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Learning to be a coper without an ACL

marzNC

Angel Diva
#1
As some of you know, I popped off the ACL in my right knee in early June. Not skiing. The MRI in early July confirmed a fully ruptured ALC, plus an intermediate/advanced strain for the MCL and a 2-3 cm tear the meniscus. The MCL and meniscus can heal. Bottom line is that I am taking a conservative approach so not planning any surgery until I know how much I can do with good PT support.

Most threads I've found about ACL injuries are related to reconstruction surgery and rehab. So thought I'd post some info as I work on being a "coper." I've learned that people who are "ACL deficient" fall into roughly three equal groups: copers, adapters, non-copers. A coper can do everything they want, including sports that don't involve intense pivoting. Adapters give up activities to avoid surgery. Non-copers continue to have so much instability that they have problems even with daily living.

A paper by a couple UK doctors classified activities by risk level for someone with ACL issues. The low risk list included cycling and swimming. Skiing is rated medium risk, along with tennis and golf, because these sport involve predictable pivoting action. High-level skiing is high risk, as is basketball, football, soccer, volleyball, because there is a lot of risk for an unexpected twisting injury. For me, I stopped playing those sports a couple decades ago. What I want to continue is advanced-level skiing and intermediate level rock climbing. Haven't played golf in a while for assorted reasons, but would like to golf again at some point.

I started formal PT about 4 weeks after injury. Mostly for Range of Motion (ROM) since we didn't have the full diagnosis from the MRI yet. But the orthopedic PA found a little laxity that meant the ACL was probably messed up. After three days of twice daily no-impact exercises and stretches, ROM was about 5 to 120. Still limping a bit and using a cane (on opposite side) when leaving the house. Got to 1-130 in another week. That's enough to walk normally (heel to toe), but it took concentration to avoid the limp that had already become a bad habit.

Started strength exercises at about 5 weeks after the diagnosis from the MRI and discussion with my orthopedic surgeon. He noted that the tear in the meniscus was in the thicker part near the edge, so could heal easier. At that point, he said even a compression sleeve wasn't really necessary since I had no pain and very little swelling. Only a small sore point where the MCL is attached.

ROM was at 1-130 after 5 weeks. Could do full forward rotation on a stationary bike. So the bike my husband bought some years ago that he doesn't use is being put to good use.

After two weeks of ongoing PT exercises, I'm walking around without the cane and not having any balance issues. Feels a lot different than before I did any strength exercises. Started working on step up/down and sit-to-stand this week. No limitations on whatever I want to do on a stationary bike as far as time or resistance level. Trying to get in two 15-min sessions per day.
 

VickiK

Angel Diva
#2
Thanks for posting this, it's very interesting - best wishes with healing and recovering!
 

altagirl

Moderator
Staff member
#3
I went for a full year after my first torn ACL before I had surgery, skiing on it a fairly full season at the time of something like 30 days.

My understanding is that whether you can "cope" with it or not depends on how your individual knee is shaped and the condition of your meniscus. I had a torn meniscus as well. I went without surgery because I was in the military and they kept refusing to send me to a specialist and then I was in this school and it's a long story, but it wasn't by my choice. But I kept doing everything I normally did with no ACL.

Anyway - I could ski fairly well for the most part, but every so often, it would give out again - that same collapsing event as with the initial injury. And it would swell back up and get stiff but the swelling would go back down and I'd go back to doing whatever. But eventually, I got to the point where I couldn't even walk around a corner without it collapsing and me flat on the floor. That was the last straw.

Now, mind you, I've heard of people who get along just fine with no ACL - skiing competitively, you name it. But I think mine was exascerbated by the way my meniscus was torn (there are a lot of ways for that to happen) and maybe I just don't have the right shape bones... who knows.

I do think it's worth going through rehab and seeing what you can do if you're not on a tight timeline. Fingers crossed that you're able to do just fine without it!
 
#4
I know that it is possible to have a completely torn ACL and still ski on it. I know someone who skis on his with just some sort of brace for support. I was not in that situation. I had surgery immediately (6 weeks) after the swelling went down. Definately a non-coper here. I couldn't get around without an immobilizer at first and then later a hinged thigh-to-ankle number.

Best of luck to you. Sounds as if you have the support, desire and body mechanics to succeed.
 

marzNC

Angel Diva
#5
Thanks for the good wishes!

What I'm doing is certainly not for everyone who pops off an ACL. A big physical factor is that the MCL is intact and the meniscus damage should heal okay. The meniscus tear is in the thick part, closer to the edge. Apparently that means more blood flow and quicker healing. From what I've found online, the MCL needs 6-12 weeks to recover completely. My surgeon wouldn't give any time estimate for the meniscus.

