Ruptured ACL, one year on

A snowHead

Just posting this in case anyone is interested in another ACL experience, as I know I wanted to read as many accounts of people's experiences as possible when it happened to me.

12 months and 2 weeks ago I fell off an indoor boulder wall and snapped the ACL in my right knee. I opted not to have it reconstructed, and have been rehabbing all year. At my last appointment, in February, the doc asked what I wanted to be able to do, and I said that if I can ski on it without worrying about it, then I'd be happy. I had 2 separate weeks skiing in March and after the first day or so I didn't really think about it at all. Today the consultant (or rather, one of his team, NHS and all that), discharged me, saying that if I was skiing and hadn't experienced any instability, I'd be fine.

It was a difficult choice back last year, trying to decide whether to have it reconstructed or not, and in the end my plan was to see if I could ski on it at the end of a year's rehab. The consultants ( I saw 2, one private and one NHS) were not inclined to tell me what they thought would be best, they left the decision very much up to me, which wasn't as helpful as it could have been. I'm very glad that rehab seems to have worked, and I haven't got to go back to square one, have the op, and do the rehab all over again - it's been a long year.

I'll still probably have to have the meniscus tidied up at some point in the future, but for the moment it's not too bad.

My one remaining query is what one does about ongoing maintenance, as I really hate going to the gym, and since the physio discharged me in mid March I have been pretty bad about keeping on doing the exercises. What are people's experiences on that one?

A snowHead

Bike!

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@karin, I religiously go to the gym personally. To maintain the muscles to a good level. When lockdown closed tĥe gyms I really struggled to do enough and right exercises to keep that high level of muscle strength. Bike was OK (aside from added danger of doing it on icy roads in the dark!).

Pilates is another I do. Squats are a good idea. However whar I like about using the weight equipment in the gym is I am do that single legged to ensure I am not favoring one leg

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@karin, good to hear that. Well done you. I quite like going to the gym so I am no help on that snowHead

I would think that e.g. a swiss ball and core exercises plus 60 or so squats every morning will take 5-8 minutes and keep everything in place? Or just learn to love the gym wink

Anyway, snowHeads is much more fun if you do.

@NickyJ, hmm yes I am just moving in to the phase of "what did you do to my hamstring?"

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NickyJ, "a hockey incident" ooh err missus

Yes, just at the beginning of the rebuild on that and it is quite a painful thing

After all it is free

@under a new name, Smile

The people running training session decided to just do a match (it was towards end of season), I always wore a just in case knee support for matches but not training. I played defence and I was going in to tackle they changed direction so I tried to change but weight came down "wrong".... I knewnt wasn't right so took all my weight off the leg which is what preserved half the recon, however left it not stable. Of course I didn't realise as physio's and doctors could still feel what was left of graft. So when I went back to training it collapsed under me while sprinting and that caused a lot of other damage Sad

@NickyJ, ooh, ow, ouch. very unfortunate.

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@karin, glad to here rehab's going well. I'm now 23 years on from a knackered ACL and I didn't get surgery, and all's still going pretty well - drunken dancing is probably the greatest cause of subsequent tweaks.

In this time my use of gyms has varied; some regular (at most twice a week), some sporadic (depending on travel), and some large gaps without. I have always done a lot of cycling, and sporadic running. What's been most important for me is to build up strength, balance and confidence for about 6 weeks prior to my first ski trip in a season. The main things I've done for this are:
Plyometric exercises - I'd typically do around 8 sets of about a minute, across 3 or 4 different exercises. This can be done with no equipment, though I prefer to have some box or bench (ideally height adjustable between maybe 20 and 50 cms) to jump on, off or over
Leg blasters - this is a combination of squats, lunges, jumps done at high speed. 5 sets with a 30 sec rest between. No equipment needed (though I like to progress to doing them holding a light dumbbell - up to 5 kg)
Running, including downhill
One-legged balance exercises on a Bosu ball (at one point I also has a mini-trampoline)

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@NickyJ, I've been pretty regular at the gym for about 30 years, although no exercise at all last year (contributory I am sure) - and very definitely 5/7 exercise is now mandatory.

