I had an MRI yesterday and found out that I have a complete ACL rupture on my left knee. It was a shock, since I have been walking on it and didn't have much swelling, but something didn't feel quite right and it's been a bit unstable since I fell on it 12 days ago. The MCL and other knee ligaments are intact. I've been following the thread on copers, but I'm leaning towards doing the surgery with donor graft because I also compete in three day eventing with horses. Any recommendations with respect to surgery or rehab?
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Complete ACL rupture
- Thread starter valli
- Start date
MaineSkiLady
Angel Diva
Ouch - really sorry to hear this. Doing any “pre-hab” yet? First order of business: find an orthopedic surgeon (your info doesn’t say where you’re located). S/he will get you on a pre-hab routine, to increase range of motion and get swelling down (some people don’t have any swelling), flexion, extension, etc.
The type of graft is a decision between you and the surgeon, but allografts are generally fine for people over 40. Otherwise, a patella tendon or hamstring autograft might be your better option.
Frankly, the sooner, the better for ACL reconstruction, because recovery IS a +- 5 month process. Physical therapy starts REALLY soon after the surgery - how soon depends, again, on the surgeon and your circumstances. DH and DS started theirs at 2 weeks post-op. Some people start sooner. Since you’d be in an immobilizer, that would require having someone else drive you for those first sessions. Usually, depending on which leg, driving can happen in 3+- weeks, taking off the immobilizer ONLY to drive, back on before leaving vehicle.
All grafts, whether allo- or auto-, go through a “weak phase.” I’ve forgotten the exact time line of this, but it lasts about 6 weeks and is when great caution has to happen with regard to the graft. It’s actually stronger immediately after the surgery than it is during this phase.
My son (both knees, one right after the other) and husband were on their feet and ambulatory without crutches within 3 weeks of the surgeries. Son had patella tendon autografts. Hubbie had patella tendon allograft. The difference: pretty large scars for my son, $8,000 for the allograft for DH. (Yikes.)
The surgery is usually outpatient - in and out same day.
Pre and post-op meds will vary per surgeon and patient.
Ice will be your best friend for at least 2 months. Cryo-cuff.
Physical therapy focuses on regaining leg strength (which rapidly diminishes after surgery) via VMO stimulation, ambulation, range of motion and proprioception (the graft initially feels VERY different than what had been your ACL). An active/sports orientation to PT would be excellent - and many are. Although not always, many ACL ruptures occur in very active individuals. And all of them want to get back to their sports and lives.
The first 2 to 4 weeks aren’t fun. Grit your teeth and get through it. Mine are intact, but I’ve been through 3 of these surgeries with immediate family members - and neither of them would have done it any other way. They are pain-free (and in DH’s case, in that knee, arthritis-free!), active, mobile - skiing and riding as if it never happened. Both were released from PT and ortho 5 months post-op. My son was 24-25 with his. Hubbie was 55.
Wishing you all the best, and hope you can quickly find an OS you trust and believe in.
“This Too Shall Pass!”
The type of graft is a decision between you and the surgeon, but allografts are generally fine for people over 40. Otherwise, a patella tendon or hamstring autograft might be your better option.
Frankly, the sooner, the better for ACL reconstruction, because recovery IS a +- 5 month process. Physical therapy starts REALLY soon after the surgery - how soon depends, again, on the surgeon and your circumstances. DH and DS started theirs at 2 weeks post-op. Some people start sooner. Since you’d be in an immobilizer, that would require having someone else drive you for those first sessions. Usually, depending on which leg, driving can happen in 3+- weeks, taking off the immobilizer ONLY to drive, back on before leaving vehicle.
All grafts, whether allo- or auto-, go through a “weak phase.” I’ve forgotten the exact time line of this, but it lasts about 6 weeks and is when great caution has to happen with regard to the graft. It’s actually stronger immediately after the surgery than it is during this phase.
My son (both knees, one right after the other) and husband were on their feet and ambulatory without crutches within 3 weeks of the surgeries. Son had patella tendon autografts. Hubbie had patella tendon allograft. The difference: pretty large scars for my son, $8,000 for the allograft for DH. (Yikes.)
The surgery is usually outpatient - in and out same day.
Pre and post-op meds will vary per surgeon and patient.
Ice will be your best friend for at least 2 months. Cryo-cuff.
Physical therapy focuses on regaining leg strength (which rapidly diminishes after surgery) via VMO stimulation, ambulation, range of motion and proprioception (the graft initially feels VERY different than what had been your ACL). An active/sports orientation to PT would be excellent - and many are. Although not always, many ACL ruptures occur in very active individuals. And all of them want to get back to their sports and lives.
