Dealing with a new knee injury

The first thing I recommend doing if you think you have injured your knee is to get a proper assessment. I can help you if you are looking for a sports medicine oriented chiropractor or physiotherapist in Vernon, BC.

Sometimes, though, getting in to see someone you trust can be a challenge. Your chiro doesn’t have an opening, your physio is off, or your athletic trainer is busy. It is helpful to have some strategies to manage your knee injury in the meantime.

IMPORTANT NOTE:

If you have severe swelling, heard a pop/snap followed immediately by pain, or you have any reason to suspect it is fractured, you need to get an x-ray as soon as possible. Visit your local emergency room or urgent clinic.

ACUTE knee pain just means that you had a recent injury that might be responsible for your pain. A slip and twist, or a fall and catching yourself. Even just a long day of skiing or hiking hard can lead to an incident of acute knee pain.

When a patient comes to me with acute knee pain, we have 3 goals:

1. Limit or reduce swelling

2. Maintain active range of motion

3. Preserve muscle mass and strength, especially in the quads (front of the thigh)

Managing Swelling

Swelling leads to pain and stiffness, which usually leads to inactivity, which always leads to loss of muscle mass and strength. So in essence, managing swelling is already starting to accomplish the other two goals.

Here is how we manage swelling with acute knee pain:

• Keep the joint in motion as often as possible within pain-free (or manageable pain) range of motion. Keeping the ankle and hip moving is also helpful in pumping out swelling.

• Elevation to take advantage of gravity to clear swelling

• Compression to increase clearing of fluid and limit swelling

VIDEOS: 

Maintaining Range of Motion

Motion is the lotion. You don’t use it, you lose it. Same same. We want to keep moving as much as possible, within reason, immediately following injury. That might mean you are literally moving your knee joint 5 degrees, or your knee doesn’t even move but you are pumping your ankle through range of motion. Do as much as you can within PAIN-FREE RANGE (or at least tolerable pain). 

Here are the exercises I recommend to my patients to maintain range of motion:

1. Quad Sets

2. Passive Range of Motion

Maintaining Strength and Muscle Mass

The key to maintaining muscle mass after an injury is: movement and nutrition. If left immobilized, the leg muscles can atrophy (i.e. shrink) by ~5% in a single week. Atrophy tends to slow over time (since there is less muscle to waste away), but it is not uncommon to have upwards of 15% muscle loss in a month of mobilization. That is a big deal.

Here are the first things we do to prevent as much muscle mass and strength loss as possible:

1. Nutrition:

   1. Immediately increase protein consumption. Your body NEEDS protein to heal your injuries, and even though your activity level may decrease, your protein needs often INCREASE

   2. Avoid highly inflammatory foods whenever possible (even though I know how tempting it is to finish that pint of ice cream to cope with the frustration)

2. Isometrics or low-load movements - keep the injured joint moving as often as possible with as much stress as you can handle.

   1. Isometrics: activates the muscle without moving the joint through range of motion, and is often tolerable even when in a lot of pain

   2. End range limited range of motion exercises like Quad sets

   3. Contralateral leg training: i.e. exercising with the OPPOSITE limb can actually maintain both muscle mass and strength (pretty cool, eh?)

Exercise for Acute Knee Pain:

Not sure where to start?

That is where a qualified Chiropractor or Physiotherapist in Vernon, BC can help. A good Chiro or Physio will put you through a thorough assessment and help identify the extent of your injury and your pain triggers. Then, they will help you put together a rehab plan to get you back in action.

Author: Dr Mark Murdoch, Chiropractor and Co-Founder at Base Camp Sport and Spine in Vernon, BC.

Mark Murdoch is a Doctor of Chiropractic with a Master’s Degree in Sports Medicine.

www.BaseCampClinic.com

Contact: drmurdoch@basecampclinic.com

Book an Appointment with Dr Murdoch: book here

Instagram: Base.Camp.Doc

Skiing and ACL injuries part 3

This is PART 3 of a three-part series about skiing and your ACL

Part 1: What is the ACL Sprain? Check it out here

Part 2: What to do if you think you injured your ACL? Check it out here

How can I prevent ACL injuries?

This is the golden question. Unfortunately, the answer is unclear.

