No ACL, no surgery, no problem - My new normal as a Coper

[diymom]

This all has me wondering if I needed the surgery, and the current waiting for my knee to be cleared. But at the same time, although I never had any pain, the continuing instability (even with pre-hab) in my knee was very annoying. And nearly 4 months after injury there was still a significant amount of swelling that just did not want to go down. No way to know now, or to go back, but it is promising to hear that not as many people might have to go through the surgery and rehab in the future.

 

[floatingyardsale]

This all has me wondering if I needed the surgery, and the current waiting for my knee to be cleared. But at the same time, although I never had any pain, the continuing instability (even with pre-hab) in my knee was very annoying. And nearly 4 months after injury there was still a significant amount of swelling that just did not want to go down. No way to know now, or to go back, but it is promising to hear that not as many people might have to go through the surgery and rehab in the future.

At least according to my surgeon, instability in day to day life means surgery is warranted. It's a thing that they know through clinical practice but don't have a good sense of why. I've opted against surgery for now but for what it's worth, I wasn't unstable after the second week, and that was with a complete MCL tear. I think you made the right call.

 

[marzNC]

This all has me wondering if I needed the surgery, and the current waiting for my knee to be cleared. But at the same time, although I never had any pain, the continuing instability (even with pre-hab) in my knee was very annoying. And nearly 4 months after injury there was still a significant amount of swelling that just did not want to go down. No way to know now, or to go back, but it is promising to hear that not as many people might have to go through the surgery and rehab in the future.

Definitely seems better to go ahead with surgery with any ongoing instability. In my case, after I got my balance back from the shift in proprioception after popping off the ACL (not related to skiing), there was relatively little swelling, ROM came back pretty fast after starting PT about a month after injury (I was on a trip overseas when it happened), and the amount of laxity compared to the other knee was/is minimal.

Every knee injury and overall situation is different. It's good there there are more options these days than a decade ago. Just being able to have a diagnosis based on an MRI made quite a difference when that became the norm (in some countries).

 

[JaneB]

This all has me wondering if I needed the surgery, and the current waiting for my knee to be cleared. But at the same time, although I never had any pain, the continuing instability (even with pre-hab) in my knee was very annoying. And nearly 4 months after injury there was still a significant amount of swelling that just did not want to go down. No way to know now, or to go back, but it is promising to hear that not as many people might have to go through the surgery and rehab in the future.

I would wait and try to rehab before considering surgery. I had the ACL/ meniscus surgery five weeks after injury and had a bad outcome. I would have been better off doing nothing but PT.

It's a MAJOR surgery. You will definitely develop osteoarthritis down the road. Do not undertake without exploring all your options.

Getting the surgery was a horrible and life altering decision for me. There is a significant risk of complications. It is not a visit to the dentist to have your tooth filled.

 

[Trailside Trixie]

My SO tore his ACL and Meniscus and his surgeon is a skier and advised my guy that if skiing is a major part of his life that it's best to get the surgery. He was a candidate for an alagraph (sp??) so the doc was really able to fatten up the ACL and now he has the knee of a teenager to quote his doctor. Tear in April, surgery in May and PT all summer. He was skiing groomed blues and greens by the following Januayr. Now it's the 2nd season post surgery and he's cleared to ski whatever he wants. I know a few people who didn't have the surgery and they spend much of their time in fear or reinjury. Not that surgery eliminates that but it seems any athlete who's very much into skiing would choose to have the surgery but tomato tomahto, etc. To each their own and all that but it really worked for my guy.

 

[JaneB]

Yes, that's what I thought.
Years down the pike not so much.

 

[floatingyardsale]

My SO tore his ACL and Meniscus and his surgeon is a skier and advised my guy that if skiing is a major part of his life that it's best to get the surgery. He was a candidate for an alagraph (sp??) so the doc was really able to fatten up the ACL and now he has the knee of a teenager to quote his doctor. Tear in April, surgery in May and PT all summer. He was skiing groomed blues and greens by the following Januayr. Now it's the 2nd season post surgery and he's cleared to ski whatever he wants. I know a few people who didn't have the surgery and they spend much of their time in fear or reinjury. Not that surgery eliminates that but it seems any athlete who's very much into skiing would choose to have the surgery but tomato tomahto, etc. To each their own and all that but it really worked for my guy.

