or Connect
EpicSki › The Barking Bear Forums › Ski Training and Pro Forums › Fitness, Health, Nutrition, Injury, and Recovery › ACL Reconstruction: Questions for prospective orthopedic surgeon
New Posts  All Forums:Forum Nav:

ACL Reconstruction: Questions for prospective orthopedic surgeon - Page 2

post #31 of 53
Quote:
Originally Posted by Eagles Pdx View Post

 

As you see, the mechanics are just not in play in snowboarding, extremely low injury rate and as your reference noted limited to advanced expert end of the spectrum.

 

My original comments seemed to parallel your reference.

 

 

I was addressing this:

 

Quote:
Originally Posted by rx2ski View Post

 

Landing in the back seat from a large air onto the flats may cause it.

 

PDX: "No...the mechanics just aren't there.  Snowboarder will land on his butt, the bindings rotate, the board does not create the leverage on the knee.  It's why ACL's are all from skiing."

 

 
Landing on a flat DOES cause it. I too said that it happens, but infrequently. Your statements
 
"Again this is why we see no snowboarder ACL's"  
"Snowboarder landing in back seat won't tear an ACL"
"It's why ACL's are all from skiing."
 
You make only definitive statements. That's the problem.
post #32 of 53
Quote:
Originally Posted by valli View Post

As far as the stats on allograft failure, my understanding is a lot of it depends on age and activity level, as well as a willingness to carefully follow rehab protocol. One of the top doctors I met with says he only does allografts now, and he treats a lot of US Ski team athletes and professional snowboarders. Often times an allograft procedure allows you to feel better faster, and then young athletes in particular will try to return to high demand activities too quickly. He said if they follow the correct rehab protocol he has not found graft failure rates to be higher with allograft. The other factor is that with each decade of age your own tissue has less resilience, so different doctors have different recommendations for switching to allograft, although if you are 40 or over they all seem to recommend allograft. As far as total number, I've read studies saying that doctors develop more competence after they've done at least 60 ACL reconstructions, but I wouldn't care if they are doing 2 or 10 per week. They are probably doing other procedures ss well, and you want them to spend some time with you. Surgery is hard work, and most docs I've met do 2-3 days of surgery and use the other days for patient care.

Well, I'm 56 and had an autograft.

 

I can see how it would be easy to forget you are still injured and do damage.  I am 7 and a half weeks out and feel perfectly normal a lot of the time.  If I actually compare them my surgical leg is a lot weaker, and it is sore sometimes, but it is not noticable just doing stuff.

post #33 of 53
Thread Starter 

When your butt goes below your knees--including on a snowboard--there is a possibility of blowing your ACL.

post #34 of 53
Thread Starter 

 

Current Concepts: The Skiers Knee

 

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 1 (January), 2003: pp 75-84

 

 

 

The Snowboarder
While the patterns of injury in snowboarding differ
radically from alpine skiing, the overall injury rate is
similar and approximates 4 to 6 injuries per 1,000
snowboarder days.63,64 Upper-extremity injuries occur
20% more commonly than lower-extremity injuries in
snowboarders,64 and fractures occur more than twice
as frequently as in alpine skiers.63 Injuries specific to
the knee joint occur approximately half as often in
snowboarders compared with skiers and approximate
16% to 23% of all snowboarding injuries, a rate equal
to the number of snowboard injuries to the foot and
ankle.63,64 Knee injuries in snowboarders are generally
less severe than in alpine skiers; complete rupture
of a ligament occurred in only 2 of 62 reported knee
injuries in 1 series.63 Knee injuries in snowboarders
most commonly occur in novices and in those wearing
hard-shell boots (the style of boots most commonly
worn by novices).63,64,65

 

The mechanism of injury in snowboarders is different
from that in skiers consistent with the radically
different equipment. A snowboarder concentrates
most of his or her weight on the forward foot,
and 91% of lower-extremity injuries in both regular
(left foot forward) and “goofy foot” (right foot
forward) boarders involve the forward limb.63 Injury
is caused mainly by a direct blow to the limb
(63% of cases).65 Specifically, falls onto the slope
are the most common mechanism for lower extremity
knee and ankle injuries in snowboarders.63 As a
direct result of both feet being fixed to the same
surface—the board—the torsional mechanisms
found in alpine skiing are uncommon in snowboarding.
65

 

 

 

post #35 of 53
Thread Starter 

Anterior cruciate ligament injuries in snowboarders: a quadriceps-induced injury.

