ACL reconstructions (ACLR) are often thought about in a similar manner as the Space Shuttle program was five years ago. This huge 240,000 lbs space ship would be launched into space at over 17,000 mph and it might only get a quick 30 second side-comment on the local news.
It’s not that simple and when there is a problem, with an ACLR or with the space shuttle, the results are not good.
Here’s a look at a present ACL reconstruction situation with a friend of mine that will show you what happens when all doesn’t go according to the plan. She’s struggling to get her knee and her athletic career back on track.
“Katie” is an athletic 42 years old rockin’ soccer player at the time of her ACL tear in June 2011. She gave me permission to share her story with MikeRyanFitness readers.
Katie had ACL surgery reconstruction (ACLR) in mid-July 2011 with an allograft. I was surprised to see that she used a tibialis anterior tendon from a cadaver. When this form of harvesting tissue from the surgical patient themselves, it is referred to as an autograft.
Braced in week #1 along with ice, very little weight-bearing and no physical therapy.
Katie’s rehab started during week #2 with 50% weight-bearing, strengthening exercise only in open chain (foot off the ground) and range of motion (ROM) drills.
The brace was removed during week #4, full weight-bearing was started, only open chain exercises continued, ice and starting Russian Stimulation using an electric stimulator to aid in muscle strength.
Time for Concern
During the start of week #5, the surgeon expressed concern with the limited ROM.
His Plan: He drained fluid out of the knee, gave her a cortisone injection and instructed physical therapist to implement closed chain activities, which is a great way to rehab ACLR patients by exercising them with their feet on the ground.
Katie has endured dozens of hours of painful rehab with minimal improvement and few examples of improvement.
“My frustration is mostly due to the inconsistency in treatment and shifting focus constantly with my rehab plan…”
This 10 to 14 week phase of rehab should be the exciting part of her knee marathon but it has turned into a painful and stressful time for Katie.
The knee remains significantly stiff, swollen and limited in range (limited by approximately 10 degrees from full extension). Katie complains of pain during all activities and while at rest. Her family and social lives are significantly limited. It’s understandable that Katie is frustrated with her care and her inability to remain active.
Her doctor wants to perform an arthroscopic surgery (“a scope”) in the next two weeks to remove scar tissue, based on the recent MRI. I assume some form of a manipulation may be performed at the same time to regain needed ROM after the scar tissue is removed and while the Katie remains under anesthesia.
“I have let this knee consume me for months and I finally just took a mental vacation from it the past few weeks.”
After the scope, rehab will continue immediately. A continuous passive motion (CPM) may be utilized to help the knee to remain in motion while Katie is resting and sleeping. I think the CPM is a great tool to help maintain ROM and decrease pain.
My Advice to Katie
- Have a detailed discussion with the surgeon before the ACL surgery. Ask the important question:
“What do you expect to find in my knee and what are my options in managing these findings?”
“What kind of ACL surgery graft will you use with me and how many of these types of surgeries do you perform every year?”
“Do I need a micro-fracture surgery?”
- Your articular cartilage may be damaged and it may be the reason why you’re having so much pain and swelling.
- Excess scar tissue is not too common but I’ve seen it with pro football players. They did very well after a scar tissue removal scope.
- After the scope, start your aggressive rehab ASAP. (note the capital letters!)
- Use a CPM machine as much as possible.
- Seek the opinions of other knee doctors and physical therapist in your area. Remember that it’s your knee that’s in turmoil so stop worrying about their feelings.
- As for the mental vacation, it’s needed and truly justified. Get your mind “right” because you still have some heavy work ahead of you, Katie.
- Keep your quad strong!! Gains in quad strength may come in smaller chunks after the scope but it may prove to be the #1 variable if you want to be an athlete for the next 30 years.
- From what you’ve been thru, the next phase will be a bit easier and MUCH more rewarding.
Mike Ryan’s Sports Medicine Tips for an ACLR Rehab Plan
- Research your doctor and his/her exact surgical technique before your ACL surgery.
- Get a copy of your surgeon’s WRITTEN rehab protocol before your ACL surgery.
- Meet your physical therapist and review your rehab protocol with her/him. Ideally, schedule 1-3 rehab appointments with your therapist before the surgery to increase both knee ROM and quad strength
- Plan on a marathon. Get your body and mind right to put in the necessary work for 6-9 months to successfully put this injury in your rearview mirror.