Can you 100% guarantee you will not have an ACL injury if you do “these 3 exercises!”? No. Can you reduce your risk of an ACL tear? Probably.

The principles outlined below are no guarantee that you will stay injury-free, but they are what I recommend if you are worried about injuring your ACL.

1. Get Strong

Leg strength does not guarantee you won’t get injured, but it will help you power through tough terrain, maintain your form and technique throughout the day, and improve your chances of keeping your balance.

Pair it with core strength, and you have a better chance of handling anything the mountains have to throw at you.

Below is a basic strength program you can use to help strengthen your body for ski season.

2. Hit the technical stuff while you are fresh

Fatigue leads to decreased strength, worse technique, more mistakes, and worse balance. If you are trying to hit technical terrain and really pushing your limits, don’t wait until the end of the day when you are starting to get tired. When you ARE getting tired, stick to runs you are really confident in.

3. FOLLOW THESE TIPS

These tips put out by Vermont Ski Safety Equipment Inc and can be helpful for avoiding knee injuries. For the full article, check out: https://vermontskisafety.com/research/tips/

TIPS: 

Recognize Potentially Dangerous Positions

If you find yourself in this situation, it is important to take a second and correct your position before panicking and potentially putting yourself at risk:

• Your uphill arm is back.

• You find yourself ‘in the back seat’ (off-balance to the rear).

• Hips are below your knees.

• Your uphill ski is unweighted.

• Most of your weight is on the tail of the inside edge of the downhill ski.

• Upper body generally facing downhill ski.

If you do find yourself in this position, here is the solution:

• Stick your arms out in front of you.

• Bring your feet together.

• Keep your hands over skis.

TRAINING FOR SKI SEASON

Before ski season, I like to focus on 3 things:

• Single-Leg Strength/Control/Balance

• Core Strength

• Aerobic Base

Single-Leg Strength, Control, and Balance:

• Train 2-4 times per week

• Use a mix of moderate and heavy loads

• Limit your reps and weight to your weaker side to limit the development of asymmetry

• Make sure you still have a decent base of bilateral strength (traditional squats, deadlifts, etc.)

My favourite single-leg exercises for Skiing:

• Single-Leg Deadlift

• Hip Airplane

• Hamstring Sliders/Single Leg Glute Bridge

• Bulgarian Split Squats (aka Rear Foot Elevated Split Squats)

• Single-Leg Bounding

• Pistol Squats to a Box

• Adductor Plank

Core Strength

• Train 2-5 times per week

• Emphasize movements that keep the core stable, while moving the limb

My favourite core exercises for Skiing:

• Pallof Press (single leg if capable)

• Side Plank

Aerobic Training

• The goal is to increase your aerobic capacity so that it is not limiting you when you hit the slops

• Train 3+ days per week, 30-45 minutes of moderate-intensity

• Train 1-2 times per week of high intensity

• The activity itself doesn’t matter too much. Choose one or a couple that you enjoy and rotate between them (e.g. running, rowing, cycling, hiking, etc.)

I put together a sample 4-week program for prepping for ski season you can use and adapt to your own training

Get the 4-Week Training Program for Skiing

4-Week Ski Training PDF

TRAINING DURING SKI SEASON

During ski season we can still train and improve strength, but we don’t want to do anything that compromises our day on the hill. Your training regiment will be highly specific to your experience, injuries, skiing ability, and skiing frequency.

If you only ski occasionally (once or twice per month) then you can train as if you are leading up to ski season, but refrain from heavy training a couple of days before you plan to hit the slopes.

The goal DURING ski season is to maintain the strength you already have and stay sharp. If your training compromises your fitness on the mountain, then we have screwed up the program and forgotten what the goals are.

Generally, I recommend strength training 1-4 times per week, but limiting heavy lifting or really taxing training 1-2 days leading up to putting the skis on.

For cardio and aerobic fitness, this is a great time to increase your volume with low impact activities such as rowing or cycling.

