Robin Sias was feeling great about her ski season in February 2013. The Wood River Valley writer and mom of three school-age kids had chalked up an impressive 99 days on Bald Mountain in the previous year and was steadily scanning her pass again in the current season.
And then, on a flat-light, hard-pack day at the bottom of the Hemingway ski run, she caught an edge.
“I knew something was wrong with my right knee immediately,” Sias said. “It didn’t really hurt, but when I tried to stand up, it felt unstable, and I got really nauseas.”
Once at the ER, the diagnosis came quickly: a torn anterior cruciate ligament (ACL). An a appointment with orthopedic specialist Anthony Buoncristiani, M.D. and an MRI in the following days confirmed the ACL and added tears to her meniscus to her injury tally. Both would require surgical repair.
The Club Nobody Wants to Join
According to Sun Valley Sports Medicine orthopedic surgeon Alison Kinsler, M.D., damage to the ACL is among the most common knee injuries local doctors address.
“We see a spectrum of injuries in our active population,” Dr. Kinsler said, “including a lot of non-operative overuse injuries, like tendonitis, and more acute injuries, like sprains or tears in the ACL and the medial collateral ligament (MCL), meniscus tears, as well as tibial plateau fractures.”
ACL injuries often occur alongside other damage to the knee. “Concomitant injuries are common with ACL tears,” Dr. Kinsler said, “and can include other ligament sprains, meniscus tears and damage to the articular cartilage.”
Treatment for knee injuries varies considerably across different types of injuries.
“Overuse injuries, like tendonitis, are generally successfully treated with activity modification, physical therapy, icing and anti-inflammatory medications,” Dr. Kinsler said.
Mild sprains to the medial collateral ligament (MCL) or posterior cruciate ligament (PCL) can also generally be treated with physical therapy and will heal on their own with time and activity modification, she noted.
Injury to the ACL is a different story.
The ACL doesn’t have the capacity to heal, so you have to reconstruct it to restore knee stability,” Dr. Kinsler said.
Like many who tear their ACL, Sias underwent arthroscopic reconstructive surgery. In her case, Dr. Buoncristiani performed an “autograft” surgery, in which her torn ligament was replaced with a piece of her own tissue (taken from her hamstring). During the same surgery, the tears in her meniscus were repaired.
The autograft surgery is one of two options to repair the ACL; an “allograft,” in which tissue from a cadaver is used to replace the torn tendon, is the other option.
“Autografts tend to incorporate into the knee faster,” Dr. Kinsler said. “I generally recommend autograft to patients who are 40 or younger.” However, she noted, “if you’re first concern is a fast return to work, an allograft might be the right choice because you won’t have the pain from the donor site to manage.”
Ultimately, decisions about surgical approaches and overall treatment planning are made based on activity level and age, Dr. Kinsler said. Non-surgical treatment for an ACL injury is rare in the Valley, given the stability required for the active pursuits we enjoy, but it can be an option if the ligament is not completely torn and the joint remains relatively stable, Dr. Kinsler added.
The Road to Recovery
Each knee injury is as unique, and recovery time and rehab plans are wide ranging.
“An MCL sprain that doesn’t require surgery might require six-to-eight weeks in a brace and physical therapy, while ACL reconstruction generally requires six-to-nine months of rehab,” Dr. Kinsler said.
The importance of rehab can’t be overstated, according to Dr. Kinsler, especially in the case of surgical interventions: “You can reconstruct an ACL, but if you don’t rehab the knee properly, you’re not going to be happy; the surgery could be a failure.”
Sias, now almost four years out from her injury and grateful for the consistent work she put in to regain strength and mobility, advised the same: “You have to really commit to rehab.”
If you’ve hurt your knee, don’t play Dr. Google; seek accurate information through a trusted source. Dr. Kinsler recommends the patient site of the American Academy of Orthopedic Surgeons: Orthoinfo.org.
Anatomy of an ACL Injury
(accompanied by medical illustration of knee joint)
The ACL connects the top of the tibia (shin bone) to the lower back part of the femur (thigh bone) and controls the forward and backward motion of the knee; it also provides rotational stability.
There are several different types of ACL injuries, according to the American Academy of Orthopedic Surgeons, described on a graded scale of “sprain”:
- Grade 1 sprain: a mild stretch of the ligament that does not affect stability in the joint;
- Grade 2 sprain (“partial tear”): ligament stretched so much it causes instability;
- Grade 3 sprain (“complete tear”): ligament split in two.
Ski Safe: Preventive Tips
Troy Quesnel has been responding to skiers’ injuries on the slopes for 17 years as a member of the Sun Valley Ski Patrol (SVSP). Quesnel says that SVSP sees quite a few ACL and MCL injuries each year, and while skiers of all abilities are affected and injuries can be the result of elements beyond a skier’s control, or just bad luck, many share some similarities.
“The commonality seems to be hesitancy in a skier’s form, which can be the result of skiing in conditions that aren’t familiar or comfortable or from fatigue,” he said. “We see a lot of ACL and MCL injuries through slow, backward twisting falls, where the skier is sitting in the backseat, with their skis in a wedge, and then catches an edge.”
Quesnel advises the following basic preventive tips to avoid this scenario:
- Maintain fitness: “Living in the Valley, there are so many opportunities to stay fit all year round; maintain your fitness so you start the ski season strong.”
- Focus on form: “Aim for a forward, athletic stance and pay attention to your posture across all types of terrain.”
- Be aware of conditions: “If you’re a groomer skier and you find yourself in new terrain or changing conditions, you’re going to ski hesitantly. Be aware of changing weather and know your limits.”
- Listen to your body: “Don’t push yourself to the point of fatigue. If you’re getting tired, take a break.”