Most of what I want to stress is that people have SO MUCH more time that they think they have to make the decision. I haven't been skiing yet, mostly because the snow is bad and I'm not risking my knee for lousy rock strike skiing, but my surgeon thinks that it's unlikely that surgery would leave me noticeably better off, and there's a decent chance that surgery would leave me worse off. The reason is that my hamstrings are compensating remarkably well for the lack of ACL, and the surgery would disrupt that connection. It would likely come back, but the odds aren't as favorable; I could have a successful surgery with *more* laxity than I currently have.

What helped me with my decision: about half of people who get surgery to return to their sport don't anyway. There's no difference in outcomes with respect to arthritis; the damage is done with the initial injury. There's no guarantee that one won't retear the repaired ACL further down the line.

I also had a moment of clarity: I wasn't going to get a surgery just to be able to ski, if I could do everything else in my life. And everything else -- mountain biking, hiking, sprinting, lifting -- came back in about three months.

 

[MaineSkiLady]

I think it should be noted, in the interest of fairness, that there are many who have had great success with ACL reconstruction, restoring them to as close as possible to pre-injury.

A few “minor” names come to mind, like Tom Brady, Rob Gronkowski, Tiger Woods, Lindsey Vonn. It’s a long list.

Among the lesser known: a good friend of ours (high-level skier), my husband and my son (son=both knees, 10 months apart).

They are all quite a few years out from surgery. None has weakness or issues, none has osteoarthritis. Friend and husband are 69 and 70 y/o, respectively. Surgeon told my son that his ACL’s were “insufficient,” due to how rapidly his bones and muscles grew (based on scope photos). Friend and son had autograft, husband had allograft. All by the same surgeon.

Everyone is fine, no pain. All active, all skiing well.

There are 2 sides to every coin.

 

[JaneB]

I think it should be noted, in the interest of fairness, that there are many who have had great success with ACL reconstruction, restoring them to as close as possible to pre-injury.

A few “minor” names come to mind, like Tom Brady, Rob Gronkowski, Tiger Woods, Lindsey Vonn. It’s a long list.

Among the lesser known: a good friend of ours (high-level skier), my husband and my son (son=both knees, 10 months apart).

They are all quite a few years out from surgery. None has weakness or issues, none has osteoarthritis. Friend and husband are 69 and 70 y/o, respectively. Surgeon told my son that his ACL’s were “insufficient,” due to how rapidly his bones and muscles grew (based on scope photos). Friend and son had autograft, husband had allograft. All by the same surgeon.

Everyone is fine, no pain. All active, all skiing well.

There are 2 sides to every coin.

I would agree that many notables have had good outcomes. It is likely that they've also had the best of care and the highest of motivations for recovery.

The statistics do show that on average around 50% will have OA in ten years. That means also that 50% won't.

There are many variables that affect outcomes; (age, fitness, skill of the surgeon , expectations re.return to sport, etc. ) and it is ultimately an individual decision, hopefully guided by good science and accurate knowledge, that should be considered before any major surgery.

Any individual's experience, including my own, is essentially meaningless in the
overall picture. But it can be useful to hear the stories of both good and bad outcomes in order to make a decision.

 

[marzNC]

Just a friendly reminder that I started this thread a decade ago to document my experience as a successful coper who happened to be over 50 when the knee injury occurred. At the time I found few stories online about copers.

Every knee injury is different. Working with medical professionals is the best approach for making a personal decision of how to move forward. Please use another thread to discuss the pros and cons of different treatment options that involve surgical intervention.

