KneeHab: Mythbusting for ACL surgery and other sports knee injuries
Editor’s note: This column is part of an eight-week series about ACL, MCL and other knee injuries. See the Summit Daily sports section for the next installment, and head online to SummitDaily.com for past articles.
When Silvia Mittermüller injured her knee for the first time in 2007, the German-born pro snowboarder had one question in mind: How long until I’m back on a board?
“At first I thought it wouldn’t be so bad because after a week I was running, jumping, dancing in high heels — I thought I got lucky,” said Mittermüller, a 33-year-old slopestyle veteran who has lived and trained in Breckenridge for more than a decade. “I didn’t know that if you have a stressed ACL and are somewhat strong, you can get by.”
Mittermüller was in for a dose of harsh reality. Over the next three seasons, she battled with a new knee injury each year: partial tear on her right knee in 2007, full tear on the same knee at X Games Aspen in 2008, and then a full ACL tear plus menisci damage on her left knee at a California rail jam in 2009.
After each injury, between daily physical therapy and a self-imposed water rehab program at the Breckenridge Recreation Center, Mittermüller struggled with the same questions: How long until I recover? How long until I compete? Should I be at the X Games? Can I? Will I ever be whole again?
“I started thinking, ‘Maybe I should stop being a snowboarding person,’” said Mittermüller, who has competed at Dew Tour, X Games, the European Open and World Cup events across the globe. “Then I thought, ‘How many days on a snowboard are epic, and how many days are like this?’ I just want to do what my heart desires, and that’s to keep riding. That’s the path I took, but I just totally destroyed my knee.”
After completely destroying her left knee in 2009, Mittermüller took nearly a full year to recover and recoup, both mentally and physically. She was forced to miss the first women’s slopestyle at the 2014 Olympics due to a ruptured Achilles tendon, but her knees stayed healthy until October 2016, when she partially tore her right ACL again and completely ripped the outer meniscus from the bone in Saas Fe, Switzerland, with the German national team. A few months later, she was hit by a snowboarder on one of her first visits back to the Woodward Copper park.
But, again, Mittermüller bounced back. She recovered in time to place third at a Czech World Cup Olympic slopestyle qualifier in March and take second at the Breck Parks Spring Open on April 1.
“Despite crazy knee surgery and being out almost all season — all the crap I’ve had in my life — I might have a realistic chance to do this Olympics thing at age 30-plus,” Mittermüller said. “That will be icing on the cake of this snowboarding career.”
Mittermüller’s story shows there’s no simple shortcut for knee injury recovery, but there are plenty of roadmaps. We talked with local athletes, physical therapists and orthopedic surgeons to bust common myths and misconceptions.
| Pre-injury myths |
Skiers and snowboarders are equally at risk for ACL and other knee injuries.
False. In general, skiers are more likely to suffer knee and lower-body injuries, while snowboarders are more likely to break bones in their wrists, arms and upper body, according to Paula Ashbaugh, a physical therapist at Avalanche Physical Therapy in Frisco.
That said, snowboarders aren’t immune to ligament tears and other knee damage. Look at Mittermüller: short or long landings on jumps caused the majority of her injuries. A 2009 sports medicine study showed that quad muscles are often stronger than knee ligaments, and so when a snowboarders comes up short — the equivalent of jumping from a three-story building — the muscles recoil with enough force to snap ligaments.
Men and women are equally at risk for ACL and other knee injuries.
False. While guys and gals both suffer from knee injuries, women are at greater risk. It comes down to anatomy. Most women’s hips are naturally larger and wider than men’s, Ashbaugh said, which leads to natural bowing and pressure at the knee joints. Women also have smaller ACLs and different, more upright posture than men that doesn’t protect ligaments as thoroughly.
Skiing and snowboarding are the most dangerous activities for knee, wrist and head injuries.
False. Knee and other orthopedic issues are common at mountain-town medical centers, but they pale in comparison to motor vehicle and poisoning traumas. According to the Centers for Disease Control, 192,000 Americans died from trauma injuries in 2014. Of those deaths, 33,736 were related to motor vehicle accidents and 31,959 were due to accidental falls, including traumatic brain injuries. Skiing and snowboarding account for just a fraction of the total.