Well that was pretty stupid of me to start a thread last thing on a Friday night and then go away for the weekend!

@abc, hmm, I do have a decent bike, but for me it's only a Summer activity because I don't like going out in the dark

@NickyJ, but what happens to you if you don't keep the strength up, because it doesn't sound like that was the cause of your re-injury? Also, how on earth do you find time to go to the gym 5 days a week?!

@under a new name, no, not going to learn to love the gym! The one that is convenient, ie on my way home from work, is always heaving, and full of Surrey Uni students who are young, fit, and all (well mostly all) look amazing in thier gym gear. Makes me want to hide in a corner. It is also a very wierd environment if you go on your own - full of people, but mostly in their own little headphone worlds (me included). It's just so boring. Maybe I should have tried a different gym. Good luck with your ongoing rehab Smile

@viv, glad your approach seems to have worked, because that sounds very much like what my approach will be. I have a swiss ball, a bosu ball, some hand weights, and a variable height box to jump on and off. I climb once a week, do Ceroc twice a week, and do a fair amount of hillwalking, so hopefully all of that and some home gym stuff will be ok

You know it makes sense.

@karin, get up at 5:10 to get in for 6am so can go before work 4 or my 4 working days. Then a trip ON sunday for when it opens at 7:30am.

Original damage was a fall skiing and it ski not twisting off.... it doesn't twist at heel from normal bindings, I now have my own skis and kneebindings.

Reinjury was weight coming down wrong when trying to change direction quickly... similar to root cause of many hockey and rugby players ACL injury. I always ensure I where hinged knee support for skiing

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I have no knee problems. However, I do read up about potential knee problems and ways to avoid getting them.

https://taichionlineclasses.com/the-tai-chi-knee/

I have tried Yoga and Pilates, and incorporate both into my regular routines to a greater or lesser extent. Tai Chi is something which I have not looked into, but I know it is advocated by the NHS for certain aspects.

The above link seems to say that Tai Chi could be helpful for knee strength and stability as we age. Using body weight to strengthen, and no need to go to a gym. This kind of thing can be done on the lawn at 7am every day!

What made me think of it for you is visions of slow steady movements which often incorporate knees.

A snowHead

@karin, ...obviously the key thing is just how badly you damaged your ACL.

An ACL injury may be diagnosed when the ligament is overstretched or torn. The tear may be partial or complete; a complete tear of the ACL is also known as an ACL rupture.

Grade I tears refer to a slightly stretched ACL. Symptoms are typically mild. The ligament can still keep the knee stable.
Grade II tears refer to stretching of the ACL to the point of looseness. These injuries are often referred to as “partial” tears. Symptoms are more severe than Grade I tears. Range of motion may be restricted and the knee may occasionally feel unstable (the knee feels like it is “giving out”). 1
Grade III tears (ligament rupture) are complete tears (the ACL has been split in two). Grade III tears may also be referred to as an ACL rupture. A person may not be able to bear weight on the injured leg.

Do you know whether you were grade 2 or 3?

I suffered two Grade II injuries - massive haematoma first time around, not so bad second time but still needed needle aspiration.
This was forty years ago.

It has been through various weird stages: periods of complete stability, followed by dislocation sideways, then dislocation front and rear direction. Cycling, climbing, skiing - do them all keenly. I had one period of instability, so sbout fifteen years ago I saw Sir George Bentley at Stanmore and after a thorough examination he simply advised 'stress it as much as you can, you've done a great job at keeping strength and mobility - the more you stress it and use it, the better it will be'. No signs of arthritis, contrary to what I was warned.

Building up muscle around the joint is simply fundamental, and cycling is best for that. I mountain bike, and the occasional 'off' means knee pads are essential - POC and 7idp. But the experience skiing is interesting.

Know your DIN and watch the forward pressure on the binding. This is ALL IMPORTANT. If you know these two things and have your own skis, then fine. If not, really get on top of them.

