Complete ACL rupture

[vickie]

Long post ... key stuff is in bold.

I tore my ACL skiing last season and fractured the proximal tibia. My stupidity injury occurred on Monday. An MRI was done on Friday. In the MRI, the attachment of the ACL to the bone looked grayish and "fuzzy". I gather that if it's fully intact, it will show up as a distinct line; "indistinct" says yes, it's there but it's messed up. The extent of "messed up": Unknown. The MRI is where they first saw the fracture; normal X-rays didn't show it. The doctor (sports medicine ortho) explained the injury like this -- the ACL overextended, allowing the femur to crash down onto the tibia, fracturing the proximal tibia.

Questions I asked over the course of this:

Q: Will you order another MRI after the 6 weeks of non-weightbearing to verify the bone has healed?
A: No, bones heal in 6 weeks so there is no need to look at it again. With respect to everything else, an MRI will look much the same at that point. The dark areas of fluid will still be there. It takes the body as much as 6 months to absorb all of the fluid.

Q: Will I need the ACL replaced?
A: I don't know. You don't know. Your knee will tell us. If you can do all of your normal activities with no problem, then no, you don't need surgery. If your knee "gives" and causes you to fall, then yes, you will need surgery.

Q: Can I ski this season?
A: No. Due to the fracture, ski season is over. (It was December.) Had it been only the ACL, then yes, you could ski again this season - just not right away. You will need to wear a brace for skiing - and ONLY for skiing. Prior to the damage, your ACL demonstrated the ability to overextend (hence, the fracture). With less ACL, it may be more prone to overextending again.

According to my doctor, it comes down to how your knee functions for you and your normal life.

If you want surgery, a doctor will do it. If you are interested in avoiding surgery but concerned about being able to continue the more intense activities that you have been doing, you might ask whether there are braces that will provide the support you need for those activities ... assuming your knee is stable for normal daily living. If you prefer to avoid surgery and the doctor is pretty sure you will regret that decision, I expect s/he will tell you so.

 

[SnowHot]

Well, now I'm even more befuddled. The second and higher quality MRI came back with a report of "at least high grade partial ACL tear." The rest of the knee structures are in pretty good shape. I'm having some pain and instability, but it also seems to be improving. The surgeon recommended that I do surgery, since he said the ACL doesn't get heal, and I'm at higher risk of getting injuries to the adjacent areas. That made sense, but then I came home and read the article by Dr. Marx, the guy who wrote book on ACL Prevention listed above. The article just came out and it's entitled Nonoperative treatment for anterior cruciate ligament injury in recreational alpine skiers. It found that a substantial portion of recreational skiers who showed rupture on MRI's did show improvement on knee laxity scores and MRI's at 6-12 weeks, and that of that group, all had favorable scores at two years post injury. This seems to fly in the face of the commonly accepted idea that ACL's don't heal.

I'm not a medical professional, and I haven't had a knee injury so I'll refrain from adding more advice to the mix, but I want to send good healing thoughts your way and say that I don't envy your situation. Its kind of like you're in the middle of the intersection and there's no easy way to decide which way to go.
Listen to the medical professionals, then listen to your heart.

 

[vickie]

Q: Will I need the ACL replaced?
A: I don't know. You don't know. Your knee will tell us. If you can do all of your normal activities with no problem, then no, you don't need surgery. If your knee "gives" and causes you to fall, then yes, you will need surgery.

I realized afterwards that I should clarify ... in my Q&As, I was paraphrasing my conversation with my doctor. So, in the example above, "I don't know" was the doctor saying HE does not know. Etc. Those were not intended, in any way, to refer to your situation, Valli.

I do feel for you. Waiting to see whether I was destined for surgery was really hard. The thought of hobbling on crutches, going through physical therapy -- for WEEKS -- only to find that I was going to need surgery and go through it and even more all over again? That was tough, but I didn't have a choice. I sympathize with your trying to make the right decision now. SnowHot is right ... in addition to all of the things you hear and read, you have to listen to your heart. (Luckily, I didn't have to do that. I was whining to myself so much that I probably couldn't have heard my heart anyway.)

