Knee injuries, especially the anterior cruciate ligament (ACL)  injuries, are a potentially devastating problem among athletes and impose substantial time loss in a player’s career and financial burdens on athletes’ families and the healthcare system. In this blog we intend inform about exercises for ACL recovery as well.

ACL INJURY STATISTICS:-

This study of level 4 evidence conducted on Indian athletes revealed that ACL injuries compromised 86.5% of all the knee injuries. ⁽¹⁾

WHAT IS ACL INJURY?

ACL is one of the central knee ligaments which is responsible for maintaining the knee stable during various activities. The ligament may be completely torn, partially torn, or avulsed from its origin or insertion. The ACL is the primary restraint to excessive anterior translation and rotation of the tibia on the femur. ⁽⁴⁾ It is one of the most common injuries worldwide, which usually may occur along with other structures in the knee.

CAUSES OF ACL INJURY

This injury may occur while playing sports like football, rugby, cricket, kabaddi, basketball, and handball or may occur due to trauma. The incidence rate is higher in women compared to men, the reason being wider pelvis, hormonal changes, and weak neuromuscular co-ordination issues. ⁽¹⁾ Complete ACL disruption typically results in dynamic knee instability or the inability to respond to quick changes in position. ⁽⁴⁾

ACL ligament exercises are usually based on all these points which are guided by our expert physiotherapist. we recommend you to sign up for physio for ACL tear with us for the best results

ACL INJURY MECHANISM:-

The mechanism by which an ACL injury or a tear can occur can be traumatic or non-traumatic. Nontraumatic mechanism is faulty landing from a jump, sudden turns, and sudden stops while sprinting. Traumatic could be tackled from fellow players or accidents.

                                                             Figure 2 Faulty jump landing.

other than the mechanisms, it is important to look into Movement factors increasing susceptibility to ACL Injuries.

ACL INJURY SYMPTOMS:-

• The typical symptoms of an ACL Injury would be
• hearing a pop sound,
• with inability to continue the activity pain,
• Swelling may be minimal in the beginning but may increase after few hours.
• If the swelling becomes tense with blackening immediately then you should rush to a nearby emergency unit.
• The other sign which may come in after 48 hours of the injury or more:-
  • Difficulty in straightening the knee. This is due to acl injury as well as the swelling.
  • Few individuals may be mobile and may be able to walk but they will have repeated locking of the knee.
  • Symptoms like cramps in the back of the thigh or calf may also appear if the injured person continues to move around and not take rest.

TEST FOR ACL INJURY:-

An immediate examination is not advised rather following the Acute injury management of RICER and HARM is advised. After 24-48 hours based on the history few special tests may be carried out by your physio/ortho.

Figure 3:  tests for ACL Injury

If there are other structures in the knee that may be suspected to be injured with the ACL then few more tests will be carried out to rule out a Triad which involves Medial Meniscal & Medial Collateral ligament (MCL) Injury.

 

Figure 4: Special test for MCL Injury                   Figure 5: McMurray’s test for Medial Meniscal Injury

INVESTIGATIONS:-

Figure 5: Image on the left shows how an ACL tear looks like on an MRI versus a normal healthy ACL image on the Right

An X-ray &/or just a CT/MRI will be called for usually after the swelling subsides. MRI Research studies by wing hung et all (2011) concludes that most ACL tears (approximately 80%) are complete, occurring around the middle one-third of the ACL (90%) or less frequently close to the femoral (7%) or tibial (3%) attachments X-rays have limited value in the diagnosis of acute ACL injury.⁽⁴⁾

Findings are indirect and limited to bone abnormalities. On X-ray, there are several indirect signs that could raise suspicion of underlying ACL injury.

Figure 6: A shows x-ray image which may find an avulsion fracture along with ACL tear, but figure B is a CT scan which defines the Avulsion fracture better.

