Ligament copers - when are you ready to ski again?

[Grizzla]

Hello again ladies.
After ACL and MCL (and doubtless other) injuries to both knees in March, it appears, I hope, that I've joined the ranks of the Copers - and thanks for the reassuring threads posted on this Forum about that: it's given me a lot of hope over the past many months of sitting on the settee.
My knee surgeon in the UK told me that I can ski again "when you're strong enough" (without a brace, according to him). My physiotherapists, who have just seen me a few times and given me lots of exercises for strength and stretching, tell me the same. However, no-one will define what strong enough is! Apparently, I'm the expert, being the skier...
I've been doing all the exercises, and static cycling and now some hill walking, and in one way feel stronger now than I did before. In other ways I feel that my knees and leg muscles in general are far from ready to be attached to a pair of planks and aimed down a slippery hill, and I'm certainly not going to try it just yet. But one day, try it I must: scary as the thought is for many reasons.
So can anyone give me any indicators as to when you are ready? How did you choose when and how and where to try it again for the first time? (In the UK I can try an indoor slope, horrid as they are; else it's flying over to Europe come the next season.) Did any of you have to reach a minimum exercise tolerance or post-injury time? What tests or conditons did your doctors or physios put on you? Or is it just a case of take the plunge when you think you're ready, suck it and see and hope that you're not testing yourself to destruction?!
Thanks, all.

 

[Pequenita]

I think the challenge for you is that both legs are injured. Usually the rule of thumb is when the muscles on the injured legs are as strong as -- whether by feel or lifting the same weight, etc. -- the other leg. The physios should be checking to make sure that you're working out imbalances in the muscles, I hope! Things like, if you're doing squats, the knees aren't buckling inward...

 

[Grizzla]

Yes - both knees took good damage. My left one was/is more painful and irritable (I think it took the brunt of my unintended aerial stunt's landing) and is taking a mite longer to recover fully, with still a little reluctance to do an absolute flat extension, especially when 'stiff'. The right, however, is much more sensitive to landing (e.g. on hops and jumps) and seems to have less power and enthusiasm to hop or jump, plus can be more pained/irritable on the outer side. But they're starting to get to about the same point now - so both of them then have little competitions to see which one is going to be weaker or stronger, balance better or worse, get more achy tired muscles... And, boy, are they aching!

Physios are indeed advising 'good form' in doing squats etc, making sure knees don't go inwards (long been aware of that from my skiing!) - not so easy on single legged ones... Those You Tube vids (and one of my very muscle-bound male basketball-playing physios) make it look oh so easy.
Not been advised of any muscle imbalances as such - just told to concentrate on anything that gets quads and hams (plus I try to keep the Abs in trim when I can).

At least my bum is getting a lot firmer

 

[VickiK]

I injured my right MCL in early March 2011, was back to doing most activities by summer, and back to skiing by December of that year. I did have some trepidation at first, but skiing seemed to be ok. I wore a brace skiing at the beginning, but stopped after a few times.

Since then, I've noticed that my right leg is prone to injury. I took up running for short time in 2013/14, and quit due to a foot injury. In January 2016 I over-did a workout (doing a 'skater' move with a TRX device too aggressively), then a week later, went on my planned ski vacation. My knee didn't like that at all, major hurt. Ibuprofen helped, but I was freaked about so I saw a knee specialist. Thank goodness I didn't do any lasting damage, it improved by itself, it just needed some rest.

Since then I started exercising regularly and lost a little weight. If I keep that up, I think I'll be ok. I don't know if I'll ever manage single-legged squats. But age is a factor--I'm almost 60. I notice that well-cushioned shoes and a slightly padded floor are important to both my knees in general, not just because of my MCL.

