Complex meniscus tear + partial ACL tear

A snowHead

(update posted below dated 4 Oct)

Hello,

(cross-post from TGR's Gimp Central forum)

I've started searching on meniscus tears but I'm getting information overload so perhaps someone could help me out.

MRI results (sorry if I'm getting terms wrong, I'm translating them back from French)

- synovial tumefaction
- partial ACL tear
- thickening of internal collateral ligament probably due to a small associated sprain
- complex interesting (!) tear of the postero-median meniscus segment, with multiple tears
- normal external meniscus
- small oedema from impact in the posterior region of the two tibia heads

History and current symptoms:
This is a reoccurring injury. 3 years ago, in the beginning of the season in St Anton, I felt my knee buckle inwards and heard a pop. I was afraid I had done my ACL and didn't stand up for about 10 minutes, but then I was able to ski down. My knee hurt but hardly swelled. I was able to ski the next day with antiinflammatories and an elastic brace. I skied the rest of the season (my usual 25 days over a whole season), giving up the brace half-way through as I didn't need it. I assumed it had been a minor sprain and forgot about it (no doctor visit, no MRI at the time etc - stupid, I know, although in my defence my wife's a GP and she said this didn't look like a serious injury from how it healed). From the following spring, I also played tennis without problems.

Since then, a lot of skiing and tennis without any problems (and I tend to run and pivot like a madman on the tennis court, and ski reasonably hard offpiste as some snowheads may attest).

Fast forward to last week, I'm trying to surf in the North Sea and I felt the same buckling inwards. The knee swelled a little the next day but more importantly it half-locked for a couple of days - range of motion from about 10 to 70 degrees bent. It hurt and clicked while walking but then got better in about 3 days just with antiinflammatories. Right now I can walk normally but I would not run, let alone play tennis. I'm careful about bending the knee more than 90 degrees but I can do it.

What to do
The MRI doctor, who's the husband of a colleague so I trust his good intentions, says I will need an arthroscopy. The earliest I can see an orthopedist is Oct 14th - no idea if and when an op will be scheduled.

Some questions:
- where can I find a simple guide to meniscus tear repairs and recovery? I don't know what are my options for fixing it, and I hear anything from 4 weeks to 6 months for recovery
- more specifically, any chance of skiing this season post-arthroscopy or should I forget it?
- if I'll be able to ski (assuming a successful repair) - when?
- is it a bad idea to try to ski with this injury and postpone the operation until spring? (After all, I did it three years ago - I know this may be poor thinking)
- if I do the latter, will a proper brace reduce the risk of re-injury?
- any complications from the combination of meniscus tear and partial ACL tear?
- should I keep taking antiinflammatories while waiting to see the knee doc? Any other medication?

A big thanks!

A snowHead

I have had an arthroscopy on both knees, one to repair the meniscus, one to just clean out the joint but no meniscus damage.

I had my operation at the end of January and went skiing in the Easter (mid march) and it was fine. I was however only 16/17 at the time so the recovery time might have been quicker.

Hopefully then if you have the op in October you should hopefully be able to ski this season.

If you have to have anything done to the ACL though it might increase the recovery time.

I would get the injury sorted sooner rather than later.

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

horizon, have you had an MRI? Personally I'd have that and XRays done before anyone goes into my knee.......

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kitenski, I've had an MRI, that's where the detailed diagnostic results are from. No X-rays though, would they show the meniscus and ACL problems?

Anyway, snowHeads is much more fun if you do.

horizon, sorry I didn't read the huge red text saying MRI results Embarassed

I am no expert, but if they can see the tear then I guess it is there and needs repairing!! Have you had a chat with a physio, they may have some ideas which differ from a surgeons?

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kitenski, horizon, x-rays only show bone damage, not soft tissue injuries. They will indicate whether there is any narrowing of the joint spaces in the knee (indicates arthritis), and maybe the presence of ossophytes (bone spurs). These are often the cause of multiple meniscus tears of the more superficial type. Deep full thickness tears are usually associated with some kind of trauma or a long-standing mechanical problem.

The best advice is to get to see an orthopaedic surgeon who is also a knee AND sports injuries expert. I can recommend a few that are highly regarded in this field if you indicate where you are based for the time being. I seem to remember horizon that you move around a wee bit!

