Torn ACL - Next Steps With NHS or Private

A snowHead

My wife, in her mid 30's, sustained a knee injury on the preBBWUW10 at the start of February. Until now she has always lead a very active life consisting of multiple annual marathons, cycling, hiking, water sports, etc. Upon returning back to the UK, our local GP and the NHS have been absolutely brilliant. In the space of a couple weeks, she has had referrals and results from the fracture clinic, x-ray and MRI scans. The MRI scan has supposedly shown that the ACL has completely ruptured and the MCL is slightly sprained. This morning, the GP confirmed a referral to an osteopath with a date to be confirmed in the next week and stated that surgery will be necessary.

However, having read a fair number of threads on the topic of damaged ACL's, it's abundantly clear that there are numerous forms of surgery as well as rehab-only routes. As brilliant as the NHS have been to date with confirming the extent of her injury, we would now like to be sure that we are receiving the absolute best advice on her next steps (pun intended) and that she will be placed in the hands of a highly experienced consultant/surgeon.

Two orthopaedic surgeons for whom I have read countless recommendations are Gordon Mackay and Jonathan Bell, as well as some very recent recommendations from this thread.

We do not have private healthcare insurance which covers the cost of surgery (only a small limit on consultations and our holiday ski insurance which I do not believe would now cover the costs of surgery without any proof from the injury having taken place on the slopes). However, we are open to paying for private surgery if it means that the chance of my wife's recovery has a higher probability of being superior and faster. Hence, despite our recent experience with the NHS having blown all expectations, would it now be more prudent to follow up with a private consultant and surgeon (such as the aforementioned above)? In addition, is there a method for requesting copies of the completed MRI scans from the NHS and passing these on to a private consultant?

Alternatively, are there any highly recommended NHS orthopaedic surgeons which my wife could request to be referred?

A snowHead

@EViS, a lot of the private consultants also work for NHS. My consultant I started with was the NHS one, my cover at that point only covered if your treatment needed and overnight stay. So I asked him if it would need this (without saying why) and he confirmed it did, so I was able to switch to him as a private patient. The main difference this made was geting surgery sooner. Due to the nature of the way the bupa hospital did it, it was a package treatment which included the physio Thankfully. I did have to pay a certain amount towards it all due to the limits on the policy.

That phsyio was a huge part of my good outcome and seems most lacking if under nhs. I had a LOT of physio and it was needed.

I would ask how long the waiting lists are. I would suggest it would be worth getting private physio post op (that wont be cheep). I would research your consultant to find out if they are one who are focused on getting you walking again or one focused on getting you back to sport.

My original recon was done with Mr O'Leary who did a great job, based around Reading area. He was a rugby player and has had a recon himself. I think this is a good trait to look for. Smile

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^^^ similar experience for me. I would have had the same (very well regarded) surgeon whether I went with the NHS or private. Going private meant I got to choose exactly when to do the surgery and had a slightly nicer room to recover in.

By some sort of glitch, I went back to NHS for physio. I got lucky and had a therapist who seemed very good and who I got on with and it was somewhere convenient but YMMV

So… if I was you I’d see who your surgeon is through the NHS and take it from there

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@Arno, thats good about your NHS physio. For the original acl recon I only had the NHS physio pre-op. Every question I asked about what I could do in gym as part of my physio to get full ROM back and swelling down, she couldnt answer and had to come back to me at next session. If you are just going to google it.... I can do that!

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@NickyJ, I somehow got one of the more senior people and it was the physio associated with a teaching hospital so I’m sure that all helped

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Hi. I'm the guy that brought his bad knee to the Pre BB. My wife has worked in the NHS and private. She would agree with the opinions above. Other than a few who work solely privately, the majority of orthopods work on both sides. The differences are in speed, quality of surroundings and their courtesy.

There's no point chasing assumed excellence when the majority will do the same job. You may receive differing opinions, but that's not to say one is wrong. My nephew had an ACL reconstruction, the orthopod opined there were two potential methods of repair. When quizzed as to which one he would employ, his answer was 'depends how I'm feeling on the day'.

