View Full Version : ACL injuries - reconsidering surgery
10-09-2003, 09:01 AM
Between 1993 and 1996 I had the misfortune of having both of my ACLs torn. When I had them confirmed by MRI the doctor gave me a list of options:
1. I could stop practicing certain sports
2. I would have to wear these huge knee braces while playing sports
3. I could have surgery
Option #1 was, IMO, a joke. Option #2 was impractical – I don’t think I would find many training partners willing to grapple with me while I was wearing a huge plastic brace (in mixed martial arts (mma), the legs are frequently used as levers against an opponent’s head, body and limbs when applying submissions). Option #3 I didn’t want to have done because I have heard a couple of horror stories about people who had undergone the procedure.
For the past couple of years I choose deadlifting and squats as my form of therapy (this was before I found about O-lifting almost a year ago). It has worked reasonably well. Although both of my knees will slip ‘out of joint’ occasionally, it has happened a lot more often during the times I had taken a break from lifting. As long as I pay attention to certain technical issues (keep the knee aligned with the toes, don’t allow the knee to traverse to far over the toes, keep heels flat, etc.) I am able to perform the lifts used in Crossfit with no threat of re-injury. The problem has arisen during my stand up classes in mma. My right knee has become more of a problem. While doing certain footwork and kicking drills it will pop ‘out of joint’ with only a small amount of pressure. In addition it has taken longer for it to pop back into place (up to a minute) during which time no weight can be placed upon it. Up until recently, when it did pop out of place, there would be a second or two of pain, it would pop back into place, and I could continue as normal.
Because of these recent events, I’m reconsidering option #3. I’m hoping that the techniques/success of this procedure have improved in the past couple of years. Does anyone know? Has anyone who routinely Crossfits, O-lifts, or practice mma and/or gymnastics had this operation performed? If so, what were the results? I do have an appointment with my physician set up, but I was hoping I could get some informative views from people more familiar with the physical activities I practice.
Thanks a bunch,
10-09-2003, 01:07 PM
I know many that have had ACL surgury. Mixed results, but typically the poor results have been in those that have not done the rehab sufficently or properly. I know of one instance where a guy had ACL surgury and he's better off now than he was before the injury. He wasn't in terrible shape to begin with either, but was really dedicated to the PT and rehab.
Keep in mind you will have a significant amount of downtime with the surgury option.
With your joint destabilizing it sounds like the situation will get worse with time. The connective tissue will get more and more stretched out.
10-09-2003, 03:35 PM
I would recommend asking the orthopedic surgeon about his/her success rates with the procedure.
Additionally, there are issues with regards patient confidentiality, but you could inquire about speaking with his/her patients who have gone through the surgery and post-op recovery about their experiences.
Here are some more articles for your reading pleasure that should be helpful:
The Complex Challenge of Treating Knee Instability
Knee Braces: Current Evidence and Clinical Recommendations for Their Use
The Natural History and Tailored Treatment of ACL Injury
ACL Reconstruction With Autografts
Weighing Performance Considerations and Postoperative Care
A Perioperative Rehabilitation Program for Anterior Cruciate Ligament Surgery
Hope this is helpful
10-10-2003, 10:00 AM
Thanks for the feedback gentlemen.
Roger- Hopefully, I can be as dedicated to the rehab program as the individual you mentioned. I think your right when you say the injury will get worse with time (the third link that John referenced would seem to confirm this). The downtime part doesn't bother me to much - it will give me more time with my kids and allow me to focus on pull-ups and HSPUs,which are two of my weaknesses.
John- Thanks for the links! They really helped to clarify and confirm some of the issues I've been dealing with lately.
Before posting this thread, I had briefly checked out a couple of sites on the subject. One of them gave me the impression that rehab consisted solely of leg extensions. Nice to know that this is not the case. Also the realization that I may be causing or have already caused damage to the meniscus and nearby ligaments has swayed me more torward the surgery option.
On a side note - the second article listed kind of surprised me when it said that some NFL players will wear a brace during practice but not during a game because they feel it limits their performance. Don't you think that by giving a muscle/joint support for the majority of the time and then taking away that support when you need to perform under maximum duress (i.e. game time), that they may be setting themselves up for injury?
10-10-2003, 01:34 PM
Once again your instincts are right.
I agree. Training with the brace and not using it during times of maximum performance would potentially increase your likelyhood of injury.
The American Academy of Orthopedic Surgeons (AAOS) also agree.
If you follow the link in footnote #5 from that article (http://www.aaos.org/wordhtml/papers/position/1124.htm) you'll find the AAOS Position Statement on the Use of Knee Braces.
I haven't had ACL surgery but I did have surgery in March 2002 to repair cartilage damage and remove a bone spur that had completely moved the knee cap out of its track. I also have a lot of football and soccer buddies that have had ACL surgery. Some have had great success while others haven't. Following surgery I did exactly what both sets of my ACL buddies had told me: follow the surgeon's advice exactly on recovery and rehab. I took recovery very slowly and was able to be back squatting and deadlifting in about three months. Five months later I was back on the football field (I'm an official) with a strong knee, no knee brace, and no reservations.
