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Learning to be a coper without an ACL

marzNC

Angel Diva
For those with less collateral damage due to an ACL injury who are seriously considering becoming a coper, I suggest reading/viewing what a physical therapist in the Cleveland Clinic Sports Medicine said recently about the topic.

ACL Tear May Not Require Surgery (Video)
https://health.clevelandclinic.org/2013/05/acl-tear-may-not-require-surgery-video/

A source referenced by the Cleveland Clinic is a summary of the BMJ article published in January 2013 by Richard Frobell in Sweden. Prof. Frobell is continuing to research the long term impact of ACL injury on knee health, with or without ACLr surgery. Many people continue to believe that ACLr surgery decreases the risk of OA, but that is not necessarily the case.

Ultimately, your ortho surgeon is the best source of advice for your situation.

My on-going thread as I continue to enjoy skiing as a coper is here.
 

marzNC

Angel Diva
Recently heard of a long time coper who didn't know for 10 years that he was missing an ACL. Has been skiing without one for 20 years. Also met a woman at Alta who has been skiing for 20 years without an ACL. Both are active in other sports as well.

Having spent more time on ski conditioning as well as high level lessons the couple seasons, I'm skiing much harder terrain than before injury. Just returned from Utah where I skied 13 days straight, mostly at Alta.

My on-going thread as I continue to enjoy skiing as a coper is here.
 

Colleen

Diva in Training
Hi there. Just wanted to let you know your blog has been so inspiring to me. I lost my ACL on a simple jump skiing 1 year ago. Back skiing this year using a brace but no surgery. Double black runs & all.
I agree with you. Surgery is not always the answer. There are 10% of people that manage. We are called ACL copers. Even with surgery the risk of osteoarthritis is 3x the normal population. Surgery can't completely return a normal gait to a person.
Happy to be blessed to be a coper. Have done a ton of physio & continue to work hard on the weights but as a coper we can & do ski, run, wall climb, backpack..Basically can do all things as before.
Thanks so much for your blog. It sure gave me hope when I didn't know what to expect.
 

MaineSkiLady

Angel Diva
Even with surgery the risk of osteoarthritis is 3x the normal population. Surgery can't completely return a normal gait to a person.
Sources/links on this?
I will beg to differ, based on what I have seen.
 

altagirl

Moderator
Staff member
Sources/links on this?
I will beg to differ, based on what I have seen.
My surgeon told me something similar. I don't remember the exact stat, but it was something to the effect of your rate of arthritis being drastically higher even with a successful surgery. Now in my case I skied on it for months but eventually couldn't even walk around corners about my knee giving out so I definitely needed that first ACL surgery. it does depend on the individual variances of the knee joint.
 

Gloria

Ski Diva Extraordinaire
Sources/links on this?
I will beg to differ, based on what I have seen.
Lots of stuff going on in this realm. They are finding that the higher rates of arthritis are due to the fact the new ACL is attached at a steeper angle and often dissimiliar to the original and does not offer the support they once believed it did. There is currently work underway to try and figure out how to match better the patients original tendon and reattach at same location.
 

Colleen

Diva in Training
Source I will quote is Braden Fleming - researcher at Brown University. Article link is:

https://onlinelibrary.wiley.com/doi/10.1002/jor.22420/abstract;jsessionid=5B71AB3B83B13A0403FBB6460D4F7003.f01t03
Quote:
A recent prospective cohort study suggests that 62% of ACL reconstructed patients with an isolated ACL injury presented with radiographic evidence of post-traumatic osteoarthritis 10–15 years post-surgery.[5]

Another interesting read on ACL Coper is follow Lynn Snyder-Mackler. Her sub specialty in her research is following those who are able to cope with ACL reconstructive surgery.

I do agree the rate of osteoarthritis is better with the surgery. When I attended a lecture given by Braden Fleming he stated the stats indicate 5x the rate if no surgery but it only improves to 3.62x the rate of a normal population if you under go surgery. Thus surgery or no surgery, the case of osteoarthritis is greater.

