There can be fewer tougher challenges in physiotherapy than returning a victim of an anterior cruciate ligament reconstruction to full fitness. Of course at Brighton Sports Therapy we love a challenge and aim to get people back even better than before the injury. New insight into rehabilitation enables us to restore your body to full function faster. Read on if you want to find out how…
The Anatomy
The anterior cruciate ligament 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. For any traditional anatomists this is quite a controversial statement. But when you take a step back and consider this statement without any preconceptions it makes perfect sense.
If 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.
The 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. Option 1 is rotational. For those old enough think Paul Gascoigne in the 1991 FA Cup Final. In this movement 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.”
Option 2 is over extending your knee. This can be coupled with articular (joint surface) issues due to extra force that goes through the knee as the ligament is damaged and the joint goes beyond it’s normal range.
Who’s Most Likely?
Some people are 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 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 of course we have lots of party tricks to help you with this if you have such a movement pattern.
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 going the way so many people do and having a reconstruction is the way forward. Surely this will give you more stability?
But the jury is still out. You 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.
This is not without it’s problems though. I’ve yet to find a piece of research for this one yet but I find in these cases the hamstrings seems to develop over use conditions. Which makes sense, as they quite simply have more work to do. This can be quite easily managed with massage in most cases.
I’ve just spent half an hour trying to find research recommending an operation or not. But it’s not that straight forward. 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 Does Arthritis Really Exist? As an addendum to this post yet another case in the clinic this week of someone turning up being told they need an immediate hip replacement and walking out pain free.
To clear up the confusion 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 is a no brainer. 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.
Accelerated Return To Sport
Return to full competitive sport is getting quicker and quicker. Back in Gazza’s day the injury was considered career threatening. And if you did make it back were you ever the same player again. These days players are back in 8-9 months with no obvious affect on performance.
So why the shift. Firstly, improved quality of surgery has a massive impact on recovery times. This coupled with vastly improved physiotherapy. Simply because more is understood about the condition and the operation. The buzz word in physiotherapy is accelerated protocol. This is to avoid bracing post operation, reduce pain and inflammation as quickly as possible, regain full range of motion and re-establish full strength and neuromuscular control of the knee complex.
Neuromuscular might sound a bit fancy dangled but all it means is to get the muscles and nerves working in harmony again to give maximum stability around the knee. This is where our combined muscle activation and sports massage treatments come into their element. Immediately improving these neural pathways to your knee so it feels more stable and less painful.
Risk Of Re-Injury And New 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.
What does this mean? To me this suggests that there are imbalances that have not been fully addressed in their rehabilitation. This is where we find muscles activation invaluable in that we can predict, with reasonable accuracy, which muscles are working to their full capacity. We can then tailor our treatment and rehab to address these imbalances before they cause a problem.
What Do We Recommend?
Always start with the end in mind. What we mean by this is work backwards 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 were 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, sports massage and strength and conditioning as absolute musts. Be disciplined in your mentality and also 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. But 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 our experience suggests there is little worry about. With the right mental approach and the correct treatment you’ll be back to your best sooner than you think. Whether that’s with our help or anyone else’s. Go out there and do it!