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ACL injuries: surgery, recovery and prevention

Australians in general and those of us on Northern Beaches especially are an active bunch. Unfortunately, activities that are great for the waistline can spell trouble for the musculoskeletal system when injuries occur. More people are playing sports, running or participating in some kind of physical activity than ever and that means more injuries. Aussies are world leaders in most sports and unfortunately we’re also world leaders in ACL injuries and that rate has been climbing consistently.[1]

Between 2000 and 2015 nearly 200,000 ACL reconstructions were performed in Australia with men aged 20 to 24 years and women aged 15 to 19 years the most common patients, but the fastest growing demographic was 5–14-year-old children.[2] Apart from being painful and ongoing, ACL repair can also be painful to the back pocket, costing on average over $8000 including hospital fees.

What, if anything can physiotherapists do to help prevent ACL injuries, and how do we make sure that a full recovery after ACL surgery occurs?

What is an ACL, what does it do and how are they injured?

Ligaments are strong bands of tissue connecting bone to bone and are among the most commonly injured part of the musculoskeletal system. Your anterior cruciate ligament or ACL for short is one of the four ligaments in your knee that keep your knee joint stable. Your medial and lateral collateral ligaments stop your knee from moving side to side, while your anterior and posterior cruciate ligaments keep the knee from sliding front to back.

ACL injuries can occur at some pretty random and innocuous times but usually are a result of rapid changes in direction at speed, typically in non-contact sports or events. ACL tears also commonly occur during sports that involve sudden stops, jumping and landing such as soccer, AFL, basketball and netball.

It’s common to hear a “pop” in the knee when an ACL injury occurs accompanied by some pretty rapid swelling, instability and an unbearable pain that won’t let you put weight on it. Depending on the severity of your ACL injury, treatment is likely to include a good chunk of time on the sidelines and probably some surgery.

What does ACL surgery involve?

A surgeon chops out a piece of another tendon (usually the hamstring), removes your damaged ACL (because it can’t heal itself) and replaces it with the new tendon. Your new replacement tissue is called a graft which will be attached to your bones with screws (airport security just got more fun) or other fixation devices and serves as the point where new ligament tissue can grow. Fun fact, if the tissue is taken from you, it’s called an autograft but if it was donated by another person it is known as an allograft.

How long until I can play sport after ACL surgery?

The recovery period after ACL reconstruction surgery varies from one person to the next and there are many factors that determine how quickly and adequately you will recover and how low it will take until you can get back into the full swing of things.

One of the biggest factors influencing how long ACL surgery recovery takes is whether you have an orthopaedic pre-habilitation and rehabilitation plan and you stick to it. A well designed pre ACL surgery body strengthening regime can shave weeks and pain off your post-surgical recovery. The physical shape your affected area is in is one of the strongest predictors of the chances of a fully successful recovery. It is likely that you have pain and weakness operating in tandem leading up to surgery, but you’re going to need every ounce of strength you’ve got to recover fully. In prehab your local physio will help you build strength and stability where you need it most to ensure you get the most out of your rehabilitation.

Your surgeon and musculoskeletal physio will be able to advise you when you’re good to go for most activities, but this is usually only once you have adequate flexibility, strength and fitness.

Can physiotherapy prevent an ACL injury occurring?

Because ACL injuries have been becoming increasingly common, more time and research is being devoted to understanding the mechanisms behind ACL injuries and what steps can be taken to reduce the possibility of an ACL tear happening. Prevention is much better and less painful than a cure.

Over the last two decades multiple randomised controlled trials have shown that anywhere between 50–80% of ACL injuries can be prevented by regular neuromuscular agility training programmes.[3] A number of these studies have shown that many ACL injuries are caused by faulty mechanics during dynamic movements performed under fatigue.[4]

These prevention programs include various modes of exercise such as plyometrics, neuromuscular training, and strength training designed to teach the body to perform movements deliberately and with precision even under fatigue. A trained musculoskeletal physiotherapist will be able to observe your technique and address the faulty movement patterns in a personalised injury prevention program.

 

[1] Janssen KW, Orchard JW, Driscoll TR, et al. High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model? Scand J Med Sci Sports 2012;22:495–501.

[2] Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015 David Zbrojkiewicz, Christopher Vertullo and Jane E Grayson Med J Aust 2018; 208 (8): 354-358. || doi: 10.5694/mja17.00974

[3] Caraffa A, Cerulli G, Projetti M, et al. Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc 1996

[4] Mandelbaum BR, Silvers HJ, Watanabe DS. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005;33:1003–10

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