Torn ACL

**hez** · 03-03-2008, 11:13 PM

I tore my ACL skiing a double black diamond back in January, and have Kaiser insurance. It has been more of a pain dealing with them than the actual injury, and thus my surgery is slated for May or June at this point. I am interested in suggestions on how best to ski on my torn ACL.

First off, I have skied all my life (literally all 25 years, first time I was 10 months old, in a snuggly strapped to my dad's chest). I have also tried snow skates once, I have never tried snowboarding, skiing has always been what I live for in the winter.

I cannot stay off the slopes any longer! Which of the options should I do? To ski, snow skate or board.. that is the question... Logically I feel snow skates might be the best as they are shorted so would torque the knee less, and perhaps encourage me to go a little slower. Any advice?

Also what sort of knee brace should I wear? Are there any favorites? I have a hinged walking knee brace Kaiser put me in after the injury and am considering that, but it is pretty cumbersome.

Second, If my surgery is in May or June, how does that effect next years skiing? I was told my healing time should be about a year. Please let me know your thoughts. I am opting for the cadaver ACL replacement, not the hamstring harvesting that was also offered as an option. I am female and also have started seeing information about drilling/reshaping the bones in that area to help prevent ACL wearing/tearing, is this something worth looking into?

**Rain King** · 03-03-2008, 11:58 PM

I am no doctor, but I've screwed up my right knee twice. The first was an avulsion of the tibia (the acl ripped a chunk of the bone off). They screwed it back in, but the rehab and length of time out was the same as an ACL. The second time, 3 years later, was a full tear of the ACL and I roughed up the meniscus too.

It's certainly easier to give advice than to take it, but from all of my experience, if you are going to have the surgery this summer, please please please, sit the rest of the season out. Without the proper leg strength to compensate for the missing ACL you are bound to screw something else up. Something like the meniscus...which is something that you can't truly ever replace. Any additional damage could add months to your recovery and shorten the life of your knee overall.

If you decide to tempt fate, stay with your skis. You already know how to do that. Why try to learn something new on a bum knee. Learning usually equals more falls and spills. More falls and spills usually equals more potential for injury.

And each doctor will tell you differently and every knee and body is ready at different times, but both of my surgeries were in or around early May and I was able to ski lightly by December.

If you don't take any other advice from this, at least follow this one simple thing...take your physical therapy very seriously.

Sit tight for the rest of the season. Your knee will thank you later. Plus all of your friends will love you for having a warm seat and a cold beer ready for them when they are done for the day back at the bar.

**FredsTrees** · 03-04-2008, 05:18 PM

I have a summary of the ligament graft choices is my thread near the top of the board...

Um the cadaver is pretty popular because it is easy to do, anyone can do it, no harvesting no graft site issues, but it also is way more likely to blow out. Not to my body, no way would i take that chance.

And why would you deliberatly place your meniscus and your MCL in danger for a few turns?.Because of some sentimental reason? That is really bad decision making. you really need to take this seriously. Get the best person to do your knee with a solid prcedure and stay off the slopes.

**ikkin** · 03-05-2008, 10:12 AM

hez, tons of threads about everything you're asking about. just do a search and you'll find quite a few. good luck!

and, for what its worth, i did an allograft in october (check out my surgery report thread for all the details and recovery, etc.), and i'm already back doing mellow stuff on the hill with my doctor's blessing. the knee feels great. so you should be fine for next season if you have surgery in may...as long as stick to your rehab, which is incredibly important.

**hez** · 03-05-2008, 10:33 AM

I have been reading all of the threads on recovery and rehab, and it definitely is encouraging. Someone mentioned skating as a good exercise to do for getting muscle strength back and I definitely plan on spending a lot of time on the exercise bike as well. I have even started the bike now (pre-surgery) with the understanding that I will lose some of the muscle during that first week or two of recovery. I also tried the weight machines that focus on hamstrings and quads and whatnot, but am a little hesitant as to if I should be doing those machines two months after injuring the knee.

My physical therapist was rather useless, I had one meeting that was not hands on, she just gave me a sheet of stretches and leg lift-esque exercises to do, and the second meeting was just a follow up where she told me I could do all of the exercises at home, and since I was getting surgery it really was more important to come back post-surgery.

