Knee injury ACL tear
A Pain In the Knee: Joel Adelman’s ACL Injury and Rehab
Let me set the scene. It’s Monday night at my mixed social netball competition. We are currently up by 11 goals in the final stages of the fourth quarter. This game is in the bag. The ball gets thrown in from the sideline into the back court and I start to chase it down at top speed as a member of the opposing team does the same. To avoid colliding into each other I skid to a halt.
The result? My knee locks out. It rotates inwards and buckles under me. It was INSTANT sharp pain as I collapsed to the floor screaming, feeling as if my knee snapped underneath me. I know in my mind what has just happened… I’ve torn my ACL.
Rewind a few hours ago. My loving and protective mother calls out before I leave; “Joel Adelman you do not injure yourself! Make sure you wear your ankle guards!”. I look at her, then look at dad chuckling. “Don’t worry Mum” I say jokingly, “I’ll only roll two of my ankles!” Not so funny now is it?
As you now know, my name is Joel Adelman. I’m a Master of Physiotherapy student. Final year. Almost done. Home stretch. Then this happens! But they say injuries are our best teachers and being able to walk (read: hobble) in my patients’ shoes will help me be a better health professional.
As a soon to be physiotherapist I’ve decided to share my post ACL surgery rehab journey with you; giving you both the patient and professional perspective. I’ll be using the knowledge I’ve gained through studying to self-direct most of my rehabilitation, with a little bit of help from Andrew, my own Physio.
I’ll be walking you through this process step by step, not only relaying what I’m doing, but why I’m doing it. So let’s get started!
ACL ANATOMY & FUNCTION
Your ACL is your anterior cruciate ligament, a band of fibrous tissue that connects the femur (thigh bone) to the tibia (shin bone). Its main function is to control stability when performing twisting actions. Interestingly, the ACL is actually not usually required for normal daily living and you can most certainly get by without one. However, it is essential in controlling the rotation forces developed during side stepping, pivoting and landing from a jump, which is needed for most sports.
SIGNS AND SYMPTOMS OF ACL INJURY
This is one reason why the ACL is often injured whilst playing ball sports like netball or soccer and also a common injury when skiing. Upon attempting to pivot, side step or land from a jump, the knee gives way. Common signs and symptoms include:
- Feeling or hearing a snap (I felt mine)
- Severe pain and inability to continue activity
- Swelling that begins within a few hours
- A feeling of ‘instability’ or giving way during weight bearing
- Loss of range of motion
ACL INJURY TREATMENT
Now let me just say this, not all ACL tears require surgery. Those who are content with activities that require little in the way of change in direction activities, like running in a straight line, swimming or cycling, may opt for conservative treatment. This usually takes the form of a progressive rehabilitation programme that includes exercises aimed at improving strength and balance.
However, that’s not what I want. My desire is to get back to competitive ball sports and back to skiing. Recent evidence has shown that there is no difference between surgery and conservative treatment in patient-reported knee scores at two or five years post injury. Therefore, I believe that each case is personal and that you will have a more positive outcome if you go with the approach that YOU want to take.
Talking more technical now as a soon-to-be physiotherapist, here are some key tests and information that are needed to diagnose an ACL tear or injury:
1. How did the injury occur? The mechanism of injury will be one of the key indicators.
– Was there rapid deceleration/change of direction, knee hyperextension, internal rotation?
– Is there sharp pain at the front of the knee?
– If both A and B are present you may start to suspect an ACL tear.
2. Lachamans/anterior draw test: both of these tests create a forward translation of the lower leg relative to the thigh. In a person with an intact ACL you will reach an ‘end point’ feeling, whereas those with a tear will show no clear end point. It’s important to test both sides as some people have naturally lax ligaments. If one side has a significant forward translation with no ‘end feel’ then you have a positive test.
3. The Lever Sign/Lelli’s Test: this test will give you extra confirmation that you’ve done your ACL. Get your fist under the upper calf and push down on the patient’s thigh to try straighten their leg. If the ACL is intact you should see the heel come off the bed (be careful as this isn’t always the case). However, if the heel doesn’t move off the bed, high chance they’ve torn your ACL.
In my case all three tests were positive and an MRI confirmed the ACL tearing along with some bone bruising and posterior capsule damage.
Whether opting for surgery or taking a conservative approach post ACL tear the immediate rehab is the same. Two key things come first:
1. Reduce swelling: follow standard acute injury management with rest, ice (20mins every 2 hours), compression (restrict fluid movement), and elevation (keep injury above the level of the heart)
2. Regain full range of motion (ROM): Static muscle stretches for the calf and hamstring are often used for leg extension range. Activities such as heel slides while applying overpressure with a towel wrapped around your foot can help to promote flexion range. You can also use an exercise bike to promote ROM, strength and endurance. The goal is to have as close as possible to full ROM prior to surgery for best outcomes post op and for a better recovery conservatively.
Once those two key elements of treatment are attended to you can start to work on the following:
Quadriceps strength (specifically VMO – medial quad)
a. What to do: VMO squeezes/co-contractions
b. Why it’s important: you want to strengthen key muscles around the knee joint for stability and muscle balance to prevent unwanted pressure on your knee. Evidence suggest that individuals will have improved outcomes post op with a strong VMO.
a. What to do: single leg glute bridges
b. Why it’s important: like with your quad muscle, a strong hamstring will help with strength, stability and control around your knee. Furthermore, those who are taking a hamstring graft for the surgery want to strengthen the muscle as much as possible as a stronger muscle equals a stronger graft.
a. What to do: heel raises
b. Why it’s important: on top of muscle strength and control about the knee, calf raises help to flush out swelling by acting as a muscle pump to move fluid from the lower limb back towards the heart.
For me a few key things stood out during my two weeks of prehab prior to my surgery. The first was that muscle strength and bulk goes very quickly, even with the above exercises being performed each day. Specifically, my VMO wasted away no matter how hard I pushed the exercises. I also experienced quite a bit of hamstring pain, which felt like a niggle or strain and all my muscles were very tight as they worked to protect my knee without its ACL.
Joel has 7 years combined study and has gained experience and developed skills across a broad range of areas including sports, orthopedic rehabilitation, neurological rehabilitation, geriatrics, pediatrics and cardiopulmonary. Joel uses a combination of exercise therapy, manual techniques and evidence-based practice to help his clients return to optimal health and to prevent further injuries.
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