ACL Injury For Skiers

 

Living without an ACL is quite possible, but ACL deficiency carries some risks with it. In addition to an increased risk of damage to other structures in the knee during a future injury, the ACL deficient patient is at increased risk of osteoarthritis in the longer term . The ACL provides vital lateral support for the joint, and without this support the knee joint is more susceptible to instability, buckling, and wear and tear during lateral movements. The risks of further damage increase if you have an active lifestyle that includes participation in sports, especially those which require cutting and pivoting (for example: soccer, basketball - and skiing.) 

 

You can reduce the risk of further damage considerably by participating in a strengthening program to build up the muscles around the knee, compensating for the loss of the support provided by the ACL and increasing the stability of the joint. Hamstring strengthening and functional training is vital in living an active life without an ACL in that the hamstrings will perform the function of preventing the tibia (lower leg) from moving forward on the femur (thigh). This program should be managed by a professional physiotherapist as certain exercises should be avoided until the leg is strong enough to manage them. In addition, a ligament brace can help protect against the kind of excessive lateral movement that can put the knee at risk of injury.

 

(More information at: http://www.wheelessonline.com/ortho/natural_history_of_the_acl_deficient_knee)

 

 

Generally ACL deficient patients fall into three roughly equal groups. A third are able to continue with all activities, including sports, without problems (copers). A third can live without an ACL, but have to give up sports and activities that place particularly strenuous demands on the knee (adapters). The final third have such severe instability following an ACL tear that even everyday activities become challenging (non-copers).

 

The challenge is that without an attempt at conservative therapy (i.e. the kind of strengthening program mentioned above) it is very difficult to know whether you're going to be a coper, an adapter, or a non-coper. For some people the choice to devote some months to physiotherapy in an effort to avoid surgery is an easy one, but for skiers this may mean the loss of a full season or more.

 

(More information at: http://bjsportmed.com/content/40/10/853.abstract)

 

 

In general, the more active the patient the more strongly recommended it is that they seek reconstruction. Reconstruction is usually considered essential for professional athletes, and encouraged for anyone who has an active job or for whom sports are an important hobby. (It should be noted that as with any rule, there are always exceptions - that's part of what makes this a hard decision.)

 

Ultimately the decision to opt for or against surgery is a very personal one, but the most significant factors to consider are:

 

 

Seeking advice from an orthopedic surgeon is highly recommended before making a final decision. The surgeon can assess the level of laxity in the joint, and provide an estimate of the risk to the long-term health of the knee. An excellent list of orthopedic surgeons specializing in knee problems can be found here: http://www.kneeguru.co.uk/KNEEnotes/knee_surgeons_around_the_world.

 

If you opt for surgery, the optimal time frame is generally considered to be approximately six weeks after injury. Although some surgeons will operate right away, most require you to go through a "prehab" program to ensure that all swelling is gone and you have regained full range of motion in the knee (ROM) before operating. A patient going into surgery without full ROM will find it very hard to regain normal ROM afterwards, so this initial delay is in the best interest of a successful outcome. If surgery takes longer for reasons outside your control, which is often the case, make sure you're working with a physiotherapist and looking after the knee joint appropriately (e.g. by wearing a brace as required) in the meantime.

 

(More information at: http://www.ehealthmd.com/library/acltears/ACL_have.html)

 

 

During an ACL reconstruction the remains of the original ACL are removed, and a graft is placed through tunnels that have been drilled through the tibia (shinbone) and femur (thighbone). The graft is then fixed in place with bioabsorbable interference screws (these gradually integrate with the new bone growth in the tunnel over time) and/or endobuttons (a small, button-shaped device that is wider than the tunnel and sits at the end of it), and sometimes staples for extra security.

 

When the new graft is placed in the knee, it initially undergoes a period where cells die off and it becomes progressively weaker. It then gradually develops its own blood supply, and eventually lays down collagen and begins to resemble a true ligament. While the graft is revascularizing, it is very vulnerable to damage and stretching and so the early stages of rehab focus on regaining joint mobility while protecting the healing graft. As the graft strengthens and new bone growth fills the tunnels, more advanced exercises are introduced.