 

Anterior cruciate ligament (ACL) injuries in snowboarders are rare. However, in expert boarders landing big jumps, ACL injuries are occurring more frequently. We identified 35 snowboarders with an identical injury mechanism. All these patients were landing from a jump. All described a flat landing on a flexed knee with significant knee compression. In 31 of 35 boarders, it was the front knee that was injured. Only two riders felt there was any twisting component to their injury. We postulate that the ACL rupture is due to maximal eccentric quadriceps contraction, as the boarder resists a compressive landing. Internal tibial rotation of the front knee in the snowboarding stance results in preloading of the ACL predisposing to injury.

 

Knee surgery sports traumatology arthroscopy official journal of the ESSKA (2009)

post #36 of 53
Thread Starter 

Well, I had the surprise yesterday. OS's first choice for a graft for me was allograft. Second choice would be hamstring autograft. If he couldn't get enough hamstring, he'd bundle with allograft. Could have surgery in April and ski in November. (Too short, IMO.) I'll write more later.

post #37 of 53

Agree with most of what Finndog had to say here, however, I am not referencing Steadman's article only.  Over the last four to five years, those studies which compare allograft to autograft have consistently shown a higher failure rate with allografts.  These studies take into account surgeon experience, graft placement, etc.  As I said in an earlier post, what seems to be most important is that the surgeon is a) experienced (your definition may vary) and b) he/she is using what works best for them, and they feel most comfortable with.  That is what will have the best results.  If your surgeon only harvests hamstrings once in a while, do you really want them to try on you?  I don't. Let him use allograft!

 

I just knew somebody would bring up double bundle eventually.  I will agree with you Finndog, that Freddy Fu's bench studies seem to show a slightly higher stability rate, especially with respect to rotation, as compared to the more vertical femoral tunnel (11 o'clock).  Not so much when compared to the more anatomic location most of us are using now with the accessory medial portal.  More importantly, double bundles really aren't showing any difference in vivo (in patients), and in fact in some studies, seem to have a higher complication and failure rate.

 

Just my opinion, but I'm not convinced the technology is there yet for double bundle.  Not rushing to judgement, but not jumping on the band wagon yet.  Too may good results with a more anatomic single bundle.

 

Thanks for the good discussion though!

post #38 of 53
Thread Starter 

Quick background on my injury: Female, mid-40s. Besides skiing, no other high risk sports. Pop, no pain and minimal swelling with injury. MRI = high grade tear. I'm almost 2 months post-injury. 5 weeks of physical therapy. Feel great most of the time and ankle has probably held me back more than knee with rehab. About 2.5 instances of instability/buckling. Have full extension and just short a little in flexion. Poor balance/proprioception (was bad after previous ankle surgery and now worse.) My physical therapist worked on mobility with my ankle and it's the best it's been in 10 years.

 

Appointment with orthopedic surgeon yesterday:

  • Two options: 1) Continue with PT for another couple months and re-assess, or 2) Schedule surgery
  • Knee feels very loose to him.
  • Indicated that allograft was best choice and said there was only minimal differences in failure rates with autograft. Said he's only had a couple of failures of each type.
  • I asked if rehab was longer with allograft and he said no. Then asked whether ligamentization takes longer with allograft and he said no.
  • He had ACL-R a couple of years ago and was going to do allograft and then decided 2 days before to go with autograft (can't remember if he did hamstring or patella). Went skiing 7 months after with kids.
  • Asked what kind of things might come up unexpectedly during surgery and he indicated that other ligaments, meniscus, and cartilage were good on MRI. Didn't see bone or cartilage bruising on x-ray, so wouldn't expect to see it during surgery. If something showed up, I'd end up being non-weight-bearing longer.
  • Four-five days to return to work (I have a job where I sometimes can work from home.) Formal PT at about 10 days.
  • He's a knee and shoulder guy, but when I asked how many ACL he does a week the response was a lot.

 

He's a really nice guy and caught himself rushing through and then sat back down and said, I see you have written down questions--ask me more. I told him that I had a 2nd opinion scheduled. He said it was a good idea and was curious what the other doctor would recommend.