My recommended schedule is:

3 days of strength training at moderate intensity. Focusing on general physical preparedness. Most of my sessions look like this:

• 1-2 Upper Body Pushing Exercises (e.g. push up and military press)

• 2-3 Upper Body Pulling Exercises (e.g. bent over row and pull-ups)

• 1 Knee Dominant Exercise (e.g. lunges or goblet squats)

• 1 Hip Dominant Exercise (e.g. Romanian Deadlift or Hip Thrust)

• 1-3 core exercises (e.g. Pallof Press and side plan)

Author: Dr Mark Murdoch, Chiropractor and Co-Founder at Base Camp Sport and Spine in Vernon, BC.

Mark Murdoch is a Doctor of Chiropractic with a Master’s Degree in Sports Medicine.

www.BaseCampClinic.com

Contact: drmurdoch@basecampclinic.com

Instagram: Base.Camp.Doc

Disclaimer: This blog is intended for general informational purposes only and is not intended for the delivery of medical advice. No doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog and website is not intended to be a substitute for medical advice.

Skiing and ACL Injuries - Part 2

This is PART 2 of a three part series about skiing and your ACL

In this article, we are going to cover:

What to do if you think you have an ACL injury

• How do I know I have an ACL injury?

• Do I need surgery to fix my ACL?

• Will I have knee pain forever after hurting my ACL?

• Can I still ski after I tear my ACL?

You missed Part 1? Learn about the fundamentals of ACL injuries here

In part 3, we will cover training and injury prevention.

How do I know if I have an ACL injury?

If you suspect you might have an ACL injury, I highly recommend getting assessed. Proper assessment and rehab is essential for preserving your ability to use your knee long term.

In the case of ski-related ACL injuries though, most skiers know when they had a major ACL injury. This is usually because they couldn’t make it off the mountain on their own and had to be towed out on a stretched or sat on the back of a sled.

If you are NOT sure though, here are a couple of things that I look for as a Chiropractor in Vernon, BC when I get a skier with knee pain who I suspect might have an ACL surgery:

First, I ask a series of questions looking for some common signs and symptoms of ACL sprains:

• Knee pain following trauma

• “Pop’ or ‘snap’ sensation at the time of the injury

• Pain and/or rapid swelling in the knee at the time of the injury and ever since the injury

• Catching or locking while walking

• A subjective feeling of instability or ‘giving way’ when weight bearing

Then I look and test for:

• Swelling or bruising around the knee joint

• Structural integrity of the ligaments in the knee (checking for instability)

• Ability to weight-bear and/or walk

Ultimately, if you suspect you have an ACL injury from skiing, I highly recommend you get an assessment. The clock may be ticking on your rehab protocol. Whether that is from us at Base Camp Sport and Spine, another chiropractor in Vernon, a physiotherapist in Vernon, a physiatrist or someone else doesn’t matter (but I do recommend a clinician with experience working with skiers or sports injuries). 

PRO TIP: if you can’t find someone in your area that often works with skiers, working with someone experienced with soccer players is also a great option because of the prevalence of soccer-related ACL injuries.

What should I do if I injure my ACL?

The first thing I recommend doing if you think you have injured your ACL is getting an assessment by someone who knows what they are doing. A good physiotherapist, sports medicine provider, or sports chiropractor will be able to help start you on the right path.

One of the first things we need to decide after you get assessed following an injury is whether or not you are interested in surgery.

Do I need surgery to fix my ACL?

Let me be clear: even a FULL ACL rupture does not automatically mean you need to have surgery. ACLs can heal, but they heal slowly and only heal in a small percentage of people. Conservative care (i.e. a proper rehabilitation program) can get a lot of people back to their activity WITHOUT surgery (even if their ACL doesn’t fully heal). The caveat is that sports that require high amounts of cutting and twisting (like soccer, tennis, skiing, etc) put you at higher risk for meniscus injury later on if you do not have an ACL.

Whether or not you decide to have surgery is a personal decision that you need to make in conjunction with your provider and your surgeon. There are costs and benefits to either decision, so you need to understand them before jumping into one decision or another.

If you decide that you want to go down the surgical route, one of the first steps is getting a consult with a good orthopaedic surgeon and getting an MRI (the best way to see the ACL). Hot Tip: if your doc tells you your ACL is ruptured because they saw it on an X-ray, get a new doctor. X-rays only show us the hard stuff (bones) and will not show your ligaments or tendons).

Will I have knee pain forever after tearing my ACL?