THEN....For years my knee became hugely swollen during a couple of weeks' skiing. We ski for around five-six weeks a year. Then I had two days training really focussing on forward lean and pressuring the ski at every part of the turn. This really reduced the swelling to my knee, since I was not using my knees to steer so much - I had always been muscling my skis rather than really finessing control. This year I focussed on hip position and this again improved my knee - every time I imporve my core technique, the better it is for my knee.

At times, my knee has given me serious problems of pain and instability. Each time, exercising hard as soon as I can has paid off massively...with cycling being very much the best option.

A snowHead

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@valais2, it was definitely a full rupture. With meniscus damage as well. After the fall I had to hobble back to the car with support from the friends I was climbing with, and then drove myself from Hounslow back to Guildford so I didn't end up in an A & E miles from home. Got seriously told off by the nurse for having done that. Next day I could barely walk, and was using crutches for quite a while.

Interesting that you have had periods of greater and lesser stability - do you think they were they related to how strong the muscles were at any given point?

I do know all about binding set up, and ski on the appropriate setting for my height, weight, shoe size and age. Although I think I only came off my skis twice this Winter, I'm pretty sure they're not too tight - I know that on one of the falls I had done absolutely nothing wrong, my heel binding released when the ski hit a particularly thick, squidgy bit of snow and stopped sliding. I was fully in control and felt that I should have just skied through it. I have wondered about setting the toe binding 1/2 a notch looser than the heel so that it gives me more protection from a twisting fall, but doesn't make me feel that if I keep my weight forward/centred I'm going to risk the heel releasing when I don't need it to.

Knee was more swollen than normal after a week skiing (and it does similar if I do much running), but it calmed down again after a week. I would like to think that my technique isn't too bad, and that I don't muscle my way through things, since I have been an instructor (albeit dry slope only) for over 20 years! My legs were definitely getting less tired than the other folks I was skiing with.

Sounds like another vote for cycling, though!

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@karin, …strong recommendation NOT to have different DINS - have a chat with SpyderJon about which bindings are best for those with ACL injuries. Even in a given manufacturer there are difference - eg Tyrolia and Marker. That does sound like a pre-release, and is to be avoided.

Note that the morphology on my left knee (the injured one) is VERY different. The musculature has now grown to be very different (bigger) and the bony structure of the joint significantly different (much wider across, using calipers to measure) - there’s been a lot of growth and change to deal with the instability in the joint - and to counter it. The body’s response over time has been impressive and interesting. My meniscus damaged - lots of meniscal fluid released at the time - but that’s responded over time too, so that whilst I had nasty crunching for many years, that’s reduced too. Stressing the joint enough but not too much has been vital - and only a few bangs which have set me back - one being a recent slam-dunk from a mountain bike whilst in singletrack - and the knee caught the stem full on. But the knee pad I was wearing was very helpful in avoiding serious damage - just swollen and painful for a week.

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Unlike @valais2, I've had little variation in stability (drunken dancing notwithstanding), though over the last nearly 15 years I've had pretty consistent levels of exercise (though varying throughout the year). I race cyclocross, which makes for a 3 month block of structured cycling training, followed by a 4 month race season. Then there's winter, with the specific prep for skiing as posted above, and in non-skiing weeks generally ticking over with cycling, running and maybe gym work, and the odd out-of-season bike race.

I'm not sure there's anything particular that makes cycling significantly better than e.g. hill-walking, Ceroc, running - I think what's most important is keeping up a decent level of activity, and maintaining consistency. Prior to starting cyclocross, I still got most of my exercise from cycling (mostly road), though at lower intensity and consistency, and looking back I think I needed the ski-specific prep more then than I do now with my current activity levels.

