Whether you are sitting in the orthopaedic surgeon’s room or on a physio treatment table, when you hear the words: ‘You have torn your anterior cruciate ligament and will probably need a knee reconstruction’; I am sure the reaction is fairly similar. After a few expletives and overcoming the shock of the scary sounding words, you start to wonder whether you’ll have a reconstruction and what it actually involves. Bode Miller, Alicia Camplin, Tiger Woods and even Powderlife’s own Bevan Colless have found themselves in this situation!
The ACL is the main stabilising ligament in the knee and without it the knee is vulnerable to giving way. Due to the design and tension of the ligament, the odds of this healing on its own once it has ruptured are less than 1 in 100. The ligament tends to fray like a horse’s mane when it ruptures so for it to heal naturally is quite some task. Sometimes, you can get lucky and the scarring of the injury may lead to a functionally ‘stable’ knee, but for most people sustaining this injury surgery is the advised option.
The good news is that you are much better off having this procedure done now than 25-30 years ago. The surgical techniques are far more advanced now than they were back then. These days the entire procedure is performed arthroscopically (via a camera) and usually as a day procedure. You should be walking very soon afterwards and not need crutches for very long. In days gone by a reconstruction required a week or two in hospital, a long zipper scar over the knee, a cast and months on crutches.
These days, there are generally three types of ACL repair techniques being used:
1) Hamstring graft – a strand of the hamstring tendon is cut from behind the knee and then looped 4 times and inserted into the bones where the ACL attached and held in place with screws. This is currently the most commonly used technique. Occasionally patients will have hamstring strains in the early phases of rehab, but this is usually not a long term issue.
2) Patella tendon graft. This procedure involves a strand of your patella tendon with a piece of bone off either end that is then screwed into the bones where the ACL was attached. This is less suitable for those who have to kneel a lot or possibly in jumping athletes due to the loads on the patella tendon with this activity. AFL players often tend to use this technique due to the higher risk of hamstring tears in these athletes.
3) Allograft, from a cadaver. This is generally only used for repeat offenders when the hamstring or patella tendon has already been used, but is gaining popularity in the United States, due to the lack of extra trauma to the body.
There is also a new procedure called the LARS technique which involves using a synthetic graft. This is not widely practiced and generally only useful in ACL injuries that rupture in the middle of the ligament. The benefits are that the rehab takes about half the time, and for an elite athlete this could be the difference between missing a season and not. It will be interesting to see the development of this technique, but it is unlikely to ever be the first choice for an amateur.
So I’ve ruptured my ACL. Do I have to have a knee reconstruction?
The simple answer is no, but it generally means you have to modify your lifestyle to straight-line activities. Contrary to what you may think, you can ski without an ACL and plenty of people do, often with a brace. However, if you want to be involved in directional-change sports or activities, knee reconstruction is usually recommended, which is why a younger, more active patient will usually be advised to take this route.
There is a school of thought that stabilising the knee via surgery will lead to less degenerative changes over time as there is less ‘wobbliness’ of the joint. Whilst this makes clinical sense, in reality it appears that the initial injury is enough to cause wear and tear later in life whether or not you have an operation. Surgery will reduce secondary meniscal (cartilage) tears over time.
What does the rehab involve?
Depending on your surgeon, rehabilitation will start anywhere from the next day to two weeks post operatively. Many surgeons are not even using a brace post operatively now. The goals of rehabilitation are similar regardless of the technique used. Rehab is imperative to your recovery under the supervision of a knowledgeable physiotherapist. It will focus on regaining range of motion, reducing swelling, improving strength and proprioception (balance reactions), and a graded return to sport.
A general rule of thumb is a full return to sport at six months for an elite athlete and closer to nine months for the amateur. With regards to skiing, it is recommended you start on groomed runs with lowered DIN settings prior than racing for the Niseko back bowl deeps.
So you may be asking how can you prevent rupturing your ACL in the first place?
There is some research involving American female soccer players and Scandinavian female handball players that a program focussing on proprioception, landing technique (with the knee bent more than 30 degrees) and strengthening (particularly of the thigh muscles) may help reduce the incidence of non-contact ACL injury. Although not skiing, this may have some relevance for a get fit to ski programme before coming to Niseko.
Happy skiing and with any luck you won’t be hearing me talk to you individually about ruptured ACLs at Niseko Physio.
These are some events you may experience to suggest you have torn your ACL:
• A traumatic event that often involves twisting of the knee. 70 per cent of ACL injuries are non-contact and are commonly seen in touch footy, skiing and netball.
• Swelling that usually develops relatively quickly (within two hours) after the injury.
• Pain that will often get better quite quickly, however it is usually enough to stop the patient continuing the activity.
• A ‘pop’ sound at the time of injury and a sense that the knee temporarily ‘came apart.’
• A giving way of the knee after injury particularly on twisting or changing direction.