 

The exact duration of an ACLr rehab is dependent on both the choice of graft, and the individual surgeon. Commitment to rehab on the patient's part is a vital component of the success of an ACLr.

 

Autografts: hamstring, patellar tendon, and quad tendon

Allografts: donor tissue

Synthetic ligaments: LARS

 

LARS ligaments are the current generation of synthetic knee ligaments, made from industrial strength polyester fibres. These are gaining popularity as an alternative to auto- and allografts, but remain a relatively recent development as an option for ACL reconstruction. Earlier generations of synthetic ligaments were prone to failure in the longer term, leading to serious complications for many patients.

 

LARS ligaments can be used on their own or as a scaffold for an autograft. Generally a LARS ligament requires the stump of the torn ACL to be in place, and ceases to be a viable option for older injuries.

 

The biggest advantage of LARS ligaments is that they enable a much faster return to activity than a tissue graft. Many LARS patients are able to return to sports between 3 and 6 months following surgery. Post-operative pain is also reduced because no harvest site is required, and there is no risk of disease. Short-range data (up to 5 years) indicates a very successful outcome for the majority of LARS patients.

 

However, because LARS ligaments are relatively new, there is currently no long-term (10 years+) data on the success of these ligaments over time. Additionally, LARS ligaments require the drilling of much larger bone tunnels than auto- or allografts, making revision of a failed reconstruction more difficult.

 

More information at:

 

http://www.larsligament.com/

http://www.sportsci.org/encyc/aclpros/aclpros.html

http://www.thesportsphysiotherapist.com/acl-reconstruction-with-the-lars-ligament/

 

Experience

 

There are pros and cons to all graft options, and the right choice will depend on your own preferences, goals, and required timelines. However, a very important factor in choosing a graft is not necessary the graft itself, but your surgeon's expertise with it. Given the learning curve associated with ACL surgeries (see link in section below), you want your surgeon to be confident and comfortable performing surgery with your chosen graft type.

 

Choosing your surgeon

 

Depending on your country of origin, this may or may not be an option for you. But if you do have some say in who carries out your surgery, the most important question is how much experience this particular surgeon has in ACL reconstruction. Recent studies have shown that ACL surgery has a very steep learning curve, and the odds of an unsuccessful outcome are higher with an inexperienced surgeon.

 

More information at:

 

http://www.hss.edu/newsroom_steep-learning-curve-acl-surgeons.asp

 

What to expect from surgery

 

Generally, ACL reconstruction is performed under general anaesthetic as a day surgery, enabling you to go home the same day. 

 

Because the surgery involves bone drilling, you can expect to be in quite a bit of pain immediately after the surgery. Your surgeon will prescribe pain medication for the first week or so. Be sure to take this on time, and set your alarm so that you can take it on time throughout the night. It's much easier to stay ahead of the pain from the start; if it gets ahead of you, it can be hard to catch up.

 

Post-operative protocol varies considerably depending on the surgeon, injury, and type of graft used. You may be prescribed a brace to wear for a set length of time after surgery, and advised to spend a certain period on crutches before attempting to weight bear; or you may be advised to start partially weight-bearing as soon as you are able. Your surgeon will also let you know when you should start seeing a physiotherapist, and may give you gentle exercises to do in the meantime. 

 

Your surgeon should provide you with instructions about post-operative care and weight-bearing either before or after surgery. It's very helpful to have a family member present to take notes, as under the circumstances their instructions may be hard to remember! Some helpful surgeons will provide written instructions, but not all do.

 

For most individuals with a torn ACL, reconstruction will restore stability to the knee. In most cases you will be able to return to previous work and athletic activities without any residual issues. Approximately 90% of individuals return to their previous level of function without any restrictions once proper post surgical rehabilitation has been completed. A protective brace is often recommended when skiing for precautionary measures, at least for the first season back on the slopes.

