Ligament copers - when are you ready to ski again?

[Grizzla]

Just another thought... Which types of skiing do you think are best or worst or safest or most risky for those specifically without an ACL ( as opposed to those with tears or reconstructed ones)?
There were references in an earlier discussion paper linked on this thread to differences between slalom and downhill (or that's how it read), seeming to suggest that slalom is less strain? Generally people say that off-piste is more of a risk, maybe because it requires more work or more pivoting and cross-stresses?
But what about other techniques, styles, conditions...? Which do you think are hardest on your knees or need most muscle strength to hold your knees together? Do we need to take it as easy as possible, or can we go back and be as aggressive as before? Short bouncy turns or long GS carvers?
The suggestion was made early in this thread to go back to shorter skis; so does that mean bin the race skis, too?

 

[marzNC]

There were references in an earlier discussion paper linked on this thread to differences between slalom and downhill (or that's how it read), seeming to suggest that slalom is less strain?

I didn't read it that way. The doctor said the two were different when it comes to development of OA after ACLr surgery. Which is worse is not stated.

"By my personal experience — being involved in taking care of the Austria National Ski team for more than 15 years — I just can say that there is a big difference in whether one of the world cup athletes comes back as a slalom runner or as a down hill racer."
https://www.healio.com/orthopedics/...-acl-reconstruction-and-postop-rehabilitation

To throw another option into the mix, I have friends who switched to telemark because of their knees. They were advanced alpine skiers before switching and quickly became advanced telemark skiers. My sense is that telemark requires strong quads but is easier on knees.

 

[marzNC]

Just another thought... Which types of skiing do you think are best or worst or safest or most risky for those specifically without an ACL ( as opposed to those with tears or reconstructed ones)?
[snip]
Generally people say that off-piste is more of a risk, maybe because it requires more work or more pivoting and cross-stresses?
But what about other techniques, styles, conditions...? Which do you think are hardest on your knees or need most muscle strength to hold your knees together? Do we need to take it as easy as possible, or can we go back and be as aggressive as before? Short bouncy turns or long GS carvers?

As for your other questions, what I know is that I am a much better skier now than before losing an ACL because I changed my approach to ski conditioning and worked with instructors to improve technique. However, it was not a quick process. I'd say by the second season after getting back on the slopes, I was skiing about the same advanced terrain (ungroomed) although probably with somewhat better technique. That season I started actively working on bump skiing with instructors and by seeking out bumps. Took another two seasons before I had clearly reached the next level. I was Level 7 (of 9) before injury. Four seasons later a PSIA Examiner said I was Level 8. I asked the question during a semi-private lesson that I arranged together with a couple ski buddies at Snowbasin in Utah. He said they were Level 7 so it gave some context for understanding the difference.

One type of skiing I have no interest in doing is jumping, meaning catching air in a terrain park or hucking a natural feature. But I wasn't ever interested in that sort of excitement. On the rare occasions that I catch a little air on a bumpy traverse, it's not really a cause for concern. Mostly because I've practiced landing doing plyometric-type exercises so have built muscle memory that helps avoid knee injuries.

My experience is an example that may or may not apply to other people. My knee injury involved relatively little collateral damage (MCL strain, small hole in red-red area of meniscus). The only pain was related to the MCL and very easy to avoid even a few weeks after injury. There was no swelling by 8 weeks, even after a PT session. I didn't pop off the ACL while skiing, therefore no fear issues that naturally often follow a ski accident.

 

[marzNC]

From my coper thread, posted 19Oct2012:

"I started using KOOS--Knee Injury and Osteoarthristis Outcome Score--about two months after injury as a way to track progress. Checked about once a week for Months 2-3. I like KOOS better than other objective measures because it includes functional and sports/rec items in addition to stuff like pain or stiffness. Was fully validated in English by 2003. Range is 0-100. Patients who complete PT after ACLr surgery usually get to 92-97. Examples of functional: putting on socks, doing light housework, getting in/out of car. Also has Quality of Life topics like "How much are you troubled with lack of confidence in your knee?" A non-coper would have a hard time reaching 75.

