Mt. Whitney Portal Store & Hostel Forums General Mt. Whitney Portal Store Message Board Any Ruptured ACL's out there?

Just got back from a ski trip in Crested Butte and returned without my ACL intact. Now I face the surgery decision. I'm 46 and still want to ski, snowboard, bike, and hike the JMT. Do I need surgery? What are the indicators? Doctor said each case 'presents' itself differently and that I may not require surgical repair but it is hard to imagine doing such activities without the ACl replaced. Any thoughts/experiences?

Thanks,
BK

Good morning, BK. Rats! What a lousy way to come home. I heard something pop in my left knee last weekend at Mammoth myself, headed to the ortho today (for various things, but that's second on the list).

I've seen it go both ways in this situation, and I think it depends, in part, to your physical conditioning prior to the incident, and then to how much work you're willing to put in for the rehab. Both options require a lot of focus, but you're accomplishing slightly different things.

Your ACL is important in controlling the forward/backward motion of your femur (thigh bone) over your tibia (shin bone). When your knee bends and straightens, there is a translation/gliding that occurs to keep the rounded ends of the femur directly over the plateau of the tibia. Without the ACL, that translation is controlled by the remaining ligaments and the cartilage, but at a cost of increased stress on those structures. Also, their lines of pull on the bones are not optimal, which is what leads to the instability in the joint, especially when you are bearing weight through it.

Because you engage in very high-level activities like the ones listed, I am assuming that you also have a high level of kinesthetic (body awareness) sense and have good control over fine movements at all of your joints. But I could be wrong: I've had plenty of high-level athletes who were, as I affectionately refer to them, "Motor Morons" and really don't have a good connection to where their body is in space. This skill is essential for rehab in general, but if you are planning on returning to such high-level activities without replacing the ACL, it will truly become a test for you.

I am also assuming that you had a complete tear (good job! Why do something just halfway! ), and they also did not diagnose any meniscal/cartilage damage. Is this true?

OK: enough background. First, I would recommend a second opinion from a surgeon out here to evaluate the instability in your knee. Then (another shameless plug for my profession), I would recommend a course of PT to see how you tolerate the rehab without replacing the ligament. The PT and ortho can coordinate care and make recommendations as to braces (for high-level activity only, not daily use if you can avoid it) and further exercise/activity progression. If you don't see changes after sticking with a consistent program for 2 months, then it may be time to consider surgery. Take pain levels and swelling into account, too.

You listed some really high goals above of what you want to get back to once all is said and done. Remember your baby steps: first you get back to walking normally and with good control at all speeds. Then you walk on inclines/declines without your knee feeling like it's going to buckle underneath you. Then you start integrating lateral/sideways movements into the equation, then rotational... You see where I am going here. Baby steps...

Quick story to end: I was once working with a patient who had torn his ACL skiing. BIG guy, active, but really BIG. He worked like a train at his rehab (without any repair, so no ACL), losing 45 pounds, and was all set for discharge. (I remember him picking up a 45lb plate in the clinic and saying to me, "I used to carry THIS on my body??) One day after his workout, he was going to sit on a table to ice his knee when he reached under the table for a magazine and something in his knee popped. His meniscus had let go, apparently tired of taking up the slack. He ended up having surgery after all and once again did great, but it was a bit of a setback for him. Just shows some of the risks involved either way.

I hope this helps. You can pm me if you have any other questions!

-Laura

BK - I'm not a doctor or physical therapist like Laura, but I can share my experience. I trashed my knee waterskiing - pulverized the MCL and partially tore the ACL and PCL. The doc was amazed I could even walk, so rather than rush in to surgery (and replace all three as originally suggested), I had 6 months of p/t (as Laura suggests)to see what would happen. In spite of the tears to the ACL and PCL, I wasn't exhibiting the instability or slipping that one would expect, so my surgery ultimately was to replace the MCL and do some clean up. The benefit of the p/t beforehand was that I had strengthened anything and everything that hadn't been damaged, so recovery after surgery was much less complicated. My knee will never be the same, but I've learned to live with it with some modifications (the only thing I've absolutely been forbidden from doing is waterskiing). I wear a heavy duty ortho brace for snowskiing and really long hikes (especially if there is a steep downhill). It's a bummer, but considering the damage, I feel very lucky.
Laura is absolutely right about the body awareness. Another piece is your level of perseverance. When I was in p/t, it was amazing the number of patients who just whined and complained and never put any effort in to their rehab. They had to peel me off of the equipment - it felt so good to be doing something physical.
What ever ends up happening, good luck to you.