I have to say that in general the knee feels just fine, I have difficulty with downhill slopes and stairs, but am doing a lot better with stairs and have even worn heels a few times with no complaints. General walking isn't that much of a problem which makes me feel the knee is strong enough to take on a little more. Thus my question about skiing/skiing alternates comes into play.

I seriously do not want to injure myself further, but I am also sure that I am in the whole "bargaining stage" of grief. I have to say that I thought the concept of snow skates was a sound one, and so was hoping to find validation that it was in fact less stress on the knee and that other people do that as well as a skiing alternative. I guess my "brilliant" idea isn't so brilliant?

I think you just want me to keep the cabin warm and well stocked with beer, cookies and hot cocoa while you get to have fun in the snow...

**Rain King** · 03-05-2008, 03:57 PM

I would try and stay away from most machines other than a bike at the moment. Focus on your ROM. And please stay away from the mountain...even if the temptation is great. Get your mind wrapped around working hard this summer so you are ready to go by opening day.

It isn't talked about much, but I wish I would have paid a little closer attention to my calorie intake. I went from skiing 3 times a week, sailing, and playing soccer to watching cartoons. I gained ten pounds for each surgery. Some of that has to do with a slowing metabolism over the past 6 years. But I've gone from pre-surgery of 148 lbs to post second surgery of around 168 lbs. Of course everyone differs!

Take it easy, focus on your ROM and find a good PT.

**Mofro261** · 03-05-2008, 05:21 PM

skiing without an ACL is sometimes a viable option

BUT you must be very comitted to rehab to get strong prior to attempting it. I recommend at least 30-60 per day on a stationary bike, in addition to those silly exercises the PT person gave you. Do them, seriously whether or not you try to ski again prior to surgery or not. Avoid open chain exercises -leg extensions and to some extent hamstring curls as these will put added stress on the knee. IF you decide to ski again in the interim I recommend using a brace. I was Rx'd a Cti Edge brace which works great for me but will not prevent further injury due to twisting motions. It primarily seems to displace pressure off the knee joint and prevent lateral impacts/hyperextension. Skiing level can return to ~90% of pre-tear level. If you were not a strong skier, the best you can hope for is 90% of not a strong skier and you may not want to take that chance.

As for the timing and graft choice, many people have had success with allografts and been back skiing successfully 6-8 months post op. I wasn't one of them. Torn Dec 16, and 50+ ski days later had the Allograft May 2. I was very serious about rehabbing everyday which pretty much negated ANY possibility of weight gain, I was given the go ahead to return to skiing at 6 months after passing a USSA return to skiing protocol. Started back closer to 7 months and got 20 days in before I had failure 8 mos. post op dropping the equilavent of jumping off a 6ft ladder and landing solidly on grass. I have had the displeasure of skiing 2 years in a row without an ACL. Unfortunatley I have had family ski vacations each year in March/April that I have been unwilling to sit out or I'd be getting things fixed earlier this year.

**Woodlandclown** · 03-06-2008, 08:53 AM

I have posted this before on other threads, but I rehabbed for about a month after injury and am now skiing. My ortho actually suggested to me that if I wanted to ski I could with a brace. He also tore his ACL and skied. I know quite a few people who have. I have been out probably about 10 days since injury, for a few hours at a time and I am skiing great--about 90% of what i did pre injury. I am being a bit cautious, although still fairly aggressive, only skiing on days with good conditions. My surgery is just about a moth away. I am thinking I may have some issues in the spring slush--not thinking the knee will hold up well if I am sitting back on my tails alot--so we will see. May just have to ski early morning and quit. Everybody is different, but its working for me.

I can relate to the weight gain issues. I havnt been moving as much since injury and I also quit smoking, so I have put on about 10 pounds. I am going to work like mad to get it off by April 7 surgery date.

**Vinman** · 03-06-2008, 10:09 AM

skiing only 1 mo after surgery sounds like a good way to re-tear your new graft to me. And if you were my patient in rehab I'd be kicking your ass for doing it.

Within the first 8-12 weeks the graft is actually getting weaker as it revascularizes no matter what your muscles are doing. This time frame is extended even more with a cadaver graft. Cadaver grafts take upto a year to revascularize.

