When we hear about someone rupturing or tearing their ACL, our minds typically go to a sports injury such as soccer or football, where the athlete will have performed some sort of stellar stunt, jump or save, landed awkwardly on the leg, and BAM. There it goes.
However, there are so many instances where the ACL is injured or torn during daily, routine activities that have gone awry. For instance, a previous gentleman who I treated, a rancher, simply lost his balance while sitting on a fence, took a spill, and the ACL was completely torn when he stood back up.
Typically though, it is a result of an athlete or individual suddenly planting the foot and quickly changing direction. This puts a stress on the ligament and can result in injury. The individual may describe the sensation as feeling like someone had come up behind them and struck them in the back of the knee!
Unfortunately, when there is injury to the ACL, there are two other structures that might typically join the injury party. This terrible triad refers to the Anterior Cruciate Ligament (ACL), Medial Collateral Ligament (MCL) and Medial Meniscus. Because of the typical mechanism of injury for the ACL and the close proximity of these other two structures, massive strain can also be placed on the MCL and medial meniscus which are actually attached to one another.
While the ACL reconstruction or repair surgeries are generally successful in restoring ligamentous function, the rate of reinjury to this vital structure can be upwards of 20%. According to one study (referenced below), the percentage of athletes that return to competitive sport is only 44%, and 24% of those say that the main reason for this is fear of pain or re-injury. That is a huge amount of people who are too fearful to return to doing something that they love! This is where I come in.
Rehabilitation after an ACL repair is absolutely vital. The rehab process will take weeks, but it is important to ensure that you’re being monitored by a professional who can consistently assess and evaluate, ensuring a safe and appropriate progression.
Your physiotherapist can help you work through the process. It will include management of symptoms such as swelling and pain. Improving the range of motion of the knee joint as well as maintaining mobility at the foot, ankle, thigh and hip. Strengthening of the muscles surrounding the hip, knee, ankle and foot as well as the structures in the knee will come next, and restoration of knee joint arthrokinematics (the movement of joint surfaces on one another) must be restored.
Return to activity and sport must address the physical and emotional health of the individual. Of course, there will be some sort of fear behind this person returning to their routine, because of the prevalence of re-injury! The individual must be able to trust his or her body. They must be able to rely on the structure for support through movement. During rehabilitation, it is important for the physiotherapist to guide the athlete in moving through patterns that are authentic to their activity, and then exaggerate them in a controlled way. For example, if you are a basketball player who will repeatedly lunge quickly towards another player, before taking a shot or just before quickly switching direction, the knee must be able to do this safely and efficiently many times before returning to a game setting. Think of it like familiarizing yourself with a new group of people. The more you’re around them, the more comfortable you will be with them. Same thing goes for the body. Practicing real life or sport scenarios in a controlled and safe environment is key for full integration back into daily activity and sport with less fear and less pain.
Rodriguez RM, Marroquin A, Cosby N. Reducing Fear of Reinjury and Pain Perception in Athletes With First-Time Anterior Cruciate Ligament Reconstructions by Implementing Imagery Training. J Sport Rehabil. 2019 May 1;28(4):385-389. doi: 10.1123/jsr.2017-0056. Epub 2018 Dec 17. PMID: 29584538.