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ANTERIOR CRUCIATE LIGAMENT (ACL) INJURIES

The anterior cruciate ligament (ACL) is the most important ligament for proper functioning of your knee. Its purpose is to maintain stability of the knee joint. As you can see from the anatomy picture below, it runs from the shin bone (tibia) up to the thigh bone (femur).

The ACL is often injured in active individuals. People that are in high intensity sports or have jobs that require a significant amount of activity are prone to tearing (rupturing) this ligament. Unfortunately, there are rarely varying degrees of injury to the ACL. In general, the ACL either withstands the trauma or is completely torn.

How do I know if I've hurt my ACL?

You may be able to predict if you have injured your ACL based on the background and/or history of your injury. If you have any of the following signs or symptoms, you may be highly suspicious that you have injured your ACL:

At this point, your knee should probably be evaluated by an athletic trainer, physical therapist, and/or orthopedic surgeon. The primary diagnostic test that is used to determine the extent of injury to the ACL is called the Lachman's test.

If there is increased movement with this test and a feeling that there is no "stopping point", then you may assume that you have torn your ACL.

You may be sent for a Magnetic Resonance Imaging (MRI) test of your knee, which may or may not be necessary. Below is a photo of an MRI scan with a torn ACL.

This picture is provided courtesy of  Medical Multimedia Group.

Surgery

If you wish to remain active in sports, recreation, or have an active occupation, then it is recommended that the ACL be surgically repaired. Without an intact ACL, the knee may be unstable and repeated "giving way" episodes may cause injury to the surrounding structures (i.e. ligaments, cartilage, etc.)

We recommend the following physical therapy goals be met before preceeding with surgery:

  1. You should have full straightening (extension) of your knee.
  2. You should have normal tone/contraction of your thigh (quadricep) muscle.
  3. You should have no swelling (effusion) to your knee.
  4. You should be able to walk normally.
  5. You should have minimal pain.
  6. You should have no pain/injury to the ligament on the inside of your knee (medial collateral ligament).

    Types of Surgeries

      There are basically three types of ACL reconstruction surgeries. The first type is the patellar tendon-bone autograft, which means that the surgeon takes a piece of your patellar tendon and uses it as your new ACL. The second type of surgery uses "quadrupled" hamstring tendon autografts or allografts (semitendinosus and gracilis). In the second type of surgery, the physician uses two tendons on the backside of your knee and doubles them up to become your new ACL. The third type is the use of an allograft, i.e. a tissue taken from a cadaver.

      Research on Surgery Types

      There is a plethora of ACL research in the medical literature. Medical search engines such as PubMed (www.pubmed.gov) or PEDro (www.pedro.org.au) may be used to find ACL information.

      Duquin et al (J. Knee Surg. 2009 Jan:22(1):7-12) reported survey results from 993 American Orthopaedic Society for Sports Medicine physician members. Reconstruction surgery using bone-patellar tendon-bone (BPTB) autograft was most commonly preferred (46%), followed by hamstring tendon autograft (32%) and allografts (22%). Five years earlier, BPTB grafts were more frequent and hamstring tendon and allografts were less frequent (63%, 25%, and 12%, respectively).

      Searches for outcomes comparing BPTB and HG reconstruction surgery appear to suggest that both techniques work well. Surgery choice must be individualized and will depend on several patient and surgeon factors.

      ACL Surgery Videos

      Videos of ACL reconstruction surgery may be seen at websites such as Google Video (http://video.google.com) or YouTube (www.youtube.com). Type in a search phrase such as "ACL Reconstruction" or "ACL Surgery".

      After Surgery

      After surgery, you will have a dressing applied to your knee and you will return to your room. Your knee will be placed in a continuous passive motion (CPM) machine (see picture below).

      Orthologic Lite Lift CPM Machine

      This device will move your knee back and forth in a very slow, controlled manner to aid with your range of motion, swelling and pain.


      You will also be issued a cold therapy unit that will circulate chilled water through an appliance placed on the top and around the sides of your knee (see picture below).

      Gameready Cold Therapy Unit

      The cold therapy will help with your pain and swelling.


