So is my ACL really torn?

[apjmo]

(This is a really useful forum that I discovered recently. Apologies in advance for the long post)

Profile: 32 year old male, SF bay area, casual skier, biker, play racquetball ...

In Jan'08 I injured my knee while skiing (right ski got stuck in powder on a turn, lots of twisting, pain & popping sound followed by ski patrol burrito

Saw an ortho immediately, got an MRI. The MRI report said ACL is torn and there is some injury to meniscus. Doc said it is not conclusive, looks like a partial tear at best and sends me to PT after a week of healing.

I have done almost two dozen PT sessions so far. I have done really well there and can do pretty much all the stuff including agility exercises (ladder, hurdles etc) like a normal person.
However any sort of unanticipated twisting/cutting motion in the real world is still a problem. It seems like the bad knee does not react fact enough and gets stuck leading to extreme pain/some inflamation (that goes away in 3-4 days).

So today I saw another ortho (a brand name doc who takes care of many 49ers) based on my PT recommendation. This doc took less than 60 seconds after examining the MRI and knee to pronounce that I had a complete ACL tear!! He also recommended an allograft.

I am now really confused and will appreciate any feedback. Is it worthwhile getting a third opinion?

The first doc has mentioned more than once that there have been recent studies that suggest that docs have been overly aggressive with ACL reconstructions. He has been in the business for 30 years but does not seem to be a sports injury specialist and is listed as a specialist in hand micro surgery.

[StuntCok]

I was told that partial tears of the ACL are not all that common and that with a knowledge of the injury, a physical test and an MRI the Dr can be pretty sure of an ACL test. If the second Dr. is a knee specialist or even a sports specialist I would assume he is correct. Based on your post I would have diagnosed an ACL injury without the tests (armchair internet medicine! It makes me feel I am Dr. House). If it is fully torn and if you want to continue an active life then you will need reconstructive surgery as it will not heal itself. The resident TGR doctor Dr. Mark will dissuade you from an allograph in favor or an autograph (patella, in particular) but the maggot collective based on personal experience will not feel as strongly about the superiority of a particular graph type although the allo's will come in last even there.

[FredsTrees]

I was told that partial tears of the ACL are not all that common and that with a knowledge of the injury, a physical test and an MRI the Dr can be pretty sure of an ACL test. If the second Dr. is a knee specialist or even a sports specialist I would assume he is correct. Based on your post I would have diagnosed an ACL injury without the tests (armchair internet medicine! It makes me feel I am Dr. House). If it is fully torn and if you want to continue an active life then you will need reconstructive surgery as it will not heal itself. The resident TGR doctor Dr. Mark will dissuade you from an allograph in favor or an autograph (patella, in particular) but the maggot collective based on personal experience will not feel as strongly about the superiority of a particular graph type although the allo's will come in last even there.

Paging Dr. Mark?

Few comments, um a dim wit can do the pull on your lower leg test and tell if your acl is blown, no offense doc.

A guy on my sailing team tore his acl, then went 4 years without one and tore his meniscus. Bad choice? i am not sure....i favor getting her done and avoiding the tearing up the rest of your knee. The thing just gave outon him doing turns in Vermont on a poerfectly sunny non powder day.

The same guy got an allograft, another bad choice? he is 12 months post op and hitting 25 foot jumps on his all mountain bike in vermont....

Welcome to graft choice puberty. I vote for patella. you"ll hear why.

[drmark]

This is not rocket science.

From what you say, the knee is loose, and an MRI was positive.

It sounds like the ACL is outta there. You can live with it and forget your active lifestyle, or have it reconstructed.

No onto the debate about graft sources.

Allografts 80% sucess if you stay away from sports for one year

Autograft patella tendon 95% sucess, and can go back to sports in three months (opposite graft) and 6 months (same sided graft)

There is lots of scuttlebutt out there about which operation is more painful and disabling on the temporary basis, but no proof in the medical literature.

