ACL TEAR TREATMENT AND RECONSTRUCTION

The treatment options following an ACL tear are individualized for each patient depending on age, activity level, and the presence or absence of injury to other structures within the knee. In general, surgery is recommended for young patients who are active and for those in whom the ACL tear is associated with injury to other structures in the knee. Nonoperative (nonsurgical) treatment may be recommended in older or more sedentary patients.

The main reason to have surgery is to restore stability to the knee so it no longer gives out or slides too far forward, which is often painful. The other reason — perhaps the most important reason — is to protect the articular cartilage in the knee from being damaged. It is also important to protect the medial and lateral menisci in the knee.

The meniscus is a fibrous type of cartilage that sits between the ends of the tibia and femur, and is attached to the lining of the joint. There are two separate meniscal cartilages in the knee, each somewhat C-shaped: one on the inner half of the knee (the medial meniscus), and one on the outer half (the lateral meniscus). [Figure 1] The medial and lateral menisci primarily serve as shock absorbers between the ends of the bones to protect the surface or articular cartilage. With recurrent episodes of giving way, the meniscus can be damaged or torn, causing it to lose its shock-absorbing capability. Without a functioning meniscus, the articular cartilage is exposed to increased pressure and “wears” away, leading to arthritis. Additionally, the articular cartilage may be directly injured or damaged with each episode of giving way.

Nonsurgical Treatment

Nonsurgical treatment consists of physical therapy, activity modification and use of a brace. The goal of physical therapy is to strengthen the muscles around the knee to compensate for the absence of the ACL. Specifically, strengthening the muscles in the back of the thigh (the hamstrings) is helpful. Activity modification can be very successful. Sports that do not involve cutting, such as jogging, cycling or swimming, can often be performed successfully.

In addition to therapy and activity modification, use of a hinged sports brace can be attempted. While bracing may be effective in some patients, in others, instability episodes may continue despite their use.

Surgical Treatment and ACL Reconstruction

Once the ACL tears, it has usually sustained enough damage that attempts to surgically repair it are not successful. Consequently, better results are obtained if the ACL is surgically replaced or reconstructed with another tendon from around the knee. [Figure 2]There are a number of surgical options for reconstructing the ACL. The type of procedure done may vary from patient to patient depending on a specific surgeon’s preference as well as factors unique to an individual patient.

The surgical procedure is most commonly performed using arthroscopic techniques. Using one or two small incisions on the knee, the graft is taken from the patellar tendon or hamstring tendons, and a tunnel is drilled into both the tibia and femur. The graft is threaded across the knee, leaving a piece of bone in each of the tunnels and the patellar tendon in the position of the original ACL, thus reconstructing the ligament. [Figure 2] The graft is then secured in this position, most commonly by “wedging” a screw between the side of the bone and the tunnel. [Figure 3] Alternatively, the graft can be secured by other techniques — staples, sutures, buttons, etc. These fixation devices are usually left in place permanently.

In addition to the ACL reconstruction, additional procedures may be done to other structures within the knee if injury is present. A torn meniscus can be either repaired or trimmed (meniscectomy), and other ligaments can be repaired or reconstructed as well.

Figure 3

Allografts most frequently used today are of the bone-patellar tendon-bone type or from the Achilles tendon at the heel, and come from cadavers that have been screened for infectious diseases, e.g., hepatitis and AIDS. The risk of AIDS from one of these grafts is not known, but it is generally believed to be one out of 1 million. All allografts are carefully screened and tested before they are used in surgery.

How long does rehabilitation take after surgery?

The exact course of therapy may vary somewhat depending on the specific type or reconstruction done, particularly if additional meniscus or ligament surgery was done. Physical therapy is done in a supervised setting in conjunction with a trained therapist. Early in the course of recovery, visits may be two to three times per week, but later, once every week or two is often sufficient. Home exercises are done on days not scheduled for a formal therapy session.

The rehabilitation following ACL reconstruction includes essentially three phases. The first phase of rehabilitation consists of controlling the pain and swelling in the knee, regaining knee motion, and getting early return of muscle strength. The operated leg is typically placed into a brace immediately after surgery.

