Wednesday, October 11, 2017

Five years after rupturing an ACL, still a successful coper

Hearing from other people in the midst of knee rehab recently made me think back to my knee rehab process.  My knee injury resulted in a complete ACL rupture (not a skiing accident).  Using KOOS (max 100, Knee Injury and Osteoarthritis Outcome Score) was useful for tracking the healing process.  After five years I have a different appreciation for milestones during the first year.  During rehab it was not clear how long the process would take and whether or not I would have to change my approach to skiing.  I decided to take the treatment approach based on physical therapy and improving fitness only, as opposed to scheduling ACL reconstruction surgery.
  • Month 1: crutches (injury was during 2-week international trip) and rest - June 2012
  • Month 2: formal PT, mostly no impact exercises while giving MCL strain time to heal completely, MRI confirmation that ACL completely ruptured
  • Month 3: started weekly personal training, fully functional for daily living, KOOS 86-88 (Mild or Moderate for Running, Jumping, Twisting/pivoting because avoiding those actions), second and final appointment with orthopedic surgeon
  • Month 4: continue personal training, back to indoor rock climbing, avoiding jumping and running (never liked running for exercise)
  • Month 5: final PT session included agility exercises, KOOS around 90
  • Month 6: ready for easy skiing, KOOS at 94 (Moderate for Twisting/Pivoting) 
  • Month 7: skiing at speed on small hill (Massanutten) - Jan 2013
  • Month 8: started lessons with a very experienced instructor (three Silver Clinics at Massanutten with Walter, PSIA Level 3), decided not to bother getting a brace
  • Month 9: 3-hour private lesson at Bridger (Ric Blevins, PSIA Level 3, worked with Ric the season before), skiing at Bridger and Big Sky included a few bump runs steeper than the year before
  • Month 10: skiing harder ungroomed terrain at Alta than the previous year, KOOS about 96 - Apr 2013
I had a relatively easy time making an educated decision about which treatment made sense for my ACL injury. I had an MRI and was evaluated by a orthopedic specialist about a month after injury. The collateral damage was a minor MCL strain and a small hole in the part of the meniscus that could heal fully without medical intervention. By the first time I met with the surgeon I had researched the most common treatment options was ready to discuss the options. Even though I was over 50, my orthopedic surgeon was willing to do surgery if I was interested.  At three months my surgeon supported my decision to stay a coper.  I was very careful the first six months and gave my body almost a year before considering the healing process complete. I made use of Chinese medicine (acupuncture, herbal Yunnan BaiYao) from the start.

What I’ve learned since rupturing an ACL is that there are a lot of factors to consider when deciding on treatment. Initially I thought that the level of collateral damage (meniscus, bone fracture, other ligament damage) were the most important. After reading about ACL treatment options, recent research results, and learning more about copers who ski, including skiing with several older advanced skiers who are ACL-deficient, I think the following is only the start of a list of other significant factors.
  • Health care system of the patient’s country
  • Age of patient
  • Personality of patient related to fear of further injury
  • Personality of patient related to ongoing fitness exercises
  • Type of physical activities and sports the patient enjoyed at the time of injury
The medical approaches for how to treat ACL-deficient patients continue to evolve.  The knee is complicated.  Everyone's situation is different. Regardless of what can be learned online about copers and ACLr surgery patients, it's ultimately a very personal decision that should be made in consultation with experienced medical professionals.

Importance of hips when you want to dance on the slopes

After doing ski conditioning for a while and exploring ideas online and with my personal trainer, a few exercises stand out as part of almost any routine.  Most people know that lunges and squats are useful.  One objective is to work on the glutes, which turns out to be how to have stronger hips.  Bridge exercises are a good way to strengthen hamstrings, which are important for supporting knees.  For core strength, a plank with good form is a fundamental exercise.

For this set of seven ski conditioning exercises related to hip strength, resistance bands are used to increase the difficulty.

September 2017 Denver Post - includes 4 min video of seven exercises


If someone tells you that strong quads are the basis for good skiing, show them what an orthopedic surgeon at the well known Steadman Clinic in Vail, CO has to say.

“We’re finding more and more that we think strengthening of the hip muscles is as important as anything,” said Dr. Tom Hackett, an orthopedic surgeon at the Steadman Clinic in Vail who has worked with hundreds of U.S. Ski Team athletes. “I watch people in the gym getting ready for the ski season — all they’re working on is their quads. That’s obviously important, too, but we really have found that the control over your leg that prevents knee injuries is coming from the hip. So more and more, we’re really trying to encourage our patients to work on strengthening the hips.”