My guess was that my score was 38 at Week 4, before any formal PT. I did the scoring a few weeks after the fact based on remembering what I couldn't do. My score was about 75 at Week 8, after 3 weeks of PT and pretty much daily exercises, mostly no impact. By Week 12, the score was up to 85. But it was incomplete since I was avoiding running, jumping, and pivoting to let the meniscus heal more so the scores for those items weren't too meaningful. After four months, my score is 89. Fully expect to get close to 95 before ski season starts now that I'm doing careful running and jumping exercises."

I reached 95 by early January 2013, which was about six months after injury. By then I decided the meniscus was probably healed. After another six months, I was at about 97. Has stayed at that level since then, which means 4.5 years (2013-17). I check once or twice a year but don't keep records like I did in the first year. Sometimes play with the answers related to Twisting/Pivoting and a few others. The range comes out 94-98.

 

[bounceswoosh]

I'm younger than marzNC and I *think* younger than Grizzla, but just an observation -

Context: I had surgery. I am still growing my skiing and mountain biking repertoire with increasing jumps, steeper steeps, chutes, etc, and I just did not want any doubt whatsoever. That was just my personal decision.

Anyway, with that caveat, I was surprised at how things went. I expected my brain to be in worse shape than my knee. Everyone told me to expect that. Instead, I have consistently been aggressively skiing and mountain biking, and after a couple of tentative runs, I'm back to pushing my personal envelope (small as it may be). My knee, on the other hand, has continued to have difficulty. Some of this may be due to my inability to take NSAIDs and the general fact that I have an immune system related disease; some may be that I pushed too hard initially so that I would be cleared to ski; some may be that I skied an awful lot, and pushed through a lot of pain to ski, including spring skiing when the snow was grabby and inconsistent. Or maybe I backed off the PT too soon. Some is definitely compensation that I need to work through. Also, getting back to mountain biking, I've fallen and landed on the affected knee several times - it just does not like that.

I tore my ACL skiing. With skiing and mountain biking, two activities I love, I bounced right back mentally. I've actually had less severe injuries mountain biking that somehow inhibited me more.

On the other hand, the injury has clarified some things for me. I realized that I don't actually like riding my motorcycle, or at least, that it's too scary to be worth it for the fun parts. I sold it. I realized that I don't like riding my road bike, and despite multiple fits it has always hurt my knee - so I sold it. I have a much clearer picture of which activities are worth the risk to me, and which aren't.

 

[Skier31]

I was a "coper" for a long time until a relatively minor incident resulted in a torn meniscus.

Here is my take: Not having an ACL allows your knee to move in ways it can't with an ACL.
If you want to return to serious skiing, have the surgery. The surgeons are good at it and if you do the post surgery PT, you have a strong, stable knee. I did fine for many years and then it was not fine.

Have the surgery and move forward.

 

[Grizzla]

Thanks all.

Telemarking I know nothing about, though heard others suggest it. But think maybe it's too late to try to learn yet another thing and buy more equipment. I do have the boarding alternative if that works out (yet to try).

Motorcycling - yes, though I've previously put my bike down the road on both knees and many other bits (lots of gravel rash and temporary pain and swelling but nothing lasting), and OH has had a few very nasty 'accidents', I never (and I've ridden for 35 years) considered it a worrying activity - until now. Suddenly, the thought of any more pain or damage gets very worrying. More knee (and elsewhere) pads most definitley!!! Haven't actually taken it out since my ski fall, as it's got rear sets and they demand a lot of bend and pressure in the knee; hopefully soon I'll get out on that and see how I feel. The ski collision has put the scares into me generally as to any kind of traffic around me: I'm still very jirrerty and nervous even as a passenger in a car.