I had one regret with the whole episode: I let the knee problem go too long and had damaged the articular cartilage as well. Unlike the meniscus it will not heal.
One other piece of advice that served me well. Find a surgeon that understands sports - and hopefully your sport. Mine played football and works on nearly half the knees in the area. Having someone with that kind of insight pays dividends in the overall success of the surgery and the recovery.
Good luck with that knee. And - please don't let it go too long.
10-12-2003, 10:52 AM
I'll definitely look for a surgeon with the traits you mentioned,
Please keep us posted on your progress.
11-22-2003, 12:16 AM
So, Ryan, did you make a decision? Are you having the reconstructive surgery?
I'm glad this thread came up. (And thanks to John McCracken for the links to those articles.) I'm facing the same issue--only one knee though (thank god) and a more recent injury (this past summer), so I'm really curious about other folks' experiences. I'm committed to pre-surgery strengthening and post-surgery rehab, but I'm still a bit freaked out by the idea of surgical tampering with my joints--and really bummed about the long recovery and having to be laid up and then conservative with it for so long. It's even harder to imagine going through the rest of my life with it being delicate and unstable, though.
So, just wondering where you're at with the decision...
11-22-2003, 10:09 AM
I had MRIs done on both of my knees within the last two weeks. My next appointment with the surgeon is in early December for a clinical evaluation. Although the radiologist reports give a laundry list of problems with both knees, right now I'm only dead set on having surgery on the right knee - it's so unstable now that it'll pop out of joint occasionally if I just change direction the wrong way. I really have to pay attention to keeping my toes in line with my knee at all times to prevent this from happening. For the time being, I've postponed my FSF practices until post rehab. I have has absolutely no problems the past few months with my left knee. Fortunately, I can still do the WODs. The exercises presented in Crossfit do not bother either one of my knees when executed with proper form with the possible exception of one-legged squats.
11-22-2003, 12:20 PM
Ryan, I had ACL replacement a little over 2 years ago. I think one of the key points is finding a good doctor. Go to a sports-medicine orthopedist - not somebody who is used to dealing with the general public. If you're in Seattle or Chicago I can recommend a couple guys who are really good.
The rehab was the worst part - your graft starts out strong (stronger than the original ligament) then weakens over time to be at its weakest around 6 months. After that it starts to get stronger again. So, you have to sit around (or work on your handstand push-ups) for quite a while before you seriously train again.
However, if you give it a chance to heal, and then train like hell to get back up to speed, you'll have brand new knees.
I'd recommend getting it done sooner rather than later. With out the ACL there's a greater chance of trashing the cartilidge - and that's a lot harder to fix.
Oh, you'll have 3 options for the graft: 1. donor tissue 2. a piece of your patellar tendon 3. your semi-tendinosus/grasilus (excuse the spelling). I had #3 based on the preference of my doc - but if I had it to do over again would definitely lean towards #2.
11-24-2003, 07:01 AM
Thanks for the advice and for the heads up on what to expect during rehab. The surgeon who I am seeing is from the Chicago area (Dr. Collins) and does work with a significant amount of athletes. If you know of him and have an opinion, I'm interested in hearing it. Is option #3 that you describe above the same thing as a hamstring graft?
11-24-2003, 07:15 AM
I had ACL replacement and a meniscus "trim" about 3 years ago. I had the patellar tendon graft and it works great. I do have a little tendonitis but nothing serious. I have managed to do a marathon, several tri's and some endurance races without any problem. The key thing is REHAB!! There is a bucn of good stuff out there. Balance and agility drills really helped me. BTW, The "donor" graft that Chris mentions is typically from a cadaver....kind of creeped me out but my doctor recommended it if I was going to do any serious distance running (Less tendinitis).
11-24-2003, 07:48 PM
Haven't heard of your doc but as long as he's used to dealing with people who want to seriously use their knees again then I'm sure it's okay.
Yeah, option 3 is the hamstring graft - they'll go in, disconnect part of your hamstring, and use the tendons they "harvest" to make a new ligament. The disconnected part of the hamstring eventually withers away from lack of use. In my case, I had a pretty strong tearing sensation everytime I stretched that hammie for about 18 months. I'd say it's back at 100% now and I don't really notice any difference in strength between the good and the "bad" side.
In addition to Mark, I know of one powerlifter who is having pretty good luck with the PT grafts he has on each knee... Not sure which is the lesser of the evils.
11-24-2003, 11:07 PM
Chris, it's funny that the two places you could recommend good orthopedists are Chicago and Seattle, and Ryan's near Chicago and I'm in Seattle. So, who would you recommend here?
My doc was suggesting the hamstring graft. I've looked into the patellar option a little, but the info I've found has been pretty inconclusive--some things sometimes tend to be better with patellar vs. hamstring and some things vice versa. No one seems to talk about the allograft (cadaver donor) option much that I've seen though. I kind of like the idea of not taking tissue from elsewhere in my body (like, hello! maybe my hamstring/patella has that tendon tissue there for a reason!), but apparently there's a greater chance that it won't graft as well...
