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Jan
Mountain climber
Colorado, Nepal & Okinawa
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Topic Author's Original Post - Jan 21, 2016 - 02:04pm PT
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I have a Sherpa friend who is going to the Steadman Clinic in Vail for repair of a torn ACL in his knee. Has anyone here (probably a skier) had experience with that? They're talking rehab three times a week for two weeks. I'm afraid his climbing season on Everest is going to be jeopardized. It starts in March. Any experienced advice would be appreciated.
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ron gomez
Trad climber
fallbrook,ca
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Jan 21, 2016 - 04:41pm PT
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You can't speed up healing times....let the structures HEAL SOLID. Get full extension ASAP, push flexion, do the rehab religiously, work the Quads, hip musculature, gastrocs. Stationary bike is good, get and keep swelling down, get patellar mobility, don't rush things. Nif he follows the rehab protocol from that clinic, should be GTG.
Best wishes on a solid rehab, successful procedure and healthy healing!
Peace
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Crimpergirl
Sport climber
Boulder, Colorado!
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Jan 21, 2016 - 05:15pm PT
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Glad he decided to go there. I've heard nothing but good things from climbers being put back together one at a time. :)
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AP
Trad climber
Calgary
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Jan 21, 2016 - 05:33pm PT
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Ron is right about not rushing it. Much physio, done at home with a proper program, cycling (stationary at first). It takes 1 year before the knee is as good as it will get, which should be quite useable. I had my ACL done in 1988 and it is the best ligament in that knee. It your friend careful the new ACL should last a life.
Remember
It is all rehab until 1 year
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Delhi Dog
climber
Good Question...
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Jan 21, 2016 - 05:49pm PT
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I'm 3 months and counting into the recover stage after having a new grafted ACL done in Oct.
I've begun running last week and biking.
Was in Myanmar over the xmas holidays and did a several day hike (20+miles) and biked more than that. No problem but tired (mostly 'cuz I've been sitting around healing).
Still about 20* needed for full range of motion but I'm planning on my yearly ski vacation to Italy in March ( I'm a tele skier too...but I know no ones cares:-) and I have my yearly himalayan foothills bike tour in April.
I doubt seriously if I could have done any of this prior to the 3 months of PT (3 x wk now moving to 2).
I'm 100% sure 6 months from surgery I'll be as good as new.
Your buddy might miss this season but for long term health he should follow the well laid out plan for recovery. I'll bet he's in better shape and younger too so recovery will/might be quicker but 6 month should be his plan.
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Gnome Ofthe Diabase
climber
Out Of Bed
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Jan 21, 2016 - 06:03pm PT
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I have had 3 procedures about 5yrs apart.
The first the doc left it alone . .after knocking me out and with no consult.
saying it was stretched and twisted but half intact?
WHAT? I HAD PAID TO HAVE AN ACL REPLACEMENT.
(when I finally got the films, it was a mess )
Sure enough that sucker went pop audibly.
I have had both knees' ACLs done,
replaced with cadaver tissue, as opposed to synthetic.
There is a device that is available that fully ices and moves the knee, immediately after the surgery.
The 1st time I was given the Cryo-machine & I was able to push harder faster. I feel it was what made the difference between my two experiences.
I believe in Heavy Hydration to flush the system and constant movement,
as soon as possible as I said immediately (under meds,)
with constant cooling to reduce as much swelling as possible.
. I have Very pronounced over flexion, /hyper extension. I worked hard to get that all back.
it was work.
I spent Hours using a rolling chair in a long hallway:
drawing myself forward, and then pushing back the other way , if that makes sense.
Then I went to an old school Free weight lifting gym; with a foot plate that you attached disc weights.
Starting with just the plate and adding weight (as well as wearing strap on ankle weights.)
this was all extra to my prescribed physical therapy. Where I worked like a man possessed.
The aqua tank was also key after all the skin had healed and the scabs were gone. Would do Knee bends and high steps.
Then after I got full range of motion & my hyper-extension back I wore a wrap brace for hiking
out always, Fatigue, after a long day, is still a real concern.
The recoup time for me was dependent on range of motion and strength.
With-in 5 months was back to easy Rock climbing but not carrying much or doing any long approaches for a year.
I know of good climbers in their 20s who did not take the time for the graft to adhere fully and re-tore the replaced ACL.