My surgeon did say that is compared to the normal population. The normal population has a higher BMI and is not active. Advice to me is to stay active, stay slim and don't take up smoking.
Hope this helps.
 

marzNC

Angel Diva
Quote:
A recent prospective cohort study suggests that 62% of ACL reconstructed patients with an isolated ACL injury presented with radiographic evidence of post-traumatic osteoarthritis 10–15 years post-surgery.[5]
The actual study report is not by Fleming but is a reference with the title "Knee Function and Prevalence of Knee Osteoarthritis After Anterior Cruciate Ligament Reconstruction: A Prospective Study With 10 to 15 Years of Follow-up" by researchers in Scandinvia. They probably used the database that has been kept for all ALC injuries in those countries.

From the Abstract:
"Conclusion: An overall improvement in knee function outcomes was detected from 6 months to 10 to 15 years after ACL reconstruction for both those with isolated and combined ACL injury, but significantly higher prevalence of radiographic knee osteoarthritis was found for those with combined injuries."

The key point is the mention of "combined injuries." The type of collateral damage that did or did not happen at the time of ACL injury makes a great deal of difference in long-term outcomes, regardless of post-injury treatment. I'm not a medical professional, but I am a Ph.D. biostatistician and always make note of the study population when reading research articles.
 

marzNC

Angel Diva
Hi there. Just wanted to let you know your blog has been so inspiring to me. I lost my ACL on a simple jump skiing 1 year ago. Back skiing this year using a brace but no surgery. Double black runs & all.
I agree with you. Surgery is not always the answer. There are 10% of people that manage. We are called ACL copers. Even with surgery the risk of osteoarthritis is 3x the normal population. Surgery can't completely return a normal gait to a person.
Happy to be blessed to be a coper. Have done a ton of physio & continue to work hard on the weights but as a coper we can & do ski, run, wall climb, backpack..Basically can do all things as before.
Thanks so much for your blog. It sure gave me hope when I didn't know what to expect.
Always good to hear from other copers.

Remember that every situation is unique, so the experiences of others or relevant research can help someone make more informed decisions but cannot be generalized. Any research study will be limited by the patient population selected. For example, few studies that I read covered people in my age bracket (55-60). But I was in better shape than the average 55yo at the time of injury, so I took that into account as I considered my options. I also was lucky to find an experienced orthopedic surgeon who was not in a hurry to schedule surgery. He was a good listener. He agreed with my decision.

While there are potential disadvantages to surgery, I've never read anything about issues with gait. Assuming the patient does formal PT. I have read that a little swelling after intense activity or pain when kneeling is common after ACLr surgery.
 

MaineSkiLady

Angel Diva
DH was in that age group when he had his ACLr. He is an excellent skier but not a super-jock.

Until this point, I’ve said little on the subject or thread, it largely being an expository blog of your experience. Most of your cited research supported your decision.

None of the above-mentioned effects have occurred for DH. Even DS who had both knees with patella tendon autografts, has had no swelling or issues (although was long advised against prolonged kneeling due to the specific graft type). In fact, DH comments that his non-surgical knee is usually more “achy” after a long ski day than his surgical knee. Neither has any gait issue - nor do any of the half dozen or so others I can think of off the top of my head who have had ACLr. No swelling, either.

This isn’t to say that it’s a walk in the park - hardly. It’s a major disruption to anyone’s life, and it’s a lot of hard work. But it can have some outstanding outcomes. I’ve seen it with my family members and with others.

This is a viewpoint that has been missing on this thread.
 
Last edited:

altagirl

Moderator
Staff member
I don't think we are talking about significant gait issues here, but minor imbalances can be a big deal over time. I know when I had my first few knee surgeries, protocol was to get back full extension to match the other knee. Then it changed to only bring it back to zero because some people would get too much extension. Those differences in either direction do cause issues over time. Plus there are more subtle issues of the replacement ligaments rarely being installed at the original angle. there is a surprising amount of variation between people's joint structure. But that does help explain why people have different (or no)issues with the same surgery.
 

altagirl

Moderator
Staff member
Not to mention, some people have bodies that overreact with scar tissue. I have a friend who had a total knee replacement 2 years ago and she can't even get enough range of motion to pedal a bike. (And pain while biking was her reason for having the surgery in the first place, as she had been racing for decades. ) She has had multiple manipulations under anesthesia and no improvement and is running out of options. There are times where the surgery outcome is worse than what you started with. Yes, it's relatively rare, but it's also worth researching what it's like living without the surgery. I know many people who have had successful knee surgeries and two who are worse after than before. There are risks.
 

skithesierras

Angel Diva
Not to mention, some people have bodies that overreact with scar tissue.