Not necessarily. With a proper progressive rehab plan and a focus on your overall health, you can be pain-free even after a full ACL tear.

Something to keep in mind is that following an ACL tear and ACL surgery, there IS a higher incidence of osteoarthritis (OA), but thankfully OA does not automatically mean you will have pain. It does mean that staying on top of your nutrition, sleep, and stress management are important to better manage your inflammation.

Can I ski after injuring my ACL?

Yup!

Not immediately, but most skiers who injure their ACL can get back to skiing after an ACL injury. Depending on the severity of the injury though, an ACL injury often means that you are out for the season.

Whether you decided to have surgery or not, the ACL rehab process is lengthy in order to avoid reinjury. Most of my patients who are rehabbing an ACL injury can expect at least 9 months before returning to full activity, and many as long as a full year.

Author: Dr Mark Murdoch, Chiropractor and Co-Founder at Base Camp Sport and Spine in Vernon, BC.

Mark Murdoch is a Doctor of Chiropractic with a Master’s Degree in Sports Medicine.

www.BaseCampClinic.com

Contact: drmurdoch@basecampclinic.com

Instagram: Base.Camp.Doc

Disclaimer: This blog is intended for general informational purposes only and is not intended for the delivery of medical advice. No doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog and website is not intended to be a substitute for medical advice.

Skiing and ACL Injuries - part 1

ACL Injuries are the most common injury that put alpine skiers in the hospital. They can be life-changing, they’re brutal to rehab and can truly be a depressing and career-ending injury.

In this article, we are going to cover:

• What is an ACL injury?

• How do ACL injuries happen?

  • How do I know if I have an ACL injury?

• Why are they so common in downhill skiing?

In Part 2, we will cover:

• What to do if you think you have an ACL injury

  • How do I know I have an ACL injury?

  • Do I need surgery to fix my ACL?

  • Will I have knee pain forever after hurting my ACL?

  • Can I still ski after I tear my ACL?

In part 3, we will cover:

• How to prevent alpine skiing ACL injuries

• Training in preparation for the ski season

• Training during the ski season

What is an ACL, anyways?

The ACL is shorthand for the Anterior Cruciate Ligament. Ligaments attach bones to each other and limit unwanted movement. The ACL is one of the most important ligaments that stabilize your knee, attaching your shin bone (tibia) to your thigh bone (femur). The primary job of the ACL is to prevent anterior translation of the tibia on the femur. (Huh?) In other words, it keeps your shin bone from moving forward underneath your thigh bone. (Fun fact: ligaments also help us with our ‘joint position sense’, also known as proprioception).

The ligaments are what are known as ‘passive stabilizers’ of your joints. They don’t actively contract or control movement like your muscles do. Instead, they pretty much work just by being there and waiting until they’re needed (at least when it comes to joint stability).

Most of the time, our ligaments are some of the most reliable structures in the body. They save us from ourselves all the time and keep us moving!

When they are injured though, they like to let us know about it.

What does it mean if the ACL is injured?

Ligament injuries are known as SPRAINS and come in levels, known as ‘GRADES’, each more severe than the one before.

GRADE 1 SPRAIN: some mild stress on the ligament causing irritation.

• This level of injury is almost never diagnosed in the ACL. This is because the ACL is so strong that most of the time it can handle the twists and stresses we through at it.

• The most common ligament to be sprained is the ATFL (anterior talofibular ligament) aka an Ankle Sprain

• Not usually associated with swelling or bruising

• Despite the lack of ligament damage, this injury can be extremely painful and still requires proper rehab

GRADE 2 SprAIN: some stretching and possible tearing of the ligament

• ACL injuries usually fall somewhere between Grade 2 and 3. This is because Grade 2 is very broad, and covers everything from mild tearing up to just shy of complete tearing

• Often extremely painful

• Associated with joint swelling, bruising and range of motion limitations

GRADE 3 SPRAIN: complete tearing/rupturing of the ligament.

• ACL ruptures are the most common reason a skier will end up in the hospital

• Grade 3 Sprains are often accompanied by severe swelling and bruising

• Surprisingly, a full ACL tear is not always associated with extreme pain, at least not immediately. This is because the nerves that sense pain are also ruptured, so the knee can no longer send the pain messages back to the brain. The pain usually takes anywhere from minutes to hours to develop, and in some cases, never truly comes.

