Expert Tips to Prevent and Recover from ACL Injuries

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Skiing’s not kind on the knees, that’s just the cold, hard truth. If you’ve been skiing for a number of years, chances are you’ve either suffered a knee injury yourself, or know someone who has. If we were the betting type, we’d put money on the knee injury involving a torn anterior cruciate ligament (ACL), medial collateral ligament (MCL), meniscus damage, or (hopefully not), a mix of all three. Why? Because those are the most common knee injuries that befall skiers. And because SKI’s editorial staff counts four reconstructed ACLs and one repaired meniscus between us.

According to Dr. Matt Hastings, DPT, founder of The Alpine Athlete in Denver, Colo., up to 77 percent of all skiing injuries occur in the lower body, and 27 to 41 percent of injuries occur in the knee. The most common of those knee injuries: ACL and MCL injuries, followed by fractures of the tibia.

Related: Italian downhiller Sofia Goggia races in the Olympics on a broken leg

Dr. Matt explains that most skiers sustain knee ligament injuries like these in a fall where the inside edge of the outside ski hooks up on the snow. This causes the ski to act as a long lever that maximizes torque on the knee and its ligaments. The other common way to tear an ACL while skiing is by falling backward over the tails of your skis without ejecting out of your ski bindings. If the hips fall below the knees in this scenario, all of your weight is placed on your knees as your skis continue downhill. If a ski hooks up on its edge as described above, the force or torque is likely to damage knee ligaments.

Read more: Skiing and your ACL

Because ACL tears are so common in our sport, we get a lot of questions about them. We get it—we’ve been there, desperately scouring the internet for information to help us understand how bad a torn ACL is and assess just how much it’s going to set us back in skiing and other activities.

Here, we asked Dr. Matt to answer your most pressing ACL injury and recovery questions as they relate to skiing. The good news for those who have recently torn an ACL: You will live to ski another day.

ACL Injury, Surgery, and Recovery FAQ

ACL Tear
Left: The anatomy of a healthy knee and anterior cruciate ligament (ACL). Right: Anatomy of a torn ACL.  (Photo: Wikimedia Commons)

Q: How do you know if you’ve torn my ACL?

The most common symptoms of an ACL tear are:

  • A loud pop or popping sensation in the knee
  • Severe pain or inability to continue an activity
  • Rapid swelling
  • Decreased range of motion in the knee
  • A feeling of instability or “giving way” with weight-bearing

However, ACL injuries present differently from person to person, so it’s important to be assessed by a medical professional immediately after your fall or injury.

Q: Should you get an X-ray if you think you’ve torn your ACL?

While an X-ray is not sensitive enough to show soft tissue injuries, your physician may be able to see signs of an ACL injury on the X-ray. Another reason to get an X-ray after a knee injury is to rule out a potential fracture that may have occurred in the fall or accident.

Q: Do you have to get an MRI if you’ve torn your ACL?

That’s up to your orthopedic physician. In some cases, a torn ACL can be confirmed with manual tests. But an MRI is the most sensitive test to directly visualize the ACL and its potential damage, and is therefore often required to assess the full extent of the trauma.

Q: If you think you’ve torn your ACL while skiing, is it safe to ski down the mountain?

It’s always best to contact ski patrol or some other form of help after a more serious fall on the ski hill because you just don’t know the extent of the injury. Plus, many patients report not being able to bear weight on the affected leg, or immediate swelling in the knee joint, which affects range of motion and mobility, making it difficult to ski down.

Q: Does a torn ACL require surgery?

It depends on the extent of the injury to the ligament (percentage torn and location), and what your orthopedic physician/surgeon determines is the best plan of care. Some partial tears can be managed conservatively with physical therapy. But in many cases, especially if the ligament is fully ruptured, surgery may be required.

Q: Can you ski with a torn ACL?

It’s not advised. Your ACL is a primary stabilizing ligament for the knee joint. Without it firmly in place, you put more demand on the muscles around your knee to provide that stability. Should those dynamic stabilizing muscles become weak or fatigued, you may feel your knee buckle or give way. This could cause more injury to other soft tissue structures of the knee or the joint itself. It’s always best to consult with your Orthopedic Physician and PT prior to resuming certain activities with an ACL injury.

