When is surgery necessary after a skiing injury?

Mr. Paul Trika is one of a handful of foremost surgeons on skiing related knee injuries and their treatment. In his 20 years as an orthopaedic consultant he has treated multiple thousands of knee injuries - ACL tears, meniscal tears, medial collateral ligament damage, and many more. This article was written with Mark Wilkinson, Senior Physiotherapist at Post-Op Home Physio

This time of year, one of the most common causes of knee injury is skiing accidents.

Most of us have a friend or relative who might have taken a corner too sharply or twisted their skis. When that happens either the cartilage in your knee, called the meniscus, can tear, or alternatively, one or more of the ligaments in your knee can rupture. Either one of these injuries can necessitate surgery, but neither necessarily require it.

To answer whether an injury will require surgery, we use an MRI to look inside your knee and at the tissues within it.

Meniscal Tears

When the meniscus is torn I recommend non-surgical treatment whenever possible. That typically means whenever the tear is in the outer part of the meniscal cartilage. In those circumstances, the tear can heal on its own without surgery. Instead we prescribe physiotherapy and exercises to support your own body's ability to heal.

On the other hand, when the tear is wider or occurs deeper within the knee and towards the inner portion of the meniscus, that’s when surgery to repair the meniscus becomes necessary.

Tears on the outer part of the meniscus need surgery less often, tears on the inner part of the mensicus tend to require surgery.

Ligament Ruptures and Damage

The real danger is when your ski does not unbind from your boot and the additional weight of the ski being pulled in an awkward direction, twists your knee with more force than it can bear.

Twisting your knee like that can easily result in a rupture or tear of your anterior cruciate ligament (ACL). When that happens you may find you’re unable to bear weight on your leg and in severe cases you may even hear a popping sound as the ligament tears.

Damage to the anterior cruciate ligament is the most likely of the ligaments to precipitate surgery. Whereas, the medial collateral ligament (MCL) can heal on its own, the ACL frequently cannot. And depending on severity, nearly 70% of ACL tears do require surgery to fix them.

Around 70% of ACL tears require surgery

Damage to both the meniscus and ligaments

In 50% of cases where a ligament in your knee has been damaged in a skiing accident, the meniscus will have also suffered to a lesser or greater degree. In these situations an operation can be carried out to repair both tissues. When both the meniscus and ligaments tear, a non-surgical treatment pathway is considerably longer and less succesful.

Lifestyle Considerations

‘Some of my patients who present with skiing related knee injuries will be extremely athletic people and in some cases professional athletes - or have jobs that require physical activity. In one patient’s case, a professional ski instructor, who had torn his ACL and damaged his meniscus.

In these sorts of cases, I am very aware that there are time pressures for my patient to get back to what they love doing, so a non-surgical approach is usually inappropriate - and an operation to repair the damage is carried out.

Particularly for people who are keen to continue skiing, this can be really important in the long term too - in order to ensure that their injury does not create a weakness in their knee that increases the likelihood of future injuries.

What can I expect from surgery?

Over 90% of the patients I operate on with ACL tears returned to sport at the level they were before - and the majority of the remainder could have done but opted not to after their injury.

Nationally the figure is a little lower, but the key takeaway is that surgery to repair the meniscus or the ligaments in a patient’s knee, in the vast majority of cases, returns full functionality and quality of life.

Immediately after surgery you will be on crutches in order to support your mobility. Your surgeon will advise on whether you are allowed to place all your weight through your operated leg or if this needs to be restricted for a number of weeks following surgery.

Physiotherpay

Rehabilitation and physiotherapy are crucial for regaining range of movement, strength and returning to your pre-injury level of function. Your surgeon will advise of any movement or weight bearing restriction and your physio will then guide you through a series of specific exercises, gait retraining and education around your rehabilitation process.

With any knee surgery it is imperative to find the balance between activity and rest, this is something that your physiotherapist will advise on and adjust as required.

Don’t rush into surgery

When you sustain a knee injury skiing, the first instinct most people have is to want to fix whatever has torn as soon as possible. But what I say to people, and what I have seen lead to the best long term outcome for my patients, is not to rush to an operation as soon as you can. Speaking to a medical professional is of the utmost importance to establish the extent of your injury, but rushing to surgery is not necessary and can even be harmful.
That’s why my colleagues and I tend to prefer that patients wait a few days, maybe even a week, until the injury and the knee have settled down, before an operation is carried out.

The same applies after surgery. Follow the instructions of your surgeon or physiotherapist and carry out the exercises as they suggest. If you’re confident and the repair feels strong, speak to your physio or doctor about increasing the speed of your rehabilitation and they’ll help devise a new routine that optimises the recovery.

Bottom Line

The need for surgery comes down to two key considerations - which tissues have been damaged and to what extent. There are two culprits, the meniscus, and the four ligaments that support movement in your knee. There are many factors that surgeons take into consideration when deciding on the most appropriate treatment plan, this could include what structures have been damaged and how severely, whether it is one structure or multiple, does the patient need to return to a high level of activity or sport, and of course take into consideration the thoughts and feelings of their patient.

The key then is to select a surgeon with a track record of treating injuries like yours, who can get the diagnosis right and who is achieving the best possible outcomes for their patients from surgery.