**Woodlandclown** · 03-06-2008, 10:49 AM

Originally Posted by Vinman

skiing only 1 mo after surgery sounds like a good way to re-tear your new graft to me. And if you were my patient in rehab I'd be kicking your ass for doing it.

Within the first 8-12 weeks the graft is actually getting weaker as it revascularizes no matter what your muscles are doing. This time frame is extended even more with a cadaver graft. Cadaver grafts take upto a year to revascularize.

he hasnt had surgery yet though--he said april or may. I dont think anyone on here is skiing a month after surgery--your right, that would be nuts!

**Vinman** · 03-06-2008, 05:37 PM

ahh my bad read that wrong... I'd still kick someones ass for skiing 1 mo post op ACLR though.

**hez** · 03-06-2008, 08:10 PM

...it is true that I am not SO stupid as to be skiing one month post op, I am 2 months post injury and I have not had surgery yet. My surgery is slated to be scheduled for May or June, and I am obviously in the bargaining stage of grief and trying to figure out a way to still ski regardless of the stupidity.

I am still seriously considering skiing this weekend, but am looking into good knee braces so that I hopefully don't mess up any other tendons, ligaments or the meniscus. I also will be going with my beginner snowboarding friends so should be staying on the greens and blues. No more "widow maker's" for me this year. (the double black where this whole mess started)

Honestly I will be happy if I am just picking up speed on snow, be it sledding, skiing or snow skating. I just need some blinding white scenery in my gimped-up life right now!

So just based upon physics and not intelligence, am I correct in thinking Snow Skates would be less torque on the ACL and thus less chance of further injury? (and yes I have tried them before, but only once) My main concerns (other than destroying the surrounding knee components) are:

-lateral twisting and torque, what could cause less strain on the injured knee and be less cumbersome with a brace on?

-what sorts of knee braces do crazy fools like myself prefer? I have a hinged knee brace that is reinforced with metal that I got as a "walking brace" and am thinking of getting something like that. The one I has is very long and would interfere with my ski boot.

-the weight of the skis vs. snow skates on the ski lifts... does that ever hurt anyone with an ACL tear or am I just worrying over small dangers vs. the major ones?

**FreakofSnow** · 03-06-2008, 09:20 PM

Originally Posted by hez

So just based upon physics and not intelligence, am I correct in thinking Snow Skates would be less torque on the ACL and thus less chance of further injury? (and yes I have tried them before, but only once)

Stop man.........................punch yourself in the face. You are either a troll or severely retarded. Why would you want to risk further damage for the sake of snowlerblading? Just ask yourself why

**hez** · 03-07-2008, 12:40 AM

Stop man.........................punch yourself in the face. You are either a troll or severely retarded. Why would you want to risk further damage for the sake of snowlerblading? Just ask yourself why

I am 5'3" so I am troll-like in height... however I'm female, so unlikely to take up physical violence or answer to "man"... I am just trying to get info to see if other people are as impatient as myself pre-surgery, and if so, how they manage to continue to ski.

I wouldn't be asking these questions if my knee was still hurting or unstable, but oddly enough the knee has never really hurt and I have felt stable on it for the past 3 weeks or so. I have even been wearing heels occasionally without issue. Maybe its the whole higher pain tolerance thing, or maybe that is typical with an ACL, either way information will hopefully help the retardation factor.

**drmark** · 03-07-2008, 07:58 AM

If you are doing that good, maybe you will be one of the lucky types that can go back to all their previous activities WITHOUT ACL surgery.

If you find a doctor who can put you on the KT-1000 and your knee doesn't come forward more than 3-4 mms more than the other side, you should just rehab it and enjoy your life.

You can always get cut on next year if necessary.

**Woodlandclown** · 03-07-2008, 11:06 AM

Originally Posted by hez

...it is true that I am not SO stupid as to be skiing one month post op, I am 2 months post injury and I have not had surgery yet. My surgery is slated to be scheduled for May or June, and I am obviously in the bargaining stage of grief and trying to figure out a way to still ski regardless of the stupidity.

