Can you ski with a torn anterior cruciate ligament?
As with all sports, the dose makes the poison. Alpine skiing in itself is a sport that can be practiced without any problems up to an advanced age, provided that there is adequate physical preparation. However, the ski resort is of course a thoroughly dangerous sport for the knee joint due to the constant rapid load changes and high loads with the knee bent or due to the high rotational loads that occur. In most cases, overuse symptoms occur in the area of the tendons and ligaments, especially that of the patella tendon. Meniscus injuries can also occur and, with the corresponding twisting of the knee joint, cruciate ligament tears. A tear of the anterior cruciate ligament is a severe internal knee joint injury in which, the central pillar of stability is lost. Clinically, this injury manifests itself acutely by severe pain, massive swelling of the knee joint and the subjective feeling that the knee is not holding, called a giving-way attack in technical jargon. In the case of such a constellation of symptoms, an experienced cruciate ligament surgeon should definitely be consulted in order to clarify and diagnose this injury in detail and to treat it as effectively as possible.
The cruciate ligament injury not only mechanically reduces the stability of the knee joint, but the injury to the proprioceptors within the anterior cruciate ligament also reflexively inhibits the quadriceps muscle at the spinal cord level, which additionally leads to reduced muscular stabilization of the knee joint.
How is a cruciate ligament injury diagnosed?
Diagnosis of a cruciate ligament injury always consists of clinical examination with appropriate stability testing (anterior drawer, Lachmann test, pivot shift test) and appropriate MR tomographic imaging diagnosis with special paracoronary and parasagittal imaging. If instability is diagnosed in the clinical findings and a clear anterior cruciate ligament tear is present in the MRI, the decision must be made as to whether surgery is sensible and expedient. Of course, there may be concomitant injuries such as jammed meniscus tears, blown off pieces of cartilage, which make an operation necessary and then the anterior cruciate ligament should also be addressed at the same time with the appropriate level of sporting demand, because a cartilage and meniscus injury heals much worse in an unstable knee joint. In the case of an isolated anterior cruciate ligament rupture, the therapeutic steps can certainly be approached in a differentiated manner. Studies have demonstrated over a short period of time that in amateur athletes, immediate surgery does not provide significant benefit within a two-year study period. However, the lack of stability in the knee joint is responsible for meniscus injuries occurring in greater numbers over a longer period of time.
Surgical or conservative treatment?
Patients in amateur sports with isolated anterior cruciate ligaments should first undergo intensive physiotherapy for 3 months, then attempt an appropriate rebuilding training program and return to skiing. If it is found that recurrent subjective instability occurs, surgical repair of the cruciate ligament tear can still be performed thereafter without endangering the knee joint. In no case does the amateur athlete need immediate surgery as the professional athlete does. Professional athletes only undergo surgery because they do not have the time to wait and see if the knee joint will return to a stable sporting situation without surgery.
How can a cruciate ligament injury be treated?
With the surgical techniques available today for cruciate ligament repair, we can proceed in a differentiated manner depending on the type of rupture. In the case of corresponding tears close to the bone, reinsertion and thus preservation of the patient’s own cruciate ligament can be performed if the patient is young enough. Furthermore, it is also possible today in appropriate partial tears where either the anteromedial or posterolateral bundle is ruptured, to reinforce these with suitable tendon implants and thus guarantee a fuller sports capability through a much smaller intervention. In the case of complete rupture of the anterior cruciate ligament, the appropriate replacement with endogenous tendon material is still required. For this purpose, mainly the semitendinosus tendon is used as a 4-fold graft, the quadriceps tendon as a bone monoblock implant and in exceptional cases also the patella tendon with a bone double block. If it is already a revision operation or the patient cannot use his own body material due to special sporting demands, we now have donated materials from a tissue bank at our disposal.
The aftercare is crucial!
The success of a cruciate ligament operation ultimately lies not only in the hands of the surgeon, but also quite significantly in the consistent and intensive follow-up treatment through physiotherapy and the independent training of the patient. Post-treatment of the surgically repaired ACL rupture takes a total of 12 months no matter how quickly muscular competence is regained, because only then is the full integration of the tendon graft into the knee complete and the biology within the knee joint back in balance.
It makes sense to immobilize the patient with an orthosis to prevent the graft from loosening in case of twists and falls during the early rehabilitation phase. Crutches only need to be used to relieve pain and physiotherapy begins on the first day after surgery. After 6 weeks they should be able to ride a bike on the ergometer after 3 months they should be able to run and further athletic releases will be after appropriate functional motor testing and skills. From a personal point of view, I do not recommend practicing pivoting sports or contact sports again until after 12 months.
Recovery will not occur under one hour of daily attention to the operated knee joint, whether it is physical therapy, lymphatic drainage, ergometer training, motorized splint mobilization or strength training. The more consistent the recovery of the knee joint is, the faster the sporting level before the injury will be regained. Studies show that about 40% of patients regain their previous level of athletic performance. However, secondary meniscal and cartilage damage is much more common in non-operated patients.
In summary, anterior cruciate ligament rupture is a severe internal knee injury that results in a large degree of mechanical destabilization of the knee joint. From my personal point of view, life without an anterior cruciate ligament is quite possible. However, the question is whether you, as the patient, want to adapt your athletic demands to the injured knee, or you want to adapt your knee to your athletic demands. If you have high demands on your sporting level, I consider the surgical repair of an anterior cruciate ligament tear to be essential, especially to avoid long-term damage.