 

[marzNC]

Hello again ladies.
After ACL and MCL (and doubtless other) injuries to both knees in March, it appears, I hope, that I've joined the ranks of the Copers - and thanks for the reassuring threads posted on this Forum about that: it's given me a lot of hope over the past many months of sitting on the settee.
My knee surgeon in the UK told me that I can ski again "when you're strong enough" (without a brace, according to him). My physiotherapists, who have just seen me a few times and given me lots of exercises for strength and stretching, tell me the same. However, no-one will define what strong enough is! Apparently, I'm the expert, being the skier...
I've been doing all the exercises, and static cycling and now some hill walking, and in one way feel stronger now than I did before. In other ways I feel that my knees and leg muscles in general are far from ready to be attached to a pair of planks and aimed down a slippery hill, and I'm certainly not going to try it just yet. But one day, try it I must: scary as the thought is for many reasons.
So can anyone give me any indicators as to when you are ready? How did you choose when and how and where to try it again for the first time? (In the UK I can try an indoor slope, horrid as they are; else it's flying over to Europe come the next season.) Did any of you have to reach a minimum exercise tolerance or post-injury time? What tests or conditons did your doctors or physios put on you? Or is it just a case of take the plunge when you think you're ready, suck it and see and hope that you're not testing yourself to destruction?!
Thanks, all.

Yes - both knees took good damage. My left one was/is more painful and irritable (I think it took the brunt of my unintended aerial stunt's landing) and is taking a mite longer to recover fully, with still a little reluctance to do an absolute flat extension, especially when 'stiff'. The right, however, is much more sensitive to landing (e.g. on hops and jumps) and seems to have less power and enthusiasm to hop or jump, plus can be more pained/irritable on the outer side. But they're starting to get to about the same point now - so both of them then have little competitions to see which one is going to be weaker or stronger, balance better or worse, get more achy tired muscles... And, boy, are they aching!

Physios are indeed advising 'good form' in doing squats etc, making sure knees don't go inwards (long been aware of that from my skiing!) - not so easy on single legged ones... Those You Tube vids (and one of my very muscle-bound male basketball-playing physios) make it look oh so easy.
Not been advised of any muscle imbalances as such - just told to concentrate on anything that gets quads and hams (plus I try to keep the Abs in trim when I can).

At least my bum is getting a lot firmer

Hello @Grizzla ! Sorry to hear about your injuries. Sounds like you've been working hard at rehab. You might get some ideas of easier exercises related to hamstrings and ski conditioning in my fitness blog. Note that a lot of what I do is based on using the TRX. I learn good form from my personal trainer.

https://over50skifitness.blogspot.com/search/label/knee

Did you damage both ACLs? Am I correct that you didn't have an MRI to confirm the diagnosis? Have you used KOOS to put your current status in perspective?

In my case, what hurt most was the MCL strain even though it healed without medical intervention in a couple months. My surgeon wouldn't give any sort of time estimate for how long it would take the small hole in the thick part of the meniscus to heal. From my general reading, I decided to give it 6 months. My approach was very conservative when it came to running and jumping. Avoided both for 4 months. Really didn't do much in terms of jumping exercises until about a year after injury. Although I did do a little in order to build basic muscle memory for the proper way to land a jump.

As for your question about when and how to get back on skis, everyone is going to be different depending on their personality and knee situation. My ACL rupture was in June and had nothing to do with skiing. I never had any pain once the MCL healed. I never had any instability after the first week after injury. I started skiing in Dec, which was a couple months after I finished formal physical therapy. I did a lot more ski conditioning that fall that I ever had after starting to ski more when I got my daughter started on skis. I skied at my small home mountain (1100 ft vertical, 75 acres) and used slightly shorter skis the first few times out. I opted not to get a brace. Instead I spent the money on lessons. By Feb I felt quite ready for Diva Week West at Big Sky. I wasn't worried or holding back when it came to skiing during that trip.

 

[Grizzla]

Thanks MarzNC. I've been reading your blog posts and they've been very helpful, including the links.
Yes I did try that KOOS, but it didn't seem very relevant to me as far as I could tell; my symptoms didn't really seem to fit in. I'm keeping a daily diary though, and things hopefully are getting better, slowly - although it feels sometimes like a bit backwards, or a stall.

