Introduction
Anterior cruciate ligament surgery and rehabilitation have undergone dramatic changes over the past decade, due to extensive clinical experience, improved surgical technique and better understanding of the rehabilitation process.
Pre and post-operative rehabilitation is a major factor in the success of ACL reconstruction. Early restoration of full joint movement and weight-bearing are of paramount importance for successful rehabilitation.
The aim is to ensure a complete understanding of the basic principles of the ACL reconstruction, to restore the full range of motion, near normal strength and to mentally prepare the patient for the operation and accelerated rehabilitation.
The major goals of ACL surgery and rehabilitation are:
- to restore normal joint anatomy
- to provide static and dynamic knee stability
- return to work and sport as soon as possible
It is very important that the patient takes an active part in the rehabilitation, both before and after the operation.
What is the ACL?
- The ACL prevents the shinbone from sliding forwards beneath the thighbone.
The ACL can be injured in several ways:
- Changing direction rapidly
- Slowing down when running
- Landing from a jump
- Direct contact such as in a football tackle
Diagnosing an ACL injury
A diagnosis of ACL injury is based on a thorough physical examination of the knee. The exam may include several tests to see if the knee stays in the proper position when pressure is applied from different directions. An X-ray and MRI (magnetic resonance imaging) or, in some cases, arthroscopic inspection will confirm a diagnosis of a torn ACL.
A partial tear of the ACL may or may not require surgical treatment. A complete tear is more serious. Complete tears, especially in younger athletes, may require reconstruction.
Immediate Treatment
Immediately after the injury you should rest the knee. This reduces swelling and bleeding and helps prevent further injury.
You should then apply ice to your knee (ice cubes in a plastic bag or a packet of frozen peas are ideal – tied on, but not too tight). The ice should be applied for 10-15 minutes twice hourly and repeated several times a day.
The effect of the ice is to reduce the swelling by causing your blood vessels to contract. It also helps to reduce pain and muscle spasm by numbing your nerve endings. Don’t overdo the ice however as this will start to have the opposite effect. Keep light pressure on your knee during icing (perhaps with a supportive bandage) and keeping your knee lifted up on a footstool both help to reduce swelling.
Applying heat, massage or creams to an acutely swollen knee is not a good idea. This will increase blood supply and make your pain and swelling worse.
The pain and swelling will normally go away within a couple of weeks but your knee will probably feel unstable, as if it might give way each time you put weight on that leg. This instability can be treated by physiotherapy, using braces, or, if necessary, by surgery.
You may have injured other parts of your knee at the same time as your ACL – particularly your cartilage (or meniscus). This is a rubbery substance that acts as a shock absorber between the bones in the knee. If this is damaged you may find it painful to walk and, in time, a cartilage problem may lead to the knee joint wearing out.
Recognising an ACL Injury
If you injure your ACL, you may not feel any pain immediately. However, you might hear a popping noise and feel your knee give out from under you. Within a few hours, the knee will swell, and you will feel pain when you try to stand.
If you walk or run on an injured ACL, you can damage the cushioning cartilage in the knee. For example, you may plant the foot and turn the body to pivot, only to have the shinbone stay in place as the thighbone above it moves with the body.
Treatment of a Torn ACL
Non- surgical and surgical treatment choices are available.
1. Non- surgical treatment:
- May be used because of a patient’s age or overall low activity level.
- May be recommended if the overall stability of the knee seems good.
- Involves a treatment program of muscle strengthening, often with the use of a brace to provide stability.
2. ACL Surgery
The choice is to reconstruct rather than repair the ACL as this gives better results.
There are a number of ACL graft choices. These include either using the patellar tendon, your hamstring tendon, or using an allograft (taken from another person). The choice is usually tailored to your specific problem.
In a typical ACL reconstruction, we drill a diagonal tunnel through the shin and thigh bones. Into this tunnel we insert the new ACL which will be fixed into place with small screws and similar devices.
Types of grafts
1. The patellar tendon
This tendon connects your kneecap (patella) to your shin (tibia). About a third of the tendon is taken from the middle.
2. The hamstring tendon
The hamstrings connect the back of your thigh to your lower leg. These tendons are taken and woven together like a rope to form a new, strong ACL.
3. An allograft
The third option is an allograft – tissue taken from another person. The advantage is that the surgeon does not have to disturb or remove any tissue from your knee.
Physiotherapy after your surgery
After surgery your knee will be swollen and painful. Your physiotherapist will begin a rehabilitation programme immediately.
Physiotherapists and surgeons are constantly improving their understanding of how best to rehabilitate knees which have undergone ACL reconstruction. Generally, rehabilitation programmes are getting faster so that almost immediately after the operation you will be asked to undertake mild exercise of the knee. By doing this your knee is prevented from becoming stiff which would prolong your rehabilitation.
Of course, whilst your knee is still sore from the operation it is more painful to undertake rehabilitation exercises. This is one of the reasons we stress the importance of a good mental attitude. A small amount of effort on your part will be rewarded with superior results from your surgery.
It is common after surgery to have swelling of the whole lower leg, extensive bruising and some numbness both around the scars and going down the inner side of the shin. These symptoms will gradually reduce over a few weeks although you may be left with a patch of numbness around the scars.
Rehabilitation Programme
A typical rehabilitation programme would look like this:
Stage 1: First two weeks after surgery
The objective is to reduce swelling, regain muscle control of your leg, restore your normal gait as well as the ability to extend and flex your knee.
Your physiotherapist will use lots of ice and compression to reduce your swelling. You will be encouraged to exercise in short, regular bursts – say five to ten minutes every hour.
Initially your physiotherapist will concentrate on getting you upright and weight bearing with support and trying to get you to walk without limping.
It is important to be able to fully extend and lock your knee as soon as possible. This action helps the quadriceps muscle above the knee to pump blood away from the knee and reduce swelling.
Exercises include hamstring and calf stretches, static contractions of quadriceps and gentle bending.
Stage 2: Two to six weeks after surgery
Now the objectives are to stop using crutches, gain confidence and strengthen the knee whilst restoring full flexion.
Typical exercises will include stair climbing, static cycling, knee bends and lunges. Weights will be introduced and you may begin to swim but do not breast stroke until you are medically cleared to do so.
Stage 3: Six to twelve weeks after surgery
You will now be gaining in confidence and fitness and will have a regular programme to improve coordination and balance.
The speed and resistance exercises will be increased; progressive hamstring and quadriceps strengthening will continue.
Stage 4: Three to six months after surgery
Now the objective is to maintain motivation, improve aerobic fitness and develop sport specific skills.
Your programme will include progressive running and agility skills and a tailored sports programme. Jumping, running and rotating skills will be introduced.
Stage 5: Six months onwards
The objective is for you to return to a full level of activity at any chosen sport. Three to four months of sports training may be required before you are in condition to compete effectively.
Naturally the above is only a guide and will be tailored by your physiotherapist to your progress and to the instructions that we give.
RISKS
ACL surgery is complicated by infection in less than 1% of cases. You will be given antibiotics to decrease that risk. If you notice fevers, increased pain or night sweat you should contact us.
Blood clots are rarely see after ACL surgery. You will be given stockings to reduce that risk, If you are a smoker or on medication such as the combined oral contraceptive pill, you may be given blood thinning drugs to take after surgery,
Please talk to Professor Haddad before your operation if you have concerns about possible risks.
We hope the information provided has been of benefit to you. For further information please contact us on 0207 935 6083.