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rgold
Trad climber
Poughkeepsie, NY
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Jan 21, 2016 - 06:29pm PT
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I had an ACL reconstruction at age 68, so am not a good model for the healing process of a younger person. I was leading moderate climbing seven months later, harder climbing within a year, but still I'd say it took more than a year before I stopped being "aware" of the repaired joint. This isn't all that bad, considering that the average pro football player needs 54 weeks to return to pro football after ACL surgery---according to http://www.foundrysportsmedicine.com/popular/2015/6/18/why-are-professional-athletes-able-to-return-from-acl-surgery-sooner-than-me. Like most of us, I wasn't ever going to, much less going back to, pro football, and I didn't have the kind of time and access to rehab activities a pro athlete has. So even if we aren't trying to make the starting team, expecting something like a year to fully recover is pretty reasonable.
The healing process of "ligamentization" involves the death of the original graft cells, their replacement by cells from the patient, the creation of a new blood supply to the graft, and changes in the morphology of the new cells. During this process, the graft gets weaker before it gets stronger, so activity has to be carefully controlled to supply the stresses necessary to promote growth and development without injuring the relatively delicate graft, which may however feel fine.
Here's one of many animated descriptions of the healing process: [Click to View YouTube Video] Googling "ACL healing process" will turn up more.
This situation makes it imperative to follow rehab protocols and not let enthusiasm for a knee that may feel pretty good rush you into strains the ACL isn't ready for. I'm not a medical doctor, but I haven't seen anything in the research I did that would suggest that someone could be ready for the "Everest season" three months after ACL surgery. And I suspect that walking in crampons, an activity in which the foot is going to remain fixed when the leg twists, is not something one wants to do any time before that tendon is at full strength.
Again, I'm not a medical doctor, but some of the descriptions of activity posted above sound to me as if they might be pushing the envelope in terms of the timing of physiological processes. The knee may feel fine before the graft is at full strength.
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Delhi Dog
climber
Good Question...
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Jan 21, 2016 - 09:08pm PT
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Again, I'm not a medical doctor, but some of the descriptions of activity posted above sound to me as if they might be pushing the envelope in terms of the timing of physiological processes. The knee may feel fine before the graft is at full strength.
rgold may not be a medical doc. but speak/write with wisdom.
The activities I started (hiking + biking) are all encouraged by my PT and surgeon.
They have also encouraged me to "listen to my knee" and let me knee guide me it what I can and can't do. So far this has been working.
It is easy at this point though to overdue it as it feels so much better than it did, however being patient and careful is critical and one I'm trying to be conservative with rather than the other.
Humping loads at altitude in crampons...uh, good luck with that.
My "new" ACL was harvested as a graft of my hamstring.
http://en.wikipedia.org/wiki/Anterior_cruciate_ligament_reconstruction
"...Advantages of using a hamstring graft includes its high “load to failure” strength, the stiffness of the graft, and the low postoperative morbidity. It has shown that the natural ACL can withstand a load of up to 2160 Newtons.By using a hamstring graft, this number doubles. The "load to failure" is twice as high as the natural ACL, helping to decrease risk of becoming injured again. The stiffness of a hamstring graft also contributes to this risk factor. If the graft is stretching out instead of staying stiff, this increases the shift between the tibia and the fibula. In comparison to the stiffness of the natural ACL, the hamstring graft quadruples (Bartlett, Clatworthy and Ngugen, 2001). Therefore, using a hamstring graft for a torn ACL has a variety of benefits including stability and recovery purposes, decreasing the chance of re-injury."
Here's a pretty cool animation of the procedure:
http://www.youtube.com/watch?v=Xsq0sQp6DwU
Here's the real deal:
http://www.youtube.com/watch?v=TVnlW86TZ4g
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Jan
Mountain climber
Colorado, Nepal & Okinawa
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Topic Author's Reply - Jan 22, 2016 - 12:16am PT
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Thank you everyone for taking the time to give such detailed advice.
I will print it out for him. He is having an MRI on Monday so we will know more then but it seems the rehab is long as I had feared.
Really unfortunate.
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Delhi Dog
climber
Good Question...
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Jan 22, 2016 - 01:51am PT
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Really unfortunate. Yeah but...
the alternative is probably worse.
Surgery now is so simple compared to not that long ago. Way less invasive.
I'm glad I live in a time when a blown ACL is not a major set back to the quality of life.
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Jan
Mountain climber
Colorado, Nepal & Okinawa
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Topic Author's Reply - Jan 22, 2016 - 02:40am PT
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I'm glad it happened in America where he can get good care.
The unfortunate part is that it will so negatively affect his income.
There's no unemployment insurance in Nepal.
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altelis
Mountain climber
NM
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Jan 22, 2016 - 09:56am PT
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Orthopedic Resident here...
We typically tell our elite athletes (and he would qualify) 6-9 months to return to sport, assuming he has full range of motion and his quad is symmetric compared to the other leg, and he has progressed with proper rehab during that period.
