A skiers recovery from an ACL reconstruction

The accident

It was the last run of the last day of a holiday in March 2014, when skiing off-piste on Whistler Peak, I jumped a small cliff, landed awkwardly in wind affected snow, legs too tired to adjust, one ski caught in the crust and twisted me round, my momentum still carrying me forwards I fell and instantly felt a pop in my knee.

The day before, I was cat-skiing in heavy wet snow when my binding released under about 2 foot of snow. Luckily, I saw the trail it left and found it after 10 minutes of searching. It was then I decided to crank up the binding to avoid losing a ski. I was skiing on DIN setting of 8 so to be sure, I cranked it up to 10. I’d invested a significant amount for the day, so didn’t intend to waste the money searching for lost skis.

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Cat-skiing with Powder Mountain just outside Whistler

The next day, remembering that I needed to change the DIN, I thought with the snow conditions back in Whistler not as heavy as the day before, I’d reduce it to 9. In hindsight, this was a big mistake. The conditions were quite cut up in resort, and when realising this I should of reduced it again. When I fell, instead of the binding releasing as it should, my ACL was the bit that gave.

After the sharp pain I felt of the ACL rupturing, the pain subsided quite quickly. I managed to traverse back onto the piste, and skied the remaining section to the nearest gondola on one ski, where I down-lifted to the nearest pub.

The physio’s opinion and MRI scan

After performing stability tests and feeling the swelling in the knee, the physio in resort concluded it was not the ACL, but the MCL and LCL ligaments. Because these have good blood supply, they can repair themselves and therefore don’t need an operation. I therefore decided to continue skiing on it to complete an avalanche awareness course. Although painful, I was able to complete the course including two days of ski touring in avalanche terrain.

It wasn’t until after returning to the UK, another physio suggested I go for an MRI scan to see exactly what damage was done. On receiving the result, I was shocked to find that it was in fact the ACL ligament which was completely ruptured and meniscus cartilage which also has a partial tear. Without any private insurance, I was placed onto the NHS waiting list, and referred to Pinehill hospital in Hitchin to have an ACL reconstruction.

The operation

14 weeks later, I found myself being briefed by the surgeon. He would initially attempt to clean the meniscus. If that went well, and my knee gained full extension he would attempt an ACL reconstruction in the same operation. Receiving a general anesthetic injection was the last thing I remember. I awoke some hours later to find the operation was a success. The meniscus tear was near the end of the cartilage, so it was just trimmed off. The new ACL was taken from my patella tendon, the surgeon later explained that this was done to keep my hamstring in tact, knowing that I was a keen skier, he didn’t want to weaken the hamstring. The only downside to having a patella tendon reconstruction is the huge scar it leaves down the front of the knee.

Recovery

The first few hours after the operation were fine due to the painkillers I’d been dosed up with. It wasn’t until night came when I was trying to sleep that the painkillers wore off, I felt a throbbing pain. A couple of doses of morphine later, I felt OK and was able to get some sleep, however sleeping in the same position for 8 hours I realised, is not something I’m good at.

I met with a physio the next day who took me through walking on crutches up and down stairs etc. and was promptly discharged. Apart from feeling a little groggy from all the drugs and lack of sleep, the knee felt OK. I was prescribed paracetamol, ibuprofen and codeine for pain relief. The first two days were mostly spent on the settee, getting used to the brace and crutches around the house. The initial throbbing pain I felt on the first day had subsided, my only problem was trying to sleep in the same position.

1 Week

After a couple of days, I was walking around the house – able to perform everyday tasks without too much trouble. My brace was locked into the 180 degree position and was instructed to wear it whenever moving. Around a week from the operation, I was performing simple exercises to try and keep the muscles moving without putting much weight on it such as static quadriceps, knee bends and patella mobilisations – it was then I noticed how much muscle strength I’d lost in the quadricep. Even just trying to straight lift the leg felt like an impossibility.

2 Weeks

I had my brace adjusted to allow a 90 degree movement and the pain had subsided enough to allow me to start working again. I’d also been provided new exercises from the physio including knee bends, knee extensions, straight leg raise, heel raises and heel hangs. The straight leg raise was still the most difficult – I could barely move it an inch.

4 Weeks

I was now able to walk freely without crutches, albeit with the knee brace to prevent the knee bending anymore than the 90 degrees. Straight leg raises were now possible, however the physio felt that the quad muscle still wasn’t contracting well enough so provided me with muscle stimulater (electric impulses) to try and stimulate the muscle.

6 Weeks

At this point I saw the surgeon who informed me everything was on track, the strength of the knee felt solid enabling me to start pushing the knee a bit more – but to avoid any exercising that involved pivoting the knee. The extension of knee was good to the point where it becomes hyper-extension, whereby a little pain was still felt. I was given new exercises which included single leg squats, lunges, hamstring stretches, glute stretches and more. I also started cycling at this point, just on a turbo trainer I’d setup inside the house for around 30 mins.