 

[RX2SKI]

Here is a description of the study in layman's terms:
https://teenasingh26.blogspot.com/2013/02/study-identifies-skiers-who-can-be.html

In the article, Dr. Marx is quoted: "Some patients who tear their ACL while skiing can get away without surgery. Their ligament heals by itself, they will have stable knees, and they will be able to do whatever they want, including skiing," Of the 11 who did follow up, 10 had knees that were "rock solid." Only 8 had decided to continue skiing.

I guess I really don't like his use of the word "heal" in the lay article. There is scar tissue and adhesions (sometimes to the PCL), but IMO I don't think that equates to re-vascularization and re-connection of the mechanoreceptors. He states in the actual article that the MRI was not routinely performed at the follow-up so he couldn't confirm anatomical healing.

 

[marzNC]

I was surprised by the quote from Dr. Marx. Per usual, better to read the journal article for the real story.

 

[valli]

One thing that I've been curious about is that there is so little research on what happens to the ACL in those skiers who are either copers or people who have partial tears and are able to regain full stability. There's a few researchers who have studied materials that might be used to stimulate regrowth in partial tears, like Martha Murray at Children's Hospital in Boston, but not that much seems to be really known about what happens to the ACL after injury. The Dr. Marx article said a few of the study participants had follow up MRI's, and the injuries appeared healed, but I don't know if MRI's show the different between scar tissue and normal tissue. The common wisdom is that the ACL, unlike the ACL, cannot heal due to poor blood circulation, but there do seem to be some cases where ACL's heal, at least for partial tears. Martha Murray uses a collagen gel that has been somewhat successful, at least in adolescents, and other researchers have tried PRP gels and stem cells, with less success. The Steadman clinic does the Healing response technique of microfracture and blood clotting, which is what Bode Miller did.

I've had a fair amount of experience rehabbing ligament injuries in horses, including some cases that usually have a poor outcome. A few years ago I had a very nice upper level horse who badly injured one of his collateral ligaments and remained lame more than a year after injury. My vet agreed to participate in a clinical trial for a biocellular matrix material by a company called Acell, and she injected it into the unhealed lesion. It stimulated blood flow and tissue healing, and within six months he was sound, and has remained sound since then. My mother rides him now and he's still jumping and competing at the lower levels at the age of 21. The company now have a material that is FDA approved for humans called Biomatrix, but I'm not sure if they've ever tried it for ACL injuries. The interesting thing about it is that it is supposed to encourage tissue regrowth in a normal ligament pattern, not the more typical disrupted pattern characteristic of scar tissue. The two types of tissue do look different on high resolution ultrasound, and my vet monitored the lesion healing as part of the clinical trial and showed me the ultrasounds as we went along. Her opinion was that it looked like normal tissue, and she has since used it in several other cases successfully.

 

[Vista freak]

^^fascinating.

 

[contesstant]

One thing that I've been curious about is that there is so little research on what happens to the ACL in those skiers who are either copers or people who have partial tears and are able to regain full stability. There's a few researchers who have studied materials that might be used to stimulate regrowth in partial tears, like Martha Murray at Children's Hospital in Boston, but not that much seems to be really known about what happens to the ACL after injury. The Dr. Marx article said a few of the study participants had follow up MRI's, and the injuries appeared healed, but I don't know if MRI's show the different between scar tissue and normal tissue. The common wisdom is that the ACL, unlike the ACL, cannot heal due to poor blood circulation, but there do seem to be some cases where ACL's heal, at least for partial tears. Martha Murray uses a collagen gel that has been somewhat successful, at least in adolescents, and other researchers have tried PRP gels and stem cells, with less success. The Steadman clinic does the Healing response technique of microfracture and blood clotting, which is what Bode Miller did.