Initially, weight bearing is allowed with crutches and is progressed to full-weight bearing independent of crutches as swelling, motion and muscle strength allow. Most patients are on crutches for one week, although some may be on crutches longer and some shorter. This phase typically takes six to eight weeks.

The second phase emphasizes recovery of full knee motion and muscle strength. Cycling, running on the treadmill and light jogging are started in this phase. In some patients, a sport brace is obtained to replace the postoperative knee brace. This phase typically lasts from two to four months after surgery.

The final phase consists of graduated return to full activity. Normal muscle strength, coordination and the absence of swelling are required for successful return to activity. A brace may be recommended early in the return to cutting and pivoting sports. This phase occurs at four to eight months after surgery, depending on the particular patient and the nature of his or her activities.

A patient’s rehabilitation is monitored closely by both the therapist and surgeon for evidence of potential problems. Most significantly, patients are cautioned not to attempt a too premature return to full activity, which may cause the knee to be inflamed or reinjured. In every patient, the graft must both heal into place and be incorporated into the knee. Too much stress too soon may increase the risk of graft failure.

What are the potential complications after surgery?

Most patients experience no complications and return to full activity between six and eight months after surgery. However, the most common complications include pain in the front of the knee and loss of knee motion.

Pain in the front of the knee occurs in 10 to 20 percent of patients. Fortunately, it can usually be controlled by modification in the physical therapy protocol. Loss of motion occurs in less than 5 percent of patients and is most common in patients with limited motion before surgery. In some individuals, intermittent pain and swelling occur with activity despite a successful ligament reconstruction. This is often related to the amount of meniscal or cartilage injury that was present and identified at the time of surgery.

In the absence of identifiable causes, a small percentage of patients will end up with a persistent detectable increased amount of motion in their knee (a “loose” graft). This may be related to stretching of the graft over time or due to an additional injury.

Will I be able to return to my previous sporting activities?

Approximately 85 percent of patients return to their previous level of activity without restrictions. In the other 15 percent, full return may be limited by a number of causes: pain, swelling, persistent laxity, change in lifestyle related to age, intentional choice or other unidentifiable causes.

7 EXERCISES YOU CAN DO NOW TO SAVE YOUR KNEES LATER

1. You have healthy knees – and you’d like to keep it that way. That’s not a job you can tackle sitting down, though getting into a 90-degree position could help. First, though, you’ll want to heed a simple but central lesson roughly adapted from age-old song lyrics: “The hip bone’s connected to the knee bone.” Physical activities that strengthen your hips, quads, calves, and ankles are also good for your knees, while weakness in any of those areas can increase knee strain and risk of injury. So think “holistic” leg health.

2. Indelicate squat discussion first. You’re going to be doing that kind of loading on the knee joint just to get on and off the toilet. It’s important to do exercises that prepare the knee for regular day-to-day activities. Squatting really affects all the muscles around the knee joint, including strengthening the muscles around the knee joint. Haven’t done squats in a while – or ever? Start by doing at least 8-12 reps with just your weight, going down to just above 90 degrees, or right at 90 degrees if you don’t have any discomfort, injuries or issues that prevent that. Alternative: try leg press if you have back problems or other issues preventing you from doing squats.

3. Like squats, lunges can also be an excellent exercise to improve strength in your quads and butt o help support your knees. With both exercises, he notes, make sure you’re in good position – feet firmly planted. So that you’re not coming too far forward and putting more stress on the joint. Talk to your doctor before doing lunges if you’re concerned about a preexisting issue, like osteoarthritis or a knee injury, to keep from exacerbating it.

4. Whether you’re familiar with step-ups or not, you get the general idea. You’re lifting your body weight using one hip, one leg to get that weight, like you’re going up the stairs. Keeping the hip joint muscles strong and well-conditioned along with muscles around the ankle strong and well-conditioned will help minimize the risk of injury at the knee joint. To get started with step-ups, place your foot on a high step, weight bench or plyo boxes, so that your leg is bent at about a 90-degree angle. Then bring your other foot up onto the surface. Repeat for 12-15 reps, and add weight as you’re able.