 

[RachelV]

While it might be nice to have all the posts about treatment in their own thread -- both to keep this thread focusing on coping and so people can find treatment / surgery discussion more easily in the future -- less than 1 page of treatment discussion in a 10+ year old, 17 page thread is pretty par for the course. Long threads always drift a bit. I think most importantly we don't want to discourage people from contributing if their comments aren't strictly "on topic".

If this turns into a treatment thread I'll clean it up and break it into two threads, but for now I think it's fine as it is. Please do feel free to reach out to me or any mod via PM if there are unruly threads that you think could use some reorganization.

 

[MaryVA]

I blew out my knee badly skiing last April (complete obliteration of the ACL, partial tears of the MCL and LCL, and tear in the medial meniscus) and had surgery in May. Finally caught up on this thread, which has been very interesting to read given that so much of my past year has been taken over the injury, surgery and recovery, and I still have a ways to go until I'll feel like my old self again. First, I echo what others have said in that ACL reconstruction is MAJOR surgery, and is not to be taken lightly. This was unquestionably the most significant and humbling medical event in my life thus far (I realize that this makes me lucky), and I don't think I was fully prepared going in for just how painful, serious and difficult recovery would be. Every knee, every injury, and every personal circumstance is different, but I would counsel anybody dealing with a ACL, meniscus, or similar injury to get opinions from multiple surgeons and to do their own independent research before making any final decisions regarding whether to get surgery and, if so, which type. And regardless of whether you get surgery or not, physical therapy is paramount ("prehab" before surgery is important too!), and you should get started as soon as you are able post-injury.

In my case, I don't harbor serious doubts that surgery was the right option given the extent of damage to my ACL and my age/activity level, but I do still wonder at times if I should have opted for a less extensive surgery than the one I had, which included not just a quad graft to reconstruct my ACL, but also meniscus repair and an IT-band graft to reinforce my LCL (more on that below). I spoke to three surgeons after the injury (though only really seriously considered two of them, as the third was a friend who gave me some solid advice but who specializes more in hips in his everyday practice), and all of them told me that I would need surgery if I wanted to keep participating in high-level skiing and other rigorous sports and activities for decades to come. The consensus seemed to be that if I was a few decades older or if I was more sedentary, I could probably get by without repairing the knee, but that my knee wasn't going to be stable enough without surgery to withstand heavy use over time. Of course, not being a doctor myself, I'll never know for sure if this advice was true or not, but I did seem my MRI (looked like a bomb had gone off in my knee) and it was clear that the ACL was torn completely in half, and that scar tissue alone wasn't going to make up for that.

Where I have harbored some doubts is in whether I needed to get as complex and aggressive a surgery as I did. While all the surgeons I spoke to agreed that I needed ACL reconstruction, they were somewhat split on whether I needed meniscus repair given that the meniscus, while clearly torn, appeared to have stayed put in its proper place. Of the two surgeons I considered, one told me that he might need to operate on my meniscus, but that he wouldn't know for sure until he had my knee open in the OR. The second surgeon told me straight away that meniscus repair was necessary. I opted for the second surgeon (primarily because he was more experienced and comfortable with quad grafts, which my own research suggested had a better long-term success rate for female athletes than hamstring grafts, but also because he made better eye contact). In addition to the ACL and meniscus repair, he grafted a piece of my IT band to act as a sort of secondary LCL. He said that he did this because studies show that younger and active women who suffer secondary damage to the LCL show lower long-term rates of re-injury when this LCL operation is performed alongside the ACL reconstruction, but I don't think my LCL was sufficiently injured that it would have required surgery on its own. All this to say, while I probably did need the ACL reconstruction, it's possible that I would have been fine foregoing the work on my meniscus and LCL, and those extra aspects of my surgery have absolutely made recovery longer, more difficult, and more complex. This is particularly true with the meniscus repair, which required me to keep my knee locked in full extension and to avoid any weight-bearing for a full 6 weeks post-surgery (with ACL reconstruction, I could have begun bearing weight and working on ROM much sooner), which I think contributed quite a bit to the severe quad atrophy that I am still struggling to overcome.