      The usual hospital stay is approximately 24 hours. Before you leave the hospital, a physical therapist will show you how to walk with crutches and you will be required to wear a post-operative brace (see picture below).

      Donjoy ELS Post-Operative Brace

      The brace will be locked so that your knee will be fully straight. Your supervised rehabilitation will begin 48 hours after surgery.

      Rehabilitation

      Supervised rehabilitation usually involves following an ACL protocol agreed upon by the surgeon and physical therapist/athletic trainer. We recommend the use of either one of the following two protocols listed below:

      ACL PROTOCOLS

      1. Standard Protocol


      The following protocol has been developed in conjunction with Peter Buck, M.D. and Tom Greenwald, M.D., who are both orthopedic surgeons at McFarland Clinic, P.C. in Ames, Iowa.

      Dr. Peter Buck M.D. Dr. Tom Greenwald M.D.

      This protocol is Criteria/Evaluation based. Time basis is included. (Time based protocols apply to approximately 70% of the patient population, another 15% may heal faster and the remaining 15% may heal slower). We are suggesting approximately 20 physical therapy treatments, TIW (three times per week) for 3 weeks, BIW (two times per week) for 2 weeks and QW (one time per week) for the last 7 weeks. The patient will be expected to perform some therapy independently.


      INITIAL:Goals: Full extension equal to contralateral knee, edema control and active quadricep control.
      Brace locked in extension while walking and sleeping
      Weight Bearing as tolerated with crutches
      Prone Hang
      Bridging
      Active Hamstring Curls
      Wall Slides
      Patellar Mobilization
      Quad Sets
      Straight Leg Raises
      CPM on Biodex
      Gastroc Exercise
      Biofeedback
      Russian Stimulation
      Modalities as needed for control of pain and edema
      Evaluation: Full extension, mid-patellar edema, flexion ROM to 90 degrees, patellar mobility, Quad control/tone/isolation.


      1-2 WEEKS:Goals: Maintain full extension, decreasing edema, return of voluntary muscle control, prevent soft tissue scarring, ROM: 0 degrees to 90 degrees, full weight bearing as tolerated.
      Continue Initial Exercises and Treatment
      Cross Friction Massage to Incision
      Stationary Cycle-Active Assistive ROM
      CPM on Biodex-Active Hamstring Exercise
      Weight Shifting with Arm Support
      1/4 Squats/Wall Squats
      Cone Walking (neuromuscular control)
      Standing Terminal Knee Extensions on N-K Pulleys
      Step Ups-Unilateral
      Gentle Forced Extension to 0 degrees-PRN
      Weight Bearing Full, if no pain, edema or abnormal gait
      Modalities as needed for control of pain and edema
      Evaluation: Full extension, mid-patellar edema, flexion ROM, patellar mobility, and evaluate quadricep control.


      2 WEEKS:Goals: Maintain full extension, decreased edema, maintain voluntary muscle control, ROM: 0 degrees to 110 degrees. May start to unlock brace, only if full extension is maintained.
      Continue Previous Exercises
      Leg Press-Unilateral
      Gastroc Exercise-Unilateral in Leg Press, or Standing-Bilateral
      BAPS, Monitored, Level #1, Start with A-P Motion
      Evaluation: Full extension, mid-patellar edema, flexion ROM, patellar mobility, terminal knee extension with quad set.


      3 WEEKS:Goals: Full extension, increased flexion ROM, full weight bearing without complications, increase exercises as tolerated.
      Continue Previous Exercises
      Evaluation: Full extension, flexion ROM, gait, edema, patellar mobility, gait.


      4-5 WEEKS:Goals: Full extension, ROM: 0 degrees to 120 degrees, increase exercises as tolerated.
      Continue Previous Exercises
      Stairmaster-Monitored
      Swimming (flutter kick)
      Evaluation: Full extension, flexion ROM, gait, edema, patellar mobility.


