Return To Skiing Post ACL Reconstruction

Returning to skiing after an ACL injury can be daunting. After a full year of rehab, pain, and endless doctors appointments, the last thing you want to do is retear your ACL. Returning to the slopes following a major surgery can be physically and emotionally challenging. Here is what to expect following an ACL injury and a few tips on how to prevent the injury in the first place.

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The ACL is an important ligament in your knee. It prevents your tibia from shifting forward on your femur, and it prevents rotation of the tibia on the femur. This ligament is most commonly injured when a skier falls without the binding releasing causing excessive rotation of the knee in a fully flexed or fully extended position. An ACL injury can also happen when a skier jumps and lands with their weight behind them causing their skis to run out underneath them. When the ACL is damaged, your tibia is able to move excessively on the femur causing pain and instability in the knee. A physical therapist can help to diagnose an ACL tear and start your rehab process. Oftentimes, a complete tear of the ACL requires surgery to stabilize the knee, but may not be necessary depending on the extent of the tear and the level of skiing you wish to return to.

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Following surgery, the best outcomes result from compliance with your physician and the physical therapy plan of care. Immediately after surgery, Your knee will be painful, difficult to bend and straighten, and feel weak. A physical therapist can guide you in exercises to do immediately after surgery to speed your recovery. Return to recreational sports varies based on a patient's individual rehab progress, however, this can usually happen between 4-6 months. Due to the stresses placed on the knee while skiing, it is usually around 9-12 months before returning to skiing can happen. But how do you know when you’re ready to return to sport? How do you know if your knee is strong enough to withhold the stress of skiing?

Your physical therapist can help you with this. They will run you through a series of tests and measures that assess your strength and endurance, movement patterns, and balance. If there is any deficit in these areas, the therapist will prescribe exercises that help to mediate potential risk factors for retearing the ACL. The therapist will also go over assessments that judge your readiness to return to sport. Some activities that the therapist might have you do include squats, lunges, resisted running, plyometric exercises, and balance exercises. When you are doing this, the therapist is looking to ensure you have the correct form even when fatigued.

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This section will talk about how to avoid the ACL injury before it happens

Skiing with good form: Good ski form is hard to master. It may be worth your while to have a ski lesson or two in order to ensure proper technique. Generally speaking, you want your feet to be hip distance apart, knees and hips should be maintained in a deep squat, and your knees should not collapse inwards. Your torso should be pointing down the slope as this will give you more control from the hips when turning. The majority of your weight should be on the downhill ski, and you should be digging the edges of your skis into the slope.

General Fitness: The stronger your legs are, the less likely you will fatigue, which means, the less likely you are to make mistakes and injure yourself. Here are some exercises you can work on to build your strength:

• Squats (pulses, holds, jumps)

• Lunges and lateral lunges

• Running or cycling program

• Single leg balance exercises

• Jumping activities

Stretching is another important activity to prevent injuries. The major muscle groups you should stretch are listed below:

• Hamstring stretch

• Quad stretch

• Piriformis stretch

• Lower back muscles

• Hip flexors

It is always best to consult a professional prior to starting these exercises in order to assess your form and ensure safety when completing a new exercise program.

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We may have done everything in our power to avoid an injury, however no one is safe from a serious injury. In the unfortunate event that you have torn your ACL, here is a list of additional factors that can contribute to your rehab and return to the slopes. This article is not designed to replace the advice from medical professionals due to the variability between people and injuries.

Patience

You just had your ACL repaired and are ready to hit the slopes, but you have to remember what your knee just went through. You don’t want to stress the knee too much too soon. Start on easy slopes to warm up your body. Listen to your body, are you having pain? Is there any instability in the knee? Is there any difficulty with the easy slopes? Does your form feel correct? If the answer to any of these questions is no, then you should stay on the easy slopes. Don’t expect to ski first to last chair, since your endurance may not be up to par. If you feel tired, you should take a break since you are more at risk for retear when your muscles are fatigued.