I'm trying to work hard at the exercises, but I've reached a point right now where my body seems to be screaming for a rest, leg muscles have reached fatigue point, other mature person niggles and bodily complaints also taking their effects and tolls.
My physio OK'd me for jumping and hopping and landing fairly early, but I've never had that kind of muscle response in my legs and it's not easy, though I do a bit now and again and it's getting better. Interestingly the leg which is more painful will actually hop longer and more easily than the 'better' leg, which also had a lot more outer pain on landing. Odd.

My best measurement is just how well I can do everyday things (kneeling has been a big problem) and how well I can walk the steep hills where I live, which I used to do 3-4 times a week in all weathers and I guess was my main cardio and leg exercise. Up is fine. Downill is still a bit 'iffy'. I think probably that's going to be one measure of when I'm strong enough and have enoug stamina: when I can do my full old distances repeatedly and not be worried or troubled about a steep rough descent and not need a walking pole to assist me.

I did have an MRI and x-rays out in resort shortly after I had the injuries (yes, on both legs - I was hit by another fast skier, took air, somersaulted and landed like a frog doing breaststroke with very painful inner knees. Got to my feet eventually, buckled at the first go, and there were 2 loud pops, so someting definitely went on 1 leg at least). According to the MRI it was a complete tear of both ACLs and an unspecified rupture ("which will heal") on both MCLs. There was blood in the joints and a lot of general pain, tenderness and swelling for quite a few weeks and then it's slowly subsided, but like you the MCL (and LCL it seems to me) has been the pain and problem bit. I suspect some bone bruising as well, but that's never formally been remarked on. I seemed to have stability and balance from the start, fortunately - though maybe that was aided by the swelling!
My UK doctors and physios have been pleased with how well and quickly the initial laxity has tightened back up, so won't confirm what they think has really happened - if the MRIs gave a false reding or if there's been a partial rehealing or reattachment somewhere, if it was somehow a huge stretch which has re-tightened or...? My surgeon was admitting to scratcing his head when comparing the MRIs to what my legs felt like, but wasn't surprised at the recovery eiter. Make of that what you will...

It's taken a lot of time to get final extension (still not easy, definitely stiff and not right on 1 leg) and things like kneeling back, not because of the knee per se but becuase the muscles seem to get very tight, feel blocked or whatever. No-one knows exactly what this is or why. It's not swelling at all. I put it down to Unhappy Irritable Knee Syndrome...

I'm glad that you got back at 6 months. In some ways I feel ready now, strength-wise. Maybe... I feel in some exercises a lot stronger than I was before, although that's isolated muscles as opposed to the whole leg and body working together as it does in sking. But in other ways I know that I am far from it, the pain on the outer and inner areas is still there, there's still some random weird catching and not-right-knee feelings, and my muscles just have no stamina (or, rather, they're OK short-term but then give up and demand a long holiday to recover after every bit of training). I cannot believe how much stamina I've lost, even though I've been trying to train up the strength from day 1.

Like you, I'm going to go back to using my shorter slalom-type skis; happier on shorter ones anyway to tell the truth. (Not a speed demon!) I've got some race SLs and want to see what it'll be like to use them on piste (though I bought them to play indoors in the UK), and also to find out whether edging, carving, pivoting, skidding or what will be most easy and most difficult, whetehr I should use wider or narrower waisted skis etc.

I also snowboard, though at a lesser ability, and am keen to see how that compares in ease, strain, strength etc. Shame that I don't live near enough the snow to get a full season; a few weeks a year is normal, thog I was planning for a lot more, loads of coaching adn training, upping it to several months a year maybe, going out to the glaciers in summer... Hey ho...

