When to try skiing again (knee ligs?)

A snowHead

There seems to be a structured timetable for returning to snow sports after ACL graft reconstruction, sometimes after other surgical interventions too, but little guidance for nonsurgical rehab and 'conservative' management of ligament damage (and general traumatised unhappy irritable knee syndrome) - which is the way that I've been directed very quickly (for my apparently fully-torn ACLs and partially ruptured MCLs) by all healthcare persons thus far seen.

I asked my surgical knee Consultant (at 7 weeks): you can ski (or board) again as soon as your Physio says that you're strong enough (Consultant notes no laxity at that time which he could improve upon.)
I asked my NHS non-specialist Physio last week (not a snowy person): um, you seem pretty strong already, MCLs and anything else should be healed by now (12+ weeks - though others say they'll carry on healing and rebuilding for many months to come), can't see a problem, can't see or find anything to explain your remaining pains and twinges. The exercises seem to be working and your balance and proprioception's fine. Any problems you have are probably just muscles which are reaching their fatigue point early (no s**t!). Best way to train them is to do your activities.
Asked my specialist knee Physio (non snowy also) at week 8 and prior: um, I dunno, you're the skier... No reason why you can't do anything you want to. Just don't twist and pivot too much and stop when any pain gets significant.

Sounds great - but I just ain't convinced, nor reassured, and gut feel (never mind knee feel) says not yet. However, one also reads of people returning a lot sooner, and that part of rehab is pushing things a bit harder than you want or think that you ought to. Sometimes...

So, just how the heck do I know when I'm ready or safe to get back on the horse again? (It's going to have to be indoors too:something which I'd really prefer it not to be.) How do I (or said Physios) know what is "strong enough"? If I wanted to compare myself to many fitter and better skiers, I could say that's never... How do I know if it's ever going to feel 'right' or 'normal' again - at least for a long time - and what's possible or not advisable in the meantime? I don't know what irritated or post injury knees feel like, having never had them before...
I'm also just plain terrified that whatever's holding everything together will all give way and fall apart (never mind if or when I fall!); that or I'll do more or different damage by pushing it before I've attained that magic "strong enough".

Fundamentally, though, I can't see that there's any kind of test for being strong, ready or able except by taking the risk and trying it (gently, to be sure - but then how and when does one start to push it, if things seen OK?) Therefore, whilst appreciating that most of you are not medically qualified, I throw this open to your collective experiences and opinions. It seems that it's been left up to me to make my own decisions and judgments, so I can only do my own research too. Sad

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A snowHead

Personally, I'd try to avoid skiing until I believed my knee strength was near enough as strong as it was before.

As you've said. The problem isn't so much the skiing on it but more the 'what happens if I fall' problem. I suspect the issue for me is that you're safest skiing when you're skiing strongly. If you're trying to take things easy and not fully committing to the turns because of caution then I think it's even more likely that you'll fall and risk doing some more damage.

So I'd be doing rehab, rehab, rehab and then more rehab to get the strength built up first. If you're at all worried then exercising in a controlled environment has to make sense to get your strength back, not least because you can push yourself without taking any big risks.

