Ski Knee Pain

Revision ACL Reconstruction

by ACL research
Ski Knee Pain

Injury
The anterior cruciate ligament (ACL) is a ligament located inside the knee and responsible for providing stability to the knee with rotational movements or twisting. For a complete discussion on injury to this ligament, see our blog article (https://adamanzmd.com/acl-knee-injuries/).   While ACL surgery is most often successful, there are occasions where reinjury can occur. In some instances, reinjury may involve a tear of a previous ACL reconstruction or repair.

When looking at reinjury rates in the general population, one study found a 4.2% rate of revision reconstruction at 5 years1 and that patients who were young at the time of the reconstruction were more at risk of reinjury.  Another study in patients under 20 years of age who had an ACL reconstruction found that 18% reinjured either their reconstructed knee or their other knee2.   Of reinjuries, 90% occurred during high-risk sports.3  A systematic review comparing autograft and allograft reconstructions in young patients found a higher reinjury rate in patients under the age of 25 who had an allograft.  (9% and 25%, respectively).4  It is clear that reconstructions involving younger patients are more at risk of reinjury, and allografts in young patients are at a higher risk of reinjury.

Symptoms

When an individual retears their ACL, there may be less pain and swelling then when they injured their knee the first time.  Patients typically report similar feelings of instability than what they felt prior to their first surgery.  In some instances, they may sustain a meniscus tear at the time of their reinjury, and the knee may be locked from full extension (straightening).  In younger, active patients a revision ACL reconstruction surgery is often recommended.

It is hard to know for certain why a re injury occurs. Some reasons may include: a too soon return to cutting/pivoting activities, too little rehabilitation, or new trauma to the knee (such as a fall or impact to the knee during sporting activity). Once a re-tear occurs, the knee is likely unstable and must be carefully addressed to restore function to the knee.

Diagnosis

Dr. Anz will assess the knee carefully and will order new X-rays and most likely an MRI.  New X-rays and MRI help to fully understand the extent of, possible reasons/risks for, and the best steps to take to address the reinjury.  In some instances, a CT scan helps to see the status of femur and tibia bones, considering the previous bone tunnels/sockets used during the first surgery.

Treatment
An ACL revision surgery may be the best way to return athletes to the level of sport which they seek.  Revision surgery is more difficult to perform because previous devices used with the first ACL surgery and the tunnels created for the first surgery affect the revision surgery.  In certain cases, a revision ACL reconstruction can be performed immediately, in one stage.  In other cases where the previous bone tunnels create hurdles, a revision surgery in two stages may be the best course of action.   In two-staged revisions,  a bone grafting surgery to fill the areas with new bone is the first stage, and a second-stage surgery , 3-6 months after the first stage, to place the new ACL reconstruction graft follows.

Post-Operative

Patients will be prescribed a clear and thorough rehabilitation program following revision ACL surgery. After surgery patients will be placed into a brace and will typically use crutches for 2 weeks.  Rehabilitation will be a progressive process that may initially limit movement.  The first phase focuses on swelling and the return of normal knee motion.  Further phases focus on regaining strength, balance, and functional movement patterns.

Recovery Time

After a first ACL reconstruction, cutting and pivoting activities are limited until around the 7 month time point as graft maturation takes time.  With revision reconstructions, this may be pushed to the 9 month time point.  Two studies on reinjury rates suggest that risk decreases significantly with every month until the 9-month time point. For this reason, in most instances a return to cutting/pivoting sports is cautioned before the 9-month milestone.5  However, every athlete is unique and situations are unique.  Some instances dictate a sooner return to sport than 9-months understanding the risk.  Post-operative rehabilitation and returning to sport is a joint effort/decision between the patient, Dr. Anz, the physical therapist, and the athletic trainer and is necessary to achieve the most optimal outcome.

Athletes with ACL injuries should not feel bad if it takes time to return to their sport.  In many instances it takes athletes one to two years to make a full return.  A study in high-school and college football players found a return to sport rate of 32% at one year and 64% at two years.  53% of high school players and 50% of collegiate players identified fear as a major or contributing factor to not returning to play sooner.6 Dr. Anz and his team serve as advocates to help athletes return safely and expeditiously to their sport, considering and helping with all hurdles along the way.

For additional information on revision ACL reconstruction surgery, or to learn more about common knee injuries involving one or more ligaments within the knee, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.