Q: What does ACL reconstruction surgery entail?

Generally speaking, during ACL reconstruction the torn or ruptured ACL is removed from the joint and repaired or replaced with another piece of tissue (graft). If you’re using a graft from your own tissue, the surgeon harvests this from the predetermined location (typically hamstring, quadriceps, or patellar tendon). They then take your grafted tissue or tissue from a deceased donor and secure the graft in the place where the old ACL was located. This is an outpatient procedure performed by an orthopedic surgeon who specializes in bone and joint disease.

Q: What kind of graft is best for ACL reconstruction?

There is no clear consensus on the best graft choice. It’s up to the discretion of the orthopedic surgeon and should be based on a discussion between the two of you to determine the best plan of action. The main options consist of allograft (donor tissue) or autograft (your tissue), which can come from the patellar tendon, quadriceps tendon, or hamstring tendon. Graft choices are based on variables that include age, gender, stability, strength, function, return to sports ambitions, patient satisfaction, and potential complications.

Q: Can you walk immediately after ACL surgery?

Assuming the procedure only involves ACL reconstruction, most patients can start walking after surgery. However, it may be a few days to a week before you feel comfortable putting weight on the knee due to swelling and surgical pain. This is generally one of the first things we address on day 1 of ACL rehab.

Q: How long before you can run after ACL surgery?

You can generally begin the return to running activities around three to six months after surgery. This milestone is not usually timeline-based but rather dependent on a few variables such as knee function, symmetrical limb strength, and minimal pain and swelling, among other factors. Even once you reintroduce running to your program, you and your PT will likely start with a progressive walk/run routine to build up endurance and ensure you’re not overloading the knee too soon.

Q: How long does it take to get back to skiing after ACL surgery?

Every case is different and should be approached on an individual basis. Generally, return to sports protocols encourage waiting as long as possible to return to high-level activity. Typically, patients can return to snow as early as seven months to a year after ACL reconstruction. Before returning to snow, you should complete a rigorous return to sport test with your PT. If and when you pass the test with satisfactory scorers, your orthopedic surgeon should clear you for activity.

Read more: ACL recovery timeline for skiers

Even once you return to snow, you shouldn’t expect to jump straight back into skiing double-black diamonds or extreme terrain. We recommend starting with a series of drills and easy skiing on groomed terrain for a few weeks to months before cautiously easing back into any high-level/high-risk activities.

Q: How often and for how long should you do physical therapy after ACL reconstruction?

PT should be done as frequently as one to three times per week and can take upwards of seven months to a year. Even once you get to the late stages of ACL rehab, the weekly frequency of physical therapy may be reduced, but that doesn’t mean it’s time to stop training. You should carry on with the exercises and weekly training as your PT has prescribed until you’re discharged from PT. Once you are formally discharged, it is always a good idea to have a post-rehab training plan and to continue with strength training in conjunction with skiing activities.

Q: Can you get back to full strength after ACL reconstruction?

Absolutely! It takes consistency and it isn’t without potential setbacks and roadblocks, but full recovery is always possible. The goal is to leave PT feeling stronger and more confident than before your injury.

Q: Do you have to ski with a brace after ACL reconstruction?

That’s up to the discretion of your surgeon and PT, and the decision can be based on the type of skiing activity you plan to get back to. Braces can help improve confidence and joint proprioception, but don’t always guarantee you won’t re-injure the knee.

Q: How likely are you to re-tear your ACL after reconstruction?

Activities such as skiing always carry an inherent risk of injury and unpredictability, so re-tearing your ACL after reconstruction is always a possibility. The best way to mitigate the risk is by completing your ACL rehab program, passing your return to sport testing with satisfactory scores, and slowly returning to higher-level activity with guided supervision.

Dr. Matt Hastings, PT, DPT is an orthopedic and sports physical therapist. He founded The Alpine Athlete to specialize in treating a variety of alpine sports injuries and orthopedic conditions. When he’s not helping others get back to the activities they love, you’ll find him pushing himself around his home in Denver, Colo. on skis or a bike. 


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