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@Raceplate, @olderscot Thanks. Yes, the snowdome route is going to have to be on the cards - just when. (Don't use anti-inflammatories.) Also, not really the ideal wide, long and gentle, nice conditons, uncrowded, idiot-free option which I'd like (having been collided into, the latter is a huge confidence part now). But short of spending a lot of money on an overseas trial, it's the best not-terribly-nearby option (when I also have a spare car driver, just in case...).
The other decision is whether I try boarding or skiing first. Instinct says boarding might be less forward strain (although there's still lots of flex, extension and general stressing) but more rotational transverse plane strains (and pains) and potentially more falling.
The twisting pivoting thing is partly that I was having, and still have some, lateral and medial pain, but mainly because of ACL deficiency risk to the rest of the knee - in which case, as you say, one never skis agressively or in bumps again. But they also say that with good quads and hams it shouldn't be a problem; apparently. Maybe. The Physio who warned me off thee twisting is a ball sports player, and the jump, catch, land, twist aspect (and/or kicking) of those is defintiely an ACL risk.
As you say, it's difficult to test the legs/knees (plural in my injury case) and build up the muscles without doing the actual activity - although I'm fortunate to live in a steeply-hilled area and to be at home, so once it stops either raining or being too blinking hot, there's good training ground there.
Been doing various hopping and jumping, plus single-legged squats and the like, and they're getting there, certainly: perhaps ready acccording to your test (although my version is probably a little less athletic than yours - never having been a running, jumping or hopping creature, I don't know how to compare with what's normal for me). It would be so nice if there was a baseline 'if you can do x squats to y depth' test: though I doubt that I'd have passed that in all my years of skiing to date, then... Of course, I also had rather less ripped-apart knees before.
Is my "knee strength" as strong as it was before? I don't know: that's the problem. It certainly doesn't feel ready or strong in many ways (not per se unstable, just 'wrong'... and sometimes sore or irritable or painful in the joint or the muscles, or sometimes restricted in the muscles) but I don't know whether the actual feeling or perception will ever be the same, at least for a long time; and how much of that is now in my head? "You'll get back what you get back" were the Consultant's wise words on this, with no guarantee that anything will ever feel or react the same again, post trauma.
However, the odd issue is that in many ways (certainly as far as static and isolating exercises) I'm already a good deal stronger in the legs than I was before. Something to do with a lot of days spent at home (where I have some limited exercise space and equipment) doing lots of quad and hamstring and balance exercises (don't have a local gym, annoyingly). Never did things like single-legged squats and static lunges before, so again don't have a comparison. Certainly can't do a full pistol squat, but wouldn't have been able to do so before, and have always had some wobble on my knee/feet/something and some other not-perfect-form issues, so again I'm probably better now than I was before in those exercises (even though I don't feel it). Of course, I could also do a lot more exercising, and hopfully get a lot fitter and stronger still - but then again I could also just become a full-time body-building athlete (I think not, appealing as it actually could be) and do nothing else for the rest of my days.
I think, however, that whilst there's some pretty good kinds of stamina there, it's still not what I had before in other ways or places; maybe not the same kind of muscle fibres, same speed ('twitch'?) responses or whatever? Certainly the muscles are tiring more quickly (albeit being pushed harder too?) and then they feel weak and 'fizzy', don't want to work properly and then the knee feels as if it might not be stable. Hopefully this will get better as I continue to rehab. That, maybe, is the issue for me rather per se than strength.
Trouble is, it's really hard to try and think back to compare, except by doing the things which I did before to the level and length and intensity at which I did them. Without trying snowsports, my only available comparison is when I can yomp around the same walking rounds/distances/terrain (including rough, slippery, steep descents) that I used to, at the same speed and stride length, without using any poles, preferably without any braces or tubigrip, and without suffering any more after-effects or restriction or twinges: if, of course, the latter will ever happen (which I hope it will, but have been been warned that it might not). I am now getting back to being able to walk the terrain, but not yet the full distances, and still am very wary (in potential for things being too strained) of steep descents (perhaps psychologically worried more than any major or real structural problem - or so the NHS Physio says). That used to be my main fitness and leg strength training (apparently hills are good for you!) - so perhaps therefore that's the only test which I can use to judge when I'm ready to try skiing/boarding again?

It's all a very scary lot of thoughts - and as said, it's only if one of both knees "blows up" again (or collapses or whatever) that there's anything to go forward on in terms of a baseline. Otherwise it's a constant forward 'what if', trading off caution and risk, just in case. Even if everything feels normal and pain free, there's always now that thought at the back of the mind. Keep it all strong enough, I'm told, and it won't be a problem. What's strong enough? When it gives out, it isn't strong enough. Oh goody... Confused

Anyway, snowHeads is much more fun if you do.

@Grizzler, Jonathan Bell runs a return to ski from injury day at Hemel with his excellent physio James Vickers.

"Preparation for 'The Return from Injury Ski' Day will start in early October 2017 with an hour long assessment with James Vickers at Wimbledon Clinics where you will be able to discuss your progress, any niggles and check that you are on track to be able to ski in December. You will then be given a ski specific programme to work on to get you ski fit."

On the day Warren Smith's team will give instruction. Jonathan Bell and James Vickers will attend and be on hand if there are any concerns.

http://www.wimbledonclinics.co.uk/the-return-from-injury-ski-day

http://www.wimbledonclinics.co.uk/consultants/mr-james-vickers/

You can also get a free phone consultation.

I went on it after my injury and highly recommend it

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@Grizzler, I'm not sure why you expect to get any useful information from a bunch of mostly blokes on the internet.