I had ACL reconstruction in 1996 (really no choice, as I couldn't straighten the knee due to the ACL pieces). But for years I dealt with pain and limited ability until I finally had a Lateral Release in 2007. Finally! My knee was back to normal! A blessed 4-5 years of a normal knee again. Fast forward to 2014... scar tissue is back, and now dealing with knee pain and limited ability again. I guess I'm one of those people...
 

marzNC

Angel Diva
As I approach the third anniversary of my ACL injury (not skiing), I continue to be a successful coper. The reason I started my threads about being a coper is that most threads or blogs about ACL injuries are related to reconstruction surgery and rehab. People who are "ACL deficient" fall into three 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 and/or pain that they have problems even with daily living, which makes ACL reconstruction surgery the obvious treatment.

In my case, the collateral damage to the meniscus (2-3cm tear in red-red zone) and MCL (strain) could heal without medical intervention. Given that what I like to do does not include pivoting sports (basketball, soccer) or running, there was little reason for ACLr surgery. My research in 2012 showed that 5-10% of ACLr surgeries involve post-surgery complications of varying degree. For me, that was a factor in deciding to work on being a coper initially instead of opting to schedule surgery.

A 2015 paper in the Clinical Journal of Sport Medicine followed 330 patients who had ACLr surgery for 2 years. The mean age was 29. From the conclusion: "27% reported an adverse event due to surgery within 2 years but only 2 adverse events (0.6%) were considered major complications and 24 (7%) required a repeat surgery. This suggests that overall, ACL reconstruction surgery is generally safe and the adverse events which do occur can be treated relatively successfully."

A 2014 paper in the Journal of Athletic Training looked at many studies to consider the issues related to OA after ACLr surgery vs no surgery. The "Take Home Message [was]: There is very little evidence that an anterior cruciate ligament (ACL) reconstruction can reduce the risk of knee osteoarthritis (OA).

In short, the knowledge base about ACL injuries and how best to treat ACL-deficient patients continues to evolve. The knee is complicated. Everyone's situation is different. Regardless of what can be learned online, there is no substitute for working with experienced medical professionals.

Click here for my on-going thread as a coper who is skiing better than before injury.

 

marzNC

Angel Diva
It’s been five years since I popped off the ACL in my right knee (not skiing). Those who have followed my ongoing thread know that I am a successful coper. I took the conservative approach of exercise therapy only, no surgery. In my case, the collateral damage was a minor MCL strain and a small hole in the part of the meniscus that could heal fully without medical intervention. I was very careful the first few weeks before diagnosis, did formal physical therapy for a few months, then continued with exercises related to avoiding any other knee injury. Starting in with the 2012-13 season I usually ski 40 days or more, including 2-4 weeks at destination resorts in the U.S. Rockies. I take advantage of being retired.

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. Some sources say the groups are roughly equal, but there is a fine line between copers and adapters. I consider myself a coper but there are activities I avoid. For example, when I took my daughter and a friend to a trampoline gym, I just watched. I have not given up any physical activities that I did on a regular basis before injury.

As I mentioned in Post #1 in 2012, a paper by a couple UK doctors from 2001 classified activities by risk level for someone missing an ACL. The low risk list included cycling and swimming. Skiing is rated medium risk, along with tennis and golf, because these sports 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.

My approach the first year after injury was to improve my fitness level and skiing technique in order to continue skiing at an advanced level. I was never interested in the terrain park, hucking, or steep chutes. I am in much better shape and a much better skier than five years ago. I’m enjoying trees and bumps in ways I never expected given that I become an advanced skier after age 50. I ski at an advanced level (Level 8 of 9) but in a way that I consider medium risk. I have no knee pain, no knee swelling, no instability, and my KOOS score is about 98 (of 100). For my situation, becoming a coper was the correct choice.

The treatment approaches for how to treat ACL-deficient patients continue to evolve. The knee is complicated. Everyone's situation is different. Regardless of what can be learned online, there is no substitute for working with experienced medical professionals.

Click here for my on-going thread as a coper who is over 60.
 

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