5. A weak back and stomach can put extra stress on the joints that support your body. A good core strengthening program is important and paramount to the health of your knees, hips, and lower extremities. It’s important to do plenty of back and abdominal strengthening exercises. A range of activities can help in core strengthening, experts say, while improving flexibility, balance, stability, which are also protective of joint strength.

6. Running has taken a pounding for the pounding it can take on the knees. For most people, it’s a safe activity. It’s easy, low cost, and we’re all designed to run for the most part. IT’s just being smart about what you can tolerate. That goes for not ramping up too quickly to longer distances or pushing through the pain of an injury – and taking time off to heal as needed. While some who have arthritis in their knees are still able to run, experts say it’s important to talk with a physician about any existing knee issues to determine what’s safe, including when walking might be more appropriate.

7. Whether you’re biking with friends or riding alone, racing the clock or just catching a cool breeze, taking to two wheels can strengthen your quads and calves – and even improve overall leg strengthening to bolster the knee health. Cycling is also a low-impact activity. The circular, rhythmic pedaling is easy on the knees and it can provide a great aerobic workout to boot.

8. Though many do just fine running on a treadmill, trying alternating an elliptical machine for an aerobic workout that works the legs while being easy on the knees. With your foot planted against a platform, there’s not repetitive impact that leads to the degredation of cartilage over time. And! It can help maintain muscular endurance.

9. While certain exercises target muscles are the joint, at the end of the day any strength training or aerobic exercise that helps you maintain a healthy weight reduces pressure on your knees. When you stand on one foot, 5-8x your body weight goes through your knee joint. If you gain 5 pounds, that’s an extra 25-40 pounds of pressure going through your knee joint. If for no other reason, exercise to keep your weight in check to decrease the stress on joints. That goes for knee-friendly exercises ranging from the elliptical machine to cycling, experts say, and anything else that gets you moving. 

POOL SEASON IS RIGHT AROUND THE CORNER

Pool (aquatic) exercise provides many benefits, including an ideal environment to exercise throughout the year. The buoyancy of the water supports a portion of your body weight making it easier to move in the water and improve your flexibility. The water also provides resistance to movements, which helps to strengthen muscles. Pool exercises can also improve agility, balance, and cardiovascular fitness. Many types of conditions greatly benefit from pool exercise, including arthritis, fibromyalgia, back pain, joint replacements, neurological, and balance conditions. The pool environment also reduces the risk of falls when compared to exercise on land. Below are some tips and tricks provided by the APTA as suggestions to get you started in the right direction.

Preparing for the Pool

Before starting any pool exercise program, always check with your physical therapist or physician to make sure pool exercises are right for you. A wonderful option is asking your physical therapist to take your home exercise program and adapt it so that it's possible to do in the water. Here are some tips to get you started:

• Water shoes will help to provide traction on the pool floor.
• Water level can be waist or chest high.
• Use a Styrofoam noodle or floatation belt/vest to keep you afloat in deeper water.
• Slower movements in the water will provide less resistance than faster movements.
• You can use webbed water gloves, Styrofoam weights, inflated balls, or kickboards for increased resistance.
• Never push your body through pain during any exercise.
• Although you will not sweat with pool exercises, it is still important to drink plenty of water.

10 Excellent Exercises for the Pool

1. Water walking or jogging: Start with forward and backward walking in chest or waist high water. Walk about 10-20 steps forward, and then walk backward. Increase speed to make it more difficult. Also, increase intensity by jogging gently in place. Alternate jogging for 30 seconds with walking in place for 30 seconds. Continue for 5 minutes.

2. Forward and side lunges: Standing near a pool wall for support, if necessary, take an oversized lunge step in a forward direction. Do not let the forward knee advance past the toes. Return to the starting position and repeat with the other leg. For a side lunge, face the pool wall and take an oversized step to the side. Keep toes facing forward. Repeat on the other side. Try 3 sets of 10 lunge steps. For variation, lunge walk in a forward or sideways direction instead of staying in place.

