Just Tore My ACL... AGAIN! Time For A Knee Brace?

So, I tore my ACL last July landing a 3 with my knees locked and had a hamstring graft reconstruction done in September. I was back on the water in April (7 months post surgery) and feeling pretty good. My knee was feeling pretty good, occasionally I'd feel a little pain on a hard landing, but for the most part no pain at all. I was pretty much back to where I left off by May, backrolls, scarecrows, tantrums, 3's, without any problems… until May 23. It was about 8.5 months after surgery, I had just landed a Raley but I have a tendency to star gaze it pretty bad. Someone reminded me to put more weight on my front foot (left & the knee I just had surgery on) while cutting in. I had heard that before & was working on it last year, so I tried doing just a straight heelside jump with more weight on my front foot to get the feel of it, but I lost my balance and landed pretty heavily on my front leg out in the flats. I landed with my knees bent, but kind of "punched" the water and instantly felt pain shoot through my knee… I thought right away "oh $h!t, I did it again" It swelled up pretty bad so I went to have it checked out and sure enough, I completely tore the new graft, and this time I also tore my meniscus, chipped a piece of bone from the outside of my knee, and bruised my tibia & femur pretty bad. And the worst part of it all, I just moved to a Lake in January and summer is just getting started!

Has anyone else re-tore their ACL? Was I going to hard too soon?

My doctor was very anti-brace so I never wore one after my first surgery. He said I could get one but it would be a waste of money because my knee would be stronger than before so there would be no need for a brace. He also says that when people do get them it's really more of a mental reminder than anything because a brace won't stop your ACL from tearing. Even now that I re-tore my ACL he still says I don't need one, but I feel like there's a reason so many people wear them. And I REALLY don't want to do this ever again… I'm going to get a second opinion, but I can't get in to see the doctor I want until July.

I know a lot of people on here wear braces and swear by them, Should I get a brace this time around? If I get a brace now could I wear it and still do some light riding until I get surgery?

I really don't want to give up my whole summer already so I'd like to wait until the end of summer for surgery, but I also don't want to do more damage to my knee in the meantime…

What should I do different the second time around, maybe a longer transition period back into it? Rehab longer to rebuild the muscles in my knee & get them back to full strength first?

I am 5 months out of my second surgery. My first graft never survived and failed for bad surgery practices back in 2002. I rode every summer without an ACL and would have occasional swelling but nothing major. I took a hard fall last summer and tore my Meniscus also. Finally I got a MRI and learned they were both torn with severe damage to my cartilage. I have always worn a knee brace for anything atheletic and really believe in them. Don Joy has a new dynamic brace that is spring loaded to help with the landings...

I would go to a new Dr. Not wearing a brace on a injured/surgerized knee seems stupid. How could it hurt? May have prevented this from happending. I tore my ACL and Meniscus in 2002.Got surgery and 7 month later i was snowbaording, but with a brace. Wore a brace for the next 6 yrs whenever doing impact sports. 2 yrs ago i stopped wearing it and on a simple wake to wake jump i landed sorta funny and hurt it. Didnt tear but somethign moved around and now I have slight pain. I wear the brace again. Why not. Most dr's swear by braces from what ive seen. If a big CTI brace is too much for you you can get pretty descent ones at Sports Auth. they arent great but will keep you stable. hope this helps. Good luck with surgery~

Three time ACL champion here....I rode all summer on the last one with a CTi brace. I don't know an ortho surgeon that would say an ACL graft is stronger than the original. If you seriously rehab post op, your leg muscles (hamstring is key) should be stronger (which obviously helps with prevention). Within the 1st year, I'd say the brace might be as important mentally as it is physically. However, a good brace has extension stops and it's pretty hard to tear your ACL if you can't land straight legged. If knee braces don't help prevent injuries at all, I wonder why nearly every lineman in college football has one on each knee.

Riding with a torn ACL, I wouldn't advise it without a brace and even then, you have to use good judgement not to go out and make it worse.