At this point, I'm a little over eight months out, have decent ROM (though its not fully symmetrical with my good knee, and I still can't sit cross-legged or comfortably hang out in a deep squat), have minimal to no pain, and am finally noticing more steady increases in my ability to tolerate higher volume and intensity of weight and agility training. I've also been skiing some, though I've stuck to groomed blues and been keeping a firm check on my speed to avoid having to make any sudden movements that my knee won't like. My knee joint feels quite solid. My biggest issue now is the significant atrophy to and insufficient control of my affected quad, which is proving a stubborn impediment to my getting back to full activity. The atrophy and lack of complete muscle control also seem to be reinforcing each other, with the lack of control making it hard to find exercises that sufficiently isolate the quad to achieve hypertrophy and rebuild muscle, and the lack of muscle mass making it hard to work on stability and control. I spent the better part of my 20s and 30s building muscle tone and strength in my legs that is completely gone now, and I worry that I'll never quite rebuild what I lost.

On the arthritis issue, my understanding is that, once you have sustained major injury to the knee joint (whether that be a severe tear in one or more ligaments, meniscus damage, or both), you are are facing a significant possibility of future arthritis whether you have surgery or not. I both sprained and broke my right ankle in separate injuries years ago, neither of which needed surgery, and at 39 I am already starting to feel the beginnings of arthritis in the joint. With my knee, I was advised that, by limiting instability and helping to prevent future injuries and complications, surgery would actually decrease my chance of arthritis rather than increase it (though, again, the recommendation that I have surgery was based on the specifics of my injury as well as my age and fitness level, and so I don't think that the advise regarding surgery and arthritis is necessarily universally applicable to all). But basically everyone, including the (extremely lovely and competent) doctors and nurses at the Alta clinic who first examined my knee, multiple doctors, my physical therapist, and even the many random strangers who noticed my post-surgical brace and felt compelled to tell me their own knee-injury sagas, have told me that arthritis is a strong possibility in my future. Though neither both of my parents had bad arthritis without ever suffering serious joint injuries (my dad even had both knees replaced), so maybe I was doomed anyway.

 

[floatingyardsale]

Quad atrophy is tough because it initially results from the body's protective mechanisms when the injury occurs; your brain basically shuts down the quad when the knee is damaged.

I'm sure you're getting PT but what worked for me was leg extensions --- works the VMO, the inside quad muscle. I used a theraband tied in a loop around a chair leg -- it's actually still tied to my desk at work to do leg extensions whenever I thought of it.

The Knees Over Toes guy on YouTube and the Prehab guys are good for exercises for fixing knees. The joint may be fubared, but the muscles can account for a lot.

 

[diymom]

Not quads, and not from my PT, but at my last appointment my ortho stressed that nordic hamstring curls are key for my knee.

 

[floatingyardsale]

Not quads, and not from my PT, but at my last appointment my ortho stressed that nordic hamstring curls are key for my knee.

Yup. Basically, your ACL is a seat belt. You don't actually need it to ski (though skiing is bad for ACLs) because your muscles are doing the work. If your knee is slightly bent, your hamstrings keep things stable. ACL doesn't do anything until full extension.

Nordic curls are both evil and badass.

 

[MaryVA]

Quad atrophy is tough because it initially results from the body's protective mechanisms when the injury occurs; your brain basically shuts down the quad when the knee is damaged.

I'm sure you're getting PT but what worked for me was leg extensions --- works the VMO, the inside quad muscle. I used a theraband tied in a loop around a chair leg -- it's actually still tied to my desk at work to do leg extensions whenever I thought of it.

The Knees Over Toes guy on YouTube and the Prehab guys are good for exercises for fixing knees. The joint may be fubared, but the muscles can account for a lot.

