Partial ACL tear - no surgery

[mouk786]

Hi

I posted on this forum before - thanks for all the help.


My situation is this

I am 23 years old, male and fairly fit.

I got my MRI results today and have a partial ACL tear (not sure to what extent).

I definitley want to get back to having a strong knee/leg and am willing to work like a btich to get there.

I also wanna get back to being able to run properly and play soccer. Not to a high level but to a fairly decent standard maybe once a week.

Now reading (hundreds) of pages online about ACL tears and surgery I geared myself up for some news on surgery today as I expected a full ACL tear.

The Dr says that he recommends I take physio instead as if I do it well enough I can go back to near enough where I was pre-injury and that surgery was a last resort and he doesn't recommend it.

There MAY be pressure on him to prevent people going for surgery as its on the NHS (in the UK) and so it costs them a lot of money - but I do udnerstand his reasoning - though he was pushing hard for physio rather than surgery.

I spsoe worst case is I do physio for 3 months and if its still not OK I can have surgery.

I spose I am looking for re-assurance. Can I really get back really good just with physio therapy? I dunno how much is left of my ACL though.

Also the physio he was talking about seems to be about strength,control and all sorts -which sounds good as it may help me A LOT more than I originally expected.

Has anyone recovered prerly from a aprtial ACL tear like this?

Also, when I originally saw my physio (not on the NHS) he suggested that continuing without a proepr ACL may lead to artiritis. However the guy today said that now I have the knee injury I have a higher risk of arthiritis anyway - who is correct? Do i leave myself open to a much higher chance of arthritis if I have no surgery or is it possible to recover enough to be on roughly the same level (i.e surgery and physio and no surgery and physio).

Also can any physios who actually do the treatment give me a rough idea of what to expect? What kind of treatments do you do that i wouldnt think of myself (i.e squats/ankle weight exercises etc)


Any suggestions?

[Canuck Physio]

The ACL should be able to heal naturally with Physio, a conservative treatment and a progressive program would probably do it.

[karen.hankey]

There are people out there in high level sport without an ACL at all. The preference for most people is conservative rehab intially. Surgery is only indicated if conservative rehab fails or there is instability.

Your rehab will entail gaining full movement and get rid of any swelling. Once that is done, you start on strength exercises. I can't be too specific on exercises because it is individual to each person. But a basic programme usually involves, squats (both two-legged and singe-leg), going up and down stairs, jumping and hopping. To enable you to run you must be able to hop without pain. The emphasis for the exercises is to be able to control the knee, so that the muscles take over the job of the ACL.

With regard to a physio I would reccommend someone who has done this sort of rehab before.

Hope that helps a little. Any more questions just ask

[physiobob]

I tend to agree with the above comments. The ACL does NOT provide any direct structural support to the knee joint. What it does is send information about load and angular velocities to the brain so that the brain can then send messages to the muscles to support the knee during activity. A reconstruction tries to create a structural stability to the knee because this feedback is not working anymore without an intact ACL.

So overall a partial, still functioning ACL is a better option than having it removed even if it were replaced with a graft as the graft cannot replace the actual function of the ACL.

[Canuck Physio]

I agree, no surgery if it was me

The ACL (anterior cruciate ligament) is one of two "hidden" knee ligaments that attach the thigh (femur) to the lower leg (tibia) by "crossing" each other at the knee joint, hence the term "cruciates".

As the name suggests, the ACL attaches from anterior surface of the tibia, blends with the anterior horn of the lateral meniscus and travels backwards to attach to the posterior part of the medial surface of the femoral condyle (thigh bone). The PCL (posterior cruciate ligament) crosses the knee joint the opposite way and works with the ACL to hold the knee together when the joint is under load or tension. Injury to the ACL is much more common.

At an American Osteopaedic Sports Medicine Society meeting, Dr Bernard Bach presented an insightful discussion on the indications and contradictions for ACL (anterior cruciate ligament) surgery. He concluded with the old adage emphasized by Dr Jack Hughston years ago, "nothing is so bad that it can't be made worse by surgery". Implying that not all patients with ACL tears require surgery.

The ACL provides 86% of stability in anterior displacement and 30% to any medial displacement. However, rupturing the PCL is worse, as it provides 96% of stability to any posterior movement and 36% to lateral stress. As you have probably found, closed chain movements such as the squat and leg presses are fine. It's not until you attempt to perform some form of dynamic action that involves movement in all three dimensions that you have trouble. This is why many doctors and surgeons adopt a "wait and see" approach on ACLs before recommending surgery. Unless the patient regularly performs dynamic, open chain movements they see no need to operate.

With the correct rehabilitation strategies the hamstring muscles learn peripheral compensation and provide a great deal of anterior shift stability.

