The time has come for a blog about the ACL. If you are a human, 99.9% chance you have heard of the ACL. Okay, I made that statistic up, but I say it because it is a common injury with a long recovery so if someone in your circle had an ACL injury, you have probably heard of it.
Now, let’s talk about real ACL facts.
First of all, ACL stands for anterior cruciate ligament and is one of the four main ligaments in your knee. The ACL resists forward movement of your tibia (your shin bone) as well as controls medial/lateral rotation, inward/outward movement (valgus and varus) and hyperextension of the knee.
In the United States alone, an estimated 200,000 ACL injuries occur each year and ACL reconstructions are the 6th most common orthopedic condition. 70% of ACL tears are non-contact injuries and occur due to the landing position of the leg that the body doesn’t have the requisite strength and stability to control. When this happens, the person will hear a “pop,” the knee will give out, and they will experience swelling within 0 to 2 hours.
The literature varies but women are reported to have 2.4 to 9.7x an increased risk of injury and specifically it’s been found that women are 4-6x more likely to injure the knee by excessive valgus (inward movement of the knee). This, my friends, is where we can play a part in injury prevention. A dynamic valgus is typically a result of a lack of hip strength and lower limb motor control. That is absolutely something that we can improve, but I will save that for another blog.
So say you think you tore your ACL. What’s next?
Well first, I would advise that you get an opinion from multiple orthopedic doctors. Believe it or not, there is an entire camp of people with ACL tears that do NOT need an ACL reconstruction. We call these people, “copers.”
Copers are able to stabilize their knees using muscle strength and control and are able to return to their activities without their knees giving way. Any surgery comes with risk, so we always recommend trying conservative care first. Unless there is additional injury to other structures, there is no difference in measures of function and knee structure at 5 years whether or not surgery was delayed. On the flip side, if you rush into surgery, you risk having a big surgery and recovery that could have been avoided.
Whether or not you choose to do surgery, completing physical therapy before the procedure makes a huge difference in your recovery afterwards. Prior to surgery we want your knee to have full range of motion extension, at least 125 degrees of knee flexion and as much single leg strength as possible. That is going to make your post-op training progression faster.
That being said, the phases of physical therapy post-op are greatly based on how you present and progress as an individual versus time based.
Generally speaking, we are looking at 5 phases of rehab. In each phase, we have specific goals and “tests” that tell us it’s time to move on to the next phase. Without getting into too much detail, phase 1 focuses on improving range of motion and getting the quadriceps to fire. Stage 2 begins strengthening and proprioceptive training and stage 3 adds plyometrics to the table. In stage 4, we are working on advanced plyometrics and spore specific training while stage 5 is our gradual return to sport stage.
While I say that this is not strictly time based, we also cannot fight with physiology and the healing process that our body needs to go through. First, the timeline can be impacted if other structures were injured and if the graft was harvested from another tissue in the body. The reconstructed ACL also needs to go through a process called “ligamentization.” The reconstructed ACL is made of a tendon but needs to structurally change to be more like a ligament, which has more give to it. The elasticity of this new ACL will be not be “normal” for at least 12 months and can continue to remodel up to 2 years.
Your ability to return to your sport will differ based on many things, including what exactly your sport is, but just know that for every month that return to sport is delayed, up to 9 months, the risk of reinjury is decreased by 51%. All of that is to say, what you do in physical therapy plays a huge role in your ability to get back to your activities safely, but keep the long-game in mind and know that sooner is not better.
Now, after surgery, your surgeon will send you to physical therapy. Unfortunately typical insurance-based clinics can only see you for the first 1-2 phases of rehab. Our space at MOTION RX is the perfect spot to finish off your rehab in order to get you back to the activities you love pain free. We will make a plan for you to work on when not in the clinic and compliment that work with supervised strength, plyometric, and sport specific training. Your goals are our goals.