MILAN – When sports fans hear that an athlete has torn his ACL, the immediate assumption is a year out of competition. Maybe nine months if all goes well.
Lindsey Vonn is trying to win an Olympic medal in a few days.
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“No doctor could advocate for a normal person to go skiing, much less compete,” said Dr. Yair David Kissin, an orthopedic surgeon and knee specialist at Hackensack University Medical Center (NJ).
But Vonn is not a normal person — or even a normal competitive athlete, which explains in part why sports medicine practitioners interviewed by Yahoo Sports said it was within the realm of possibility that she could compete in the women’s downhill at Cortina on Sunday, just nine days after a devastating fall that required her to be airlifted to a hospital following a crash in Switzerland.
“From a purely physical or biomechanical standpoint, it’s possible if you’re an elite alpine skier like Lindsey to perform at that Olympic level,” said Dr. Catherine Logan, an orthopedic surgeon at the Joint Preservation Center in Denver, who also works with U.S. Ski and Snowboard. “Alpine skiing is very different from your traditional field, cutting, pivoting sports. The movement patterns are relatively predictable in comparison, so there’s less demand on the ACL when we’re trying to decelerate or change direction. There’s still an increased risk of secondary injury to the meniscus or her cartilage, but really her ability to generate force, tolerating those speeds in the ACL, isn’t just eliminated by keeping those edges in the ACL deficient. So, despite all that, she still has a great chance to perform well.”
Of the four major ligaments of the knee, the ACL has the greatest impact on stability. It also doesn’t heal very well on its own, which is why the normal course of action is reconstructive surgery and a long period of rehabilitation for an athlete to regain the ability to plant and twist and change directions.
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“Think about being in your car and knowing that when you turn, it’s going to stay on the road,” Kissin said. “If you take a front wheel off and do a turn, it’s kind of what the knee does where it’s not there for you. It’s not reliable.”
But Vonn’s situation is atypical for two reasons.
First, people who tear the ACL usually experience some type of loss of neuromuscular control in the surrounding muscles, according to Darin Padua, an athletic trainer and professor in the University of North Carolina’s Department of Exercise and Sport Sciences with a focus on ACL injury research. Vonn, because of her physical gifts and years of training as a world-class skier to develop her quadriceps and hip muscles, probably has enough built-in strength to keep her in some control and compensate for the loss of stabilization that the ACL provided.
The fact that Lindsey Vonn was able to ski the mountain after the accident that tore her ACL is a good sign, doctors say, that she will be able to compete in the Olympics. (REUTERS)
(REUTERS/REUTERS)
Second, Vonn, at age 41, may be looking at her last chance to compete in the Olympics. So while most people, or even most professional athletes, should consider long-term considerations for their careers and weigh the risk of further injury, Vonn is in a different situation. It really comes down to if she feels like she can do it.
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“This is going to be difficult, but she’s as tenacious as they come,” said Dr. Samuel Ward, professor of orthopedic surgery and co-director of the Wu Tsai Human Performance Alliance at UC-San Diego. “There’s also a little bit of mind over matter here. The combination of those things either gives him enough stability where he can do it or not, and I think he’s going to figure it out. The average human being would be like, ‘I hurt my knee and I’m scared of it.’ In her situation, she has the ability to overcome whether or not the knee itself has the intrinsic stability to do what it needs to do during the race. I don’t think anyone knows the answer to that until she competes.”
Ward said that while the headlines made Vonn’s crash last week sound catastrophic, he interpreted it as good news that she was able to ski to the bottom of the hill before getting into the helicopter. All things considered, the fact that she wasn’t immobile is a decent base to start from. And in Tuesday’s press conference, Vonn said she’s not suffering from any swelling.
This is key, as Ward characterized knee swelling as a “circuit breaker” that shuts down the quadriceps and would make it difficult to compete.
“When the knees are bent like when you’re skiing, the quadriceps are the shock absorbers of the knee,” he said. “They allow you to squat in that position and manage the terrain of the course. So without strong quads, that’s not a reasonable task. That’s why the focus is on managing the bump. The tendency after you get hurt is to try to protect it, and it’s going to have to go after it instead of protecting it.”
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Logan said the key from now until Vonn competes will be around-the-clock therapy and a testing protocol to make sure she has enough knee stability to confidently step out of the starting gate. That starts with on-land assessments of her ability to jump, land and twist before she gets to the mount and replicates the moves she would make in the race.
“It’s a progression from bench testing to dry to snow,” Logan said.
However, trying to compete in a race so soon after such a devastating injury is not the norm. Padova said it’s the shortest turnaround he knows of.
“There aren’t many cases where you can look and say these three or four people did something similar,” he said. “She’s definitely an amazing athlete in the sense that she’s an amazing athlete. If there’s anyone who can handle this injury and still compete at the highest level, she’s that type of individual. Unfortunately, she’s had these injuries in the past, so she knows what to expect and how to manage it internally. She’s probably a very rare group of people.”
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By attempting this, Vonn likely risks some additional damage to her knee, particularly to the meniscus or cartilage. But medicine here is both art and science, with doctors offering both best- and worst-case scenarios and ultimately working with her to make a decision.
“It’s not always one answer, it’s the only answer,” Logan said. “Several doctors are consulted and that’s normal. There is no one voice, but the athlete should ultimately be the driver of the decision.”
In the end, it all comes down to one thing: When it’s time to compete, does Vonn feel like her knee is stable enough to carry her to the foot of the mountain?
“Her body is so conditioned that she most likely has the compensatory mechanisms that very few people in existence have ever had and she might be able to do it,” Kissin said. “If she doesn’t feel like it’s a good idea, I hope she has the means to stop and not risk something that’s inevitable. In her case, if she thinks she can do it, her doctors might not completely agree with her — I wouldn’t want to be them, but at the same time I envy them — because she’s a different level of ACL patient and it has to be an individualized case-by-case example.”
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If Vonn were at the start of a long career, the calculus may be different. But after coming out of retirement for another run at Olympic glory, the risk-reward equation probably favors trying.
“I’m not a betting person,” Ward said, “but I wouldn’t bet against her.”