Physical rehab v ACLr- options & outcomes for older people

[Forwood]

I'm a 58 yr old male with a complete rupture skiing 3 months ago.  The strong message being given is that surgery isn't a realistic option.  

The surgeons seem to be saying the older you are, the stiffer the knee so the less need for surgery to improve stability ... and also that age means surgery is less likely to be successful in terms of improving outcomes!

Although heartened by studies suggesting little difference in outcomes between physical rehab and ACLr, and that some people seem to be good 'copers' without acls, I wonder about the age issue:
- is it really too late to have ACLr?
- do skiers really need a reconstruction?
- will my knee ever feel 'normal' again?
- what's the outlook for arthritis, further damage etc?
- will I always need to keep the knee in shape with strength exercises?

My knee is relatively stable and has been ever since the accident. But it is signficantly weaker and has been very stiff - less so now.  I can walk almost normally, jump, take stairs 2 at a time, also run a bit without much of a problem (am taking Chondroitin and Glucosamine as I've read this may help recovery).  I've booked my first skiing holiday for 2 months time - a fairly gentle 3 day skills course so will have an idea then about how it affects the skiing.  At the moment it feels risky because although much better, my knee tires easily and 3 days a week physio is still pushing the boundaries of pain / weakness.

The key question for me is the scope for improvement without ACLr and whether continuous strengthening exercises will be needed to prevent deterioration.  Would love to hear from older people who have gone down either route on how it's been for them - or just generally, is it even worth asking the question, and outcomes all come down to individual differences?

[Kaputt_Knee]

As an older ACLr myself, I think you need to shop around until you see someone who disregards your age and looks at the long term quality of life aspect.

Whilst you are currently not having any issues with stability and have good muscle control and definition, you are not urgently needing treatment. However, the long term prognosis is that there will be deterioration due to the missing control element within your knee. The ACL has a function that can only be partly compensated for with muscle power from the exterior of the joint. Should you lose that for any reason, then you are looking at a downward spiral of deterioration that is really a vicious circle.

Here in Germany, I live in the Alps and am also a passionate skier, age is never taken into consideration. The highest priority is the functionality of the joint and prophylactic measures to prevent the need for a total knee replacement. In my last rehab centre there were 80 year olds rehabbing with me who had also undergone ACL reconstruction. My surgeon says that he finds that older patients not only rehab more intensively, they do not assume that they are able to go beyond the protocol set. Younger patients often disregard caution at the stage where everything appears to be back to normal, but in reality the graft is very vulnerable. Hence the higher number of failures amongst younger patients.

Try and find a sport specialist who sees beyond the date of birth, and get as many opinions as you can. From the time you posted I am assuming that you live in the USA, and the fact that you were skiing in June implies you are probably on the west side somewhere. Why not look at visiting some of the specialists in the mountain areas who deal with these injuries more or less on a daily basis? They would also be in a position to advise you as to whether a functional brace would be advisable and which one(s) are particularly worth your while looking at.

By the way, my last reconstruction took place shortly before my 58th birthday!     I was back skiing within 5.5 months and am representing myself for my ski instructor's license in November. My coach says I have no worries about renewing it and was the person who persuaded me to re-present! As a national examiner for the Austrian system I assume he knows what he is talking about.

Good luck and good skiing!

 

[Audice]

As I read your post I thought, "At last there's someone who's as old as I am who's being told by an OS that ACLr isn't a realistic option." Then I read that you're 58. <g>

I came off my horse when I was 67 & caused a whole lot of knee damage. My OS made no bones about saying, when I told him I would have no surgery until the riding season was over, that if I were to have reconstruction of the ACL I would be the only person in history of that age to have it done. Since I joined the forum I've heard differently from various people.

So I went no further & lived with that pronouncement. I'm one of the fortunate horse people who can ride a horse comfortably w/o an ACL but as I've said so often on this forum, when one has no repairs, one's life tends to revolve around the knee. Just too much time spent deciding whether the next step is going to be the one that'll have the knee crumbling.

