There can be few tougher challenges in physiotherapy than returning a victim of an anterior cruciate ligament reconstruction to full fitness. Of course at Brighton Physiotherapy & Sports Therapy we love a challenge and aim to get people back even better than before the injury.
New insight into rehabilitation helps us to remove residual compensation patterns and enables you to return back to full function without fear of re-injury. Read on if you want to find out how…
Anatomy Of The Anterior Cruciate Ligament (ACL)
The anterior cruciate ligament (ACL) is one of only 4 true ligaments in the body. By this I mean one that goes solely from bone to bone and is not enveloped in layers of fascia and muscle. It runs from the back part (posterior) of the articular surface of the femur to the front (anterior) articular surface of the tibia. It prevents the tibia sliding forwards on the femur and resists excessive rotation of the knee joint.
Anterior Crucite Ligament (ACL) Injury
Those unlucky enough to have had this injury will know all too well how it comes about. There are two classic ways to damage this ligament. Rotational and hyper extension. With rotation you are quite likely to also damage the medial collateral ligament (MCL) and / or the medial meniscus (cartilage). The 3 together are known as “the unhappy triad.”
Hyper extension injury can be coupled with articular (joint surface) issues due to extra force that goes through the knee as the ligament fails to stop the joint going too far.
Who Is Most At Risk From Anterior Cruciate Ligament (ACL) Injury?
Some people are genetically just more at risk from anterior cruciate ligaments injuries. Two of the more curious pre-disposing factors are gender and race. Women have a 3 times higher incidence of ACL rupture than men. As mentioned in this article here. Race also is a factor in the likelihood of injury. As this article here shows white European origin ladies playing basketball were 6 times more likely to rupture their cruciate ligament than non-white players.
As to why this would be the physiotherapy world is not all together sure. There are lots of theories. For ladies we talk about the Q-angle. This is the angle of the femur relative to the pelvis. From experience however I would extend this to a more functional view. If your knee moves inwards relative to your hip as you do functional exercises such as a squat or lunge then you are more at risk.
Happily there are ways to minimise or mitigate this movement pattern for prevention of ACL injury or post surgical rehabilitation.
To Operate Or Not To Operate, That Is The Question
If your leg isn’t quite connected the way it used to be this might seem a peculiar question. Surely having a reconstruction is the way forward. Surely this will give you more stability?
But the jury is out. We really need to consider what you will be using the knee for. The human body is incredibly adaptable and some people are even born without cruciate ligaments and don’t even know. If you rupture your ACL your hamstrings will compensate and adapt to perform the roll of the ACL. This really is quite clever. And in many cases the ACL can magically re-attach to itself over time!
This is not without its problems though. I’ve yet to find a piece of research for this one yet but I find in these cases the hamstrings can develop an over use condition. Which makes sense, as they quite simply have more work to do. This can be quite easily managed with corrective bio-mechanical work particularly making sure the glutes are firing properly and some fascial release and massage of the hamstring to ‘freshen’ them up.
I’ve just spent half an hour trying to find research recommending an operation or not. The research is conflicting. If you look here versus here. Some research suggests if you have reconstructive surgery then your knee will be functionally more stable with reduced risk of meniscal problems. It then goes onto to state that you will be slightly more at risk of osteo-arthritis. But other research claims it makes no difference!
Of course even if you do get a bit more “wear and tear” leading to osteo-arthritis it needn’t be symptomatic as we discuss in our previous post about arthritis.
If you’re contemplating having an operation or not I would suggest if you are involved in sports with high impact and lots of cutting, weaving and rotation then having the operation could be the best option for you. If you are more into single planar sports (e.g. running) or you are relatively inactive then you may wish to consider not having the operation. Your surgeon will consider the pros and cons in detail with you.
Risk Of ACL Re-Injury And Additional Injury
So if you’ve chosen operative or not what is your prognosis? With surgery there is the risk of the graft failing. This is increasingly rare but can happen. Of course if you don’t reconstruct there is nothing to re-injure! But you may get complications as a result of your altered movement patterns. Equally you may get away with it and be just fine.
Interestingly I read a piece of research (sorry don’t have the reference!) which analysed injuries after returning to professional football post ACL reconstruction. Within 6 weeks of return the players have an 80% chance of picking up some kind of additional soft tissue injury. I was keenly following Virgil Van Dijk’s return to action to see if this pattern was followed. And it wasn’t. But he is quit an athlete. But over 12 months later he did succumb to a hamstring injury. A muscle he had never injured before.
So why would muscles strain so consistently after reconstruction surgery? To me this suggests that there are imbalances that have not been fully addressed in their rehabilitation. This is where we find our whole body approach to physiotherapy invaluable. We can not only assess the affected muscles that act across the knee but the wider ramifications of the traumatic injury through the whole body. We can then tailor our treatment and rehab to address these imbalances before they cause a problem.
What Do We Recommend For ACL Rehabilitation
Always start with the end in mind. What we mean by this is work backwards from what you are trying to get back to. Whether that’s professional football or simply walking around pain free. Deconstruct the movements and then put them back together again into the full functional movements you’re aiming for.
Get treatment as soon as you can. Of course we would say that. But the more you have people check everything is working as should be along the way the better your outcome. I would include physiotherapy, fascial release, sports massage and strength and conditioning as absolute musts. Be disciplined in your mentality and focus on what you can do, not what you can’t.
You will need to keep a positive mindset. You will have setbacks along the way. It’s not whether you have setbacks but it’s how you respond to them. Some days you will just push your knee too far. That’s ok. With the right treatment and approach you can get things ‘tidied’ up and go again.
Don’t Fear, It’s Not The End Of Everything
When you’ve had such a severe injury then it is inevitably scary. You wouldn’t be human if you weren’t worried about whether you’ll ever be the same again. But actually learning not to worry is a key component in full recovery. We also focus our work on helping you to believe that your ACL is fine. That your movement patterns are strong enough to hold.
When you believe in your body you hold your body less tense and it is relaxed muscles that are stronger, not tense ones. Contrary to some beliefs out there. By working on the psychological factors as well as the physical ones and combing that with a progressive return to rehabilitation, then drills and then finally sport (or just life) we find most ACL reconstructed knees, or those left without ACLs, can get pretty damn close to their former glory and in many cases all the way to 100% of previous function.