All the expert female skiers that I know have torn knee ligaments at least once. I don't know any who haven't had surgery but do know two for whom it was unsuccessful, one of those has skied a fair bit without an ACL but felt that it was causing meniscus damage. I think that Jo Ryding did both knees at the same time, everyone else that I can think of just one.

I can't remember if you wrote whether you are going to use rigid braces or not, as a coach I would have a bit of a concern that using two of them could mess up your alignment.

Then you can post your own questions or snow reports...

After all it is free

@Grizzler, downhill walking is definitely a good test for knee stability so I guess that's your yardstick.

There's a few other knee injury threads around but I can't see one specifically on yours? TBH, I know people do do it but I wouldn't want to ski without one, let alone two ACL's so I'm curious as to why you've gone down the non-surgical route. I guess you have your reasons but surely the only real answer to "What's strong enough?" is being in it's original configuration. Several consultants have told me that the ACL is only 20% of your knee stability so of course you can manage without it. But by default, that means it can only ever be 80% strong/stable. What if you ski at a level or (probably poor) technique that requires 90% stability?

It's not going to help your mindset but all my problems were caused by my ACL being "interstially" torn (i.e. frayed) and the resultant small amount of laxity in the joint. When I first started getting pain, my knee muscles were extremely strong but that didn't prevent some serious muscle wastage and osteoarthritic complications as time went on. The laxity was minimal to the point that some consultants said it was normal, some said, "it's fine for everyday life but skiing loads are not everyday life" and only one instantly said, "it's very loose".

I tell you this because I think my point is that only skiing is skiing. Nothing else replicates it. There are not the same additional G forces in a downhill walk as a carved turn at 50mph (or worse, catching an edge at that speed). I don't see how a person with no ACL can ever have the same strength and stability as someone with all their ligaments intact, assuming similar muscle mass, and you will always have some degree of laxity in the joint. Therefore, it will always be a risk.

I understand your concern that you might spoil an expensive trip but I don't really see how else you'll ever know if 80% strong is strong enough for you. As long as you feel your knees are back to normal, stock up on diclofenac, buy a couple of braces as an emotional crutch and take a cryocuff for afters.

In your scenario, my self-justifying logic would be that other than swelling, it's unlikely that I'm going to damage anything seriously enough to stop me skiing on this particular trip (you can't tear your ACL twice, right) and if anything else tears it was going to happen at some point anyway (because 80% isn't enough and I need a reconstruction) so I might as well get it over with.

*Ski* the Net with snowHeads

Can't say for sure as not there myself yet, however...

This may sound obvious but not until it feels right. Having spent 10 weeks not mountain biking following what physio believes is a partial tear of MCL (thanks to being too cocky at the EoSB), I got itchy feet last weekend and caved when a mate asked if I wanted to go for a ride. 11 miles of rough but not overly strenuous riding my knee didn't quite feel as good as before I started. Although I haven't completely blown the thing out I reckon that it's put me back to the position I was 3-4 weeks ago. Physio again tomorrow so looking forward to the telling off, and hopefully the news that I haven't completely trashed it.

If you're happily walking around steep descents then you're better off than I am.

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@rjs, maybe I posted thinking that some of those nice helpful expert female skiers would have something useful to say, given how our bodies and physiologies and ski techniques are so terribly different wink

Seriously, re your point on braces, I did ask about this a few weeks ago, pointing out that my Consultant was very against them per se; physios seem to think that skiers can or should use them, but clearly don't have specific expertise, so again another risk that I'll have to think about. Can't see why 2 would mess up alignment more than only 1 would.

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@Grizzler, james vickers...who i refer to above...recommends a brace only for MCL damage, which I have. It would be worth looking at the website and getting the free phone call

@holidayloverxx, I had heard of that Wimbledon assessment & programme, and it sounds a really good idea - except that I'm a long way north of Wimbledon and can't get down there. Is there no-one else who offers such a service? I must admit that I'm not finding too many physios in my area who are technical skiers or boarders, annoyingly.

@SnoodlesMcFlude, Like you, I think that it's easy to overdo it when feeling enthusiastic and good. I'm learning what's possible, sensible and probably too much though. Steep descents are not per se bad, just pretty worrying (what's that twinge, is my tibia going forward, why's that hurting...?) and definitely requiring caution if the muscles are tired and not working at full efficiency any more. Only started doing them after Physio clearance and reassurance. It's rare I use a walking pole, but it's certainly coming out on each descent now, just to provide a third point of support. Good luck with your forwards progress.