Complications like Avulsion fracture of ACL can be found on x-rays but is better defined by computed tomography (CT)

MANAGEMENT:-

There are several areas of controversy regarding the management of ACL injuries. These include whether to opt for surgery or Conservative is more effective or; the use of braces to prevent ACL injury or control ACL deficiency; whether surgery should be performed immediately after the injury or should be delayed; which surgical technique is more superior, and the different Physio Rehab Programs
followed after surgery. Let’s address these one by one:-

ACL INJURY SURGERY COST:-

Not all people injured with an ACL tear require surgery. currently, the ACL surgery success rate in India is only 50%. the cost of an ACL reconstruction surgery spans somewhere between 2 to 5 lakhs minus the cost of rehabilitation and yet the clients only become mobile after completing the rehab program. what are the negative side effects of these surgery costs is that most of the time the clients do not spend on post-operative physio which is a must to restore the range, strength, balance, and stability in the knee.

however , an exclusive physiotherapy program for ACL injury without any surgery would require 3-6 months of rehabilitation, which would involve around 40 sessions over a period of 3 months. the cost of which is less than 50 thousand INR.

ACL INJURY RECOVERY TIME WITHOUT SURGERY?

By the time the client completes the 3-month sessions, he/she can run, jog, and definitely walk pain-free. so all in all, physiotherapy for ACL injury is cost-effective but it takes time. ACL injury recovery takes around 6-9 months with physiotherapy. however, it depends on case to case and the client’s fitness levels.

It’s one of the most feared injuries in almost all sports as the knee stability is compromised and the fear of not being able to participate in the sport fully, pushes most athlete’s to opt for surgery, for that matter even people who are fitness freaks or play occasionally have ended up opting for surgery in a fear to prevent early development of arthritis!!

There is no fixed recipe for ACL Rehab. Research studies have proved that when a group of athletes was put in for rehab compared to those who underwent an ACL reconstruction before starting the rehab had similar results. In fact, the non-operated athletes were able to get back to sports not requiring surgery at all & they did not show any signs of early osteoarthritis of the knee.

So if you are worried that your knee stability will never improve because of the ACL tear, think again. You may want to follow a well-designed physio rehab program.

BRACES FOR ACL INJURY:-

we recommend these braces post an acl injury for easier recovery and painfree walking. these can be used post op as well as for just post the ligament tear rehab time. however the goal should be to exercises your way to recovery and reducew the usage of the braces by 3 months post injury:-

 

HOW TO FIX ACL INJURY?

An ACL injury may be scary but the truth is our body is smart and can start operating normally with help of 12 other ligaments in the knee and muscle support, in the absence of ACL. so definitely you want to start with a physio rehab program that runs until 3 phases.

1st phase:- mainly concentrates on reducing selling, improving your knee mobility, and get those knee muscles working again.

2nd phase:- concentrates on strengthening the entire leg and the core. improving balance and overall knee stability. goals like walking normally, stair climbing, and the ability to function without pain are achieved

3rd phase:-this phase is essential so that you are not prone to re-injury. in this phase, rehab concentrates on activities that promote agility, reaction time, and more strength.

this is just a rough idea of the rehab plan, however, it changes with the client goals and type of structures involved.

ACL INJURY WORKOUTS:-

check out this basic exercise program for ACL injury

PREVENTION:-

We at Physiocure strongly advice ACL Injury Prevention strategies as it is a known fact that prevention is better than cure.

Webster et all (2018) published a research which combines all previous meta-analyses into a single source and shows “conclusive evidence that ACL injury prevention programs reduce the risk of all ACL injuries by half in all athletes and non-contact ACL injuries by two-thirds in female athletes. There is insufficient data to make conclusions as to the effectiveness of ACL injury prevention programs in male athletes.” 

REFERENCES:-

1: Epidemiological profile of sports-related knee injuries in northern India: An observational study at a tertiary care centre –

2: ACL Injury Prevention: What Does Research Tell Us?

3: Meta-analysis of meta-analyses of anterior cruciate ligament injury reduction training programs. 

4: Imaging of the anterior cruciate ligament 

5: Clinical Sports Medicine. 3^rd edition by Brukner and Khan

6: Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial