The Anterior Cruciate Ligament (ACL) is one of 4 major ligaments (ligaments connect bone-to-bone) of the knee–it connects the femur (thigh bone) to the tibia (shin bone). A torn ACL is a devastating knee injury that commonly affects many athletes…soccer/basketball/football players, gymnasts, skiers just to name a few. Surprisingly, 70% of ACL tears do not involve contact, while 30% of ACL injuries are contact related (either play-to-player or player-to-object). Also, the predominance of ACL tears is 4-6 times higher in women than in men.
When you tear your ACL you may hear a loud “pop” or snap and you may feel a sharp, intense pain. You might not be able to walk on the injured leg because you might not be able to support your body weight through your knee joint. Swelling is almost immediate (usually within minutes to a few hours) and your knee might feel like “buckling” when you try to walk or put weight on it.
In most circumstances immediately following an ACL injury you are usually examined either by a Physical Therapist or an orthopedic surgeon. Many individuals who suffer an ACL tear will opt for surgery to repair the tear; however, it’s possible to avoid surgery in some instances by modifying their physical activity to reduce stress on the knee. A select group can actually return to vigorous physical activity following Physical Therapy without undergoing surgery.
Your Physical Therapist should collaborate with your orthopedic surgeon to determine if non-operative treatment is a reasonable option for you. If you decide to undergo surgery your Physical Therapist will help you both prepare for surgery and to rehabilitate your knee after surgery to regain mobility and strength.
WHAT CAN CAUSE THE ACL TO TEAR?
Some of the ways you can tear your ACL are:
- Jump and land on an extended (straightened) knee
- Suddenly shift your weight from one leg to the other
- Twist your knee while your foot remains firmly planted on the ground
- Stop suddenly while running
- Suffer a direct blow to the knee
- Stretch the knee farther than you should
HOW IS AN ACL TEAR DIAGNOSED?
If you see a Physical Therapist first, they should conduct a thorough and comprehensive evaluation that starts by reviewing your medical history, including mechanism of injury. Some questions may include:
- Did you experience a direct blow to the leg while your foot was firmly planted on the ground?
- Did you feel/hear a “pop” when you twisted your leg with your foot on the ground, stopped quickly when running, jumped, or stretched your knee farther than normal?
- Did you experience swelling around the knee within the first 2-3 hours after the injury?
- Have you experienced “buckling” (giving way) of the knee when you turn while walking, go up/down steps, or attempt to get out of a chair?
Your Physical Therapist should then conduct a thorough hands-on evaluation to look at your knee range of motion, strength, swelling, and to watch you walk and move. Special tests should also be included that are specific for knee injuries–among these are the anterior drawer or Lachman’s test (bending your knee and gently pulling on your lower leg) as well as the pivot shift test (gently bending and twisting your knee simultaneously). You may feel discomfort or instability during these tests–this is perfectly normal. Additional tests should also be conducted by your Physical Therapist to determine if there is damage to other structures of the knee as well (i.e., testing the other 3 ligaments as well as assessing for torn cartilage, called the meniscus).
In the event your Physical Therapist determines you have torn your ACL (or diagnosis another knee condition involving a tear), he/she should refer you to an orthopedic surgeon who may order further diagnostic tests, such as a MRI, to confirm the diagnosis.
HOW CAN PHYSICAL THERAPY HELP FOLLOWING AN ACL TEAR?
Once you have been properly diagnosed with an ACL tear you will work with your Physical Therapist and orthopedic surgeon to determine if surgery is your best option or if you can attempt to manage your recovery non-operatively. Should you opt against surgery, your Physical Therapist should work with you to restore mobility, muscle strength, coordination, and endurance so that you may return to your normal activities. In some instances you may need to be instructed in modifying your physical activity to reduce stress on your knee. If you choose to go ahead with the surgery your Physical Therapist can help you both before and after the procedure.
PHYSICAL THERAPY WITHOUT SURGERY
Evidence from current research has identified a specific group of individuals known as copers, who have the potential for success without undergoing surgery. These people only have an injury to their ACL and report no instability (“giving out” or buckling) since their initial injury. This group of individuals can be determined by the Physical Therapist based on specific functional tests, namely the Global Rating of Knee Function, Knee Outcomes Survey, and the Timed Hop test. Should you fit this category your Physical Therapist should design an individualized, specific treatment program for you. This would most likely include traditional muscle strengthening, cardiovascular training, and balance training.
