ACL TEARS – CAUSES, PREVENTION & TREATMENT

1
ACL TEARS CAUSES, PREVENTION TREATMENT
http//www.virtualphysicaltherapists.com/
2
The Anterior Cruciate Ligament (ACL) is one of
two ligaments that cross in the middle of the
knee. The ACL stabilizes the knee by preventing
forward motion of your lower leg. It is a very
strong ligament but also the most commonly
injured ligament in the knee. ACL injuries are
often higher in those who participate in
high-risk sports, such as basketball, football,
skiing, and soccer. It is estimated that 100,000
-200,000 ACL tears occur each year in the US, and
ACL reconstruction is one of the most common
surgeries performed by orthopedic physicians.
3

• ACL Anatomy Biomechanics
• The ACL is a band of dense connective tissue that
  connects the femur (thigh bone) to your lower
  leg. Two cruciate ligaments are in the knee, the
  anterior(ACL) and the posterior cruciate ligament
  (PCL). Cruciate means cross and signifies the x
  shape the ACL and PCL make as they cross over
  each other. The primary function of the ACL is to
  stop forward movement and rotation of the shin
  bone on the thigh bone, and the secondary role is
  proprioception or providing position awareness.

4

• What causes ACL injuries?
• Athletes and weekend warriors who participate in
  sports that involve a lot of knee cutting, sudden
  stops, or a change in direction have a higher
  risk of ACL injury. Most injuries are not by
  contact or colliding with another player.
• Instead, non-contact injury of the ACL is the
  most frequent, involving a combination of knee
  valgus and internal rotation or dropping your
  knee and foot arch down and in.

5
Approximately 50 of ACL tears are accompanied by
other knee damage, including injury to the medial
collateral ligament (MCL), a tear in the
meniscus, and a bone bruise. Because most ACL
tears are non-contact, avoiding stress in the
problematic position of knee valgus with internal
rotation will reduce ACL tears and other overuse
injuries, including Achilles tendonitis, ITB
Friction Syndrome, Infrapatellar tendonitis, and
Plantar Fasciitis.
6

• What are the types of ACL tears?
• Injury to your ACL ligament does not always mean
  a complete tear. Similar to an ankle sprain, you
  can have varying degrees of involvement.
• Grade 1 Your ligament is strained but intact.
  Your knee is sore, but there is no disruption in
  the stability of your knee.
• Grade 2 There is a partial tear in your
  ligament. There may or may not be a feeling of
  instability or your knee giving way.
• Grade 3 Your ligament is completely torn. There
  is a feeling of giving way, but this feeling of
  instability may improve as the swelling reduces
  (2 weeks) or after the body compensates, usually
  after two months.

7
What are the risk factors for ACL
injuries? Injury to the ACL ligament is caused
by high-pressure loading of the knee in a valgus
and internal rotated position (inward knee with a
flat foot). This stress can occur when stopping
suddenly, cutting, or turning quickly, especially
during sports participation. An ACL tear can
happen to anyone at any age, but the most common
age is between 19-25 in males and 14-18 in
females. Females have another peak in their
forties and some research report that they are
four times more likely than males to sustain a
tear. Experts disagree on why girls have higher
rates, but if we look at the positional cause
knee valgus and internal rotation is a common
running form found in females and should be
addressed with education and biomechanical
changes to reduce the stress on the knee and
other overuse injuries.
8

• Factors associated with an increased risk
  include
• Poor running mechanics knee valgus,
  pronation, heel inward during swing
• Participation in sports activities that requires
  cutting and pivoting
• Age 14 -25
• Female
• Decreased physical condition.
• Fatigue causes poor mechanics
• Wearing ill-fitted footwear or improper equipment
• Playing on artificial turf

9

• What are the symptoms of an ACL injury?
• A loud pop is usually the first thing one
  feels/hears, followed by severe pain and a
  feeling that your knee is unstable or giving
  out. Within a few hours, there is immediate
  swelling. (Only a fracture and ACL tear cause
  immediate swelling. A meniscal tear usually takes
  24 hrs. for swelling to appear.)
• Feel or hear a pop in your knee
• Feeling of the knee giving way
• Pain
• Swelling starts immediately or a few hours later
  and lasts up to four weeks.
• Loss of range of motion in your knee, especially
  extension
• Tenderness
• Discomfort and. difficulty with walking

10

• Do ACL tears hurt?
• Yes. You will hear or feel a pop when the injury
  happens and then pain. Trauma triggers a complex
  healing process, starting with inflammation or
  releasing chemicals to clean and repair the
  injury. Inflammation also triggers pain to
  caution you, let you know that you have an
  injury, and to be mindful of the injured joint.