 

[VickiK]

Hi @Grizzla , for me building overall strength through my workouts has been much slower than what I expected. Whether that's age-related or me not pushing enough, I am trusting that just doing it is the biggest positive I can do for myself. I know I am getting stronger, and I just keep doing it. I could feel it on a recent bike ride. I could climb consistently whereas before I think I would've just stopped and walked the bike. Keep at it with the hill walking - seems like an excellent whole-leg/body workout.

 

[marzNC]

Thanks MarzNC. I've been reading your blog posts and they've been very helpful, including the links.
Yes I did try that KOOS, but it didn't seem very relevant to me as far as I could tell; my symptoms didn't really seem to fit in. I'm keeping a daily diary though, and things hopefully are getting better, slowly - although it feels sometimes like a bit backwards, or a stall.

Glad my posts are helpful.

As for KOOS, you may be overthinking the responses a bit. Best to simply go with your first response and see what the total score ends up. Then can change a few responses to get an idea of the range for the score. For instance, when I first starting using KOOS I wasn't doing any jumping so couldn't really answer that question. I picked one of the middle answers, then the two extremes.

What I like about KOOS is that most of the questions are related to daily living, like the level of pain going up and down stairs. Doing it about once a month in the first six months was helpful to me. Once I got over 90, I would only check every 2-3 months for the next year. Essentially have been stable around 97 after that.

 

[marzNC]

Like you, I'm going to go back to using my shorter slalom-type skis; happier on shorter ones anyway to tell the truth. (Not a speed demon!) I've got some race SLs and want to see what it'll be like to use them on piste (though I bought them to play indoors in the UK), and also to find out whether edging, carving, pivoting, skidding or what will be most easy and most difficult, whetehr I should use wider or narrower waisted skis etc.

I also snowboard, though at a lesser ability, and am keen to see how that compares in ease, strain, strength etc. Shame that I don't live near enough the snow to get a full season; a few weeks a year is normal, thog I was planning for a lot more, loads of coaching adn training, upping it to several months a year maybe, going out to the glaciers in summer... Hey ho...

In general, narrower skis is going to be easier. Working with an instructor is the best way to find out how to improve technique so that you are using less muscle and letting the skis turn as opposed to working to make them turn.

Be interest to hear what you find in terms of snowboarding. Have read mixed comments when someone is wondering whether skiiing or boarding is easier on the knees.

Have you ever seen the SkiA Sweetspot videos? I got it for balance training and found it useful for building confidence for putting skis on edge. Mostly because you can practice with the Sweetspot trainers indoors while wearing ski boots. Getting balance sorted out by re-training for better proprioception is in some ways more important than strength training after a certain point. When an ACL ruptures, all the proprioceptors in it are gone. The body needs to recalibrate and that takes a while.

 

[santacruz skier]

I googled the SkiA Sweetspot trainer and see that @ski diva posted in her blog about it.

https://www.theskidiva.com/gear-review-skia-sweetspot-ski-trainer/

 

[Grizzla]

Hi @Grizzla , for me building overall strength through my workouts has been much slower than what I expected. Whether that's age-related or me not pushing enough, I am trusting that just doing it is the biggest positive I can do

Yes: my patience is bring sorely tested by my lack of instant miraculous strengthening! Worse, the exhaustion in my whole body, never mind my legs - and I would push it harder if I could, but there just seem to be limits which I have to work within. Definitely not what I was when younger...

marzNC - I'll have a look at that SweetSpot thing. I have a wobbleboard, though it seems to cause a fair bit of outer & inner pain still (guess that something there's still being irritated) and have being doing a lot of balance stuff generally. Fortunately, my proprioception doesn't seem to have been affected.

I intend to get lots of instruction one I know I can physically ski again. Problem is, it really means a trip abroad (the indoor slopes are not worth it and the instruction terribly expensive), and finding a foreign instructor who speaks English well enough and can specialise in what I need. Not had a huge amount of impressive instruction abroad so far... If we have the snow without winds, I hope to be able to get to Scotland in 2018, which I like.

