 Poster: A snowHead
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I'm just over a week post-surgery, and the info on the forum was very helpful, so I thought I'd add my own tale - not least because I've also had an 'LET' which I've not seen mentioned here before. I've been told ACL injuries are more common in women, and an LET apparently has good outcomes for women re. long term stability, and lower incidents of ACL re-rupture.
TL;DR
43yo, female - ruptured ACL in early Dec, surgery 5 months later in early May - ACL reconstruction with LET (Lateral extra-articular tenodesis - using IT band), and trim of medial meniscus. In between included 3 weeks of skiing, a knee collapse causing damage to the meniscus (not skiing!) and lots of work with both a physio and a rehab/strength coach. Some restrictions on movement for 6 weeks post surgery, plus a big brace, and physio restarting shortly.
Timeline
- 2nd Dec, on the way to the airport for the PSB, tripped on stairs while rushing and carrying a lot of bags, twisted a bit, and suddenly found myself half collapsed on said stairs with a knee in agony. After a couple of minutes the pain subsided enough that I could attempt to move, and decided to keep going to the airport.
- I stuck a (basic) brace on it the next day, took some ibuprofen, and went out skiing every day. My skiing ended up being quite limited, and more so as the week went on, with different muscles up and down the leg complaining each day, and the leg just not quite working right.
- I got in touch with a trainer at my gym while in Tignes, who I'd used before for ski-specific training, and he referred me to the head of the rehab clinic at the gym (I didn't know it had one!) - who turned out to have previously been a rehab coach for the British Olympic ski team for Sochi! As well as Leicester Tigers, and currently some other Midlands rugby and soccer teams. It felt like overkill, but also too good to turn down.
- @12th Dec, first meeting with Rehab coach (qualified as a strength coach), first 'Lachman test' (and others) - results inconclusive, and MRI advised. We agreed an initial program anyway for a couple of months, and got started
- I contacted my health insurance (through work) for the MRI, and had to work through various online questionnaires, video consults etc, and finally got to a physio in person mid-late Dec. 2nd Lachman test (and others) - results inconclusive, MRI advised. Yet another phone consult after that to finally get the MRI approved!
- early Jan, MRI. By this point my knee had stabilised, and the rehab program was going reaaalllly well, so I thought it would only show a sprain of some kind, and wasn't too worried about it
- 10th Jan, MRI results - full ACL rupture, some bone bruising, surgical consult recommended...
At this point I was pretty shocked, but the physio giving me the results was very helpful. We discussed rehab only vs surgical options. I said I wanted to continue with my rehab program initially, and ski in early Feb to see where I was, before making any decisions - I was given a 3 month window to come back to my insurance to request the surgical consult under the same claim. We also discussed the causes - the view from all the experts I've consulted is that it was likely already damaged (from various ski falls over several years  ) and this was just the final blow.
Approval was given to continue to ski (I did point out I'd already skied for a week on it without realising  ), but a proper brace was *strongly* recommended, specifically Donjoy if it fitted - Donjoy Armor FP was procured, and it's brilliant! Rehab program at my gym continued, and progress was good.
- Late Jan/early Feb - I did a half day skiing in Chamonix with my new brace to test everything out, and things were a bit better. Also had a couple of beers with @under a new name who was brilliant in talking me through his experience, and very reassuring.
Then a week later I headed over to Arabba for the Birthday bash. It was better than in Tignes - but I only skied 4 out of the 6 days, and only one of those was approaching a 'normal' day. After the first couple of (half) days I needed a full day off as my leg had basically seized up along its entire length!
- When I got home I went straight back into my rehab program, and also picked up weekly sessions with the physio through my health insurance again, and scheduled the surgical consult. I was able to choose a surgeon, and went with one my rehab coach had strongly recommended, as well as others.