For what its worth, I had a meniscus trim and general tidy up in the first week of February 2004 and was skiing 3 weeks later on my own and teaching a further 3 weeks later.

Sue wink

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

Samerberg Sue, thanks for the info and the highly encouraging recovery time info!

I'm based in Brussels - right now I'm asking around for a doc who can see me as early as possible.

After all it is free

horizon, I've had arthroscopy's on both knees for meniscus tears, one of them also with a partial ACL tear. Here are a couple of good resources for the rehab: http://www.stoneclinic.com/rehabilitation (one of many good rehab guides from orthapedic clinics), and the book "fit to ski" by Carl Pieterson (ex physio to Canadian ski team). Also this simple guide from Bill Knowles who's a bit of a knee guru amonst elite skiers, rugby players etc http://www.nationalgeographic.com/adventure/fitness-training/ski-exercises-0612.html

In my experience: start working with a good physio today, there is loads of stuff you can do pre-op which will help post-op rehab go better. How quickly you can ski post-op depends on what damage there is; for my mensicus/ACL knee, I had the op (mensicus trim, no ACL repair) in June, overdid things in July & got set back a bit, took it easy in August then started rehab again from basics in September. In October I was doing well, did a bit of snowdome in november and was skiing close to 100% in December. But, the key is a good physio to guide you through this process, esp. as a partial ACL tear does complicate things a bit (I had a bit less stability, had problems fully flexing under load, and was prone to more swelling with that knee). (I assume your doc wont repair the ACL - it depends how functional what you still have is. If not, then the rehab is vital. If they do recontruct the ACL, you're looking at season 11/12 to some back). PS, by rehab I don't mean the "get back to the office" type of rehab you initially get, but a proper ski focused programme with a physio who understands the demands of skiing.

As for skiing with the injury, listen to your body & discuss with said physio. Loads of elite skiers & rugby players compete with damaged meniscus and ACLs, but they are incredibly well conditioned & ready to take the risk of adding more wear & tear as they are paid for it. Maybe, if you do the right rehab, you can indeed ski OK.

Braces - psychological benefit mainly, unless you get a monster carbon fibre thing which is meant for serious ACL damage. With the right rehab, not even sure that is worth it.

Long term anti-inflammatories not really recommended, if you need for the long term then you should be getting it sorted so you don't need. With knee damage, I would recommed both fish oil & glucosamine, which keep the joints healthy for the long term (but are not miracle cures)

horizon, The best for meniscal problems in Belgium are Verdonk (Father and son based in Ghent) these two are acknowledged experts worldwide. They are doing cutting edge work with meniscus transplants for example.

In Brussels you have: Dr Frank Handelberg (http://www.vub.ac.be/index.php) and Dr Jose H F Huylebroek (jose.h@pi.be) - the latter is a sports ortho. ( website: http://www.cavell.be/content/default.asp?key=0403&subitem=04&id=350

Good luck. with regard to physio, ask around as good ones have a great network of "Mund-Propoganda!". You may also get some recommendations as to who to avoid, just as useful!

Smile

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Sorry to hear bout this, horizon. (I've answered your email)

I rather doubt they will suggest doing anything about the partial ACL tear. I discovered when a medial ligament injury was investigated a few years ago that I have been skiing for years with ACL ligament "insufficiency" from a previous injury, but the specialist made no suggestion of doing anything about it. (But perhaps it has some impact on your other injuries - I don't have a clue).

snowHeads are a friendly bunch.

Best of luck. I am scheduled for an athroscopy for 7th October, with a skiing holiday already booked before doing the damaged for the 12th Dec.

I have previously had a complete rupture of my ACL and then reconstructive surgery, which was completely successful. Though it took 6 months of intensive physio before I was given the all clear to go back to hockey training. I had been planning on going skiing again about 9 months post op but found out I was expecting my eldest daughter (we were trying) and got told you weren't allowed to ski while pregnant so it was a long time after before I skiied again.

snow reports

snowball, thanks. For some reason your email didn't arrive yet.

I did speak briefly to the doctor who operated on my wife's ACL - his view was that if the knee is unstable then he would operate on the ACL. That's the one I'm afraid of. But is my knee that unstable?? yes - once 3 years ago and once last week, but in the meantime you've seen the kind of regime I've subjected it to without any problem...

