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ACL *repair* experiences ("internal brace")

 Poster: A snowHead
Poster: A snowHead
I agree with @Raceplate: on a brief read of the posted link, the BEAR does look promising, at least in theory, and seems to offer a much less traumatic approach (at least to other tendons) to ACL damage/loss utilising a natural healing process (so I am reading it). I believe that the ACL does have the ability to regrow/heal/reattach, as the MCL can, but normally doesn't becasue it's flapping around in a load of blood or fluid (???) inside the injured knee - hence the scaffold giving it something to cling onto whilst healing.
(Oddly, the exact visualisation which I used - though knowing nothing of this procedure or idea - when desperately trying to encourage my very-recently-ruptured ACLs to grab hold of their frayed ends and regrow/attach themselves. Heck, might even have worked... wink Need a hope and pray emoticon here. )
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 Obviously A snowHead isn't a real person
Obviously A snowHead isn't a real person
@Raceplate,
Itís very frustrating that there are no published results for some of these techniques. Lack of fundings for research is often the block but had a tiny bit of the marketing budget been allocated we would have them.
A cynic might suggest that the lack of results means they are being buried.

The BEAR found whole blood better than PRP in a study they did. They wet the sponge with it.

The PRP/ arthritis literature is showing a bit more promise and I have used it in a small number of arthritic knees with, so far, good outcomes.
Iím watching the mesenchymal stem cell literature very carefully as there is a bit more promise there aswell. Itís a very hot, very hyped topic but we may be seeing some progress. A review paper is out this month which is making me look at whatís available.

The PRP and MSC injections are, as you say, aimed at modifying the response
to the arthritis rather than curing it. That is fine as some manage to live with a worn knee for decades if it doesnít hurt.

Jonathan Bell
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 Well, the person's real but it's just a made up name, see?
Well, the person's real but it's just a made up name, see?
Reading this with interest.
Im now in the torn acl club too, after 35 years of mountaineering and no injuries, the odds have caught up with me, amd In a similar mental position visavis what to do amd who to believe.

Left leg
Ruptured quadriceps muscle, tendon is fine.
compresion fracture postero lateral capsule attachment at the tibia
horizontal oblique tear of lateral miniscus from the anterior horn to the rior articular surface, the rest of it is intact and normal
medial menisucs isn intact and normal
pcl normal
focal acute full thickness tear to acl at its proximal end
full thickness tear to proximal medial ligament with the deep menisco femoral component

consultant is focusing on healing the medial ligament and not to rush in to reconstruction of acl at the moment, but that if i develope subjective instability after full rehab of me knee then it may be necessary further down the line.

part of me wishes that I can recover from this quickly by having the internal brace operation, but then my consultant, who is a knee specialist, want me to heal medial as priority and see him again in one month.

like all things of a specialsed nature, there is a minefield of information to wade through.

If i worked in a sedentary job and only had weekends and annual leave to enjoy hobbies etc then my mindset may be different, But I work full time in the mountains, climbing, hiking, skiing, plus a whole heap of outdoor Ed stuff, So itís my job that is at stake, and hearing a consultant tell me I might not even need an ACL was not what I expected.
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 You need to Login to know who's really who.
You need to Login to know who's really who.
@Markhandford,

The combination of a MCL and ACL is a relatively rare combination. However, sadly, i see it fairly frequently in skiers.

I have treated these non operatively, but rarely, as they do not in my experience do not very often end up with a satisfactory outcome. Even those that "feel "ok at a few months tend to stretch out.

To give you some background. It may be surprising that advice on these matters isn't black and white. This is because the "trend" on how best to treat tends to swing a little from one extreme to another. We are, as a community of knee specialists, in a phase where the pendulum has swung a little away from surgical reconstruction back towards less invasive treatments. It's probably worth saying that we have come from a phase where knee surgeons were offering surgery to virtually everyone. We then get a few studies/scientific papers that question whether too many patients were being offered surgery ( they almost certainly were). Part of this has been a re-interest in using bits of polyester (was a disaster last time round and proven to be this time round). The other is a resurrection of repair - i can assure you the concept of internal brace is not new. It looks like a small number may benefit from repair. Along the way some of us has always tried to take a sensible route that doesn't apply the "current trend" and we apply an amalgam of what we have learned over time.