Get it repaired now... sucks giving up your entire season but you'll never progress riding on a torn ACL, so go ahead and take care of it. Rehab like a mother and get a CTI, DonJoy, or Breg (I love my CTI).... wear it for at least 1-2 years post op. My $0.02

I was told the new ACL takes 18 months to full encapsulate and therefore get to full strength. Why not wear one at least during that time? I had mine fixed in September and honestly am still taking it easy. I am 35 with kids though...

Quen, you pretty much hit the nail on the head. I want to go into orthopedics for my specialty and have done two rotations in it so far with 3 more to follow before I graduate in 10 months. To not wear a brace while WAKEBOARDING for a minimum of 18 months after surgery is basically asking for another tear. Yes the graft is stronger than the old ACL but it has not loosened up nor has it completely healed after 8 months. There is still swelling at this point. Your surgeon is absolutely correct about not wearing a brace while walking around, but I don't think he intended for you to wakeboard without a brace that soon. If there is still pain in the knee after you ride than the healing process is not complete, end of story. At around 18 months out or even a little sooner you should start riding without the brace so you can rebuild the strength of that knee to get it up to par with your healthy knee. The first surgery is always the best/strongest surgery too so with this new knee you need to be even more careful. I have a torn medial and lateral meniscus in my right knee that would have actually been worse off if I had surgery because they would have to remove to much of the menisci and would almost leave me bone on bone, so all i did was get a brace. I wore the brace for about 6 months to let the swelling subside and take off any stressors and now I don't use it and my knee feels stronger than it has in a long time.

I had an ACL reconstruction in November, and my doctor told me I wouldn't need a brace as well. I showed him a video of me riding, and he instantly wrote me a perscription for a fully custom CTi knee brace. Most docs don't really understand how hard we are on our knees. I don't plan to wear the brace forever, but at least until i'm 18 months post op or I feel fantastic. Before I had the brace, I was super scared to even go wake to wake but once I rode with it I felt really good agian. My first set last week I was spinning no problem!
I hope this was of some help..

I would have to agree with all of the above. It sounds like you tore your acl and meniscus the 2nd time around through rotation, not through hyperextension. The acl prevents forward movement of the tibia, and also prevents rotation of the 2 bones on each other. The typical way of injuring is hyperextension or twisting with a planted foot. The rotation with a bent knee is also what probably caused the meniscus tear.
Most of the braces post surgery for athletes are de-rotation braces with extension stops. Wakeboarding landings are so high force, and at times unpredictable with catching edges or rotational forces that I personally feel a brace is absolutely necessary. Rehab must consist of alot of plyometric exercises to train the muscles in high force, quick responses, and the correct firing pattern of the muscles to protect the knee. Most non-athletes do not get this specific training from their PT because it is not necessary for day to day life.
I actually tore my acl and both meniscus recently, and have also opted to wait until the fall to have surgery so I can somewhat enjoy my summer and save money to be off work. I am doing some light riding with a hinged knee brace and knee sleeve, with the permission of my ortho surgeon. However this bracing will not protect from rotational forces, and really only acts as a support.
Keep in mind that without an acl the knee is much less stable, and therefore you are much more suseptible to further injury to the meniscus, pcl, and collateral ligaments. Do as much pre-surgery rehab as you can, both for strength and balance. Only do exercises where your foot is planted on the floor, and concentrate on hamstrings and contraction of both the quads and hamstrings at the same time. Ask your MD if you can get a few PT sessions now, so they can give you an appropriate home exercise program to keep your leg strong and give you the most stability for your knee before it is repaired.
Also keep in mind that in a couple weeks you will no longer have much pain in your knee, but that does not mean it is healed. The acl has just died off and the swelling is down, so the pain stops. You're meniscus will remind you that it is torn if you twist it wrong though, and your knee will feel less stable. So try not to up the activity level because it stops hurting.
Good luck with it. I will be going through the same process at about the same time probably. Private message me if you want to compare experiences