I've had a fair amount of experience rehabbing ligament injuries in horses, including some cases that usually have a poor outcome. A few years ago I had a very nice upper level horse who badly injured one of his collateral ligaments and remained lame more than a year after injury. My vet agreed to participate in a clinical trial for a biocellular matrix material by a company called Acell, and she injected it into the unhealed lesion. It stimulated blood flow and tissue healing, and within six months he was sound, and has remained sound since then. My mother rides him now and he's still jumping and competing at the lower levels at the age of 21. The company now have a material that is FDA approved for humans called Biomatrix, but I'm not sure if they've ever tried it for ACL injuries. The interesting thing about it is that it is supposed to encourage tissue regrowth in a normal ligament pattern, not the more typical disrupted pattern characteristic of scar tissue. The two types of tissue do look different on high resolution ultrasound, and my vet monitored the lesion healing as part of the clinical trial and showed me the ultrasounds as we went along. Her opinion was that it looked like normal tissue, and she has since used it in several other cases successfully.

I was just thinking about all the great therapies we can do to our horses and wondering why they aren't used on humans more often. My horse has an arthritic hind fetlock which caused a pretty significant amount of damage to his distal suspensory branches. (Those are ligaments, for those of you who don't speak equine .) He is technically "permanently lame" but don't tell him that! Between Pentosan polysulfate, adequan, and shockwave treatments, he is doing very well and has won two national titles and multiple regional titles with me since his diagnosis :D (He just finished a series of three shockwave treatments today, preparing for show season.) He has also had several IRAP injections, however, they seemed to have minimal effect.

I did some research on shockwave therapy in humans, and it IS being done. I love how non-invasive it is.

Anyway, I'm really sorry you are dealing with this. I get scared of threads like this because it makes me paranoid! And reminds me to remain cautious. Best of luck, keep healing, and keep us posted!

 

[valli]

Pentosan is the bomb, they use it for arthritis for people in Europe and Japan, and for other purposes in the US. My mare has hock (kind of like the knee) arthritis and Pentosan has been incredibly beneficial. I have problems with my neck and back, and I'm always asking my doctors why there are so many more treatments for the horses. I've been thinking of trying shock wave for my neck, I have bone spurs but don't want to do surgery for it.

 

[contesstant]

Pentosan is the bomb, they use it for arthritis for people in Europe and Japan, and for other purposes in the US. My mare has hock (kind of like the knee) arthritis and Pentosan has been incredibly beneficial. I have problems with my neck and back, and I'm always asking my doctors why there are so many more treatments for the horses. I've been thinking of trying shock wave for my neck, I have bone spurs but don't want to do surgery for it.

So, my farrier takes pentosan for himself! Says it works WONDERS. He has back issues (shocking!) and used to have to visit a chiro weekly, but he doesn't any more. It's approved for use here in the states for surgical lavage. It's frustrating it's not approved for anything else.

I would love to have shockwave on my knees and shoulder. If you end up doing it, please report back how it works! I am amazed at how much the inflammation in my gelding's fetlock has gone down.

 

[valli]

Pentosan is also FDA approved for interstitial cystitis, both as an oral medication and as a localized treatment. Some docs do prescribe it off-label, and when I researched it there is even a compounded inhaler version that some people use. With respect to both pentosan and shockwave , the interesting thing is that there have been clinical trials on both treatments used post-ACL reconstruction to enhance healing, with good outcomes. For some reason, some of the local chiropractors do shockwave, not the regular mds, so I may investigate it.

 

[marzNC]

Very interesting study . . . the original journal article was published in Nov 2012. The study was based on patients who tore their ACL while skiing 2003-2008. The results were recently presented at a major medical conference. Pretty small cohort given that only 11 patients did the final follow up at least 2 years later. What I find worth noting is that the median age was 42, with a range from 29-68 at follow up. More relevant to situations where there isn't other knee damage since those cases were excluded.

Here is a description of the study in layman's terms:
https://teenasingh26.blogspot.com/2013/02/study-identifies-skiers-who-can-be.html

In the article, Dr. Marx is quoted: "Some patients who tear their ACL while skiing can get away without surgery. Their ligament heals by itself, they will have stable knees, and they will be able to do whatever they want, including skiing," Of the 11 who did follow up, 10 had knees that were "rock solid." Only 8 had decided to continue skiing.