Re swelling, I was used to the knee swelling up after a couple of days skiing, and every evening thereafter icing it (swelling was mostly around the hamstring tendon). I seem to have fixed it this season, though not in a way that will help most people. I've been pretty much only telemarking (with occasional forays into snowboarding and teleboarding), but this year I got a set of alpine touring bindings mounted on a pair of skis, and have typically done 2 days telemarking for one day of alpine skiing. The relative rest / change due to doing alpine skiing seems to let my knee recover much better over the course of a skiing week or two

After all it is free

@viv, …interesting…main things to note about cycling:

No impact to joint - unlike running etc

No significant twisting - if everything adjusted properly on bike and you get the right plane of movement

Easing up - you can ease up with one leg if necessary - although you need to ensure that this doesn’t develop into a permanent imbalance

@valais2, I agree with all you say about cycling, but my thinking is that it is beneficial to get exposure to a level of impact and twisting to build resilience. I've no research to quote on this, but my view is that moderate intensity exercise on a bike in isolation doesn't help much to build up muscle around the joint.

With cycling I'd favour a mix of cycling which includes some high intensity and also the need for balance through the legs (such as cyclocross or the mountain biking you reference), rather than lower intensity road mileage. However, I also see the benefit of other exercise (running, hill walking, Ceroc etc) that includes an element of impact and forces in variable directions.

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@karin, yes. My physio used to shout the direction changes...much easier if you've got someone to do that

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https://www.nhsinform.scot/healthy-living/keeping-active/activities/tai-chi-pilates-and-yoga

This is what the NHS says about Tai chi, Pilates and Yoga in Scotland.

You know it makes sense.

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

@abc, Turbo trainer is already a thing in our house, because my husband has had a dodgy knee for far longer than I have, from an accident 25 years ago. Unfortunately he has nabbed the only usable corner in the garage, because we actually have a car in there, and as he is 6' and I'm only 5'4" we would find it hard to use the same bike!

A snowHead

@Bigtipper, I did yoga before Covid, but the class didn't restart again afterwards. It was quite enjoyable, might be something to take up again in the Winter

A snowHead

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@karin, re different settings there’s long been a controversy about doing it or not doing it.

But I imagine release forces expressed as a kind of disc floating above the binding. With dins the same front and rear, the disc is hovering flat above the binding, the force to release will be in line with the design spec of the binding. Tighten the rear binding more and the disc tilts upwards at the rear, with more force needed to release - and the forces ramp down towards the front but can be higher right over a large segment of the disc. The release modes of the binding have now been changed quite a bit - and remember a fall can happen in any direction. Basically, it looks like a simple question of ‘it’s now a bit tighter at the back’ but the release modes have been changed in a complex way.

Spyderjon has said in the past that he will increase rear slightly or front slightly if someone has a particularly acute joint problem but it needs to be done by someone like him - highly experienced.

He has said:

On an Italian tech always having the rear higher: Just because someone talks a good talk doesn't make them right. Whether this is a bygone era thing I don't know but I can categorically tell you that not one current binding manufacture states that the heel release should be higher than the toe. In fact the toe & heel piece sets have been designed to work in harmony with each other when both are set to the same value. In the last few years I've done binding tech courses for Salomon, Tyrolia, Atomic & VIST & the instruction from all is to set the the same. The only time they should be set differently would be as the criteria I listed earlier.

Reminds me of the loads of shop techs that are still detuning brand new shaped skis when they arrive in the shop. They'd give you a very good explanation if you asked them why but it doesn't make them right rolling eyes

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@abc,

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@valais2, I'll assume the experts know what they are talking about, then - although I'm not sure I quite understand your explanation/analogy!

After all it is free

I'm current ten weeks (4th March) post ACL rupture and have been told by the NHS waiting list coordinator that I'm not an urgent case so need to wait in line like everyone else.

I'd booked an Ironman (Bolton) for July this year which has now been deferred to 2024 and at this rate not looking like an achievable goal.

I've been getting out on the road bike a few times now the pain is subsiding but cannot turn a pedal in anger just yet and had a failed first attempt at a leg raise in the gym this morning.

I'm not holding out much hope of skiing next season so am pretty grumpy on a good day.

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@homers double, might be worth finding out what it would cost to self fund the repair. When I did mine they did a package fixed price deal which included all the physio after and that was a huge amount. Make sure they know you are self funding when getting the prices

Help!!

Ruptured ACL, one year on

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