Torn ACL - pre- and post-surgery training

Hi all,

I just found out that I have a grade 3 ACL tear. I can't get the surgery until February, and I'd really like to be climbing by the summer, which gives me four short months after surgery for rehab. A few questions for any climbers who've had experience with this in the past:

1. What can I do specifically to strengthen my knee BEFORE surgery? The swelling is down and I have nearly full motion (although with some pain). It seems as though it's important to get your knee as strong as possible before surgery, so I'm wondering the best way to do that.

2. What non-knee releated exercises did you do to train for climbing in the meantime? Until the summer, I'll only have access to a bouldering gym, which isn't ideal for this type of injury.

3. What can I do during my pre-surgery travels that won't aggravate my knee further? It seems like I can't do much more damage to an ACL that's already completely torn, but I wouldn't want to stress the other ligaments in my knee more, of course. Can I cross country ski? Hike? Follow climbs one-legged?

Thanks!

The stronger you are before the surgery, the quicker you will respond after the operation. I suggest lots of cycling including 1 leg work to maximize the resistance training aspect of cycling. DO NOT LET YOUR LEG ATROPHY.

My doctor told me I could do anything that did not cause excessive swelling, or risk other ligament damage while in a weak state. Even top roping indoors was on the table for me, though I suggest you get of the ground and up high enough to avoid any impact should you come off the wall, before you climb in earnest. Don't expect to climb as normal, but lower grades, careful footwork without knee torches and more are all possible.

Of most importance......don't over do it, always ice afterward and don't expose your knee to additional damage while in its vulnerable state.

I road my bike as soon as the swelling was down for 2 weeks....hard but sensible I then had the surgery and was back on the stationary bike about 30 hours after the operation and on the road bike in less than a week.

In both cases, pre and post operative, start in small doses and progress each day. Don't start out with big volumes even if all seems good. It is the post exercise condition that matters, so if 30 minutes did nothing bad, then try 45 minutes and then 60 minutes and so on.

Good luck,

ekh...hit the weight room and make the leg machine your best friend. Leg extensions, etc. just be sure that you're strengthening your quads, calves, etc equally. It's the rare athlete that overcomes an injury completely (mentally & physically), so after surgery hit the weight room at least every 6 months as you will always favor the injured leg whether you realize it or not. Follow your PTs instructions...make her/him your 2nd best friend. Good luck. I'm 33 years post ACL surgery and have many mountains and Grand Canyon runs without issues.

That's great advice. My doc said that, post-op, my ACL was stronger than it would be 6 months later. Has something to do with your body finally accepting and supplementing the site versus the extremely strong hardware. My doc had a patient that re-tore his ACL 6 months later when he was fly fishing.. You MUST avoid anything that would twist or overextend it. Bouldering is a big time no-no. TR is perfectly fine.

Are you going with cadaver or is the replacement taken from your leg? If you have the choice, cadaver all the way. The recovery for the ligament they remove from your leg (thigh?) takes longer to heal than the ACL itself.

Ray

I would suppose you could xc ski, hike, and climb. I would not do any rigorous activities without a brace though. Now that you don't have the ACL support you can easily tweak your knee and cause more inflammation or worse tear your meniscus (I hope you don't have a tear already).

I would stick with mellow but long walks on paved or well established trails and for sure bicycling for the pre surgery.

I had the bone tendon bone procedure to replace my ACL about 6 years ago. If I remember my PT and my Ortho both did not want me climbing for more like 6-7 months. The Doc told me that at month 4 my tendon was still transforming into a ligament and therefore still very fragile.

When I was done with PT (5 months or so) I hiked mountains with decent trails a ton. I also continued bicycling as well. My muscle came back fairly quick. Eventually I was able to run which gives me more enjoyment than biking but that was more like ten months or a year post before that felt good.

The main thing is to be careful, patient, and follow your doctor's schedule and stay dedicated with the PT. You are paying for it and more importantly you don't want a half-assed, loose knee as your final product.

GOOD LUCK TO YA!

A slightly different perspective. I ruptured my ACL jumping off a boulder problem (onto a pad) when I was 68 years old. I also had sprained the lateral collateral ligament and had a partial meniscus tear. My leg was extremely unstable afterwards and I had the surgery done within several weeks of the injury, so pre-conditioning was not an issue. In addition to reconstructing the ACL, some of the meniscus had to be trimmed.

Recovery time depends on many things; in my case advanced age was not in my favor. But there is also a question of what type of graft to get. Recovery times are longer (and post-op experience is more painful) if you get graft from one of your own tendons, eg the patella tendon, because in addition to the replaced ACL you have surgical wounds to the tendon site and in some cases there can be complications associated with those. A second option is to get a cadaver graft, which saves you some of the post-op trauma.