 

Rehab and Recovery

What to expect from rehab

 

Remember, surgery is the easy part. The hard work - and ultimately, your successful return to the slopes - depend on your dedication to rehab. 

 

First of all, find yourself a good physiotherapist who has plenty of experience with ACL rehabilitation. Secondly, make sure you follow your surgeon's protocol and physiotherapist's instructions to the letter. The graft will be fragile at first, and the limitations of early rehab - which rapidly become frustrating as your mobility and strength increase - are specifically designed to protect it. 

 

This description is very useful for understanding exactly what happens to the graft after it's implanted in your knee. http://www.kneeguru.co.uk/KNEEnotes/node/1644.

 

If you live alone, make sure you're prepared to be quite immobile for at least a few days after surgery. Prepare meals that can be frozen and quickly reheated in a microwave or oven; make sure you have a good stack of books and DVDs to keep you occupied. If you live with someone (or multiple someones), make sure they know that you're going to need lots of support. Rest in the early stages is critical to the healing process. Don't make anything harder than it needs to be; sleep downstairs for a few days if your bedroom is upstairs, and don't be afraid to ask someone to stay and help out for at least the first 24 - 48 hours.

 

Physically, the first few days after surgery are the hardest. You'll spend most of this time lying down with your leg elevated; it's important to keep the knee above the heart (this encourages blood to drain out of the knee, reducing swelling) and to ice regularly. A Cryo-cuff (a simple machine that allows you to continuously cool and compress the joint) is an excellent investment that is worth its weight in gold at this stage, as you can fill it with ice and it's good for 6-8 hours. This saves trips to the freezer for additional ice packs. Don't be tempted to put a pillow under the knee when you're resting or sleeping, even though this is the most comfortable position to be in. This encourages the knee to stay in a slightly bent position, which isn't a good idea when you're trying to regain extension (critical to walking with a normal gait, and one of the most important things after ACL surgery). Putting a pillow or prop under the ankle and leaving the knee unsupported allows gravity to encourage it into full extension.

 

In addition to pain from the surgery sites, something that's often overlooked is the "blood rush." This is where the surgical haematoma rushes down the leg when you go from a sitting to a standing position, and it causes pain in the calf that can be excruciating. It can't be entirely avoided, but moving very slowly to an upright position will help. If the pain seems unusually severe or persistent, don't hesitate to ask your OS or family doctor to take a look. Excessive pain, swelling and redness can all be signs of a DVT (deep vein thrombosis), so it's worth taking seriously.

 

You'll most likely experience lots of other additional aches and pains, and sensations so strange you have no idea how your leg could be producing them. (ACL surgery often involves severing a branch of the saphenous nerve, which leads to a lot of very unusual sensations as the nerve responds and regenerates.) Checking in on the Knee Geeks forum is great as a quick temperature gauge as to whether what you're feeling is normal and expected, but again don't hesitate to talk to a medical professional if you have concerns. That's what they're there for, and it's always better to play it safe.

 

Early rehab exercises focus on regaining flex and extension while giving the joint time to heal. Later exercises work on restoring strength, and ultimately preparing for a return to activity. It's a long process, and at times can seem incredibly frustrating. Remember - it's a marathon, not a sprint, and it will be worth it in the end.

 

The following is an example of a fairly standard ACL rehab protocol. Your individual protocol may vary quite considerably depending on your surgeon's preferences and the type of graft used in your reconstruction. Remember, your physiotherapist is your best friend in rehab. If you don't feel fully supported, your PT deviates from your surgeon's rehab timeline, or you have other concerns, get a second opinion. It's much better to be safe than sorry.