 

[marzNC]

marzNC - I'll have a look at that SweetSpot thing. I have a wobbleboard, though it seems to cause a fair bit of outer & inner pain still (guess that something there's still being irritated) and have being doing a lot of balance stuff generally. Fortunately, my proprioception doesn't seem to have been affected.

Since you're most likely dealing with a ruptured and/or torn ACL, you have lost proprioceptors. That said, your body has probably already compensated. For me, it took a week to get over the initial loss. My balance was very bad the first few days. But after a couple of weeks, I felt pretty stable. Only kept using two crutches because I was traveling in China with family and was being very cautious. Even so, I insisted on going up and down stairs in a Beijing train station to get to the metro instead of waiting in a long line for a taxi. Had figured out how to use crutches on stairs by then.

Everyone can improve their proprioception. But pushing too hard when there is pain may not be worth it. I still do a variation of the following balance exercises as often as possible during the inevitable times when waiting on line or whatever. What I found is that doing a little, even 5 min, every day made a difference in the long run.

Have you read the conclusions of Dr. Marx's study about HSS patients who had ACL injuries while skiing?

https://www.hss.edu/newsroom_skiers-acl-tear-without-surgery.asp

Remember every knee injury is different. There are situations when reconstruction surgery make sense and situations where people can return to the slopes as successful copers.

 

[marzNC]

I intend to get lots of instruction one I know I can physically ski again. Problem is, it really means a trip abroad (the indoor slopes are not worth it and the instruction terribly expensive), and finding a foreign instructor who speaks English well enough and can specialise in what I need. Not had a huge amount of impressive instruction abroad so far... If we have the snow without winds, I hope to be able to get to Scotland in 2018, which I like.

Understand the cost issue for instruction at an indoor slope. However, might be worth the investment initially when compared to the cost of a ski trip.

I didn't feel I needed special instruction. I was lucky that at my small mountain (northern VA, 75 acres, 1100 ft vertical) I could take advantage of the 2-hour clinics offered to skiers over 50. There was more than enough terrain to learn and practice good fundamentals. My initial practice was on a blue slope that takes at most 5 min for an intermediate to finish. (Would be a green at a big mountain.) The instructors I've worked with since my knee rehab at Massanutten or at destination ski resorts were generally PSIA Level 3 instructors with 20+ years of experience.

 

[Grizzla]

Yes, the cost per se is worth it: if (and that's a big if) the quality of instruction is worth it too. Past experience indoors says that it's not; and it's not really possible to get what I ideally want out from an indoor session. Better than nothing, maybe - but indoors is soooooooo short: you spend more time on the low drag lift than the slope! (I used to train there quite a lot; OK for slalom short turns, but that's about it.) Also very busy with criss-crossing idiots and learners (not great when I already got taken out by a blindsider ; nor when I'm trying not to make sudden sharp avoidance stops or turns at the moment.)

I'm very jealous of what you have on your local hill. Sounds lovely. A nice short (ish) easy run to get confidence back on and to try out back-to-basic technicals. It's what I need: and then to pull in an instructor to make tings better. Your experienced instructors sound great too.
It's what I'm basically expecting (and have previously experienced) in Scotland; a nice quiet and fairly large confidence-inspiring area - just that it's still a very long drive up there even if the conditions are useable (2016-17 they hardly had any snow at all!) and very hard to plan a trip more than a day in advance (no good for my hubby, who'll come with and drive).
Sadly, here in the UK, we're pretty stuck unless you actually live in N. Scotland or can fly out easily to Europe. My preference for slopes to try again on are probably in Finland, oddly enough. Nice short-ish and usually empty pistes - but the weather there can be very bad, too, and it's very expensive, and the package oeprators only go for January and February.

