ACL: Reconstruction and Rehab

ACL: Reconstruction and Rehab

By Andrew Richardson

In this article I will be looking at the anatomy of the knee, the ACL and its role, how does the ACL tear, the surgical procedure to repair it. Then to finish the rehab protocol to get athletes back playing their sport. I will be making reference to my day spent in SSC (Santry Sports Clinic) in Dublin, where I learned a lot more about ACL’s and their own World Class Return to Play Protocol.

Anatomy and Type of Joint of the Knee

The knee joint joins the thigh with the leg and consists of two articulations: one between the femur and tibia, and one between the femur and patella.[1] It is the largest joint in the human body.[2] The knee is a mobile trocho-ginglymus (a hinge joint), which permits flexion and extension as well as slight internal and external rotation. The knee joint is vulnerable to both acute injury and the development of osteoarthritis.It is often grouped into tibiofemoral and patellofemoral components.[3][4] (The fibular collateral ligament is often considered with tibiofemoral components.)[5]Below are a few images of the knee from a range of angles (this will help understand the terminology further on). 

What is the ACL?

ACL stands for “Anterior Cruciate Ligament” and is one of four ligaments that help to stabilise the knee joint through an array of movements. A ligament is a very tough/strong band of tissue which its role (no matter the location in the body) is to connect bones together at joint. Ligaments are found at all joints. For the knee in this case it is the femur to the tibia. The ACL is one of two ligaments that cross each other over deep within the centre of the joint.

The front of the human body is known as the anterior and the back is known as the posterior. The front ligament is called the ACL (Anterior Cruciate Ligament) and at the back is the PCL (Posterior Cruciate Ligament). The ACL is a very important structure as t helps with preventing the tibia (shin bone) from sliding and rotating too much (prevents a large range of motion and instability). It particular provides stability in twisting and turning actions. The PCL prevents the tibia from moving backwards and is the less frequently injured out of the two cruciate ligaments.

Good video from SSC on the ACL: https://www.youtube.com/watch?v=PAWXQ9TPnhM  

Then we have two ligaments at either side of the knee, they are known as collateral ligaments. One is called the MCL (Medial Collateral Ligament) as it’s on the inner side towards the body’s midline. The other is called the LCL (Lateral Collateral Ligament) as it’s on the lateral side. These ligaments provide the knee with stability during sideways motions.

How can the ACL tear?

The most common way the ACL can tear is through a combination of sudden stopping motion on the leg while pivoting on the knee. In 70% of cases this happens during non-contact movement e.g. rapidly changing direction, landing from a jump, an abrupt deceleration or twist. Particular sports e.g. soccer, GAA, rugby and basketball commonly demand these activities of the knee. Skiing is another common mechanism of cruciate injury and various falling mechanisms have been described. A contact injury e.g. a rugby tackle or road traffic accident is whereby the knee is forced excessively into a stressful position by outside contact. An ACL tear can mean a range of things as shown from the video https://www.youtube.com/watch?v=TSMA5EQZuTk

Here  is an example of an ACL tear;

What other Knee structures can be injured when the ACL tears?

Approximately half of all ACL injuries will be isolated. This means many patients injure another knee structure at the same time. These include the meniscal cartilage, the articular cartilage surface and other ligaments around the knee. Any additional damage will be identified on MRI and confirmed during surgery. Some of these cartilage tears can be left alone but some require treatment with either partial removal or repair. Some injuries require time to heal pre surgery, whereas other such injuries are addressed during surgery.

How will my Knee function if the ACL is torn?

It is possible to function without your ACL. If you have appropriate lower limb strength and control then low level activities are possible. Young athletes and athletes looking to return to sports involving twisting, turning and landing will most likely require reconstruction. Return to these higher level sporting activities is the principle indication for ACL reconstruction.

Repeated unstable episodes are to be avoided as it increases the likelihood for cartilage damage in the knee and increases wear and tear in the longer term. ACL reconstruction offers excellent stability and outcomes on return to sport for athletes who are motivated and compliant with the rehabilitation programme.

ACL surgery

An individual embarking on ACL reconstruction should have an understanding of the procedure and fully commit to the rehabilitation process. The operation involves replacing the torn ACL with a graft taken from another part of the knee. The aim is to positon this graft within the knee to take the place of the torn ACL and mimic its stabilising function. The two most commonly used grafts are constructed from either the patellar tendon or the hamstring tendons. The graft chosen will vary according to the patient and depends on other injuries, sports occupation and individual anatomical variations. The majority of the operation is performed arthroscopically (key hole surgery).