3. One leg balance: Stand on 1 leg while raising the other knee to hip level. Place a pool noodle under the raised leg, so the noodle forms a “U” with your foot in the center of the U. Hold as long as you can up to 30 seconds and switch legs. Try 1-2 sets of 5 on each leg.

4. Sidestepping Face the pool wall. Take sideways steps with your body and toes facing the wall. Take 10-20 steps in 1 direction and then return. Repeat twice in each direction.

5. Hip kickers at pool wall: Stand with the pool wall to one side of your body for support. Move 1 leg in a forward direction with the knee straight, like you are kicking. Return to start. Then move the same leg to the side, and return to the start position. Lastly, move that same leg behind you. Repeat 3 sets of 10 and switch the kicking leg.

6. Pool planks: Hold the noodle in front of you. Lean forward into a plank position. The noodle will be submerged under the water, and your elbows should be straight downward toward the pool floor. Your feet should still be on the pool floor. Hold as long as comfortable, 15-60 seconds depending on your core strength. Repeat 3-5 times.

7. Deep water bicycle: In deeper water, loop 1-2 noodles around the back of your body and rest your arms on top of the noodle for support in the water. Move your legs as if you are riding a bicycle. Continue for 3-5 minutes.

8. Arm raises: Using arm paddles or webbed gloves for added resistance, hold arms at your sides. Bend your elbows to 90 degrees. Raise and lower elbows and arms toward the water surface, while the elbows remain bent to 90 degrees. Repeat for 3 sets of 10.

9. Push ups: While standing in the pool by the pool side, place arms shoulder width apart on pool edge. Press weight through your hands and raise your body up and half way out of the water, keeping elbows slightly bent. Hold 3 seconds and slowly lower back into pool. (Easier variation: Wall push up on side of pool: place hands on edge of pool shoulder width apart, bend elbows, and lean chest toward the pool wall.)

10. Standing knee lift: Stand against the pool wall with both feet on the floor. Lift 1 knee up like you are marching in place. While the knee is lifted even with your hip, straighten your knee. Continue to bend and straighten your knee 10 times, and then repeat on the other leg. Complete 3 sets of 10 on each leg. For more of a challenge, try this exercise without standing against the pool wall.

COULD YOU HAVE PATELLOFEMORAL PAIN SYNDROME?

Patellofemoral pain syndrome (PFPS) refers to pain at the front of the knee, in and around the kneecap (patella). PFPS is one of the most common types of knee pain experienced in the United States, particularly among athletes, active teenagers, older adults, and people who perform physical labor. Patellofemoral pain affects more women than men and accounts for 20% to 25% of all reported knee pain - and is very, very common in adolescence and young adulthood for active or athletic individuals. Physical therapists design exercise and treatment programs for people experiencing PFPS to help them reduce their pain, restore normal movement, and avoid future injury.

What is Patellofemoral Pain?

Patellofemoral pain syndrome (PFPS) refers to pain at the front of the knee, in and around the kneecap. (The kneecap, or patella, is the triangle-shaped bone at the front of the knee joint.) Pain occurs when friction is created between the undersurface of the kneecap and the thigh bone (femur). The pain also is usually accompanied by tenderness along the edges of the kneecap.

Current research indicates that PFPS is an "overuse syndrome," which means that it may result from repetitive or excessive use of the knee. Other contributing factors may include:

• Weakness, tightness, or stiffness in the muscles around the knee and hip
• An abnormality in the way the lower leg lines up with the hip, knee, and foot
• Improper tracking of the kneecap

These conditions can interfere with the ability of the kneecap to glide smoothly on the femur (the bone that connects the knee to the thigh) in the femoral groove (situated along the thigh bone) during movement. The friction between the undersurface of the kneecap and the femur causes the pain and irritation commonly seen in PFPS. The kneecap also may fail to track properly in the femoral groove when the quadriceps muscle on the inside front of the thigh is weak, and the hip muscles on the outside of the thigh are tight. The kneecap gets pulled in the direction of the tight hip muscles and can track or tilt to the side, which irritates the tissues around the kneecap.