Irene, saw that you were a PT in your profile. Pretty ironic that you tore your ACL and now get to be on the opposite of the therapy side wanting to KILL your therapist lol. The only PT i've had to do is for my index finger (lacerated extensor digitorum tendon at the second MCP). My ortho gave me the option of doing PT or just doing home exercises, but being that I am most likely going into ortho (fingers crossed) I figured I needed maximum use of my index finger of my dominant hand if I want to be a good surgeon...and for wakeboarding of course (which was actually the best therapy it I think). I wish there were some videos of people tearing their ACL's wakeboarding because the method of injury from the type of falls we take confuses me. With say a football player you get the classic terrible triad where they plant their leg and it gets hit inward doing in the medial meniscus, MCL and ACL but with wakeboarders you most commonly hear (well at least on the boards here) that they just tore their ACL. Physiologically you would have to have a hyperflexion injury, not hyperextension, to place all of the force on the ligament and tear it. This would make sense if you landed very front foot heavy and basically had the entire weight of your body act as a fulcrum of energy right down onto the knee "punching the water" as Chad said before.

If you went the "hyperextension" route as Irene mentioned where you are planting an outstretched leg and then buckling inward do to the force and speed of the fall plus your weight, you basically do the terrible triad to yourself, but like I said, you rarely hear of anyone saying they did the MCL, MM, and ACL wakeboarding. This type of injury would probably happen in beginner riders more often that do not know how to land properly and very advanced riders that are trying tricks that are contorting their bodies in such ways that anything can happen.

Irene, since you deal with this everyday, I am actually curious about you referring to the tear as a hyperextension tear and not hyperflexion. We learned that essentially you plant your foot with your leg extended then get hit and the knee buckles inward into an accentuated valgus position tearing the MCL and Medial meniscus basically putting all of the force onto the ACL which hyperflexes and then goes too. So wouldn't hyperextending the knee make the PCL go, not the ACL? Isn't hyperextension theoretically the least amount of strain placed on the ACL? The orthopod that I extern for rarely gets any ACL repairs which is weird with all of the call we take and knees we do. All of our knee stuff are chronic problems doing a lot of total knee replacements and an occasional scope if the patient is too young for a total knee ie <50 lol. It is amazing that I made it through my wakeboarding career without doing my ACL though *knock on wood* being that I'm not at the trying crazy new trick stage anymore. My MRI is pretty frightening looking of my right knee. The meniscus is torn everywhere medial and lateral and there is already arthritis and cartilage breakdown along with some really nice crepitus when you flex and extend it. The guy I went to said it looked like a 70 year old runners knee.

Has anyone had a situation where they were 1.5 years out and still did not have full extension? My knee feels stiff all the time, I am like 1 or 2 degrees from full extension which is what I am asuming is keeping my muscles from fully forming. Quad is weak ect.... My legs are so skinny! I feel ok when I ride but look at my legs and think I am gonna screw something up because the muscle is not there.

Hey Kyle,

I'm glad you asked about the mechanism of injury. I am actually an Athletic Trainer also, and we got very extensive education on mechanism, kinesiology, and structure-function of the joints, especially in relation to sports. I actually learned more about these things in undergrad for ATC than in grad school for PT, because ATC is more intensive in ortho injuries, and PT has such a broad scope of practice. I'm not sure if you get a lot of kinesiology in Med school, but if you don't I would strongly recommend taking extensive courses to understand all the forces involved in normal movement and injury. I'm sure you will get more as you speciallize. Its great that you are interested in the "hows and whys" of injuries, as often focus is just put on the "carpentry" of putting things back together.

I did look some things up just to verify that I was giving correct info, and my references are "Principles of Athletic Training" by Arnhiem and Prentice, "Athletic Injury Assessment" by Booher and Thibodeau, and "Orthopedic Physical Assessment" by Magee.

I appologize ahead of time for any spelling or gramatical errors.... I did not spell check because it wanted me to download spellcheck for explorer, and I would have lost all my writing.

Here goes:
The ACL attaches from the anterior tibia to the posterior/lateral femoral condyle. It prevents the femur from moving posteriorly with the foot planted, prevents the tibia from moving anteriorly, stops excessive tibial external rotation (ER), prevents hyperextension, and helps stabilize the knee in full extension. In full extension the ACL is mostly taut, and loosens in knee flexion (although parts are taut then also). The ACL is typically injured when the leg is rotated or hyperextended with the foot planted.