I think there are, possibly , some patients who will benefit from repair but it will be the minority and i very much doubt ( and there is no evidence ) that the best candidates will be those with combined injuries to the ACL and MCL. The main protagonist of the internal brace has repeatedly failed to publish his results - not a good sign. He was asked when they would be published four years ago at a meeting i attended and the same in November last year.

It is sensible, IMO, to treat the MCL non operatively in the early stages but it needs assessing at about 6 weeks to test if there is any residual laxity - there almost always is if it was a grade 3. Some surgeons, i believe, over treat the MCL so i wouldn't be over concerned at an initial non operative treatment of it. At about 6 weeks i would then tend to offer reconstruction of the ACL and, usually , a bit of work on the MCL. However each case must be taken on its merits. That is to say we need to take into account what you want to do ( alot in your case) , the laxity, the other damage to the knee etc.

Get your self to a point where the MCL has healed - are you in a brace? Then see what the advice is, and if uncertain, get a second opinion.



Joanthan Bell
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 Anyway, snowHeads is much more fun if you do.
Anyway, snowHeads is much more fun if you do.
Thank you for such a straight forward email and your expert opinion.
It follows what my consultant has said, heal the mcl with physio and rest and to gain range of motion.

I donít start physio for a week or 2.

Iím in the nhs Hospital fracture clinic tomorrow.

Iím back to consultant late March.

Iím currently in a hinged brace set at 20 degrees and I can straighten my knee pain free when itís horizontal. But canít do this when Iím standing, too much swelling in my knee, it hasnít gone down much.

I need to be able to hike, in summer,
Kick steps in hard snow and Ski mountaineer in winter, plus swim in the sea and scramble up and down mountains - am I asking too much Smile
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You'll need to Register first of course.
@Markhandford, so sorry to read of your plight. Hope you have a full and swift recovery.
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 Then you can post your own questions or snow reports...
Then you can post your own questions or snow reports...
Many thanks for the thanks @Hurtle Smile
Im looking forward to getting fixed hahaha
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 After all it is free Go on u know u want to!
After all it is free Go on u know u want to!
Markhandford wrote:


I need to be able to hike, in summer,
Kick steps in hard snow and Ski mountaineer in winter, plus swim in the sea and scramble up and down mountains - am I asking too much Smile


It depends which summer! 2019 yes with limitations, 2020 at full strength. Goals are vital. Men's downhill has just been won in Korea by a guy 2 years post ACL reconstruction and 1 year dislocated meniscus. Next to him our demands are modest!
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 You'll get to see more forums and be part of the best ski club on the net.
You'll get to see more forums and be part of the best ski club on the net.
@Markhanford, 'A Bay' Colorado took my ACL and had a good go at my MCL on Dec 30th. I'm not in your league, either on the injury or activity front, but as a fairly active half centurian, was looking forward to the top of Cotopaxi in July this year. As with many on this site I read all I could, struggled to digest the information, struggled to find much on those who 'cope' without an ACL - skidivas is good for this, questioned the mind vs physiology, thought about the costs, both financially and on getting on with life, and ultimately did what was right for me - it will be different for everyone. 5 weeks ago Prof Wilson stitched my ACL back together and threaded the 'internal brace' through it, using tape that has been used for a good 10 years plus in other orthopaedic procedures. I'm not back running yet - hope to next month, but I can walk in the country (rough ground) for an hour or so, or do a session of cardio and resistance for an hour, the ROM on my repaired knee is within about 15% of my good leg, it's been hard work but I can hyperextend my leg, my KOOS score is at over 80%, and I feel positive - I haven't always over the last couple of months. if you are thinking of repair, don't leave it too long, as there's an optimum time post injury for the surgery. Good luck with whatever you decide
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 Ski the Net with snowHeads
Ski the Net with snowHeads
@ACLess, Thanks for your post, glad you are on the road to recovery Smile

So itís now 7 weeks post accident.
I have 90 degrees flexion and swelling has gone down considerably.

Consultant was very happy with progress so far and was surprised that my mcl has healed so well and now have no pain on it, not so medial condyle which gives 8/10 pain when poked with finger pressure., not sure what that is all about, and no feedback on what it could be.