I'm very fortunate in that to this day my work at the farm & with the horses has preserved the integrity of my leg muscles & about the only time I use my custom brace is when I'm walking my two big dogs - one of them having a penchant for smacking into the leg with the missing ACL & very unceremoniously I will go down.

I have a veterinarian friend who's been w/o an ACL for many years but she's skiis, she does wear a custom brace which seems to work well for her. But I agree with Kaputt_Knee who says that you miht do well to shop around for an OS who will make the repairs for you so that your life, like mine, won't center around your knee & what you're going to do on any particular day. Wishing you well...a 72 year old

[mollyc]

Hi there: I was told the same thing, and I ruptured my ACL at 41!  I then went out and researched it and found a series of studies that suggest that there are no differences in ACLr outcomes with those over 50 than those under 50, as long as rehab protocols were followed. (I just looked around my hard drive to see if I could find links to those studies and haven't found them.)

My surgeon also told me I could ski without reconstruction as long as I was not an aggressive skier (which I'm not). Ultimately, I decided that since I was healthy now, I wanted to do the surgery now rather than risk having further knee damage down the road and perhaps I wouldn't be in as good physical shape to do the surgery and rehab at that point.

I was probably a border-line case for reconstruction, given my activity level and the fact that my knee was pretty stable sans ACL.  Would everything been OK had I not done the reconstruction? I don't know.  You can't know.  You just have to evaluate the risks in both directions and make a call about which set of risks you're willing to take. Good luck with your decision making. Molly

[Forwood]

Thanks for all the advice. There is another factor which I didn't mention - that I had a knee twist when I was about 12 which ended up in plaster.  I don't recall the rehab being difficult but it is possible that I ruptured the acl then.  3 weeks after this latest accident, one of the surgeons noted that the MRI showed no sign of an acl or recent injury.  Certainly the level of trauma feels like something has fundamentally changed (plus I damaged the mcl quite badly this time) but if I did rupture it a long time ago then presumably I have muscles which should recover substantially over the next few months. I'd like to see how it goes this season.  If there's really no progress in feeling secure, I'll try and go for it around May June next year.

What I'd really like to know is how many 50+ don't have reconstructions, lead active lives and 10 years on don't have problems. However, I guess there won't be many on these boards in that category.  Unless of course Audice's experience is typical.

Incidentally Kaputt_Knee, I'm in the UK - just tend to roam the net late at night!

[Kaputt_Knee]

Regardless of when the rupture occurred, do you want to spend the rest of your active life thinking about your knee?

OK, say it occurred when you were 12, you remained very active and have good muscle tone, strength and definition. you are now entering a phase in your life where these things, sadly, start to deteriorate. It is a lot harder to build and maintain muscle strength and integrity as you get older. The injuries occur more frequently, take longer to heal, etc. This is when you can get the onset of osteoarthritis and rapid degeneration of the joint surfaces. You are losing muscle bulk, tone and strength while you rehab the MCL tear. Getting it back will be difficult, especially if you are ACL-deficient.

You will have a problem in the UK as this is seen in many Health Authorities as elective surgery these days and they are cutting back on that in terms of prioritisation.

I had my last recon as I said shortly before my 58th birthday and was back to full activity level within 8 months. I do not have to stop before any activity and think about my knee. I know what I want to do, can do and trust my knees completely.

Age is irrelevant when it comes to knee surgery, it is your quality of life that counts. That's a way healthier point of view and one supported in my neck of the woods by all the health agencies.

Sue 

[Audice]

I wish I had known 5 years ago that had I pushed for reconstruction, I might have found someone who would do the surgery. My lifestyle hasn't changed all that much but I surely have a less secure feeling - almost as though my balance were off. Is that age or my knee? I honestly don't know...Ellie

[Forwood]

Regardless of when the rupture occurred, do you want to spend the rest of your active life thinking about your knee?