Sunday, October 1, 2017

Balance is key and easy to improve

My first blog post was about balance exercises.  Three years later, I'm still more likely to do something related to 1-leg balance every day than any other type of exercise.  A few minutes a day makes a difference after a month or two or three.  That's what I learned doing knee rehab for about four months.  Consistency matters.  Can do something to improve balance anywhere, anytime:   indoors, outdoors, waiting in line, watching TV, in the bathroom.

A very basic introduction to a few balance exercises (6 minute video)

A balance routine that doesn't take long, which can be easy or hard (5 minute video)

Easy balance exercises that give a clear view of good form (9 minute video)

Saturday, September 23, 2017

Strong adductor muscles are good for skiing and mountain biking

Recently I did a little downhill mountain biking for the very first time.  It was a 1-day workshop for women at Massanutten in northern VA, which added lift-served mountain biking a few years ago.  Turns out that in a bike park, you spend pretty much the entire time on the bike going downhill while standing on the pedals.  What little uphill there is does not require sitting on the seat, which is kept low so that it's out of the way.  Learned a lot from the two instructors that worked with the group of ten women, which included a few novices.

The muscle that didn't appreciate the extra work was the adductor muscle that goes to just above my  knee that is missing an ACL.  When I did the knee rehab, working on adductors and abductors went together with hamstring exercises.  Those muscles are also important for downhill skiing.  While my MCL was healing after the knee injury, it was obvious whether or not it was too soon for these exercises because there would be pain.  I would wait another week before trying again.  In my case, it took about three months for complete healing.

Adductor exercises are easy to do at home.  Take a look at the videos for an introduction.  When I was doing formal physical therapy, I learned how to do all of them at some point.

Using a soft ball to strengthen adductors

Two knee exercises using a resistance band

Eccentric exercise for adductors

Inner thigh exercises to strengthen adductor and groin muscles

Wednesday, August 24, 2016

Focus on eccentric exercise to build leg strength for skiing

Regardless of how you exercise, it helps to understand what "eccentric" means when it comes to muscle movement.  The opposite type is "concentric."  Doing squats or lunges is not as effective if you don't know which direction is an eccentric exercise.

Here is what I found in a Backcounty.com article:

"Think of concentric strength as “positive” strength. This is the strength you use to stand up from the bottom of a squat, or hike up a steep hill. Eccentric strength is “negative” strength. You use eccentric strength to lower yourself into the bottom of the squat, and hike down a steep hill. Eccentric strength absorbs force.

My observation at the fitness center is that some people tend to think that going faster is better when they are using fitness machines.  Meaning to the point that they ignore the speed warning provided by the machine.  They also tend to do relatively heavy weight that they cannot handle slowly.  For ski conditioning, a weight that can be handled slowly for 10-15 reps is more helpful in the long run.

Friday, July 29, 2016

Balance training with BOSU and TRX

Balance training is a critical component for skiers.  The TRX is good for working on core strength.  Pretty effective when the two are combined.  I have done most of the exercises in the video but adding the BOSU would certainly make them more difficult.


The exercises are variations on squats, planks, and lunges.

Friday, June 24, 2016

TRX for core strengthening, plank variations and more

While almost any exercise using the TRX is good for strengthening the core, there are many ways to focus on core muscles.

The plank is accepted as a basic exercise for building core strength.  There are many possible variations of a plank.  Not surprisingly, there are TRX plank variations as well.  The seventh variation on the following webpage is not one I'll ever try.  It's a handstand with one foot in the TRX!

7 TRX Plank Variations

TRX rotational ward
TRX plank
TRX side plank
TRX 1-arm plank
TRX forearm plank
TRX single leg plank
http://www.acefitness.org/blog/5693/7-trx-plank-variations-for-a-stronger-core

For those familiar with TRX exercises, this webpage is a nice summary of core exercises.  If you don't know an exercise, finding a video on YouTube is fairly easy when you know the name.

20 TRX Core Exercises

Overhead back extension
Hip drop
Torso rotation
Kneeling roll-out
Kneeling oblique roll-out
Standing roll-out
Overhead squat
Assisted sit-up
Resisted single-leg raise
V-Up - heels in cradles
Suspended plank (elbows or hands)
Crunch (elbows or hands)
Oblique crunch
Mountain climbers
Pike
Pendulum
Body saw (elbows or hands)
Side plank (on elbow, with or without arm assist)
Side plank with hip drops
Side plank with reach-through
http://www.cyberpt.com/documents/CORE%20EXERCISES.pdf