Remember surgery is not the only option for a torn ACL: https://www.youtube.com/watch?v=6zN-C-4nayw

However an incision is required to harvest the graft over the front of the knee. During surgery any other structures damaged during the injury will also be repaired. While viewing the inside of the joint through arthroscope, guides are used to drill bony tunnels to allow placement of the graft. The graft is then pulled into these bone tunnels and spans the knee joint. Screws are placed to wedge the graft against the wall of the tunnels to give immediate stability and allow healing of the new graft. This early bonding of the graft takes approximately 6 weeks for patellar tendon grafts and 10 weeks for hamstring tendons. The graft is strong enough at 6 months post-surgery to withstand load associated with sporting movement but continues to mature over the course of the following 6-12 months.  

You’re Role in Rehabilitation

It is important to follow the RICE regime following your injury (Rest, Ice, Compression and Elevation)

-          Rest: Reduce your activity levels for the next 2-5 days depending on the level of your injury. This minimises the chance of further tissue damage facilitates healing of the injury.

-          Compression: Your knee may be supported by a dressing during the day, which should be taken off when exercising and at night time.

-          Ice: Ice is an effective means of decreasing swelling and pain and can be used as long as you have swelling. Use a cold gel pack or ice cubes in a bag. Apply the ice to the affected joint, with the leg elevated. Apply the ice for 20-30 min max, then reapply every 2 hours.

-          Elevation: Lying down, elevate the joint above the level of the heart as much as possible in the initial 72 hours of injury.

Restoring your ROM

Restoration of full knee extension and as much flexion as possible is important as this facilities normal gait and movement. This can be achieved by working on the appropriate exercises as tolerated.

Key is doing functional movements to repair the ACL and prevent another ACL tear: https://www.youtube.com/watch?v=ezbY-IvHmFM

Gait

Due to pain, reduced proprioception ROM, muscular strength and control, we can have altered or compensatory movement. While it important to RICE the knee you are encouraged to walk with a normal gait pattern as early as possible (crutches may be necessary initially) starting with short distances and progressing as tolerated. Gait refers to walking pattern

Normal Gait

Improving Neuromuscular Control and Strength

As with any knee injury, pain and swelling in the knee are associated with muscle inhibition (reduced muscle function) and loss of proprioception/control. Sufficient strength and control around the hip and knee are vital to support the knee and thus avoid excessive load through the joint. Appropriate strength (based on symmetry and body weight) in the quadriceps/hamstrings and optimal single leg control are an important component of a pain free return to performance. Therefore any improvements that will improve strength and control pre surgery, will facilitate faster recovery times following surgery.

Video on neuromuscular training for ACL rehab: https://www.youtube.com/watch?v=V7alxsuQxIE

Mental Preparation

Mental preparation prior to surgery plays an important role in your rehab. It is based on your education and knowledge of both the surgery and the rehabilitation process and what a fully rehabilitated athlete returning to sport looks like. A good understanding will enable you to set realistic goals with your physiotherapist both pre-operatively and postoperatively. Focusing on short term goals on what you can achieve between diagnoses and having surgery will be very beneficial. Positive self-talk regarding the successful outcome and return to sport as well as imagery of returning to play can assist during this period as well.

Intrinsic and Extrinsic factors will play a role as well during this: https://www.youtube.com/watch?v=hPu4y6-t1Qg

Individuals will have a different response to surgery post operation so psychological support needs to be provided and individualised to each person: https://www.youtube.com/watch?v=scgoZ9l7VMY

Exercise Programme

These exercises are to be done prior to your surgery (all done with light weights and or no weights)

-          Knee Extension

-          Knee Flexion

-          Straight Leg Raise

-          Single leg Chair Squat

-          Leg Press

-          Hamstring Curl

-          High Knee Walking

-          Single Leg Balance

Exercises shown below

As a coach the athlete/client puts their trust in you. They are paying for a service to get them back playing to the same level as before in a quick time period. Trust is key between you and the athlete: https://www.youtube.com/watch?v=aoKwQH04KXk

MRI and ACL

Here is a good short video on how to read an MRI and to see if you have torn an ACL

https://www.youtube.com/watch?v=x8YVRZcBJE

SSC ACL Rehabilitation Pathway

In my professional opinion after spending a day at SSC I can honestly say this is the best protocol for a successful ACL reconstruction/rehabilitation programme out there (that I have seen). It combines the fields of Strength and Conditioning, Physio, Biomechanics and Surgery all under one roof for each individual patient.