Of equal importance is that I have the luxury of time for daily PT at home since I'm not working. I also have the financial resources to deal with the cost of PT sessions 1-2 times a week for the first few months. So far, I'm adding something new every session.

Oh yeah . . . the fact that I'm a 56 year old advanced skier, not a 36 year old expert skier, is a big factor too.

Since my ski season is mostly weekends at Massanutten, I won't be tempted to try anything hard in Dec-Feb since it doesn't exist. The goal is to get into good enough shape to have the confidence to check out more than the blue groomers at Big Sky and Alta in late March. Planning on being with friends, so have every intention of make the trip even if I don't ski that much.

Had another 30-min PT session today. Got more resistance band exercises to work on lateral movement more. Still a little sore in one direction because of the MCL sprain. A session also includes 3 min on various low impact machines: recumbent stepper, stationary bike, hydraulic vertical stepper. Plus leg presses while lying down (no weights, just sliding your own body weight).

Strong quads and hamstrings are crucial to help stabilize the knee when the ACL is missing. Started exercises for them at the first PT session. "Open chain" exercises are a no-no without an ACL. So no leg extensions. Hyperextension when weight-bearing is also to be avoided.
 
#6
I guess I'm perplexed as to why ACL reconstruction is so totally out of your picture? :confused:

DH had his in March 09, was back to work within 30 days, without any ambulation device or even a brace (he has never worn one, per OS preference), fully released from orthopedic and PT by August, waterskiing that same week, and skied the next season almost as if it never happened. (more mental than physical)

He was 56 at the time, also advanced/not expert, no MCL injury but did require some meniscus trim. It was 2-3 unpleasant months, gradually improving. Sounds to me as if your rehab is going take longer than reconstruction rehab.
 

marzNC

Angel Diva
#7
I guess I'm perplexed as to why ACL reconstruction is so totally out of your picture? :confused:

DH had his in March 09, was back to work within 30 days, without any ambulation device or even a brace (he has never worn one, per OS preference), fully released from orthopedic and PT by August, waterskiing that same week, and skied the next season almost as if it never happened. (more mental than physical)

He was 56 at the time, also advanced/not expert, no MCL injury but did require some meniscus trim. It was 2-3 unpleasant months, gradually improving. Sounds to me as if your rehab is going take longer than reconstruction rehab.
What I've learned from my research is that the decision whether or not to have reconstruction surgery is a very personal one. Lots of factors to consider. I would rather see how far I can go as a "coper" first. There is evidence that some people can do just as well in terms of function and pain level with solid PT when compared to surgery. There is no clear evidence that doing surgery sooner leads to a better outcome, assuming the patient does not do things that mess up the knee more.

Not sure what timeframe you are thinking about for my rehab. My hope is to be done with the bulk of the retraining in another month or two. The unknown is part is the meniscus tear. I have an appointment with the surgeon in late August to talk what happens next.

Also happens that the next 12 months is not a good time for me to be dealing with major surgery and rehab. After that would be much less of a problem for my family.
 
#8
MarzNC good for you for your commitment to your rehab. I was also called a Coper by my surgeon. I sustained a severe MCL strain, meniscus tear and ruptured ACL, however the ACL was not diagnosed for 6 months as I did not have obvious knee instability after the accident. I only noticed my knee sometimes popping when i ran down stairs and decided to have it checked out after i knew that my MCL should have recovered. I'm 52 and a rabid skiier. My surgeon highly recommended the surgery for my situation even though he acknowledged that I would also be fine without it. He stated that there is a significantly high correlation between arthritis occurring in knees without ACL's particularly in the active sports knee (he forecast this outcome for me if I continued skiing and surfing without an ACL). This was the deciding factor for me to have the op. I know I made the right decision for me as knee feels great and now skis great I would do it again in an instant even though rehab was very painful due to adhering scar tissue from op. I have very strong legs (I work on it) and this helped in being a Coper. Even though they say no open chain exercises I used to do single leg - leg extensions and hamstring curls very slowly with heavy weights and low reps to build up and maintain leg strength before the op. If you are sensible about it then these exercises are fine IMHO. I see people doing these exercises like frenzied rabbits on crack and yes ... This is a bad idea if you don't have an ACL. I'm with MSL on this one and am wondering why you have ruled out the reconstruction as a viable therapy? ... Good luck though with your chosen option.
 

litterbug

Ski Diva Extraordinaire
#9
It sounds like 1) this year isn't a good time for surgery (and by the time marzNC got it, she'd be risking missing ski season anyway), and 2) it's good to see whether the knee will be good enough without it. The only reason I went ahead with my AC fix so quickly was that the OS gave me close to 0% chance it would heal on its own after failing to do so in 5 months, PT would have no effect, and a cortisone shot had a 5% chance of helping. With my SLAP tears, I managed to avoid surgery in one shoulder with PT; if I hadn't given PT a chance, I'd have had both done, which would have been a royal pain.
 
