The Inside Scoop on ACL Tears

Mechanism for an ACL Tear

The evolution of sports has proved to be a fascinating and often amusing combination of creativity, science and hype.  From the lightest of high-tech equipment to the craziest of celebrations, the world of athletics is changing every year.

In the minds of those involved in sports, some aspects remain the same.  One of those constants is the impact of the three most feared letters in sports.  Those letters linger in the minds of the athletes, coaches, team owners and the fans themselves.  They all brace for the injury reports hoping not to hear those three dreadful letters.  They all know the significant downtime needed to recover from these alphabet season assassins.  No one talks about it but we all know that when these three letters “come to town”, this athlete’s season is over.

ACL

There they are.  Although not everyone knows what the three letters stand for, we all hope that our anterior cruciate ligaments remain strong and healthy for our entire lifetime.  An ACL or anterior cruciate ligament tear requires 6 to 9 months of intense rehab with no guarantee that the athlete will fully recover.  Those two simple facts justify the reason why we all fear a torn ACL.

ACL Tear Success Story

During the 2009 season Tom Brady, All-Pro quarterback for the New England Patriots, returned from an ACL tear that took place during the 2008 season.  The media and the fans spent most of the off-season pondering the questions:  “Can Tom fully recover from this surgery and will he be the same superstar player that he was before the injury?”

The wait is over and Tom has returned to his winning ways with two outstanding seasons since he was helped from the field in pain with an anterior cruciate ligament tear.  To put an exclamation point to his successful recovery, Tom was recently awarded the 2010-11 NFL Most Valuable Player Award.  It’s a true credit to Tom’s dedication to his profession and the Pat’s Head Athletic Trainer Jim Whalen and his staff’s efforts.

ACL and Its Role in Stabilizing Your Knee

The anterior cruciate ligament (ACL) is the key stabilizing ligament in the knee.  The ACL starts at the distal posterior lateral (back and outside) femur (thigh bone) and crosses the knee joint and attaches to the proximal anterior medial (upper front and inside) tibia (shin bone).  The ACL is one of the two internal knee cruciate ligaments that serve to stabilize the forward/backward shifting of the knee along with a considerable rotational controlling function to the most common injured joint in sports.

The ACL’s most important role is to keep the skin bone properly positioned under the thigh bone by applying a backwards force to the shin bone when the athlete is decelerating and changing directions.  With an ACL tear, this shifting and rotational instability are the most common complaints of someone who has a torn ACL.

Knowing the Truth about an ACL Tear

Now that the formal medical stuff is covered, let’s talk about the reality of the ACL and how it impacts you as an athlete.

Personally, I’ve been involved with the rehabilitation of close to eighty high-level athletes with ACL injuries.  Over 90% of the outcomes of these athletes who required ACL reconstruction surgery has been outstanding.  The average length of time for a full recovery and return to full and unlimited activity has been approximately 8 months.  Depending upon the time of year and the NFL schedule, a quicker recovery is easily possible.  I’ve worked with professional athletes who have returned to full speed in almost half that time. Sometimes that is not always a good thing and I’ll address that in upcoming articles.

With a more aggressive return to full activity, the risks of tendonitis, chronic swelling and articular cartilage complications are often increased as well.

To Brace or Not to Brace

Preventative bracing before you get hurt for high-risk players is a smart decision.  Knee braces may appear bulky but when a brace is fitted properly and the athlete becomes comfortable wearing the brace, few athletes will notice that they are wearing a brace.  Research clearly shows that a properly fitted knee brace will not limited agility movement or negatively affect a football player’s ability to perform.  Especially when the sport includes contact such as football and hockey, preventative knee bracing is the practice of the wise athlete who wants to stay active for a long, long time!

The various types of ACL tear surgeries and the rehabilitation of an ACL tear are topics for future MRF articles.  The objective for this article is to help you shed light on the sports medicine facts related to anterior cruciate ligament tears.

Telling the Athlete the Bad News

No athlete wants to hear a certified athletic trainer or doctor tell him/her “…your ACL is torn and your season is over.” I’ve personally been that person dozens of times who has looked into the eyes of elite professional athletes to give them that very same message.   Their tears say it all.

I was involved in the HBO show called Hard Knocks with the Jaguars in 2004.  During one of the episodes they aired a gripping live scene of me telling an emotional player on the practice field that he had a torn ACL and his season was over.  I love my players and moments like that never get any easier for me.

Questions to Ask About an ACL Tear

A smart professional athlete with a torn ACL who wants to safely return to his/her sport will ask his sports medicine specialist the following questions:

  1. How much of my ACL is torn?
  2. What medical grade, from 1 to 3, would you grade my instability for the following tests for both knees?
    1. Lachman Test
    2. Valgus Stress Test at 30 degrees.
    3. Anterior Drawer Tests
    4. Posterior Drawer Test
  3. If you are recommending an ACL reconstructive (ACLR) surgery, which type of surgery and why?
  4. Who do you recommend to coordinate my treatment?
  5. Do you recommend that I wear a brace for future athletic events?