On the other hand, apparently another twist/fall could lead to another meniscus injury, which creates more problems down the road.

Samerberg Sue, I'll try to contact one or more of the specialists you recommended. Thanks!

The key to living without an ACL is good muscle strength in you leg. With my knee prior to the surgery, I could literally feel my knee doing a figure of eight just walking normally. It was incredibly disconcerting. I couldn't even manage going down stairs at a normal pace without it collapsing underneath me. However I know there are cases of people running marathons (though bear in mind those are in a straight line not stop, start, turn of hockey which is my other passion) without an ACL.

There are knee dedicated forums which I have inhabited which know a lot about knees and ACL's especially. I don't know if we are allowed to link to other forums here?

You know it makes sense.

horizon, NickyJ, here's an article that discusses the pros and cons of not operating on a ruptured ACL

http://www.eorthopod.com/node/26439

In short it says you can live without but you need to modify your activities and lifestyle if you are to slow down the inevitable consequences in terms of osteo-arthritis. That means eliminating all cutting, pivitting and high impact activities, while maintaining good to excellent muscle definition all around the knee. Easier done when one is younger, not so easy to maintain later on in life.

I forgot to include the contact details for Drs Verdonk (they are father and son by the way!):

Professor Rene - Maaltebruggestraat 260, 9000 Ghent, Belgium. fax:+32-9-240-4975
Dr Peter - Department of Orthopaedic Surgery, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, email: pverdonk@yahoo.com

snowHead

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

If I had a completely torn ACL, then I'm pretty sure I would want an operation.

It's having a partially torn one that's the issue. Operation now? Operation next spring? Wait for it to tear completely?

A snowHead

horizon, my sympathy.

I've been carrying an injury that will be one next week. Happy Birthday dodgy knee.

I avoded surgery as the MRI revealed no damage to ligaments or meniscus, but the physio work is a pain (in both meanings). I'd agree with Kitenski though; regard surgery as a last resort and not a first option.

Get yourself to a good physio and see what they think, and buy a knee brace.

A snowHead

horizon, Sometimes in life we make decisions and then suffer a guilt/doubt complex afterwards. During this sensitive time doubt and/or validation of a decision can be difficult relations, hence perhaps your posting?

I tore my interior meniscus and as you say you've now been diagnosed by MRI which is very good.

Mine was misdiagnosed so exercise/therapy for 6 months for an ACL strain etc made it worse. After the MRI diagnosis I asked for a cancellation at any time and got an appointment within a week.

The arthroscopy/keyhole surgery was straight forward but the healing took longer due to the extra wear/strain imposed on the meniscus and the surrounding bone which became "gnarly". This was the odema which you mentioned. This necessitated opening/stretching the joint to enable bones to be smoothed down, which is good but increases soreness/recover time. The consultant told me about that and the “extra” work weeks later when I asked why it was so damn sore and the longer things are left, the worse the odema will become, plus large opening/complications/Osteoarthritis etc Sad

Given the chance all over again I'd push, and push for diagnosis (which you already have) and then push hard for treatment ASAP. Recovery afterwards is a matter of time, doing the exercises and not overdoing the wear and tear. You sound fit and sensible-ish (delays aside). I now try not to kneel down on hard floors/concrete and think twice about running unless there's a real need. Bottom line is that if I injure myself skiing it’s kind of a price one pays for enjoying the sport I’m passionate about. If I bug my knee kneeling on the floor or running for a bus, that would be a pointless consolation.

BTW you cannot physio a meniscus tear better and from what you’ve said in your results post, if it was me I’d stop digging, especially as you also have an ACL complication. Sad

http://wimbledonclinics.co.uk/south-london-knee-clinic/

This link has a lot of good information but you will also come across many alternative stories which worked for other people. None of us are you and you ultimately have to make your own decision.

Wish you luck and a speedy recovery.
snowHead

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

horizon, Sorry to hear about your knee.

You've had the MRI - & thats good. I'd try & get to see a good knee surgeon ASAP, & ask his secretary for the name of the physio he uses, so that hopefully you could get going on some physio in the meantime. I'm sure its good to keep it as mobile as possible. Also, dont forget to ice it regularly - several times a day. Its very soothing, & reduces the swelling. Every time I sat down, I put my foot up & iced my knee.