My impression is that the post op pain a disability is a functon of the doc's technique and the patient's neurological psychological makeup.

[apjmo]

Thanks for all the replies.

My new doc is clearly an allograft proponent. He says 95% of his patients go that route. An advantage that he described (that I have not seen discussed in the threads on this forum) for allograft is that he can use a bigger tendon which is expected to perform better.
Any experience or feedback on this claim?

[drmark]

Again, wil someone show me the evidenced based literature on the subject?
Idealy from the Journal of Bone and Joint Surgery and/or the Am. Journal of Sports Medicine. I can think of only one article amongst a sea of articles regarding autogenous tissue repairs in the Am J. of Sp. Medicine, and nothing good to say about allo ACLs in the Journal of Bone and Joint Surgery.

The abstracts are aviliable to the public without charge. go to their home pages and do a search.

[FredsTrees]

Thanks for all the replies.

My new doc is clearly an allograft proponent. He says 95% of his patients go that route. An advantage that he described (that I have not seen discussed in the threads on this forum) for allograft is that he can use a bigger tendon which is expected to perform better.
Any experience or feedback on this claim?

Bigger is clearly better when it comes to some things, havn't heard that one yet in an acl though.

Read my thread on my genius doctor hammie repair, summary for you to read of the different types.

One comment is that the success is associated with the comfort and skill of the doctor of that graft choice. But why lower your odds with the allograft? Then you pick you graft choice and your done. You know my vote from what i chose patella, opposite.

[MHSP #1497]

I had an allograft reconstruction in February after having a rather heated discussion with my surgeon about graft sources. He pointed to 6 other patrollers and a number of other local hard-core skiers that he reconstructed using allografts successfully (no re-injuries).

However, he did not advise that my chances were only 80% if I avoid sports for a full year. In fact, he is encouraging me to work hard to get back into the "red coat" next season (which on Mt. Hood starts in late November).

Is he leading me down the primrose path here? Should I worry about whether I might be setting myself up for disaster? I'm not a pessimistic guy by nature, but the thought of going thru another ACL reconstruction is mortifying... I didn't have the option of harvesting from my left patellar tendon as that was reconstructed in 1994 and my doc was dubious of it's viability...

Thanks!!!

Josh
Mt. Hood Ski Patrol

[drmark]

Six consectuive good results does not make for a statistically signifigant conclusion. When we did allograft reconstuctions we had patients restrict their athletic activities to the gym for one year.


Its is to be expected that the average joe will choose an allograft repair. Its like gettng a free lunch. Everyone will choose one when its offered to them without much explanation, and the doc pushes them in that direction. In the 90s when I did allografts not a single patient every wanted anything else.

Unfortunately, there are no free lunches in life. You always have to pay somewhere. Whether you pay by sitting out a year, or you pay by needing it redone..............

[MHSP #1497]

drmark- Point taken.

Will try keep myself in the First Aid room until I pass the 1-year mark.

Though, might I be able to shorten that timeframe thru vigorous PT effort, or is the 1-year constraint a matter of the allograft taking longer to re-vascularize (it was a B-P-B graft)? Would returning to the slopes sooner jeapordize my efforts by a statistically significant number?

I'm just trying to weigh the pros/cons to returning to duty. Though the idea of not only risking my own knee, but the safety of a patient in the sled is compelling...

Thanks!!!

Josh

[drmark]

It has absolutely nothing to do with PT. The graft just needs at least one year to 18 months in order for new cells to move in and replace the dead person's collagen. It doensn't matter what type of dead person's graft it is. If if were your own bone-tendon-bone, four months would be about average for our cases.

In the meantime, you can pump all the iron, spin. or use the eliptical as much as you want, but it won't change anything.

[MHSP #1497]

Thanks for the input. I appreciate the advice amd factual response.

I'll take your suggestions under advisement and proceed with extreme caution.

Thanks!!!

Josh

[airborn]

What about using a prescription brace in the mean time. Thats what was recommend for me. I went with the allograh.