Sources: 

  1. PubMed.gov, Authors: Andreas Persson, Knut Fjeldsgaard, Jan-Erik Gjertsen, Asle B Kjellsen, Lars Engebretsen, Randi M Hole, Jonas M Fevang. Date: Dec 9, 2013. Link.
  2. PubMed.gov, Authors: Sue Barber-Westin, Frank R Noyes. Date: May 6, 2020. Link.
  3. PubMed.gov, Authors: Hideaki Fukuda, Takahiro Ogura, Shigehiro Asai, Toru Omodani, Tatsuya Takahashi, Ichiro Yamaura, Hiroki Sakai, Chikara Saito, Akihiro Tsuchiya, Kenji Takahashi. Date: Dec 9, 2013. Link.
  4. PubMed.gov, Authors: David Wasserstein, Ujash Sheth, Alison Cabrera, Kurt P Spindler. Date: May 7, 2015. Link.
  5. PubMed.gov, Authors:
    Susanne Beischer, PT, PhD, Linnéa Gustavsson, Eric Hamrin Senorski, PT, PhD, Jón Karlsson, MD, PhD, Christoffer Thomeé, BS, Kristian Samuelsson, MD, PhD, Roland Thomeé, PT, PhD. Date: Jan 31, 2020. Link.
  6. PubMed.gov, Authors: Kirk A McCullough, Kevin D Phelps, Kurt P Spindler, Matthew J Matava, Warren R Dunn, Richard D Parker, MOON Group; Emily K Reinke. Aug 24, 2012. Link.
Biking Knee Pain

When Is An Athlete Ready For Contact Sports After ACL Surgery?

by ACL research
Biking Knee Pain

Returning to Sport Following ACL Reconstruction

After ACL reconstruction1, the most common question is also the most difficult to answer: “When will I be ready to go back to ___?” In short, there is no blanket answer; there are many factors that determine when the time is right for a patient to return to sport. These factors are physical, biologic, and psychological in nature and they affect each patient’s recovery in a unique way. At the end of the day, returning to sport is a decision that needs to be made on a patient-to-patient basis, weighing the benefits of continued rest and rehabilitation with the risks and benefits of returning to sport.

How and When Do Most Athletes Return

It is helpful to consider the track record of other athletes’ road to recovery following ACL reconstruction. Traditional wisdom holds that athletes return to sport within 6-12 months of an ACL injury. However, recent studies have turned this idea on its head. One study evaluated 187 amateur and competitive athletes with ACL injuries and found that only 31% returned to the sport in the first 12 months, and that number only climbed to 60% at 24-months post-surgery.2 Another multicenter study examined the question with a specific focus on football. Researchers contacted 147 high school and collegiate football players and found similar return-to-play rates in both groups two years post-surgery—63% and 69%, respectively. However, only 43% of the players interviewed believed they returned to previous self-reported levels of performance; 27% felt that they never reached their pre-surgery performance and 30% were unable to return at all. Surprisingly, fear of re-injury or further damage to the knee was cited as the most common reason that players did not return to play.3 This study highlights two important facts: 1) return-to-play rates for football players are not as high as one might expect, and 2) psychological factors, particularly fear of re-injury, play a key role in athletes’ return to sport.

Physical Therapy: Motion, Muscle Strength, and Proprioception

Physical therapy following surgery is just as, if not more, important than the surgery itself. After most ACL reconstructions, full restoration of range of motion in the knee is the first goal of therapy, except in cases involving complex meniscus repairs. Once motion is restored, strength becomes the next goal. During this phase, athletes may find that it takes longer than expected to recover pre-injury strength and mass in the muscles surrounding the knee. This can be frustrating, and it is surprising how different patients recover at different rates. The key during the strengthening phase is to work hard and be patient. While strengthening the muscles, therapists will also help restore normal/athletic proprioception and functional movement patterns. At this point, it is common for athletes to not experience pain, yet still have significant strength and coordination deficits.

A physical therapist is your most important resource during rehabilitation. They have the experience and skills necessary to help athletes realize where they are in the process, set appropriate goals, and find a balance between activity and rest—both of which are critical to recovery. The athlete, their family, their therapist, athletic trainers, and the physician are all part of a team working together during the recovery process. This process takes time—anywhere from 6 to 24 months—and can vary due to the extent of injury, the athlete’s stage of life/career, and how quickly one’s body recovers. The key is to be patient and persistent, allowing the entire team to help guide the process.

“No Doubt”- The Return of the Confident, Athletic Mindset

Confidence and risk are the final factors that must be considered as an athlete prepares to return to sport. As highlighted earlier, 50% of athletes cite fear of reinjury as the primary obstacle to returning to competition. There are two potential explanations for this fear: 1) a graft that “just doesn’t feel right” may not have completed the ligamentization process, or 2) traditional rehabilitation does not focus on the athlete’s competitive mindset.