I am still seriously considering skiing this weekend, but am looking into good knee braces so that I hopefully don't mess up any other tendons, ligaments or the meniscus. I also will be going with my beginner snowboarding friends so should be staying on the greens and blues. No more "widow maker's" for me this year. (the double black where this whole mess started)

Honestly I will be happy if I am just picking up speed on snow, be it sledding, skiing or snow skating. I just need some blinding white scenery in my gimped-up life right now!

So just based upon physics and not intelligence, am I correct in thinking Snow Skates would be less torque on the ACL and thus less chance of further injury? (and yes I have tried them before, but only once) My main concerns (other than destroying the surrounding knee components) are:

-lateral twisting and torque, what could cause less strain on the injured knee and be less cumbersome with a brace on?

-what sorts of knee braces do crazy fools like myself prefer? I have a hinged knee brace that is reinforced with metal that I got as a "walking brace" and am thinking of getting something like that. The one I has is very long and would interfere with my ski boot.

-the weight of the skis vs. snow skates on the ski lifts... does that ever hurt anyone with an ACL tear or am I just worrying over small dangers vs. the major ones?

I think you are overanaylizing--i'll admit i was a little freaked first time out, and did a few runs on the greens, but the minute i started skiing, i was fine. just get a brace and try it.

**ikkin** · 03-07-2008, 08:47 PM

woodlandclown makes a good point. if you;re feeling good, why not just put your skis on and start slow and mellow? if slow and mellow feels good, slowly progress to more challenging. don't worry about it too much. i wouldn't even consider snowblades. yeah, they may produce less torque, but really, they're sort of silly (for lack of a less PC term), and common sense says its simply a better idea to stick with what you're already most comfotable/familiar with. which would be regular skiing in your case.

for what it's worth, i felt really stable before surgery too- danced my BUTT off at my wedding on a rough barn floor with no problems at all. and i'm female too and you and i are about the same size, height wise at least. sometimes i reflect on that stability and i wish i'd tried to be one of the "lucky" non-surgery ones...i really never considered not having sugery. sounds like you have the opportunity to try. you'll never know unless you give it a shot.

don't agonize too much. and this injury is not as dramatic as it first seems. plenty of people tear ACLs, most have surgery, some don't, but almost everyone recovers and figures out a way to adapt, if not become stronger than before. you will too. just like mofro and WC and escii and connersw and and vinman and altachic, among a million others. good luck.

**saltwater.freshpowder** · 03-08-2008, 06:14 AM

OHMYGOSH, I've torn BOTH right + left. No. 1 [right] - I pushed, and pushed hard, all I wanted was to get back on that mountain. Doc told me to sit out the season (June surgery). I told him he didn't know me. I skied like my mom that season, but other than that felt okay. Next season after that FINALLY back on target, beautiful March spring day Peak 10 Breck -AMAZING... POP! My left ACL blew for no apparent reason. I am an artist, not a orthapedic surgeon, but I do believe that if I would of just sat out season 2006 that my left one would NOT of torn. I am sitting out this season (in Florida) haven't seen a flake of snow --my skies are right here and I look at "the girls" every day, because next year --I'M IN!

It's a serious injury and a shitty one to boot, but now I am 41 and really am focused on being a life-time skier instead of squeeking in one more season.

For the love of the mountain!

-k

**FredsTrees** · 03-11-2008, 03:30 PM

I HAVE DECIDED TO MAKE A SUMMARY FOR EVERYONE BELOW. I AM NOT A DOCTOR, BUT I CAN READ AND SUMMARIZE.

Research, the cornerstone of all the information discussed here. I am learning that what your buddy tells you is just that, consider the source. Remember Mikey from the Life commercials who was killed by Pop Rocks and soda? If you are an avid reader and feel like researching peer reviewed material check out this link.http://ajs.sagepub.com/. There are other journals and a lot of material to go thru. You can read all the abstracts and if you feel like it go for the individual subscription and have access to the documents, there is mounds of good info here. This is hard research. If you want advice like "don’t be a pussy", go to the "I huck myself off everything" thread....

The functional success rate for first time ACL reconstruction most publications put it at 85-95%, see #5. This is for 1st time surgeries and not “revision” surgeries. I am not commenting on revisions, whole different animal.