Best wishes for a speedy repair. I've just had a six week follow up and have started weight bearing and can drive again in two weeks (yippee).

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I've experienced ACL care both on the Nhs and privately - and am an Nhs surgeon. Agree with @Val Desire! (hope you are recovering...)

It's all about the rehab - I'd do surgery in either sector but would spend money on physio care both pre and post operatively as NHS now don't have the resources and time for as much as you will need!

After all it is free

Is it not the case in UK (like in Ireland), if you go private, the consultant will be doing the whole of the operation, whereas if you are public, the Registrar will be doing large parts or all of it? So outcome may depend on how good the Registrar is, which could be more of lottery

Just to add another perspective: "This morning, the GP confirmed a referral to an osteopath with a date to be confirmed in the next week and stated that surgery will be necessary."

I don't know how the GP has reached that conclusion, obviously, but perhaps think more about finding a consultant than necessarily rushing for a surgeon. Get a top specialist's opinion on whether invasive procedures are actually warranted; or, at least, yet.
It's a debatable decision as to whether surgery or a more 'conservative' route is best: obviously depends on the person and injury. But don't necessarily rush to surgery at this stage if there's a chance of the knee recovering and holding its own with enough dedicated physio rehab and strengthening. Can take a good while, but the same will effectively be required pre and post surgery anyway.
I had an initial private physio for my ACL & MCL injuries, and he not only worked for the top local NHS and private consultants, but had done both of his ACLs playing basketball. He was personally convinced that, if at all possible, he'd never have surgery (as he'd had on one knee) but just go for rehab (as on the other).
Plenty of snow sports and generally active people gave got away without surgery, and it can have its downsides too, or fail or get torn again later. So go talk to a consultant armed with as much research as possible, and then take it from there.
Good luck to her either and all ways

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@Grizzler, absolutely a sensible perspective but for me, I was unconditionally advised by GP, physio, pisteur and surgeon that if I wanted to go back to activity as I was before, I would need surgery.

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@under a new name, And I, as a counter balance, and as a far from as fit - yet apparently still "very active"; racquet sports, dancing, snow, hill walking - and quite a bit older person than the OP's good lady, was advised by an NHS consultant (also well regarded private) and subsequently several physios, that I wouldn't, and shouldn't, and that I'd get just as good an outcome without. Bear in mind that I did both of mine at the same time, too, so maybe that made a difference.
Not as good as I once was - though most of that is 'head', to be sure, plus a lack of enough ongoing strengthening exercise for various other reasons - but still good enough: so who knows whether they were all right or not.
I didn't want surgery, either, if I could possibly avoid it.
The Austrians were very keen to operate straight away. The hotel staff in Austria assumed that I'd be having surgery immediately. (I never asked the pisteur!). Every Austrian ski instructor whom I tell can't understand why I never had surgery. Every UK physio seems to think that I don't need it.
Different countries? Different health systems? Different people and their specific injuries?
The OP obviously needs their own specialist advice. (Which they are trying to find.)

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There is no doubt each persons stability can vary massively. I could feel my knee making firgure of 8 movements every step before mine was done. I was similar age to OP (29).

Saying that I wouldn't now do it again but rely on muscle strength. I have only half that reconstruction left and made the choice to give up hockey. I am leg pressig 105kg weight on each leg individually now to make sure my surrounding muscles are strong enough to make up for the damage.

@Grizzler, age apparently plays a part (although activitiy levels should be more important!)

@EViS, worth reading this thread if you haven't ... https://snowheads.com/ski-forum/viewtopic.php?t=130739&highlight=internal+bracing&start=40

You know it makes sense.

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

Not having ACL surgery could leave your knee unstable during the most innocent of activity imo. Climbing stairs, turning corners, walking icy pavements. Can't imagine doing any strenuous exercise without worry. Had mine done on private HC at Rosshall, Glasgow about 15 years ago. The graft survived a subsequent torn cartilage injury during 5 a sides which has proven much more troublesome and limiting. I would recommend to get it done.

