Ligament copers - when are you ready to ski again?

[marzNC]

FWIW I do not consider 10 years to be long term.

Agree that what is more useful would be to know what happens 20, 30, 40 years out starting from a variety of well documented baselines. However, the nature of medical research in a clinical setting is that any study that runs more than 5 years is pretty unusual. Partially because of the effort required to maintain funding. Also hard to find patients willing to be involved for an extended period of time.

The ACL database being built somewhere in Scandinavia (forget the country) includes every patient in a large number of hospitals treated for ACL injury. Has data for at least 20 years already. So those people are the basis for a number of studies.

Bottom line is that working with medical professionals who keep up with the latest research is the best way to make a well-informed decision for a specific situation. Coming up with the best treatment plan after a knee injury will always be part science and part gut feeling because the human body is so complex.

For those who don't know . . . I'm not a medical professional. The experience I use when reading medical journal articles is based on working as a Ph.D. biostatistician in pharmaceutical clinical trials for 15 years.

 

[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. [snip]

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

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

Finally found Part II of the round table discussion. This discussion is from Orthopaedics Today and is probably from about 2005, which means it's pretty dated. However, I found the comments useful because I learned about the concerns of doctors who were interested in treatment for ACL injuries. Turns out that one doctor, Karl-Peter Benedetto, had been working with the Austrian ski team for 15 years at the time of the discussion.

https://www.healio.com/orthopedics/...-acl-reconstruction-and-postop-rehabilitation

 

[santacruz skier]

@marzNC I just took the KOOS test and am at 81.5... but I am not running or jumping so chose "moderate" ... There were other scenarios that did not apply as well. Avulsion fracture to ACL and flap tear meniscus on March 11. Weekly personal trainer plus 3 months of PT and continuing exercises at gym (leg press, seated leg curls, abduction, adduction machines).... and home exercises (calf stretches, quads)...
Cycling daily for about 5 miles + on flats mostly. And still only 81.5 KOOS score.

 

[marzNC]

@marzNC I just took the KOOS test and am at 81.5... but I am not running or jumping so chose "moderate" ... There were other scenarios that did not apply as well. Avulsion fracture to ACL and flap tear meniscus on March 11. Weekly personal trainer plus 3 months of PT and continuing exercises at gym (leg press, seated leg curls, abduction, adduction machines).... and home exercises (calf stretches, quads)...
Cycling daily for about 5 miles + on flats mostly. And still only 81.5 KOOS score.

KOOS is a "self administered outcome score" that was developed to help deal with knee injuries and OA. Can you think back and answer based on how things felt a month ago? Right after injury?

Until someone is fully recovered, which can take a year or more in some cases, I think it's more interesting to monitor any change in the KOOS score. When tracking weekly, there can be backsliding in early stages. Tracking more than monthly is probably not that valuable. For research purposes, subjects are often evaluated at 3 or 6 month intervals.

My KOOS scores were in the mid-80s about four months after injury, which was after I did formal PT for about 10 weeks. When I played with changing answers between the two extremes, seems as of the range for the score was on the order of plus/minus 5. Didn't start trying that until the answers for all of the Pain and Daily Living questions were None/Never.

In my notes during the first few months after injury I got the same score two weeks apart. The note I wrote says " no change although stronger and doing more naturally." What KOOS helped me do was consider the various aspects of recovery.

 

[Grizzla]

Well, I'm 83.5 on the KOOS, give or take. I don't run, full stop, and aren't a jumping person either ( unless on skis with poles in bumps and crud!) Not quite sure what drags the score down, even when you're feeling that things are pretty good. And as for questions about modifying activities - well, yeah, severely, coz I ain't skiing at all, nor dancing like a whirling dervish or marching up and down hills & mountains like I used to!!!