Of course not Sue.  I am hugely impressed by your experience with surgery though if you could have avoided that, wouldn't it have been better?  And isn't the fact that you went through so many procedures indicative that surgery is not a straightforward option, and carries a risk of complications, even failure?

I'm wise enough to be able to take advice but also to recognise that people have different experience / outcomes and in some cases vested interest.  I just had a very curt response from a US surgeon one member kindly suggested I contact who said 'skiing without an acl is an accident waiting to happen'.  Mind, even with an acl, skiing is accident waiting to happen - and in about 6 weeks since starting 2 years ago I must have fallen well over a 100 times!  (I am getting better at it - honest!)

I think the course I have suggested makes sense.  I will give myself another 6-9 months to see what happens, including skiing again.  If I am still bothered after my january trip, I will progress the surgery option. I'm hopeful of getting this done on the nhs as I currently work for them and used to chair my local NHS trust. In any event, the holidays are booked now so I have little option.

I will keep checking in here in the meantime

[Kaputt_Knee]

My first accident resulted in all my ligaments being either snapped or badly sprained - I had no choice and it was done via open knee surgery. The joys of being a ski instructor! The operation took place within 24 hours of the person hitting me. I spent the summer in a wheelchair and was back skiing by the end of the next season.

The second knee went in a similar way, again there was nothing I could do about it. Except get it sorted as quickly as possible. Unfortunately this time I was working with the industrial injuries board in Germany. A bureaucratic nightmare but an exceptional safety net if your accident results in not being able to return to your job.

I never stopped to think should I or shouldn't I. The longer you mull over things the worse it gets to be honest. Sure I could have avoided surgery but I asked a simple question and got an answer from an extremely smart and experienced surgeon: Will I be OK without surgery - answer: Yes but I'll see you in 5 years at the most for a new knee. When he was finally allowed to operate on me (the IIB surgeon was crap but I had to go that way first) he had me back skiing within 6 months (5.5 to be exact!)

I've worked professionally in sports all my life to me. If the doctors are happy with it, so am I. And I got back on with my work and my playing in the great outdoors.

Your problem is that you didn't know that your knee was suspect all that time - now you do. Believe me it will change your perspective.

Good luck and please prove me wrong 

[Audice]

Sue said, "Your problem is that you didn't know that your knee was suspect all that time - now you do. Believe me it will change your perspective."

You're so right, Sue. The first time I saw my OS some two weeks after the injury he informed me that all the damage had been done recently. I couldn't convince him that I'd had off & on problems with the knee since I was a kid. But nobody til that time had put a label on the extent of damage. That's all it took to totally change my perspective. My right knee became the focal point of my existence & it's likely to be so for the rest of my life.

[Forwood]

Knees and hips - I broke a car headlamp with my right knee when I was about 9, had Osgood Schlatters there diagnosed when 14 and Osteoarthritis in the right hip about 15 years ago (skiing's great for that btw).  Now I've got a left knee problem  - nature's way of evening things up I guess!  Not going to let it become too consuming.  I still think on balance I did the acl just recently but it's possible earlier.  I'd never have thought it unstable for the past 45 years to the point I gave it a huge thwack falling on an off piste road.  Bloody ski just didn't come off!  

Anyway,  Sue - you're right on the button.  I can't yet respond to private posts yet so will do so here. I am doing Rob & Scott's 3 dayer!  I say gentle because there's only 2.5 hours of tuition.  If they really do push us my wife's in for a shock! with my sister and brother in law also going, there'll be enough of us to slow things down if necessary.  I'm the better of the four of us and reasonably confident I'll be ok by then.  Thanks for the advice re the brace. I've got a metal hinged one - a MUELLER HG80 - cheap and it does slip a lot. Not sure I can lay out 500 eu fot eh Townsend but will see if I can persuade someone to prescribe it!.  Yes you were right about the motor cycling doc. Urged to communicate with 'he's a great guy', I got a 3 line answer.  What a prat!

Good luck with your retrun to instructing. What's your SH monike btw?