A snowHead

A snowHead

@Grizzler,

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

Did my ACL last April. I've had a mix of private and NHS appointments and physio, but if I had opted for surgery, it would have been the same consultant either way. The difference would have been in the timing, as others have said. I think I've been quite lucky with my NHS physio - he seems to know what he is talking about, it can just be a bit too long between appointments, so in the early days I saw a private physio as well. Now I kind of know what I need to be doing, it's just a case of actulaly doing enough of it!
I didn't opt for surgery, it's never felt unstable - the test will be next week when I ski on snow. The option is still there to have it reconstructed if I'm not happy after I've been on snow.
I have 2 active friends who did their ACL's in their 30's. One had it reconstructed, the other didn't. From talking to them both, I think the one who didn't have the op is in a better place than the one who did.
Every case is different - how your injury manifests, your long term goals, the state of your local NHS orthopaedic department, and the state of your local NHS physio. And it's not easy to decide what to do at a point when you are probably quite emotionally fragile about it all as well.

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Much sympathy to your wife as it’s an injury that takes a lot of getting over (having had one myself , along with my adult daughter ). The advice on here is very sensible and I agree with it - you will probably get the op quicker privately but ask your GP . But the op itself is only part of the picture - lots of physio and exercises will be the order of the day , I think .

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@johnE, I'm going punt that itv was obvious and osteopath was autocorrect

After all it is free

Thank you very much for all of your replies. I'm OPs wife and not the most efficient forum user hence the initial posting being from @EViS Smile

It's been really helpful reading through the advice and experiences that people have had here, thank you VERY much. I have to admit to feeling a bit 'at sea' when I had been injured and also getting the MRI results from the doctor. Exercise and physical activity is definitely a 'happy place' for me so I think there will be a lot of patience in recovery but ultimately the end goal will be to get to a place where my knee is as close to 'as good as' before to ski, run, hike etc.

I'm waiting on the referral in the next week to the orthopaedic consultant/surgeon to speak about the surgery that I have been told by the GP that I will need to allow for a few more considerations there too. I'd read that prior to this some gentle exercises to strengthen my leg in advance would be beneficial. Has this been the general experience of others in a similar situation too? I'm trying as much as possible to walk 'normally' too to avoid causing further damage to my back/other leg too.

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@Gremlin, what @Grizzler said. Me, injury 18.01, op sched 29.03. A contributory factor to the injury I am now sure was that I did no sport at alll from early May till early October last year in advance of cardiac surgery => my muscle mass had atrophied considerably (I'm normally pretty fit albeit skinny).

So my physio is very much concentrating me on pre-hab - building up my knee/leg muscle mass as much as possible, ensuring maximum ROM especiallly full extension and, as @Grizzler says, getting my quads to activate as much as possible as one post op issue is that much of your proprioception is driven by nerve(s) that run thru (or very close to) your ACL and they won't be there afterwards.

So your brain has to rely on alternative sources of info as to where your leg is.

Anyway, I am more or less walking normally and did a gentleish 30 min snoeshoe up to a nice resto last week.

Re the physio, after a couple of weeks of very gentle leg raises and knee flexions/extensions to the extent possible, she now has me on the bike for 25 mins or so to warm up, then variously leg presses, curls and extensions (with pathetically low weights), squats, ball squats, bosu squats on 1 leg, etc. I have bike and ball at home so much of this is being done as near daily as possible.

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@under a new name, what reconstruction are you having?

Just that a Norwegian friend said that on hers a couple of years ago then took a tendon below the knee, I questioned whether she meant patella tendon and she said no, and she said that now pretty well all the ops in Norway no longer go with the hamstring method?

@Weathercam, doubled hamstring, at least as far as is planned. That sounds odd as I haven't come across that method in my researches.

You know it makes sense.

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

@under a new name, I'll ask her again, I can only still think it was patella tendon?

A snowHead

@Weathercam, indeed, my understanding is that those are the only non-dead donor options?

A snowHead

Thank you again for all of the help. Hoping it’s ok to ask for a couple of other bits of advice.