11

• Can you walk with a torn ACL?
• Significant swelling in the knee causes neural
  inhibition of the quadriceps muscle. The quad can
  suddenly shut off when walking, causing the knee
  to give way. As long as swelling is in the
  knee, the quad may be shut down, leading to loss
  of strength over time. Marked weakness is
  typically observed following any injury, surgery,
  or pathology affecting the knee joint, and
  giving way is a common complaint. For those
  that have recently torn their ACL, the
  instability can be from swelling, quad
  inhibition, and lack of ligamentous support.

12

• Some people feel stable enough to walk as long as
  they do it slowly and carefully. Others use
  crutches and/or a knee brace with lateral bars
  for more support). As the swelling subsides.
  quadricep strength returns and the body
  compensates for the ligament loss the stability
  in the knee often also improves, and this usually
  starts to occur by the second month after injury.

13

• How is an ACL injury diagnosed?
• Your healthcare professional will take a medical
  history and ask specific questions about the
  cause of your knee pain. History of turning on
  your knee, hearing a pop and immediate swelling
  are usually indicative of ACL involvement. A
  physical exam is performed, including a Lochmans
  test for knee stability (stabilizing your thigh
  and moving your tibia forward), range of motion,
  test for swelling, and palpation for
  abnormalities and tenderness.
• An x-ray or MRI will probably be ordered to rule
  out fractures and potential ACL tears. An MRI may
  not be necessary because a physical exam may
  reveal that the ligament is torn.

14

• What is the immediate treatment for an ACL
  injury?
• As soon as you sustain an acute injury to your
  knee, use RICE therapy
• R Rest.
• I Ice.
• C Compression.
• E Elevation.

15

• What is the BEST long-term treatment? Surgery or
  Conservative Care?
• While surgery is the most common treatment and
  advice for athletes or anyone who would like to
  continue with a higher activity level, surgical
  outcomes are not as great as they preach. Surgery
  is painful, and rehab after surgery is long and
  grueling. The rate of returning to sports
  activity after surgery is only 55, and you are
  15x more likely to get a second ACL tear within
  12 months of ACL surgery compared to healthy
  subjects (contralateral knee higher rate).
• The rate of ACL spontaneous healing is at least
  56 and as much as 85! Yes, ACLs can heal!
  Contrary to popular belief, internet searches,
  and many physicians, full ACL tears can heal.
• (Our next blog will review and compare ACL
  surgery versus conservative care.)

16

• What is conservative care for an ACL tear?
• Conservative care consists of
• Reducing stress on the healing knee
• 1. Crutches initially as needed (2 weeks)
• 2. Caution with twisting, turning
• 3. Option of a knee brace with metal hinges until
  knee feels stable. Wear the hinged brace with all
  weight-bearing activity while the knee is
  unstable. Start to wean at 2 months, but if the
  knee still feels unstable, use a brace for up to
  10 months.
• 2. Regain full AROM
• 3. Regain full strength
• 4. Progress to balance and proprioception
  exercises
• 5. Finally, progress to high-level
  proprioception and sport-related activity

17

• Should I have surgery or conservative care if I
  want to go back to sports activity?
• The type of treatment you receive is up to you.
  The most important thing is to allow and give
  your knee time to heal. You should consider
  surgery only after you have completed
  conservative care for at least 5 months and your
  knee is still unstable. Do your own research, and
  weigh the options that are best for you.
• Can I live a normal life with an ACL tear?
• Absolutely, but it may take some time before
  youre completely back to how you were before the
  injury. . ACL tears are quite common, with 70
  occurring in every 100,000 persons or
  100,000-200,000 each year. Almost all are able to
  return to full daily activity. Returning to
  high-level sports activity is much lower, but
  there are factors that can improve return to
  sport, and these will be discussed in our next
  article. Whether you choose to have surgery or
  not, with proper exercise, you will eventually be
  back to normal and able to live your life.

18

• Can I play sports with a torn ACL?
• Yes, many athletes have returned to sports and
  even professional sports after ACL reconstructive
  surgery and after no surgery at all.
• After surgery, it takes about six to nine months
  of physical therapy to regain full range of
  motion, balance, strength, endurance, and
  proprioception. Returning too early significantly
  increases your risk of tearing your ACL again.
  There is also a high risk of tearing the opposite
  (contralateral) ACL within two years of returning
  to athletics, with females being much higher than
  males. But proper rehabilitation includes not
  only regaining full range of motion and leg
  strength but also proprioception and
  biomechanical correction of knee valgus and
  pronation while running and pivoting.
  Proprioception is your awareness of your body in
  space. Exercises to improve proprioception
  include balance with eyes open and closed,
  lunges, quick turns, jumping, etc..