Seek out a local physio before you contemplate going under the 'knife'

[mouk786]

Originally Posted by physiobob

I tend to agree with the above comments. The ACL does NOT provide any direct structural support to the knee joint. What it does is send information about load and angular velocities to the brain so that the brain can then send messages to the muscles to support the knee during activity. A reconstruction tries to create a structural stability to the knee because this feedback is not working anymore without an intact ACL.

So overall a partial, still functioning ACL is a better option than having it removed even if it were replaced with a graft as the graft cannot replace the actual function of the ACL.

The partial ACL cannot heal proeprly right? but can it still send signals back?

I have felt a difference and slight instability in my knee (i.e no cofidence to play football/soccer) so that must mean the partial tear is fairly significant - the Dr wouldn;t say how much though.

Any info on arthritis on surgery v no nsurgery scenario? i am thinking long term effects here. should i give up footy?

[physiofixme]

Your success is going to depend on the type of exercises you get given. you need a programme that is going to incorporate leg strength with core strength. Your Quads are probably the focus but you should also be looking at strengthening your butt, hamstrings and core stabilising muscles. Basically this means you need to seek out a good sports physio!! Your rehab programme should also involve some sport specific drills later on before you return to football. Things like running, kicking changing direction etc. This all helps retrain your muscles to send the right signals back to your brain, and to get your muscles co-ordinating properly.

There is some evidence that a damaged ACL can cause extra load to be placed on your cartilage and therefore increase the liklihood of arthritis??? I don't think this is proven however. If your rehab isn't working/helping then you can rethink the surgery option.Do you want to be injury free? Physiofixme

[mouk786]

Hi
Thanks for the reply

The Dr mentioned regaining 'control' of my leg - any info on this? this is probably the major annoyance i have as my leg/knee doesnt seem to go back ot the normal range of motion all the time - i.e when i am walking

I have been recommended to a physio at an NHS hospital - i'll assume theyre pretty good!

[physiobob]

Originally Posted by mouk786

The partial ACL cannot heal properly right? but can it still send signals back?

I have felt a difference and slight instability in my knee (i.e no confidence to play football/soccer) so that must mean the partial tear is fairly significant - the Dr wouldn't say how much though.

Any info on arthritis on surgery v no surgery scenario? i am thinking long term effects here. should i give up footy?

Hard to say what fibers are torn and therefore how much that relates to the signals going to the brain. The feeling of laxity often increases with time but in terms of the early onset of arthritis that is more related to intact menisci (knee cartilages). Surgery is likely to involve trimming or removing some of that which if possible is best avoided as we are making steady progress in the medical fields or tissue replacement, growth, repair etc so the longer the joint surfaces are protected the better.

As for "footy", this is something hard to play without an intact ACL due to the pivoting and side to side movements. If the knee is unstable and you continue to play chances are you will progress to a full tear and the likelihood of injuring the menisci at the same time.

[mouk786]

I suppose the essential questions are can I :

a) go back to a near normal knee without surgery but with physio
b) can i get back to some sort of level of playing football without surgery

The Dr/specialist at the hospital seemed confident and kept say that I don't need surgery to get back to what I want.

[physiobob]

Originally Posted by mouk786

I suppose the essential questions are can I :

a) go back to a near normal knee without surgery but with physio
b) can i get back to some sort of level of playing football without surgery

a) Depends on the extent of the tear and which fibers are damaged
b) This is possible although you will always be at more risk of further injury than prior to the recent tear. Surgery will provide perhaps a reduced risk or reinjury but the functionality and dynamic movement "might" be better without.

As I read in another post somewhere a surgeon wrote "The is no condition so bad that cannot be made worse with surgery". This is something worth thinking about.

[physio.smith]

I hope since you last posted that you are making good progress.

One of the key things is regain the strength at your knee before doing anything too dynamic. You really need 80-90% strength in your injured leg (compared to your non injured) before doing anything too dynamic.

You must ensure however that you have full range of motion at your knee before embarking on too much else. If you are lacking full extension (or hyperextension) compared to the other side you are more likely to cause long term damage and not full trust the joint and will struggle to regain strength. Also if you are lacking full range you may still have swelling, this can take a long time to settle and range may change if you over do the exercises and stir up the joint, so do monitor.

You may find that due to NHS constraints that you are not taken as far as you need to in terms of rehab (not sure if this is true...as not worked in NHS for a long time). They should however ensure that you regain full range of movement and start you on a program, with specific goals and targets to meet. You may need further input as you progress.

Please seek the advice of a physio who has assessed you (as these may not be appropriate for you and technique is important), however below are a few tests that you may find useful to help you monitor your progress....

*Single leg press (1 Rep max) assertain limb symmetry
*Star excursion balance test
*Step down test
*Figure of 8 shuttle runs
*Cross over hop tests
(obviously there are much more basic tests and many more others out there)

The Lower Extremity Functional Scale (Brinkley et al. (1999) Physical Therapy. 79: 371-383) may help you monitor how your knee is feeling.

Good luck.