The anterior cruciate ligament, frequently known as the ACL, is the most commonly injured ligament in the knee. Approximately 1 in 3,000 people injure their ACL every year. Several of these injuries occur while skiing in the winter months. Skiers are more susceptible to ACL injuries because they are constantly flying over bumps, landing a jump on the tails of their skis, recovering from a skid, or finding themselves temporarily off-balance. Most skiing injuries occur when a skier “catches an edge” as a result of these actions and their ski is pushed sideways and to the outside, resulting in a twisting motion of the knee. Advancements in surgical techniques and rehabilitation over the years have allowed patients with ACL injuries to participate in early pre and postoperative rehabilitation to return the patient to a preinjury performance level.
Before surgery, patients should focus on reducing knee swelling and establishing a normal walking pattern and active range of motion between 0° and 90°. Elevating the leg with a cold compress or using compression sleeves are two techniques that can be used to reduce knee swelling after the initial injury. If a patient is stable with a normal walking pattern, they may keep the brace unlocked and bear weight while performing daily activities. Otherwise, the brace should remain locked to provide support to the unstable knee. Patients should establish a good range of motion after the initial injury because preoperative range of motion is an important predictor of postoperative range of motion.
To re-establish range of motion, please try some of these techniques:
1. Prone hangs: Lie on stomach and slide down to the end of the table so that the thigh is supported and the lower leg hangs off. Hold this position for 30 to 60 seconds and repeat 5 to 10 times.
2. Heel slides: Lying on your back, slide your heel towards your butt
3. Prone flexion: Lying on your stomach, flex your knee and bring your foot towards your butt
During the early postoperative phase (0-4 weeks after surgery), patients must strive to minimize pain and swelling, form a normal walking pattern with a goal to discontinue crutch use, achieve 90° flexion and full extension, and establish quadriceps function and control. Always ensure that the incisions are clean and dry and the knee is iced and elevated until the acute inflammation is controlled. After this inflammation is controlled, ice and elevate the leg 3 times a day for 15 minutes. Weight bearing with a brace and both crutches should also begin the day of surgery. Crutch use should be discontinued when the patient establishes a normal walk pattern without a limp and can walk up and down stairs without pain or instability. This phase is also important to establish range of motion and quadriceps function. We recommend attending physical therapy 2 to 3 times a week to extend range of motion to 120° and demonstrate straight leg raises without lag by week 4.
During the strengthening phase (4 weeks-6 months after surgery), the brace should be shortened and unlocked. There should not be an increase in swelling or pain and the patient should focus on proper technique and achieving full range of motion as soon as possible. The following exercises should be performed during this phase of recovery: mini-squats, mini-lunges, leg press, hamstring curls, step-downs, wall sits, one-legged dead lifts, and 4-way hip exercises. Weights should gradually increase as strength improves. The patient can also start walking for exercise and use balance cushions to improve endurance and balance.
The return to activity phase begins 3 months after surgery and ends when the patient returns to his or her sport. The patient must continue improving muscle strength with activities such as squats, lunges, plyometrics, and agility drills. At the beginning of this phase, the patient should perform low-impact activities on softer surfaces, eventually introducing walk/jog intervals and agility ladder drills, and finally cutting and pivoting with advanced plyometrics and team participation without contact. Each patient is unique and his or her return to sport should be individualized instead of follow a strict time line. Once the patient can jump without pain or instability, has full range of motion, regained muscle strength and balance, and can perform sport specific activities without pain, swelling, or instability, the patient is ready to return to the sport.
If you suspect you have an injured ACL, it is important to see an orthopedic surgeon. To schedule an appointment with board certified orthopedic surgeon, John Vitolo, MD, call 973-300-1553.