While research seeks to eliminate the first cause—and our next blog will address these efforts in detail—only a team-based approach, consisting of the athlete and their family, the physical therapist, athletic trainers, and physician can resolve the second. Close communication is important to understand risks and expectations, set and achieve rehabilitation goals, and confirm the return of normal function and strength. While it is ultimately up to the athlete and their family to decide when he or she is prepared to return to full competition, at the Andrews Institute in Gulf Breeze, Florida, Dr. Anz, and his team work together to aid you in this difficult time.

“The Sports Test-” Progress Report of Recovery

Dr. Anz’s team uses a ‘Sports Test’ to determine where an athlete is in the rehabilitation process. The test is usually scheduled at the eight- to nine-month mark, depending on the athlete’s goal for return to sport. The test evaluates strength through a mechanical test called a Biodex test, and coordination, proprioception and balance through functional movement screening and a y-balance test. There are many versions of this test, but their main goal is to objectively grade an athlete’s strength, coordination, proprioception, and functional movement patterns and, therefore, determine when they are physically equipped to return to sport. Again, there is no standard timeframe outlining when an athlete can return to competition. Therefore, Dr. Anz works with his medical team to evaluate each athlete and determine the goals they have met and the goals that still need to be accomplished. It is not uncommon for previously unknown deficits to be uncovered during a Sports Test. Through this identification, the athlete’s rehabilitation team can refocus and continue their efforts.

The Andrews SCORE: An Evidence-Based Multi-model Return to Sport Evaluation

At the Andrews Institute, a project is starting in 2022 to develop a data-driven decision making model to assess a competitive athlete’s readiness to return safely to sport after ACL injury and surgery.  The model will include patient-reported outcome measures, objective and modern strength/ability testing, and MRI evaluation of healing tissues.  The MRI evaluation will involve techniques already studied by the Andrews Institute and Auburn University.4  This return to sport algorithm will target competitive athletes with a return to sport that is congruent with their pre-injury level of play.  The goal is to have a system to confirm that injured athletes are ready physically to return safely to their sport.  This system will then allow for further study of biologics to expedite this return, proving readiness before return. The ligamentization process of the graft is always the wild card of knowing when athletes are ready for a full return.5  Our goal is to study if further and advance the biologic capabilities of ACL surgery.

 

It is critical to always keep the athlete’s best interests in mind, understanding the short-term gain and long-term health consequences of every decision.

As an Orthopedic Surgeon and Sports Medicine Specialist, Dr. Adam W. Anz is dedicated to providing individuals and athletes from all over the world with the highest possible quality of care. He serves his patients at the world-class Andrews Institute in Gulf Breeze, Florida. If you have sustained a sports-related injury, please contact our office today to schedule an initial consultation with Dr. Anz.

Sources:

  1. https://adamanzmd.com/acl-reconstruction/
  2. https://journals.sagepub.com/doi/abs/10.1177/0363546514563282?journalCode=ajsb
  3. https://pubmed.ncbi.nlm.nih.gov/22922520/
  4. https://adamanzmd.com/wp-content/uploads/2021/11/2019-3T-MRI-mapping-is-a-valid-in-vivo-method-of-quantitatively-evaluating-the-anterior-cruciate-ligament-rater-reliability-and-comparison-across-age.pdf
  5. https://adamanzmd.com/thebiologyofACLhealing-thewildcardofrecovery/
Family Hiking.

ACL Knee Injuries

by ACL research
Family Hiking.

Injury Overview

ACL knee injuries are among the most common injuries for athletes.  The ACL (anterior cruciate ligament) is one of four ligaments that make up the knee joint and is responsible for keeping the shinbone (tibia) from sliding forward on the thigh bone (femur) and providing stability for movements requiring rotation of the knee. Cutting and pivoting athletes, including soccer players, football players, basketball players, and skiers, are at a higher risk for developing an ACL knee injury because of the sudden pivots, twists, and turns associated with these sports. The ACL can also be torn in cases that do not involve sports, such as tripping, missing a step, or any other traumatic hit to the knee.  Typically, the knee sustains a “pivot shift” event where the bones of the knee shift in an abnormal way.

Symptoms

Patients who have an ACL injury are typically present after a twisting injury event. If during a practice or competition, athletes typically report that they could not continue to perform/compete during that day and that the knee swelled immediately after the injury.  Swelling inside the knee from the injury routinely causes it to swell to the size of a softball.  Sometimes, athletes report the sound of one or more pops.  