I’ve since had an appointment at the hospital to review the MRI and look at next steps. The consultant examined my knee and the MRI result (almost complete rupture of ACL, grade 1 MCL sprain, considerable subchondral marrow oedema and a number of other minor knee injuries).

The consultant checked my knee for stability and advised that he didn’t think that surgery would be necessary since he gave me a Lachman test for stability and my knee is quite stable although doesn’t have a full range of mobility bending it back and forth. I’ve been advised to spend the next few months doing physiotherapy. He also suggested lifting my leg up onto a pillow or block and forcing the leg to straighten which is quite painful at the moment. Has anyone encountered similar exercises in ACL repair?

I have a slight concern without surgery and fully fixing the ACL completely, will this leave my ACL more likely to break fully should I fall again? I do a lot of running, swimming, hiking, yoga etc and want to return fully to skiing and any other sports possible. I’d like to know that I’m leaving my knee in the best possible position to do that. Any similar experience or thoughts, I’d really appreciate, thank you.

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@Gremlin, for what it is worth, I ruptured my acl April last year and was told that I wouldn't necessarily need surgery, as it wasn't particularly unstable.

The initial physio was all about developing range of movement, particularly getting the leg straight, just like you've been asked to do.
I was concerned about how well it would function without surgery, and decided that I would go down the rehab route and see how it coped with skiing, and then get it reconstructed if skiing was a problem.

I went skiing 2 weeks ago for the first time, and am skiing this week, and the knee has given me no grief whilst actually skiing, although it was more sore than normal for most of the week between the 2 trips.

I can hillwalk, rock climb, dinghy sail, dance and ski. Running isn't quite as comfortable as it used to be, but I haven't done much of that cos it's not really my thing. The knee doesn't bend quite as much as the other one, but since I can bend the good one right up to my backside and very comfortably sit on that foot, I think I still have pretty good movement in the damaged one compared to most people!

I have 2 friends who have done their acl in the past, one had reconstruction, the other didn't, and the latter says he can do anything he needs to, which includes some pretty extreme off piste skiing stuff. So my experience is that it may not be necessary?

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@Gremlin, The exercises aren't to "repair" the ACL but to strengthen all the muscles in your leg (primarily quads and hamstrings, also TFLs and glutes, + others) so that they hold things together in lieu of the ACL. These *will* become your lifelong friend rolling eyes

Sometimes, I understand, the ripped ends of the ACL can reattach themselves to something else inside the knee, but rarely to themselves, so once they are 'kaput', then they are gone in terms of original design specs. But for some people it isn't a particular problem, and I don't know if there's any evidence to say that you're likely to do worse damage to yourself if you hurt the knee again +/- reconstruction surgery. (Ask various and several clinical experts, which I am not: you'll probably get several differing answers, too.)
I lost both my ACLs completely, so they told me, both at the same time, plus bad MCL trauma (and hooooge and very painful long-lasting swelling, but apparently no meniscus damage). Bit different for me to most, maybe, coz I don't have a bad and good leg as such, so no real comparisons ever to make. Took me 6+ months to be able to kneel fully, and a lot longer to get it all feeling fully back, but with a lot of exercises and being an outdoorsy and dancing person anyway, I went the non-surgery route, which is what my UK consultant and several physios all advised me from the outset. I will admit still to being a total wuss when walking or climbing on anything slippery (psychology?fear? proprioception changes?), but my knees will now far outski my technical ability (in whatever snow conditions there are), never mind my knackered lungs and general aching tired body, my only remaining issue being a bit of rotational pain on one fibular head which limits my snowboarding (but may well not, or primarily, be ACL related): and it's still all getting better and feeling stronger as I carry on doing more exercises and more strenuous stuff generally. (I am not a spring chicken.) Just finally chucked the wraparound brace on 1 knee completely, which is a big psychological step for me.
Yes, things are different (though not too much): but I was told that they could never wind back the clock 100% one way and another, probably couldn't surgically give me anything better than what I had then/have now, and considering what happened, and other problems which I have, I'm OK with where I am. There's never been any knee instability since day 1, never any collapse, no giving way, etc.
Personally - and it's all very personal - the last things which I wanted were 2 more years of building up the legs after the injury, then having them in turn all cut open, then hobbling around all cautiously for months after surgery, then doing loads more exercise rehab again, then still having the chance of ripping it all to pieces anyway. Twice. If they clearly hadn't seemed stable or were giving me a load of problems then I would have asked for surgery. But I was advised to avoid if I didn't need it, and so far I haven't.

