ACL Rehab

[sarahkelly]

Just a few questions I should probably already know the answer to:

When I'm doing acl rehab (eg hams strenghtening) should I be doing the same exercises on the "good side" as well as my affected side in order to prevent myself from getting an imbalance?

Also how long roughly after an ACL tear (managed conservatively) can a person run? (I know that this varies from person to person) but roughly how long?

Finally how much "better" do people get after ACL rehab, will I always have a "dodgy knee" - I'm not intending to return to sports but to run 2km per night (I need to do it more than most as its the only way I can control my SLE). Will there be a time when I walk and don't feel like I'm dragging everything below the knee? Will I ever be pain-free and will the joint ever feel stable?



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[sarahkelly]

Also for the conservatively managed patients, do they cut out the pieces of torn ACL or just allow it to rot? I'm in a hell of a lot of pain (even at rest) and suspect that it's the torn ACL inside the joint coming in contact with the joint surfaces?

[bikelet]

I don't know the answers to all of your questions but on the first point are you following any post op rehab protocols? If you aren't then i'd suggest it as a good idea. When you can handle more dynamic exercises and single limb exercises in your rehab program then you would be able to start running. As you are running for fitness, you would be able to return to this relatively quickly (sooner than someone who needs to return to sport and be able to dodge obstacles etc). A fitness alternative is cycling and this can be started very early in a program, provided the seat is high enough and there is low resistance for minimal knee stress. In fact many exercise protocols use static cycling as a means of trying to increase knee range of movement.

[physiofi]

Cannot give any definitive answers as obviously differs from person to person. All the surgeons in the acute hospital I worked in had different protocols regarding their ACLs (one instructs patients are NWB for 4 weeks whereas another gets them FWB from first day post-op). In most ACL reconstructions I've seen, and the conservatively managed ones who weren't operated on, I never stressed that they perform exercises on both sides (unless it was unintentional) as generally found that the affected limb would be considerably weaker and require much more rehab to get back to the uninjured level.

As bikelet said^, rehab is important. What specific rehab protocol are you following? The surgeons where we work have differing rehab protocols, also depending on what type of graft it was. Generally most that I've seen have said to avoid any open chain activity and work hard on proprioception and hamstrings strength. As a rule of thumb, they said to avoid full return to sports until 12-18 months post-op. Specifically 16-18 if contact sports, if I remember correctly.

P.S. how far post-injury are you? perhaps you're being a little hard on yourself. I have treated an 18 year old whose MRI showed complete ACL rupture who had superb core stability and muscle strength and on examination was completely asymptomatic after a few sessions "prehab." He was continuing with all sports aside from football as he had been advised against this (by myself and the surgeon) but he was continuing to run considerable distance every night (although on the advice to avoid sharp turns/fast changes of direction).

I would say you probably need to give it more time before you judge whether or not you're "back to normal." If you're working hard at your exercises and core stability, you will reap the rewards.

[sarahkelly]

Hi there,
Sorry for the lack of details.
I'm 5 weeks post-injury, MRI scan next week, but me and physio pretty sure its ACL tear, Im not following a specific protocol but a physio is overseeing the rehab, I'm not even sure how it works from here, does an orthopaedic surgeon look at my MRI and prescribe a protocol? I will be managing this without surgery regardless. I've been working my ass of at rehab in gym/pool every day etc, but not working too hard on core strength (should probably focus a little more on that...). The reason I ask about jogging (jogging in straight lines, its my only sport, I don't play nor wish to play other sports) is that I have SLE and the muscles around some of my joints tend to get a bit weak and my nightly jog is the one thing that keeps them strong. But the physio said I wasn't allowed to jog right now (Next physio appointment = next week). I'm just wondering if it will be months b4 I can jog again, also the feeling of instability when I turn (even slowly) in walking, is that something that will never go away or will it decrease the more I work on proprioception, I'm ok walking in straight lines but cannot turn I have to pivot on the good leg, and that's not improved at all...
Also despite slight improvements, (I no longer feel that I'm going one way and everything below the knee is going another) will I always have a "dodgy knee"? Everyone keeps talking about rehab but how much of a recovery will I be able to make and will it ever feel "normal"?

[physiofi]

Hi, thanks for the extra info.