I'm certainly not doing as much exercise by far as Santacruz - well done, girl! - but trying what I can at home (no gym or trainer as such) and doing 20 min static cycling most days. Fighting gritty catchy kneecaps and all kinds of tight soft tissues at the moment, so don't know how normal this is. It's more like very slow recovery from overall trauma so far, plus muscles that just don't belong to Lindsey V... ( and are somewhat older). Got to get that all sorted before I test the strength and stamina on skis.
Like I said at the start, though, it seems that you've got to get and stay a lot stronger than you used to be before the injury, presumably to compensate? And of course you've also got to get back whatever the swelling and injury and enforced rest has also cost. 30+ years of no thought to strengthening what I naturally had, never really did huge amounts even of pre ski physical prep, and never had a twinge or problem, knee or leg wise. Never had a problem from all kinds of twists and falls either. (This time, however, I was pushed... ) Peed off ain't even near it at the moment

On the other topic, that's an interesting debate you linked to, MarzNC. Like you and others have said, there are so many factors about every person, never mind their specific injury, ever to be able to make meaningful comparisons, it seems. Even looking only at ski injuries, there's so many ways that they happen, different types and combinations, different types and abilities of skiers - it's really hard to draw any conclusions, especially as historic surgical techniques have changed so much. It's also really hard to know what state a previously healthy knee was really in and how predisposed a person is to OA or any other future problems.

Still, think positive, huh? (And lots of hot wheat bags.)

We used to have a Government sponsored TV advert in the UK many years ago, anti drugs, which then got taken up by a comedy programme as a silly slogan. So, something along the lines if: OK, so I do a bit of ligament damage now and again. (Sniffs.) I can cope... Can't I..?

 

[santacruz skier]

Can you think back and answer based on how things felt a month ago? Right after injury?

Well yes that's a different story. Three days after injury I had mobility assistance at both Geneva and Heathrow airports. I was literally dragging my leg. Could barely lift it. But compared to a month ago, not much change. It seems like every little twist, pivot or even getting in and out of a car can tweak the knee. I skied for 40 years without injury and only pre-season workout I ever did was in line skating... I stopped 2 years ago as was having lower back issues (MRI showed bulging discs, annular tear) which are 90% better now. I was in line skating a few times a week all year long. Lucky me, climate in SC is conducive to activities year round. (most of the time)

 

[marzNC]

Like I said at the start, though, it seems that you've got to get and stay a lot stronger than you used to be before the injury, presumably to compensate? And of course you've also got to get back whatever the swelling and injury and enforced rest has also cost. 30+ years of no thought to strengthening what I naturally had, never really did huge amounts even of pre ski physical prep, and never had a twinge or problem, knee or leg wise.

Completely agree that being a successful coper requires putting in work to get into good shape. How much work depends on the starting point. I think consistency may be more important than intensity. Certainly true for balance exercises and strengthening hamstrings.

Given what I experienced in the last year, I have a slightly different view of the level of strength needed to compensate as a skier for being ACL-deficient. It's been five years since I blew an ACL (not skiing). Like you, I hadn't done any deliberate fitness exercise as an adult. I was sporty when in school (soccer, basketball, tennis, etc.). I played some sports in my 20s and 30s but wasn't doing much by my 40s. I was in pretty good shape for my age (around 55) but preferred to take it easy on groomers after lunch at big mountains and rarely lasted until the lifts closed.

After knee rehab, I spent a couple years making ski conditioning during the off season more of a priority. I started taking lessons. Being in better shape, skiing full days at a big mountain for 6+ days in a row became fun on the trips to big mountains I took twice a season. I pretty much maintained the same level of ski conditioning for the next two years, while taking more lessons and getting in more ski days. However, last year I wasn't exercising regularly for assorted reasons. I skied far fewer days. What I discovered is that having better technique meant that even though I wasn't as strong as the year before, I had no trouble having a good time on complex and steep terrain. In my case, that meant terrain that was not even on my radar a few years ago. For those that know Taos, that meant an adventure with an instructor on a double-black bump run. For those who know Alta, that meant skiing Sunspot solo pretty much non-stop and having no worries at all.

So, agree that a coper who wants continue to be an advanced skier needs to be willing to work at getting in shape and staying in shape. The flip side is that means being in much better shape in the long run for daily living. For me, that means skiing is providing an incentive to exercise even as I look forward to getting senior discounts for lift tickets. Not for everyone, but works for me. Had I been 10-15 years younger, might well have proceeded differently.