 

I know there are no "right" answers to the questions I asked, but I guess I was looking to see the rationale behind making a choice. The answers to the autograft/allograft questions did surprise me. I heard him dictating right after wards and an hour or so later I got the updated notes via email. I know doctors are busy and there is no way they can remember the details on everyone, but for my 2 follow-up visits I felt like a new patient again. Then I read the notes and it states that he ordered x-rays (I have not had any x-rays there at all and the order was for the wrong knee). I thought maybe there was a clerical error that someone else's notes got "into" my chart, but the DOI and type (skiing) were the same and stated I was getting a 2nd opinion. Other things like "in a lot of pain" were not accurate. I heard him dictate hamstring allograft, but nothing in notes about it. I left message with office first thing today and didn't hear anything back. I'm not impressed by the office staff, but my mom had a great experience with them.

 

Kind of frustrated and confused at this point and trying to put it out of my mind for now. Just trying to "look forward" to the appointment on Monday and stay optimistic about it.

 

It's weird to think that it seemed "easier" messing up my ankle and seeing it deformed and just getting the surgeon that was available when I got to the ER. But I know that didn't work out the best since I had repeat surgery.

 

I kept my physical therapist appointment for that afternoon so we can talk about it.

 

I apologize for any typos or disjointed thoughts--I'm tired but needed to try to organize my thoughts and figured it might help to get it down on paper.

post #39 of 53
Quote:
Originally Posted by rx2ski View Post

Quick background on my injury: Female, mid-40s. Besides skiing, no other high risk sports. Pop, no pain and minimal swelling with injury. MRI = high grade tear. I'm almost 2 months post-injury. 5 weeks of physical therapy. Feel great most of the time and ankle has probably held me back more than knee with rehab. About 2.5 instances of instability/buckling. Have full extension and just short a little in flexion. Poor balance/proprioception (was bad after previous ankle surgery and now worse.) My physical therapist worked on mobility with my ankle and it's the best it's been in 10 years.

 

Appointment with orthopedic surgeon yesterday:

  • Two options: 1) Continue with PT for another couple months and re-assess, or 2) Schedule surgery
  • Knee feels very loose to him.
  • Indicated that allograft was best choice and said there was only minimal differences in failure rates with autograft. Said he's only had a couple of failures of each type.
  • I asked if rehab was longer with allograft and he said no. Then asked whether ligamentization takes longer with allograft and he said no.
  • He had ACL-R a couple of years ago and was going to do allograft and then decided 2 days before to go with autograft (can't remember if he did hamstring or patella). Went skiing 7 months after with kids.
  • Asked what kind of things might come up unexpectedly during surgery and he indicated that other ligaments, meniscus, and cartilage were good on MRI. Didn't see bone or cartilage bruising on x-ray, so wouldn't expect to see it during surgery. If something showed up, I'd end up being non-weight-bearing longer.
  • Four-five days to return to work (I have a job where I sometimes can work from home.) Formal PT at about 10 days.
  • He's a knee and shoulder guy, but when I asked how many ACL he does a week the response was a lot.

 

He's a really nice guy and caught himself rushing through and then sat back down and said, I see you have written down questions--ask me more. I told him that I had a 2nd opinion scheduled. He said it was a good idea and was curious what the other doctor would recommend.

 

I know there are no "right" answers to the questions I asked, but I guess I was looking to see the rationale behind making a choice. The answers to the autograft/allograft questions did surprise me. I heard him dictating right after wards and an hour or so later I got the updated notes via email. I know doctors are busy and there is no way they can remember the details on everyone, but for my 2 follow-up visits I felt like a new patient again. Then I read the notes and it states that he ordered x-rays (I have not had any x-rays there at all and the order was for the wrong knee). I thought maybe there was a clerical error that someone else's notes got "into" my chart, but the DOI and type (skiing) were the same and stated I was getting a 2nd opinion. Other things like "in a lot of pain" were not accurate. I heard him dictate hamstring allograft, but nothing in notes about it. I left message with office first thing today and didn't hear anything back. I'm not impressed by the office staff, but my mom had a great experience with them.

 

Kind of frustrated and confused at this point and trying to put it out of my mind for now. Just trying to "look forward" to the appointment on Monday and stay optimistic about it.

 

It's weird to think that it seemed "easier" messing up my ankle and seeing it deformed and just getting the surgeon that was available when I got to the ER. But I know that didn't work out the best since I had repeat surgery.

