Torn ACL

[Bruno Schull]

Hi Folks,

Bad news--my wife tore her ACL skiing last week. She just had the MRI. Her ACL is almost completely torn, hanging on by a little bit. Not an equipment problem, skis, boots, bindings all in good working order. Just skiing in misty conditions, and slipped and fell, not at high speed, but had the bad luck to fall incorrectly.

I feel sad, because she was having a great season, skiing well, doing tours, skiing side piste and back country, having fun, feeling healthy and fit...and now she faces a long recovery.

I understand because in the past I have had two knee surgeries and one foot surgery (not from skiing).

So the big question is, should she have surgery or not?

I'm sure she can get her knee back to a relatively pain-free and semi-stable state with no surgery, but would she be risking greater injury in the future?

If she has surgery, the recovery will be longer, and she may end up with a stronger and more stable knee, but there are no guarantees.

She is 47, active, fit, but like many people could do more focused exercise and strength training. Doing outdoor sports like mountain biking, hiking, and skiing are a big part of our lives.

What are positives and negatives of having or not having surgery?

So frustrating. I feel really bad for her.

OK, thanks,

Bruno

 

[François Pugh]

There are no guarantees, but what are the odds? I would go with the Odds. A good physiotherapist can help a lot, but if 2 out of 3 medical doctors who specialize in these injuries say the odds of being better off a year from now with the surgery, then surgery it is.

 

[Nancy Hummel]

I am sorry about your wife. She sounds very active. I had ACL surgery almost 20 years ago. I am so thankful I had it. If she has surgery soon, she will only miss next season.
I think the long term benefits of an intact ACL are worth a season of revovery.

With the use of cadaver grafts, the pain/healing is not as bad as it was with other grafts. (So I have been told by friends who have had both).

 

[VickieH]

If she has the surgery soon, she may not have to miss next season. IIRC, @Monique suffered the injury toward the end of one season and was able to get back out the next season ... maybe not on day 1 and not full-bore right away.

Reviewing Monique's journey might help in making the decision. She was really dedicated to her recovery.

 

[Monique]

If she has the surgery soon, she may not have to miss next season. IIRC, @Monique suffered the injury toward the end of one season and was able to get back out the next season ... maybe not on day 1 and not full-bore right away.

Reviewing Monique's journey might help in making the decision. She was really dedicated to her recovery.

My doc said I could go back at 6 months post recovery on very very easy stuff with no chance of falling. Certainly no bumps. Well, I sort of followed that - I skied things where I had no chance of falling, which to me included people skiing into me.

I actually suspect I may have been too aggressive with rehab, having feared that I wouldn't be cleared at 6 months.

My knee still causes me a fair amount of trouble. It's hard to say exactly why. I had autograft patellar tendon, and I had some meniscus repair, and I have a chronic disease that causes inflammation. My main problem seems to be a little swelling and a lot of my quad muscles going on lock down and not letting my kneecap move freely. Powder is much, much easier on my knee than groomers, so I recommend skiing powder as much as possible ;-)

 

[VickieH]

A woman on the Ski Diva forum opted to not have surgery. Her experience is documented here.

 

[Bruno Schull]

I really appreciate the replies so far. I think my wife is leaning toward surgery. She has no other soft tissue damage, no meniscus problems, and so on, just the ACL. At 47, she's a little older than when the doctors would immediately recommend surgery, but she is active, and it's important to her to stay active. The doctors have suggested that she wait until the swelling and acute injury heal somewhat, then decide in about 3-4 weeks. If she does have surgery, I think it would be in mid-April, and that would give her about 8 months before the new year, which is about when she would like to start skiing again (slowly and gently). She does hope that she can return to other activities, such as cycling, much sooner, hopefully as part of the recovery/rehabilitation. Right now, I think she is coming to terms with the hours that will be needed in physical therapy and "running" in the swimming pool. I've been trying to encourage her that she can come back stronger than she is now, is she really works hard. I'm going to help her make a recovery plan, and I assembled a great deal of photos of she and I and our daughter doing the outdoor things we love to help get her on the right track.

Any thoughts about when people can get back on a bicycle post-surgery? Two months? Three months?

Any other recommended recovery sports?

This is probably more for the doctors to discuss, but any thoughts about patellar tendon vs. hamstring vs. cadaver grafts?

Thanks again.

 

[Spring1898]

Given her activity level, surgery is probably her best bet. If it was PCL, that would be a different story, but success with ACL repair with rehab is very high and a relatively common procedure. With the time frame around injury, she is likely to be ready for next ski season barring complications.

BUT with every surgery there is risk, and this needs to be well discussed ahead of time with your surgical team.

The advantages of Allograft via Cadaver are that there is no need for an additional harvest procedure to acquire the needed replacement. As long as she doesn't mind have a cadaver part. The recovery can be longer but at her age any healing would be longer than a highschooler or college level. The cost can also be higher, so check your insurance coverage. Another advantage is that this leaves the other tendons as options in case of additional injury.

BUT your surgeon will likely have a preference so listen to him or her rather than a forum post.

