Knees: To Have ACL Surgery Or Not
Last year, while skiing Whistler B.C, I tore my anterior cruciate ligament and medial collateral ligament (ACL and MCL) and recovered without surgery. According to a study published last month by the world leading Hospital For Special Surgery (HSS) in New York City, “Roughly a quarter of recreational skiers who tear their anterior cruciate ligament (ACL) while hitting the slopes can be successfully treated without surgery.”
Robert Marx, M.D., Orthopedic Surgeon at Hospital for Special Surgery, who led the study said, “Some patients who tear their ACL while skiing can get away without surgery. Their ligament heals by itself, they will have stable knees, and they will be able to do whatever they want, including skiing. It is a huge deal to avoid surgery.”
It took me eight months to get back to peak performance in all areas of activity I enjoy including running, cycling, advanced yoga, tennis and dancing. I have not yet skied but am heading to the mountains next week.
Wondering if I am really safe to ski and “do whatever I want” or if the Marx study is too good to be true, I called my doctor, David Altchek, who is Attending Orthopedic Surgeon and Co-Chief in the Sports Medicine & Shoulder Service at Hospital for Special Surgery. According to Altchek, the Marx study is “oversimplified.” He explained, “Skiing ACLS are a little different than other sporting ACLS because skiing is a non-contact sport, doesn’t involve pivoting and the tears are usually only partial. Whereas most non-contact ACL injuries are seen in aggressive athletes who create their own velocity and torque, the length of skis intensifies the torque of the knee, which causes tears even at slow speeds because the skiers don’t have enough energy in the fall to get out of their bindings.”
If the knee is stable, Altchek agrees that people with partial ACL tears who are not going to return to contact sports such as basketball, lacrosse or soccer, can heal without surgery and return to skiing. Professional and teenage athletes who want to return to contact sports however, don’t do well says Altchek. “The whole thing about the ACL, the only reason we fix it, is to protect the cartilage. If you don’t have instability, there is not as large a chance of damaging cartilage. But if professional and teenage athletes go back to their sports and tear their meniscus, it’s over.”
That said, this past Christmas, Altchek saw fifteen people in one week from Aspen alone who sustained ACL and MCL tears and who were likely to have surgery. When I asked why the high number of these injuries, he said that he believes it has to do with contemporary ski technology.
Today, skis are made without edges to make carving easier. C-curves are cut into the sides of skis under the boot so the skis slide and turn on their own without the skier having to dig their edges into the snow. The problem according to Altchek, is that people have not spent enough time understanding and learning how to use the new skis. The result? The skis turn but the rest of the body doesn’t, which causes the knee to torque and the ligaments to tear. When I asked if I should go back to old-school skis with edges Altchek said that this would not be a bad idea, that in the least, side cut skis should be gentle, not extreme.
While many people do in fact need surgery for ACL and MCL tears for anyone who is advised by their doctor to wait to get an operation, below are ten key yoga and PT exercises I did that helped me recover. Consult your doctor and physical therapist before attempting these moves.
Bridge 2 legs
(Strengthens leg muscles, gluteus and knee joint)
Lie on your back. Bend both knees and walk your ankles directly beneath your knees keeping your feet straight. Extend your arms along your body, palms face down. Press evenly into the soles of your feet, lift your pelvis off the ground, walk your shoulder blades towards one another and underneath your back. Puff your chest towards your chin. Roll your thighs inward and down. Keep your knees stacked over your ankles throughout the duration of the exercise. Hold for 20 seconds. Add 10 seconds every other day until you reach 1-minute. Then, build to two minutes.
Bridge 1 Leg
(Strengthens legs and gluteus muscles and stabilizes knee joint)
Assume bridge position as described previously. Elevate one leg directly above your hip so that your foot points towards the ceiling. Hold for 20 seconds. Add 10 seconds every other day until you reach 1-minute. Make sure that the bent knee tracks between your second and third toes for the entire time.
Moving Warrior 2
(Strengthens all leg muscles, keeps the knee joint mobile, helps stabilize the knee joint)
Stand with your legs 1 leg’s distance apart, feet parallel. Pivot your right foot out to ninety degrees. Line your right heel up with your left arch. Engage your core by lifting your navel towards your chin. Keeping your chest and hips open, elevate your arms to shoulder height. Bend your right knee so that it stacks over your ankle and keep it tracking between your third and fourth toes. Hold for 10 breaths. Then straighten your leg making sure not to lock your knee and bend it again to come back to warrior 2. Do 10 reps of this moving warrior. Switch sides. Complete 2 sets.
Reclined Leg Raises
(Strengthens the quadriceps)
Lie down supporting yourself on your forearms. Bend your left leg and place the sole of your foot on the floor. Keeping it straight, elevate your right leg to the same height as the knee of the left making sure to isometrically hug your quads (upper thigh muscles) into your thighbone. Lower the leg to an inch above the ground and then repeat the lift. Do 25 of these and hold the last one up for 10 seconds. Add 10 reps every other day until you reach 50 leg lifts with a hold of 1- minute at the end of each set.
(Stretches MCL of bent knee, stabilizes the knee joint and strengthens the muscles surrounding the knee of the standing leg)
Stand with your feet together, toes all facing forward, hands on hips. Elevate your right knee to hip height. Turn out your right hip and place the entire sole of your foot onto your left calf or inner thigh (grab your ankle to hike the foot up to the thigh). With an MCL tear, you might not be able to turn your hip/leg out a lot at first. Ease into this external rotation over time. It can take months to get to a full turn out. Keep your gaze steady on a single focal point. Hold for 5 breaths. Build to 10 breaths and ultimately one minute. Repeat with the left leg.
(Helps reduce swelling, keeps the knee joint mobile and helps improve knee flexion)
Lie down with your legs up the wall. Cross your ankles and bend your knees. Slide your heels up and down the wall working between flexion and extension. Do 20 reps. Complete 3 sets.
Seated Staff Isometric Quad Engagement
(Helps quadriceps begin to fire again after the injury and assists in stabilizing the knee joint)
Sit with your legs straight in front of you. Keep your shoulders aligned over your waist and your spine tall. Gently press your legs against the ground and hug your quadriceps (thigh muscles) into your thigh bones. Do of 20 reps. Complete 3 rounds.
(Helps to strengthen all leg muscles and stabilizes knee)
Stand straight with your feet together. Slowly tip your torso forward as you elevate your left leg behind you keeping it straight. Pause and hold when your torso and leg are parallel to the ground. Build to holding up to 30 seconds on each leg.
(Stretches the MCL and helps regain flexion limitations due to ACL injuries)
Very slowly test sitting back towards your heels and bringing your forehead to the floor. Hold yourself up with your hands to control how far you go. Stop when you feels any sign of slight discomfort. Over time, gradually increase your range lowering your buttocks closer to your heels. It can take many months to assume the full child’s pose position.
Moving High Lunge
(Strengthens all leg muscles and the knee joint, stabilizes the knee)
Stand with your feet together. Place your hands on your hips. Step your left foot back as you bend your right knee over your ankle. Straighten and bend your right knee very slowly, making sure not to lock the knee when you extend the leg. Repeat 10 times. Switch sides. Do 3 sets.