Tips to Have a Successful Recovery from an ACL Tear

  1. No Special Pill – A torn ACL is what it is.  No one has invented any special ACL vitamins or specific exercise to make the ligament stronger.  Training properly and protective knee braces may prove to be your best medicine.
  2. Coaching Tip – The best prevention principle for ACL tears is to slowly progress with the fundamental basics of your sport to ensure that your lower extremity strength and flexibility are optimal.
  3. Where the Rubber Meets the Road – Proper shoe wear is crucial to avoid too little or too much traction.  Both of which would negatively impact the knee stability.
  4. Surgery? – If you suffer a torn ACL and your future plans include being active at a moderate to high level, reconstructive surgery is highly recommended.
  5. “Pop’s” Are Not Good – According to research, 60% of athletes who hear a “pop” in their knee have an ACL tear.

Chondromalacia of the Patella Tendon

Chondromalacia - Dreaded Runner's Knee

Chondromalacia, known as “Runner’s Knee”, is one of the most common sources of knee pain for athletes over 20 years old.  The patella injury involves the patellofemoral joint, where the patella (kneecap) and the femur (thigh bone) interact.

Chondromalacia is the pathology that takes place when the articular cartilage on the back of the kneecap becomes irregular and damaged.  Because the back of the patella is now not the smooth and firm surface it usually is, it can damage the distal femur articular cartilage surface.  Much like a damaged pulley, the stresses that are placed on the moving surfaces being loaded become a source of patella pain.

Healthy articulating surfaces in the human body, including the patellofemoral joint, have 3 times less resistance than a wet ice cube on ice!  Think about that for a minute. This simple yet amazingly efficient system of transferring forces over joint surfaces allows 400 pound men to run and jump with minimal damage to the joint…..until that articular cartilage becomes damaged.

The back of the patella has a medial (inner) facet and the lateral (outer) facet that both come into contact with the medial and lateral condyles on the distal femur bone.

What Happens When You Have Chondromalacia

In between the two facets is the intrafacet ridge which glides in the trohclea groove located between the medial and lateral condyles of the femur or thigh bone.  Patella injury can result in damage to any combination of these articular contacts or the patella tendon itself.

With activity, the patella may not glide or track in the proper manner with knee flexion and extension.  With abnormal motion, damage to the surrounding tissues and/or the cartilage on the underside of the patella or distal thigh bone can take place.

The vastus medialis muscle, the most distal and medial of the quad muscles, will usually become weak with any patella injury.  With this inner quad weakness and resulting tightening of the outer knee structures, the patella tends to shift too far laterally or to the outside.

Younger Athletes and Osgood Schlatters

With younger athletes who have not physically matured enough to close their growth plates, they are susceptible to Osgood Schlatter disease.  Osgood Schlatters is a condition where the insertion of the distal patella tendon is elevated.  It significantly changes the tracking and movements of the kneecap.  Because of the alterations with the wear patterns of the backside of the patella, excessive articular cartilage damage occurs and patella tendon quickly becomes symptomatic.

Signs and Symptoms of Patellofemoral Pain Syndrome

  • A visible (atrophy) and functional quadriceps weakness when compared bilateral.
  • May have discomfort/pain in the anywhere around the patella with prolonged sitting and activities involving resistive knee extension such as running and jumping.
  • May have a history of Osgood Schlatters disease or patella injury.
  • Swelling sometimes occurs after activity.
  • A palpable grinding/clicking sensation from behind the kneecap with leg extension that may or may not be accompanied by pain.
  • A Q-angle greater than 20 degrees.

Professional Treatment for Chondromalacia & Osgood Schlatters

  • A product like the Trigger Point Quadballer is a great therapy option to relax the quad and increase the knee range of motion
  • Biomechanical analysis to assess the lower extremities bilaterally to determine if there are specific mechanical issues that are contributing to the Chondromalacia.  Common factors are:
    • Leg length discrepancy
    • Poor flexibility
    • Excessive pronation or supination
    • Quad weakness
    • Weak abdominal musculature
  • Consistent use of rollers and massage to the entire thigh area including the lateral thigh, groin and hamstring muscles.
  • Implementing aggressive quad strengthening exercises that are pain-free with minimal patella crackling or noise present.  To accomplish this, the types of exercises, the specific range of motion and the amount of resistance must be closely monitored to safely improve strength without increasing the symptoms.
  • Full flexibility of the lower extremity and low back.  The hip flexors, the IT band, the calves and, believe it or not, the big toe are the most overlooked areas for athletes who are not successful in overcoming this patella injury.
  • Warming up the knees are often overlooked but it is priceless with this injury.
  • Aggressive manual therapy and modalities to decrease the pain while increasing the mobility of the soft tissue associated with the patella.
  • Ice, ice, ice….immediately after any activity.