After a few days, the swelling improves and the function returns. After an ACL injury,  recurrent feelings of “giving away” or instability of the knee are common. These episodes can be problematic because continued pivot shifting events can be associated with further injury to the knee, including injuries to the medial meniscus.   The knee can shift with certain movements such as pivoting to open a door or cutting with an attempt to return to sport.

Diagnosis

Listening carefully to the athlete’s history of injury is always the most important first step to knowing the problem.  Examining the patient thoroughly is the second step, and the Lachman test, anterior drawer test, and pivot shift test are ways to test the ACL for injury.  These tests are not painful; however, it is understandable to be apprehensive of tests of knee stability.  X-rays are important to see the bone anatomy of an injured athlete, as overall alignment affects the forces on ligaments and knees, and to rule out fractures.   MRI is an additional necessary test when an ACL is expected in order to confirm the diagnosis and look for associated injuries, as in many instances the lateral meniscus is injured at the time of an ACL injury.

Treatment

Nonoperative Treatment

Depending on the patient’s lifestyle and goals, the ultimate objective is to return the patient to their pre-injury activities.   This involves an individualized treatment plan to regain stability and full mobility of the knee.  In some cases of isolated ACL injury, surgery may not be necessary, depending on a patient’s goals. Conservative treatment consists of rest, ice, elevation, anti-inflammatory medications, and physical therapy to strengthen the muscles around the knee and to improve neuromuscular control around the knee.  An ACL brace can also help protect the joint during the rehabilitation process.

Surgical Treatment

In athletes who are returning to cutting and pivoting activities, ACL reconstruction surgery is most often recommended.  In some instances, an ACL repair can be considered. During ACL reconstruction surgery a tendon graft of a similar size is used to replace the injured tissue. Reconstruction surgery is performed arthroscopically and involves removing the injured tissue and creating a new ligament with a graft. The graft used during the reconstructive process is most often taken from the patient.   The central third of the patellar tendon, the central third of the quadriceps tendon, or two of the four hamstring tendons are the most commonly used grafts.   Although donated tissue using a graft bank from a donor can also be used, it has been associated with a higher reinjury rate in some studies.  Graft choice is individually decided with the patient.

Post Operative

After a reconstruction surgery, a thorough physical therapy program is extremely important for rehabilitation.  Rehabilitation will be a progressive process that may initially limit movement.  The first phases focus on swelling and the return of normal knee motion.  Further phases focus on regaining strength, balance, and functional movement patterns.

Recovery Time

After an ACL reconstruction, cutting and pivoting activities are limited until around the 7 month time point as graft maturation takes time.  Two studies on reinjury rates suggest that risk decreases significantly with every month until the 9-month time point.1,2  

For this reason, in most instances a return to cutting/pivoting sports is cautioned before the 9-month milestone.  However, every athlete is unique and situations are unique.  Some instances dictate a sooner return to sport than 9-months understanding the risk.  Post-operative rehabilitation and returning to sport is a joint effort/decision between the patient, Dr. Anz, the physical therapist, and the athletic trainer and is necessary to achieve the most optimal outcome.

Post Op Protocols:

Isolated ACL Reconstruction with No Meniscus Repair
Isolated ACL Reconstruction with Minor Meniscus Repair
Isolated ACL Reconstruction with Major Meniscus Repair
Rehabilitation Protocol: Major Meniscus Repair
Rehabilitation Protocol: Minor Meniscus Repair

Athletes with ACL injuries should not feel bad if it takes time to return to their sport.  In many instances it takes athletes one to two years to make a full return.  A study in high-school and college football players found a return to sport rate of 32% at one year and 64% at two years.  53% of high school players and 50% of collegiate players identified fear as a major or contributing factor to not returning to play sooner.3 Dr. Anz and his team serve as advocates to help athletes return safely and expeditiously to their sport, considering and helping with all hurdles along the way.

References:

For additional information on ACL knee injuries, or to learn more about what is involved during ACL reconstruction surgery, please contact the office of orthopedic knee surgeon, Dr. Adam Anz, serving the greater Pensacola, Gulf Breeze, Florida communities.