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@Gremlin, +1 to all the sort of stuff @Grizzler has just said

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Thanks again all for advice given on my ACL injury earlier this year. For something which was both physically and psychologically quite a big hit for me at the time, it was incredibly useful to read your advice and experiences and has really helped in informing my decisions in the past few months. I have been at the gym most days working on strengthening exercises and flexibility, along with a lot of time on the bike and rowing machine. Sadly the return to running hasn't happened yet due to pain still in my knee. The advice given on strengthening and thoughts on surgery vrs no surgery have been really helpful and thankfully received.

I wanted to share some experience from my time in the hospital with the hopes that this may help anyone in a similar position to me in the future. Since coming back, I have had a bit of a fight to have surgery on my ACL (something I had been advised to try for if I wanted my leg to be fit to run and hike to the same level again). I've found that pushing for this (politely) has been helpful when reiterating to the doctors that I want to return to a sporting level of fitness rather than the ability to walk around from place to place.

My most recent experience was with the consultant and surgeon in the NHS clinic. The consultant checked my 'bad' leg only with the Lachman's test once again to check for stability (my leg still doesn't feel as stable to me as pre injury) but because I've always had reasonably strong leg muscles, the test comes back that my leg is still stable. It was only when the surgeon came in and checked both legs (no one has done this up until now) that he could see that the leg with the broken ACL is less stable than the one without a broken ACL. I'd advise if you can to ask that one leg is checked against the other in case you have a similar issue to me here. I wish I'd have done this earlier.

I wanted to ask advice please on returning to skiing. I'm conscious that I've not done anything post injury. Being a relatively new skier, I feel like I'm increasing in anxiety towards skiing because of the accident and the more time that passes, the more the anxiety grows. Before I have surgery to repair my ACL, would it be a silly idea to get some more lessons at Milton Keynes/Hemel just to get in a better psychological headspace about returning to skiing? Has anyone had more of a mental block returning to skiing post injury? Any thoughts about how you overcame this?

Thank you again for all of the help and advice.

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Sounds like you’re planning to have surgery? If so, why not wait till you had it done and fully recovered before returning to skiing? Doing it now may reinforcing the negative psychological headspace.

Definitely a good idea to have some lessons once you decide to return to skiing

After all it is free

@Gremlin, very odd that no-one had done a comparative test on both legs Puzzled

everyone who's looked at mine have done that.

My leg felt immediately better and more stable after surgery. But if no-one's telling you not to ski, I know a few fold skiing without reconstruction. Immediately pre-surgery my leg felt pretty normal to the extent that I questioned my decision!

But, I'm very happy it's been rebuilt. At my advanced (!!??!!) age of 57 several non-Chamonix docs were reluctant but the Chamonix/Annecy ones were all for it. I mean, why does one live somewhere like Chamonix if one doesn't do lots of sports?

Anyway, just signed off for golf, roller blading and table tennis Little Angel

@Gremlin, very odd that no-one had done a comparative test on both legs Puzzled

everyone who's looked at mine have done that.

My leg felt immediately better and more stable after surgery. But if no-one's telling you not to ski, I know a few fold skiing without reconstruction. Immediately pre-surgery my leg felt pretty normal to the extent that I questioned my decision!

But, I'm very happy it's been rebuilt. At my advanced (!!??!!) age of 57 several non-Chamonix docs were reluctant but the Chamonix/Annecy ones were all for it. I mean, why does one live somewhere like Chamonix if one doesn't do lots of sports?

Anyway, just signed off for golf, roller blading and table tennis Little Angel

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@Gremlin,

Help!!

Torn ACL - Next Steps With NHS or Private

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