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.
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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.