10 weeks

I was now getting close to the full range of movement with the knee. Walking down stairs became easier with minimal pain. The physio advised against impact sports such as running. New exercises included kettle bell swings, wall sits, squats to high rises, two-leg press, cross-trainer, steps with the addition of weights. I’d also started rowing at the gym which I felt helped with the knee bend and extension.

3 months

I was cycling and rowing a lot now, the knee had gained full bend and the quadricep was beginning to gain strength. A dull achey pain in the knee prevented me from running or putting too much impact on the knee. Exercises were now targeting my balance and control on the knee now (bosu ball), as well as the usual strength building exercises.

4-5 months

By this point I could start running again, just at low speed (around 9km/h) on a treadmill but gradually increasing the time from 10 – 20 mins, and continuing to alternate between cycling and rowing cardio workouts. Exercises now consisted of doing more weights at the gym, such as leg extension, leg curl and single leg squats to build up the muscles again. Physio advised against any pivoting on the knee joint still.

6 months

After seeing the physio I was advised that the next few months were all about improving the strength, control and power. He instructed me to start pivoting on the knee, using sideways movements whilst running backwards and forwards. He also introduced hopping using a range of techniques. The goal I was targeting was the ability to hop the same distance on my right knee as my left (good knee). I was also slowly increasing the weights at the gym – most single leg exercises were around 50% of the weight I could lift on the left leg.

9 months

I had an appointment with the surgeon who felt everything was on track. He tried pushing the knee at angles which might cause the knee to dislocate, but found it was solid. The distance I could hop on the right leg was now similar to the left leg, although control was not quite 100%. He advised that I could start training again seriously for any sports such as football or rugby. I’d considered going skiing at end of ski season (as was now April), but was advised against by surgeon who said that it takes at least 12 months for the new ACL to transform from a tendon. The amount of effort it had taken just to get back to where I was, simply told me it wasn’t worth the risk.

12 months

By now I was lifting about 95% of the weights that my left leg could lift (leg extensions). Hopping had a similar level of control to the left leg. I was running long distances (10K) without any pain in the knee, although I sometimes noticed a nerve pain in front of my left foot – possibly because of a changed running gait (although the physio was unsure). Cycling was my preferred cardio, and I was now riding most days, sometimes doing interval sessions. Exercises consisted of plyometrics to increase power and balancing techniques using bosu balls.

18 months

It was now December and the call of the mountains was too strong to resist. My knee felt solid and was keen to put it to test on skis again. Snow was scarce across most of the alps, but Austria’s Tyrol region had the highest depths, so decided to head up high on Sölden’s glaciar and attempt some carving. Although strange at first, I’d soon got back into it. There was a definite weakness compared to the left, but after a couple of days I was confident enough to start throwing it into some high speed carving.

Carving on Solden's glaciar

Carving on Solden’s glaciar at 18 months

I had a couple more trips throughout the season, and on each occasion pushed the knee a little more. On a trip to Verbier in February, I was fortunate to have powder conditions, so decided to test the knee on the off-piste of Bruson and the backside of Mont Fort. It held up well, and I didn’t really feel the weakness noticed in December. In March after a week long Avalanche Operations Level 1 course in Canada, I headed to Banff National Park for a weeks touring the Wapta Icefields and climbing several surrounding peaks for some good ski descents. Again, the knee held up well and had no ill-effects of six days touring with a 65 litre backpack laden with supplies and equipment.

24 months

Two years after the operation, the strength of the knee and the quadricep muscle is probably about 99% of what it was. The muscle bulk is slightly smaller than the left. According to the surgeon, when muscle loss occurs, some fibres die off which cannot be replaced. However, this does not mean that strength cannot still match that of what it would be without muscle loss with continued training. I continue to exercise regularly to keep the knee active.

Conclusion

In terms of sports, I’m able to do everything I was before the injury. The nerve pain I did have in my left foot when running long distances has disappeared. Skiing and tennis, the two sports I play where serious pivoting are involved, I’m able to perform at 100% of my ability. I do get several clicking noises when moving after rest (the surgeon says this is related to the meniscus damage, which will probably result in arthritis), and the occasional ache if I don’t exercise on it regularly. The only thing I’m unable to do is kneel on the floor with my right knee fully bent due to an achey pain – not something that really concerns me. All told, I’m happy with the operation, and subsequent progress I’ve made.

I feel strongly that the muscle loss experienced was made worse due to the fact I had to wait 1 month for diagnosis and a further 14 weeks for the operation due to NHS waiting lists. If I can give any advice to fellow skiers, it’s to always carry private health insurance to ensure any diagnosis and subsequent treatment is prompt. And secondly never ever tighten a ski binding beyond your recommended DIN setting. A lost ski that will cost a few hundred pounds to replace, is no-where near comparable to the energy cost spent rehabilitating a ruptured ACL and subsequent reconstruction operation.

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