Studies have shown the self-graft to be a bit stronger. If you are a young athlete and/or participate in sports with a lot of violent forces on the knee (such as basketball), then the self-graft seems to be the way to go. If you are older and heal slower and your athletic motions are either slower or more controlled, then the cadaver graft might be a better option---it's the one I chose. (I call my knee by Zombknee...)

There are things to understand about the cadaver graft that might also be true of the self-graft (obviously I didn't bother to check information about a procedure I didn't have). There is a process of biological incorporation that takes place over about half a year. During this process, the cadaver graft actually weakens before it gets stronger, so it is especially important not to overdo rehab during the first six months. (Edit: this is true for all grafts. The "biological incorporation" mentioned has to do with adding collagen.)

Because of the differences in the way the graft heals, a person with a self-graft may, immediately post-op, get a passive exercise machine to move their leg constantly, but this is not likely with a cadaver graft.

People have mentioned gym exercises. From what I've read, one of the standard ones might be contraindicated---leg extensions. These can place very large loads on the ACL. Some orthopedic surgeons go so far as to say you should never do this exercise, others counsel caution, and others just include in the rehab prescription. My PT wanted me to do them and had never heard about the reservations some ortho's had. I decided to do them with very light weights and to not go anywhere near pushing that particular exercise.

Rehab should involve not only strengthening exercises but also balance and agility drills. The operation destroys nerves that control propriaception. My understanding is that at least some of these nerves do not regenerate, but that one can, through the drills, train others to take over the task. Presumably any good PT will incorporate such drills, but you should ask if you are only getting strength training.

Another aspect of PT is range of motion of the joint. The PT folks I had were focused on making sure you could fully straighten your leg. But a climber would like to be able to sit on their heel, and you should mention this to the PT and/or design your own exercises to try to get back this mobility as well.

Recovery times: everyone is different, and remember I was 68. I don't bike much but I did start moderate trail hiking with poles as soon as possible and slowly escalated to trail running with poles as I got stronger and more confident. (The use of the term running is a bit optimistic; perhaps trail shuffling would be a better description.) One of the things I found is that going uphill is much easier on the knees than level or downhill running, so for quite a while I chose hilly courses, "ran" up the hills, and walked everything else.

I was leading moderate trad climbs outdoors about seven months after the surgery, but I think it took a bit more than a year before I stopped being aware of the repaired knee. Four years later, I haven't totally recovered from the muscle atrophy. There are no strength differences that I can perceive between the two legs, but the calf muscle on my repaired leg is a bit smaller and doesn't seem to be in any hurry to catch up. One of the things this might suggest is that calf exercises are important too, don't just concentrate on quads and hamstrings.

I've also found that my knee tends to stiffen up if I don't continue to do the range-of-motion exercise for full flexion, so I have now made that a daily occurrence. I do have some pain in the knee from time to time, but am fairly sure, from the location and nature of the pain, that it is a consequence of the meniscus dissection.

Patella mobilization is key post surgery too! Do it all the frikin' time, any dull moment!

Ask your doctor about the chances of rejection using cadaver ligament too. Six years ago I didn't like odds but maybe technology has improved. I do know a couple of people that took the cadaver route and had no problem.

I had to look up "patella mobilization." No one mentioned it to me during rehab and so of course I never did it. Perhaps it would have made my recovery quicker. As far as I can tell, four years later, there is no difference in patella mobility in my repaired and untouched knees.

rgold wrote:I had to look up "patella mobilization." No one mentioned it to me during rehab and so of course I never did it. Perhaps it would have made my recovery quicker. As far as I can tell, four years later, there is no difference in patella mobility in my repaired and untouched knees.

Just out of curiosity what kind of graft did you get? Mine was a patellar tendon graft and maybe this is why it was preached to me so much. I could see it possibly being unnecessary for a hamstring graft.

Yes obviously with a patella tendon graft one would want to work on the patella! As I wrote originally, mine was an allograft, i.e. a cadaver tendon (I think actually an achilles tendon).

Thanks everyone for your detailed responses! I really appreciate it.
Regarding graft choice, I'm inclined to go for an autograft rather than cadaver because as a 22 year old athlete, I'm looking for the best/strongest long term solution. Does anyone have any feedback on the choice of patellar vs hamstring tendon?

I don't know about which tendon to choose, but there is a lot of info on the web if you search. Note that some docs specialize in a single type of operation, so choosing the tendon might involve choosing the surgeon too.

It's already been said, but the summer is pretty close to that six-month danger zone for full tendon strength, and the desire to get out and climb will probably be pretty strong, so be very careful or you'll end up back on the operating table again. (Note that there are no pain signals to warn you about partial incorporation of the tendon; you might feel great.) Personally, I gave it a full seven months before I started climbing. I might add that I started back outdoors, not indoors. This did have risks (I was mostly leading), but I think the terrain---steep but less than vertical slabby stuff---was far more suited to rehab than typical gym terrain. In particular, you might not want to be doing any kind of deep strenuous drop-knees for a while.)

