Injury Prevention

ACL Rehabilitation: Getting Back in the Game

Lyn Ausdemore, Chris Green, Tyler Lathrop, Zalie Limbach & Allen Jackson ABD, share thoughts on Anterior Cruciate Ligament rehabilitation

Once an injury occurs, rehabilitation must take place in order to heal. Rehab can take weeks or months, depending on the severity of the injury. Many athletes do not take rehab exercises seriously and will not complete the whole rehab schedule. While many do the exercises, they do them incorrectly. One factor that causes many re-occurring injuries is poor technique during rehabilitative exercise. Many young athletes may never experience full recovery until they understand that improper technique is the cause of the on-going problem. When you are in recovery, the information received can be very helpful and can provide the analysis recovery based on performance and personal commitment. The focus of this paper is on injuries occurring to the Anterior Cruciate Ligament (ACL) and what it takes to overcome such adversity.

Cluett (2008b)^[3] explained the function of the anterior cruciate ligament (ACL) as the primary resisting force to forward motion of the tibia. The anatomical construction of the knee joint helps in understanding this relationship (Cluett, 2008b)^[3].

The femur (thigh bone) sits on top of the tibia (shin bone), and the knee joint allows movement at the junction of these bones. Without ligaments to stabilize the knee, the joint would be unstable and prone to dislocation. The ACL prevents the tibia from sliding too far forward. (Cluett, 2008b, p.1)^[3] As portrayed, the ACL is a broad ligament joining the anterior tibial plateau to the posterior femoral intercondylar notch (Cross, 1998)^[1].

The stabilization process of the ACL has four complex functions:

• It maintains mechanical stability
• restrains anterior translation of the tibia
• prevents hyperextension of the knee
• acts as a secondary stabilizer to valgus stress by reinforcing the medial collateral ligament and controls rotation of the tibia on the femur in femoral extensions of 0-30 degrees. (Cross, p.1)^[1]

ACL injuries are common problems involving the knee joint

Recent studies indicate that 1 in 10 female college athletes have sustained this type of injury some time during their athletic carrier. Research indicates that females participating in activities that "require cutting and jumping activities were 5 times more likely to suffer serious knee injuries compared to their male counterparts" (NWS, 2008, p.1)^[7].

The ACL is one of four ligaments critical to the articular stability between the upper and lower leg. Many wonder why the ACL is so vulnerable to injury, especially among females. The ACL can be hurt when one puts force on the knee while twisting. Examples of this kind of action happens during a side-step, pivot, or when landing. Other examples include contact injuries in contact sports when someone hits the knee or it gets twisted in a pile.

The ACL is more vulnerable to some people than others. The reason for this is based on osseous landmarks of femoral attachment of the ACL.

The ACL femoral attachment has a unique topography with a constant presence of the lateral intercondylar ridge and often an osseous ridge between anterior medial (AM) and posterior lateral (PL) femoral attachment; commonly referred to as the lateral bifurcate ridge. In the anatomy of the knee joint, an intercondylar notch lies between the lateral and medial condyles of the femur.

The ACL moves within this notch, connecting the femur and the tibia, thus providing stability to the knee. The ACL prevents the tibia from sliding forward and rotating medially. The majority of females have a small notch, therefore restricting ACL movement. "When movement is restricted, the femoral condyles can pinch the ACL within the joint, especially during twisting or hyper-extended movements often resulting in a tear or rupture of the ligament" (Vlach, 2008)^[11]. For some athletes, especially females, these attachment points may be smaller; a contributing factor involving female susceptibility to ACL injuries.

Assessment

With all knee injuries an assessment must be done to know exactly what damage has occurred. "The knee needs to be examined systematically, since so much can go wrong with the knee, and so many signs and symptoms may be produced, that only a systematic technique will ensure that nothing of importance is missed" (Neyret et al. 2008, p. 1)^[5].

There are three different tests that can be performed:

• the Lachman test
• the dynamic extension test
• the Pivot Jerk test (Cross, 1998)^[1].

The most important out of these three tests, the Pivot Jerk test was first described by M. Lemaire, in 1968.

• The patient's foot is wedged between the body and the elbow of the examiner
• The examiner places one hand flat under the patient's tibia, pushing it forwards (force applied in an anterior direction), with the knee in extension
• The other hand is placed against the patient's thigh, pushing the other way (force applied in a posterior direction)
• The lower limb is taken into slight abduction, by the examiner's elbow, with the examiner's body acting as a fulcrum to produce the valgus
• The examiner maintains the anterior tibial translation and the valgus, and imparts flexion. At 20°-30° flexion, pivot shifting will occur, with a clunk as the lateral tibial plateau suddenly reduces. (Neyret et al, p.14)^[5]

When this procedure produces a shift rather than a clunk and the patient is unaware of the slip of the plateaus on the femoral condyles. The valgus component is less pronounced than are the compression and anterior drawer applied by the examiner therefore producing joint play rather than a pivot shift, indicting a tear of the ACL.