 

Phase I: Pre-Operative Phase

 

Goals:

 

a) Restore normal motion of knee

b) Restore normal walking

c) Mentally prepare for surgery

 

Exercises:

 

a) Stretching, active assisted range of motion (movement of knee with help), pushing knee into extension (straighten).

b) Muscular strengthening

c) Balance training

d) Other physical therapy activities

 

Phase II: Immediate Post-Operative (Day 1 - Day 7)

 

Goals:

 

a) Reduce and control swelling and pain

b) Restore full passive knee extension (straighten)

c) Bend knee to at least 90 degrees

d) Walking with brace

 

Exercises:

 

a) Active movementof knee through partial range of motion

b) Tighten quad muscles with straight knee

c) Straight leg raises

d) Toe calf raises

e) Weight shifting, small squats and lunges

f)  Walking

 

Phase III: Controlled phase (Weeks 2-3)

 

Goals:

 

a) Maintain full passive knee extension (fully straightened knee)

b) Progress flex of knee to 115-125 degrees

c) Reduce swelling

d) Improve muscle strength

 

Exercises:

 

a) Straighten knee with physical therapist helping pushing it straight

b) Leg press and hamstring curls

c) Toe calf raises and wall squats

d) Lunges (forward and to side)

e) Balance drills, stationary bike, pool program

 

Phase IV: Intermediate phase (Weeks 3-6)

 

Goals:

 

a) Improve leg strength

b) Improve muscle control and endurance

c) Normalize knee movements

d) Perform more functional activities

 

Exercises:

 

a) Step-up / step-downs

b) Lunges and squats

c) Leg press and toe calf raises

d) Hip strengthening

e) Balance and endurance training

f) Agility drills in pool

 

Phase V: (Advanced strengthening phase (Weeks 7-12)

 

Goals:

 

a) Maintain motion

b) Protect knee joint and cartilage in knee

c) Maximize leg strengthening

d) Promote more functional activities

 

Exercises:

 

a) Step-up / step-down on balance beam

b) Squats on uneven/unstable surfaces

c) Double and single leg jumps

d) Rotation movements at the knee

e) Agility drills with sideways and backward movements

 

Phase VI: Return to activity phase (Week 10/12 and beyond)

 

Goals:

 

a) Gradual return to sport activities

b) Continue muscular strengthening and endurance training

 

Exercises:

 

a) Lunges and advanced balance activities

b) Elliptical, cycling and running

c) Returning to skiing and other sports

 

*Must meet criteria set by physical therapist before returning to sport activities.

 

*Rehab information adapted from Kevin E. Wilk, PT's work

 

For a comprehensive guide to ACL rehab exercises, see :http://www.kneeguru.co.uk/KNEEnotes/node/775

 

Return to Play

To brace or not to brace?

 

This is a tricky question. Studies have shown mixed results when it comes to the efficacy of wearing a brace when returning to the slopes after an ACL reconstruction. The best thing you can do is consult with both your surgeon and physiotherapist, and follow their advice. Remember, a brace is never guaranteed to prevent another injury or compensate for a leg that's not back to full muscular strength; the most it can do is act as an element of extra protection if you do fall or twist your leg.

 

ACL Smart Skiing

Some excellent guidelines to help you avoid having to go through all of this again:

 

1) Stay balanced and ahead of your skis.  Avoid muscling your turns from the backseat, keep your hands up in the line of sight and stay forward.  This will help to keep you off the tails and in a better anatomic postion.

 

2) Know when to call it quits: avoid skiing well above your level or when you are extremely fatigued.

 

3) Get in ski shape.  This should occur well before the season.  Strength, balance, plyometric, and proprioception drills in the late summer (year round really) will give you a good base for athletic skiing. You can find specific drills for skiing and even to guard against ACL injury online.

 

4) Use the right gear: just because the latest fat ski in a 193 cm is all the rage, does not mean that you are ready for it.  Don't be the guy that had to be rescued by patrol 10 into a tree because he turned his bindings up to 17 to impress his friends (true story).  Always have your gear checked by a shop!!!

 

5) Take a lesson.  Do it, you can always improve.

 

6) If you fall, try not to fall backwards.