1. Auto graft patella tendons are the "gold standard", have the most frequent usage rate and have a long running refinement of technique, used by most professional athletes. Dr. Mark (not Dr Mork ) uses a contra lateral (opposite side) patella graft and accelerated rehabilitation protocol stressing early movement and weight bearing made popular by Kenneth D. Shelbourne, MD. This is an excellent option Well known and highly respected amongst the pro athlete crowd, Dr. James Andrews does a same side patella graft with high profile clients such as Donovan McNabb. Negatives include having a slightly higher (OA) osteoarthritis occurrence than hamstring grafts, also have higher incidence of graft site pain, morbidity, numerous recent studies. Rigid Bone to bone fixation and high tensile and stiffness are bonuses, providing excellent outcomes for high impact athletes looking to get back on the field.

2. Zombie aka dead guy aka cadaver aka Allo graft are becoming more popular. There is significant gain in not having a harvest site, therefore reducing pain and rehab associated with this type. There is a fair amount of development going on in this area, mostly to do with things like the PIG LIG and Dr. Stone in SF, or using stem cells to augment the vascular health or regeneration process. Recent reports have noted a traumatic rupture rate of autogenous ACL reconstruction of 2% and an allograft rupture rate of 15% (references). In the case of Allo grafts a low level of immunologic reaction can weaken the graft and cause early failure. There is still a risk of infection, disease transmission, however remote this is a risk not yet 100% solved. Doctors I have spoken to are spooked by this graft especially when referring to graft failure and the lingering risk of graft source pathology. To solve this irradiation has been introduced and there is research that shows higher failure rates for irradiated tissue, Rappe, Horodowski. May 21, 2007. In addition there is debate about how long the vascular health of non native tissue takes, see #4. None the less the success rate is very high for this surgery despite some of the controversy. A Doctor that addresses these issues accurately and is comfortable should be considered. You can see there is a ton of evidence I found that gives it a thumbs down, however there are a lot of successful allo grafts being done, and comfort with the procedure and all the risks still can fall into the 85-95% category of success.

3.Hamstring Auto grafts have several variations. Although Hamstring grafts have shown greater (although small in scale, as in mm significance) laxity in research 6, 12, 24 month studies, there have been significant improvements in technique that have specifically addressed this regarding anchoring and sutures. A variety of methods are used including cross pin, endo button, screw and post, or belt-buckle staple technique – each can produce favorable results. Doctors are now using the "Quad" graft, the double braided hamstring and are attaching with reliably strong biodegradable tacks. Subtle changes such as a slight twist to the graft and the careful placement of the tack into the graft attachment point have improved results and sharply strengthened the auto graft (of self, meaning same ) tissue . Doctors are sighting recent, (as in the last 2 years) research pointing to incredibly high graft strength, although there is till some lingering concern about the tissue to bone “attachment point”, often cited as the most significant point of any graft surgery. The other major issue remains tunnel widening. Examples of this include the following ; because the graft is smaller in size to the tunnel it is strung thru, the graft itself to move back and forth across the tunnel, widening it and causing a "windshield wiper effect" where it slowly stretches the graft out. This remains a controversy for this graft syleIn my case 2 of the top knee doctors in Philadelphia are now doing Hamstring grafts "exclusively" as of 2-15-08 citing best rehab, low graft site - itis, and stronger and biodegradable tack and sutures points. Each stated this is what they would do to themselves (the salesman doctor!) and felt the minimal long term stretching due to the windshield wiper effect was negligible and heavily outweighed the downsides of the other graft choices.

4. Comments about the tissue from the graft and when it is repaired or healthy; there has been some controversy about when the graft is healthy, strong and part of the body. The tissue is alive within months and becomes your own vascular tissue at some point, this happens well before 12 months, perhaps as quick as 3 months, and there are suggestions your own tissue does this faster. This happens for Allo grafts as well, but there is some indications that this may take longer in Allograft repairs. Some of the reading indicates that, 1-2 months is the time when the vascular health returns.

5. Research shows that the best ACL recon result is actually more dependent on the comfort level, expertise and experience of the surgeon and NOT the actual graft type. Find good competent doctor and consult.

6. The strongest tightest and thickest ACL is not necessarily the best. The best recon ACL is one that is most similar to the patience own native acl, free from defect of course, healthy, giving and taking load appropriately. There was some reading indicating an over strong or tight graft may produce other problems such as loss of range of motion.