Well I certainly appreciate the thoughts and effort put into these responses. The rupture was complete, there is nothing left of a connection. I'm pretty lightweight already (6'1", 140 lbs) so there's not much wiggle room in that category. I feel like I'm in decent shape, biked across Iowa in the summer. work out weekly. Hopefully those things will help. I will try to keep the baby steps in mind (just like Bill Murray in "What About Bob?") - I'm a bit impatient since I have family airline tix to Denver in two months. Since I almost can't imagine not having surgery I needed a little braoder perspective. Thanks again and Laura I may take you up with further questions as this thing develops.

BK

Hi,

I had Arthroscopic Knee Surgery about 25 years ago (cartilage removed and cleaned up the ACL which was about 2/3 gone)

Then about 15 years ago I had an ACL replacement after a injury at work (playing basketball), during PT they think I pulled it loose and after having a PE (Pulmonary Embolism)and dealing with that they recommended I wait as long as I can to have it redone.

So since then I have been operating pretty good without it or at least with a loose one. I am a Firefighter and hit the treadmill almost every day at work and hike almost every week. The wife and I climbed Whitney last August as a day hike with little problems (other than going slow). The down hill pressure on the knees is the worst for me but I use poles and they help.

All I do is take Joint medicine and try to be careful were I step. The time line for me from surgery to back to work was 6 or 7 months.

Hope this helps,

Ron

sorry about the injury BK.

i ruptured my L ACL in 2004 mountain biking.

i had two opinions and two MRI's to help me make my decision. i also snow and water ski, hike, mtn bike and until then had been an avid trail runner.

they say that if you are not an athlete you can live with a ruptured ACL (as long as there isn't severe instability.) but i am an athlete, so that was not an option.

i always recommend a second opinion and if you're still not sure, a third. i'd advise you to see the knee specialist in your community or at a teaching university and consult with them. i also would choose an orthpaedic surgeon who does this surgery ALOT. not someone who mostly does shoulders, low backs, etc. i had reconstruction with a graft two months after the injury. i had such severe swelling that i needed to have PT to regain some range of motion with lots of ice before i was ready for surgery.

the slow recovery was the hardest part for me. i tried running at 8 weeks and that was not smart. i was snow skiing at 5 mos post-op, but could only ski one day and then ice my melon-sized knee for two days. it would have been wiser to skip that first season and snow ski 18 mos post-op. i was backpacking at 12 mos post-op, in pain. in hindsight at our age, it takes a good 18 mos to stress your knee with activity, without taking two steps back in recovery. only last year did my knee stop swelling from activity.

now 4.5 years later i can do everything but run. that was a bitter pill to swallow, but i now hike trails passionately to make up for the hours i spent running them. turns out you see more wildlife when you go at a slower pace and sure do get to smell the wild flowers!

good luck and remember ice is your friend.

Great advice here. Laura as usual is spot on.I have seen many athletes continue their sport with grade III complete ACL tears without surgery. Stability is the key and the sport you pursue makes a huge difference.
One thing you should look into is Prolotherapy. Prolotherapy is an alternative to surgery. Prolotherapy is a sterile dextrose solution injection into the site of injury and helps the body repair musculo-tendonous and ligament tissues. I have had amazing success personally on 2 torn shoulder tendons. You can google Prolotherapy to look into the procedure.
I know of 2 great MDs in SoCal that perform prolotherapy. Where do you live BK? I would be glad to forward their information or list links to websites.

Just a few things to add to the discussion: Like Laura said, your muscles can supply a great deal of the stabilization in an ACL-deficient knee. I've seen figures of up to 95% of the stability. I believe Hines Ward of the Pittsburgh Steelers (my team, incidentally) plays football without an ACL in one of his knees. However, you will note that most athletes get reconstructive surgery done on the knee, so, depending on the type of activity, in most cases these athletes or their doctors see it as necessary for a return to full participation in their sport, so as some of the posters have mentioned, you may have a decision to make as to what level of activity you wish to return to.

I have a couple of concerns. You mention that you are 6'1" and 140 lbs. Are you male or female? If you are male, that's fairly light; I mention this because if you are going to depend on your leg muscles for stabilization in the sports of your choice, you are probably going to have to put on a good deal more muscle on your legs than you have right now. Take a look at Ward, and you'll get an idea. Bird legs won't do it. In particular, your hamstrings are going to have to bear the brunt of preventing anterior translation of the tibia, so they are going to have to be resistance trained fairly vigorously. Proprioception is important, but if the muscles aren't strong enough to convert the proprioceptive signals into the appropriate forceful muscle contraction it won't matter.