The first 2 to 4 weeks aren’t fun. Grit your teeth and get through it. Mine are intact, but I’ve been through 3 of these surgeries with immediate family members - and neither of them would have done it any other way. They are pain-free (and in DH’s case, in that knee, arthritis-free!), active, mobile - skiing and riding as if it never happened. Both were released from PT and ortho 5 months post-op. My son was 24-25 with his. Hubbie was 55.
Wishing you all the best, and hope you can quickly find an OS you trust and believe in.
“This Too Shall Pass!”
marzNC
Angel Diva
So sorry you've joined the ACL-injury club. Shoot me a PM if you want to get more info that I found researching the topic last summer/fall. Every situation is different, so ultimately it's up to you to make the final decision. Definitely want to find an experienced ortho who is up to date on the latest research from the last decade or so.
A good book to consider:
https://www.amazon.com/ACL-Solution-Prevention-Recovery-Devastating/dp/1936303337
Definitely good to start formal PT sessions ASAP regardless of how you are thinking about ACLr surgery. The better shape you are in before surgery, the better the post-surgery rehab will go. How has your balance felt?
My balance has felt ok, but the knee feels a bit strange. I just ordered the book you recommended. I am in pretty good condition, and started pt last week to keep things moving and keep my quads strong. I suspect my biggest challenge will be that I am not terribly patient and tend to tune out pain. I'm lucky in that there are some very good knee specialists in our area, and my insurance is fairly flexible. I'm meeting with Stephen Isono, whose apparently the team knee doctor for a couple of the Olympic teams. I also have an appointment with Steve Howell in Sacramento, who has designed a lot of the ACL and replacement knee hardware. He advocates a fairly quick recovery, and supposedly with his method you can be back competing in 4-5 months. I do wonder, since most other information I've read says 9-12 months. I know another horse person who had ACL surgery with him and had a great experience, but I've also read a couple of negative reviews on the healthgrades website, although those were for knee replacements. I've heard nothing but good things about Isono, including friends who are doctors and physical therapists.
marzNC
Angel Diva
In terms of knee rehab and knee injury prevention, your focus should be on hamstrings, not quads. Or at least an approach that involves both. Having quads that are too strong compared to hamstrings is a risk factor for knee injury.
<mom hat on> If you're doing an exercise that hurts, you should stop. That's your body's way of telling you it needs some healing time. This is not a situation where "no pain, no gain" applies. <mom hat off>
How is your Range of Motion (ROM)? Any limp left?
Definitely listen to the pain, not only now, but also after the surgery, precisely because of the reason that MSL listed. Also, for allograft patients, because there's no donor site, the body starts to feel better before the graft has necessarily held. IMHO, allograft patients need to be extra diligent in following their physician's post-op protocol for this reason.
MaineSkiLady
Angel Diva
All grafts, whether aut0- or allo-, go through this "weak" phase prior to re-vascularization. Son had 2 auto's, DH had allo -- both had the same caution/red-flag time lines @ 8-12 weeks post-op.
Right, but what I mean is that because allograft patients are only having one procedure, they often feel better earlier than autograft patients, ignore the protocol, and start pushing things because they feel better, not realizing the protocol is based on the weak graft. At least with autograft patients, they often still have pain from the harvest site to slow things down.
So I'm embarrassed to admit how I fell, because it didn't involve one of the more interesting black diamond runs DH and I regularly do, but it happened later in the day in the terrain park. I went over what looked like a small jump, but had a bit of a drop and caught some air. I know, not the smartest thing to do, and I'm never going in the terrain park again. According to the knee specialist I saw Monday, the injury happened when my leg was in a flexed position, not hyperextended. I landed with more weight on one leg and it almost felt like the injury happened on impact, although it all happened rather fast. I think I then went over my side or shoulder, and flipped. I've been skiing on the Knee Bindings since they came out four years ago (a 40th birthday present to myself), and they have released a few times when I've had those slow backward rotational falls that are the classic cause of ACL injuries. There's apparently a video that a friend took that shows at least part of it, but I haven't seen it.
So the initial MRI report and the first doctor I saw said that I had a full tear, as well as a very mild meniscal tear (less than 6mm), and a contusion of the tibia, later deemed a microfracture by the doctor. I saw Stephen Isono, who treats a lot of professional athletes and is the team knee guy for a couple of the Olympic teams. He said that my knee has some laxity but a clear endpoint, and based on the clinical signs and the fact that the MRI is somewhat fuzzy in the ACL area, he thinks it's more likely that I have a partial tear. When it happened, it was painful, but thn I stood up and it didn't feel too bad, so I kept skiing for another hour or so. I iced it that night but it didn't really swell and didn't feel too bad the next mornng, so I even skied the next day. I know, really stupid in retrospect, but I stayed on blue runs and took it easy.