I do definitely want instruction now - I really want to go right back to basics and make sure that I really understand every bit of technical skiing technique. Plus, I really want to get myself into a situation where I can feel confident skiing any grade of piste, whatever the conditions (soft, slush, crud or hardpack and ice) under total and utter control, confident, no effort, no fear... That too much to ask?
Seriously, having been collided into and hurt as a result, I just want to be able to get away from anything remotely filled with any other skiers or boaders. OK, impossible - but the better I can ski, the happier I'll be taking myself to play on whatever's quieter and hopefully only wit better, more responsible skiers on, rather than the more crowded, popular ones. And if I can't do that then I want to be the best, most in-control skier on there so that I can feel confident to get out of their way. (With rear view mirrors attached, obviously ) I don't think that I'm going to feel confident skiing at all, especially if I have a bad leg or two, unless I also feel very very confident in my own abilities. Not that I was too bad before, I reckon: but I can get a good deal better. I just need to prove to myself first that it is physically possible and safe to ski, then I can go and learn how to do it properly.
There's a lot of week courses which are run out in Europe, some in the UK (though mainly indoors) and they all sound good. A lot run throuh the spring or summer, so that's 2018 I hope. Again, though, it's just getting strong and fit and confident enough first.

 

[marzNC]

@Grizzla : Can certainly understand not wanting to deal with a crowded slope, whether indoors or on a mountain. Since I'm retired, it's relatively easy for me to ski midweek. My "home mountain" is a 4-hour drive but I can stay for at least 2-3 nights when I go, which is obviously a luxury.

You have obviously thought things through. What I found is that I ended up in much better shape in general because I knew that would make it more likely I would be able to not only keep skiing, but to actually become a better skier. The surprise was how much a stronger core made a difference on and off the slopes. That was a side benefit of learning to use the TRX with the help of my personal trainer. Agree that having the confidence and ability to ski on slopes where there aren't any beginners or even very many intermediates involves a lot less stress looking out for others.

You might research knee braces a bit. A brace cannot protect against every possible knee injury, but can be helpful in certain situations. Definitely can help with confidence for some people.

 

[Grizzla]

MarzNC - re braces. Another interesting decision for me to make.
I had firmly decided that I would get a pair of something like the Donjoy Armor or a CTi (i.e. rigid hinged) and always use them for skiing from now on, maybe for hard walking/mountaineering too. They are very expensive (£500 each give or take, and I need 2!) but it would be worth it if it stops a bad fall injury, takes some strain off the weak or missing ACL (and other ligaments?) and gives me extra confidence.
I know that a lot of UK skiers use them after ACL recon or injury, and my physios and another therapist have mentioned them, although none of them know where to get one or know any more about the subject or items (only 1 is a skier and they can't remember what make, just got it via their private surgeon, custom made - which I cannot afford!)
However, it's very difficult to get to see or try them on in the UK. No-one does DJ ones at all unless you pay a £185 'assessment' fee (!), and that's just 1 place only within any driveable reach of where I live, and they also only stock a limited amount of models. They are also more pro the CTi than Donjoy for some reason. I did find someone who fitted CTi carbon rigid braces and got to try 1 on but found that it was just a little too long in the lower leg for me and it fouled my ski boots (and I have quite enough problems getting them to fit, having narrow heels and low volume feet, so I'm not changeing them again!) Apparently the CTis don't do variable lengths like the DJ do, which is really annoying for the price. You can get custom fit ones at a really stupid price, but they only adjust the frame for your thigh, and I don't know about you but my thigh size goes up and down like a yo-yo naturally, never mind if I'm in strength training or not!
Also, more annoying and worrying still, when I asked my OS Consultant about wearing one he reacted very sharply and told me in no uncertain terms not to wear one. Not only shouldn't I need one if I got "strong enough" (back to start of thread...) but the risk of transferring injury to the upper leg, hip or back was too great. He tinks that they're very bad things. I have read a bit about this risk, and about weighing up the trade off with knee stability, and it's just another uncertainty. Aaaaaagh!