Publications:

Venous Thromboembolism in Lower Extremity Arthroscopy – 2008

Distal Insertions of the Biceps Femoris A Quantitative Analysis – 2015

Viable Stem Cells Are in the Injury Effusion Fluid and Arthroscopic Byproducts From Knee Cruciate Ligament Surgery – 2017

Biomechanical Assessment of BF Repair – 2018

3T MRI Mapping is a Valid In Vivo Method of Quantitatively Evaluating the Anterior Cruciate Ligament Rater Reliability and Comparison Across Age – 2019

Blog:

Media:

ACL Injury Healing

The Biology of ACL Healing: The Wild Card of Recovery

by ACL research
ACL Injury Healing
Ligamentization – The Wild Card After an ACL injury1, reconstruction of the ligament is often a recommended treatment.  One of the most critical steps in ACL reconstruction2 is grafting a tendon into the knee to replace the damaged ACL. Following surgery, the graft not only has to heal tightly in its new position but also transition structurally from a functioning tendon to a functioning ligament—a process known as ligamentization. Believe it or not, this process takes time! Microscopic studies, in which physicians have taken small samples of healing ligaments following ACL reconstruction to determine their rate of ligamentization, suggest that this process can take anywhere from 6 to 24 months. The ligamentization process is frustrating because it is an unseen rate-limiting step in an athlete’s recovery. Some athletes regain motion, strength, and proprioception at the six-month mark and appear outwardly healed, but the level of ligamentization of their graft is unknown and therefore a return to sport can jeopardize their recovery. For this reason, it is ideal to allow athletes recovering from ACL reconstruction as much time for rehabilitation as logistically possible, assuming it doesn’t jeopardize their return career goals.  Two studies on reinjury rates suggest that risk decreases significantly with every month until the 9-month time point.3,4  This time delay is directly related to the ligamentization process.  For this reason, in most instances, a return to cutting/pivoting sports is cautioned before the 9-month milestone.  Many instances of ACL reconstruction failure can be attributed to a failure of graft incorporation and/or the ligamentization process, so giving the athlete adequate time for recovery is best. One of Dr. Anz’s most passionate clinical research interests revolves around using biologics to improve and/or expedite the ligamentization process following ACL reconstruction. His interest is driven by how critical the ligamentization process is to the full recovery and return to the sport of injured athletes. Animal studies have suggested that slower graft incorporation correlates with increased laxity and stiffness, increasing the likelihood of re-injury, and have illustrated improved tendon healing in ACL reconstructions that incorporate the use of stem cell technologies.  We theorize that optimization of stem cell technologies for tissue regeneration requires the use of the ‘regenerative triad’—a scaffold, stem cells, and growth factors. For that reason, regenerative models with ACL reconstruction combine biologic technologies with a scaffold wrap to produce a new “sheet” of cells around the ACL graft. There are two studies that illustrate the effectiveness of biologics in improving the rate of ACL maturation. The first of these studies involved injecting leukocyte-poor platelet-rich plasma into the fascicles of ACL grafts and the other involved loading of a gelatin carrier with platelet-derived growth factors. Prior to the injury, the ACL and PCL are covered by a synovial lining—essentially a layer of collagen that ensures adequate blood and nutrient supply to the ACL. It is now believed that the lack of this synovial lining following traditional ACL reconstruction may delay the process of ligamentization. We believe that the use of a collagen membrane will protect and create a healing environment like the synovial lining of a healthy joint. At the Andrews Institute, we are interested in building a scientific body of work “brick by brick” to advance the biology of ligamentization.  In 2016, we completed a study determining how many cells can be collected from a patient’s knee, including swelling and by-products of the reconstruction surgery at the time of ACL surgery.5 This study is helping us to better understand ideal methods for collecting a patient’s stem cells.  In 2019, Dr. Anz and colleagues at Auburn University completed a study using MRI to map the ACL to develop normative values for future ACL maturation studies.6   In 2020, we completed a study that used blood concentrating devices (PRP machines) to harvest stem cells from the injury fluid at the time of ACL reconstruction for use at the time of the surgery.7  In 2021, Drs Anz, Jordan, Ostrander, and Andrews completed a study on biologic augmentation of traditional ACL reconstruction.  The theory was that collagen membranes can be used to re-establish the natural synovial lining of the ACL and that the collagen would serve as a container to hold biologic adjuncts around the ACL. This study combined collagen-wrapped graft tissue with cells from the patient’s bone marrow fluid.  This study found that wrapping a graft with an amnion collagen matrix and injecting bone marrow aspirate concentrate was associated with lower MRI T2* values, a surrogate measure of improved graft maturation and collagen content. While early studies are promising, further development is needed to determine if the ligamentization process can be sped up.  At this time, no change in rehab protocols or strong recommendations can be recommended, but the future looks bright.  It is important at this time, even with biologic adjuncts available, to stick to 9-month return to sport timelines.  There is a significant risk of reinjury if athletes push too fast too soon based on exciting theories.  With more time and study, evidence will emerge as to whether biologics can improve ligamentization.  In the meantime, we continue to work on the science to find the truth- “brick by brick”. As an Orthopedic Surgeon and Sports Medicine Specialist, Dr. Adam W. Anz is dedicated to providing individuals and athletes from all over the world with the highest possible quality of care. He serves his patients at the world-class Andrews Institute in Gulf Breeze, Florida. Sources: 1.) https://adamanzmd.com/acl-knee-injuries/ 2.) https://adamanzmd.com/acl-reconstruction/ 3.) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4912389/pdf/nihms782171.pdf 4.) https://www.jospt.org/doi/full/10.2519/jospt.2020.9071 5.) https://adamanzmd.com/wp-content/uploads/2021/11/2017-Viable-Stem-Cells-Are-in-the-Injury-Effusion-Fluid-and-Arthroscopic-Byproducts-From-Knee-Cruciate-Ligament-Surgery.pdf 6.) https://adamanzmd.com/wp-content/uploads/2021/11/2019-3T-MRI-mapping-is-a-valid-in-vivo-method-of-quantitatively-evaluating-the-anterior-cruciate-ligament-rater-reliability-and-comparison-across-age.pdf 7.) http://box5216.temp.domains/~adamanzm/wp-content/uploads/2021/11/2021-Synovial-Stem-Cells-Harvested-with-PRP-Device.pdf   Additional ACL blog articles: 1. ACL Knee Injuries 2. When is an athlete ready for contact sports after ACL surgery? 3. ACL Reconstruction 4. Revision ACL Reconstruction 5.ACL Knee Injuries 6. Save the Menisci: Meniscal Root Tears 7. Meniscus Repair Paper Published in the American Journal of Sports Medicine 8. FCL Reconstruction 9. PCL Reconstruction 10. Multi-Ligament Knee Reconstruction 11. MCL Reconstruction 12. PCL Reconstruction 13. FCL/LCL Knee Injuries
ACL Reconstruction