Still a definite no to surgery from the consultant, he has told me no need for the hinged brace anymore and to continue and perhaps increase physio, with the objective of as much ROM over the next 6 weeks, aiming for same ROM as good leg. And to be more weight bearing and less reliant on crutches at the end of the 6 weeks.
And as summer approaches to get out hiking and see how things progress.
If there is instability present that he will review.

I have tried and tried to increase my knee bend, but it comes to a solid stop, with feeling of explosive pressure inside my knee that wants to burst out the medial side of my knee cap,
Also the pain 10/10 is not in the same place inside my knee all the time.

So mentally Iím all set for upping the rehab and to give it 100% for the next phase- ruptured quadriceps muscle is starting to get better and not so flabby.

I donít know what my laxity score was, but he was really happy with my progress.
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 snowHeads are a friendly bunch.
snowHeads are a friendly bunch.
@Markhandford, Good to hear you are on the mend. On the the surgeon is saying no to the ACL reconstruction, is that because more rehab is required or just because he thinks you can do without ?

IIRC I wasn't using crutches when I went in for mine.
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 And love to help out and answer questions and of course, read each other's snow reports.
And love to help out and answer questions and of course, read each other's snow reports.
AndAnotherThing.. wrote:
@Markhandford, Good to hear you are on the mend. On the the surgeon is saying no to the ACL reconstruction, is that because more rehab is required or just because he thinks you can do without ?

IIRC I wasn't using crutches when I went in for mine.


By the time I had my ACL recon my knee felt almost normal and I had full range of movement back, something which the consultant insists on before doing the recon.
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 So if you're just off somewhere snowy come back and post a snow report of your own and we'll all love you very much
So if you're just off somewhere snowy come back and post a snow report of your own and we'll all love you very much
Thought Iíd update the forum a year later...
I bust ACL and tore medial skiing in March 2017 and reported on this a year ago. Prof McKay was very nice on phone but booked me in to have op without seeing me provisionally which kind of alarmed me, as did the fact he declares a commercial interest in the product he is using. Neither should put anyone off as he may be genuinely brilliant and kind but it just put me off a bit. Went to see Sam church in fortius in London. He refused to operate for first 16 weeks to heal medial and then refused again as doing pretty well on rehab. Had two awesome physios, one a technician who is an ex international water skier and the other more sporty.
First time I got on bike I could not even do one turn; I cried! Within a week though through gritted teeth managed to go round, itís helpful to get on a rowing machine in my view as you can control how much you bend and slide into it...I used to mark it and each day try to do one mm more ... slow progress... but within 3 months into squats... and I mean into them : did 10,000 one legged jobs, then onto trampoline doing another 5000... loads of one legged leg presses and all bespoke stuff for each of the quad muscles... anywAy one year later back on the slopes with a one to one instructor and an issue brace. On GREENS for a day, blues for two days as instructor would not let me do anything else but back on the off piste blacks by end of week, confidence fully restored having a total ball at least on skis. So pleased that I feel I got the right advice from Sam church and did physio as opposed to the op two other surgeons inc prof McKay suggested I have. I never think about the knee now at all. I actually splurged our the fish and have 2 braces an ultra light one for ocean surfing and hiking and a light one for skiing which is a bit stronger in case I hit a rock!
To be honest after 15000 squats my knee feels as if itís in the best shape itís been for years.
Moral of tale: everyone is different, my ACL was torn in the middle and I didnít have a positive pivot. In 40% of these cases the frayed edges of the ACL can attach itself to the PCL and stabilise; also seem to have been lucky with the medial teAr as it seems to be stronger having healed than it was before, must have been all those one legged squats and leg presses.
I gather from fortius that the knee takes 18months to repair... it continues to repair for a long time even if you think you are ok. The footballers who go back after 9 months etc etc are taking a risk... the club wants them back, they need the contract financially, life is about risk and they take that risk. I think what I learned was donít take undue risks without a custom brace in the first 18months unless someone is paying you shedloads. The guy I saw - Sam church - had ruptured his, played rugby without one for some years, then had a replacement and has I think also had a revision so knew what they all felt like.
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 You know it makes sense.
You know it makes sense.
Sorry for the typo! I have two OSSUR CTI customers made braces. Awesome.
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