 

I kept my physical therapist appointment for that afternoon so we can talk about it.

 

I apologize for any typos or disjointed thoughts--I'm tired but needed to try to organize my thoughts and figured it might help to get it down on paper.

 

 

Yeah, it's a lot.  Did you bring anyone with you to the appointment?  Always a good thing, going to the doctor.  My wife's surgeon recommended cadaver over hamstring, I believe, because menopause tends to loosen your own tendons.  (Staff aside, your surgeon seems ok.)

post #40 of 53
Thread Starter 
Quote:
Originally Posted by lakespapa View Post

 

 

Yeah, it's a lot.  Did you bring anyone with you to the appointment?  Always a good thing, going to the doctor.  My wife's surgeon recommended cadaver over hamstring, I believe, because menopause tends to loosen your own tendons.  (Staff aside, your surgeon seems ok.)

 

Actually got a call from the head of the staff yesterday to talk to me about a correction I wanted made on my notes (i.e. which leg was injured). We did discuss at length some of the issues that have come up with the staff and she was going to have to bring some things up at the next meeting.

 

I'm usually the person that is brought along to family member's appointments (cancer, total knee replacement, masectomy, infertility). My mom says that you just trust the doctor and don't ask questions--they all know what to do. Yesterday she said "what you don't know won't hurt you". I prefer to be more pro-active.

 

I'll be bringing all of my records straight to the doctor on Monday so I've organized my own summary/chronology based on those notes so I make sure I cover everything. Doctors are given a stack of pages before a new appointment so I wanted to be able to hit the high points.

post #41 of 53
We are around the same age and all the surgeons I've met have said allograft for patients over 40. I'm having surgery next week at the Steadman Clinic and I know they do pt twice a day for 1-2 weeks after surgery to bring the swelling down quickly and keep range of motion.
post #42 of 53
Thread Starter 

Valli,

I checked into Steadman Clinic but they don't take my insurance. :(

post #43 of 53
Quote:
Originally Posted by rx2ski View Post

 

Actually got a call from the head of the staff yesterday to talk to me about a correction I wanted made on my notes (i.e. which leg was injured). We did discuss at length some of the issues that have come up with the staff and she was going to have to bring some things up at the next meeting.

 

I'm usually the person that is brought along to family member's appointments (cancer, total knee replacement, masectomy, infertility). My mom says that you just trust the doctor and don't ask questions--they all know what to do. Yesterday she said "what you don't know won't hurt you". I prefer to be more pro-active.

 

I'll be bringing all of my records straight to the doctor on Monday so I've organized my own summary/chronology based on those notes so I make sure I cover everything. Doctors are given a stack of pages before a new appointment so I wanted to be able to hit the high points.

 

The more questions the better -- always -- but not questioning the doctor is typical of persons of a certain age.  My parents were the same way, which could be excellent leverage on occasion.  My mother's gerontologist suggested to do something I'd been urging her to do, and she did it right away.

post #44 of 53
That's too bad about the Steadman clinic and your insurance, but if you are Colorado it seems like there are a lot of experienced knee surgeons, right? The primary reason I'm going there is that the LCL reconstruction is a much less common procedure, and there are only a few surgeons who have done a lot of them (Frank Noyes and Robert Marx being two of the others).

The double bundle question is fascinating, and I thought about going to someone local to me that trained with Freddie Fu and does them, but the fact they are drilling four holes instead of two is daunting. It's also only possible if you have a big enough leg to fit the two grafts in, so it probably works better for men and wasn't an option for me.
post #45 of 53
Thread Starter 

I went for my second opinion today.

 

Although the exams today were more bad news, I feel a lot more confident with this doctor. I've had other pain with this knee that worried me and when I asked the previous doctor about it, he said I probably have a bruise. Two surgeons examined me today. Not just look to see if it's puffy and wiggle the knee cap "examine". I had the full battery of manual tests on both knees. With one of them we discovered the torn meniscus clicking away (which also spiked on the MRI). ACL on the good knee isn't exactly tight either. I'll just have to work even more on those hamstrings.

 

New diagnosis is complete ACL tear with partially torn meniscus. I'd rather know now than later. It does make a difference in post-surgical preparation when you live alone. I guess I will be staying at my parent's house a little longer since I want to be weight-bearing before I take the dog home. Pushes off the ski season another couple of months (November versus February) so I guess I'm not buying a season pass or planning an EpicSki vacation. Guess I'll have to stick with some 4-packs.