PHYSICAL THERAPY BEFORE SURGERY
Some orthopedic surgeons proactively refer their patients to a Physical Therapist for a brief course of rehabilitation before surgery. The goal here is to decrease swelling, improve knee range of motion, and increase strength of your quadriceps (front thigh muscles). In the instance that you have a quadriceps lag (where you attempt to perform a straight leg raise but you are unable to keep your knee totally straight, resulting in a slight bend of the knee), research has determined that improving this condition prior to surgery will lead to a better outcome after surgery.
PHYSICAL THERAPY AFTER SURGERY
Your orthopedic surgeon should provide you with post-operative instructions. Physical Therapists have developed and published specific guidelines on knee stability and movement difficulties, which recommend the following actions:
- Weight bearing–You will use crutches to walk immediately after your surgery. The amount of weight you may put on your leg and how long you will need to use the crutches will depend on the type of reconstructive surgery you had. Your Physical Therapist will instruct you through this phase of your rehab.
- Ice and compression–Your Physical Therapist will work to control your swelling immediately after your surgery by using an ice sleeve that goes around your knee and provides compression.
- Bracing–Some surgeons will issue you a brace following surgery to limit early knee movement. Some will also give you a brace to use during sports (much later in your recovery). Your Physical Therapist should be able to fit you with a brace and instruct you how to use it safely.
- Exercises to improve mobility–You will begin certain exercises immediately after surgery. During your first week your Physical Therapist should assist you with your knee range of motion and instruct you in gentle exercises that you will perform at home. The goal here is to regain full movement of your knee. Be patient…this may take a little time! Your exercises will include both non-weight bearing exercises (no pressure on your leg) as well as weight bearing exercises (where you are allowed to place weight on your leg). These exercises may initially be limited to a specific range of motion to protect your newly healing ACL graft.
- Exercises to improve strength–As mentioned above, your Physical Therapist will help you to increase your ability to put weight on your knee using a combination of weight bearing and non-weight bearing exercises (in the first 4 weeks after surgery). These exercises will focus on your quadriceps (front thigh muscles) and hamstrings (posterior thigh muscles), and again might be limited to a specific range of motion to protect the newly healing ACL graft. Crutches are generally eliminated between weeks 5 and 12 to focus on regaining a normal walking pattern. The intensity of your exercises will be ramped up during this time frame, and balance activities will be added to your program as well. After 3-4 months your thigh muscles on your surgically repaired leg should be about 75% of the strength of your muscles on your uninjured side. During this time phase you should receive a plan by your Physical Therapist to initiate a return to higher level activities.
- Return to your sport or physical activity–You may begin running, jumping, hopping, balance exercises, and other sport-specific exercises during this phase (usually around 6-12 months). This phase varies greatly from person to person. You may be ready to return to your sport if:
—- You have no feelings of instability during sport-specific activities, such as cutting, jumping, and landing
—-You no longer have pain and swelling
—-Your quadriceps strength is 90% of that of your good leg
—-Your performance of the 1-legged hop test is at 90% of that of your good leg
**It is important to note that these are only broad guidelines describing what you might expect for your recovery and that each surgeon might have a specific plan for you**
CAN AN ACL TEAR BE PREVENTED?
Current research suggests that a certain% of ACL tears has been reduced in certain populations. Much of this research has been conducted on college female athletes, since women are 4-6 times more likely to sustain this type of injury. For example, preventative Physical Therapy programs have proven to lower ACL injury rates by 41% for female soccer players. The following recommendations have been suggested by researchers for a preventative exercise program:
- The program should last a minimum of 6 weeks
- Exercises should be performed 2-3 times/week and should include sport-specific exercises.
- The program should be designed to improve balance, strength, sports performance, as well as core strengthening in order to prevent injury
If you or someone you know is experiencing signs and symptoms consistent with an ACL tear don’t wait to take action. Call my office at once at (302)691-9055 or visit my website at www.wildermanpt.com to schedule your FREE 30 minute consultation to see how Physical Therapy can help. Don’t delay–schedule now!