Ah, the complicatedness of it all.
11-25-2003, 10:19 AM
Carrie, the doc in Seattle is Richard Zorn with Orthopedic Physician Associates 206.386.2600. He's the team doc for the Sonics and does some really nice work.
I'd agree with you that carving up one part of your body to fix another seems a little weird. If there was a synthetic part out there I'd have been all over it. But the prospect of somebody elses germy tissue in my knee just didn't do much for me (even if the risk of infection is really really low).
12-03-2003, 10:24 AM
Last night, my doctor reviewed the MRIs with me. The damage to my right knee is considerable:
1. Tears on both the ACL and MCL.
2. Multiple tears on the meniscus
3. Indications of bone lining deterioration and early arthritis
Several procedures were discussed and my doctor is referring me to a knee specialist in Chicago (Dr. Brian Cole). He said that I may be in crutches for up to six months and multiple operations may be necessary. He also indicated that FSF practices/tournaments would be ill-advised post surgery/rehab. Surgery is necessary because, if left untreated, a knee replacement will likely be required within 5-10 years and, at my age (soon to be 31), the replacement would probably wear out before I die.
I was prepared to hear a lot of this. I haven't been in the ring for a couple of years anyway, so if someone told me I could no longer participate, I wouldn't be totally crushed. Crossfit can easily fill that void and keep me going. The issue that left me shocked and depressed was lifting. The doctor advised me that after surgery/rehab that I avoid squatting/deadlifting/Olympic lifting-type movements. When I asked what type of resistance exercises would acceptable for keeping the muscles near the knee strong, he suggested swimming and biking.
I don't feel I can willingly follow this advice. Until recently, the couple of times I've taken a break from full body lifts are the times my knees have been the most unstable. Also, I consider these lifts to be the foundation for any meaningful functional movement. To me, this is extremely frustrating because the main reason I am willing to put up with a lot of surgery and rehab is knowing that eventually I'd be able to return to working out Crossfit-style. What's the point of fixing a knee if I can't use it properly? I am hoping the specialist will give me more positive news on this subject.
For a couple hours last night, I was feeling very depressed. Then I realized there are many people who are far worse off than me. It reminded me of a quote I heard/read somewhere - "I once was sad that I had no shoes, until I met someone who had no feet." I guess things could be worse.
12-03-2003, 11:42 AM
I never understood why doctors think that putting the knee through a couple thousand cycles per workout, either running or biking, is okay but that doing 25 reps of squats a week is verboten.
12-03-2003, 12:15 PM
Ryan, Don't buy into their crap! I had some damage to the cartlidge and bone surface and was, accordingly told to never squat heavy. After wasting a lot of time and money on "rehab" it was squatting heavy that finally rebuilt my knee. Like you, the only time I have problems with it is when I stop lifting for a while. I know Dave Werner (now running Crossfit North) had some awful problems with his knees (to the point of having to walk with a cane) and it was squats and O-lifts that fixed them.
I'd tell your specialist what you want to do with your knees in the future - if he/she balks, find another specialist (here's one possibility: http://www.orthomds.com/hefferon.shtml).
Cheer up! With a good saw-bones and some Crossfit-rehab, I bet you'll be back to kicking-*** in no time.
12-04-2003, 10:26 AM
Providing me with two examples like that reinforces my own experience and helps put things in a better light. I realize that doctors don't know everything (and some are dead wrong on certain things), but it was still difficult to hear that I wasn't supposed to O-lift coming from a medical expert. I'll make sure that the knee specialist knows that, as long as my legs are attached to my body, I have no intention of giving up on the O-lifts and their variations.
12-09-2003, 08:46 AM
Another knee update:
I saw the knee specialist last night. He said that, because I'm only experiencing symptons of knee problems during times of instability, fixing the ACL may be enough to restore full function. He does plan on examining the meniscus and bone lining during the operation and plans on monitoring me closely afterwards, however. He said that, with aggressive therapy, I'll be back on my feet within 5 weeks and placed no restrictions on my activities after I am fully recovered. After describing what I do and demonstrating the motion required for the O-lifts he decided an allograft (cadaver cartilage) would be my best bet and help to reduce both post op pain and recovery time. Surgery is scheduled for early February.
Initially the thought of having someone else's body parts inside me didn't really phase me, but then I remebered reading/hearing something about how a woman received an organ transplant and, soon afterwards, was craving McNuggets and beer. She never drank alcohol and rarely ate at McDonald's. Somehow she found out that the food above was a regular part of the organ donor's diet. Hopefully cartilage won't have as much of an impact on my dietary habits as an organ! (of course, what I heard my just be an urban legend).
12-09-2003, 09:14 AM
There are studies that indicate that some learned behavior can be acquired through different mechanisms. An example is earthworms "trained" to avoid an electrofied section of dirt, ground up and fed to other earthworms. Those earthworms then avoid the electrofied section of dirt even though they were never exposed. The correlation is not strong, but is present enough to not be a statistical anomoly. So the story could be valid, but I'm not terribly confident it is.
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