Another concern is the rehab. As others have said, it is fairly intensive and time-consuming. You have to be patient. Unfortunately, one of the complications that occurs with individuals trying to do too much before they can properly use the knee is rupturing the ACL on the GOOD leg, due to favoring the other leg and therefore putting too much load in biomechanically unfavorable positions on the opposite leg, so you have to be careful you don't get impatient and try to snowboard, etc. just because you have one good leg. There can be other complications as well depending on the type of graft you choose. This is usually dependent on the type the doctor you choose favors, but you might want to research the different types.

Lastly, the scientific and medical literature now shows that the majority of individuals who do not have replacement will be more likely to develop osteoarthritis than an uninjured individual or one who has ACL reconstruction. Keep in mind that the older you get, the more difficult the recovery process will be and the more reluctant some doctors will be to perform the surgery.

Good luck!

As a light-weight male, I do have the bird legs. I will see how the PT goes when I start next week, but as I've said for some reason It's hard to see avoiding the surgery. I will have to try and be patient. Thanks for the input though; this will give me some things to think about. It is good to know there are positive experiences on both sides of the coin. As easy as that thing seemed to pop it's amazing it didn't go sooner.

BK

Seriously BK check out Prolotherapy before you have surgery.ACL reconstruction is serious stuff. They either have to harvest tissue from somewhere on your own body (ie. patellar tendon, IT band etc.)or use cadavier tissue with its possible rejection potential and contaminated cadaver issues.
Not to be taken lightly IMO. Surgery is only as good as the surgeon and the rehab long and arduous.

Hey Doc,
Just checked out the prolotherapy.com website to see what they have to say. They indicate "the treatment causes the proliferation (growth, formation) of new ligament tissue in areas where it has become weak." In my case where the ACL is completely ruptured and there is no longer any connection do you still feel the treatment offers some remedy? I'm in the Cincinnati area. If you know of anything local I would be interested in getting an opinion.

Thanks

BK yes it is my understanding that prolo will help regrow torn tissue to include grade III rupture.I will call the 2 MDs I know that perform prolotherapy and ask if it is indicated in grade III ligament tears and if they know of someone in Cincy.Certainly worth investigating.

BK check your PM box

Does anybody speak English any more?

This whole thread makes no sense at all...It appears the pharmaceutical commercials on TV and text messaging have reduced meaningful speech to using single letters...

Near as I can figure, someone's American Civil Liberties is ruptured and they may need Part Time (PT) help this afternoon (PM), from a lawyer, I assume?

I've been living with a torn ACL since 1975. (I think the only possible treatment back then involved leeches and poultices, anyway.) I'm still hiking when I can, albeit with my fingers crossed...

BK, sorry about the ACL rupture. Here's my story:

Three years ago (2006) in late February, at the age of 50 (5' 10" and 140 lbs.), I ruptured the ACL in my left leg while skiing at Squaw Valley. Although I didn't feel anything at the time, I knew it was gone because I felt like I was dead drunk while walking.

My doctor confirmed that my ACL was completely torn and that I had some meniscus damage. Three weeks later I had surgery and my ACL was replaced with an Achilles tendon from cadavar tissue.

Recovery after ACL surgery is arduous. For the first week I was on my back with a brace and had to use a knee extension machine quite frequently. Sleeping was almost impossible.

I then started therapy. Be prepared to take alot of time if you want get back to "near normal". Progress at first was slow but I was highly motivated and was up and running in a couple of months. I competed in some races a few months after. Still, my times were nothing to brag about. During the summer I started golf. I skied again the next January.

Although I was proficient in all of the activities that I participated in prior to the ACL rupture (hiking, running, swimming, skiing, golfing), my left leg was never quite "right". I wasn't able to get full extension and I felt somewhat unbalanced and weak in my left leg. So running and other activities were never quite as efficient as they were prior to the injury.

Also, six months after surgery, while running, my knee was hit by an SUV.

Even so, I was able to climb Mt. Rainier in 2007 and Mt. Hood last year. After long hikes in Yosemite (e.g. Cloud's Rest) this past summer I was starting to feel more pain in my left knee.

In October I visited my knee doctor. After taking an MRI he indicated that my left knee had some scaring as a result of the ACL operation and subsequent overstress. I decided that I would once again go under the knife to correct these problems.

I had surgery the first week of November. Recovery and therapy was nothing compared to the ACL operation. Six weeks after the operation my knee was able to fully extend and flex. It felt remakably more balanced and stronger than before surgery. I continue to do therapy at home by balancing on a BOSU and performing strengthening exercises.

In January I was able to run some personal bests!