      6 WEEKS:D/C ELS brace if approved by Physician.
      Quad isometrics at angles of 90 degrees, 70 degrees, 50 degrees.


      7-8 WEEKS:Goals: Weight bearing activities tolerated without brace, ROM: 0 degrees to 125-140 degrees, begin more functional exercises.
      Continue Previous Exercises
      Slide Board
      Mini-Tramp
      Skier's Edge
      Perturbation Drills
      Lunges
      Cycling
      Sub-max Quadricep Isokinetic Exercise (90-30 degrees ROM)
      Evaluation: As in prior weeks.


      3 MONTHS:Goals: Continue increasing exercise and function as tolerated.
      Continue Previous Exercise
      Leg Extensions (if needed) full ROM
      Begin Running
      Brace Fitting-Physician prescribed functional ACL brace with 10 degree extension block to be worn for 2 years.
      Evaluation: As in prior weeks.
      P.T. Discharge Criteria: Full ROM, Good Quadricep tone/control/isolation, patellar mobility, consistent edema, good stability, and understanding and compliance with continued rehab program.


      4 MONTHS:Goals: Begin more progressive functional rehabilitation.
      Begin Functional/Agility Drills as allowed by Physician.
      Evaluation: As in prior weeks.


      6 MONTHS:Goals: No restrictions to activities.
      Continue Previous Exercises
      May perform Isokinetic Test, Functional Test and/or Leg Press Test if prescribed by Physician
      Continue working toward full function/return to sports
      Evaluation: Isokinetic test, Functional tests, Leg Press test


      2. Accelerated Protocol

      This protocol is Criteria/Evaluation based. Time basis is included. (Time based protocols apply to approximately 70% of the patient population, another 15% may heal faster and the remaining 15% may heal slower).


      2-3 DAYS POST-OP:Goals: Full extension, decreased edema.
      Continue CPM
      Weight Bearing with crutches and brace on, as tolerated
      ROM 0 degrees to 90 degrees
      Prone Hang 3-4 times daily
      Active Hamstring Curls
      Evaluation: Full extension, mid-patellar edema, flexion ROM.


      7-10 DAYS POST-OP:Goals: Maintain full extension, decreased edema, return of voluntary muscle control, increased weight bearing.
      Weight Bearing-gradually increase to full with brace on
      ROM 0 degrees to 90-100 degrees
      Stationary Cycling-Active Assistive ROM
      Prone Hang-begin using 2#
      Active Hamstring Curls-isotonic
      Wall Slides
      Quad Set with Biofeedback
      Partial Squats/Wall Squats
      2"-4" Step-Ups
      Cone Walking (neuromuscular control)
      Heel Raises-standing
      Patellar Mobilization
      Standing Terminal Knee Extensions
      Cross Friction Massage to incisions
      Grade 1 (gentle) posterior tibio-femoral glides
      Modalities as needed for control of pain and edema
      CPM on Biodex, active Hamstring exercise
      Evaluation : Full extension, mid-patellar edema, flexion ROM, patellar mobilization, evaluate quad set.


      2-3 WEEKS:Goals: full extension, decreased edema, increased voluntary muscle control, full weight bearing.
      Weight Bearing
      Brace-may be discontinued if above goals are met
      ROM 0 degrees to 110 degrees
      Continue all previous exercises and treatment
      Leg Press-Unilateral
      Increase Step-Ups tp 4"
      Heel Raises, unilateral in leg press or standing
      Quad Isometrics at angles 90 degrees, 60 degrees, 45 degrees
      Start Stairmaster
      Perturbation Drills
      Standing terminal knee extension in N-K Pulleys
      BAPS
      Continue modalities as needed for control of pain and edema
      Evaluation: Full extension, mid-patellar edema, flexion ROM, patellar mobilization, voluntary terminal knee extension, gait.


      5-6 WEEKS:Goals: Maintain extension, increased ROM, decreased edema, increased weight bearing exercises as tolerated, begin functional drills.
      Weight bearing-full
      ROM 0 degrees to 120-130 degrees
      Continue all previous strengthening exercises and proprioception
      Squats-gradually increase ROM and add weight
      Leg Extension-90-30 degrees (if needed)
      Additional Proprioception e.g. Skier's Edge, Slide Board, etc,
      Isokinetic Test-high speed, extension block, anti-shear or proximal shin pad
      If strength is greater than 70%, may begin functional drills, e.g. jogging, agilities, jumping rope
      Evaluation: ROM, edema, isokinetic test.