I saw an integration of the above fields all corresponding with each other which is fantastic for the athlete but also accelerates research and CPD for all the fields in the facility.

Dr Edna King breaks down what he is looking during a successful ACL Rehab: https://www.youtube.com/watch?v=ZG9A-7TKFdk

Components of a Successful ACL Rehabilitation Programme at SSC

                        Single Leg Neuromuscular Control + Full ROM (Range of Motion) + Strength/Power

Running + Turning + Training = Graduated Return to Performance

ACL Rehabilitation Pathway

Here is a video of the pathway in action: https://www.youtube.com/watch?v=xV9KyGzT3tg

Stage 1: Rehabilitation

What’s involved?

-          Education on the rehab process

-          Assessment of your gait

-          Assessment of knee joint ROM and strength

-          Assessment of single leg control

-          Provision of prehabilitation exercises and pre-operative advice

-          Outline of what to expect during your in-patient stay and during the early stages of rehab

Stage 2: Post-Operative Inpatient Rehabilitation

What’s involved?

-          Assessment of the knee

-          Completion of post-operative rehabilitation exercises

-          Gait practice with crutches

-          Completion of stairs assessment

-          Discharge paperwork for your physiotherapist who you will see within 7-10 days of discharge

-          Review the ACL Rehabilitation pathway and  outline early rehabilitation phase

-          Answer any questions you may have about the surgery, rehabilitation and biomechanical reviews.

Stage 3: Initial 2Dimensional (2D) ACL Review

What’s involved?

-          Feedback on your rehabilitation to date

-          Assessment of knee joint range of motion

-          2D motion analysis of Single leg Control

-          Isokinetic Strength testing of the quadriceps and hamstring muscle

-          Mid-Thigh pull to assess strength through the kinetic chain

-          Single leg vertical jump height

-          Progress report for you, your consultant and physiotherapist

-          Overview of 6 Month 3D testing protocol

Stage 4: 3 Dimensional (3D) Biomechanical ACL Review

What’s involved?                                                                               

-          Review of your rehabilitation progress to date

-          Assessment of knee joint range of motion

-          3D motion analysis of single leg control and sports specific movement including indecision testing using Smartspeed gate system

-          Isokinetic and mid-thigh pull strength testing

-          Single leg vertical and horizontal jump profiling

-          Progress report for you, your consultant and physiotherapist  

Stage 5: Final 3D Biomechanical Review

What’s involved?

-          This testing process will mirror that of the 6 month protocol ideally placing you in the best position for a successful return to your chosen sport and completion of the rehabilitation process. You will be advised on how to resolve any remaining deficits and maintain healthy and high performing knees.

Here is a video of me using the Biomechanics Lab at my university (when I was bald and thinner hahah). It is a similar set-up compared to SSC. Teesside University Biomechanics Lab: http://www.tees.ac.uk/sections/common/video_player.cfm?videoid=579&catid=12

ACL Research

Some of my favourite ACL related journals;

-          Torg, J. S., Conrad, W., & Kalen, V. (1976). Clinical I diagnosis of anterior cruciate ligament instability in the athlete. The American journal of sports medicine, 4(2), 84-93.

-          Shelbourne, K. D., & Nitz, P. (1990). Accelerated rehabilitation after anterior cruciate ligament reconstruction. The American journal of sports medicine, 18(3), 292-299.

-          Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., ... & Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes a prospective study. The American journal of sports medicine, 33(4), 492-501.

ACL’s and Powerlifting

Now to apply this to Powerlifiting. The only exercise which poses the greatest risk of an ACL tear is during the squat through a knee valgus collapse.

Now during an ACL rehab all clients are made to do squats as part of their rehab protocol which is good. All of them keep a neutral foot positon for quad activation and to help speed up recovery. Looking at powerlifters and weightlifters a lot external rotate their feet so it activates the hamstrings more/glutes more. This is fine for the sport but for rehab purposes it should be gradually phased in.