@Raceplate, As I said to myself back in March, when I failed to land my spectacular skier-assisted aerial 360: well, at least I needn't worry about busting my ACLs now Laughing

But, yes, the reduced overall holding-togetherness of my knees and the resultant overall loss of strength and the possibility or likelihood of cartilage or meniscal or other ligament damage weighs heavily on my mind now. I agree with you, it's a risk.
As far as I can find research evidence ( and it's far from overwhelming!) I'm on the crux of being recommended for ACL reconstruction or not merely by the sports and activities which I do - ball sports being the ACL evils these days, apparently -
and my amateur (and less than expert, although aggressive and occasionally reasonably advanced) snow sports status.
But why specifically no surgery? Because those who earn their daily crust being experts at this are all dismissing the need for it out of hand. The surgeon said he could offer no better a stability or "tension" than I had at week 7, the specialist Physio ( with 1 ACL recon and 1 nonsurgical ACL tear) was very keen on the 'conservative' route from the start and also found no abnormal laxity. Long may that continue!
So I'm taking their advice and hoping that my poor aching ageing (female!) muscles will carry on doing a good enough job for me. After all, 2 x 9 months of pain and rehab (which is going to involve the exact same exercises and muscles) after 2 x surgeries just to get to somewhere which could introduce complications and won't 100% guarantee me anything better in any outcome measure...? Well, I think that I have to go forwards on the hope it doesn't give way or cause problems route, and deal with anything nasty that does come along if it ever does. Maybe I'll back off a bit, but I've never been a great speed freak anyway, and I'm certainly not a World Cup downhiller, so if I can just stay out there and enjoy many more years on a board or skis, that'll have to do. Not necessarily what I'd planned, but it could have been worse... Now, where's that damn reckless idiot who hit me..? Evil or Very Mad

You know it makes sense.

Otherwise you'll just go on seeing the one name:

I separated 3 of the 4 major ligaments in May age 38 in 1987.

I was lucky to get a custom fit walking brace instead of the standard hip to toe plaster.

I was pretty diligent about following the physio instructions and advice. I was totally gobsmacked by those who did not.

I skied at Christmas that year. Albeit pretty conservatively.

Still skiing.

A snowHead

@Grizzler, no offence but I think that's BS from your advisors. Assuming you're in the UK, that sounds like the NHS "we only operate as the last resort because it's expensive mentality". It's not the answer I'd expect in an "the insurance will cover it" country and I've lived in both. Ultimately, if you're an advanced intermediate skiing in a controlled fashion on blue/red runs in nice conditions, I'm sure you'll be fine with some decent braces. Doesn't mean you won't have issues long term and (naysayer that I am) I'd be amazed if you didn't.

Around 5 years ago, my girlfriend at the time did her ACL in a typical slow, twisting, backwards fall. She didn't believe the consultant that told her her ACL had gone because everything still felt stable. She's no gym rat so obviously that has an effect but when I saw her last year she was having trouble just walking normally Sad

Maybe I'm super neggo but I find it very hard to believe you will be able to ski long term with 2 torn ACL's. Boarding, maybe. Whatever, I wish you well.

A snowHead

@Grizzler, Maybe look for a local female instructor. You could have a chat now and also make sure you didn't talk down your skiing level by too much when you were talking to your doctors, then arrange a private lesson for your first time at a snowdome.

I know someone who works at CFe.

Well, the person's real but it's just a made up name, see?

@rjs, Thanks. Instructor recommendations welcome - though at Chill Factore I don't know if you can book anyone specific (couldn't when I last had instruction there).
But what's the need for a female instructor got to do with it, please? I just want a good one who'll understand my needs and learning style. What's between the legs and hanging off the frontage really has little to do with it IMHO.
I don't think that I talk down my skiing style or level in general. However my doctor (singular) never even asked. Unortunately, you don't get to specify what sports your Consultant does... He is, however, well regarded in the general field of Sports Trauma Orthopaedics - which may or may not mean something.