Sorry to hear you're feeling so rubbish - it's a painful and sickening injury, especially with that giving way/instability feeling, not that any injury is pleasant! I know it's difficult but honestly can not give a definitive answer with regards to being back to "normal" or how much of a recovery you will make. Everyone is different.

If the MRI shows a tear and you are conservatively managed - as far as I know, the physio would probably oversee your rehab and base it on principles similar to the post-op protocol e.g. closed chain exercise initially, hamstrings strengthening, lots of proprioception work etc...gradually increasing intensity to return to exercise as able. You may still be given a follow up with orthopaedics to see how you're progressing during/after physio.

5 weeks post-ACL tear you are relatively early days so I wouldn't be too negative regarding recovery/rehab. I know everyone wants answers but sometimes it's a case of work hard, wait and see. You're under a physio and getting an MRI scan so sounds like all is in hand and proceeding well.

Definitely focus on core stability, it's something people tend to forget but just as important as hamstrings/quads strengthening and proprioception! What about static bike? You could get cycling relatively early on which would help maintain fitness. The feeling of instability should decrease as you train your hamstrings and other muscles to take over the job the ACL would be doing...it's obviously going to feel unstable at the moment - you're not far on from the injury and you still need to allow time for proprioception training and graded strengthening.

I tend to progress my patients slowly and gradually...I know you're impatient and keen to get back jogging, but you need to make sure you work hard on strengthening and training your muscles/core stability etc first so that you don't possibly re-injure or do too much too soon, which may set you back with regards to pain etc.

As I said previously, I saw a young man with a complete ACL rupture who was completely asymptomatic and carried on running because all his other muscles/core stability were strong enough to function without it. In fact, I was convinced it was probably only a partial tear as initially I saw him pre-MRI, so was rather surprised when the MRI said the opposite! But just goes to show sometimes presentation isn't always what you expect...

Hope this helps.

[sarahkelly]

Thanks for the advice, I will try and focus more on core stuff. I thought I was doing ok but have regressed once again. I know its' early days but the pain was terrible today and I felt like I was dragging a dead leg attached to an elastic band around with me, there is a lot of talk about what ex's to do when, surgery vs conservative management etc but a steep lack in info on outcomes, will it ever feel like a normal leg? do patients ever get "better" or will my leg always feel unsteady? Will I always walk with a limp? At what stage do you discharge your patients? and have any of them get their leg back to normal? I really don't care if it take 3 years and 5 hours of rehab a day, I need my leg to work and more importantly I need a realistic idea of my outcomes.

[physiofi]

Hi Sarah,

I understand you're impatient and frustrated with a lack of information/advice regarding outcomes. I would say (in my limited exp) that it's very difficult to answer this - particularly over the internet and without having assessed you myself. It sounds like you're highly motivated and committed to rehabbing your knee as best you can, which sets you in good stead. You're aiming to get back to jogging, not high intensity/impact level sports, which again is more realistic to obtain/aim for.

Are you taking any painkillers? Regular analgesia will help control your pain while you're working on rehab.

I can only speak from experience, as I have treated several ACL injuries, but only one was conservatively managed. He was an 80 year old male who ruptured his ACL 2 years previously but was misdiagnosed. Obviously, it is very difficult to draw similiarities...but 2 years on after initially having no physio/rehab whatsoever, he got to the stage where he had minimal pain, his knee didn't give way any more and he was walking without a limp.

I'm sorry that there's no concrete answer for you, but as you can see - it all depends, everyone is different. I recently saw a 35 year old male who had an ACL reconstruction 2 years ago and had been fine since although had not returned to playing football. He came in complaining of some discomfort/pain and generally feeling the knee "wasn't right" although he had no limp. He did have considerable quads weakness, decreased proprioception and poor core stability. I think his lapse in symptoms were due to not following through his rehab fully and continuing with his return to exercise afterwards.

Generally, I will discharge patients when they are a) asymptomatic or b) symptoms have reduced, they are able to self-manage and continue progressing their rehab on their own / at home / in a gym etc. This evidently varies depending on your patient and their age/goals/ability.

I hope this helps you. Please focus on yourself and working on your recovery and I'm sure you will reap the rewards in time. No study or list of outcomes will definitively give you an answer as to how you personally will progress.