Found an example in the annual TGR thread about ACL injuries that reminded me of this article. The end result for a 53yo woman in Colorado was that she was told in the recovery room:

"It [the ACL] had been almost 100% torn, but had vascularisation and reattached to the femoral condyle. It is as if, he said, I have a native ACL repair 3 to 4 months into the healing process. Says that this only happens less than 3%."

Her knee was messed up in Dec 2012 after a collision with someone else. Surgery was in March 2013 after consulting three experienced surgeons, including one at the Steadman clinic. Her original surgeon removed 10% of the meniscus and there was other damage as well.

 

[marzNC]

Since this thread is useful for those interested in basic info about options after ACL injury, here is a reference with a collection of stories from 2011 by people who enjoy cross-country skiing, including racing. In general, each paragraph is a separate "post." Some opted for surgery, some did not, a few have been without an ACL for more than a decade, most were over 50 when they wrote their story.

https://skipost.wordpress.com/2011/06/01/torn-acl-advice/

 

[hawaiigirl808]

Hi all, I tore my ACL two months ago in Alta, Utah. MarzNC, I met you there and you told me about this site and your forum. I don't know if you remember me, but I had a crutch and was limping and you told me how you tore your ACL too and did not have surgery. I am thinking of going the NO surgery route as well. I am not a very active person, although I would like to try skiing again.

This was my very first time skiing in my life and it happened on the very first day out. I skied about an hour, just practicing going down the hill. Then I tried the tow-in rope and that's where I fell and twisted my leg. I didn't know what I did to myself. I thought I might've just pulled a muscle. My leg was sore from my knee down my calf. I managed to walk up the hill and sat in the lobby a while. After about an hour of massaging and sitting, I decided it felt better and went back out to try again. It was still in a little pain but I made it all the way down the hill. It wasn't until after dinner, when I got my from the table and walked out of the dining hall that I felt excruciating pain and could barely walk out of there.

After a couple days of icing my knee, it felt much better and was not in much pain and I was able to walk around ok. A couple of skiers at the lodge told me it might be an ACL tear and I should go see the doctor. So the day before I left, I went to see Dr. Ken and he did confirm an ACL tear. He wrote a prescription for physical therapy for when I go home. And I started PT two days after I got home. I am on session #12 of 13. My range of motion is still not completely there. I cannot bend my knee all the way and cannot extend it all the way straight. I was wearing a hinge brace(given by the doctor in Alta) for the first two weeks. But my ortho here didn't want me wearing it anymore because he said it makes my leg stiff.

My doctor talked to me about surgery and I feel that I really don't need it. I think if I strengthen my muscles around my knee it will be ok. Like I said I'm not a very active person. I don't play any sports, don't dance. The most physical activity I do is at my job. I am a housekeeper at a resort. It's a very physical job, always moving all day. What type of exercises should I do to strengthen my knee? I have one more therapy session and want to know what I can do at home. I will see my doctor again next week and see if he wants me to continue going to therapy.

Thanks all.

 

[altagirl]

They should give you home exercises or things you can do at a gym for strengthening at physical therapy. Make sure they give you this info at your next session! And good luck!

 

[marzNC]

Hi all, I tore my ACL two months ago in Alta, Utah. MarzNC, I met you there and you told me about this site and your forum. I don't know if you remember me, but I had a crutch and was limping and you told me how you tore your ACL too and did not have surgery. I am thinking of going the NO surgery route as well. I am not a very active person, although I would like to try skiing again.

This was my very first time skiing in my life and it happened on the very first day out. I skied about an hour, just practicing going down the hill. Then I tried the tow-in rope and that's where I fell and twisted my leg. I didn't know what I did to myself. I thought I might've just pulled a muscle. My leg was sore from my knee down my calf. I managed to walk up the hill and sat in the lobby a while. After about an hour of massaging and sitting, I decided it felt better and went back out to try again. It was still in a little pain but I made it all the way down the hill. It wasn't until after dinner, when I got my from the table and walked out of the dining hall that I felt excruciating pain and could barely walk out of there.

