Unfortunately, the back rail of my board hung up and did an el-rollo with my foot while my knee went in the opposite direction. I felt a major tearing. I paddled back into the lineup and talked to the physical therapist who was surfing with us. He suggested that from the symptoms, it was a MCL tear - one of the most common surfing injuries. He also said that if the injury didn't involve other ligaments or the meniscus, it likely wouldn't need surgery.
Ironically, a few minutes later, my friend hurt his back, so we hobbled up the cliff together, disappointed at the number of uncrowded perfect waves we were going to miss.
I raced home, showered, iced, and elevated my leg, then waited patiently for the arrival of Karen's son and daughter-in-law, both Osteopaths and specialists in Neuromuscular Medicine. They were planning to spend part of the weekend with us. Two rounds of disc golf were scheduled for the next day and I envisioned being able to play. Little did I know.
The MCL is a ligament that runs on the inside of the knee. It is frequently injured in soccer, football, and rugby in a tackle where the foot is planted and the knee is struck from the outside, tearing the supporting ligament on the opposite side.
Mine was caused by my foot being pulled upward by the wave as my knee went downward and my body rebounded upward causing the same effect - a tearing on the inside of the knee.
I also discovered that MCL tears have three classifications:
Grade 1 - a minor strain with recovery times of a week or two
Grade 2 - a significant tearing of the MCL with recovery times of 4-12 weeks
Grade 3 - a complete rupture of the ligament with recovery times of 12-16 weeks.
The primary test used to diagnose MCL strains is called a Valgus test. Basically, your knee held steady while your lower leg is pushed outward. If your leg flops outward with little resistence, little pain, and just keeps going past 45 degrees (even 90 is possible), you have a complete tear (Grade 3) of the ligament.
If your knee is stable and there is good resistance to the outward pressure, though painful, it is most likely a Grade 1 strain.
If your knee is unstable and your leg moves independent of the knee, but encounters resistance, it's a Grade 2 tear.
Mine was Grade 2 as there was significant instability in my knee. I was surprised that there wasn't significant swelling, but it appeared the wetsuit provided good compression and the cool water didn't hurt.
The Docs arrived and confirmed my diagnosis. They did some Osteopathic treatment to help realign the knee and to encourage fluid flow. But according to Karen's son, I was likely looking at 12 weeks for full recovery and certainly wouldn't be playing disc golf any time soon. Of course I didn't want to believe him. I'd never had an injury that was that debilitating and I couldn't imagine this one would be.
That night I tried to sleep in bed, but just the weight of a single sheet was too much if I moved my leg to the side. For the next two weeks, I slept in a recliner chair with my knee elevated.
Karen's son also recommended an offload brace. Unfortunately, the medical supply store didn't have any so I made do with a hinged knee brace. It helped, but with my now very swollen knee, the hinges pressed on the MCL. I later saw an offload brace and wished I spent the money (my insurance deductibles are ridiculous).
Partly because of insurance, but even more because I like to think I can solve every problem myself, I decided to do my own rehabilitation. I must admit that after all I'd read about unnecessary knee surgeries and their complications, I was skeptical of entering that process. But, I had the opinions of two Osteopaths (see my previous post on Why I Believe in Osteopathy) and a physical therapist, so I wasn't going into this completely blind. Based on their input and the analyses provided by sports medicine websites, it was almost certain I had an MCL tear with no other complications. So, from what I can see, it was just (!) a question of rehabilitation.
After studying numerous physical therapy and sports medicine sites, I ultimately settled on the Sports Injury Clinic. I also used Summit Medical Group's exercises. In particular, the initial stretching and strengthening exercises helped tremendously, particularly the passive knee extension (which hurt like hell), the heel slides, and the leg raises. I did the knee extension and flexion along with the heel slides several times a day until I got enough consistent flexibility to walk with minimal pain. Ultimately, I moved on to more challenging exercises. My progression went something like this:
First four days - RICE - the swelling was so bad I really couldn't do even the most basic exercises.
Beginning day 5 - easy stretching exercises, especially knee extension and heel slides.
Second week - added strengthening exercises with bands.
Third week - started increasing walking distances and began gym workouts (bike and weights).
Fourth week - added Plyometric exercises (one legged jumps).
