The ACL: Much more than “just a ligament”

ACL injuryWelcome to part two of my three-part series dedicated to understanding the recovery from ACL injury.  In part one, we heard from Veronica and Melinda about their experiences and challenges (physically, mentally, and emotionally).  Now, I’m going to share the experiences of two more people who both dealt with multiple ACL tear episodes, using different types of surgery, and making different decisions when faced with their most recent and final episode of re-injury.

Here is Niki’s story, with (some interjections by moi):

“As a 34-year old school teacher, volleyball coach, and former player, I’ve had my fair share of knee injuries and surgeries. I was a junior in high school, playing a varsity volleyball match at a rival high school. I ran to chase down a pass, stopped, changed directions, and immediately fell to the ground. I remember trying to get back up and falling again. I didn’t hear a “pop” like most people hear when tearing an ACL.  (Not all people who tear their ACL hear/feel a “pop”.  I personally know four previous clients who had no idea that they tore their ACL when it happened, reporting nearly no pain or swelling, merely a weird feeling of instability.)

I went to a recommended surgeon. He was trying a new style of surgeries (allograft – cadaver ligament via arthroscopic surgery), so I signed up.   With only 5 surgical portals, he sold me on the fact that recovery would be quicker, with less scar tissue (it’s typically true that cadaver ACL surgeries have an easier first phase of rehab, however I wouldn’t go as far to say that someone recovers quicker in the long run). He failed to mention the cadaver ligament was not as strong as other choices (Allografts have a much higher risk of rejection by your body, with more potential complications, increased knee laxity, and scientific studies show as high as a 3-fold risk of rerupture vs autograft). In February of 1997, I had surgery. I don’t remember being in pain or taking pain medication. The uncomfortable moments were sleeping and showering.  Stepping into the shower proved to be a deadly feat every day. My parents put a chair into the shower for me (external support is a key part of recovery – family and friends can play a big role in addressing daily challenges!). I no longer felt like I was going to slip, fall, and reverse all of the repairs that had just been made to my new, bionic knee (anything that can be done to boost confidence is a big “plus” during the recovery.  A lingering deficit in confidence can have a series impact on recovery).  To alleviate leg pain and to make sleeping more tolerable, I would put a pillow underneath my knee. Upon returning to my doctor for a follow-up, I told him about my new sleeping habits. He was VERY quick to scold me (Great interpersonal skills on display here by the MD <he says sarcastically>). According to him, sleeping with a pillow directly underneath your knee would lead to hip pain and other problems (Seriously?  I can think of a hundred other things the physician should be concerned about at this point post-op).

I listened diligently to my physical therapist, and hoped to recover in time to do preseason workouts for the upcoming volleyball season. (She was told) the recovery time was 6-9 months (6 months is very early for someone, especially a teenager, to be returning to full unrestricted sports participation.  Of course, it varies based on the sport.  Typically my goal for those I work with is to be full go, performing at a level higher than prior to the injury, and unrestricted around 8 months s/p – a sufficient physiological healing time-frame). Rebuilding my quad strength and regaining my range of motion were the main goals (I hope Niki’s rehab team stressed the importance of many other important goals beyond these two.  Interesting that these are the only two goals that stick out in her memory).  With the style of surgery I had, I was able to rehab faster (see above – allograft). I went to physical therapy twice a week for three months and did exercises at home. I was able to fully rehab my knee to do preseason workouts and fully participate in upcoming season. I did experience pain during jump training and sprints because it was the most impact my knee had taken in over a year (likelihood is that she was having pain due to unaddressed biomechanical issues and/or lack of proper preparation – at that point, it should not have been the most impact her knee had taken in over a year.  While occasional knee discomfort in the area of the scar tissue can be normal in the short-term, a proper reconditioning program prepares someone to withstand that stress with no problem.  THIS SHOULD NOT HAPPEN).ACL frustrated

