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.

PT'S GUIDE TO PELVIC FRACTURES

A pelvic fracture is a break in 1 or more bones in the pelvis. It is sometimes referred to as a "hip fracture" or "broken hip" because it occurs in the bones that make up the hip area. A pelvic fracture causes difficulty walking or standing. It can also cause abdominal pain, bleeding from pelvic cavities, and difficulty urinating. Pelvic fractures in the United States are relatively rare, making up 0.3% to 6% of all fractures. Pelvic fractures are most common in people 15-28 years of age. In people younger than 35, males suffer a higher incidence of pelvic fractures than females. In people older than 35, females suffer pelvic fractures more often than males.

What is a Pelvic Fracture (Hip Fracture)?

A pelvic fracture is a crack or break in one or more of the pelvic bones, which are located at the base of the spine. The pelvis is often referred to as part of the hip. (When you "put your hands on your hips," your hands are actually resting on your pelvic bones.)

A pelvic fracture can result from a low-impact or high-impact event.

Low-impact pelvic fractures most commonly occur in 2 age groups: adolescents and the elderly. Adolescents typically experience fractures of the tips of 1 of the pelvic bones, resulting from an athletic injury (football, hockey, skiing) or an activity such as jogging. Pelvic fractures also can occur after minor falls in people with osteoporosis or even occur spontaneously when bones are weak. The elderly frequently suffer fractures of the thicker part of the pelvic bones. These "pelvic ring fractures" result from falling onto the side of the hip. These falls can be caused by balance problems, vision problems, medication side effects, general frailty, or unintended obstacles such as pets underfoot, slippery floors, or rumpled rugs. Low-impact pelvic fractures often are mild fractures, and they may heal with several weeks of rest. Physical therapy is very helpful in restoring strength and balance in these cases.

High-impact pelvic fractures most commonly result from major incidents such as a motor vehicle accidents, a pedestrian being struck by a vehicle, or a fall from a high place. These pelvic fractures can be life-threatening, require emergency room care, surgery, and extensive physical therapy rehabilitation.

How Can a Physical Therapist Help?

Pelvic fracture recovery often involves surgery or long periods of bed rest. In the case of athletes, avoidance of sport activities is recommended until pain has resolved. During these periods of rest, which are usually weeks to months, a person often loses strength, flexibility, endurance, and balance abilities.

Physical therapists can help you recover from a pelvic fracture by improving your:

• Pain level
• Hip, spine, and leg motion
• Strength
• Flexibility
• Speed of healing
• Speed of return to activity and sport

When you are cleared by your physician to begin physical therapy, your physical therapist will design a specific treatment program to speed your recovery, including exercises and treatments you should do at home. This program will help you return to your normal life and activities and reach your recovery goals.

The First 24-48 Hours

Your physical therapist may help you learn to use crutches so you can move around your home without walking on the leg of the injured side. This will more commonly apply to low-impact pelvic fractures, as in athletes. More severe pelvic fractures will require a wheelchair, in which your physical therapist can instruct your safe usage.

Reduce Pain

Your physical therapist can use different types of treatments and technologies to control and reduce your pain, including ice, heat, ultrasound, electrical stimulation, taping, exercises, and special hands-on techniques called manual therapy that gently move your muscles and joints.

Your physical therapist will choose specific activities and treatments to help restore normal movement in the leg and hip. These might start with passive motions that he or she applies to your leg and hip joint, and progress to active exercises and stretches that you perform yourself. Treatment can involve hands-on manual therapy techniques called "trigger point release" and "soft tissue mobilization," as well as specific stretches to muscles that might be abnormally tight.

Improve Strength

Certain exercises will benefit your healing at each stage of recovery, and your physical therapist will choose and teach you an individualized exercise program that will restore your strength, power, and agility. These exercises may be performed using free weights, stretch bands, weight-lifting equipment, and cardio exercise machines such as treadmills and stationary bicycles. For pelvic fractures, muscles of the hip and core are often targeted by the strength exercises.

Improve Balance

The hip area contains many muscles that are vital for balance and steadiness when walking or performing any activity. Your physical therapist will teach you effective exercises to restore strength and endurance to these muscles so that you can regain your balance.

Speed Recovery Time

Your physical therapist is trained and experienced in choosing the treatments and exercises to help you heal, get back to your normal life, and reach your goals faster than you might be able to on your own.

Return to Activities

Your physical therapist will collaborate with you to decide on your recovery goals, including return to work and sport. Your treatment program will be designed to help you reach these goals in the safest, fastest, and most effective way possible. Your physical therapist will use hands-on therapy and teach you exercises and work re-training activities. Athletes will be taught sport-specific techniques and drills to help achieve sports-specific goals.

Prevent Future Problems

Your physical therapist can recommend a home exercise program to strengthen and stretch the muscles around your hip, upper leg, and core to help prevent future problems, such as fatigue and walking difficulty. This program may include strength and flexibility exercises for the hip, thigh, and core muscles. Your physical therapist will also review with you and your family ways to prevent falls in your home. These fall-prevention strategies may include clearing the floors of loose obstacles (throw rugs, mats), using sticky mats or chairs in the shower, preventing pets from walking near your feet, and using non-slippery house shoes, as well as installing grab bars or rails for the shower, toilet, and stairs.