I’ll check out Knees Over Toes and the Prehab guys. Thank you! Using a band to do quad extensions is a great idea, too. I only have free-weights at home, which are great for general strength training but are not so great when you need to strictly isolate a single muscle group. Even now as I start to creep the weight back up on my squats and other lifts, I can feel my glutes and healthy quad taking over and doing most of the work. And single-leg free weight movements that should hit the quad, like Bulgarians, run into the quad control issue. I’ve been thinking I might need to suck it up and get a gym membership so I can access machines, but I’d rather not spend the money, and I much prefer working out at home anyway. Maybe I just need to try getting more creative with bands.

Diymom’s nordic curl suggestion is a good one too, though I agree that Nordic curls are brutal (but badass). Even though my quad is where I’m having issues, my physical therapist has been stressing the importance of re-bulking my hamstring as well, since the hamstring and quad work together to stabilize the knee, and a stronger hamstring might help add the extra strength and stability I need to get the quad fully back online. I can do deadlifts and RDLs now without much problem, but Nordic curls would be a great addition that I could probably rig up at home.

 

[altagirl]

I had my ACL with a hamstring graft done.... 23 years ago I think? And I notice every time I work single leg hamstring exercises (several times a week) that the one the hamstring was taken from is noticeably weaker. I had gotten them back to even in rehab and then tire the other ACL (allograft repair on that one), so if anything that leg should be the stronger of the two but it just continually gets weaker than the other leg. And both legs have something of a tendency to want to catch/make grinding noises, etc. (And both have had follow up surgeries to work on the meniscus)

I mean, I couldn't even turn corners walking down a hallway without my knee collapsing before that firat ACL surgery so it was certainly necessary but... I also know I went into the first surgery thinking it would just be "fixed" after rehab. And honestly it's been good enough to ski on but never remotely good as new. I know some people are lucky and seem to honestly get back to 100%, but I have friends in both camps. Those who feel truly good as new and others like me who get back to functional but it's just never quite right again even with monster efforts at rehab.

 

[JaneB]

I blew out my knee badly skiing last April (complete obliteration of the ACL, partial tears of the MCL and LCL, and tear in the medial meniscus) and had surgery in May. Finally caught up on this thread, which has been very interesting to read given that so much of my past year has been taken over the injury, surgery and recovery, and I still have a ways to go until I'll feel like my old self again. First, I echo what others have said in that ACL reconstruction is MAJOR surgery, and is not to be taken lightly. This was unquestionably the most significant and humbling medical event in my life thus far (I realize that this makes me lucky), and I don't think I was fully prepared going in for just how painful, serious and difficult recovery would be. Every knee, every injury, and every personal circumstance is different, but I would counsel anybody dealing with a ACL, meniscus, or similar injury to get opinions from multiple surgeons and to do their own independent research before making any final decisions regarding whether to get surgery and, if so, which type. And regardless of whether you get surgery or not, physical therapy is paramount ("prehab" before surgery is important too!), and you should get started as soon as you are able post-injury.

In my case, I don't harbor serious doubts that surgery was the right option given the extent of damage to my ACL and my age/activity level, but I do still wonder at times if I should have opted for a less extensive surgery than the one I had, which included not just a quad graft to reconstruct my ACL, but also meniscus repair and an IT-band graft to reinforce my LCL (more on that below). I spoke to three surgeons after the injury (though only really seriously considered two of them, as the third was a friend who gave me some solid advice but who specializes more in hips in his everyday practice), and all of them told me that I would need surgery if I wanted to keep participating in high-level skiing and other rigorous sports and activities for decades to come. The consensus seemed to be that if I was a few decades older or if I was more sedentary, I could probably get by without repairing the knee, but that my knee wasn't going to be stable enough without surgery to withstand heavy use over time. Of course, not being a doctor myself, I'll never know for sure if this advice was true or not, but I did seem my MRI (looked like a bomb had gone off in my knee) and it was clear that the ACL was torn completely in half, and that scar tissue alone wasn't going to make up for that.