Does no-one know what people like me should do???!! Clearly, as per the reason for this thread, there is very little practical help out there for me, except for trying and risking things myself - which is getting somewhere between very worrying and very expensive (I don't have insurance to cover things like braces and the NHS won't provide them). I have done a lot of online research (well, I had the time, sitting around...) and have some medical and science training in my bacground, so I can read a lot of papers and general advice: but none of it gives anyting conclusive at all, most of it just no real help at all. Pretty much all the advice that I get from UK skiers is that I should, really must, have the ACL recon surgery, which I something that I really don't want to do if I can avoid it and don't need it (which is so far what my Consultant and physios have said - although the skiers are saying that's just because the NHS doesn't want to spend the money on me and they aren't skiers and don't understand...). It seems to me that the exercises and strength rehab are exactly the same, and that there's no absolute guarantee that I'll end up with a new ACL that'll hold for a long time or hold any better or that the knee per se will be any more resistant to further or later damage or... well, whatever. It might be better and worth it, too; but I really don't fancy the surgery, never mind the long rehab (x2) if I don't need it. But there seem to be very few people (skiers, anyway) except for you and a few others (mainly on this forum) who have waited it out or had hopefuly enough signs from the start to cross their fingers and be Copers for a good long while - or, at least, to try to be. Which again brings me round to needing to get out there at some point and try it and see how it goes...

(Feeling sorry for myself this morning as someting has upset my 'bad' leg a bit over the weekend and it's sore at the outside - though interestingly more supple and extending better and fully as well. Hopefully it's all part of the mending process. Will see what exercises it will tolerate later.)

 

[marzNC]

@Grizzla : Hang in there. You are at a most annoying stage.

MarzNC - re braces. Another interesting decision for me to make.

Sorry, can't help with braces. I suggest you start reading Knee Guru, which is a UK-based website and forum where I learned some useful stuff back in 2012. Understand about the cost. While my insurance would have covered a brace in theory, in reality the way my insurance coverage was set up the cost would've been out-of-pocket for me.

https://www.kneeguru.co.uk/KNEEtalk/index.php

But there seem to be very few people (skiers, anyway) except for you and a few others (mainly on this forum) who have waited it out or had hopefuly enough signs from the start to cross their fingers and be Copers for a good long while - or, at least, to try to be.

Actually, I discovered on EpicSki (a large international ski forum that disappeared recently) that there are far more advanced skiers who are missing an ACL than you might imagine. In some cases, they are men who ruptured an ACL and didn't know until years later because they were misdiagnosed by a family physician or didn't bother to see a doctor until much later since they had no stability or major pain issues relatively soon after injury. Also found other examples on forums for other sports such as soccer, tennis, or rock climbing. Found a story about a female ski patroller who is missing both ACLs. Needless to say, she has very strong legs (hamstrings and quads). However, most copers who are advanced skiers don't talk about their knee history. Some wear braces so there is some indication if someone skis with them. But many don't use a brace so there is no way to tell. At the same time, there are many blogs by people who have ACL reconstruction surgery. Some of those people wear a brace, while others don't.

When it comes to deciding about ACLr surgery, my sense is that Dr. Marx and his colleagues at HSS in NYC are in the minority in suggesting that a skier wait a few months before even beginning to consider whether or not surgery is the best option for their situation.

The knee is a complex structure. Knee injuries that include a ruptured ACL vary a lot in terms of collateral damage to other ligaments and/or bone. That's part of the reason it's not easy to decide what treatment makes the most sense for a given situation. The insurance and medical system factors, which vary a great deal between countries, adds another level of complexity to any decision. Keep reading and talking to your medical professionals. Best to read studies from the last decade or so. ACL treatment is evolving constantly as the results of longer term studies come out. The good news is that there is no rush if you decide to have surgery. As you've discovered the "pre-hab" exercises are exactly what you're doing.

