Valjean Clark

Right knee medical history

This post is intended for orthopedic doctors and physical therapists.

Short version

This is as short a summary as I could make without losing any important information. Please read all of it!

All MRI reports and post-op notes

All my MRI reports and post-op notes are available here.

The image below shows a side-by-side MRI comparison of my good knee’s ACL and my right knee’s ACL. The anterior placement of the graft, bowing, and impingement are all visible.

Left/right ACL comparison

Full version

I tore my ACL skiing in January 2019. ACL reconstruction surgery was soon scheduled for March 2019 at Kaiser in San Francisco. For the 2 months before the surgery, I did “prehab” to keep the knee and leg strong. I was pain free at this time.

I was given a choice between a hamstring graft and a BTB patellar graft. The surgeon advised me to do the BTB patellar graft because it is the “gold standard” and the graft is stronger than the hamstring graft, and hence more resistant to re-tear.

As soon as I started PT exercises after my ACLR surgery, I started experiencing pain and stiffness that has stayed with me to this day. The pain presents under and slightly below my patella, and it is strongest in the ~20º arc leading up to full knee extension. Consequently, it is easy to trigger with simple PT exercises like quad sets and banded terminal knee extensions. Kaiser PTs encouraged me to “push through the pain”, but it was clear my experience was different than the others in my group PT sessions. The pain was blocking me from being able to perform movements correctly.

After initially regaining extension, I started to lose extension a few months into PT. Because of this and the strong patellofemoral pain I was experiencing, while my rehab stalled. After another MRI, we discovered that a cyclops lesion had developed. Another surgery was performed in December 2019, after which I regained extension. The hope was that this, combined with some debridement, would reduce pain, but it did not.

I spoke with several different surgeons at Kaiser about my situation, and they all said 1) that BTB patellar graft can result in unresolvable patellofemoral pain and 2) given my cartilage damage, I could consider a cartilage restoration surgery like OATS.

Disappointed with the quality of Kaiser’s PT department and skeptical that more surgery would fix my problems, I left Kaiser to gain access to a broader set of institutions, PTs, and doctors. I found some PTs who treated my condition as they would general patellofemoral pain, which allowed me to restore some strength and function. This envelope of function approach instructed me to keep pain 3/10 or below and slowly build up strength while avoiding any movements that cause spikes in pain. This allowed me to regain a lot of muscle mass, and it also made it possible to return to hiking and cycling. These activities were still not pain free, but I could do them at a seemingly manageable low level of pain.

I tried reintroducing running at multiple points, but it would always lead to large spikes in pain that took weeks to recover from. Over time, my pain levels kept increasing with activities like hiking and weightlifting. I had an MRI done and found that the cartilage damage to my patella had expanded to become a 2cm defect. I had several different surgeons look at this MRI (Brian Gilmer, Drew Lansdown, and Ken Akizuki), and all 3 mentioned MACI as an alternative to OATS for cartilage restoration.

With pain worsening, I decided I needed to try another surgery, and it seemed like I had broad consensus that MACI was worth a try. (Aside: I learned recently that not all surgeons are as optimistic about MACI’s effectiveness, particularly for a large patellar defect, so it seems I just had a sample of surgeons biased toward MACI.) I had the MACI graft implanted in Sep 2023.

A few months into the PT for MACI, it became clear that it did not have any impact on the pain. All the same exercises involving terminal knee extension still hurt. Walking on flat surfaces still hurt. Discouraged but still determined, I spent the following year rehabbing using the same envelope of function approach as before.

Given all the focus on cartilage, my PT suggested that I could pay out-of-pocket for an MRI of my good knee to get a better idea of the state of the cartilage in my good knee as a baseline. This ended up being very interesting - the MRI showed that I have similar cartilage damage in the same area on my good knee. Between the MACI and this MRI, I became quite skeptical that cartilage damage is the cause of my pain, since cartilage damage does not always present with pain.

In March 2025, I was now 1.5 years since the MACI surgery. The envelope of function PT approach had allowed me to return to some cycling and hiking, but pain levels were higher than before. PT exercises that were not painful in 2024 started becoming painful. Walking on flat surfaces is much more painful that it used to be, sometimes even 6/10 pain, which is very difficult to live with. With some reluctance, I decided I need to talk to orthopedic doctors. I wanted a fresh perspective, so I set up appointments with doctors and surgeons I haven’t spoken to before. An x-ray and MRI were performed.

This MRI report contained some new findings:

  1. the tibial tunnel of the graft is positioned anterior to Blumensaat line
  2. the ACL graft is bowing
  3. evidence of fat pad impingement

As of May 2025, I am in the process of talking to surgeons about my situation. One surgeon (Keith Chan at California Pacific Orthopaedics), upon seeing the MRI and understanding that I’ve already tried managing it conservatively, suggested ACL revision. Keith also said that the MACI surgery I underwent was a “long shot” for treating my pain.

The anterior placement of the graft is new information to me, and initially reading about it line up with my lived experience and symptoms much better than general post-B2B graft patellofemoral pain. Namely:

I’m seeing more surgeons at UCSF and Stanford over the coming weeks.