So if you think about a leg with the foot planted on the ground or in a binding...if the knee is hyperextended the foot cannot move, therefore effectively the tibia stays where it is at and the femur glides posteriorly (which is from a kinesiology standpoint is the same as the tibia moving forward), which stretches the ACL, causing it to tear. The PCL is usually so strong that it does not tear, and actually prevents further hyperextension. In addition, when a foot is planted and a hyperextension force is applied, the natural reaction of the body is often to offweight the leg and rotate the leg inward to unlock the extension, but if the foot/lower leg cannot move it just causes a twisting at the knee which further damages the ACL, and usually damages meniscus too.

The ACL can also be easily damged with the knee somewhat flexed (less than 30 degrees) because this is a less stable position for the knee to be in. It is more susseptable to rotation forces when it is flexed. Again, if the foot is planted in a binding and we land, absorb weight by flexing, then catch an edge or rotate our hips, and therefore rotate our leg, then that twisting force has no where to go but our knee, which is the weakest point. Usually we turn the leg (femur) inward, causing a technical external rotation of the tibia (because of internal rotation of the femur without the lower leg being able to move with it), and this tears the ACL, and most likely the meniscus with it. If the foot isn't planted then the lower leg just moves with the upper leg, and the knee is not injured. I would bet you would find very few ACL injuries in wakeskaters because they are not fixed to the board.

When the knee is in flexion past like 30 degrees it is actually quite flexible, and therefore less prone to injury in that position because it will just absorb the force. In extension, and small amounts of flexion, the knee is more rigid, and therefore the ligaments take all the stress and fail. The planted foot thing is the key to the more isolated ACL/meniscus injuries because the forces have no outlet, like the lower leg moving with it. This is why we see them in wakeboarding.... there are a ton of twisting, shock-absorbing forces, funky landings, then you add in a boat going 23 mph attached to a rope that is just begging to pull you out of alignment, and you have a recipe for knee disaster

With twisting and hyperextension on a planted foot, much less force is needed to tear the ACL. In fact, in younger, less muscular people, an ACL tear can occur from something so simple as stepping down from a curb and hyperextending/twisting the knee. You would also probably see more isolated ACL tears in a sport like soccer where they constantly plant their foot then twist at the same time to kick or quickly change directions. Females are also more prone to ACL injury because the increased "Q" angle, the angle at the knee from hip to knee to foot, due to wider hips. The devistating triads you see in football and contact sports are usually from high force blunt trauma to the leg.

Now to the PCL: It is considered to be the major stabilizer of the knee and is thought to be up to 2 times stronger than the ACL. It prevents hyperextension on the knee, prevents the femur from sliding forward with the foot planted, prevents the tibia from moving posteriorly, prevents tibia internal rotation (IR), and helps guide the knee in flexion. The PCL is at most risk when the knee is flexed to 90 degrees, and is injured with forceful posterior force to the tibia with the knee flexed, such as falling onto a bent knee, and also injured with rotation. However since the PCL is so strong it is injured much less often, and much larger forces are required to tear it.

The MCL: This is a very strong ligament, and is usually only injured by a strong blow to the lateral part of the knee inward, causing a valgus force. We just don't have sufficient forces of those kind wakeboarding most of the time. So we don't ususally get MCL tears or the classic "unhappy triad".

So there is my explanation. It would have been much easier to show you on a model knee or even a person's knee, but hope this helps. If there is anything I left out, just ask.

Wkbrdrchad, sorry we sort of hijacked your post

Tore my right one twice, after my first surgery my doctor said I did not "need" a brace. I tore it again and had another surgery while in the army. The army doctor told me I should never ride without my brace on after the first tear. ever since I have been wearing a brace 4 years later with no problems other than the occasion tweak.

Thanks everyone for the advise so far, I'll definitely be going with a brace this time. I only wish I knew this last time around, but what can you do. I wonder if like Cody said maybe the doctor didn't fully understand the level of wakeboarding I was doing.

I think I'm still going to put off surgery until September, but will definitely be taking it easy this summer. I'm hoping to find an air chair and just mess around on that since it's a little easier on the knees.