      10 WEEKS:Goals: Increase exercise and functional activities as tolerated.
      Continue all previous strengthening exercises and proprioception
      Add Advanced Proprioceptive Exercises, e.g. mini-tramp, running with theraband, etc.
      Increase functional drills e.g. shuffles, cutting, carioca, figure 8's, etc.
      Leg Extensions, full ROM (if needed)
      Isokinetic Test at high speeds, Full ROM
      Evaluation: ROM, edema, isokinetic test, functional test, leg press test.


      4-6 MONTHS:Goals: Return to full activity.
      Continue all previous strengthening exercises and proprioception
      Increase level of functional progression, include sport specific drills
      Evaluation: Isokinetic Test, sport specific functional test, leg press test.


      NOTE: Functional Brace Use: This will be determined by the Physician.


      REFERENCES

      1. Shelbourne KD, et al: Accelerated Rehabilitation after ACL Reconstruction. Am. J. Sports Med.
      18:292-299, 1990.
      2. Blair DF, Wills RP: Rapid Rehabilitation Following ACL Reconstruction. Athletic Training. 26:32-43, 1991.
      3. Wilk, K.E. & Andrews, J.R.: Current Concepts in the Treatment of ACL Disruption. JOSPT. Vol. 15, No. 6,
      pp.279-293, 1992.
      4. DeCarlo MS, et al: Current Concepts on Accelerated ACL Rehab. J. of Sport Rehab. 3:304-318, 1994.
      5. DeCarlo MS: Presentation at NATA National Meeting, Salt Lake City, Utah, June 1997.
      6. Wilk, K.E.: Presentation at NATA National Meeting, Salt Lake City, Utah, June 1997.
      7. Shelbourne KD, et al: Preventing Anterior Knee Pain after ACL Reconstruction. AJSM. 25(1):41-47, 1997.
      8. Shelbourne KD, et al: ACL Reconstruction with Autogenous Patellar Tendon Graft followed by Accelerated
      Rehab. AJSM. 25(6):786-795, 1997.
      9. Beynnon BD: Strain Behavior of the ACL During Squatting & Active Flexion & Extension. AJSM.
      25(6):823-829, 1997.

      FUNCTIONAL BRACES

      A functional ACL brace may be prescribed by your orthopedic surgeon. As a general rule, the surgeon recommends this type of brace as the demand and level of activity increase. We recommend that this brace be fitted at approximately 12 weeks post-operatively, or when the size of the thigh is nearly equal to the size of the opposite leg.

      Different functional ACL braces are available, some are seen below.

      Townsend Rebel ACL Brace

      CLICK HERE to view other Townsend Design knee braces and products!

      Breg Fusion ACL Brace

      CLICK HERE to view other Breg knee braces and products!

      Shoulder Anatomy

      Although the "shoulder" is typically thought to include only the glenohumeral joint (the ball and socket), the shoulder complex actually consists of three joints (sternoclavicular, acromioclavicular, and the glenohumeral). The shoulder complex also includes the junction of the scapula (shoulder blade) on the posterior (back) body wall.

      This picture is provided courtesy of  Medical Multimedia Group.

      This picture is provided courtesy of  Medical Multimedia Group.

      The glenohumeral joint is a ball and socket joint similar to the hip. However, unlike the hip, it does not receive much stability from its bony structure. Instead, the shoulder has several soft tissue modifications that help improve its stability, including ligaments (connecting bone to bone), cartilage, and muscle.

      The ligaments of the shoulder are the thickest on the front and undersurface of the shoulder, the direction in which most dislocations occur. A rim of cartilage, the labrum, surrounds and serves to deepen the socket. Finally, the rotator cuff is a group of four small muscles that originate from different positions on the scapula, but insert through a common tendon onto the head of the humerus. These muscles help improve the stability of the joint by "steering" the ball on the socket. Shoulder injury/instability results from an inability of the rotator cuff and ligaments of the shoulder to maintain the ball firmly within the socket. Because the rotator cuff muscles originate on the shoulder blade, it should be apparent that shoulder stability is largely dependent upon the scapular muscles (trapezius, rhomboids, serratus anterior). If these muscles were deficient, the rotator cuff would not have a stable platform from which to pull.

