ACL Injury: To have surgery or not to have surgery?June 6, 2019
The knee is composed of the thigh bone (femur) and shin bone (tibia). Between these two bones are ligamentous structures that give your knee stability. The ligamentous structures include the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL), and menisci.
The anterior cruciate ligament prevents the tibia from moving too far forward in front of the femur as well as preventing the knee from twisting, providing stability. Each year, around 250,009 ACL injuries occur in the Untied States. Common causes of ACL injuries include:
- Overextending the knee
- Landing from a jump incorrectly
- Rapidly changing directions while running or turning
- Direct contact or collision involving the knee. For example, a football tackle
Immediately following the injury, individuals may report hearing a “popping ” sound, experience increased swelling around the knee, and may feel pain when placing weight through the joint.
Of the 250,000 that sustain an ACL injury, ~100,000 will undergo reconstructive surgery. A recent study published in The New England Journal of Medicine compared the outcomes of those who had physical therapy and early ACL reconstruction within 10 weeks of the injury to those who received physical therapy with the option of later ACL reconstruction if needed. The patients progress were evaluated at 3, 6, 12, and 24 months measuring the motion at the knee, muscle function, and ability to perform activities of daily living such as walking. At the three and six month follow up, those who were in the physical therapy group with the option of later ACL surgery
if they felt they needed it scored higher on measures that evaluated symptoms like pain and swelling, activities of daily living like climbing the stairs, and recreational activities like running and jumping. At the 12 and 24 month follow all patient regardless of their treatment had the same outcomes. Of the 59 individuals designated to the group who received physical therapy with the option of later ACL surgery, 23 of them went on to have surgery and at 12 and 24 month follow up had the same outcomes as those who had early reconstructive surgery and those who had no surgery at all.
A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010;363(9):893-893. doi: 10.1056/NEJMx100049.
Ultimately, it is up to the patient to decide what treatment option would be best for them, but all options demonstrate favorable outcomes for the patient.
In the early stages of your rehabilitation process, the physical therapist will work on decreasing the swelling surrounding the knee and achieving full knee extension. Full knee extension is important to regain early on because it is vital for walking and running properly.
Quadriceps strengthening will also be an important aspect of your physical therapy program. After ACL surgery, the quadriceps are weak and patients have a difficult time activating the muscle. The therapist will work with you on retraining and strengthening the quadriceps muscles. As therapy progresses, hip and core strengthening exercises will be added to help further improve stability at the knee.
Even if you do not have surgery, you will also work on strengthening the quadriceps, hip, and core musculature to improve the stability at the knee. Strengthening these muscles is even more vital for these patients because we want to prevent excessive movement at the knee so patients can return to their every day activities.
Each exercise program, will be individual tailored to the meet the patient’s needs and goals. If you would like to be evaluated by a physical therapist, please contact Total Performance Physical Therapy.