After a couple days of icing my knee, it felt much better and was not in much pain and I was able to walk around ok. A couple of skiers at the lodge told me it might be an ACL tear and I should go see the doctor. So the day before I left, I went to see Dr. Ken and he did confirm an ACL tear. He wrote a prescription for physical therapy for when I go home. And I started PT two days after I got home. I am on session #12 of 13. My range of motion is still not completely there. I cannot bend my knee all the way and cannot extend it all the way straight. I was wearing a hinge brace(given by the doctor in Alta) for the first two weeks. But my ortho here didn't want me wearing it anymore because he said it makes my leg stiff.

My doctor talked to me about surgery and I feel that I really don't need it. I think if I strengthen my muscles around my knee it will be ok. Like I said I'm not a very active person. I don't play any sports, don't dance. The most physical activity I do is at my job. I am a housekeeper at a resort. It's a very physical job, always moving all day. What type of exercises should I do to strengthen my knee? I have one more therapy session and want to know what I can do at home. I will see my doctor again next week and see if he wants me to continue going to therapy.

Thanks all.

Welcome! Yes, I remember talking with you at Alta Lodge. Sorry it did turn out to be the ACL.


What have you been doing at home between PT sessions? If you read thru my first thread about dealing with ACL injury, I mention some of the exercises and basic equipment that I got for home use. The BOSU was the first. Basic ankle weights were useful too.

Consistency is key for completing rehab. Doesn't need to be that much every day, but definitely helps to do something often. Even if it's just balancing on one leg at a time while waiting in line or watching TV at home. Or doing some heel slides in bed when you wake up and before going to sleep.

 

[ski diva]

Hi, Hawaiigirl. Wow, that's a major bummer. First time on skis and a torn ACL! I have no advice, but just wanted to say welcome and wish you fast healing.

 

[hawaiigirl808]

Hi MarzNC, I'm glad you remembered me! I have been doing the basic exercises at home that I do at PT. Like calf raises, hamstring extensions with rubberbands, hamstring flex, stretches, prone hang, etc. I saw your post about equipment you use, and was thinking of getting me a BOSU ball, ankle weights, and a pedal bicycle. Do you still go to PT sessions? How long should I be going to PT? or should I just do it on my own at home? how long did it take you to fully extend and flex your leg? how long before you were able to ski again? We had wanted to come back next April to Alta again. But I'm not sure I'll be ready. Thanks for any advice.

 

[marzNC]

Hi MarzNC, I'm glad you remembered me! I have been doing the basic exercises at home that I do at PT. Like calf raises, hamstring extensions with rubberbands, hamstring flex, stretches, prone hang, etc. I saw your post about equipment you use, and was thinking of getting me a BOSU ball, ankle weights, and a pedal bicycle. Do you still go to PT sessions? How long should I be going to PT? or should I just do it on my own at home? how long did it take you to fully extend and flex your leg? how long before you were able to ski again? We had wanted to come back next April to Alta again. But I'm not sure I'll be ready. Thanks for any advice.

Every knee situation is different. Read thru my first ACL thread for details of what I was doing last summer:
https://www.theskidiva.com/forums/index.php?threads/learning-to-be-a-coper-without-an-acl.14847/

I did formal PT for about 3 months, more or less twice a week. After that I was working with a personal trainer 2-3 times a month during the fall. I started skiing in Jan, which about 7 months after injury. I was ready in Dec but there wasn't any snow at my home mountain in VA. But remember that I am an advanced skier who has been skiing for quite a while. Even so, I took more lessons last winter to improve technique.

Have you had any instances of instability? Is there any swelling any more?

 

[hawaiigirl808]

MarzNC, I did have periods of instability where I could feel my knee slip, but not anymore. This past month of PT has been more aggressive and I feel it's helped strengthen my knee a little bit. My doctor wants me to do one more month of PT strengthening before returning to work. He cleared me to return to work the end of July. I have not worked since we got back from Alta on April 14.

No, I don't have any swelling anymore. I saw my doctor 2 days ago and he agreed that I didn't need surgery. He said my ACL is 75% torn and since I don't do any sports and not very active, I could live without the ACL. As far as me skiing again next April, he said if your knee if strong enough, you can try. I would like to try skiing again next year and come back to Alta year after year, so we'll see. It was our first time at Alta, and we loved it. Hope to see you there again real soon.