Learning to be a coper without an ACL

[skibum4ever]

DH catches me limping sometimes too, just a habit from years of having a bad knee and then a new healing knee.

After I had my TKR, the surgeon told me that when he opened up my knee, I didn't have an ACL. I tore it in 1980 skiing in Sun Valley and I guess it degenerated over the years. That area of my knee ached for years, before being supplanted by the greater ache of my tibia fracture repair and the increasing arthritis.

I was surprised that I'd been skiing, maybe for years, without an ACL. This may have contributed to the arthritis that eventually led me to the TKR in June.

Sounds like you're progressing well. Watch out for those uneven surfaces.

 

[marzNC]

After I had my TKR, the surgeon told me that when he opened up my knee, I didn't have an ACL. I tore it in 1980 skiing in Sun Valley and I guess it degenerated over the years. That area of my knee ached for years, before being supplanted by the greater ache of my tibia fracture repair and the increasing arthritis.

I was surprised that I'd been skiing, maybe for years, without an ACL. This may have contributed to the arthritis that eventually led me to the TKR in June.

Sounds like you're progressing well. Watch out for those uneven surfaces.

Spent some time on an uneven surface yesterday. Used a soft velcro brace with embedded metal supports. It was Family Night at my indoor climbing club. Walking around the mat floor of the climbing gym is a great balance exercise. My daughter and I met a couple other families. I could belay the kids, especially since most of them are beginners who don't climb very high before wanting a ride down. So all the neuromuscular exercises, aka balance, are making a difference.

I'm lucky that there is no pain unless I'm pushing against the MCL. Even that is decreasing steadily. While not having an ACL can be a contributing factor to early onset arthritis, it also seems to depend on how the person handles the knee and related fitness and what sports they continue to do. Those who choose to have ACL reconstruction surgery seem to be a similar risk of early arthritis.

Have come across many stories of people who ski at a high level without an ACL. Certainly be more than happy if I could ski the runs you did at Squaw during Diva Week a few years ago.

Has become clear that getting a functional brace for skiing is worthwhile. The custom lightweight aluminum models sound like they are reasonably comfortable. There are models designed for petite women, which makes sense given the increasing numbers of women who are injuring their ACL in general. Especially true for young female soccer players.

 

[vickie]

Early in my recovery, the PT mentioned "so you don't have a permanent limp". Mentally, I gasped. It never occurred to me that a tibia fracture could result in that. Over the course of my rehab, I consciously did a number of things:

• shorten the stride of my left leg to match that of my right (affected) leg -- I watched the lines on tile floor or sidewalks to gauge how well I was doing;
• slow down my pace so my left leg moved as slowly as my right leg -- counting "1....2....1....2...." as I walked;
• rolling heel-to-toe as I walked;
• keeping my upper body fairly stable instead of swaying side to side.

It was interesting to observe how my body wanted to protect the once-injured limb. Also interesting to have to turn something as natural as walking into a totally conscious activity.

 

[marzNC]

It was interesting to observe how my body wanted to protect the once-injured limb. Also interesting to have to turn something as natural as walking into a totally conscious activity.

Exactly how I feel!

Early on, my PT said something about heel-to-toe and it sounded like a completely new idea. He wanted me to continue using the cane so that I would have the confidence to walk properly. I would use the cane when going out in July. Now sometimes I watch how other people walk. Never paid attention before.

My count for walking is 1-2-3-4. Sometimes slow and sometimes faster.

 

[litterbug]

It can seem normal to move side-to-side while walking, but it certainly isn't 'normal' for our joints and backs. Just like it can seem normal to lean a little forward or slouch and collapse the shoulders.

Every PT I've had (every good one, at least) has urged me to 'strut my stuff', meaning to think of sticking my chest out, which solves or improves all my neck and upper back troubles. Decades of walking with my shoulders collapsed and slumped make me feel like good posture means sticking my tits in people's faces, but it's worth the lack of pain. And swaying side to side means not moving the pelvis, which messes up the knees and lower back. I know I've gotten sloppy again because I keep catching myself slouching or limping from ancient injuries, and I'm positive that'll be one of our PT goals.