Skier 31 - I have received a lot of the same advice from other skeirs. The thing at the moment is that my surgeon and physios don't recommend surgery (so a surgeon won't do it if not deemed necessary, private or NHS) and I don't want to go in and irritate a knee (or 2 in my case) which may well be recovering if I don't have to. I'm well aware of the risk of carrying on without, and don't like it, but equally there's a risk and no guarantee if I write off another 9 or 18 months in surgery and rehab, and I certainly don't want to lose the time in not being able to do other things in everyday life, walking and other actvities whilst rehabbing again and not damaging the graft.
I think at the moment I'll have to take my chances, and if I'm unfortunate and damage something else in the future then that's the point where I look at surgery and get the other things and the ACL fixed at the same time.
Equally, I am still rehabbing the knees and getting the legs strong and stamina-filled enough to be able to ski and do everything else that I want. I've got at least to given them some time to try and recover and do them the justice of trying them out, given how hard they've worked to try and get themselves back together...

 

[bounceswoosh]

The thing at the moment is that my surgeon and physios don't recommend surgery (so a surgeon won't do it if not deemed necessary, private or NHS)

Genuinely curious - what would have to be true for it to be deemed necessary?

Arguably no one "needs" an ACL. We can all walk around and do a job.

 

[Pequenita]

Genuinely curious - what would have to be true for it to be deemed necessary?

I don't think this surgery is ever necessary, vs. recommended or not. Lifestyle, age, and health are often the factors. I'd imagine with NHS, length of time until the surgery (and thus, age), would also matter. FWIW, I do think that the first reaction for too many people is to get surgery.

 

[Grizzla]

bounceswoosh - as far as I know, there are 3 main factors they'd look at from a medical or surgical perspective:
a) is the person suffering instability in the knee, chronically or in acute episodes of collapse, pain, hyperextension, inability to balance or do other everyday things and desired activites;
b) what are the person's necessary and chosen activities - job, family responsibilities, hobbies, level of engaging in sports etc.;
c) how lax is the knee as measured by Lachman or Anterior Drawer or Pivot Shift tests - i.e. how much does the tibia (shin bone) more forward relative to where it should do when someone tugs on it in the right forwards or sideways way, especially when it's bent. (The theory being that the muscles, quads and hams in particular, can stop this anterior translation happeneing if strong enough.)

Ability to rehab properly and to comit to it (+ other personal and medical factors) are also relevant; probably others wich I've missed. Possibly other concurrent or prexisting knee/leg injuries as well (legaments, meniscii, fractures).

Some people cannot manage without an ACL at all (never mind without 2) and can't even trust themselves to walk the street, never mind do a job which requires a lot of leg work, standing, heavy lifting, quick moving or whatever; same's true of badly injured other knee ligaments, although generally they have some change of healing unless very badly ruptured. I have a relative who does rehab for the Fire Service - they have a lot of knee and ACL rehab cases, and I guess they wouldn't be much use in their job unless they had stable and trustable knees. However, she was the first one who told me that you can avoid surgery and just get your hamstrings stong - so that's saying something too.

I have seen lists (just Googled when bored, and found them) which are drawn up to assist in deciding necessity of ACL reconstruction vis a vis sports (and job) activities. They distinguish amatuer and professional (e.g. in skiing a racer or instructor) and the level of impact and pivotting, cutting and other stresses involved. Basketball, soccer, hockey, tennis and the like are top of the risk list. Professional freestyle skiers and boarders and ski racers come about 3 down from the top (below amateur ball players I recall, or at least no more than equal to). Amateur/recreational downhill skiers (including amateur racers) come just on the 50:50 line, which makes it difficult to decide, but clearly says that the risk of not having an ACL isn't considered that high. Obviously depends on your technique, ability, agression and what terrain you choose too - though I've not seen anyone analyse that one out (hence my question). Doesn't comment either on if it's the skiing or the falling that's the real risk!!!

 

[Grizzla]

Pequenita - it's true that the NHS isn't always the speediest or best funded of services, but as far as I know, if they think that you need ACL or knee surgery because of your symptoms or your activities then you'd get it. You might have to wait a few weeks to months (and some people will go private, though it would cost a fair bit - I don't have private insurance but a lot of UK people do, with their jobs usually) but you'll get it done, even if the reason is just that you want to return to skiing, soccer or whatever caused it or wouldn't be possible without it. They didn't used to like people over 50 but now it's not a barrier if you're fit and active, or so I hear.

