There's a pop you can hear when your anterior cruciate ligament goes. Some people describe it as sickening, as though your knee is not quite attached and will no longer hold you up.
ACL injuries are common in various sports, especially snow sports.
Studies indicate that the number of skier-related ACL injuries tripled in the past 20 years. Time was that broken legs and heavy casts were the norm for skiers, but thanks to advances in boot design and quick release bindings, lower-leg fractures have all but disappeared. The changes, however, transferred stress to the knees. On the other hand, technology goes beyond that. Other advances—such as MRIs—have given doctors the ability to diagnose knee injuries more precisely, helping untold people to be able to walk and ski well into their later years.
Skiing is not the only sport that can induce ligament injuries. Soccer, basketball, football and tennis are all injury-prone sports because of pivoting, stop-start action. Even golf can be hazardous. Witness Tiger Wood's season-long absence from the sport he dominates, though word is that he injured his already fragile knee by running.
Athletes always want back on the playing field. How long they rehabilitate and how successful they are with it depends on the kind of injury and the athlete's level of conditioning.
Physical therapist Winston Purkiss at Sun Valley Sports Rehab said the resumption of activity is often "significantly shortened by the wish to return to the playing field. Rehabilitation for nine months to a year is what I recommend. With pros it's maybe six months."
A properly functioning knee, the largest joint in the body, is essential to movement and comfort. For every injury, a course of rest, ice, compression, and elevation (RICE) are imperative. Once the swelling is down, a fracture will demand partial or no weight bearing, while a ligament injury, which generally requires surgery, takes a different approach.
"The key is to get motion back first, then start on strength training," orthopedic surgeon Dr. Tony Buoncristiani said. "With the knee you can have a fracture, a patella break, a ligament or meniscus (cartilage) injury, and whether repair is performed or not will dictate the length of time. Bones take six to eight weeks to heal and an ACL can take from six to eight months. You may get strength back but what people forget is endurance."
"Often a non-pro will get in better shape from learning new exercises," physical therapist John Koth said. "But people will do their plyos (plyometric exercises) and still get to the bottom of Squirrel and their legs are burning. It's overall training."
And it just won't happen overnight since healing and rehab go in stages.
"Fifty percent of a (tendon) graft is incorporated in about six months into the bone tunnel," Buoncristiani said. "To ensure long-term survival, the graft must become revascularized. It continues to graft over the course of a year before it's 100 percent. Nerve fibers need to heal. The surrounding musculature needs to be strong. If not there is a chance of re-injury."
There are all sorts of exercises that a physical therapist should take one through, such as isometric and plyometric exercises like hops, jumps and bounding movements, and concentric movements like riding a bicycle.
"If you're weight bearing there is less of an atrophy effect," Buoncristiani said. In fact, crutches (of all kinds) can help with healing but hurt the mental side of recovery.
Plyometrics are the final phase. Building on the basics, specific sports programs are then added on.
OK, you're back in shape, so now what? Does a recovered knee injury require a brace? Buoncristiani thinks not.
"There are several published articles in sports medicine journals that show no decrease rate in ACL tears while wearing a custom brace," he said.
"It's shown braces don't do very much other than act as a reminder," said certified Feldenkrais physical therapist Mary Kay Foley at St. Luke's Elks Rehabilitation. "You have to make sure you are strong enough to adequately do the activity your doing. Neoprene sleeves keeps the tissues warm. But they don't prevent reinjury."
Koth agrees: "If you do all the rehab, the strength training, balance, sport-specific training and you have a functional ligament, then why do you need a brace?"
"A neoprene brace is anatomical mind-knee connection," Buoncristiani said.
"Right. Just don't do anything you're not good at," Koth said. "Otherwise you have repeat offenders."
Foley said functional testing will help determine one's readiness to hit the slopes. Tests include such movements as jumping, one-legged strength tests and one-legged squats.
"It's best to be led through those by a professional," she said. "Going back up depends on what type of injury you have. With bundled injuries and more involved surgeries, it's less likely you'd ski that year."
Despite the agreement on braces, there are several that people with injuries have used, including versions by Breg, Ossur, Bledsoe and DonJoy.
"They do have to be special ordered," Foley said. "It varies by the doctor."
Hailey Sport and Spine physical therapist Kim Mazik said some braces can help with "mild to moderate knee arthritic and dysfunctional proprioception, which is your body's awareness of itself in space."
"As for ligament injuries, you might need a custom-made brace to prevent rotation and or hyperextension," she said. "They give you more stability. Doctors have their own favorite brand. A knee is a hinge joint—it's not all that complicated. If you want a little extra support, a neoprene sleeve is fine. I love mine. I wear it for hiking."
Gloria Gunter of Physical Therapy Plus of Idaho, said that if a person has no ACL,. Even if he or she doesn't feel any instability, "a brace is an added protection along with your musculature, if you've had an injury and you're engaging in high-level sports."
"I err on the side of caution," she said.
Physical therapist Gloria Gunter works on a client’s knee, that was recently operated on for an ACL tear.
Photo by David N. Seelig