Where I have harbored some doubts is in whether I needed to get as complex and aggressive a surgery as I did. While all the surgeons I spoke to agreed that I needed ACL reconstruction, they were somewhat split on whether I needed meniscus repair given that the meniscus, while clearly torn, appeared to have stayed put in its proper place. Of the two surgeons I considered, one told me that he might need to operate on my meniscus, but that he wouldn't know for sure until he had my knee open in the OR. The second surgeon told me straight away that meniscus repair was necessary. I opted for the second surgeon (primarily because he was more experienced and comfortable with quad grafts, which my own research suggested had a better long-term success rate for female athletes than hamstring grafts, but also because he made better eye contact). In addition to the ACL and meniscus repair, he grafted a piece of my IT band to act as a sort of secondary LCL. He said that he did this because studies show that younger and active women who suffer secondary damage to the LCL show lower long-term rates of re-injury when this LCL operation is performed alongside the ACL reconstruction, but I don't think my LCL was sufficiently injured that it would have required surgery on its own. All this to say, while I probably did need the ACL reconstruction, it's possible that I would have been fine foregoing the work on my meniscus and LCL, and those extra aspects of my surgery have absolutely made recovery longer, more difficult, and more complex. This is particularly true with the meniscus repair, which required me to keep my knee locked in full extension and to avoid any weight-bearing for a full 6 weeks post-surgery (with ACL reconstruction, I could have begun bearing weight and working on ROM much sooner), which I think contributed quite a bit to the severe quad atrophy that I am still struggling to overcome.

At this point, I'm a little over eight months out, have decent ROM (though its not fully symmetrical with my good knee, and I still can't sit cross-legged or comfortably hang out in a deep squat), have minimal to no pain, and am finally noticing more steady increases in my ability to tolerate higher volume and intensity of weight and agility training. I've also been skiing some, though I've stuck to groomed blues and been keeping a firm check on my speed to avoid having to make any sudden movements that my knee won't like. My knee joint feels quite solid. My biggest issue now is the significant atrophy to and insufficient control of my affected quad, which is proving a stubborn impediment to my getting back to full activity. The atrophy and lack of complete muscle control also seem to be reinforcing each other, with the lack of control making it hard to find exercises that sufficiently isolate the quad to achieve hypertrophy and rebuild muscle, and the lack of muscle mass making it hard to work on stability and control. I spent the better part of my 20s and 30s building muscle tone and strength in my legs that is completely gone now, and I worry that I'll never quite rebuild what I lost.

On the arthritis issue, my understanding is that, once you have sustained major injury to the knee joint (whether that be a severe tear in one or more ligaments, meniscus damage, or both), you are are facing a significant possibility of future arthritis whether you have surgery or not. I both sprained and broke my right ankle in separate injuries years ago, neither of which needed surgery, and at 39 I am already starting to feel the beginnings of arthritis in the joint. With my knee, I was advised that, by limiting instability and helping to prevent future injuries and complications, surgery would actually decrease my chance of arthritis rather than increase it (though, again, the recommendation that I have surgery was based on the specifics of my injury as well as my age and fitness level, and so I don't think that the advise regarding surgery and arthritis is necessarily universally applicable to all). But basically everyone, including the (extremely lovely and competent) doctors and nurses at the Alta clinic who first examined my knee, multiple doctors, my physical therapist, and even the many random strangers who noticed my post-surgical brace and felt compelled to tell me their own knee-injury sagas, have told me that arthritis is a strong possibility in my future. Though neither both of my parents had bad arthritis without ever suffering serious joint injuries (my dad even had both knees replaced), so maybe I was doomed anyway.

It's life altering, isn't it?

I wasn't "okay" for several years after the surgery. And my knee was never the same again. It's just not possible.
But you can get back to close to where you were.
You are not very far out at all from your surgery.

 

[floatingyardsale]

Arthritis is weird. Most adults will show some kind of degeneration in their knees on an MRI but it doesn't really correspond to symptoms at all.

 

[contesstant]

Arthritis is weird. Most adults will show some kind of degeneration in their knees on an MRI but it doesn't really correspond to symptoms at all.

Until menopause! Then it's like "damn, I hurt ALL THE TIME!" Hormone therapy helps a ton. Estrogen is amazing.