#10
Fair enough - sounds like you have done copious homework and made careful choices. Hope it all goes as hoped for you. Meniscus tear can be particularly painful; it certainly was for DH (and the type he had prevented full extension, until repaired). As you said, the surgery will remain a future option, should this more conservative approach not pan out. Much luck to you! :goodluck:
 

marzNC

Angel Diva
#11
Thanks for the good wishes. As always, Divas can be counted on for good questions and moral support. :smile:

My meniscus tear is small and in the thicker part so the surgeon said it would have a better chance to heal. Going in to clean that up is certainly a possibility. I have had no pain since Week 2 when not moving. No pain when moving either since I was avoiding any lateral movement. Got to full extension around Week 6.
 

marzNC

Angel Diva
#12
For me, having an early diagnosis by an orthopedic specialist and MRI was important. I knew that starting formal PT quickly would make a big difference no matter what other treatment or surgery I decided to do. Since there was no significant swelling after Week 1, getting back as much ROM as possible was the first goal.

Saw my family practice physician during Week 3, as soon as I got back from China. X-ray confirmed no major bone issues. She got me a quick appt with a large orthopedic group practice in our area. The orthopedic appt was the week of July 4th when many folks were on vacation. The PA's evaluation was needless to say much more thorough than my family doctor. He could tell the MCL was okay but found a small laxity that probably meant the ACL was in trouble. Luckily I could get the MRI done that morning. Started PT the next week, but very low key until the MRI evaluation by the surgeon a couple weeks later. Mainly building up quads and hamstrings, mostly while lying down. Also heel slides to get more ROM. All that was needed even if I was going to have early surgery.

After the first PT session in early July, I did not have any swelling after doing PT exercises. That makes it much easier to do a few exercises here and there through out the day. By now the list is long enough, I can find something useful to do almost any time.
 

Pequenita

Ski Diva Extraordinaire
#13
Marz, I'm sorry about your injury.

Despite (or maybe in spite of?) two knee surgeries, I personally wish more people with ruptured ACLs considered non-surgical options, so I'm rooting for you! In my humble and non-medical opinion, although the reconstruction procedure is a lot less invasive than 20-30 years ago, it's still a pretty significant surgery requiring diligence pre and post op to get to the new normal....because it is going to be a new normal. I don't know what the other physical factors are that would be for or against reconstruction; I'm just talking from more of a general "surgery" perspective.

My best friend's mom, who is 15 years older than you, has lead an active life – including skiing – without an ACL for....I dunno the last 20 years? She's also stubborn, so maybe that's a factor, too. :becky: I don't know what her specific experience is, but I do know that she has always been out there hiking in the Adirondaks, White Mountains, skiing (although not super aggressively), etc., with a prescription brace. I'm not sure what regular exercise she gets aside from that. I know she goes to Silver/Sassy Sneakers at the Y. :smile: She's recently dialed things back for health reasons unrelated to the knee. I can find out more details if you're interested.

My best wishes to you, friend!

EDIT: btw, I didn't get my reconstruction until 4+ months after injury. I golfed shanked a few golf balls in that time. I agree that unless the situation is precarious, not everyone needs to get surgery immediately.
 

Skier31

Ski Diva Extraordinaire
#14
Can you cope? Most likely. However, no matter how strong your other muscles are, no Acl means you are without an important stabilizer which can lead to other injuries. . Acls can be replaced but meniscus damage is much more difficult to repair. I had no problems skiing, biking etc without my Acl but tore meniscus with a minor incident. Acl surgeries are fairly routine and you will be back in no time. If it were me, I would get it fixed and move forward.
 
#15
MarzNC there is no time limit on having surgery. I wondered whether my late diagnosis would affect my reconstruction outcome but surgeon said it makes no difference and is considered an advantage due to allowing time for muscle strength to compensate for missing ACL. So you always have this option open to you. But it sounds as though you have it covered. Will you be wearing a brace when you ski?
 

marzNC

Angel Diva
#16
My best friend's mom, who is 15 years older than you, has lead an active life – including skiing – without an ACL for....I dunno the last 20 years? She's also stubborn, so maybe that's a factor, too. :becky: I don't know what her specific experience is, but I do know that she has always been out there hiking in the Adirondaks, White Mountains, skiing (although not super aggressively), etc., with a prescription brace. I'm not sure what regular exercise she gets aside from that. I know she goes to Silver/Sassy Sneakers at the Y. :smile: She's recently dialed things back for health reasons unrelated to the knee. I can find out more details if you're interested.
Thanks for the story. I'd be curious to know if she had any issues with her other knee. Also what level of damage there was to her MCL and meniscus.
 