Questions a Pro Athlete Would Ask about Chondromalacia

To ensure you are treated like a smart professional athlete with a patella injury or Chondromalacia who wants to safely return to his/her sport, you’ll want to ask your sports medicine specialist the following questions:

  1. Are you certain of the diagnosis?
  2. Do I need any other tests to determine the extent of this injury?
  3. How badly damaged is the cartilage on the back of my kneecap and are there any activities that I need to avoid as I rehab this injury?
  4. What are my options with treating this injury?
  5. What factors do you consider to be the main reasons for my injury and, more importantly, need to be addressed with my rehab?
  6. Quad Weakness
  7. Poor Flexibility
  8. My Sport(s)
    1. Who do you consider to be the expert patella rehab specialist in this area?
    2. Do you have a detailed rehabilitation protocol to direct my rehab for both my therapist and me?

Tips To Help You Heal And Reduce Knee Pain

  • Be Farsighted – Chondromalacia is often the result of a biomechanical problem that needs to be corrected.  Look above, below, behind and in front of the kneecap to find the source(s) for the pain..
  • Change Now & Stay the Course – Most factors for patella injuries don’t just go away.  Plan on finding the problem, making the necessary changes and then maintain those changes for the long haul.
  • Be Honest With Yourself – Look closely at your workouts for the past 3 months and ask:  “Did I change too much too soon?”  Increasing the workload too fast is a common problem with athletes suffering from acute patella injuries.
  • Ice is Your Friend – Here we go again…….Ice hurts but it’s exactly what you need for this injury.  The Pro’s will tell you that ice is their best teammate. You’ve heard me say this many times throughout MRF, however I can’t stress the importance enough. You need ICE and lots of it. Also, if you have a child with Osgood Schlatters, make sure he/she is icing properly.
  • Father Time Has a Bum Knee – As we age our flexibility naturally decreases unless we work at it.  Consistently maintaining out flexibility is the key while joining a yoga or Pilates class is the ideal solution.  Start stretching NOW and take a lot of stress off your knees, patellas and low back so you can make this patella pain a thing of the past.

How Professional Athletes Successfully Treat Knee ITB Syndrome

Running With ITB Syndrome

Iliotibial band syndrome (ITBS), or Illiotibial band tendonitis, is a frustrating and troubling injury.  Because of it’s common mechanism of injury involves repetitive knee flexion and extension, it is often associated with runners.

Personally, ITB syndrome has proved to be one of the most difficult injury that I’ve dealt with as an athlete.

The IT band is a sheath of dense fibrous connective tissue which originates on its upper end to the tensor fascia latae muscle on the upper outer thigh.  The ITB extends down the lateral thigh and inserts into the outer surfaces of both the fibula and tibia bones of the shin. The function of the IT band is to help extend the knee joint, externally rotating the upper leg along with abducting of the hip.

Illiotibial band tendonitis is usually a result of the ITB being inflamed with excess friction of the ITB passing over the lateral epicondyle (the bony ridge on the outer distal thigh bone) of the femur (thigh bone).  With a repetitive knee movement like running or secondary trauma, the rubbing of this tissue over the hard bony ridge will result in inflammation and movement discomfort.

Signs and Symptoms of Runner’s Knee/Iliotibial Band Syndrome

  • Pain on the outside of the knee above, at or below the lateral knee joint line.
  • An increased tenderness with palpation(note: palpation is a method of clinical examination using gentle pressure of the fingers to detect growths, changes and unusual tissue reactions)of the iliotibial band.
  • An inability to squat through a full range of motion because of lateral distal thigh pain and weakness.
  • Knee pain normally aggravated by running, particularly downhill.
  • Pain during flexion or extension of the knee with both the foot on and off the ground.

How to Professionally Treat Iliotibial Band Syndrome

  • Apply cold therapy with ice bags, ice massage or ice bath.
  • Rest the knee and lower extremity from running, quad strengthening and painful activities.
  • Implement self myofascial mobilization and massage techniques such as rolling the thigh, lateral thigh and calves.
  • Aggressive flexibility of the IT band and the entire lower extremity including the ankle, great toe and low back.
  • Lateral knee and thigh massage is an effective treatment to reduce painful ITB tightness.
  • Assessing leg length and foot biomechanics bilaterally.  It is common to trace the source of lateral knee pain to a leg length difference or excessive pronation involving one leg.(Pronation means that the feet roll inward and cause the ankles to turn in.)
  • A thorough analysis of the athlete’s training program

Asking the Right Questions With Lateral Knee Pain

When faced with runner’s knee or Illiotibial band tendonitis, the wise professional athlete who wants to safely return to his/her sport and avoid further injury will ask his sports medicine specialist the following questions:

  1. Are you certain of the diagnosis?
  2. Do I need an MRI to rule out any other problems?
  3. What are the best options with treating this injury?
  4. What can I expect with this injury for the next 2, 4 and 6 weeks?
  5. Who do you consider to be the expert knee rehab specialist in this area?
  6. Will I be given a detailed rehabilitation protocol to direct my rehab for both my therapist and me?