- late Feb - had the consult with the surgeon. 3rd Lachman test - results again inconclusive! (though we had the MRI results) He did another test when I wasn't paying attention, and sounded very concerned - and had to repeat it to show me. He was basically able to visibly move my entire lower leg sideways (inwards) relative to my knee/upper leg, by at maybe an inch and a half  . That was not pleasant to see, though it didn't hurt - we both agreed legs should NOT do that. I decided I wanted surgery  We scheduled it for early May so I could continue to push rehab/physio in advance, attend the EOSB (!) and get some stuff tidied up at work - the joy of going private!
We had also talked through my activities, ambitions, latest research specifically on ACL injuries in women etc, and he suggested an additional 'graft' using the IT band if I did want to go ahead, that had promising results for longer term stability in women, and lower rates of re-rupture - the 'Lateral extra-articular tenodesis' (LET).
My knee had been stable for a while, so I did consider not going for surgery - but I want to get back out touring, so I really want to be able to trust my knee will be functional. I also knew there was a risk of meniscus damage if it did collapse again, which I was keen to avoid long-term. Buuuuuuut...
- early March - the knee collapsed. Badly. I was following my rehab program in the gym, same exercises I'd done many times, and suddenly found myself collapsed again in agony. I barely managed to hobble home, and very luckily had some friends coming round that day anyway to watch rugby, including a physio, and the ortho trauma nurse, who brought me a crutch. was really worried I'd done what I'd hoped to avoid i.e. damage to the meniscus. They didn't seem too concerned from how I was moving, but I spent a few days stuck in my apartment (though constantly improving) before taxi and hobbling to my next scheduled physio appointment. He examined me, said it was a sprain, and then sent me up a flight of stairs and onto an exercise bike which was all doable.
My programs were quickly tweaked by the physio and rehab coaches, and things improved steadily. After just over 2 weeks the physio started me jogging gently again - and then I woke up the next morning with an unstable knee, and weird swelling developing over the next couple of days - bursitis!
Programs tweaked again, strong focus on 'prehab' ahead of surgery, strengthening muscles to help me get around in the immediate aftermath, and working through various exercises to set a baseline for post-surgery progress.
- mid April - skiing again at the EOSB! Unfortunately I had more pain, difficulty, and swelling than at the BB. I wasn't sure why - but once the surgeon checked out my knee in surgery, he unfortunately found the damage to the medial meniscus... So the collapse did actually do more damage than thought.
- 10th May - surgery! Discussed what I'd been doing re. physio, rehab etc in the past couple of months, the collapse etc. The surgeon was still inclined to do the LET as well as standard ACL reconstruction, and would also review the entire knee for other damage as standard. It was all very efficient on the day - I walked down to theatre around 9.45am, and woke up around 12noon in a very large brace, but little pain.
Confirmed it was an ACL reconstruction (autograft - edit: using hamstring), plus LET, and trimming of the damage found to the medial meniscus.
Because of (I think) the LET, the range of movement in my leg is limited to 0-30deg for 6 weeks! The brace has pins set to that, but I am allowed to take it off to shower, use cryo-cuff etc - I just have to be careful not to bend it more than 30deg myself. It's already annoying - occasionally I REALLY want to bend it! I was also told to wait 2 weeks before resuming physio etc, instead of 1, due to the restrictions on movement (but given interim exercises).
Next steps
All the 'prehab' has really helped - although I may have occasionally cursed at endless banded leg raises, glute bridges, split squats, reverse lunges etc - the resulting muscle strength has meant I've easily been able to move around from the start post-surgery, with one leg semi-out-of-action. Sessions with the physio, and the rehab coach both restart at the end of this week, and I'm reallllllly looking forward to getting back in the gym, even if just on a physio bed to start with!
The plan discussed with both is standard 6 month program with the physio, and continued sessions with the rehab coach in parallel - we've fallen into a pattern that I think has been working well to date, with the rehab coach more focussed on strength, and the physio more focussed on balance and flexibility. And both are very experienced with ACL injuries.