ACL Reconstruction

by ACL research
ACL Reconstruction

Injury Overview

ACL knee injuries are among the most common injuries for athletes.  The ACL (anterior cruciate ligament) is one of four ligaments that make up the knee joint and is responsible for keeping the shinbone (tibia) from sliding forward on the thigh bone (femur) and providing stability for movements requiring rotation of the knee. Cutting and pivoting athletes, including soccer players, football players, basketball players, and skiers, are at a higher risk for developing an ACL knee injury because of the sudden pivots, twists, and turns associated with these sports. The ACL can also be torn in cases that do not involve sports, such as tripping, missing a step, or any other traumatic hit to the knee.  Typically, the knee sustains a “pivot shift” event where the bones of the knee shift in an abnormal way.

Symptoms

Patients who have an ACL injury are typically present after a twisting injury event. If during a practice or competition, athletes typically report that they could not continue to perform/compete during that day and that the knee swelled immediately after the injury.  Swelling inside the knee from the injury routinely causes it to swell to the size of a softball.  Sometimes, athletes report the sound of one or more pops.  After a few days, the swelling improves and the function returns.   After an ACL injury,  recurrent feelings of “giving away” or instability of the knee are common. These episodes can be problematic because continued pivot shifting events can be associated with further injury to the knee, including injuries to the medial meniscus.   The knee can shift with certain movements such as pivoting to open a door or cutting with an attempt to return to sport.

Diagnosis

Listening carefully to the athlete’s history of injury is always the most important first step to knowing the problem.  Examining the patient thoroughly is the second step, and the Lachman test, anterior drawer test, and pivot shift test are ways to test the ACL for injury. These tests are not painful; however, it is understandable to be apprehensive of tests of knee stability.  X-rays are important to see the bone anatomy of an injured athlete, as overall alignment affects the forces on ligaments and knees, and to rule out fractures.   MRI is an additional necessary test when an ACL is expected in order to confirm the diagnosis and look for associated injuries, as in many instances the lateral meniscus is injured at the time of an ACL injury.

Treatment 

Nonoperative Treatment

Depending on the patient’s lifestyle and goals, the ultimate objective is to return the patient to their pre-injury activities.   This involves an individualized treatment plan to regain stability and full mobility of the knee. 