One thing I only realized in retrospect that I think is important is the degree of involvement of the surgeon in rehab. There is a spectrum from almost totally uninvolved to very attentive in terms of what exercises are prescribed and how the program is modified as you progress. My surgeon---who did an excellent job as far as I can tell---was more of a "have a nice life, my work is done here" type of guy, and being a lot fitter than the average 68 year-old with goals for recovery well beyond perambulation without a walker, I ended up having to do my own research and make decisions I really wasn't qualified to make. So I'd want to find out, during the consultation, the degree to which the surgeon keeps track of and advises the PT's doing the rehab, and make decisions that take this important part of the process into account.

I can at least tell you why I chose my Patellar tendon graft. Most of my BC skiing partners worked in the medical profession. Two of which where orthopedic reps that had to attend every surgery (or they gave me that impression). They basically had to know every surgical procedure for the supplies they sold to answer any questions the surgeon had during procedures. Also I toured with my Doctor that did my procedure probably 6 times, 3 pre surgery and 3 post.

All of them told me that the patellar graft was the best way to go for the tightest knee. The reps both swore by them over all other grafts.

My Dr. was less convincing because he wanted me to examine and weigh all options. He told me he did a cadaver graft for his knee but he was in his late forties when he did his. He said the hamstring was just fine and there was little or no proof to say it was better or worse than patellar but he said in his opinion was that patellar was a touch better.

Professional athletes such as NFL players do the hamstring option more frequently because it allows them to get back in the game a little faster. I think the idea with why the patellar is the tightest is they harvest a small amount of bone on both ends of the patellar tendon. That bone is therefore already bonded to tendon and can set up solid in its new location. Six years later I still can't kneel directly on the spot where the bone was harvested from. Not a major problem IMO.

I lived in Durango CO when I had my procedure, when I was 30, at the end of February. By september I was ready to take week long trip hiking mountains and climbing routes too. It was a fantastic trip and my leg wasn't terribly sore. I still was not pushing my limits for about a year post surgery though. I have had many giant adventures (at least to me) post surgery and the worst I get is a little throbbing/aching at camp at the end of the day.

I was lucky to have a plethora of great sports medicine doctors and PT to choose from living in Durango. I ultimately chose my Dr. because he climbed, skied, hiked, biked, etc. That made me feel he really understood what adventures I wanted to do post surgery. I also took his recommendation for PT and was extremely pleased. I hope you find a doctor you like and trust!

I tried to climb the Petit Grepon the beginning of september after surgery. I was fully confident in my knee for the trip. Unfortunately we were snowed off the route a few pitches up.

It is a little tough being grounded for a while but you will be able to have fun times soon enough!

Thanks! All good information. I'm certainly leaning more towards the patellar graft based on research, with only a few concerns:

You mentioned that you still can't kneel directly on the spot where the graft was harvested - Does that ever affect your offwidth climbing? (Or, if you're not an offwidth climber, would you expect it to be painful? How large is the area that tends to be painful to kneel on?)

I've also been getting into doing alpine climbs car-to-car to avoid hauling large amounts of gear. Is the anterior knee pain enough to prevent you from wanting to do 16-24 hour days of hiking and climbing, or is it fairly mild? Do you notice it during activity or after?

The area that brings sensitivity when I kneel on it is maybe the size of a dime tops. It was a somewhat larger area for probably a couple of years post. That said, OW is limited for a while. I could get up some wide stuff but it was only repeats of routes I had done so I knew what I could get away with. I LOVE OW but I didn't really get back to it for around 2 years post. I think the squirmy and thrutchy nature of OW will allow you to avoid super sensitive areas and you can develop technique to get around it.

The damn brace! That is the killer for all routes. Mine pictured used to be all black but the scratches are a good indicator that it gets in the way some. I can't remember how long I used it for climbing but I think I climbed with it say 6 month to month 20 post. I skied with it for about 3 yrs post. Knee scumming is about impossible with a brace. If your in the alpine and have a windbreaker pants on over your brace it is easy to shred the pants too.

Long days probably will be harder on the knee at first but I was belting out 12-15 hour days by september. My knee really ached after those days though. Nothing hurt too bad while I was moving around, just the end of the day or perhaps some long belays on a multi pitch. I barely notice it anymore and don't even think of it as any different than my other knee. When I chain longs days that involve more hiking than climbing my knee still holds up quite well. I feel like throwing in a long climb into a long day can only help your knee from wearing down, especially in the beginning.

I got into some situations I should not have early on post surgery. Luckily it worked out for me though. Be careful!! I will PM you if you want some 1-3 week post surgery advice, let me know. You should have a roommate at the least to help you out.