Once signed off by the physio, then it's another 3 months focussed ski prep with the rehab coach - and then hopefully back skiing in February! (In a brace, and still taking it easy next winter - I'm aiming for the following winter for heading back offpiste, touring, no brace etc). My surgeon has also suggested that I learn how to jump (or rather land) properly?! - apparently it's a big reason for ACL injuries in women. The rehab coach is already plotting exercises, but that's a long way off 
Last edited by Poster: A snowHead on Thu 23-05-24 13:21; edited 2 times in total
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Obviously A snowHead isn't a real person
Obviously A snowHead isn't a real person
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@fixx, thanks for the write up. Will do more research into that.
I ruptured my ACL in 2004 and recon in 2005 but damaged the recon playing hockey so no only have half it left. So fall into thaat re-injury category.
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Well, the person's real but it's just a made up name, see?
Well, the person's real but it's just a made up name, see?
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@fixx, Thank you for that, it`s very interesting. Apparently I`ve done ligament damage and torn the meniscus, getting off a plane upon arrival in Germany! Currently waiting for an mri and doing physio recommended by my osteopath. I`ve been told that post menopause women are more likely to damage the meniscus and I think we are only just beginning to recognise that women may need to follow a different recovery pathway to men in all sorts of medical issues.
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I recommend doing your best (both) to make sure you work on your leg strength. I am hugely conscious that this is all that is maintaining my stability. I am now leg pressing 1.5 times my body weight on each leg. Fingers crossed this will help me maintain an activities like skiing.
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Anyway, snowHeads is much more fun if you do.
Anyway, snowHeads is much more fun if you do.
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Female, 28yo at the time, hugely interested in every research combining acl + women
All the best of luck, it's a process but I'm very glad to have gone through it in the end.
I tore my acl early february 2022, reconstruction from patella tendon with monoloop procedure on 10th of march and was back skiing indoor in september of that year and on the glacier training SL in early november.
Sticking with the protocol, it's limited in the beginning but then step by step you unlock skills and it gets better and better as you get very strong. Wishing you a very good recovery!
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You'll need to Register first of course.
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It's interesting how everyone's experiences are so different.
I did my ACL in April 22 (falling off an indoor boulder wall). It was painful, I was hobbling around on crutches, but it wasn't particularly unstable. I found it kind of unhelpful that the doctors (several NHS, one private) wouldn't/couldn't tell me whether to have a reconstruction or not, and left the choice to me, when I felt I knew so little about it. Anyway, opted for rehab only, with the goal of seeing how I coped skiing on snow the following Winter. If that hadn't gone well, I would then have gone for recon, but it was fine, so I haven't.
I guess I have now got lazy, because once the physio signed me off in April 23 I stopped doing the exercises (I hate the whole gym atmosphere); however, the knee has never collapsed on me, and I skied twice this Winter with a Mueller hinged brace, barely thinking about it. I am still pretty nervous of falling off a boulder wall, though, and if there's a dodgy move near the top, I won't do it. The key indicator for me that it is ok, is that if I have to jump over something, I'm happy to land on the knee without the ACL, rather than the dodgy ankle on the other leg!
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@karin, I think this is because the answer is so subjective.
For me before the recon I could feel my leg doing figure of eightd while walking, and had it collapse under me while going down stairs! Others though report it feeling stable despite no ACL.
Also frankly the rehab after was incredibly hard work, and I wouldn't do it again (I was 29 when I had it before) that was 19 years ago....
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Good work @fixx! The LET thing is very interesting. I don't think (a. a chap, b. my knee was pretty stable pre-op) I'll be missing that  Also, my physio would not have been happy with restriction on ROM immediate post-op as I was still in an acute rehab phase from my cardiac surgery and rebuilding general muscle mass was high on the list.
"a year to recover, a year to forget" ... do not let up on the physio!!
@karin, every knee is different, to begin with, with different injury. Too many factors (hence why there are few black and white answers), aiui.
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You'll get to see more forums and be part of the best ski club on the net.
You'll get to see more forums and be part of the best ski club on the net.