 

I scheduled surgery for the end of the month. Will be going with hamstring tendon unless there is not enough to work with and he'll bundle with an allograft. CryoCuff. No CPM. PT starts 2 days after surgery and scheduled out already for the next 2 months.

 

This surgeon and I really clicked. We're both research-oriented, former athletes, he knows skiing and treats skiers (along with all the other athletes at CU and DU). He didn't mind me asking questions and asking why. He wanted my input on my surgery options and treatment. Peforms over 100 ACLR per year. He wanted to know about me, my goals, and my academic background. It feels very much like a partnership going into surgery and rehab--I'm not sure how to explain it. It just feels right to go with him.

 

So now I have 4 more weeks to get as strong as I can before surgery!

post #46 of 53

Sounds like a better match.  Is he going to try to repair the meniscus?

Why no CPM?  Is it related to the meniscus?  I felt the CPM was a big help for me.

post #47 of 53
Thread Starter 
Quote:
Originally Posted by mdf View Post

Sounds like a better match.  Is he going to try to repair the meniscus?

Why no CPM?  Is it related to the meniscus?  I felt the CPM was a big help for me.

 

It will depend on what he sees when he gets in there. He's hoping he just has to do a little trimming.

 

There are some studies out there that show that using a CPM does not make any difference in gaining full extension when compared to doing it on your own. Plus, I had to schedule PT 1-2 days after surgery to start doing ROM myself. I chose day 2 since my surgery is very late in the day and there is a chance that I will have to stay overnight due to a pre-existing condition.

post #48 of 53
Sounds like a good match. You will probably be weightbearing before me, but we will definitely be on the same rehab track. What persuaded you to go with hamstring? Faster graft healing?
post #49 of 53
Thread Starter 

Didn't want allograft so much due to higher incidence of failure. Concerned about patella pain since I already have crunch knee caps. But he uses primarily hamstring now since the fixation has improved so much that it makes them equivalent, if not better than, bone patella bone grafts. 40% hams, 30% patella, 30% cadaver or cadaver bundled with hams.

 

Whereas the first doctor said I'd be skiing in November (which I said that's too soon for me), this doctor said February (a bummer, but I think he's being conservative--I know he's had people skiing in 5-6 months. But they're hardcore athletes.

post #50 of 53
Quote:
Originally Posted by Eagles Pdx View Post
 

 

As you see, the mechanics are just not in play in snowboarding, extremely low injury rate and as your reference noted limited to advanced expert end of the spectrum.

 

My original comments seemed to parallel your reference.

 

 

 

Quote:
Originally Posted by rx2ski View Post
 

I'm coming up with a list to ask the doctor about the surgery and his/her skills as an orthopedic surgeon.

 

From my background (biomechanics) and all the research I've been doing, I feel like I have a good handle on what it is all about; however, I just want to hear the OS answer the following questions.

 

  1. Show me the injury on the MRI. (Pet peeve--the orthopedic I saw only read the radiologist report and there is a lot of variability in interpretations).
  2. What can you tell me about the health of the cartilage from the MRI/X-rays? (I did not have any weight-bearing x-rays. Also questions on contralateral knee and ankle.)
  3. What graft do you prefer to use for my situation and why?
  4. When is someone a candidate for non-operative treatment and would it be just postponing the inevitable for me?
  5. Where will the surgery be performed (i.e. hospital, surgery center)?
  6. How many ACLR surgeries do you perform weekly? (I'm hoping for someone that does at least 1-2/week).
  7. What should I expect after surgery?
  • Will I have a CPM?
  • Will I use a brace post-surgery & during rehab?
  • Recovery time (start working at home vs return to work)
  • When can I start formal physical therapy?
  • What is your rehabilitation protocol?
  • How do you determine readiness to return to sports (qualitative and/or functional testing)?

    8. Why should I choose you to perform my surgery? (Great question from my physical therapist!)

    9. Should I buy an early bird season pass in April? ski.gif

 

I can deal with a little cockiness/arrogance. But I know I won't be able to deal with someone that won't take the time to answer questions or pushes me off to an assistant.

Hi Rx2ski,

 

That is pretty much what I asked my surgeon. He does a lot of knee reco and is internationally known for it. I suppose this is a good start.