 

[bounceswoosh]

I had ACL reconstruction just over a year ago. Because of meniscus damage, I was going to need surgery anyway, and I was sure I wanted reconstruction.

All I want to share is - I sympathize. The fact is, after you blow out a ligament, there is no good option - only a choice among tradeoffs, all of which will in some way be less optimal than still having an intact, original ligament.

I do think it's important to find a doctor and PT who understand your passion for skiing, and understand your skiing level and the risks for different situations. For example, my likelihood of falling while taking it easy on a green, blue, or even bumps is very low. For an intermediate skier, that calculation is different.

I have been told that without reconstruction, arthritis will be worse as you age. (Arthritis after this injury is entirely expected - it's the level of arthritis.) This is not something you can determine by seeing how well you can cope today.

But my surgery approach hasn't been smooth sailing, either.

 

[marzNC]

There is quite a bit of research trying to determine the relationship between ACLr surgery and OA as well as in comparison to living without an ACL and OA. The long term studies that run over 10 years are relatively recent. From what I've read the incidence of OA is 2-3 times higher for ACLr surgery patients compared to the normal population. But often a study excludes more complex knee injury situations so it can be difficult to make a decision based on research that doesn't necessarily apply. For instance, someone who is 70 won't find any research-based treatment recommendations for that age group.

For those who feel like reading, here are a couple references to start with.

The Relationship between Anterior Cruciate Ligament Injury and Osteoarthritis of the Knee - 2015
https://www.hindawi.com/journals/aorth/2015/928301/

Controversy continues about whether ACL surgery leads to OA - medical roundtable
https://www.healio.com/orthopedics/...ntinues-about-whether-acl-surgery-leads-to-oa

 

[bounceswoosh]

There is quite a bit of research trying to determine the relationship between ACLr surgery and OA as well as in comparison to living without an ACL and OA. The long term studies that run over 10 years are relatively recent. From what I've read the incidence of OA is 2-3 times higher for ACLr surgery patients compared to the normal population. But often a study excludes more complex knee injury situations so it can be difficult to make a decision based on research that doesn't necessarily apply. For instance, someone who is 70 won't find any research-based treatment recommendations for that age group.

For those who feel like reading, here are a couple references to start with.

The Relationship between Anterior Cruciate Ligament Injury and Osteoarthritis of the Knee - 2015
https://www.hindawi.com/journals/aorth/2015/928301/

Controversy continues about whether ACL surgery leads to OA - medical roundtable
https://www.healio.com/orthopedics/arthritis/news/print/orthopaedics-today-europe/{d7f3e367-65e1-48ff-9f83-9be3859b6793}/controversy-continues-about-whether-acl-surgery-leads-to-oa

Yeah, it's tricky. FWIW I do not consider 10 years to be long term. I'm 39 and hope to be active (to varying degrees), or at least without debilitating pain, for another 30-40 years. And due to a medical condition, I cannot take NSAIDs to alleviate OA issues (vs many people who pop it like candy - I know I did so when I could!). I ski very intensely, mountain bike, would like to get back to rock climbing ... I'm drawn to risky, gritty sports. So for me personally, given all the data I had available ... well, like I said, all personal decisions and trade-offs with insufficient data, really. I also didn't want to wear a brace at all, both for psychological reasons and because I am overweight and it's difficult enough to find ski pants that fit me without trying to jam a brace in there. (Will being overweight create more OA than the injury? Who knows!)

I also got frustrated with the research. You talk to different people and they have wildly different experiences - but then you realize this one had hamstring, this one cadaver, this one patellar tendon - this one had meniscus damage, this one also tore the MCL, etc etc on down the line. This one swears by wearing a brace and has worn it ever since the injury; this one wore it one year .... this one followed PT religiously, this one got back to activity way before advised and was fine ... this one started on RoM right away; this one couldn't because other damage had to heal first ...

It seems like it's almost impossible to control for the variables. I'm amazed that studies find any meaningful results at all.