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| NickyJ wrote: |
| I am now leg pressing 1.5 times my body weight on each leg. Fingers crossed this will help me maintain an activities like skiing. |
That is very impressive! I do quite enjoy leg presses - though single leg version has been new to me (doing it since Dec). It's very satisfying to see progress.
| CaravanSkier wrote: |
| @fixx, Thank you for that, it`s very interesting. Apparently I`ve done ligament damage and torn the meniscus, getting off a plane upon arrival in Germany! Currently waiting for an mri and doing physio recommended by my osteopath. I`ve been told that post menopause women are more likely to damage the meniscus and I think we are only just beginning to recognise that women may need to follow a different recovery pathway to men in all sorts of medical issues. |
Oh no - I hope they physio works well for you! Very interesting re. menopause, I'd not head that before (I'm 43 at the minute, so not quite there yet - but did see some research suggesting women are more prone to ACL ruptures after 40 as well...). Agree re. different pathways for women. One of the reasons I was happy to go ahead with this particular surgeon was that he was very up to speed on the latest research on ACL injuries specifically in women, and had some very useful advice even if I didn't go for surgery (e.g. the focus on movement and landing, specific exercises to target agility and proprioception).
| JulieAimeLeSki wrote: |
I tore my acl early february 2022, reconstruction from patella tendon with monoloop procedure on 10th of march and was back skiing indoor in september of that year and on the glacier training SL in early november.
Sticking with the protocol, it's limited in the beginning but then step by step you unlock skills and it gets better and better as you get very strong. Wishing you a very good recovery! |
Oooh, I'd not heard of the monoloop procedure - how interesting! Thanks for the good wishes  I will indeed follow protocol - I'm sticking with the same rehab coach and physio, and they both know me well enough now to quickly tell me off if I'm not doing what I should (and that I do/will put the work in).
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@under a new name, yes, I do get that now, but at the time, as a new member of the snapped ACL club, I had a lot to learn
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snowHeads are a friendly bunch.
snowHeads are a friendly bunch.
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@karin, that's great that you've done so well without surgery, I'm rather jealous And also encouraged at what good physio/rehab can do!
Agree with people being unwilling to make a recommendation - I definitely found that all of the surgeon, my rehab coach, and my physio were all unwilling to make a recommendation too. It did mostly feel like they wanted me to decide what would be best for me, and they did give advice on pros and cons. But when you're trying to learn and make a decision it can be very frustrating! I did also feel that they wanted to recommend surgery but just didn't want to say it/push me into it. Once I'd decided, the universal response was pretty much 'excellent, here's what we're going to do...'.
It was nice not to feel rushed into a decision either - I did want to really push rehab, but it did feel like i'd started to hit limitations when skiing in Feb. And when I had the collapse in March I was very sure surgery was the right way to go! I did NOT want to deal with that again in future, or go forward always fearful on when my knee might collapse again.
@under a new name, good point re. restriction of ROM not always being possible! I am on blood thinners as well now for 28 days due to it. I do NOT like needles, and injecting myself twice a day is not fun  I'm looking at it as exposure therapy
Your skiing this winter was really encouraging and inspiring though - thanks again for the drink and chat! I'll hopefully have some time in Cham again in September and see you then.
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And love to help out and answer questions and of course, read each other's snow reports.
And love to help out and answer questions and of course, read each other's snow reports.
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@fixx, wish I had got there before damaging the graft.... oh well, but if you thinking about skiing, especially if you get into trouble thats the sort of force / weight you can end up put through your leg and I need my muscles to be able to take it as my ligament can't.
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You know it makes sense.
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Get well soon Fi! X
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Otherwise you'll just go on seeing the one name:
Otherwise you'll just go on seeing the one name:
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Poster: A snowHead
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@fixx, @under a new name, haha I'm glad both of you made this remark. I thought so too but from a 2 second Google in the morning I did not want to make any medical assumptions and so just shared that bit of information without linking it specifically to the LET.
But for me everything really worked out perfectly and while there was uncertainty at the time because it's so life changing for a moment, I turned out to be very happy with every part of my surgical procedure + follow up.
Wishing you the very best!
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Obviously A snowHead isn't a real person
Obviously A snowHead isn't a real person
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That's good. Fingers crossed it all heals quickly.
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Well, the person's real but it's just a made up name, see?