 

[marzNC]

Still, think positive, huh? (And lots of hot wheat bags.)

We used to have a Government sponsored TV advert in the UK many years ago, anti drugs, which then got taken up by a comedy programme as a silly slogan. So, something along the lines if: OK, so I do a bit of ligament damage now and again. (Sniffs.) I can cope... Can't I..?

Positive attitude makes a huge difference!

 

[bounceswoosh]

Fighting gritty catchy kneecaps and all kinds of tight soft tissues at the moment

Check with your doc/PT of course - but I dealt with a lot of this, and there are some very specific things that help.

At the PT : Find someone who can do Graston technique. Hurts like a b**** but it breaks up all sorts of tight tissue.

For yourself:
Mobilize your kneecap. This is something that squicked me out at first, but I had to learn. Push the kneecap around - side to side, up and down. Also hoooooold it for a minute to each direction, rather than wiggling it around.

Foam roller. The really firm one - from what I've seen the firm ones are always black, the softer ones white - don't ask me why. There's a quad muscle running along the outside of your quad, kind of "3 o'clock" if the kneecap is "12 o'clock." That's the one I need to roll the crap out of. It gets super tight from compensation.

You can try the foam roller for the hamstring and calf, but for me the magic is with a lacrosse ball. I put it under the meaty part of my calf or under my hamstring and roll my body around on it until I find something owie. Then gently roll back and forth an inch or two just as you would a foam roller.

Stretches. Calf stretches. Hamstring stretches. There are a million variants; find the ones that work for you. Hold for 30s to a minute each.

Quad stretches - not sure if you can do this yet or should, though.

Extension! I bought sandbag weights (the kind designed for extra resistance while walking around) and would prop my foot up on something so that my knee was unsupported, and eventually worked up to ten pounds of weight for 15 minutes. When I started, I could barely do 3 minutes without extra weight.

Hip strength is critical. Things like clamshells; frog walk with resistance; one leg deadlifts / "superman" ...

https://betterbuttchallenge.com/best-butt-exercises-clamshells/ - you don't need to use resistance at first - but you need to focus on the muscle being used. When I started, I was using parts of my quad, not my glutes. You should feel it in the middle of your buttcheek - where the dimple is, roughly.

https://www.popsugar.com/fitness/photo-gallery/28185620/image/28185661/Lateral-Band-Walks - I put the band around my ankles, not my knees. If you don't feel the glutes, try getting lower (without tipping your body forward) or try angling your feet outward.

- but go as far as you can toward your body being parallel to the ground.

For all of these exercises, focus on feeling it in your glutes. If you don't feel it in your glutes, you're not getting the benefit. My PT recently pointed out that some of my knee pain is because I'm allowing my femur to rotate inward, causing grinding against my knee. If my hip were stronger, I wouldn't be rotating.

Again though, I am not a doctor or a PT and I have no idea if these exercises are appropriate to your current state.

 

[santacruz skier]

I don't know about @Grizzla but I have been doing these exercises that you stated with both my PT and personal trainer. I need to get a la crosse ball to do at home though. Really trying to avoid surgery for both ACL and meniscus. Also I've added front /side planks to my workout but think I overdid it yesterday.

Tell me about the Graston technique . Yes I could google it, but?

 

[bounceswoosh]

Tell me about the Graston technique . Yes I could google it, but?

It feels like a foam roller x100. Hurts. But very effective.

Instead of you moving over a foam roller, a skilled practitioner takes a metal scraper (!) and goes over your muscles / fascia / scar tissue with the scraper.

 

[santacruz skier]

It feels like a foam roller x100. Hurts. But very effective.

Instead of you moving over a foam roller, a skilled practitioner takes a metal scraper (!) and goes over your muscles / fascia / scar tissue with the scraper.

I'm also going to a chiropractor that does sports chirotherapy (kind of deep deep muscle massage). It has done wonders for my back. The jury is out on the knee. Walked about 3 miles today and rode about 6 on flats along the ocean.... wish knee would be 100% but really at about 75%.

