Saturday, 23 April 2016

ACL rupture: an insiders point of view

Knee injuries are all too common in skiers, with the anterior cruciate ligament (ACL) being one of the most common and most feared injuries we see. In Val d'Isere this season, we have seen high numbers of ACL injuries occurring, greatly influenced by the snow and conditions.  This has led to this weeks blog on the recovery journey. At the end of the winter season, people are often deciding whether or not to have surgery or starting the recovery process after the operation.
This blog aims to highlight that whilst an ACL injury can be a huge shock, there is light at the end of the tunnel.  As much as a serious injury can have a negative impact, long term people often come back fitter and stronger with a better understanding of their body.

As physio's we can usually tell if an ACL is ruptured through taking a detailed history of the injury and through the tests that we perform, however ultimately an MRI scan will confirm this. The diagnosis of an ACL injury is often a huge blow but it does not mean the end to your skiing career. In fact, it is very unusual not to be able to return to the slopes once you have recovered from an ACL rupture.  Lindsey Vonn, Ted Ligety, Bode Miller, Jenny Jones and Mikaela Shiffrin are a few examples of alpine professionals that have all made successful comebacks post ACL injury.  

Recovery after an ACL reconstruction can be a long road and it is important to pay attention to your emotional and psychological needs as well as your physical ones.  People have different coping strategies to get through such difficult times and if the emotional impact of an ACL injury is overlooked it can have a detrimental effect on a persons rehabilitation and performance.  Post ACL injury, it is not uncommon for people to report feelings of frustration, isolation and disengagement. Rehabbing from ACL injury takes huge commitment and motivation which can be affected by negative thoughts. If you are struggling with the emotional impact of an ACL injury, seeing a sports psychologist can help.

To gain a better insight into the journey after an ACL tear in skiers, we have asked some fantastic instructors about what they went through when they ruptured their ACL.  As a physio, it is bad enough telling someone that their ski holiday is over if an ACL rupture is suspected, let alone having to tell a ski instructor that is likely that their season is over! Rehabbing from an ACL injury is a very personal process with many highs and lows. As you will see from the answers below, every journey is different. Sincere thanks to the instructors that have given us a personal insight to what they went through.

1 - When you injured your knee, did you suspect that it was your ACL at the time, even before it had been examined?

Clare Angus (CA)

No - didn't hear a pop and it didn't swell massively but it was a bit unstable and sore. As I have rather lax joints anyway and have had a minor knee injury before I assumed it was a tear rather than rupture

James Allen (JA)

Yes because I was skiing with a few guys who'd previously torn their ACL and they thought it was torn for sure. That said i had my doubts as i was able to ski down to the bottom of the run so thought maybe it wasn't fully torn

Joe Harkness (JH)

After an evening in denial, with the swelling in back of the knee, I knew it was the ACL.

Nicko Braxton (NB)

Knew both times (or was pretty sure). Couldn't stand on them.

2- When an ACL rupture was confirmed, how did you feel?

CA - I was anxious prior to first being examined as I knew it wasn't going to be great news. It was early season training so the whole season lay ahead. First diagnosis was as a tear which was pretty devastating as I was meant to do another 4 weeks race training and also had a number of ISTD exams booked and I wasn't sure how things were going to go. I spent 6 weeks off skis then got back on with ISTD teaching and technical exams and also did my EMS training exam and carried on training for exams and eurotest, so all in all things were looking ok. It wasn't until my knee still felt a bit wobbly 6 months later that I got an MRI and rupture was confirmed. However by this point I knew what it was still capable of and so was not too disheartened by the diagnosis.

JA - I knew what was ahead of me as I was lucky to have people there who'd been through it previously. I was determined to make a full recovery, what ever it took!! I looked upon it as a challenge to myself to prove i could rehab correctly and take it seriously from start to finish and come back stronger than ever.

JH - As I already suspected it, I was ready and accepted the injury and was just keen to get on with the rehab process and treatment to get back on my feet

NB - Miserable. Sat in a wheel chair in the restaurant at the bottom of the motte and burst into tears

3 - What was the worst part of the journey?

