ACL Tears and Reconstruction

One of the most common and dangerous injuries an athlete can endure is a torn ACL.  At the very best the athlete will have a long road to recovery and at the very worst a torn ACL can mark the beginning of the end of a young athlete’s career.  It’s estimated that there are over 250,000 ACL related injuries each year, and more than 100,000 ACL reconstruction surgeries are performed in the United States every year. To understand why ACL injuries are so common in athletics one must understand the basic anatomy of the knee.

The ACL (anterior cruciate ligament) is one of the four ligaments in the knee. This ligament is essential for maintaining knee stability.  It accomplishes this by limiting the overall motion of the knee joint. Approximately 70% of ACL injuries are non-contact injuries.  Usually when an individual plants their foot down and then attempts to pivot the ACL is more likely to be torn. This is because this particular position places more stress on the ACL and makes it more likely to tear.  Another common way a person will tear their ACL is when they are landing after jumping.  If an individual lands with their knee bowing inward this will also place additional pressure onto the ACL and make it more prone to rupturing.  Because of this sports that require frequent jumping, cutting and juking increase the likelihood that an athlete will tear their ACL. In fact, out of all sports basketball and soccer have the highest exposure to ACL tears.

Other than what sport a person plays the gender of the individual can place the athlete at risk for developing an ACL tear.  In fact, females are three times more likely to develop an ACL tear than males. This is most likely due to several factors including muscle imbalances, biomechanical and anatomical differences, hormonal changes and strength deficits. Another risk factor is having a past history of injuring or tearing an ACL.  This makes the individual much more likely to re-tear their ACL. When a person tears their ACL usually they feel as if their knee is giving out.  Also an audible popping sound is heard or felt within the knee. This is usually accompanied by moderate to severe pain.  Often the athlete will not be able to place full weight through their leg and may not be able to walk without considerable discomfort for the next couple of days.  Swelling and inflammation usually occurs soon after the initial injury as well.

Determining whether ACL reconstruction surgery is the best course of action depends on several factors.  A prime candidate for surgery is a young, competitive athlete whose sport requires agility based movements (i.e. cutting).  ACL reconstruction surgery replaces the ACL with a tendon from another part of the individual’s body, usually the patellar or hamstring tendon. This aids in restoring knee stability and gives the individual the best chances of competing at their previous level. After surgery is performed physical therapy is a must. The patient will present with profound quadriceps weakness, decreased range of motion, swelling and inflammation. The most pressing issue a physical therapist will first address is achieving full knee extension and reducing swelling.  Most people would think restoring the knee’s ability to bend is more important, but if a person cannot fully straighten their knee then they will not be able to walk or run properly. The physical therapist will also focus on activating and strengthening the quadriceps muscle.  Often after a knee surgery the patient will experience great difficulty on firing or contracting their quadriceps muscle. This is known as quadriceps inhibition and it’s very common after severe trauma (i.e. surgery).  To overcome quadriceps inhibition neuromuscular electrical stimulation will be implemented.  This forces the quadriceps to fully contract and has been shown to increase quadriceps strength and accelerate the rehab. process.

In order to promote knee stability while walking and running, exercises that strengthen the patient’s hip musculature will be prescribed by the therapist. This will aid in controlling the knee when the patient is squatting, lunges and while they are running.  The physical therapist will also incorporate balance exercises which will further increase the stability of the knee and begin preparing the athlete for sport related movements. As the patient’s walking pattern normalizes and their quadriceps strength returns the patient will begin plyometrics and eventually jogging.  The physical therapist will assess the patient’s biomechanics and overall form while performing plyometrics and jogging. This will help identify any deficits and help prevent re-injury.  As the patient continues to progress agility based exercises will be stressed.  This will increase the patient’s ability to tolerate sport related movements such as cutting and pivoting.

Although ACL reconstruction surgery is usually recommended for athletes it’s not always the best option for a patient.  If a patient is older and does not participate at a competitive level in a sport that requires agility based movements, or if they simply do not want to have surgery performed than conservative management is usually the best approach for these individuals.  Although physical therapy cannot repair the torn ACL, knee stability can improve from physical therapy.  First a physical therapist will focus on reducing the swelling and inflammation by focusing on ice, compression and elevation.  As the swelling and inflammation decreases the physical therapist will focus on exercises that strengthen the quadriceps, hip and core musculature. If the muscles that surround the knee are strengthen then the patient’s knee will be less likely to demonstrate excessive motion while performing dynamic activity such as running or lunges.  The physical therapist will also evaluate and adjust the patients running mechanics.  As the patient’s symptoms improve the therapist will also incorporate balance and agility based exercises which will further challenge the patient to maintain control of their knee. As the patient strength and balance improves the patient will slowly be graded back into sport related movements and eventually back to their sport of choice.  Whether a patient’s goal is to play their favorite sport at a competitive level or just return to jogging a physical therapist will assist the patient in achieving their desired goal.

If you sustained a sport related injury don’t delay contact Total Performance Physical Therapy for an evaluation today.


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