Time Frame

The biggest factor in returning to skiing is time. The more time between return to sport and the surgery, the less likely you are to retear the ACL graft. With ACL tears, you have to be patient with the return to skiing. If you start skiing too soon without the appropriate strength, you greatly increase your risk for retearing the ACL. Adolescents under the age of 17 have a higher rate of retearing the graft site and extra caution should be taken when resuming skiing. Most people who return to skiing do so after 9 months to a year post ACL reconstruction.

Bracing

Bracing can be an effective method of preventing ACL graft tears. By using your brace, it allows more stability of the knee by preventing hyperextension and rotation of the knee. The brace can also help protect the knee in case of a fall. One downside of wearing the brace is that your body may learn to rely on the brace too much and cause atrophy of the muscles surrounding your knee. The brace should be used as a stepping stone to return to skiing, and is often only used for a year after return to skiing begins.

Higher Level Strength Training

Once you’ve been discharged from physical therapy, it is up to you to maintain and continue to build the strength in your knee. The best way to protect your knee and the ACL graft is to strengthen the muscles around your hip and knee. Plyometric exercises, or jumping exercises, can help to strengthen the muscles of the hip and knee in a way that is safe and necessary for skiing. Adding rotational plyometrics can help to prevent rotational injuries while skiing.

Endurance

Skiing is both a power sport and an endurance sport. Make sure that your endurance is up to par prior to jumping back on the slopes. We tend to make mistakes when we are tired, and mistakes can lead to retears of the ACL. It can take some time to make your way down the slopes, and you have to make sure your quads are ready for that type of stress. Take your time, and take multiple breaks before, after, and during each run to ensure that your muscles have enough time to recover.

Equipment

Having the right equipment can help to prevent injury by eliminating extraneous factors. You should have the appropriate type of skis for your height, weight, and level of skiing. If your skis are too long, you may have difficulty turning, or stopping. Make sure that the DIN settings are also set appropriately. DIN is what allows the binding to release the boots in case of a fall. A skier is less likely to injure the ACL if the skis are released from the boot in the event of a fall as the risk for excessive rotation is greatly eliminated. Alway test your equipment before use in order to make sure everything is working correctly.

Warm Up

Properly warming up your legs will help to prevent ACL retears. Prior to hitting the slopes, it is a good idea to warm up your muscles. Here is a list of things you can do to warm up:

• Brisk walk or jog

• Squats (pulses, holds, jumps)

• Hamstring and quad stretches

• Lunges and side lunges

Remember to alway do one or two runs on easier slopes prior to hitting the harder runs.

Confidence

Returning to skiing can be nerve-racking. Maybe you tore your ACL on the slopes and you are hesitant to try again. You were cleared for skiing by your physician and physical therapist for a reason! You can do it! The more nervous you are while skiing, the more likely you are to make costly mistakes. Just remember all those squats and squat jumps you did were for a reason. Your muscles are strong enough to make it down the slopes. Start slow and have fun!

Imagery and Relaxation Techniques

Imagery is easy, all you have to do is imagine yourself carving down the slopes. This will help you to gain confidence before returning to the slopes. Research shows that those who practice imagery during rehab tend to have better strength and less anxiety post operation. Relaxation techniques can help you calm your mind and body prior to returning to the sport. Anxiety can cloud judgement and become a barrier to a safe return to sport.

Overall Fitness

Keeping yourself in shape will help you to gain confidence and hit the slopes with ease. Starting and maintaining a running program will both help to build lower extremity strength and cardiovascular strength off of the ski hills. Again, the stronger you are off the slopes, the less likely you will be to injure your knee when you’re back on the slopes.

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Each person is different and so is their ACL rehab. Time frames between surgery and return to sport vary based on age, gender, prior level of function, level of activity an individual is returning to ( recreational skiing vs. competitive skiing), graft type (autograft vs. allograft), previous injuries, comorbidities, co-injuries, current strength, success with rehab, and presence of any adverse movement patterns. Since everyone is different, it is best to take your return to skiing one step at a time as you feel comfortable. With diligent work and focus, it is possible to return to the sport you love. If you are hesitant about skiing, still having pain, or want to work to prevent injury to your knees contact your local physical therapist for advice in these areas.