I  am 43 and injured my knee playing basketball ball 4 months ago now (going for the ACL reco on Tuesday).

I have complete ACL tear and the following meniscus damage:

 

Oblique longitudinal tear within the periphery of the posterior horn of the medial meniscus extending to the inferior articular surface. This extends for a length of approximately 26 mm involving the body of the posterior horn ( Is that what is called a meniscus root tear ?)
 
There is an incomplete Wrisberg rent tear of the lateral meniscus with vertical longitudinal signal within the posterior horn at the Wrisberg insertion.
 
I understand that I don't have any choice and must go the knee reco way as there are meniscus damage in my knee so can't keep it like that. I don't really feel any instability but then I am having any heavy load and I work at at desk. I like skiing 2 weeks a year and cycling as well as hiking.
 
My main choice is one of quality of life and trying to delay as much as possible the OA onset and knee replacement (that is my big worry). Happy to switch to low impact.
 
What can you tell me about the medial meniscus tear above described , on the MRI it looks like a tear in the posterior horn corner (is that a root tear ? if it is I understand that trimming even a small amount of it will make it loose the hoop which might be able to a total menisectomy ? Is that correct as this is very scary to me ?)
 
Can a tear this size be repaired during acl reco in a 43 years old. Happy to comply with any recovery process if it can save my meniscus .
 
Cheers
post #51 of 53
Thread Starter 

I was relieved when I didn't have a meniscus tear.

With a trim, you can start weightbearing almost immediately after surgery.

With a repair, you can expect 6 weeks of non-weightbearing which poses its own difficulties depending upon your job and living situation.

post #52 of 53
Quote:
Originally Posted by Eagles Pdx View Post
 

 

As you see, the mechanics are just not in play in snowboarding, extremely low injury rate and as your reference noted limited to advanced expert end of the spectrum.

 

My original comments seemed to parallel your reference.

 

 

 

Quote:
Originally Posted by rx2ski View Post
 

I was relieved when I didn't have a meniscus tear.

With a trim, you can start weightbearing almost immediately after surgery.

With a repair, you can expect 6 weeks of non-weightbearing which poses its own difficulties depending upon your job and living situation.


I would be do. I don't mind not weigh bearing if it saves the integrity of my meniscus (it is much more important to me). Also I am 43 and surgeon tend not to repair tears at my age.

post #53 of 53

Just a general comment about surgeon volume. Most studies of surgical volume show that above a certain threshold results don't get any better. Beware the surgeon who does too few, but also beware the surgeon who does too many, because they may not be careful about case selection and will operate on anyone who comes through the door. Often the most important factor in the success or failure of an operation is not the technical skill of the surgeon but his/her skill in case selection. Plus when a surgeon is too busy they can lose sight of you as a person and may be too busy to detect and deal with problems after surgery. Best way to tell--if the surgeon always seems rushed and doesn't have the time to thoroughly discuss with you. 

 

 Understand too that most operations have different technical options, often at multiple points in the procedure. Sometimes there are real options with pros and cons that should have the patient's involvement in the decision making. More often the best way to do the operation is whatever way the surgeon was trained and does every day. So rather than quizzing the surgeon about his or her technique, a more useful question is "What are my options?"

 

When researching the medical literature understand that things go in cycles. For a while articles that don't support the status quo don't get published because nobody believes them. Until enough debunking articles show up, at which point they become the new status quo and articles that support the old status quo can't get published. Some of us older surgeons have been around long enough to see things go in and out of fashion a couple of times. Also understand that by pure chance equally skilled surgeons will have different complication and success rates for the same operation. The great results get published, the not so great results don't. As a result estimates of surgical success and complications are usually more optimistic than they should be. 

 

Finally, surgeons (like all humans) are poor judges of their own abilities and results. We all tend to see what we want to see, especially when it comes to things like whether the patient is happy with the results of the operation. We see things that support our preconceived notions and are blind to things that don't. Someone once asked Jack Nicklaus how often he missed 3 foot putts. He replied that he had never missed a three foot putt in his career. Of course he had missed plenty of them, but he had put them completely out of his mind, which was probably why he was able to miss fewer of them than most. 

New Posts  All Forums:Forum Nav:
EpicSki › The Barking Bear Forums › Ski Training and Pro Forums › Fitness, Health, Nutrition, Injury, and Recovery › ACL Reconstruction: Questions for prospective orthopedic surgeon