I tore my ACL this winter. Now what?
May 2, 2011
I don’t need to tell many of you that this has been one of the best ski seasons in many years. For me this meant traveling with the U.S. Ski Team to Germany for the World Championships, and a heli-ski trip down to Silverton with my kids.
Unfortunately many of you did not escape this winter without tearing the dreaded ACL (Anterior Cruciate Ligament). I know, because I saw many of you being carried down the mountain on stretchers.
Injuries to the ACL are quite common on the slopes. The ACL provides our joint with stability for all of our rotational sports. This stability is more than just a “trust” issue of the knee. The ACL protects the meniscus (or cushion cartilage) caused by shear and twisting; the meniscus protects our joints from developing arthritis. This last function is why so many people in Colorado choose to have their ACL fixed if it is torn. Deciding to fix an ACL injury often has more to do with a patient’s desire to be active than anything to do with age.
If you are one of the active individuals that will soon have your ACL replaced, there are some things you should know. Your ACL will be replaced with either some of your own tissue, called an autograft, or a cadaver graft – also known as an allograft. After surgery, there usually is a fair amount of pain, but your surgeon will keep encouraging you to “work on range of motion, get the swelling down, and eliminate the risk of scar tissue forming.” Strengthening exercises will follow.
The most common question I get is “When am I allowed to get back to unrestricted sports?” The answer is not an easy one. For me, return to sports has always been a combination of rehabilitation and biology.
First, the biology
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Regardless of the type of graft that is used during ACL reconstruction, the knee must undergo “remodeling,” which is a fancy way of saying that the ligament must get weaker before it gets stronger. Your body must grow new blood vessels into the new ACL. These blood vessels take away the old graft fibers, leaving a weakened scaffold. Next, new “ACL cells” get deposited on the scaffold, making a better or stronger ACL graft.
With modern surgical techniques and graft choices, the ACL operation just doesn’t hurt as much as it used to. Along with the great therapists we have access to, we can get an athlete back up to full strength three months after surgery, but that may not be a smart decision based on the biology present. If someone getting their strength back was the sole criteria for returning to sports following an ACL operation, ACL injuries would no longer be season-ending injuries!
Next, the rehabilitation
Following an ACL reconstruction, wait until normal range of motion is achieved, and the graft and surrounding tissues are strong enough, before returning to sports. Once these have been achieved, and a patient is more than six- to nine-months post surgery, functional testing will help determine if the athlete is ready to safely return to sports. The ideal functional test will:
1. Test the strength of the muscles about the knee.
2. Test the athlete’s endurance.
3. Test agility, trust and the ability to “accept a load.”
4. Be safe. Failing the test should not put the knee at risk.
This new testing, which is now being used by the U.S. Ski Team, allows therapists to know if there are any problems with the knee accepting a load in a controlled environment, rather than on the hill. Returning to sports after tearing your ACL is tough; it’s hard and it’s a process. What isn’t hard is deciding when to get back out there.
Dr. William Sterett is an orthopedic knee and shoulder surgeon and a trauma and sports medicine specialist. He currently serves as a physician for the U.S. Women’s Alpine Ski Team and is a partner at The Steadman Clinic in Vail.