The cadaver ligament lasted for one high school season, four years of collegiate volleyball and three years of recreational volleyball. I can’t remember the exact moment in which I re-tore the same ACL (possibly repetitive biomechanical microstress combined with decreased stability from the allograft surgery). I found a well-known surgeon in Baltimore. He recommended using my patella tendon instead of a cadaver ligament because it was so much stronger (autograft). Surgery was painful (Yes, Bone-Patellar-Bone is reportedly the most painful post-op of the surgical choices). The large incision running down my knee looked gruesome. I slept in my father’s recliner, which was more comfortable than my bed. Showering still was a scary task (confidence). I often resorted to washing my hair in the sink (just one of many daily modifications someone has to make during recovery.  The rehabilitative team needs to prepare the person best they can by providing lots of ideas for modifications). My first physical therapist this time was too easy. Feeling like I wasn’t being pushed hard enough, I switched to a more aggressive physical therapist (Good for you Niki!  It’s important that patients take accountability for their care!). We worked on gait training, strength and flexibility. My recovery was slower with this style of surgery, but I felt like I had better results (because you did).

Niki’s recommendations for others: Know yourself and your needs:  My second surgeon and physical therapist were aggressive in their approaches (and she needed that). “Happy thoughts” are not going to repair your knee or regain strength (correct – you have to put in the word.  But a positive attitude can make a world of difference!).  Ask questions, and keep asking until you understand (Very important for you to be educated on your condition, restrictions, and expectations.  A good rehab professional or MD will listen and address your concerns). The surgery will repair the ligament – that’s the easy part. The difficult parts are the months that will follow (level of motivation and dedication are huge factors in the outcome).  Finding a quiet place to stay comfortable the days after surgery.  Rehabbing doesn’t end with your last physical therapy appointment. In order to maintain muscle mass and a healthy knee, stay active, do weight training.  (AMEN to this statement!  Unfortunately with PT benefits being limited to usually only the first 3-4 months, education is key for success beyond that.  Even better – when possible, work with a rehab and/or conditioning professional who can guide you through those remaining 4-5 months until you’re fully back).”

And now for another perspective from, Jen, who experienced tearing her ACL 3x over the course of 12 years (surgically-fixed the first two times, but elected no surgery the third time in functioning normally with ADLs).  She endured very challenging recoveries, facing both physical and emotional difficulties.  Jen offers her “Top 5 things she learned from her ACL”…

“Amazingly, tearing my ACL twice was a great learning experience. It was important to be patient and smart about my recovery. Time, hard work, and positive thoughts helped me reach almost 100% usage of my knee currently. The top 5 things I learned from my ACL are:

  1. Recovery is not a race. It will be frustratingly slow at times, but if you do not give your body the time to recover you are setting yourself up for setbacks.
  2. Physical therapists are magical people (as are certified athletic trainers!). Yes, the doctors and nurses are also amazing people, but your physical therapist will see you through the recovery multiple times a week over the course of several weeks. Listen to them wholeheartedly and embrace the physical and mental challenges they will put you through. When my first physical therapist told me to stand on both legs without the use of crutches I was adamant that I was not ready for that step. However, he told me that my knee is stronger than I thought it was. I listened to him and, sure enough, my knee was able to sustain my weight. I never doubted him again. 
  3. Know your body. I knew from my first ACL surgery that I have a negative reaction to anesthesia. I explained this to my doctor before my second surgery and he was doubtful of what I told him. After the third day of not being able to keep down any food and liquids, we made the decision to call the office (on a Saturday) and request an anti-nausea medication. It worked immensely and the sustenance I Was able to take in helped me recover.
  4. Know your limits. I fully accept and no longer participate in certain physical activities due to my knee not being as strong as it would be with a working ACL. I allowed myself one last “hurrah” by participating in a Tough Mudder last year, but have declined running any long distances or pivot sports since then.
  5. Be thankful. A torn ACL is nothing compared what others endure on a daily basis. Every time I went to physical therapy I was reminded of this. I think about this whenever I have to walk a longer distance than anticipated (even in a parking lot!). If the ACL is the least of your worries, than you are a very lucky person.

Thank you to Niki and Jen for sharing their stories and recommendations.  After experiencing the stories of Veronica, Melinda, Niki, and Jen, one can understand the complexity of recovery from ACL – especially when someone has to deal with a recurrence (or two!)  In the final part of this series, it’s time for me to share my personal approach and guidelines to managing ACL injuries from the time they occur until beyond full recovery.  I promise some good stuff.  Stay tuned!

RS

Ryan Stevens, MPS, ATC, CSCS
RStevensATC@yahoo.com

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