ETA: Yes, marzNC, I said I wouldn't post until I'm done with work, but I stopped for a lunch break and broke my promise.

 

[Anna]

I know I am coming into this thread late.....
I did my knee in 2003, I was 29. Within a week I had a full diagnosis:
Pratically torn MCL, dislocated patella, torn lateral meniscus and a totally ruptured ACL.
Playing netball. came down from a GREAT flying intercept, passing the ball off in mid-air before landing.... when I landed, my right lower leg bent outwards sideways from my knee.
Having seen my sister's non-recovery ((and granted I think her meniscus was WAY WAY WAY more damaged than mine plus she was stupid and insisted on walking through Switzerland on it)) from rushed physio and then later ACL reconstruction, I was determined to take it slowly and perfectly and avoid surgery at all costs.
And I have. My knee has not given way once and i have no stability issues.
I believe the key to a stable yet compromised knee is muscle and tendon strength - keep it up
My surgeon was so supportive and the physio I was lucky enough to get specialised in sports & especially knee recovery. He was training for the Australian Olympic Cycling team at the time..... no idea who he was now - sadly....
I have not gone back to unpredictable contact sports until this year - and of course I chose ROLLER DERBY No issues! Skiing - no issues and STEP AEROBICS - no issues. But I would not go back to netball - pivoting = a no-no :(
I have been lucky. I have NO pain but I DO look after my knee. Sometimes I wear a brace whilst out skiing. Playing derby and skating I will always wear knee pads and gaskets - keeping it warm and protected
Plus, you have to be careful about the "good" knee not getting more wear than it should - you don't want to get reciprocal arthritis :(

My sister, sadly, has had a second reconstruction and will probably need a replacement in about the next 10 years :( Her knee gives way still every now and then and she has pain from the fun stuff like skating and skiing.

So, whilst for some people non-surgery is preferred, and for others it's wonderful - even if you need surgery - it doesn't always solve the issue :(

I wish my sister could ski and skate with me, however it's not to be :( C'est la vie.

 

[marzNC]

I know I am coming into this thread late.....
I did my knee in 2003, I was 29. Within a week I had a full diagnosis:
Pratically torn MCL, dislocated patella, torn lateral meniscus and a totally ruptured ACL.
. . .
, I was determined to take it slowly and perfectly and avoid surgery at all costs.
And I have. My knee has not given way once and i have no stability issues.
I believe the key to a stable yet compromised knee is muscle and tendon strength - keep it up

Thanks so much for your story! I've found quite a few posts about those who ski at a high level with no ACL, but usually they are people who messed up their knee before ACL reconstruction was a relatively common surgery. Some didn't find out until much later that the ACL was gone completely. One post mentioned two PSIA Level III instructors who don't have ACLs. Also found an article about a young woman who played college basketball after using PT only to rehab after losing an ACL.

Definitely seems more common to take the conservative route in the UK. This webpage titled "Physiotheraphy Treatment of ACL Injuries that don't have Surgery" is by a man who works in Manchester, UK. Mentions that testing a patient's proprioceptive ability can be a good way to gauge whether or not they will be a successful coper. Said that there are folks who play rugby and "football" (soccer) after rehabbing an ACL-deficient knee.

https://www.physioroom.com/experts/expertupdate/interview_herrington_acl_injuries_1.php

I really like my PT. That definitely makes a big difference. Today he talked about the progression ultimately leading to working on cutting or pivoting movements, so I think that means he's decided I am a "coper." My surgeon is also supportive of seeing how far I can go first. We will talk more about a functional brace for skiing when I see him again in a couple weeks.

 

[abc]

usually they are people who messed up their knee before ACL reconstruction was a relatively common surgery

That's a mixed bag. It seems the surgery has gained popularity. But is that due to improved method leading to better result? Or due to better "marketing" of the surgury? We all know there're many areas of over-medication, aka, unneccesary surgury.

On the other hand, if we assume for a moment, the surgeries ARE getting better success rate. You might want to ask, how will this ACL deficient knee do when you're in your 70+ and starting to lose muscle strength?