 

[santacruz skier]

After I was injured in March in Switzerland, I went to an orthopedic surgeon within two weeks and had an MRI the following week. At our follow up appointment the orthopedic surgeon told me that I have a partially torn ACL and torn flap tear meniscus. I asked if I would need surgery and his answer was "we don't usually repair ACL's on patients your age (or something like that) , but I believe your meniscus will need surgery." After three months of PT, gym exercises to strengthen muscles around knee, personal trainer once a week, I was told after orthopedic surgeon performed tests that I don't need meniscus surgery. And my ACL was healing as well. To be honest, after taking the KOOS test I realize I still have many more months to get stronger.

 

[bounceswoosh]

I am horrified at the idea that even if you wanted ACL surgery, you couldn't get it - even through private practice.

I agree it's many people's default assumption - but there's a reason for that. The ACL has a purpose.

If I were 50+, would I want the surgery? Can't say. But I would want to have the option if I were as active as many 50 year olds. (Jeez, that's not even 11 years away! Time flies! )

 

[Pequenita]

Pequenita - it's true that the NHS isn't always the speediest or best funded of services, but as far as I know, if they think that you need ACL or knee surgery because of your symptoms or your activities then you'd get it. You might have to wait a few weeks to months (and some people will go private, though it would cost a fair bit - I don't have private insurance but a lot of UK people do, with their jobs usually) but you'll get it done, even if the reason is just that you want to return to skiing, soccer or whatever caused it or wouldn't be possible without it. They didn't used to like people over 50 but now it's not a barrier if you're fit and active, or so I hear.

That is great to hear. I know of 2 of people who waited years to get knee and shoulder surgeries in the late 90s, but I don't know what their personal circumstances are.

 

[santacruz skier]

I am horrified at the idea that even if you wanted ACL surgery, you couldn't get it - even through private practice.

I think I could get it, but I would have to be convincing.......but still....

 

[altagirl]

It took me over a year to have my first ACL surgery because I was in the Army and had to deal with their system. I went to the doctor immediately after the injury and they told me it was nothing but a sprain and then I kept going back and trying to get an appointment with an orthopedic surgeon to get a real diagnosis, but they wouldn't let me do that until I had an MRI and there was a six-month waiting list for MRIs. And by that point I was ready to move back to the United States, so I got the MRI once I went back to Alabama for a military school but then they wouldn't let me have the surgery until after I finished the six-month training course I was in. And at that point my knee was giving out doing things as simple as walking down the hall and turning a corner. I had done a lot of skiing (35+ days) on the torn ACL before it was diagnosed since they kept telling me there was nothing really wrong with it even though I honestly knew better.

My understanding is that it all depends on how your knee joint is built. Some of us are lucky enough to have knees that hold up to a lot of activity without an ACL and others not so much.

 

[vanhoskier]

I had a meniscus tear and underwent surgery a few months later. I'm not sure if the surgery was the best idea. I have read studies recently claiming that meniscus surgeries are not necessary and can result in more serious problems over time. I have had some muscle atrophy on that side, in my quadricep, despite PT, and a lot of exercise over the years since. Also, I've developed arthritis in that knee and have very little cartilage.

ACL...it depends on the person. I think the opinion of a reputable orthopedic surgeon (or 2nd opinion if necessary) who knows the patient's activity goals is the guiding principle in making a decision about surgery.