Rehabilitation

There are many variations of ACL rehab that take considerable time to get back in proper physical condition. Each athlete has their own specific rehab plan, even if a lot of the exercises are similar to another athlete. Each plan depends on the person's age, functional disability, and functional requirements (Cross, 1998)^[1]. The major goals of rehabilitation following ACL surgery are:

• Restoration of joint anatomy
• Provision of static and dynamic stability
• Maintenance of the aerobic conditioning and psychological well being
• Early return to work and sport

Following ACL reconstruction surgery, range of motion exercises are started immediately with walking being an important component to post operative rehabilitation. Being mobile during this time will help in incurring degrees involving range of motion with the initial focus on regaining full extension of the knee. In general, flexion (ability to bend) is much easier to gain than extension (Cluett, 2008a)^[2].

A typical rehabilitation program consists of four distinct phases. During the first phase, emphasis is placed on minimizing pain, swelling, and maximizing motion. Throughout the second phase of rehab increased ranges of motion is the main objective. During stage two the patient is subjected to resistance training designed to increase range of motion through a well designed regiment of lifting exercises specific to the quadriceps and hamstrings.

During the third phase, muscle control, increased strength, and greater endurance are the goal. At this stage, ones range of motion should be completely back. During the final phase of rehabilitation the subject will be encouraged to engage in gradually work back into their sport (Palmer, 2005b)^[9].

Working with physical therapists is one way to make rehab more successful. Therapists know what and where someone should be at during their specific program. They can make sure that one is not overdoing it. Overdoing it could result in not healing the injury properly. Different exercises that one can do tolerably include: heel slide, isometric contraction of quads, and the prone knee flexion. Other exercises that can be done once able to stand include: passive knee extension, heel raise, half squat, knee extension, and standing on one leg. (Quinn, 2006)^[10]

Getting patients on a stationary bike is a good way for them to regain motion and improve strength. Other activities that one can do are, working in a pool, on a trampoline, wobble board, and jogging, among many others. These activities are used during the different phases, so do not think that right after surgery one can be on a wobble board. Take things slow and make sure that the injury heals correctly so that one does not end up back at the beginning of rehab.

Once rehab is finished, the doctor will have the ultimate say in when one is able to return to a sport or work fully. The doctor's decision can be based on how well one did during rehab and the graft type (if one was done). Certain grafts are believed to take longer to heal and therefore, the doctor may not want to push the knee to far too soon. After all is said and done, the athlete may ask the question of "should I wear a brace?" Simply put, it all depends on the athlete. Some prefer a brace while others do not. No studies show that a brace helps or harms one when wearing it (Cluett, 2008a)^[2]

Palmer (2005a)^[8] offers some encouraging information for all to consider: Many struggle to regain form after a serious sports injury and lengthy rehab period, some take months or fail completely. Getting back into form will be slow if we do not know exactly what it is that needs to be recovered. Natural talent for a sport comes from the right sort of conditioning. Good quality movement executed in the sporting activity sets up appropriate learnt movement patterns that reside at a subconscious level. (Palmer, 2005a, p. 2)^[8]

Conclusion

Rehabilitation is defined in NRI (2008)^[6] as a combination of methods focusing on restoring a subject's useful life. Regardless of the disabling experience rehabilitation helps the body achieve normal functions through different kinds of recovery techniques. If a person has experienced a sports injury, an accident or is incapacitated due to other reasons, rehabilitation can assist in improving functionality of movements and also assist in maximizing personal health characteristics. Through rehabilitation, "not only is the physical aspects covered, but also the mental, psychological and sociological aspects in achieving full recovery." (NRI, 2008, p. 1)^[6]

Rehabilitation from injuries requires constant care by providing exercise therapies to regain muscles lost and recover from trauma experienced by allowing contact to other patients who have experienced similar injuries. For injuries involving young athletes original skill patterns are often replaced by newly acquired poor quality action following a sports injury. Some athletes never regain the ability to realize their full potential after an injury requiring rehabilitation. (Palmer, 2005a)^[8]

Referenced Material

1. CROSS, M.J. (1998) Anterior Cruciate Ligament Injuries: Treatment and Rehabilitation. Encyclopedia of Sports Medicine and Science
2. CLUETT, J. (2008a) Rehabilitation After ACL Surgery. About.com: Orthopedics
3. CLUETT, J. (2008b) ACL injury. About.com: Orthopedics
4. ehealthMD.(2008) What is the anterior cruciate ligament. Health Information Publications
5. NEYRET, P. et al. (2008) Examination of the knee joint
6. NRI, (2008) Importance of rehabilitation. NewRehabilitationInfo.com
7. NWS, (2008) Female ACL. New Wave Soccer Conditioning
8. PALMER, R. (2005a) Rehabilitation: Time to Assess. Fitness Programs for Life
9. PALMER, R. (2005b) Sports Injury Rehabilitation: Learn to take it Easy! Fitness Programs for Life
10. QUINN, E. (2006) ACL Rehab Exercises. About.com: Sports Medicine
11. VLACH, S. (2008 ACL and the female athlete: Theoretical causes and prevention. Life Fitness

Page Reference

The reference for this page is:

• JACKSON, A. et al. (2009) ACL Rehabilitation: Getting Back in the Game [WWW] Available from: http://www.brianmac.co.uk/articles/article048.htm [Accessed

About the Authors

Lyn Ausdemore, Tyler Lathrop, & Zalie Limbach are all upper division students seeking degrees with endorsements in human performance. Chris Green is a trainer for the athletic department and Allen Jackson is an Assistant Professor for the Department of Health, Physical Education and Recreation at Chadron State College.

Associated Pages

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• Literature Review