One of Summit County’s most common winter injuries: The ACL tear
Dr. Rick Bowles, orthopedic surgeon with Panorama Summit Orthopedics, explains the process of reconstructing the anterior cruciate ligament
For the Summit Daily
Editor’s Note: Sponsored content brought to you by Panorama Summit Orthopedics
The adrenaline-pumping thrills that so many skiers and snowboarders love about the sport also create inherent risks for injury, one of the most common of which is the anterior cruciate ligament (ACL) tear.
Skiing and snowboarding are sports that generate the forces and twists required to cause ACL tears. Dr. Rick Bowles, orthopedic surgeon and sports medicine specialist at Panorama Summit Orthopedics, said his patients often describe feeling a pop in the knee followed by immediate pain. Some can bear weight, but most need to be taken down off the mountain by ski patrol.
With winter upon us and Summit County’s resorts open for the season, here’s some helpful information about ACL injuries to keep in mind as you hit the slopes.
The ACL is one of four primary ligaments in the knee that connect the femur to the tibia, as well as keep the knee stable. Inside the knee, the cruciate ligaments — the ACL in front, and the posterior cruciate ligament (PCL) in back — control the back-and-forth motion of the knee.
The collateral ligaments — which include the medial collateral ligament and the lateral collateral ligament — control the sideways motion of the knee and brace it against unusual movement, according to the American Academy of Orthopaedic Surgeons.
Dr. Bowles said the ACL resists anterior translation of the tibia relative to the femur.
“The ACL also provides some lateral stability against what we call valgus stress, and it provides a little bit of rotational stability, as well,” he said.
ACL injuries in skiers vs. snowboarders
The American Academy of Orthopaedic Surgeons reports that ACL injuries are often associated with deceleration coupled with cutting, pivoting or sidestepping maneuvers, awkward landings or “out of control” play.
About half of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments, according to the academy.
Anecdotally, skiers tend to incur ACL injuries more often than snowboarders just due to the mechanics of each sport. Dr. Bowles said many skiers tend to lean back as a natural reaction to going fast, often referred to as skiing “in the back seat.”
“This is putting more force on the posterior part of the tibia, stressing the ACL,” Dr. Bowles said. “Because there’s not as much pressure on your ski tips, the edges don’t hold as well, making it easy to get into a situation where you twist when your ACL is already under stress.”
Dr. Bowles said skiers with higher DIN settings — which controls how much force is necessary to release a ski binding during a fall — have a higher risk of an ACL tear during a twisting fall.
A long process
Almost no ACL tear patients are ready for reconstruction surgery immediately after the injury. Dr. Bowles said you have to wait for the swelling in the knee to go down and for range-of-motion to improve before surgery can be done.
From injury to recovery, an ACL reconstruction surgery can be a year-long process. Dr. Bowles spends more time with ACL patients during their first visit than most other orthopedic injury patients because he wants patients to understand the process.
“Only about 75 percent of athletes return to the same level of sport following ACL reconstruction,” he said.
There are two categories of surgical ACL reconstructions: autograft and allograft. Autograft is when the surgeon uses the patient’s own tissue — Dr. Bowles usually uses either the patellar tendon or the quad tendon — to make a new ligament, and allograft is when donor (cadaver) tissue is used.
Another popular graft for ACL reconstructions is the hamstring, but Dr. Bowles doesn’t typically use a hamstring graft because the failure rate, or risk of a re-tear, has recently been shown to be higher in young athletes. Plus, the hamstring itself contributes to stabilizing the knee.
“If you’re already ACL-deficient, I don’t want to take your hamstring away,” Dr. Bowles said.
Data shows that autograft ACL reconstructions are more successful than allografts in younger patients. If there’s a clearly favorable choice based on a patient’s age, injury and activity level, Dr. Bowles will recommend the best option, but otherwise it’s a patient’s choice.
“I’ll have a conversation with patients about their goals for returning to activity and what they do in their lives outside of sport,” he said. “I try not to push patients in one direction or another if they don’t have a clear surgery choice — I share the details about each option and let them make their own choice.”
One things orthopedic surgeons can’t do is accelerate biology. Dr. Bowles said one of the unfortunate realities about ACL reconstruction is that it will take a long time to return to activity.
“We tell people six to nine months, but sometimes it could be as long as a year,” he said. “Soft tissue injuries like ACL and other ligament tears just take longer to heal and recover from than bone injuries such as fractures.”
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