I'm going for a new MRI on Friday, and also went to see a PT recommended by the doctor who specializes in athletes. She did a very extensive evaluation and says that my range of motion is basically 100%, since I can fully extend and bend it. It does feel weird and I've had a few unstable and painful moments. I'm also walking with a limp, although I'm working on it. It does feel like something is missing. I do have very strong quads and hamstrings, but that leg is clearly my weaker leg already. I've been using an exercise bike and doing some of the easier knee exercises, but she is going to have me work on a water treadmill they have at their clinic, which somehow is attached to sensors on your body so they can analyse and correct your movement patterns.
I'm very curious if it's a partial or full tear, and how that will change the treatment plan. I'm going to the Stone Clinic in San Francisco next week as well, and they do some fairly cutting edge stuff there, including biological knee replacements, and repairs of partial ACL tears, versus reconstruction. If I do have to have surgery I would like to do it soon, so I can ski next season, and also because I retain a faint hope I could recover I time to do some of the fall three day events with my mare. I've heard that donor grafts have a longer recovery period because your body has to reject and then rebuild the donor graft tissue, what do you all think about that?
So the initial MRI report and the first doctor I saw said that I had a full tear, as well as a very mild meniscal tear (less than 6mm), and a contusion of the tibia, later deemed a microfracture by the doctor. I saw Stephen Isono, who treats a lot of professional athletes and is the team knee guy for a couple of the Olympic teams. He said that my knee has some laxity but a clear endpoint, and based on the clinical signs and the fact that the MRI is somewhat fuzzy in the ACL area, he thinks it's more likely that I have a partial tear. When it happened, it was painful, but thn I stood up and it didn't feel too bad, so I kept skiing for another hour or so. I iced it that night but it didn't really swell and didn't feel too bad the next mornng, so I even skied the next day. I know, really stupid in retrospect, but I stayed on blue runs and took it easy.
I'm going for a new MRI on Friday, and also went to see a PT recommended by the doctor who specializes in athletes. She did a very extensive evaluation and says that my range of motion is basically 100%, since I can fully extend and bend it. It does feel weird and I've had a few unstable and painful moments. I'm also walking with a limp, although I'm working on it. It does feel like something is missing. I do have very strong quads and hamstrings, but that leg is clearly my weaker leg already. I've been using an exercise bike and doing some of the easier knee exercises, but she is going to have me work on a water treadmill they have at their clinic, which somehow is attached to sensors on your body so they can analyse and correct your movement patterns.
I'm very curious if it's a partial or full tear, and how that will change the treatment plan. I'm going to the Stone Clinic in San Francisco next week as well, and they do some fairly cutting edge stuff there, including biological knee replacements, and repairs of partial ACL tears, versus reconstruction. If I do have to have surgery I would like to do it soon, so I can ski next season, and also because I retain a faint hope I could recover I time to do some of the fall three day events with my mare. I've heard that donor grafts have a longer recovery period because your body has to reject and then rebuild the donor graft tissue, what do you all think about that?
I know a sometimes insurance won't pay for repairs of partial tears, so the treatment is generally just rehab if that is the case. Personally, both of my (previously repaired) ACLs are stretched out (which would be similar to a partial tear) and I won't be having surgery again unless I really feel like I can't live without it. (They've been that way for probably 5 years now.) I just keep my legs strong and do a lot of yoga and that works pretty well.
I will say that when you have even a small amount of swelling in the joint like that, it makes things feel extra unstable. It's something like that the swelling affects the firing of the nerves around the knee and because you're effectively getting some delay in the muscles firing, the joint feels unstable and the muscles feel weak. Another part of it is that when you have that swelling, it makes you limp and you don't extend the leg fully when you walk. That's the typical cause of a limp anyway. And when you don't extend the leg fully, you don't engage the VMO part of the quad, and it atrophies fast because it's never getting used.
So I've found personally that when my knee is swollen, I'm better off being patient and walking basically in slow motion but giving myself the time to get my leg all the way straight and flexing my quad consciously before taking each step. That way the muscles don't atrophy and even though it's annoying as I don't know what to walk that slow when you could limp along at near full speed, it helps you recover faster. I think taking the time to squeeze the quad with each step probably helps squish some of the swelling out of there too, so I'd encourage you to take the time to walk as normally as you possibly can.