However, just recently, and unrelated to my surgery, I pulled the groin in my left leg while skiing and turning on some ice. I was laid up for a week in some pain. My leg turned completely black and blue. Oh well, I guess it's just an unlucky leg.

I'm once again running and will go skiing in a couple of weeks. I expect to have a full summer hiking in the Sierras and Cascades and perhaps, Kilimanjaro.

Good luck BK.

BK

Was surgery immediately an option? My wife completely tore her ACL & partially tore either her MCL OR PCL skiing at mammoth 20 yrs ago. They took her down the mountain on a sled at about 1:00 and she was in surgery by 10:00. I remember the Dr. saying that the sooner the surgery the better. That the ligament wouldn't have shrunk much and the end would be in better shape to repair.
I hope you do well whatever you decide

Steve

Steve, I hope that your wife's knee is doing well to this day.

The optimal timing of ACL reconstruction is, well, a topic of discussion. Several years ago, just for fun, I attended a conference that featured lectures on knee and shoulder injuries for the non-orthopedist. The speakers were Kaiser orthopedists (I too am a Kaiser physician). Of course, ACL tears got much air time. Our orthopedists were concerned when our Northern California members sustained knee injuries while skiing at Lake Tahoe. Once taken to a Tahoe-area hospital, the local orthopedists would recommend surgery ASAP. The problem with that advice? It's fraught with self-interest - any delay in surgery would result in the surgeon getting no reimbursement, since the patient will return home to get reconstruction elsewhere.

Our orthopedists did discuss the prevailing literature. Although the "best time" is unclear, the consensus is the outcome is better when the knee has no effusion, full range of motion, and adequate strength. Hence, immediate surgery, when the knee is swollen, is not optimal. There was one review in 2005 that showed that 70% of patients who had signs of knee swelling and inflammation at the time of ACL reconstruction went on to develop arthrofibrosis (essentially scarring of the joint.)

I'm willing to believe that, 20 years ago, the surgeon who advised your wife to be operated on that day was using the prevailing beliefs of the time. Of course, he may have had other motivations as well.

PS: I do not wish to cast ski resort orthopedists in a bad light. Way back when I was a medical student, a few of my classmates who were interested in orthopedics were able to rotate through Barton Memorial Hospital in South Lake Tahoe, when the famous Richard Steadman was there. (He was one of the pre-eminent ski injury orthopedists who eventually moved to Colorado Springs and serve the US Ski Team.) My classmates would tell me that injured skiers would come in, and think, "No way will I be operated on in this little podunk hospital", not realizing he was a world-class knee specialist.

From the talks I've attended at American College of Sports Medicine conferences, most orthopedists subscribe to what enf has stated in his post. Many surgeons will also prescribe prehabilitation physical therapy if there is no meniscal damage in order to cut down on recovery time. I can tell you from having worked with individuals with the condition and from what I have read on forums that arthrofibrosis is not something you want to develop, and is a bear to deal with, as most surgeons do not have the skills to deal with the condition. Incidentally, the one surgeon who is considered an expert? Richard Steadman, of the Steadman-Hawkins institute in Vail!

I had my ACL done at age 28; even at that relativley young age, some advised against surgery. My doc asked my activities and said w/o a doubt I should have it done. I did not hurt my knee skiing, I did it local - so those concerns listed above would not have been in play.
These were key points to my doc


My wait from injury to surgery was about two weeks. This was about the time it took to see doc, schedule MRI, have MRI, see doc, schedule surgery with insurance approval. During this time I was getting a lot of PT. By the time of surgery I had very little swelling and most of my strength and ROM. I know others that waited up to 3-6 months. I wanted to get it done and over with and get on recovering.

I had the patella tendon method done and also had a medium bucket handle meniscus tear. I was awake and watched my surgery - very cool.

I began PT post surgery at three days and I felt this key. Some patients I met in PT had less aggressive docs who didn't send them to PT for many weeks. Those patients really suffered.

Since my doc has two kids to send thru college, I've since torn my meniscus twice more in the same knee and now am left with what my doc call about "5% - just to say you still have something there". During both of these subsequent surgeries my ACL graft was examined and reported fine.

It's been 15 years and I still run, hike, ski, snowboard, cycle, play hoops, football etc. It was about 9 months post ACL repair before I could do these things - on doc's orders for graft strength. I essentially lost an entire ski season. I am fortunate with no meniscus. My only problem is that I cannot run hard three days in a row - that's the only time I experience any knee pain (so far)

So, should you choose surgery, you also have to look at what type - cadaver graft, patella graft or hamstring tendon. There may be even other choices.

That's just my experience