamstring autograft. Fortunately, my surgeon was well versed in both procedures and assured me that neither was a bad option for my case, but there were a few things to consider. If I opted for the patellar tendon my chances of returning to impact activities could be as early as four to five months after surgery – sweet! However, I would be at higher risk of developing patellofemoral pain syndrome (PFPS), patellar tendonitis and long-term discomfort with kneeling. Since I wanted to return to running, avoiding PFPS and/or tendonitis was critical. As for kneeling, most people wouldn’t even blink an eye, but for my job as a PT kneeling is something I do regularly while working with patients. Not being able to do that easily would make my job challenging. If I chose the hamstring option, I would have to delay my return to impact activities, but kneeling and developing PFPS or patellar tendon pathologies would most likely be a non-issue. I would always have a hamstring strength deficit when comparing my right leg to my left, but that deficit wouldn’t be significant enough to affect my future athletic performance. Failure rates for both patellar and hamstring graft options are between 7-10% vs. cadaver being closer to 20% [1,2]. There were a lot of things to consider.
“I hate to put you on the spot Dr. Yau, but if you were in my position, which graft would you choose?”
“Well, like I said there is no perfect graft. However, I think you’re a great candidate for the hamstring option. You fit the criteria perfectly: under 30 years old, athletic, healthy, no other knee issues and first time ACL reconstruction.”
“That’s what I’m leaning towards….but I want to take some time to do a little research on my own before making my final decision. Thank you for taking the time to thoroughly discuss my options for surgery. This was all really helpful information.”
“You’re welcome. Take the time you need to decide what you think is best for you. It’s an important decision and I want you to feel confident about it.”
The next week was a processing week, letting my brain digest the information at hand while also considering the important questions I still needed answered: what graft and when to go under the knife? I knew there would never be a perfect time to take multiple weeks off from work. Yet, the task of trying to predict when it would be the least inconvenient was still challenging. It would be my first exercise in asking for help. I sat down next to Alex on the couch one evening and stared intently at our calendar.
“I’m trying to decide when it would be best, for us, to schedule my surgery.”
“Choose whatever you think is best for you,” he replied.
“But I’m going to need you, a lot, for the first few weeks so I want to make sure we choose the date together.”
“I’ll be here to help you. Pick the date that makes the most sense for you.”
I sat in silence for a few minutes with my gaze still fixed on the calendar. I thought this would have been more of a discussion. I was kind of hoping it would be in order to help put some boundaries around my decision-making…
“It’s been three months since my initial injury. I don’t want to keep putting this off any longer. I’m thinking the last week of April or first week of May? That gives me about five weeks to prepare everyone that will be impacted by my absence. That also puts me at returning to running around late October.”
“OK, sounds good,” Alex replied.
“OK! One decision down, one left to go. Now I have to figure out which graft I want…wanna help me do some research?
“Sure, what are we looking for?”
Alex and I dove into reviewing medical journals online for the latest ACL reconstruction data available. I shared with him that I was leaning towards one type of graft, but didn’t want to bias our search by revealing it to him prematurely. During this same time I reached out to two college friends, who are now orthopedic residents, to get their professional opinion on my case. After spending adequate time scouring articles and hearing back from my two friends I felt confident that I had enough evidence to make my final decision.
“Hamstring graft it is,” I announced proudly to Alex.
“Cool! Sounds like you’re ready to do this.”
“I think so. I feel a new level of calm around this whole situation. Having the what and when questions answered allows me to take a big step forward. Now I have a plan.”
It took three days before I called my doctor’s office to make the plan final. There wasn’t anything holding me back per se. I just felt this need to sit with my plan for a bit before announcing it to the world. Within minutes of speaking to my doctor’s medical assistant, I had committed to Monday April 25th, 2016. The BIG day was now officially on the calendar. Next step, share this information with everyone I work with (bosses, coworkers, and patients)… insert deep breath here.
The process of sharing my news was much more difficult than I could have predicted. I told my bosses and co-workers first. That went well and was easily communicated via email. The challenging part was telling my patients. It was important to me that I tell each person individually. I wanted to make sure everyone had adequate notice to plan accordingly and not feel abandoned by my upcoming absence since some of my patients would need to continue with therapy after my surgery date. What I didn’t anticipate was the tremendous guilt I felt around this entire process. At first it was difficult to put a finger on where those feeling were rooted. I was only certain of the rawness of my emotions without a clear understanding of why those feelings were so pressing. It wasn’t until later when I spoke with my psychologist that I was able to put the pieces together. The guilt was coming from a place of feeling like I was letting people down, like I wasn’t fulfilling my responsibilities as a therapist because I was choosing to have surgery; I was putting myself first. The act of putting myself first is difficult for me in much the same ways as is asking others for help. It means that I’m allowing myself to take up space. It means I’m tending to my needs first rather than putting everyone else’s needs before my own. That’s really foreign and unnatural for me. The logical part of my brain anticipated that my patients would be sympathetic and understanding of my situation. The emotional part of my brain however, still had trouble escaping the cloud of gilt that loomed over me.
I also began to realize how much of my own fear was contributing to my situation. The fear of being uncomfortable seeing as this entire process kept pushing me further and further outside of my comfort zone. Yes, I know, that’s where growth happens, where you become a better person, yadda yadda yadda. Believe me, I’ve given that speech to myself and others a million times. And don’t get me wrong, I subscribe to that belief, but at this moment my inner toddler wanted to flop down on the floor and scream, “I don’t wanna play today!” I so badly wanted to take the easy route and send a mass email alerting all of my patients at once. Unfortunately, that mode of communication wasn’t an option. I had to deliver my news in person, in real time. So, I made a deal with myself – I’ll start with my first patient on Monday. That gives me the whole weekend to prepare myself…and eat a little extra ice-cream to help with the process.
Monday morning arrived and I still didn’t feel ready. Let’s be honest though, I probably wasn’t ever going to feel completely ready. I knew I had to rip the band-aide off and move forward. The longer you wait the harder it’s going to be…The first few patients I spoke with were the hardest, not because of who they were or how they reacted, but simply because they were the first patients to know. They were my litmus test for how others would probably respond. Fortunately, as the logical part of my brain predicted, everyone reacted with sympathy and empathy for my situation. No one made me feel guilty about needing to have surgery. In fact, many of my patients immediately wanted to know how I was doing, how I was feeling and what they could do to help. I felt overwhelmed by the support and relieved that my feelings of guilt were entirely self-inflicted. That was an important lesson for me to learn; that it’s ok to take care of me and not feel bad about it. Others will understand. Hmmm…good to know.
- Prodromos C, Joyce B, Shi K. A meta-analysis of stability of autografts compared to allografts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):851-856
- Krych AJ, Jackson JD, Hoskin TL, Dahm DL. A meta-analysis of patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction. Arthroscopy. 2008;24(3):292-298
- photo credit: https://unsplash.com/photos/L1kLSwdclYQ