      This picture is provided courtesy of  Medical Multimedia Group.

      This picture is provided courtesy of  Medical Multimedia Group.

      Shoulder Injuries

      Shoulder problems in a young, athletic population often include one of two diagnoses: shoulder instability or shoulder impingement.

      Shoulder Instability

      Shoulder instability includes either a dislocation or subluxation. Dislocation of a joint means that the two surfaces completely separate. In a subluxation, the joint surfaces come only partially apart. Often an accident or traumatic force is the cause of shoulder instability. However, there is a group of people with generalized "loose shoulders" who may feel their shoulder "come out" with relatively simple daily activities, such as reaching for a seatbelt or sleeping with their arms overhead. In general, these individuals often experience instability in both shoulders in contrast to the one sided instability experienced by those who have suffered a traumatic accident.

      This picture is provided courtesy of  Medical Multimedia Group.

      This picture is provided courtesy of  Medical Multimedia Group.

      Regardless of whether one's instability is traumatic or atraumatic, in approximately 90% of cases the instability is in an antero-inferior direction, i.e. the humeral head (ball) slips forward and down out of the glenoid (socket). When someone suffers their first dislocation, they experience significant pain, they will typically hold their arm down by their side unable to move their shoulder, and the deltoid area may appear flatter when compared to the opposite shoulder. In general, with each subsequent episode of instability, less trauma is required to separate the joint surfaces. Subsequent dislocations typically produce less pain, less disability, and a faster recovery time. However, the unfortunate consequence is a shoulder that may have once required significant trauma to dislocate can now become unstable with simple daily tasks.

      After an episode of instability, the ligaments of the shoulder rarely return to their pre-injury length. Therefore, the hallmark of treatment for instability lies in strengthening exercises for the rotator cuff. For if the rotator cuff is strong, it can successfully steer the ball on the socket decreasing the reliance of ligamentous stability. Rotator cuff strengthening exercises would include both internal and external rotation exercises as well as resisted elevation exercises.

      Historically, individuals with atraumatic shoulder instability have done very well with rehabilitation alone. When one suffers a traumatic dislocation, often there is an associated tearing of the ligaments or the labrum that cannot be overcome by a strengthening program. This may account for the high recurrence rate of instability in adolescents- 60-90% of those who suffer their first dislocation under the age of 20 will have subsequent episodes of instability. If instability persists after a 4-6 week trial of strengthening, surgery is often necessary to either repair the cartilage tear (Bankart repair) or to tighten the ligaments of the shoulder (Capsular Shift). The rehabilitation program after either of those two procedures is very similar.

      This picture is provided courtesy of  Medical Multimedia Group.

      This picture is provided courtesy of  Medical Multimedia Group.

      Shoulder Tendonitis/Impingement

      Another common athletic shoulder injury is rotator cuff tendonitis or impingement. As stated earlier, the rotator cuff is a group of four muscles that surround the humeral head (ball). In general, these muscles are not strengthened with a typical weight lifting routine and so they are often weaker than the primary movers of the shoulder. This muscle imbalance may eventually lead to inflammation of the rotator cuff (rotator cuff tendonitis). Once the tendon becomes inflamed, it may swell and become pinched between the humeral head (ball) and the acromion process of the shoulder blade. Whether the rotator cuff tendon is merely inflamed or being impinged, the signs and symptoms are relatively similar. Individuals typically complain of pain with overhead or repetitive motions or with heavy lifting. In general, they have little pain with simple daily tasks with the arm down by the side, although their symptoms may progress to this point if left untreated.

      This picture is provided courtesy of  Medical Multimedia Group.