And personally, if it was me, I'd keep rehabbing it and see how it feels doing things the way it is. I guess I'm feeling a little disillusioned about surgical fixes at this point - not that there aren't situations where it's an excellent solution, but there are also a lot of situations where it's not really necessary and creates other problems in the process. If you decide surgery is right for you, go for it, but make sure you're really weighing your options first. I think it's at least good to see what you can get back to with just rehab, unless you really have a deadline for competitions or something that you feel you can't miss. Some people do quite well even in competitive sports with no ACL, so I think it's at least worth testing it out first.
I will say that when you have even a small amount of swelling in the joint like that, it makes things feel extra unstable. It's something like that the swelling affects the firing of the nerves around the knee and because you're effectively getting some delay in the muscles firing, the joint feels unstable and the muscles feel weak. Another part of it is that when you have that swelling, it makes you limp and you don't extend the leg fully when you walk. That's the typical cause of a limp anyway. And when you don't extend the leg fully, you don't engage the VMO part of the quad, and it atrophies fast because it's never getting used.
So I've found personally that when my knee is swollen, I'm better off being patient and walking basically in slow motion but giving myself the time to get my leg all the way straight and flexing my quad consciously before taking each step. That way the muscles don't atrophy and even though it's annoying as I don't know what to walk that slow when you could limp along at near full speed, it helps you recover faster. I think taking the time to squeeze the quad with each step probably helps squish some of the swelling out of there too, so I'd encourage you to take the time to walk as normally as you possibly can.
And personally, if it was me, I'd keep rehabbing it and see how it feels doing things the way it is. I guess I'm feeling a little disillusioned about surgical fixes at this point - not that there aren't situations where it's an excellent solution, but there are also a lot of situations where it's not really necessary and creates other problems in the process. If you decide surgery is right for you, go for it, but make sure you're really weighing your options first. I think it's at least good to see what you can get back to with just rehab, unless you really have a deadline for competitions or something that you feel you can't miss. Some people do quite well even in competitive sports with no ACL, so I think it's at least worth testing it out first.
bounceswoosh
Ski Diva Extraordinaire
If it had happened on a groomer, would you swear you would never ski a groomer again? Injuries happen. The terrain park is a more controlled place to practice jumps than anywhere else on the mountain ... I totally understand if this injury freaks you out and you just don't want to touch the park again - but if you thought it was fun before the injury happened, it's worth chalking the injury up to bad luck and heading back after you're strong again.
The ACL is a strange beast, especially in women, for a number of anatomical and physiological reasons. When it comes to jumping (or landing them), women tend to land without engaging muscles in the quads and hamstrings at the same force/rate, which affects the forces against the ACL. Honestly, you could have been "jumping" off of the third step of your stoop with your sneakers on and still ruptured the ACL (yes, I do know someone this has happened to). So, rehab, retrain the muscles, and if the terrain park still seems fun, no reason to stay out of it.
Somehow I think the terrain park is something I can willingly give up, unlike powder, steeps, or tree runs. I broke a rib in the terrain park when my bindings simultaneously released on landing from jump a few years ago (my fault for not having the DIN setting high enough for that type of activity). I don't love the terrain park the way I love skiing ungroomed areas, and the terrain park doesn't seem to love us. Last year my husband was standing watching the kids at the top of the terrain park, and he got injured when a ski patroller on a snowmobile accidentally caught the plastic rope and knocked him off his feet, giving him a concussion and rope burn.
MaineSkiLady
Angel Diva
I don't think so. My son had auto, DH had allo - same recovery period for them both.
Regional OS (a female) has done copious research on this, which has been published. I will post a link if I can get to hunting for it.
VickiK
Ski Diva Extraordinaire
Really? Do you happen to have any references on this, Pequenita? PM me if you prefer, please.
marzNC
Angel Diva
This book is primarily geared towards young women who play sports like soccer, basketball, etc. Partially because of the special issues they can have. Includes exercises that can be part of rehab or for injury prevention. Several of those involve learning to jump and land safely.
https://www.amazon.com/ACL-Solution-Prevention-Recovery-Devastating/dp/1936303337
MaineSkiLady
Angel Diva
Just for starters:
https://www.aaos.org/news/aaosnow/nov10/research3.asp
https://www.nlm.nih.gov/medlineplus/magazine/issues/summer08/articles/summer08pg24-26.html
https://www.orthopodsurgeon.com/aclinwomen.html
https://www.momsteam.com/health-safety/muscles-joints-bones/knee/acl-injuries-in-female-athletes
https://www.aaos.org/news/aaosnow/nov10/research3.asp
https://www.nlm.nih.gov/medlineplus/magazine/issues/summer08/articles/summer08pg24-26.html
https://www.orthopodsurgeon.com/aclinwomen.html
https://www.momsteam.com/health-safety/muscles-joints-bones/knee/acl-injuries-in-female-athletes
