Physical Therapy for ACL Injury: Getting Started on the Right Foot
Did you Injure Your ACL? PT Can Help!
If you are an avid sports fan or an athlete yourself, it is likely you’ve heard of athletes injuring their ACL. The anterior cruciate ligament (ACL) is part of a team of ligaments that stabilize the knee joint. This ligament runs through the center of the knee joint between the two bones that make up the knee–the femur (thigh bone) and the tibia (lower leg bone). The ACL’s primary role is to restrain anterior translation of the tibia on the femur but aids in stabilizing against excess movement in other planes as well.
HOW DO ACL INJURIES OCCUR?
Most ACL injuries occur during athletics, however, a poorly executed everyday task can also result in an injury to this area. Younger athletes seem to be at higher risk than older athletes of tearing their ACL and women are at higher risk than men. Soccer, football, and skiing are three of the most common sports responsible for ACL injuries.
Believe it or not, most ACL tears are what is called a non-contact injury meaning the injury occurs in the absence of another player, for example, crashing into the knee of the athlete (though this certainly can be the cause of an injury to the ACL). Because of the mechanics of the ACL, it is susceptible to tearing when excessive strain is placed across the knee. One common mechanism of injury is sudden hyperextension of the knee joint with internal rotation of the tibia bone such as when a basketball player lands after a jump. Deceleration injuries are common also such as when a soccer player plants their foot in the grass while pivoting their upper body to change direction. It is possible, however, to injure this ligament simply by taking a misstep off of a curb if the joint is stressed in just the right way.
When the ligament tears it often produces a sudden pop along with significant pain. Swelling often develops within the first 24 hours and may last for quite a while. A deep pain or ache felt in the knee that worsens with walking or stair climbing is typical and a feeling of instability or giving way at the knee may occur. Tenderness, bruising and difficulty straightening the knee fully are also common. In about 50% of cases other structures in the knee such as the cartilage lining the joint, the meniscus or another ligament are also injured when the ACL tears.
HOW IS AN ACL TEAR DIAGNOSED?
Because of the ACL’s role in stabilizing the knee, there are several tests that can be performed by a physical therapist, athletic trainer or physician to help rule in or out a suspected ACL tear. The Lachman’s Test, Anterior Drawer Test and Pivot Shift Test are three examples that may be performed to assess the laxity of the ACL by gently attempting to translate the tibia forward. An intact ACL will resist this movement. A low grade ACL tear (Grade I) may present with pain but laxity will be minimal whereas a larger grade ACL tear (Grade II or III) will allow the examiner to pull the tibia forward more than expected. An MRI is often utilized to confirm the diagnosis and examine the surrounding ligaments, cartilage, and soft tissue for injury. An X-ray will help to identify any injuries to the bone.
WHAT DOES TREATMENT LOOK LIKE FOR AN ACL INJURY?
The majority of people with an ACL injury will undergo surgery to help re-establish good stability and control at the joint. Some people will opt for nonsurgical management by modifying their activities to minimize excessive stress on the joint while a small number of people termed “copers” will return to athletics and be able to perform relatively well.
Nonsurgical management of an ACL injury focuses on using secondary structures such as the surrounding muscles to compensate for ligamentous instability in the long run while managing pain, swelling, weakness and range of motion impairments immediately after injury. Your physical therapist will educate you on ways to modify your activities to reduce unwanted stress across the joint. If the ligament has not completely ruptured, healing of the tissues will occur over many weeks but may never heal completely. As pain and swelling improve your PT will teach you exercises to improve strength and motor control around the knee joint and help you slowly increase your activity level. If return to sport is in your future then running and agility tasks will begin later in your rehabilitation.
Surgery for an ACL tear is the most common approach. Some surgeons will recommend a short course of physical therapy before surgery to help decrease swelling, improve knee range of motion, and strengthen the quadriceps muscles. Because repairing a ligament is nearly impossible, the torn ACL is typically removed and replaced with a graft from the patient’s patellar tendon or hamstring tendon. Sometimes a cadaver tendon graft will be used.
Physical therapy is an essential component of recovery from ACL surgery and progresses through several stages:
Recovery from surgery: Many surgeons will prescribe a knee brace and weight bearing restrictions for a period of time after surgery. During the initial recovery stage after surgery your PT program will aim to control swelling through modalities such as ice, taping or electrical stimulation; improve quadriceps muscle firing, regain full passive extension of the knee and begin to improve knee flexion mobility. Your PT will make sure you know how to use any assistive devices such as crutches and educate you on how much weight you can put through your leg based on your surgeon’s instructions.
Strength and neuromuscular control: Regaining leg muscle strength and motor control is an essential component of the next phase of rehabilitation. Exercises to improve leg muscle strength will be prescribed. Activities to challenge single leg balance and control of joint angles during tasks like a single leg step down or single leg squat are important to help recover full function of that leg.
Agility, running and landing: Once good neuromotor control, muscle strength and flexibility have been established on the surgical side it is time to begin applying more load and stress to the knee to prepare it for return to sport and recreation. Regaining full strength and balance is essential to this phase of physical rehab. Under the supervision and guidance of a physical therapist the athlete will progress through a graded jumping, running, and agility program to improve the ability of the muscles, tendons and ligaments to withstand and control acceleration, deceleration and rotation.
Return to sport: Your physical therapist will use a series of functional and sport-specific tests combined with subjective and symptom reports to guide you in returning to your sport. Re-injury of the ACL is the biggest concern when returning to sport and it is important that your knee is ready to accept the stresses that returning to sport will place on it. Sport specific drills and graded return to sport are important components of this phase of rehabilitation
Preventing future injury: Now that you’ve done the hard work of recovering from an ACL injury, it is important to continue a program that will minimize the risk of re-injury of the same knee or injury of the opposite knee. Your PT will individualize a series of balance, strengthening, and plyometric exercises to be performed more than once a week to reduce the likelihood of future injury.
If you’ve sustained an injury to your ACL, recovery may seem overwhelming at first. With physical therapy you can start taking steps toward healing even before you’ve had surgery. Schedule an evaluation with a physical therapist at Evolve to help you get on the road to recovery and minimize the recurrence of re-injury.
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