19

• What questions should I ask my healthcare
  provider?
• Do I have a partial or complete ACL? (MRI picture
  may be misleading)
• Is there any other damage to my knee? (MCL,
  meniscus, bone bruise)
• Do I need to see a specialist?
• Can you provide a good orthopedic surgeon and
  physical therapist that focus on conservative
  care?
• What should I be doing now to protect my knee and
  allow healing?
• When can I return to work/school?
• When can I drive?
• How long do you predict it will take me to
  recover?
• If I want to return to sports, what are the
  measurable signs of an excellent outcome from
  conservative care?

20

• Since this is a non-contact injury, how can I
  reduce my chances of tearing the opposite side
  and/or re-injury my involved knee?
• What are the signs of a poor conservative outcome
  and the need for surgery?
• What are the pros and cons of surgical repair of
  my ACL tear?
• What kind of graft is best for me?
• What are the milestones that I need to hit to
  have a successful outcome and return to sport?
• How soon after treatment will I feel better?
  Whats the recovery time?
• Six to nine months is typically how long it takes
  to recover from both conservative care and ACL
  surgery.

21

• Can ACL injuries be prevented?
• It is not possible to completely eliminate ACL
  injuries, but various training techniques can
  minimize the risk of tearing the ACL. Most ACL
  injuries are again non-contact, meaning that the
  ACL tore because of the position of the knee when
  pivoting, stopping suddenly, and landing from a
  jump. Planting incorrectly overwhelms the ACLs
  integrity leading to a tear. Reducing the stress
  on the knee when performing pivoting, jumping,
  etc., will reduce stress on the ACL and make it
  less likely to tear.

22

• 1. The number one position of the knee when the
  ACL tears is valgus and internal rotation (inward
  with foot pronated). Athletes should be evaluated
  and learn about this faulty mechanic when they
  are young, especially females.
• Sports physicals should include a simple
  assessment to assess knee valgus and internal
  rotation with squatting, running, and pivoting,
  and athletes should be given educational material
  and a referral for biomechanical assessment when
  found.
• 2. Fatigue as a factor in ACL injuries
• Tired athletes are more likely to use poor
  mechanics, especially when they are making a
  split-second decision to execute an unexpected
  move.
• 3. Proper training can help prevent injuries.
• Studies show that specific training programs can
  improve athletes running form, leg strength, and
  jump-landing techniques. The techniques that
  improve ACL safety can also enhance performance
  and increase vertical jump height, acceleration,
  and the ability to change direction, as well as
  reduce overuse injuries.

23

• 4. Proper footwear and equipment
• Footwear or equipment that is ill-fitted or
  compromised can cause altered biomechanics and
  lead to unusual tweaking of the knee, causing
  undo stress on the ACL. Be sure to check cleats
  and equipment for any malfunctions prior to
  playing.
• 5. Avoiding artificial turf
• It has been shown that artificial turf does not
  give as much as natural grass and has been
  correlated to increased injury and ACL tears.
• Nothing can prevent ACL injuries altogether. But
  exploring their potential causes and maximizing
  prevention strategies can stop the pop and its
  frustrating consequences.

24

• Can ACL tears be cured?
• With time, dedication, hard work, and proper
  physical therapy, you can regain full use of your
  knee within six to nine months.
• Some ACL tears do heal.
• Some ACL tears do not heal, but stability in the
  knee is regained after the swelling has subsided,
  quadricep strength is regained, and the body
  compensates for the ligament. The ACL may not be
  intact, but when balance and proprioception are
  regained, these individuals are able to return to
  play.

25

• Some individuals with ACL tears (stable and not
  stable) choose not to return to higher-level
  activity because of fear or other circumstances.
• Some ACL tears do not spontaneously heal,
  strength, balance, and proprioception are NOT
  regained, and the knee remains very unstable.
  Surgery may be an option, but first, a discussion
  must be on regaining ROM, strength, and
  proprioception, for surgery will also be a
  failure if not.

26

• Will an ACL tear ever happen again?
• Yes, you can retear your ACL, both post-surgical
  and one that has spontaneously healed. There is
  also a high incidence of having a tear in one
  and, within two years, tearing the ACL in the
  opposite knee. Being female, poor conditioning
  and improper biomechanics of knee valgus with
  internal rotation significantly increase your
  risk of retearing and tearing of the opposite
  knee.

27

• The most important thing is to prevent the
  mechanism that caused the ACL tear knee valgus
  and foot pronation. A biomechanical assessment
  only takes 30 minutes. Retraining your mechanics
  is valuable in not only reducing your chance of
  an ACL injury, but improvements in your
  biomechanics can also improve your performance
  and reduces your chances of overuse injuries!
  Schedule with one of our biomechanical experts
  now and learn simple exercises to improve your
  form!
• (Our next blog will review and compare ACL
  surgery versus conservative care.)

28
Virtual physical therapists

• info.virtualphysicaltherapists_at_gmail.com

• http//www.virtualphysicaltherapists.com/