CA - I had 6 weeks off skis early season when meant to be training. Having to make decisions about how to proceed. But all in all I have, so far and touch wood, been very lucky.

JA - Having to watch everyone go up skiing in great conditions whilst i stayed indoors resting wasn't easy, but i knew i'd had some great times in the past and also knew i'd have them again, so didn't let it get to me too much. Also having to hold back on the rehab and do as i was told by the physio was tough as I felt I could take things to the next level sooner but had to do it all by the book, otherwise risk the long term recovery!

JH - The steps backwards you take after surgery and the slow process around 3-4 weeks after surgery. The rehab initially was so slow I found it frustrating after being so active.

NB - Perhaps 2-3 months post op. Still on boring repetitive exercises.

4 - What surprised you most about the process after ACL rupture?

CA - The fact that I had a ruptured ACL that I skied to a high level on for such a long time before finding out it was ruptured!

JA - How soon i was able to push weights in the gym and generally how well the whole rehab process went.

JH - The huge loss of strength in the hamstring from losing the tendon for the graft. 2 years on and still need to do so much work to minimize imbalance between left and right legs.

NB - The amount of time you must dedicate - like a full time job but no one is paying you.

5 - What positives have your taken from your journey?

CA - What doesn't kill you makes you stronger!

JA - Plenty!! I now know what's required to recover well and more so that I'm able to recover from something as serious as this without it being a major hinderance to my life in general. I've learnt a lot about good nutrition, health and fitness which is all good, especially given the lifestyle and job i do as a sports coach. I'm almost certainly fitter than i was before the injury and probably stronger in general. Knowing that a major injury like this doesn't mean you're off games for a long time as i was able to get out and do sports again pretty soon afterwards. Even more so, the fact i was back on skis the following season and skied hard all season without any major issues.

NB - That you can make a full recovery and you are in control. The operation does not predict the out come.The work that you put in does. You get out what you put in.

6- Any tips for people going through ACL injury.

CA - My advice is to not rush into surgery. I realise some people will need to have surgery but it is not the only option, although I believe most people believe there is no alternative.

JA - One of the best bits of advise I received was from my surgeon which was to hire a 'Game Ready' pro ice machine. I'd highly recommend this for a speedy reduction in the swelling post-op. Minimum 4wks and the results will help you progress in the rehab programme much quicker. Look up online the ideal diet and nutrition for knee ligament rehab and follow this as closely as possible. Be sure to do ALL the exercises your Physio advises, especially in the early stages. Stay positive throughout, it's not as bad as you might think!!

JH - It's hard to stay motivated at times and can feel very slow, but the moment you get the clear to get in a bike was huge for me.... That gave me freedom again, and from that point on I could see the light at the end of the tunnel.

NB - Don't push at the start. It doesn't shorten the healing time. If anything you just endanger the graft. It takes longer as you get older  Be picky about your surgeon - talk to people

If you are unlucky enough to rupture your ACL, you are likely to find that everyone has an opinion on your recovery process. Whilst this can be helpful, sometimes too much information can lead to confusion and uncertainty. We hope that the insights we've been given help to show that each and every person will have a different journey. No two people will go through the same process, even with identical injuries and a full recovery is very achievable. Thank you to Clare, James, Joe and Nicko for sharing parts of your journey with us.

Prior to next season, I will publish a blog on ACL injury prevention.  Follow us on facebook to stay up to date with our blogs.


The purpose of this blog, is to provide general information and educational material relating to physiotherapy and injury management. Bonne Santé physiotherapy has made every effort to provide you with correct, up-to-date information. In using this blog, you agree that information is provided 'as is, as available', without warranty and that you use the information at your own risk. We recommend that you seek advise from a fitness or healthcare professional if you require further advice relating to exercise or medical issues.

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1 comment:

  1. People typically tear their ACL Tear when they stop suddenly, change direction abruptly, or land incorrectly from a jump. It’s one of the most common knee injuries and often occurs in athletes who play twisting sports like basketball, football and soccer.