PFPS often occurs in people who are physically active or who have suddenly increased their level of activity, especially when that activity involves repeated knee motion, such as running, stair climbing, squatting, or repeated carrying of heavy loads. Older adults may experience age-related changes that cause the cartilage on the undersurface of the kneecap to wear out, resulting in pain and difficulty completing daily tasks without pain.

How Does it Feel?

People with PFPS may experience:

• Pain when walking up or down stairs or hills
• Pain when walking on uneven surfaces
• Pain that increases with activity and improves with rest
• Pain that develops after sitting for long periods of time with the knee bent
• A "crack" or "pop" when bending or straightening the knee

How Is It Diagnosed?

Your physical therapist will review your health history, perform a thorough examination, and conduct a series of tests to evaluate the knee. Your therapist may observe the alignment of your feet, analyze your walking and running patterns, and test the strength of your hip and thigh muscles to find out whether there is a weakness or imbalance that might be contributing to your pain. Your physical therapist also will check the flexibility of the muscles in your leg, paying close attention to those that attach at the knee.

Generally, X-rays are not needed to diagnose PFPS. Your physical therapist may consult with an orthopedic physician who may order an X-ray to rule out other conditions.

How Can a Physical Therapist Help?

After a comprehensive evaluation, your physical therapist will analyze the findings and, if PFPS is present, your therapist will prescribe an exercise and rehabilitation program just for you. Your program may include:

Strengthening exercises. Your physical therapist will teach you exercises targeted at the hip (specifically, the muscles of the buttock and thigh), the knee (specifically, the quadriceps muscle located on the front of your thigh that straightens your knee), and the ankle. Strengthening these muscles will help relieve pressure on the knee, as you perform your daily activities.

Stretching exercises. Your physical therapist also will choose exercises to gently stretch the muscles of the hip, knee, and ankle. Increasing the flexibility of these muscles will help reduce any abnormal forces on the knee and kneecap.

Positional training. Based on your activity level, your physical therapist may teach you proper form and positioning when performing activities, such as rising from a chair to a standing position, stair climbing, squatting, or lunging, to minimize excessive forces on the kneecap. This type of training is particularly effective for athletes.

Cross-training guidance. PFPS is often caused by overuse and repetitive activities. Athletes and active individuals can benefit from a physical therapist’s guidance about proper cross-training techniques to minimize stress on the knees.

Taping or bracing. Your physical therapist may choose to tape the kneecap to reduce your pain and retrain your muscles to work efficiently. There are many forms of knee taping, including some types of tape that help align the kneecap and some that just provide mild support to irritated tissues around it. In some cases, a brace may be required to hold the knee in the best position to ensure proper healing.

Electrical stimulation. Your physical therapist may prescribe treatments with gentle electrical stimulation to reduce pain and support the healing process.

Activity-based exercises. If you are having difficulty performing specific daily activities, or are an athlete who wants to return to a specific sport, your physical therapist will design individualized exercises to rebuild your strength and performance levels.

Fitting for an orthosis. If the alignment and position of your foot and arch appear to be contributing to your knee pain, your physical therapist may fit you with a special shoe insert called an orthosis. The orthosis can decrease the stress to your knee caused by low or high arches.

Can this Injury or Condition be Prevented?

PFPS is much easier to treat if it is caught early. Timely treatment by a physical therapist may help stop any underlying problems before they become worse. If you are experiencing knee pain, contact a physical therapist immediately. 

Your physical therapist can show you how to adjust your daily activities to safeguard your knees, and teach you exercises to do at home to strengthen your muscles and bones—and help prevent PFPS.

Physical therapists can assess athletic footwear and recommend proper choices for runners and daily walkers alike. Wearing the correct type of shoes for your activity and changing them when they are no longer supportive is essential to injury prevention.