 

[marzNC]

I've found quite a few posts about those who ski at a high level with no ACL, but usually they are people who messed up their knee before ACL reconstruction was a relatively common surgery. Some didn't find out until much later that the ACL was gone completely.

To clarify . . . there are undoubtedly many older people who ski with no ACL as well as others who enjoy an active lifestyle with no ACL, however there are few such "success" stories posted on online forums. Many older (>50) people who rupture an ACL in the UK do not have surgery because their medical system won't cover the cost. Looking around UK-based forums I've learned quite a bit. A woman who is active on KNEEguru.com lost her ACL while horseback riding at age 67 a few years ago. She is doing just fine and continuing to do everything with horses that she was doing before.

There are increasing numbers of studies reported in the medical journals related to ACL injuries from the last 10-15 years, including those directly related to improving proprioception as an important factor for a good recovery. Evidence of the importance of neuromuscular exercises to improve balance and the ability to react to sudden changes seems to have changed the way PT is done for ACL-deficient patients, whether or not they have ACLr surgery. Several programs have been developed specifically for preventing ACL injuries for girls and young women participating in sports like soccer, basketball, or volleyball. It seems female anatomy is more prone to ACL injury than male anatomy. Plus of course there are more girls and women doing sports that are high-risk for knee injuries than a generation ago.

 

[Pequenita]

It seems female anatomy is more prone to ACL injury than male anatomy.

Yes. Also, for some reason, when women land from jumping, the quads and hamstrings for some reason don't always fire at the same time. And then add in there regular hormonal fluctuations that affect the laxity of ligaments.

Marz - I sent via FB messenger a note about my friend's mom. Did you receive it?

 

[altagirl]

That's a mixed bag. It seems the surgery has gained popularity. But is that due to improved method leading to better result? Or due to better "marketing" of the surgury? We all know there're many areas of over-medication, aka, unneccesary surgury.

On the other hand, if we assume for a moment, the surgeries ARE getting better success rate. You might want to ask, how will this ACL deficient knee do when you're in your 70+ and starting to lose muscle strength?

Technically both of my ACL's are deficient right now. Last time I saw my ortho he said both repairs have stretched enough that they should both be re-done. I've had enough though and am not convinced of the benefit for me personally. That's just for me though. I'm not seeing how the techniques have actually improved since I've had mine done or any reason to believe that if I had revision surgery they would last any longer or do any better than they did before. Plus, I can ski, bike, do yoga and whatever else I want in the state they are in. The knee pain that I get only arises if I skip yoga for more than a few days, so as far as I'm concerned, there is no reason whatsoever to bother with more surgery at this point.

I know some of the knee surgeries I had seemed like I definitely needed them at the time. But I definitely don't buy into having it just because it's common or even because your surgeon recommends it. It's what they do, not to mention how they make their money, so of course they recommend it. So my personal recommendation at this point is to figure it out for yourself. See how you feel doing things with your knee the way it is, do your own research, talk to your ortho and physical therapists and figure out what makes sense for you. If you feel that you are tearing up your knees further by not having an ACL repaired, then it makes sense to do it. But also realize that the surgery itself is not without side effects, and then you have things like muscle atrophy to deal with. I've had surgeries where the atrophy came and went no problem, but one where they kept me on crutches for 6 weeks due to a meniscus repair where it took until I injured the other knee before my legs evened out again. And I was rehabbing hard, lifting serious weights, you name it. There are people who never recover from that muscle atrophy. Some people develop a lot of excess scar tissue or even infections... there are risks either way and it's at least something to consider, just like the risks of not having the surgery.

 

[marzNC]

Yes. Also, for some reason, when women land from jumping, the quads and hamstrings for some reason don't always fire at the same time. And then add in there regular hormonal fluctuations that affect the laxity of ligaments.

Marz - I sent via FB messenger a note about my friend's mom. Did you receive it?

Got the FB message. Haven't gotten on there for a while. Thanks.

Now it makes sense that the protocols developed for ACL injury prevention for females emphasize jumping, both as high as possible and laterally. One exercise is to do 1-leg jumps over a cone, while making sure the relationship between the knee and the front of the foot is correct.