Complications: it is important to note that a severe ACL injury is often accompanied by damage to other structures in the knee. The most common grouping is known as the ‘terrible triad’ and includes the ACL, MCL (medial collateral ligament), and the medial meniscus.

How do ACL injuries happen?

Injuries happen when the forces applied exceed the body’s ability to resist them. In the case of a ligament, those injuries typically have specific patterns. We typically see ACL injuries with either a straight leg landing (for example landing a jump with stiff knees while in the backseat on your skis) or with a paired twisting and forward force (like trying to get up on your skis, but catching the tail end and torquing your knee).

Here is an example of pro skier Landon Gardner (Team USA) tearing his ACL landing a freestyle jump in 2009: https://www.youtube.com/watch?v=XguonAtk3C8&ab_channel=LandonGardner (while this is not a graphic video, it might not be the most pleasant to watch).

For skiing specifically, there are two primary injury mechanisms:

1. The Phantom Foot mechanism

2. The Boot-induced mechanism

1) The Phanton Foot mechanism happens when a skier is either trying to get up from a seated position, or they are off-balanced and fall backwards. Often the skier will place all of their weight on a single leg with weight on the inside edge of their downhill leg. The other ski basically either floats in the air or (worse) catches the ground, but the downhill leg keeps going. The ACL is unable to manage the force and snaps under the tension.

2) The Boot-induced mechanism happens when a skier is again off balance when landing with their legs straight. The landing forces the shinbone up and forward relative to the thigh bone and again overloads the ACL.

Ski-Knee.com has some great graphics on these mechanisms:

http://www.ski-knee.com/causes 

Why are ACL injuries so common with skiing?

There are many reasons why injuries happen.

In the case of skiing, the forces, the gear, and the terrain are have a large impact on the nature of the injury.

THE GEAR:

Most gear advancements have decreased skiing injuries. Improvements in ski, boot, and helmet technology have all decreased injury rates since skiing inception. However, better gear also means fast skiers and faster skiers means higher forces… which we already know is a risk for more serious injury.

Skis themselves also change the way our legs function. They limit our rotational movement through the hips (because your can’t exactly twist your skis in any direction without consequences) and essentially eliminate motion in the ankle. When we cannot perform rotation in the hips, and can’t use our ankles in rull range of motion, the only joint left to take responsibility is the knee. The knee is what is known as a hinge joint. It is great at bending forward and back. It is not so great at rotation or side bending (the two primary forces involved in ACL tears).

THE FORCES:

Any time we add in a tool, we increase the amount of force we dealing with. Try throwing a hockey puck as hard as you can slap shot it. Not going to happen. Any time we add in a form of transportation that lets us move faster than we can run (skis, bikes, skates, cars) we start exposing ourselves to forces and speeds that are much more dangerous than we can typically produce with our own power.

This is one of the reasons why skiing injuries can be so devastating. When you are moving at higher speeds, even a small mistake can lead to some pretty frustrating consequences.

THE TERRAIN:

Skiers encounter all sorts of terrain and snow conditions. The nature of the sport takes advantage of gravity while sliding along on a slippery surface. Gravity tends not to care if you are ready for it or not, so often ACL injuries involve unprepared landing or falls.

Snow conditions can also be a fracture, when one ski hits a patch of wet and heavy snow, causing it to trail behind, and putting some crazy forces through the knee.

At the end of the day, the last thing I want you to be thinking about is your ACL. Instead, I want you to be recounting the best stories from the day with your buddy over a beer or a good whiskey. The last thing I want is for you to be scrambling to make an appointment with me on Monday morning. If you DO think you have an ACL injury… well that is what Part 2 is for. (Stay tuned).

Author: Dr Mark Murdoch, Chiropractor and Co-Founder at Base Camp Sport and Spine in Vernon, BC.

Mark Murdoch is a Doctor of Chiropractic with a Master’s Degree in Sports Medicine.

www.BaseCampClinic.com

Contact: drmurdoch@basecampclinic.com

Instagram: Base.Camp.Doc

Disclaimer: This blog is intended for general informational purposes only and is not intended for the delivery of medical advice. No doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog and website is not intended to be a substitute for medical advice.