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Fat Dad
Trad climber
Los Angeles, CA
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Jan 22, 2016 - 03:37pm PT
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Although they appear to have gotten MUCH better at these, particularly in the rehab stage, it still takes time. I had my ACL done in 1986, one year after my MCL done, even though they really should have done my ACL initially. That's what happens when you injure your knee on the job.
Big scars to show for it. Back then, they'd have you on crutches for a couple of months and a big problem after the fact was atrophy. Not long ago, I saw one out mt. biking with a knee brace on. I asked them what happened and she said she had her ACL done six weeks earlier. Amazing. You really have to listen to your joint though. Be aggressive in following rehab and don't push it too hard afterward or you risk reinjury. I reinjured mine and it was heartbreaking.
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HighTraverse
Trad climber
Bay Area
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Jan 24, 2016 - 12:13pm PT
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I've had 3 ACLs
Be aggressive in following rehab and don't push it too hard afterward or you risk reinjury Absolutely.
And for the first few days don't be a tough guy and scrimp on the pain meds. Manage the pain. You'll heal faster.
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rgold
Trad climber
Poughkeepsie, NY
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Jan 24, 2016 - 01:20pm PT
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We typically tell our elite athletes (and he would qualify) 6-9 months to return to sport, assuming he has full range of motion and his quad is symmetric compared to the other leg, and he has progressed with proper rehab during that period.
Perhaps progessing "with proper rehab" is the key, remembering especially that "elite athletes" often have access to rehab facilities and expertise, as well as the time to engage in those rehab activities, that an ordinary person is just not going to have.
Moreover, in the case of a sherpa, reinjuring the knee high on a Himalyan peak is just a tad more serious than having that injury on basketball court or football field. You want to be damn sure the knee is fully ready to go.
Some relevant reading at http://www.drdavidgeier.com/when-athlete-ready-sports-after-acl-surgery/.
A few quotes:
A 2010 survey asked NFL team doctors what percentage of NFL players return to play. 90% of the physicians answered “90% – 100%.
A study of NFL players who underwent ACL reconstruction showed that only 63% returned to play in a regular-season game within two seasons after surgery. A study of high school and college football players showed similar results. 63% of high school football players and 69% of college players made it back two years after surgery. Only 43% of them had returned to preinjury levels.
Finally, a 2011 study of competitive athletes in a variety of sports showed that only 33% of athletes had returned to their sports at their preinjury levels 12 months after surgery.
Strength, motion, and neuromuscular control of the hip and knee in multiple planes, and for both legs, can all predict the risk of reinjury. All of them can be improved with training, however. This process can take as little as four months, but it can require 12 to 24 months. It is vital not just for preventing injury of the ACL graft or the opposite knee’s ACL. The work is crucial to getting that athlete back to playing at his former level. These are the criteria we are starting to use.
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Jan
Mountain climber
Colorado, Nepal & Okinawa
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Topic Author's Reply - Jan 24, 2016 - 01:37pm PT
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Those are pretty daunting statistics. He's having an MRI at the Steadnman Clinic in Vail tomorrow so we'll know more then. Again thanks everyone for your voices of experience.
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ron gomez
Trad climber
fallbrook,ca
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Jan 24, 2016 - 02:42pm PT
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Get the study done, hear out the options...surgery is not always warranted. He's a Sherpa?? Probably has better leg musculature than most of us. If surgery is the solution, get AS STRONG as possible prior to surgery, then follow docs instructions, push weight bearing status and ROM within safe tolerances. He'll be back good to go barring any complications. Be very safe at the 3-5 month post op phase, his PT/ATC will explain that. Best wishes on his recovery!
Peace
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rgold
Trad climber
Poughkeepsie, NY
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Jan 24, 2016 - 06:29pm PT
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Jan, I didn't necessarily mean to be daunting. The studies (the references are in the link I gave) suggest that there is a huge range of recovery times, from four months to two years for elite athletes, so even if the average recovery was 6--9 months, the standard deviation is so large that one shouldn't base expectations on the average.
I dare say football is more demanding of knee strength and stability than mountaineering, so the stats may not be directly relevant either.
I think the docs have gotten really good at the surgical part. Assuming no complications, rehab determines the outcome, so you want to put as much effort into finding the best rehab facilities and practitioners as you would put into finding a surgeon. Ideally, the surgeon is already associated with the best rehab folks, but I've found this is not necessarily the case, especially when the surgeon is part of a group that also has a rehab practice.
Speaking of complications, one to be aware of is blood clots. If your guy experiences considerable pain away from the knee joint, especially in the calf, get right back to the doc; a scan and perhaps blood thinners may be essential.
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