If Surgery Is Necessary

If surgery is required, your physical therapist will help you minimize pain, restore motion and strength, and return to normal activities in the speediest manner possible after surgery.

Can this Injury or Condition be Prevented?

Pelvic fracture can be prevented by:

• Warming up before starting any sport or heavy physical activity. Your warm-up should include stretches taught to you by your physical therapist, including stretches for the muscles on the front, side, and back of the hip.
• Increasing the intensity of an activity or sport gradually, not suddenly. Avoid pushing yourself too hard, too fast, too soon.
• Following a reasonable and safe nutritional plan. Nutritional factors can contribute to osteoporosis, which can put you at higher risk of pelvic fracture.
• Maintaining good balance skills. Balance problems can increase the risk of falling and thus increase the risk of incurring a pelvic fracture. Physical therapy can help maintain and improve balance ability, which can help prevent falls.
• Driving safely to avoid motor vehicle accidents.
• Clearing your house of obstacles that you could trip over, and eliminating slippery walking surfaces.

OSTEOPENIA (LOW BONE MASS)

Osteopenia, now called low bone mass, is a term used to describe lower-than-normal bone density or thickness. Approximately 44 million adults in the United States have osteopenia.The condition is different than osteoporosis, which is a disease where normal bone structure becomes thinned out and porous.

Low bone mass can occur at any age, but noticeable and significant bone loss is most likely to occur in women during the 5 to 7 years following menopause. This group is also more likely to experience a bone fracture than someone with normal bone mass.

What is Osteopenia?

Low bone mass is a condition that develops when a person:

• May naturally have less-dense bones due to factors such as body size, genetics, or gender.
• Has gradually lost bone mass over time due to lack of exercise and poor diet.
• Has begun to experience perimenopause, symptoms that signal the onset of menopause or who is in menopause.
• Has rapidly lost bone mass due to an illness or use of medication.

How Is It Diagnosed?

Low bone mass is diagnosed through a quick and painless specialized scan ordered by aphysician. If you are seeing a physical therapist for rehabilitation, the therapist may confer with your physician when detecting a possible need for bone testing.

The results of the scan are reported using T- and Z-scores.

The T-score compares your score to that of healthy 30-year-old women. A T-score between -1 and -2.49 means that you have low bone mass. Those who have a T-score of -2.5 and lower have osteoporosis.

If you have a T score of -1 or less, you have a greater risk of experiencing a fracture. A person with a T-score of -2 has lower bone density than a person with -1.

The Z-score compares your bone mineral density to the average of peoplewho are of the same age, sex,weight,and race as you. A Z-score of -2 or lower might mean that something other than normal bone loss due to age is occurring. Your doctor will likely explore other health issues that might be causing the bone loss.

Other methods of screening bone density include x-ray, ultrasound, and CT scan.If you have risk factors that includecertain diseases, short- or long-term use of steroids, or a recent bone fracture, a DXA scan may be prescribed.

How Can a Physical Therapist Help?

A physical therapist can help you prevent and treat low bone massat any age by prescribing the specific amount and type of exercise that best builds and maintains strong bones.

When you see your physical therapist, the therapist will review your health history, including your medical, family, medication, exercise, dietary, and hormonal history. Your physical therapistwill also conduct a complete physical therapy examination and identify your risk factors for low bone density.

It is important to exercise throughout life, and especially when you have been diagnosed with low bone mass in order to build and maintain healthy bones. Exercise can help to build bone or slow the loss of bone.

Your physical therapist is likely to prescribe 2types of exercise that are best to build strong bones:

Weight-bearing Exercises

• Dancing
• Walking at a quick pace (122-160 steps per minute or 2.6 steps per second)
• Jumping, stomping, heel drops
• Running at least a 10-minute mile
• Racket sports

Resistance Exercises

• Weightlifting
• Use of resistance bands
• Gravity-resistance exercises (pushups, yoga, stair climbing, etc.)

Your physical therapist will design an individual exercise program for you based on your particular needs. Your physical therapist will test you to see how much resistance is needed and is safe for your specific bone density as well asother physical issues that you may have. Treatment starts at the level you can tolerate. Once you learn how to perform your program, your physical therapist may add more strenuous activity with physical effort to encourage your bones to grow stronger.

Your exercise prescription will include guidelines for weightbearing and resistance training for the hips, spine, shoulders, and wrists. The therapist will prescribe guidelines for the intensity, frequency, and progression of your exercises.

Exercise is only 1component of healthy bones. Your physical therapist will encourage you to pursue a healthy and varied diet, including foods rich in calcium, to reach the amount recommended according to your age and health status. Your physical therapist may recommend that you meet with a dietitian to learn about the many foods that contribute to bone health. Sometimes, medication or hormone replacement therapy may be recommended. Your physician will help guide you to find the best combination of exercise, diet, and medication to treat your condition.

Can this Injury or Condition be Prevented?

Risk factors that you can avoid in order to lower your chances of developing low bone mass include:

• Cigarette smoking
• Excessive alcohol intake (greater than 1 drink per day for women, 2 per day for men)
• Poor diet
• Low calcium and Vitamin D levels        
• Sedentary or low level activity—less than 5,000 steps per day

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.