marzNC

Angel Diva
#17
MarzNC there is no time limit on having surgery. I wondered whether my late diagnosis would affect my reconstruction outcome but surgeon said it makes no difference and is considered an advantage due to allowing time for muscle strength to compensate for missing ACL. So you always have this option open to you. But it sounds as though you have it covered. Will you be wearing a brace when you ski?
I'd read that pre-op PT was an important element for the best possible situation post-op. Since I had no swelling after Week 1, I was putting weight on the bad leg early on. Just used crutches to avoid any possibility of a fall. Wasn't doing that much walking in any case.

I told my surgeon I intend to continue skiing. We talked about a custom brace. He knows about them. I probably won't make a decision about that until after I see how things go at Massanutten. I doubt I would use one in the southeast. But might be good to have when going to a big mountain. Seems like they are $600-1000. Not sure what my insurance would cover. Then again . . . I didn't buy a new pair of skis in 2011 or 2012. :wink:
 

marzNC

Angel Diva
#18
What I've learned this week is that strength training is only one aspect of rehab after an ACL injury. The other important aspect is neuromuscular and based on proprioception. I'd never heard of that before. It turns out that the reason a human can do complex movements like walking is that all muscles, tendons, ligaments have special cells called proprioceptors that are constantly sending info to the brain. That's how the brain knows where various body parts are in space and in relation to other body parts. The most obvious indication of the loss of proprioceptors when an ACL is ruptured is how hard it is to stay balanced. Usually proprioception is not something that you to do consciously. The balance boards, wobble boards, and mini-tramps used for ACL rehab are for improving proprioception. Required post-op too since a graft doesn't send signals like the original ACL did.

Some of my PT exercises make a lot more sense know that I know about proprioception. Never thought that I would be using my experience as a biostatistician who worked for 15 years in clinical trials would come in handy for personal research. Turns out that randomized clinical trials related to ACL injury treatment are being done in Europe and elsewhere. With 100,000 ACL surgeries annually in the U.S. alone, it's the most common orthopedic surgery. Pretty clear that the sports medicine community has changed their approach to the ACL in the last 10-20 years.

This was one of the first useful articles I found. Most were from Europe or Australia.

http://www.defence.gov.au/news/raafnews/editions/4718/health/story01.htm

There was a clinical trial done in Norway a few years ago comparing strength training only to neuromuscular training only for post-op ACL rehab. It was published in the American Journal of Sports Medicine. The conclusion was that both should be used based on the results: "There were no significant differences between the NE [neuromuscular] and SE [strength] programs 1 and 2 years after ACL reconstruction for the primary outcome measurement (Cincinnati knee score). There were significantly improved knee function (global function) and reduced pain during activity for the NE group, compared with the SE group, and significantly improved hamstring muscle strength for the SE group, compared with the NE group, 2 years after ACL reconstruction."
 

vickie

Ski Diva Extraordinaire
#19
My sports medicine doctor said that skiing is the one activity in which braces have been proven to be helpful. Even though I still have an ACL, he said I was absolutely to use my brace for skiing. (Unfortunately, neither of us was thinking about the impracticalities of the particular brace I had ... hip-to-ankle ... no can do with ski boots!)

I think he recommends I wear a brace to keep bad things from happening if I'm involved in any kind of fall or accident. In my fall last year, the ortho believes my lower leg drove forward too far, allowing my femur to slam down on my tibia, fracturing it. (This damaged, but did not completely rip out, the ACL.) A hinged brace should prevent that from happening again.

It was right at the end of the calendar year when I got my brace, so I got to pay the big deductible then and, sigh, will get to again for a ski-able brace. Not the enjoyable kind of ski shopping, but necessary.

Regrettably, I say ... Welcome to the Club
 
#20
MarzNC interesting article you posted from the RAAF on proprioception. My post ACL rehab followed this line of thought by focussing on controlled strength ( machines first then progressing through to free weights), clinical pilates (ROM first then propioception) and lots of cardio (recumbent bike then summit trainer, then running). I bought a BOSU ball so I could do squats, single legged squats, jumps on and off BOSU frrom all directions and lunges to challenge propioception development (exercises done with hand weights and eyes sometimes closed). I love the BOSU btw... It's really awesome for this sort of work. It took 6 months before I felt I built up/achieved good balance and small motor control in the knee post op.

Vickie good luck with skiing using your hinged brace. What brand did you buy?
 

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