Well, the person's real but it's just a made up name, see?
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Here’s a piece on LET.
Lateral (outside of the knee) extra- articular (not inside the knee joint) tenodesis (use a section of soft tissue to make a cord that is fixed at both ends).
The problem with an ACl deficient knee is that it can be rotationally unstable. The tibia ( shin) can rotate inwards excessively around an centre point in the medial ( inner ) compartment. The problem occurs is as you put weight on the knee with the tibia out of place. It will suddenly relocate with a clunk that makes the knee collapse. Under normal circumstances the ACL prevents this happening.
The LET is basically attaching a leash to the tibia and then to the femur that will tighten up like a seat belt as the knee starts to rotate. It there fore works in conjunction with the ACL to stop the excess rotation.
Studies have now confirmed that it can to some extent protect the ACL graft ( reconstructed ligament ) from reinjury and that is the primary reason for doing it. Most of us should/will be doing it in revisions and perhaps hyper mobile,those who have a compromised lateral meniscus. I’m also doing it in teens and those in their 20’s as they have the highest risk of reinjury. It is a relatively straightforward addition to the reconstruction. It leaves an additional scar on the outside of the knee as typically a strip of the ITB is used to create it. Hope that helps.
Good luck with the rehab @fixx and hope you get back skiing next year.
Jonathan Bell
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You need to Login to know who's really who.
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@Jonathan Bell, very interesting, thank Jonathan
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Anyway, snowHeads is much more fun if you do.
Anyway, snowHeads is much more fun if you do.
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| fixx wrote: |
[ I am on blood thinners as well now for 28 days due to it. I do NOT like needles, and injecting myself twice a day is not fun
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If the jab is into the stomach as mine were, and maybe you know this already but in case not, the manufactures of the particular jab I was prescribed in Germany recommend putting an ice cube in the intended spot for 30 seconds before you inject and for 30 seconds afterwards. I was not told this in the hospital and the jab was uncomfortable and left a large bruise. Once I did the ice cube thing the jab did not hurt, there was no 'stinging' and very little bruising. I don`t know if its appropriate for all but it helped me.
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@CaravanSkier, I can't see any reason why it would not be appropriate for everyone, and it is good advice. I may have aa couple of patients that will find that useful. EDIT- my slight concern is that it may affect the absorption if applied before as it will reduce blood flow to the area. Post-injection, it would just numb any pain at the site. but I will look into this tomorrow
Last edited by You'll need to Register first of course. on Tue 28-05-24 20:57; edited 1 time in total
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@Jonathan Bell, thanks for that, it's really interesting!
It is indeed quite a large incision I'm not bothered about the scars thouh - that knee already has a few from a childhood of ball games on gravel pitches 
@CaravanSkier, I'll give that a go, thanks. Fortunately I sometimes can't feel the needle, and the bruises have mostly been very small (I don't bruise easily in general) - but anything helps 
Things are going well otherwise - I've had my first sessions back with my physio and rehab coach. Both have said they're very happy with how things are going and my movement etc. They are both bemused by the limit of 0-30deg, but had no problems finding me new and progression exercises to push muscles a bit 
Bruising is almost gone, and swelling seems to go down a little more each day - apart from Sunday and yesterday that is, after I spent a bit of time on Saturday walking round a National Trust house and grounds I did have the brace on, and two crutches, but knee was a little sore yesterday - easing off already today though. And I neeeeeeeded that change of scenery!!
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@fixx, I found - actually still find having rejoined the gum last week - that an uptick in efforts, or a change in activity, gives me a few hours of grumbly knee. Not painful. just grumpy.
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You'll get to see more forums and be part of the best ski club on the net.
You'll get to see more forums and be part of the best ski club on the net.
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@under a new name, to me (as someone who's not a medical professional, but used to breaking bits of myself, and helping fix them) the few hours of grumbling is a good sign. I find it to be an indication that I'm pushing things, but not excessively, and the grumbling is a reminder to not overdo it, and allow a bit of rest. In general, I find it works well to push to grumpiness a couple of times per week
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