By the fifth week, I was feeling pretty good. The swelling was almost completely gone and although my knee would get stiff if I sat for a while, doing the passive knee extension and flexion after getting up seemed to work well. I bought a brace with a strap, and decided to try to surf. The strap is cool because you can wrap it around the weak parts of your knee to provide much more support. It stretches so you can make it really tight and it velcros to itself.
I paddled out into easy, mushy rights and lefts. My first wave was a right (backside for me), and as I started my bottom turn, I felt my knee give and pull. It hurt like hell but the pain subsided quickly, I decided to try a left and had no pain at all until I did an aggressive cutback. I stuck with lefts for the next hour and surfed cautiously. Unfortunately, I discovered that when you duck a wave, the wave pulls at your legs, sometimes to the side, and when that happened it definitely hurt. I was sore after the session but I was glad to have surfed. Still, I knew I wasn't ready. It wouldn't take much to re-injure my knee in the surf. Anything unforeseen would do real damage.
I worked hard with the exercises and the gym the following week and tried again. This time the waves were small but quick and mostly lefts. I had a great time until I tried a right. Again, driving off the back leg hurt. It wasn't unstable like it was the week before, but still.
It's now been eight weeks. This past week, I was able to make full backside bottom turns and aggressive cutbacks on my lefts. I surfed four really fun days. On the last day though, I punched through a large set and got tossed around by the last wave. I really felt it in my knee. It didn't tear, wasn't any worse later, but I know that I can't let up on the strengthening exercises. I still have a ways to go for 'full recovery'. In the meantime, I can hike, dance, and play disc golf (took 4th in a tournament yesterday with no pain).
Mistakes I made.
Realistically, Karen's son was right. It's going to be 12 weeks for full recovery, particularly for surfing. I seriously underestimated how much inward force you put on your knee in a backside turn or frontside cutback. I seriously underestimated the force of the ocean, which is a very stupid thing to do. And at the beginning, I tried to do too much too soon. I'd try to push walking and tried to do the harder strengthening exercises when I wasn't ready. Each time I did, it set me back a couple of days with renewed swelling and loss of flexibility.
Overall though, I'm almost there. Still, perhaps you can avoid some of the mistakes I made.
Set your expectations - it's going to take longer than you think.
Don't do too much too soon. Be very cautious as you restart any activity.
Spend the extra for the best brace possible.
And, I think the main reason for my successful recovery is the dedication to the daily (or more) stretching exercises, and consistent and progressive strengthening exercises.
The good news is that if it's an MCL tear with no other damage, you can rehab it yourself. But above all, you need Patience, Patience, Patience!
Update January 2018.
It's been a year and a half since I first injured my MCL as described above. The rehab program worked, and I was back to full activity with maximal stress (surfing, extreme skiing, etc.) within 4 months (with a lot of hard work in rehabbing it). Everything seemed fine and then, six weeks ago, while Salsa dancing on a rough surface, my foot caught in a fast turn and I felt my MCL pull. It was too painful to continue dancing so I stopped. By time I got home, my knee was hugely swollen. I started the RICE treatment, but underestimated the severity of the injury. Yes, it was only a grade 1 injury - there was no looseness under the Valgus test, but almost any activity caused huge swelling. I consulted my muscular medicine doc and he informed me that re-injuries are often worse from the point of view of healing time. Unfortunately, he was right.
I hate being sidelined from the surf during one of the best seasons we've had in years. And, not being able to run, dance, ski, etc. is depressing at this time of year.
So here I am, six weeks later. The pain is gone. Most of the range of motion has returned (with lots of stretching), and I'm working on strengthening. The plyometric exercises are still tough. I did try surfing and easy front side is okay but I can tell I'm not quite ready for more aggressive turns. I will be giving skiing a shot this week (now that there's a bit of snow in the Sierra). In the meantime, I'm working hard on the strengthening and I now realize that to avoid re-re-injuring my knee, I need to keep up these exercises even after I'm back to 100%. They're going to become part of my daily routine, much like core strengthening has. Core strenghthening resolved all of my back problems and I expect I can avoid further knee injuries if I keep up these knee exercises too.
So, a final word of advice. Once you're back to normal, don't stop your strengthening and range of motion exercises. Do them regularly and hopefully, you can avoid a re-injury that will sideline you for several weeks.