 

[Grizzla]

Thought that I should update this.
Nearly a year on since some kind out of control lady took out both my ACLs and generally traumatised both my up-until-then OK knees. Been a long, stiff, sore haul - but although not exactly as planned, I am pleased to report that I am skiing and boarding again. Not as planned because I had intended to take it easy, practice, do gentle pisted slopes, get lots of instruction and... Yeah, well.
Turns out that we've had a reasonable season for English skiing, never mind Scottish. So outing number one was straight up a very long, very bumpy poma lift and repeated trips down a snow-covered moorside, lots of sharp jump and pivot turns, skids and sharp hockey stops avoiding tufty grass, old sunken mineshaft holes and streams. Yes, we are mad! Then it was up to Scotland on ungroomed runs and deep powder - and more long and tiring drag lifts - then back to deeper ungroomed ( heavy and wet snow usually) terrain in England; and repeat...
Well, I'm still standing . My muscles had lost all their stamina: but I can feel power, stamina and strength coming back each time that I ski. I started not being able to do more than a couple of hours max before I got stiffness, slowness and 'blocking' feelings in my upper leg and knee areas, but I'm now able to go on for 4+ hours without stopping or resting ( and this is on constant drag lifts - yuk!) and not have any significant problems. Developed some problem with the outside of one knee, some swelling and pretty painful and stiff after a day's skiing but not a problem when on the slopes, and I hope that it's slowly getting better, physio doesn't think it's anything serious. I blame it on the drag lifts: seriously, puts a bad pull on my knees.
To be honest, with a stressful house move and a lot to do afterwards, I haven't been doing any rehab exercises and none of my former hill walking, so I'm very pleased at how it's been going. Not my old knees or legs any more, still pains and problems, mostly muscular I think, but some hope that it won't be too bad and that I'll be able to ski pretty well again if I can get my strength up properly. Boarding has been fine except when I was 'punting' along with my rear leg and it slipped out from under me; ouch! Something else I'm very wary of with the board, slipping on chairlift dismounts ( if I ever find one again) and the like.

As for the confidence... First few times out I was utterly terrified, worse than a beginner. It was horribly embarrassing. Half the time I just stood there unprepared to move: until I realised I had no choice so had to find a way down, no matter how much I hated it. My sideslipping has improved no end... I was so afraid of falling or jarring my knees, wouldn't go over any rough or banked ground, refused to go down anything steep. Couple of good tumbles and on off-piste cartwheel and ski release soon put paid to that! I'm still, however, very aware of what could happen if I fall - but in general I'm about as confident as I was before, doing small jumps, happy on rough slopes etc. Not tried ice or hardpack though, nor anything too steep or long.
I notice that walking I'm still scared on anything slippy, which is that same fear of falling and reinjuring myself.

Anyhows, that's where we're currently at. Not as good as a year ago, but a darn sight better than I could have been. Hopefully there's a couple more months to go this season, so time to get better yet; might even finally find somewhere to get those lessons. The UK is not exactly predictable or long-lasting good conditions, so you just have to grab whatever's available, as and when. Not going abroad this year: insurance cost too high and a lot of money when I'm not strong enough to make the most of it, nor I think able to do 6 long days on the run. Next year, hopefully.
Just treated myself to some new piste skis, so hope there'll be some decent carving practice soon.

Best wishes too everyone struggling with injuries.

 

[newboots]

Grizzla, how wonderful that you've made such progress! But bumpy hills, rope tows, and a cartwheel? Yikes! You're a braver woman than I.

Congratulations and keep up the great work!

 

[marzNC]

As for the confidence... First few times out I was utterly terrified, worse than a beginner. It was horribly embarrassing. Half the time I just stood there unprepared to move: until I realised I had no choice so had to find a way down, no matter how much I hated it. My sideslipping has improved no end... I was so afraid of falling or jarring my knees, wouldn't go over any rough or banked ground, refused to go down anything steep. Couple of good tumbles and on off-piste cartwheel and ski release soon put paid to that! I'm still, however, very aware of what could happen if I fall - but in general I'm about as confident as I was before, doing small jumps, happy on rough slopes etc. Not tried ice or hardpack though, nor anything too steep or long.
I notice that walking I'm still scared on anything slippy, which is that same fear of falling and reinjuring myself.

Sounds familiar. After the first fall when a ski came off, I was more relieved than scared.

As for walking around in ski boots, I take much smaller steps at a slower speed than before. Only hard falls I've had this season were in an icy parking lot at an unfamiliar place. That was in snowboots. Working on bone building has been worthwhile too.

Have fun the rest of the season!