For rugby/sprinting/soccer etc no external rotation just neutral foot position then work to isolate the glutes and hamstrings on their own. Over time once (7 months plus) introduce a slight external rotation to strengthen that plane of motion.

Work on building up the knee valgus and all quadriceps muscles. This takes priority. Use close stance box squats at start then build this up through increasing weight and increasing the ROM of the squat.

Concluding Thoughts

So you now know about the Knee anatomy, ACL, ACL tear, rehab process, SSC in Dublin and ACL research.

I hope this helps everyone in their rehab

Regards

Andrew

References

1.       Chhajer, Bimal (2006). "Anatomy of Knee". Knee Pain. Fusion Books. pp. 10–1. ISBN 978-81-8419-181-3. 

2.       Jump up ^ Kulowski, Jacob (July 1932). "Flexion contracture of the knee". The Journal of Bone & Joint Surgery 14 (3): 618–63.  Republished as: Kulowski, J (2007). "Flexion contracture of the knee: The mechanics of the muscular contracture and the turnbuckle cast method of treatment; with a review of fifty-five cases. 1932". Clinical orthopaedics and related research 464: 4–10. doi:10.1097/BLO.0b013e31815760ca (inactive 2015-05-08). PMID 17975372. 

3.       Jump up ^ Rytter, Søren; Egund, Niels; Jensen, Lilli; Bonde, Jens (2009). "Occupational kneeling and radiographic tibiofemoral and patellofemoral osteoarthritis". Journal of Occupational Medicine and Toxicology 4: 19. doi:10.1186/1745-6673-4-19. PMC 2726153. PMID 19594940. 

4.       Jump up ^ Gill, T. J.; Van De Velde, S. K.; Wing, D. W.; Oh, L. S.; Hosseini, A.; Li, G. (2009). "Tibiofemoral and Patellofemoral Kinematics After Reconstruction of an Isolated Posterior Cruciate Ligament Injury: In Vivo Analysis During Lunge". The American Journal of Sports Medicine 37 (12): 2377–85. doi:10.1177/0363546509341829. PMC 3832057. PMID 19726621. 

5.       Jump up ^ Scott, Jacob; Lee, Ho; Barsoum, Wael; Van Den Bogert, Antonie J. (2007). "The effect of tibiofemoral loading on proximal tibiofibular joint motion". Journal of Anatomy 211 (5): 647–53. doi:10.1111/j.1469-7580.2007.00803.x. PMC 2375777. PMID 17764523.

6.       Santry Sports Clinic: ACL Rehabilitation Pathway

7.       Santry Sports Clinic: ACL Rehabilitation Programme

AAndrew Richardson, Founder of Strength is Never a Weakness Blog

I have a BSc (Hons) in Applied Sport Science and a Merit in my MSc in Sport and Exercise Science and I passed my PGCE at Teesside University. 

Now I will be commencing my PhD into "Investigating Sedentary Lifestyles of the Tees Valley" this October 2019. 

I am employed by Teesside University Sport and WellBeing Department as a PT/Fitness Instructor.  

My long term goal is to become a Sport Science and/or Sport and Exercise Lecturer. I am also keen to contribute to academia via continued research in a quest for new knowledge.

My most recent publications: 

https://www.sciencedirect.com/science/article/pii/S1752928X19300216

https://www.sciencedirect.com/science/article/abs/pii/S1752928X19301076 

My passion is for Sport Science which has led to additional interests incorporating Sports Psychology, Body Dysmorphia, AAS, Doping and Strength and Conditioning. 

Within these respective fields, I have a passion for Strength Training, Fitness Testing, Periodisation and Tapering. 

I write for numerous websites across the UK and Ireland including my own blog Strength is Never a Weakness. 

I had my own business for providing training plans for teams and athletes. 

I was one of the Irish National Coaches for Powerlifting, and have attained two 3rd places at the first World University Championships, 

in Belarus in July 2016.Feel free to email me or call me as I am always looking for the next challenge. 

Contact details below; 

Facebook: Andrew Richardson (search for)

Facebook Page: @StrengthisNeveraWeakness

Twitter: @arichie17 

Instagram: @arichiepowerlifting

Snapchat: @andypowerlifter 

Email: a.s.richardson@tees.ac.uk

Linkedin: https://www.linkedin.com/in/andrew-richardson-b0039278 

Research Gate: https://www.researchgate.net/profile/Andrew_Richardson7