      Because rotator cuff tendonitis and shoulder impingement lie on a continuum, the treatment for these two conditions is similar. The primary goals of a rehabilitation program are to reduce pain and then to slowly improve the pain-free range of motion. Pain reduction may be accomplished with the use of superficial modalities such as heat or ice or with medications. If the individual is involved in a supervised rehabilitation program, physical modalities such as ultrasound or electrical stimulation may also be used. Once pain has begun to resolve, stretching exercises are used to improve the overall range of motion and specifically target the posterior (back) aspect of the shoulder. Once range of motion has been restored, the goal becomes strengthening of the rotator cuff to correct any strength imbalances and prevent re-injury.

      Rotator Cuff Tears

      A true tear in the rotator cuff typically affects only those over 40 years of age. Certainly, there are well publicized rotator cuff tears in the shoulders of professional baseball pitchers, but the amount of force and number of repetitions that they expose their shoulders to is obviously greater than the population at large. A typical rotator cuff tear is one that begins without incident as a result of minor trauma throughout an individual's life. This process is often hastened by a traumatic injury to the shoulder-fall on the outstretched arm, overexertion, heavy lifting, etc.

      This picture is provided courtesy of  Medical Multimedia Group.

      Depending on the size of the rotator cuff tear, the symptoms may range from pain with overhead activities (mimicking impingement) or may render the individual unable to actively lift even the weight of their arm. Depending upon the amount of pain and disability the rotator cuff tear causes, the treatment of choice may be simple rehabilitation exercises or may involve surgical reattachment of the rotator cuff.

      This picture is provided courtesy of  Medical Multimedia Group.

      Surgical Rehabilitation Protocols

      Rehabilitation Exercises

      As with any other joint, the goal of rehabilitation of the shoulder falls into 5 phases

      1. Control inflammation (Swelling,Pain)

      2. Restore range of motion

      3. Restore strength

      4. Improve function

      5. Return to activity

      Inflammation is typically controlled through a varitey of means including-medication, rest, ice, elevation, and compression. Typically shoulder injuries do not cause a great deal of swelling, but they can be quite painful, particularly at night. The use of medication, rest, and regular icing can help decrease pain as can the use of a pillow for support of the shoulder at night.

      Once the pain has been controlled, range of motion exercises are begun. Typically these are performed with the use of an exercise wand or towel to allow the uninjured shoulder to guide the injured shoulder through its available range of motion

      Stretching Exercises

      Cross Body Adduction Stretch

      Wand Exercise- External Rotation

      Wand Exercise- Flexion

      Towel Stretch

      During supervised rehabilitation, devices such as the overhead pulleys or finger ladder can also be used to improve overhead range of motion.

      Finger Ladder

      Pulleys

      Strengthening Exercises

      Strengthening can be performed with light dumbbells or an elastic band. The elastic band provides portability and convenience, but is limited to only 5-6 resistance levels. Dumbbells offer a wider variety of resistance levels, but are not easily portable and a wide range of weights will be needed to challenge the shoulder appropriately through all of its various motions.

      The important factor is not which mode of exercises one chooses, but that the exercises are done properly and consistently. It should be obvious by now, the importance of a strong rotator cuff and these muscles are not well addressed during a typical circuit-training regimen.

      Theraband- External Rotation

      Theraband- Internal Rotation

      Theraband- Full Can

      Dumbbells- External Rotation

      Dumbbells- Internal Rotation

      Finally, the rotator cuff can only function appropriately if these muscles have a firm base to pull from- once again highlighting the importance of the scapular muscles to stabilize the shoulder blade.

      Scapular Retraction

      Punches

      Dumbbells- Rows

      Theraband- Rows

      As range of motion and strength are returning, it is important to address any remaining functional deficits and to begin to focus the rehabilitation on tasks to which the individual would like to return. If athletic participation is desired, devices such as the body blade or Plyoballs will be helpful for enhancing neuromuscular control and dynamic, explosive strength about the shoulder.

      Plyoballs- Catching

      Plyoballs- Push

      Plyoballs- Throwing

      Body Blade

      Body Blade

      Body Blade

      The final stage of rehabilitation involves the successful return of the patient/athlete to their desired activities.

      Please feel free to contact us with questions or comments.

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