 

[santacruz skier]

It feels like a foam roller x100. Hurts. But very effective.

Instead of you moving over a foam roller, a skilled practitioner takes a metal scraper (!) and goes over your muscles / fascia / scar tissue with the scraper.

Think I *like* this, maybe not!

 

[bounceswoosh]

Think I *like* this, maybe not!

I squirm and sweat a lot when I get it done, but I manage to keep the affected leg still!

 

[santacruz skier]

I squirm and sweat a lot when I get it done, but I manage to keep the affected leg still!

if it helps then that is a good thing. I'll ask my sports chiro about it next week....I keep wondering if my knee would feel better if I had the meniscus surgery. Orthopedist said I don't need ACL surgery as should heal on its own. I don't see how as I'm not exactly a spring chicken. I guess avulsion fractures heal on their own?

 

[bounceswoosh]

if it helps then that is a good thing. I'll ask my sports chiro about it next week....I keep wondering if my knee would feel better if I had the meniscus surgery. Orthopedist said I don't need ACL surgery as should heal on its own. I don't see how as I'm not exactly a spring chicken. I guess avulsion fractures heal on their own?

I had an avulsion fracture on my middle finger, and there was no surgery. Just letting it reabsorb eventually, I guess. Not sure how similar that is. There was a teeny tiny bone chip that came off, which I assume means only a teeny tiny part of the ligament was detached.

 

[bounceswoosh]

I've now remembered a whole bunch of other exercises for posterior chain - it would definitely be good to set up a regular routine with the advice of a PT.

 

[Grizzla]

Thanks all above.
Not sure that I have access to the Graston or foam roller technique people where I live, but do have a sports injury masseuse (also an expert skier), if she'll ever stop giving me helpful exercises too.
I do think that a lot of my issues now are to do with tight or irritated muscles, tendons etc - and knock-ons to kneecap tracking, cartilage irritation etc. I'm building up the strength (in between aches!) but there's still a lot of underlying irritation. It's that, I hope, rather than any other injury as such, which is just taking a long time to settle, and holding me back. These over-50s bodies do seem to take their time... Compared to how I was at the end of March, I'm doing really well. Compared to the middle of March, pre injury..? Not so much.

I've got a whole load of exercises and stretches for all leg & bum muscles, and core, plus balance. Some are easier than others. My lower back has always been stiff, so some irritate that or can't be done. Others are already quite easy, or I'm pushing the advanced versions. Still working on really getting perfect form, doing one-legged stuff without any knee or leg wobble, which has got some way to go yet; always had wobbly ankles and supple foot arches, so it isn't that easy... Certainly nowhere near pistol squats yet, even holding onto something. (Will I ever? Well, do love a challenge!) Few exercises, if any, now cause knee pain as such, but most cause some irritation & pain afterwards, though not obvious swelling. Hot bags tend to help, plus rest.
I guess I'm lucky as I don't work and am at home all day so can exercise whenever I like and try walking when the weather's right. It is rather taking over my life at the moment though. I thought when I was injured that I'd have loads of time to get on with a book that I'm writing. Haven't got anything done at all!

Still, I'm just hoping, as MarzNC said, that it's kind of done me a favour and that I'll become a better and more confident skier and boarder as a result. Not a training route that I'd recommend, however, and I was hoping/planning to help Hubby retire so that we could both do a lot more mountain walking and snowsports ( with lots of instruction) anyway, so... Well, still early days for me, anyway.

Got a massage and exercise check appointment tomorrow, then will get a physios appointment to check on general knee things. Digits crossed...

 

[VickiK]

I recommend a conservative approach, especially with adding pain that comes under the guise of therapy. Sometimes rest is underrated. I sense that you're facing a lot of fear and self-doubt. But your progress sounds great, and you're doing the right thing in researching and investigating options and alternatives.

Trust that everything you're doing now is and will continue to be helpful for all sorts of active pursuits, including skiing, later this year.

 

[bounceswoosh]

You don't need a PT to use a foam roller. It's something you do on your own.