Human Knee Diagram

In some cases of isolated ACL injury, surgery may not be necessary, depending on a patient’s goals. Conservative treatment consists of rest, ice, elevation, anti-inflammatory medications, and physical therapy to strengthen the muscles around the knee and to improve neuromuscular control around the knee.  An ACL brace can also help protect the joint during the rehabilitation process.

Surgical Treatment

In athletes who are returning to cutting and pivoting activities, ACL reconstruction surgery is most often recommended.  In some instances, an ACL repair can be considered. During ACL reconstruction surgery a tendon graft of a similar size is used to replace the injured tissue. Reconstruction surgery is performed arthroscopically and involves removing the injured tissue and creating a new ligament with a graft. The graft used during the reconstructive process is most often taken from the patient.   The central third of the patellar tendon, the central third of the quadriceps tendon, or two of the four hamstring tendons are the most commonly used grafts.   Although donated tissue using a graft bank from a donor can also be used, it has been associated with a higher reinjury rate in some studies.   Graft choice is individually decided with the patient.

Post-Operative 

After a reconstruction surgery, a thorough physical therapy program is extremely important for rehabilitation.  Rehabilitation will be a progressive process that may initially limit movement.  The first phases focus on swelling and the return of normal knee motion.  Further phases focus on regaining strength, balance, and functional movement patterns.

Recovery Time

After an ACL reconstruction, cutting and pivoting activities are limited until around the 7-month time point as graft maturation takes time.  Two studies on reinjury rates suggest that risk decreases significantly with every month until the 9-month time point.1,2  For this reason, in most instances a return to cutting/pivoting sports is cautioned before the 9-month milestone.  However, every athlete is unique and situations are unique.  Some instances dictate a sooner return to the sport than 9-months upon understanding the risk.  Post-operative rehabilitation and return to sport is a joint effort/decision between the patient, Dr. Anz, the physical therapist, and the athletic trainer and is necessary to achieve the most optimal outcome.

Athletes with ACL injuries should not feel bad if it takes time to return to their sport.  In many instances, it takes athletes one to two years to make a full return.  A study in high-school and college football players found a return to sport rate of 32% at one year and 64% at two years.  53% of high school players and 50% of collegiate players identified fear as a major or contributing factor to not returning to play sooner.3 Dr. Anz and his team serve as advocates to help athletes return safely and expeditiously to their sport, considering and helping with all hurdles along the way.

—

Dr. Adam Anz is an orthopedic knee surgeon in Gulf Breeze, FL.  For additional information on ACL knee injuries or to schedule a consultation to discuss ACL reconstruction surgery, please call our office today.

References:

MCL Knee Injury

MCL Knee Injuries

by ACL research
MCL Knee Injury

Injury Overview 

The MCL is a ligament that links the shinbone (tibia) and thighbone (femur), and is located on the inner aspect of the knee.  It is an extra-articular ligament (not located inside the knee joint), and as a result has a good blood supply.  The MCL may be injured as the result of a direct blow to the outer edge of the knee or from landing abnormally on the leg.   MCL injuries are often seen in soccer, football, basketball, and snow skiing.  The MCL can also be injured during daily activities such as tripping or missing a step. MCL knee injuries range in severity, including stretch injuries or partial tears to the ligament and complete disruption of the fibers of the ligament.

Symptoms

Symptoms of an MCL knee injury will vary.  The most obvious symptom is pain, with bruising and swelling on the inside of the knee joint. A subtler symptom involves the feeling of instability when the leg is placed in certain positions. With complete disruption, instability may be quite noticeable.

Diagnosis

Dr. Anz will perform a detailed physical exam where he will apply various tests to determine knee mobility, pain, and stability. These tests help to detect injury to the ligament ligament.  One exam is performed by bending the knee to 25 degrees and putting pressure on the outside surface of the knee. When MCL damage is suspected Dr. Anz will usually order a stress X-ray to document to extent of injury.  An MRI is often necessary in order to determine the healing potential of the ligament.

Treatment

Many isolated MCL injuries can be treated non-operatively. Excellent results are typically seen by allowing the MCL to heal through immediate range of motion, icing, physical therapy, and bracing.

Surgical Treatment

If the MCL injury is a grade III injury, or is injured along with other ligaments, it may not heal on its own.  In this case, an open procedure to reconstruct the MCL may be necessary.   During the reconstruction process, Dr. Anz may use a graft from either the patient or a donor. This choice will be made with the patient after a detailed discussion of the risks and benefits.

