Anterior Cruciate Ligament (ACL) injuries:
what is the usual history?

A good history alone will often diagnose to near certainty an ACL rupture.  This is what you might expect to hear from a patient with acute ACL rupture:

• Non-contact event usually when decelerating, stopping suddenly, twisting, cutting, or jumping.
• “Knee falls in” with a fixed foot, creating the sheering which exceeds the capacity of the ACL.
• Oftentimes the patient will recall hearing or feeling a “pop”.
• Sometimes they may report brief a hyperextension of the knee joint.
• There is usually immediate severe pain, which eases over a period of minutes.
• Patients may then feel they can continue activity, but notice “giving way”.
• Usually considerable swelling occurs within few hours.
• In a subacute presentation patients involved in sports may describe feeling like they need to “round” their cuts rather than being able to pivot easily on the injured leg.
• In a contact injury (typically football) the ACL is usually ruptured after a direct blow to the lateral side of the knee.  Other structures are frequently injured in addition to the ACL. This is often seen as the ‘unhappy triad’ that includes the ACL, medial collateral ligament (MCL), and the medial meniscus.

Anterior Cruciate Ligament (ACL) injuries:
To reconstruct or not?

If there is one injury that strikes fear into the hearts of most active people it is the dreaded Anterior Cruciate Ligament (ACL) rupture of the knee.  It’s likely you’ll be asked, “Should I get my knee done?”

After an ACL injury, it is common for a patient to feel angry, depressed, frustrated and uncertain about their future. Making a plan with your patient is important and provides them with hope. Your plan should include (and in this order):

1. Gathering the rehab team
2. Starting rehabilitation straight away
3. Deciding whether to have surgery (or not)

The rehab team is likely to include exercise professionals (e.g. physiotherapist), a surgeon, a GP/sports doctor, a coach, team-mates, family, and friends.

Patients should begin high-quality rehabilitation immediately after an ACL injury irrespective of surgery plans.

Deciding whether to have surgery is complex.  Encourage patients to gather information, consider their goals, consider their values, and consider risks.  The best course of action is to try to return normal knee function as soon as possible while deciding whether to have surgery.

There is no clear evidence that surgery is superior to undertaking high quality rehabilitation alone. There is only one published randomised trial comparing the two options. This reported no difference in pain, function or return to pre-injury activity levels at 1-, 2- and 5-years after an ACL injury.

It is clear that some patients need surgery and that some will cope well without.  Of course in either case they need physiotherapy and indeed we typically see the surgical group for a longer period.

ACL Rehabilitation: What to expect.

We rehabilitate ACL injuries in phases.  There are many protocols, but three main phases.:

• Early:
  • Exercises to regain full range of movement and muscle activation.
  • Riding an exercise bike.
  • Practising weight bearing and walking evenly on both sides.
• Middle:
  • Exercises to single leg balance and control.
  • Exercises to improve general leg strength (eg. squats, lunges, and deadlifts).
  • Exercises to improve single leg strength with (eg. single leg squats).
  • Practising running.
• Late:
  • Exercises to improve landing ability (eg. hopping and landing practice).
  • Exercises to improve your ability to change direction.
  • Practising unexpected change of direction and agility.
  • Gradually returning to sport-related activities.

There exists a significant risk of re-injury.  We manage this risk by only clearing people to return to sport after they pass a battery of performance, confidence and functional tests and return to sport criteria.  Even after return to sport, we teach exercise based injury reduction programs as part of ongoing risk mitigation.

Of course we are happy to see your patients with knee injuries and to be part of their rehab team.  Referrals can be made by phone, walk-in, online or email found here.