[Kaputt_Knee]

For the sH moniker, do a wild card search using my first name Forwood! Not many of us there  Or PM me from there using this ID to assist you to find me.  Or sort by location - not many of us living in the Austrian Alps 

On the Inside-Outside site I'm in one or 2 or the pictures and most of the rest from the Sölden trip are mine. I let them use them copyright free (but they were supposed to acknowledge that somewhere - not found it yet!). Look for a short round type in red jacket, black trousers and of course ........... a helmet 

We'll see what happens with the instructors reassessment. I'm just happy to be back at a stage where a National Trainer reckons I'll pass with flying colours, considering an eminent ortho in the SW of the UK said I would never walk again without a limp and a stick! Think the proverbial 2 fingers to that idea. On the actual day, who knows, I'll give it my best shot and if I miss, at least I tried.

You need another few posts to reach PM status (a total of 20) - easily racked up playing in the Games Room . think Apres Ski section but for Grannies! Answer a few of the silly quizzes and you soon have the requisite number.

Sue 

[Wimp Out]

Hi there.  New in and fascinated to find this forum. I am just over 50, female, and disintegrated my ACL in 1982, about 28 years ago.  Have kept it safe with quads exercises and reducing sporting activity.  Over the years I have done some jogging/half marathon on even surfaces and lots of offshore sailing.  Now I have less sedentary work to do and have time for more sport and fun activities but find myself panicking about the knee all the time.

I have started tramping long and high and also done my first ever 5 days skiing with a hinged brace.  Walking downhill in the wet and over rocks is double the time to go uphill.  The skid and stop is painful when it happens.  Couldn't face a blue piste when I started thinking about the torque on the knee.  The green was fine but tame.

Sympathise too with those talking of loss of balance but this is related, in my case, I am sure to loss of confidence I think and possibly variofocal lenses - hard to say.  I was, pre-accident, great on balance - iceskating, roller skating, sailing - but know I know I favour the leg and it is affecting everything.  This can only get worse with age and without the fun and exercise, I know I will age all the faster!

Anyway, thanks for all your contributions because I AM going to get a replacement now.  I want to ski and tramp and should I live to 100  ( ) I have still got half my life left.  I am also going to make sure I set aside enough for physio.

Here, here to those who say that age is irrelevant.

Any advice for me in the South West of England? Thanks.
Wimp Out.

[tez27]

Hi there Wimp Out and welcome, congratulations on your decision to have a aclr, I am 49 and ruptured mine 2 years ago and had the surgery 4 weeks ago today, when my rupture was diagnosed after a scope in Jan of this year, my surgeon told me that at my age and the fact that I was not into any extreme sports I could do without the surgery and just to stregnthen the muscles and I would be fine, for a few months I tried I was going to physio regularly but the knee felt more and more unstable, so went back was reffered to another surgeon and had the op. as I said I am 4 weeks post op anf the stability in my knee has improved greatly I still have a lot of pain and swelling partly due to doing to much, but I have great hopes for thr future.
From all that I have heard and especially with the NHS this surgery in raerly done on people of our age even in the hospital when I had my pre op assesment the ward Doctor when I asked how lone would I be kept in hospital for informed me that "most patients having this surgery are 20 year old footballers and theyre kept in over night whereas you being older than the normal may be in for a few days" needless to say I was out of hospital the day after my op as no 20  year old footballer is going to beat me 
As you say you still have half your life to live so why live it with a knee that lets you down and that you cant trust to carry you through all you want to do.
Any date yet for your surgery? and please keep us informed about how your doing.
Take care Tez



2m       

[Wimp Out]

Hi Tez and thanks for the response.
Will keep you informed - likewise!

Have investigated the London end for interest.  All-in procedural costs at 7000.  Devon end seems to be 5000.

Will let you all know consultant response to a 54 yr old with 28 yr old distintegration of ACL in due course.

By the way, 28 years ago consultant said same thing.  You are not an olympian athlete so I did not repair it (with a bovine ligament) - just keep the quads going and you'll be fine....  Glad I waited for better developed options, though.

Wimp Out