New ski equipment is safer than rental or second-hand equipment.
False. When it comes to equipment, it’s smarter to buy or rent skis and boots based on your ability, not a marketing campaign. Rental shops are trained to pair clients with the right gear, so listen to your techs — they know what they’re talking about. Also trust them to set an appropriate DIN on your bindings. If the DIN is too high, it won’t release and will torque your knee into oblivion. If it’s too low, it can release unexpectedly and be just as dangerous.
If my skis are shorter, I’m less likely to blow an ACL, MCL or anything else in my knee.
False. It’s true that skiers are more prone to ACL injuries because of their equipment — giant levers on both feet can spell disaster during a fall — but the size and type of gear makes little difference, Ashbaugh says. If the lever on your leg gets torqued just right, the damage will be the same.
If I exercise enough, I can prevent knee injuries during the ski season.
Complicated, but false. This feels like a no-brainer: strength equals safety on the slopes. And it certainly helps, but Ashbaugh just needs to rattle off a list of pro skiers and snowboarders with chronic knee injuries to prove exercise isn’t preventative.
“But what about Lindsey Vonn and Bode Miller?” Ashbaugh said, referencing pros who have suffered nearly 10 combined knee injuries over their careers. “We see professional, world-class skiers tearing their ACLs. It might help you ski longer and last longer.”
| Post-injury myths |
A hot tub is the best thing I can do to ease the pain.
False. Immediately after an injury, your knee goes into healing mode: the surrounding skin, muscle and tissues turn puffy and inflamed in response to trauma. While a hot tub is relaxing for muscle soreness, it’s the last thing you want for joint trauma, said physical therapist Kyle Volkert, one of Ashbaugh’s coworkers at Avalanche in Frisco. It’s the same in the weeks immediately after surgery, when the extreme temperatures and bacteria of a hot tub can irritate tissue and sutures.
I don’t need surgery if my knee feels fine after a few weeks.
Complicated. Truth is, not everyone needs to undergo ACL, MCL or other knee repairs, especially when local costs before insurance come close to $43,000. But, if your lifestyle revolves around activities — skiing, biking, hiking, basketball, tennis and dozens of other sports — surgeons and PTs all recommend surgery. Why? Simple: ligaments and tissue like the meniscus are slow to repair. Blood flow to these areas is poor, Ashbaugh said, and so partial tears are at risk of further injury for months and even years after the initial injury. Complete ACL tears will never fully recover on their own, Volkert added, and while the surrounding muscles will compensate for the injury, the knee joint will never quite be the same.
The ligaments, bones and muscles of my knee joint all heal at the same rate.
False. Again, this has to do with blood flow in your knees. Skin and muscles are rich in blood and heal quickly, while healing time for ligaments and bones varies wildly depending on location. For example, MCLs have better blood flow than ACLs, orthopedic doctors say, which gives athletes more options for post-injury surgery and rehab. Menisci have lower blood flow than both ligaments, which is part of the reason menisci rehab requires five to six weeks of limited mobility after surgical repair.
I need to seek a second (or third) opinion before agreeing to surgery and rehab.
Complicated. It’s never a bad idea to shop around for a surgeon or PT, particularly after a complicated injury, but surgery isn’t an all-you-can-eat buffet of options. Therapists at Avalanche say it can be frustrating when clients search and search for the solution they want — but don’t necessarily need — and stall the entire recovery process.
If I exercise enough during rehab, I’ll be healthy and back on the slopes sooner.
False. To explain, Volkert uses the scab analogy.
“It’s like picking a scab: It might feel better to itch at it and pick at it, but that’s not helping your body heal,” he said. This isn’t to say post-injury PT is optional — it’s the best way to return just as strong or stronger than before — but clients need to realize it won’t work miracles in days or even weeks, Volkert said. Most surgically repaired ACLs take 12 to 18 months to fully heal, PTs agree, even though most folks feel healthy and even normal after as few as six months. There’s no way to speed up the healing process, Volkert said, but there are dozens of ways to slow it down, like biking, running, skiing or even walking before the doctor and PT agree you’re ready.
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