Irene, Thanks for all the insight, it's good to know the mechanics behind the knee to understand how these injuries happen and hopefully prevent them from happening again! I definitely know what you mean about being careful not to over do things once the pain goes away after the injury. I had the same thing last time too, right now my knee feels almost 100%, no pain at all and I feel like I could ride again. It's hard to keep it dialed back when there's no pain, but I know I've got to play it safe.

Now I have to start researching which brace to get, it seems on here most people prefer the CTI? Does anyone have any info on the brace Sam was referring to? I thought it was interesting some of the DonJoy braces come with a guarantee that you won't tear your ACL while wearing the brace or they'll pay up to $1000 toward surgery. Do any other braces have that guarantee?

If you put it off for awhile make sure you keep your leg as strong as possible. Especially before surgery. I made the mistake of letting mine go. Took me forever to get my muscles to fire. THAT SUCKS.

$1000 towards surgery ain't much. Esp if you have a high deductible plan. I had low deductible ins last year (thank goodness) and my out of pocket was about $1500. If I had the same procedure this year, I would be $6000 out of pocket.

I totally agree with Gene's comment BTW. Pre-hab makes for a much better rehab.

hey irene, you seem to have a lot of knowledge about this sort of thing! I'm currently about 6 months post-op from my 2nd acl reco, and I've been talking to my physio about altering my stance to reduce the forces on my knees - do you have any thoughts/ideas on that sort of thing? he doesn't have a heap to do with board sports, but we decided to try reducing the angle my bindings are ducked out, and narrowing my stance. what do you think?
i was riding with bindings at 12 degrees, and on the widest stance on a 134 board. any other ideas about what could help?

Reducing the angle will take a ton of pressure off your knees and so will narrowing your stance
to the right hole. You should be able to touch your knees together in your stance for optimal knee safety basically so that if you get the plant and buckle style injury your other knee is there to hopefully stop it or take some of the force of the buckle. Riding too narrow would have same problems as riding too wide. The sheer act of ducking (externally rotating) your knees is putting force on your acl and medial stabilizers. By riding less ducked you are distributing that force to all of the stabilizers in your knee giving your PCL, LCL and lat meniscus some of the force of riding and landing.

Gene, I know what you mean about keeping that leg strong. My left (injured) leg was so much smaller than the right after surgery, I never did fully get it back. I've got to start working it out again...

Dan, Thankfully I have a very low max out of pocket, so the $1000 would cover it. But ultimately I guess I want a brace that's going to prevent the surgery altogether, guarantee or no guarantee.

Thanks for the advise Kyle, I always liked a wider stance for more stability when landing. I'll have to look and make sure it's not too wide

Thanks Kyle, it sounds like we were on the right track, but it's nice to have things confirmed by people who understand wakeboarding a little better I'm thinking I'll try 8 degrees, and move the bindings in a hole or two.

Chad, I actually tore my acl for the 2nd time while I was wearing my cti - BUT, I still wouldn't dream of riding without it! there was almost 6 years between my injuries, and I wore the brace the whole time. There are definitely countless other occasions where I'm certain it has saved me.
I think the main reason it didn't save me this time was because my leg shape had changed. I'd been thinking for a few months that it wasn't fitting quite right. Even though I did tear my acl again, my 2nd injury was much less traumatic, and has been much easier to recover from, and it's my theory that while the brace allowed enough movement for my graft to tear, it still limited movement enough that other additional damage to my knee was avoided. My surgeon was amazed at how good my meniscus was looking - particularly as he had to trim it after my first injury, but apparently my joint is otherwise very healthy!

Hi Alice I would agree with Kyle on lessening your toe-out. He is right in that the toe out and wide position puts stress on the ACL, and therefore less force would be needed to injure it. It also puts your quadriceps tendon and patella in a non-optimal position, especially in a wide stance. Too narrow a stance and you lose leverage and control over the board too.
You all correct me if I'm wrong, but someone once told me to jump off a step and land with feet apart at a comfortable, natural distance... that would be your correct stance distance.
Good luck with your return to riding! Shred it!!!