@Raceplate, I note your comments, and share your concerns; and it (not you, per se) puts me in a very unhelpful position as regards my future. However, my specialist Physio - the one who has had both surgical and then non-surgical ACL treatments, and is a competitive ball sports player - is private and works in the private surgical sector where my NHS Consultant also works: and he says that he would not have surgery now for ACL damage if he could avoid it, knowing what he knows now. I know another snowboarding physio (who has not examined me) and their comment was also that hamstrings can substitute for ACLs to a good degree.
Respectfully, I'm not prepared to say that senior medical Consultants (or specialist and several non-specialist physios) are talking "BS" and that I should automatically (immediately, at least) go down an invasive surgical route (on both legs) which could end up with me in a worse position than I am at present. But a surgeon would certainly not operate on someone who is showing no medical or physical need for it: that would surely be unethical, if nothing else.
Having researched the issue at some length over the last few bored months, there seems to be no definitive answer to the best outcome treatment (nor the brace or not brace issue), except to say that there are some people who are ACL-deficient "copers" (in skiing and other risky sports), some who adapt and some who cannot carry on without surgery. In general it seems that wait and see is becoming the more preferred option for non-professionals who can afford to take a year out and try conservative rehab. Some say that skiing ACL injuries (though whether fast, slow or imapct ones I don't know) are different to those in football, hockey, basketball, etc, and that there is some evidence that they may even heal to some degree. And many say that not all surgeries are great in outcome, and not all grafts last well for one reason or another. Once you've been injured, it seems that it's all a lottery anyway as to what happens next. You seeming have an increased exposure risk to Osteoarthritis and other damages, but there isn't seemingly 100% clear evidence as to why, or if there's a correlation with bone bruising/oedema and/or meniscal or cartilage damage, and I've been told that additional surgery and inflammatory processes may even increase it. On the other hand, other research says... (etc) Confused

I really don't know whether it's clincially-driven or cost-driven; but I could say that countries who have cost-driven or private health systems (including the latter in the UK) might have just as much a financial vested interest in the surgical route than the NHS might have in avoiding it.
I can only decide that at this point in my life I want to avoid surgery and all which it entails, and I want to see how much I can do in terms of my beloved hill/mountain and winter activities (and other things which I haven't yet re-tried) by seeing how much strength and stamina I can gain to support my ligament damaged/deficient knees. At this point (well, at some hopefully not too far away point in the future) I have to try skiing and boarding again and take it from there. Maybe it holds, maybe it doesn't. Maybe it hurts and maybe it doesn't. Maybe I can board but not ski, or vice versa. Maybe I'm stuck on pisted runs and not race slalom or bumps and off-piste. Maybe braces help or hinder. Maybe I end up needing surgery for soemthing, at some point. At the moment, I just want to be able to get back out there and try - and, with no offence to you or others, I want to prove all the nay-sayers wrong! wink

@holidayloverxx, I have booked for the said free phone call and will see what they say.

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@Grizzler, The reason for suggesting a female instructor is that she would be able to use her own rehab experience to know how much to push you.

Anyway, snowHeads is much more fun if you do.

@rjs, If you know a good female instructor who's gone through rehab, then yes, please let me know who & how to contact them in due course (or for advice now?).
I know one of the CF coaches/instructors who had knee surgery but it wasn't acl or ligament as far as I know.

Realistically, though, male or female, how do I find a good instructor (likely at CF) who understands returning to skiing after ligament rehab and can take me back to and through good technical form?

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@Grizzler, I ruptured my ACL in 2004. In considering my options (my consultant was recommending surgery I was a hockey player as well as skier and still in my 20's just!). I spoke to my friend who had similar but he had lived without it for years, carrying on playing hockey and skiing. He eventually had the surgery and had caused a lot of other damage by not getting the repair sooner.

I had the surgery in 2005, but did subsequently (and unknowing demanded the reconstructions a few years ago). Physio thought it was probably just the MCL,so I rehabbed went back to hockey training and it collapsed under my whole sprinting. This damaged my cartilage, locked my knee and left me non weight bearing until I could get surgery only when they went in could they see that half my reconstruction was damaged.

Best of luck which ever you decide, but be aware of risks of both routes.

Then you can post your own questions or snow reports...

I don't think you need a female specific or ACL specific instructor. Just lay down the rules about what you are NOT going to do - no one footed drill ever and minimise pure twisting while you discover your feeling and limits. My recon took me 2 laps in a dome ( with a Donjoy brace) till I was happy. Donjoy got binned after first day on snow.

After all it is free

@Dave of the Marmottes, +1

Help!!

When to try skiing again (knee ligs?)

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