Assuming no complications, rehab would begin ASAP as acute swelling and pain allow. ROM exercises begin first, followed by strength, and integration of sport-like activities. Around week 8 she may be able to start linear activities. Stationary bike, swimming, walking, and even light jogging.
You want to avoid any side-straining activities which would stress the repair. I would avoid biking out and about as a risk for a fall and having to catch oneself on the injured side.

BUT your physical therapist and surgeon will have rehab plans they use regularly and will be monitoring her exact progress.

From month 3 on, it is a balance of increasing activity while understanding that the graft, like a transplanted plant, has to "take root", and it will "feel" secure long before it is fully healed. I would assume no earlier than 6 months from surgery.

Remember, a failed repair is worse than one that was not surgically repaired, but done well she would be expected to recover very well.

 

[agreen]

Well ,I am a doctor who tore the ACL a couple years ago and opted for the surgery. I had the cadaver graft. I had the surgery beginning of June and skied groomers mid Dec, powder late Dec, and bumps/crud/steeps mid Feb and on. I have had zero issues. My brother had both ACLs torn, one 10 yrs after the other. The 1st he had the patella graft and has had anterior knee pain and patella tracking problems ever since. The 2nd he had the cadaver graft with zero problems. I realize this is complete anecdotal evidence but I know which surgery I would opt for and I would definitely recommend having a surgery for her active lifestyle.

As a side note, I tore the ACL 2 weeks prior to a pre-paid Snowbird trip. I wasn't sure I had torn it at the time so I aggressively rehabbed it for the 2 weeks, bought a sturdy knee brace, and went on the trip. Snowbird received 2-3 feet of snow during my trip. My first run was in mineral basin in deep pow. 1st turn no problem, 2nd turn I felt my knee "give-out" and I wiped out. Had to ski on one leg down to the bottom. I was able to ski groomers and easy powder runs for the remainder but always with that fear that I would feel that big clunk and feel the bones grinding on themselves. I have a feeling even with major PT/strengthening I would never have been able to ski worry-free like I do now.

Good luck to her, I hope everything works out well.

 

[Brad J]

She is 47, active, fit,

I was 44 when i ruptured my ACL, I was self employed and had a young family and a business to run so I opted to rehab , I like another responder skied on it two weeks after for 3 day and had no real problems, I rehabbed over the summer and had a sweet brace made and after 19 years still no real problems, My doc was surprised how stable my knee was after rupture so I thing thats the difference. If its stable rehab if not operate and then rehab, either way its a lot of work and PT is the key to how the future will be . I wish her well

 

[Monique]

She does hope that she can return to other activities, such as cycling, much sooner, hopefully as part of the recovery/rehabilitation.

She absolutely will. If you haven't yet, invest in an indoor trainer for her bike or a stationary bike (not spin - that's too much force). They'll want her to work on ROM almost immediately, although possibly with restrictions (I had restrictions due to meniscus damage). But just slowly moving around that circle is good.

Note that extension is much harder to recover than flexion, so that is where the bulk of the work should be. Expect painful PT. I was religious about elevating my heel so that my knee would straighten. I even bought 5 pound strap-on sandbag style weights and used two at a time on my knee to force the issue.

Any thoughts about when people can get back on a bicycle post-surgery? Two months? Three months?

When the doctor agrees, period. Each doctor has a very specific protocol that will work with THEIR approach, and you really don't want to take the word of people on the internet. First she has to be cleared for full ROM. Then she has to be at the point where stepping off the bike suddenly isn't a risk of tearing again. This will be dependent on autograft vs allograft and a host of other things. But again, doctor knows best.

This is probably more for the doctors to discuss, but any thoughts about patellar tendon vs. hamstring vs. cadaver grafts?

There are no good answers, just choices with tradeoffs.

After the fact, I have come to the conclusion that the arbitrary "age 39" cutoff is due to one simple fact: autograft hurts more for longer. Bear with me. Allograft feels better sooner, but is weaker longer. Therefore the patient must be capable of listening to their doctor's instructions rather than their body. Autograft feels worse for longer, but it is stronger sooner. It helps to keep overeager patients from pushing too hard. This is purely my speculation, but I have found no discussion on the internet (perhaps it's in medical literature behind a paywall somewhere) attempting to EXPLAIN the age 39 results. It's simply a documented correlation.

Patellar graft can cause difficulty kneeling. Hamstring graft will weaken that hamstring. Allograft you have to hope that the cadaver was good enough. It's possible and unpredictable, but unlikely, that an allograft won't take - it's not rejected, but the vascularization can fail to happen. Choose your poison. If you have a favorite doctor, chances are HIGH that they only do one form of autograft, so that might be the determining factor more than the particular choice.

There are other ones, too, like Achilles tendon and I think even quad. You'd probably have to go out of your way to find someone like that.

 

[Snowfan]

Don't overthink it. The recovery is not to be feared as "long". Mine, 8 years ago, at 47 yrs old, was a piece of cake. Hamstring graft. April 8th surgery, skiing on December 15th.

She could easily be skiing next season. Get it fixed asap. Not getting it fixed would likely be a terrible mistake.

 

[Brian Finch]

Yes - 47 is the new 27.

Seriously return to sport 9mo post op is the literature based, current best evidence for a solid outcome.

Best,
Brian