When I did mine, I had a similar MRI to you, in that the ACL was torn - hanging by a thread, & torn medial, colateral ligaments & torn meniscuses. The worst thing I found was the lack of proprioception - where my foot was in relation to the rest of my body - very disconcerting! I resisted any surgery & really worked at the physio. I also had a donjoy knee brace which was great - I skied in it the first year after the injury & found it very reassuring. It also kept the knee stable when I played tennis.

But, as somebody said earlier, the key to stability are good strong leg muscles & good core stability. Goodluck with the rehab & I hope you get to see somebody soon.

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horizon, You skied last year with Roger who had lost one ACL the previous year. His skiing seemed remarkably unchanged.
At your age, though, I'd certainly go for surgery if I had a complete tear. Not sure about your present situation though: I think, like you, I'd just take the best advice from specialists.

Anyway, snowHeads is much more fun if you do.

horizon, i would get yourself off to a good physio ASAP - they often have a bit of a different outlook from the doctors

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I had an athroscopy on exactly the same thing in the October. Skiing again by the February with no problems. You have to do intense physio work though

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

horizon, when you find a surgeon you can discuss your options with, ask them about a LARS graft. These are augementation devices that allow fairly rapid return to full activities. It is a bit of a controversial thing, be prepared for the surgeon to give you a sign against evil Laughing

but it is gaining in acceptance, especially in Australia, Canada and New Zealand. It is licensed in Europe and Canada as well, but the FDA in the USA will not license it for use. Partial tears, or ones hanging on by a thread are almost pre-requisites for this treatment.

There's a lot of guff and marketing out there on this topic. As the recipient of 2 artificial ACL ligaments in the 1980s I was sceptical about yet another "wonder". But used in the right circumstances, for the right reasons, they are getting some interesting results. Luckily for me, both my artificial ligaments snapped within a year of placement - not that I was happy about being operated on 3 times in as many years! Others have had them disintegrate in the body, effectively poisoning them, especially the earlier carbon ones. Sad

A LARS graft would mean you could use the between season time, the skiing downtime, to get yourself sorted out and not miss any real skiing! wink

Let me know if I can help with any more contacts in Belgium - I have a couple more names but they are even further away from Brussels I think.

wink

After all it is free

Samerberg Sue, I had a LARS type opertion 28 years ago using carbon fibre. I was off sport for 20 months. It was incredibly painfull and bending of the joint is only possible to 65%. A am sure that things have moved on since then. Below is a copy of a study into some post case reviews!!!!!!!!!

A radiological and histological analysis of five knee joints after a minimum of 15 years following the implanting of carbon fibre, which had been used as a treatment for knee instability, was undertaken. All patients underwent total knee replacement for secondary osteoarthritis. Histological analysis demonstrated a variable amount of macroscopically visible carbon particles in the synovium, hyaline cartilage and menisci. At microscopy these particles were found in association with fibrous tissue adjacent to bone with no acute inflammatory changes. No intact carbon fibre ligament was noted within the joint, small portions of the old ligament were covered with a thin fibrous layer but there was no evidence of any structure resembling neo-ligament. Extra articularly the carbon fibre was covered with a thick fibrous sheath with no active inflammation changes inflammation. In the bone tunnels, the carbon fibre–bone interface showed an apposition of the bone to the carbon fibre without any interposing fibrous sheath. Carbon fibre bonds directly with the bone without fibrous interposition

Frosty the Snowman, in those days they used open knee surgery - I was in a wheelchair for 3 months after my initial operation. The new LARS materials are completely different and are augmentation devices which remain at the core of collegen-like scar tissue which the body builds up over it like over a scaffold.

What we had in the 70s and 80s was not an augmentation system - they were straightforward replacements. The carbon fibre grafts of the 70s were relatively quickly withdrawn from use when the dangers of disintegration were realised. Later versions made of Dacron and other hydro-carbon based materials were also withdrawn in favour of using autografts (own tissue) during the late 80s and early 90s.

I was told I would never walk properly again and would always have to rely on a cane until I was old enough for a total knee replacement - as a PE teacher in my 30s it was a crushing blow. But I did not accept that prognosis and researched extensively for alternatives and then pushed the NHS consultant again and again until I had the same graft as Gazza. Still in there and still taking part in sports, albeit more genteely these days wink

Can you give me the source of your quote so that I can add it to my collection of articles please?