Post-Operative

Therapy is the most important part of a post-operative course.  Dr. Anz will prescribe a complete rehabilitation program that should be followed closely to completion following surgery. Therapy will be progressive and will focus on regaining mobility and motion to the injured knee, followed by a strengthening and a functional rehabilitation program.

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For more information on the treatment following an MCL knee injury, or for more information on isolated or multi-knee ligament injuries, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute. 

Misalignment Orthopedic

Malalignment of the Lower Extremity

by ACL research
Misalignment Orthopedic

Injury Overview

The knee joint is a crucial component of the lower extremity mechanical axis in the human body. In orthopedics, proper alignment of the lower extremity is essential for normal joint function, muscle development, biomechanics, and dynamic balance.  If the lower extremity is improperly aligned, problems can arise in the knee joint including damage to the articular cartilage and/or meniscus because forces across the knee are not evenly balanced.  An improper alignment of the lower extremity is often called a malalignment. Over time, a malalignment may cause damage to the knee joint and its ligaments and can cause various symptoms in both young and older individuals.

Some people are born with a malalignment, while others can develop malalignment due to a traumatic event or damage to structures on one side of their knee..  There are a number of problems that can arise due to a malalignment, including articular cartilage damage, meniscal damage, and a ligament injury.

There are two types of malalignment in the knee:

  • VARUS: The term “bow legged” refers to a varus malalignment. This occurs when weight does not pass evenly through the knee and instead passes through the inside  (or medial compartment) of the knee joint (inside). With this condition, patients are more likely to develop degeneration of this side of the knee and are at a risk of having medial meniscal tears and cartilage injury.  With time, patients may also stretch out the ligaments on the outside of their knee and develop instability during walking.  A varus thrust involves visible instability upon walking.
  • VALGUS: The term “knock kneed” refers to a valgus malalignment.  This occurs when the weight-bearing axis passes through the lateral side of the knee (outside), predisposing this side to injury and wear.

Varus and valgus alignments occur on a spectrum.  Some people may have a mild amount of varus or valgus which does not cause any problems.  However, extreme cases of varus and valgus involve weight transmission across the knee joint which is not balanced.  This can cause unequal wear in the knee joint as one side experiences greater force than the other side.

Knee Misalignment

Symptoms

Some change in the mechanical axis is normal through childhood development, however, malalignments which persist after childhood can affect one’s stance and gait (pattern of walking).  Patients may report that they have been “bow-legged” or “knock-kneed” since childhood.  These patients may or may not develop problems later in life depending on the extent of their alignment.  Patients that develop a malalignment due to other causes often report an initial injury many years ago.  They then noticed a gradual onset of pain on one side of their knee.   Mechanical symptoms such as knee swelling, popping, catching, and a reduced range of motion may also be present.

Diagnosis

The diagnosis of malalignment will require a physical examination as well as X-rays that capture the entire lower extremity mechanical axis.  Dr. Anz will examine the hip, knee and entire lower extremities. Full length standing X-rays will document the weight-bearing axis (overall alignment) of the leg and evaluate the overall status of the knee.  For patients with mechanical symptoms, an MRI will help to evaluate the cartilage and meniscus of the knee joint.

Treatment

Some patients who are diagnosed with a malalignment can be treated conservatively without surgery. A thorough understanding of the problem and avoiding certain activities can be helpful.  Additionally, stretching and strengthening of the quadriceps, hamstrings, and calf muscles will help provide stability to the knee joint.  Weight loss, core and lower extremity strengthening, shoe modifications, and bracing to shift the mechanical axis may also be recommended.

Surgical Treatment

In certain instances, surgery may be recommended. Surgery to correct a malalignment requires an osteotomy (or cut in a bone) and realignment.   This may be performed on the leg bone (tibia) or thighbone (femur) and may also be combined with other procedures.  In certain instances of a ligament injury in the setting of malalignment, a staged surgery may be necessary.  For instance in patients with malalignment and chronic ligament injuries, two surgeries may be necessary.  The first surgery will involve an osteotomy correction of the malalignment followed at a later date by ligament reconstruction surgery. There are also procedures to treat chondral injuries that may result from the malalignment.

Post-Operative

Depending on the specifics of the surgery patients may be immobilized following surgery for a period of time and may be restricted from putting weight on their leg. Physical therapy is always important and will focus on patient mobility, returning motion at the appropriate time, and regaining strength back to the injured knee and surrounding muscles.  Rehabilitation is a crucial part of the recovery process and is recommended to achieve optimal results.

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For additional resources on knee conditions involving a malalignment of the knee, such as a varus or vargus knee disorder, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.