Tips For Successful Iliotibial Band Treatment

  • Minimize the Damage – Illiotibial Band Syndrome is not an injury that you can just grit your teeth and run through.  Be smart early and avoid creating additional injuries.
  • Look Elsewhere – IT band tendonitis is often a result of a mechanical problem elsewhere.  Look above: hip & low back…..or below:…arch, ankle or great toe.  Don’t forget to look at your shoes!
  • Ice is Your Friend – It’s a reality check:  Ice hurts but it’s exactly what you need for this injury.  The Pro’s will tell you that ice is their best teammate.  Stop complaining and do what you know you need….ICE and lots of it.
  • Lighten up, Coach! – An athlete suffering from IT Band Syndrome is usually training very hard.  A common theme with this injury is that you do not have enough recovery time during the week or you are progressing too aggressively with your workouts.  Getting your coach, which sometimes refers to YOU, to work with you on this is a key step in getting this painful injury in your rearview mirror. A thorough analysis of your athlete’s workout plan is a great start.
  • How Long? – This may be one of the toughest injuries to put a recovery timeframe on.  The downtime from lateral knee pain associated with IT Band Syndrome is significantly reduced if you treat the injury early and modify painful activities while treating the injury as noted above.

Osgood Schlatters: Managing Youth Patella Pain

Painful Osgood Schlatters Disease

He has this huge bump below his knee, his doctor says he’ll grow out of it but it hurts him all the time.  What should we do?’ his mother said, frustratingly seeking an answer.

Following a fund raising golf tournament recently a good friend of mine came to me looking for a clear answer for a strange injury with a bizarre name.  Her athletic teenager had an overly large bony lump just below his right knee.  He was 16 years old, still growing and she was understandingly concerned about her son’s knee.

Osgood Schlatters Disease is an orthopedic disorder that results in an enlarged tibial tuberosity just below the front of the knee.  The tibial tuberosity is the lower attachment of the patella tendon.  Because of the excessive forces generated by the quadriceps (muscles located in the front of the thigh) muscles, the load is transferred to the patella (kneecap) and directly to the tibial tubercle on the tibia (shin bone).

Patella injuries are usually a mechanical injury.  In a simplistic manner, when these muscles are contracted, the forces are applied to the tibial tuberosity and the knee is extended.  That’s the easy part.

A growth plate is typically a location at the end of most long bones.   At a growth plate, a cartilaginous ring allows for the growth of the bone.

Chondromalacia is commonly associated with many types of patella injuries.

Here comes the interesting part…..a growth plate is located at the tibial tuberosity.  Therefore, when an active teenager creates excessive forces at the knee with activities such as jumping, squatting, running, trauma,…etc., the rate and the direction of the growth at that tibial growth plate can easily be altered.  Hence, the bump gets larger and more painful.

Patella injuries are successful resolved when addressed promptly. With an early onset of Osgood Schlatters, if the young athlete rests the area for 2-4 weeks and avoids the specific sports activities that worsen his pain, his symptoms will resolve themselves.

Osgood Schlatters and chondromalacia are similar in the fact that when these conditions occur, the athlete is typically predisposed to having symptoms in the future.  With Osgood Schlatters, when the athlete stops growing and his growth plates mature or “close”, the athlete has much less problems with the injury other than the cosmetic appearance and mechanical issues of an enlarged tibial tubercle.

Suggestions to Alleviate Osgood Schlatters Pain

  1. See his doctor to clearly diagnose this problem and to “rule out the bad stuff.”
  2. Ice his knee after every workout and competition.
  3. Become a flexibility machine.  My advice on flexibility: start young and stick to it.
  4. Avoid aggressive leg strengthening exercises and agility work whenever possible.
  5. Rest the knees.  A little rest now will help him avoid missing large chunks of time later.

I think this young man will do well if he follows this advice.  The Osgood Schlatters will quiet down in time.  Meanwhile, the enlarged tibial tubercle will probably not return to its normal size.

As with most sports injuries, the earlier you address the problem the quicker they quiet down.  Being smart now will ensure that you will be active and healthy later!