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Most of the highly recommended people seem to have long waiting lists to even see them. Through a friend I've managed to get a booking with a Dr Cauwenbergs, the knee specialist (and head of orthopedics unit) at a hospital near home, next Monday, so I'll see what he says.

By the way, next Monday I'm also going to a physio recommended by a colleague as very good, so let's see what happens with that.

Samerberg Sue, does the name Dr Haller, from Ebersburg, tell you anything? Someone else who comes highly recommended by a friend, though a bit too far from me.

snowHeads are a friendly bunch.

horizon, if you mean Ebersberg down here in Bavaria and you are prepared to travel that far, I would highly recommend my surgeon. He sorted out a hell of mess left by several other not so capable doctors and got me back skiing inside 5.5 months! Looking at the web page for Haller's practice, he appears to be a general surgeon specializing in the larger joints, not specifically a knee surgeon.

http://www.zos-ebersberg.de/root/unsere-praxis/unser-team/dr.-med.-haller/

The length of the waiting lists is indicative of their reputation unfortunately. Even my specialist had an 8 week waiting list when I first approached him. Mind you I was contacting at the end of the ski season for ACL related problems. After that initial wait, I never had any problems organising follow-up visits. I think the waiting lists are primarily for initial visits. The ones without waiting lists probably do not come so highly recommended, rightly or wrongly. This is my surgeon's web-page:

http://www.orthopraxis-rosenheim.de/cms/pages/chefaerzte/dr.-mueller-kittnau.php

How far are Hasselt and Leuven from you? I have the names of a couple of surgeons in those towns that come highly recommended.

wink

snow reports

You know it makes sense.

UPDATE:
Saw the knee doc and the physio today.

Doctor did the stability test - there is some instability towards the inside of my leg. He said: "if you were playing football competitively, we'd operate. This way - your choice. I'd say take it easy but I'm a skier and I know that the self-control required lasts about 1 hour." He thought that doing the meniscus arthroscopy now and leaving the ACL reconstruction until spring (if needed at all) may be a good idea, coupled with using a good brace. The advantage is that he can have a look at the ACL when he's doing the arthroscopy and can tell me if I have 5% or 80% left intact.

The physio guy, who seemed very good, stuck needles in me which HURT (in more places than the needle was actually going in), aiming to "release" the muscle which was keeping the ACL under tension. He said he was very satisfied with the outcome of this first session (my range of motion increased considerably) and wondered if the arthroscopy was really necessary.

Still not sure what to do, but leaning towards the meniscus repair (I can be back walking in 2 days and doing sports in 2 weeks) plus physio and exercise, and leaving the ACL repair until spring.

More comments, as always, welcome.

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

horizon, go with the physio IMHO and keep them out of your knees as long as you can!

Note I am not medically trained at all Wink

brian

horizon, I'd definitely be leaning the same way as you.

A snowHead

another vote for getting the meniscus sorted now and having them assess the ACL while they are in there

i have a theory that my ACL popped because i had a damaged meniscus which destabilised the knee. it's just my uneducated theory so to be take with a large pinch of salt..

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

not a doctor but am a vet and I'd definitely say get the meniscus sorted sooner rather than later. You will develop osteoarthritis in this joint in the future, that is a fact, but having loose bits of cartilage inside an unstable joint will sure as hell speed up the process!

(and yes, having a surgeon poking around will also speed the process no matter how good he is, but its the lesser of two evils)

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I'll sleep on it until tomorrow but yeah, much as I'd like to keep the doctors out of my knees, I'd rather deal with at least one of the problems and get extra info on the other one.

Anyway in the meantime I'm the proud owner of a Bledsoe Axiom brace, which is supposed to be really good. It better be at nearly 1,000 Euros! (good thing I'll be paying only around 200 or more likely nothing due to additional insurance). Considering a sH name change to Robocop...

Anyway, snowHeads is much more fun if you do.

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I've had both done in the same knee. Arthroscopy & some meniscus cut out - recovery time about 2 months + some rehab - skiing would be possible at 3 months ish I guess (IANAD). ACL did without it for another 2 years before it got too much - skied at 5.8 months after recon + lots of Gym work. This knee is now better than other which I frcatured end of comeback season. I'd go PTG for any recon based on my experience - just feels bomber.

Help!!

Complex meniscus tear + partial ACL tear

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