 

[marzNC]

. . . So my personal recommendation at this point is to figure it out for yourself. See how you feel doing things with your knee the way it is, do your own research, talk to your ortho and physical therapists and figure out what makes sense for you. . . .

Makes perfect sense to me!

Reading posts on KNEEguru.com gives plenty of insight into the potential downsides to ACLr surgery. Always have to keep in mind that folks who breeze through with no special issues either never post or stop soon after their rehab is over. The stories that are really unnerving are the cases where the holes were drilled in the wrong place, which means a revision is required relatively soon after the first ACLr.

 

[Pequenita]

AG,

 

[marzNC]

Stray observations about PT exercises . . .

* for ROM, it's good to do heel slides and chair flexing as often as possible
* doing single leg exercises for the other leg becomes more important once enough balance and strength to stand steadily on the bad leg, especially when ankle weights come into play
* recumbent stationary bike on a daily basis is really good for ROM and strength training, quick and easy for warm up before general PT exercises
* well worth investing in a Bosu Ball for home use since improving proprioceptive abilities goes quickly when doing balance exercises as often as possible
* having stairs in the house makes re-training for going up and down stairs go quicker . . . lots of incentive and opportunity to practice

 

[marzNC]

One thing for sure, ACL injuries are very common. Doing a search on "ACL injury sportname" has turned up some interesting stories and links. Lots of people continue to be active with no ACL. So far I've looked at skiing, rock climbing, tennis, golf, ice skating, and horseback riding. Not bothering with the most common sports related to ACL injuries, which are soccer, basketball, volleyball, and football. Interestingly, field hockey is not a sport where ACL injuries are commonplace.

Found a book that should probably be required reading for all parents of girls playing sports that are high risk for ACL injury. "Warrior Girls" explains why there are increasing numbers of ACL issues. More importantly, there is discussion of what can be done to prevent ACL injuries in girls and women.

https://www.amazon.com/Warrior-Girls-Protecting-Daughters-Epidemic/dp/0743297555

 

[marzNC]

Learned a lot about what's possible in the last few days. I was up in the NY Adirondack mountains. Did a lot of walking around on grass and gravel, on slopes going up and going down, even a couple short hikes that included some pretty steep sections. After half a day of re-training on grass, that wasn't an issue at all. Never felt any instability, even the times I caught my foot on something or encountered an unexpected dip. Walked around in the dark during the evening without slowing down much. So my proprioception is clearly much improved. After the hikes, I was sore. But I was sore evenly, meaning my good leg and my bad leg had been working equally hard.

Not bad for Week 12. I think the MCL strain is completely healed. The meniscus is still healing. The morning stiffness is a lot less. I get out of bed without having to work on the knee before walking anywhere. ROM seems better too. Will get an official measurement at PT in a couple days.

 

[marzNC]

Been looking around for info about meniscus tears lately. Found a good website that included diagrams of common types. The Stone Clinic is in San Francisco.

https://www.stoneclinic.com/meniscus-tear

Even more interesting is learning that as more is learned about the function of the meniscus, there seems to be an inclination to remove as little of it as possible if some sort of surgery is needed because the tear does not heal, need help healing, or pieces that cause problems need to be removed.

From the Stone Clinic:
"Once thought of as a needless remnant of tissue in the knee joint, the torn meniscus was frequently removed by surgery. Over the past several years, it has become clear that the meniscus plays a crucial role in joint stability, lubrication, and force transmission. Under a weightbearing load, the meniscus maintains the balanced position of the femur on the tibia and distributes the compressive forces by increasing the surface contact area thereby decreasing the average stress two to three times. The surface stress becomes smaller, the load bearing area wider, the compliance higher, and the stiffness of the joint lower with the menisci in place. Additionally, the menisci interact with the joint fluid to produce a coefficient of friction that is five times as slick as ice-on-ice."

 

[vickie]

What a great Week 12 report, Marz ... Congratulations! All of that hard work is paying off. I think yours is the official report. In a few days, you'll get confirmation that the PT sees it also.

 

[ScottishGirlie]

Great news marzNC!

Sounds like you did brilliantly on your trip north!