Partial ACL tear - no surgery

[mouk786]

Hi

I posted on this forum before - thanks for all the help.


My situation is this

I am 23 years old, male and fairly fit.

I got my MRI results today and have a partial ACL tear (not sure to what extent).

I definitley want to get back to having a strong knee/leg and am willing to work like a btich to get there.

I also wanna get back to being able to run properly and play soccer. Not to a high level but to a fairly decent standard maybe once a week.

Now reading (hundreds) of pages online about ACL tears and surgery I geared myself up for some news on surgery today as I expected a full ACL tear.

The Dr says that he recommends I take physio instead as if I do it well enough I can go back to near enough where I was pre-injury and that surgery was a last resort and he doesn't recommend it.

There MAY be pressure on him to prevent people going for surgery as its on the NHS (in the UK) and so it costs them a lot of money - but I do udnerstand his reasoning - though he was pushing hard for physio rather than surgery.

I spsoe worst case is I do physio for 3 months and if its still not OK I can have surgery.

I spose I am looking for re-assurance. Can I really get back really good just with physio therapy? I dunno how much is left of my ACL though.

Also the physio he was talking about seems to be about strength,control and all sorts -which sounds good as it may help me A LOT more than I originally expected.

Has anyone recovered prerly from a aprtial ACL tear like this?

Also, when I originally saw my physio (not on the NHS) he suggested that continuing without a proepr ACL may lead to artiritis. However the guy today said that now I have the knee injury I have a higher risk of arthiritis anyway - who is correct? Do i leave myself open to a much higher chance of arthritis if I have no surgery or is it possible to recover enough to be on roughly the same level (i.e surgery and physio and no surgery and physio).

Also can any physios who actually do the treatment give me a rough idea of what to expect? What kind of treatments do you do that i wouldnt think of myself (i.e squats/ankle weight exercises etc)


Any suggestions?

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[Canuck Physio]

The ACL should be able to heal naturally with Physio, a conservative treatment and a progressive program would probably do it.

[karen.hankey]

There are people out there in high level sport without an ACL at all. The preference for most people is conservative rehab intially. Surgery is only indicated if conservative rehab fails or there is instability.

Your rehab will entail gaining full movement and get rid of any swelling. Once that is done, you start on strength exercises. I can't be too specific on exercises because it is individual to each person. But a basic programme usually involves, squats (both two-legged and singe-leg), going up and down stairs, jumping and hopping. To enable you to run you must be able to hop without pain. The emphasis for the exercises is to be able to control the knee, so that the muscles take over the job of the ACL.

With regard to a physio I would reccommend someone who has done this sort of rehab before.

Hope that helps a little. Any more questions just ask

[physiobob]

I tend to agree with the above comments. The ACL does NOT provide any direct structural support to the knee joint. What it does is send information about load and angular velocities to the brain so that the brain can then send messages to the muscles to support the knee during activity. A reconstruction tries to create a structural stability to the knee because this feedback is not working anymore without an intact ACL.

So overall a partial, still functioning ACL is a better option than having it removed even if it were replaced with a graft as the graft cannot replace the actual function of the ACL.

[Canuck Physio]

I agree, no surgery if it was me

The ACL (anterior cruciate ligament) is one of two "hidden" knee ligaments that attach the thigh (femur) to the lower leg (tibia) by "crossing" each other at the knee joint, hence the term "cruciates".

As the name suggests, the ACL attaches from anterior surface of the tibia, blends with the anterior horn of the lateral meniscus and travels backwards to attach to the posterior part of the medial surface of the femoral condyle (thigh bone). The PCL (posterior cruciate ligament) crosses the knee joint the opposite way and works with the ACL to hold the knee together when the joint is under load or tension. Injury to the ACL is much more common.

At an American Osteopaedic Sports Medicine Society meeting, Dr Bernard Bach presented an insightful discussion on the indications and contradictions for ACL (anterior cruciate ligament) surgery. He concluded with the old adage emphasized by Dr Jack Hughston years ago, "nothing is so bad that it can't be made worse by surgery". Implying that not all patients with ACL tears require surgery.

The ACL provides 86% of stability in anterior displacement and 30% to any medial displacement. However, rupturing the PCL is worse, as it provides 96% of stability to any posterior movement and 36% to lateral stress. As you have probably found, closed chain movements such as the squat and leg presses are fine. It's not until you attempt to perform some form of dynamic action that involves movement in all three dimensions that you have trouble. This is why many doctors and surgeons adopt a "wait and see" approach on ACLs before recommending surgery. Unless the patient regularly performs dynamic, open chain movements they see no need to operate.

With the correct rehabilitation strategies the hamstring muscles learn peripheral compensation and provide a great deal of anterior shift stability.

Seek out a local physio before you contemplate going under the 'knife'

[mouk786]

I tend to agree with the above comments. The ACL does NOT provide any direct structural support to the knee joint. What it does is send information about load and angular velocities to the brain so that the brain can then send messages to the muscles to support the knee during activity. A reconstruction tries to create a structural stability to the knee because this feedback is not working anymore without an intact ACL.

So overall a partial, still functioning ACL is a better option than having it removed even if it were replaced with a graft as the graft cannot replace the actual function of the ACL.

The partial ACL cannot heal proeprly right? but can it still send signals back?

I have felt a difference and slight instability in my knee (i.e no cofidence to play football/soccer) so that must mean the partial tear is fairly significant - the Dr wouldn;t say how much though.

Any info on arthritis on surgery v no nsurgery scenario? i am thinking long term effects here. should i give up footy?

[physiofixme]

Your success is going to depend on the type of exercises you get given. you need a programme that is going to incorporate leg strength with core strength. Your Quads are probably the focus but you should also be looking at strengthening your butt, hamstrings and core stabilising muscles. Basically this means you need to seek out a good sports physio!! Your rehab programme should also involve some sport specific drills later on before you return to football. Things like running, kicking changing direction etc. This all helps retrain your muscles to send the right signals back to your brain, and to get your muscles co-ordinating properly.

There is some evidence that a damaged ACL can cause extra load to be placed on your cartilage and therefore increase the liklihood of arthritis??? I don't think this is proven however. If your rehab isn't working/helping then you can rethink the surgery option.Do you want to be injury free? Physiofixme

[mouk786]

Hi
Thanks for the reply

The Dr mentioned regaining 'control' of my leg - any info on this? this is probably the major annoyance i have as my leg/knee doesnt seem to go back ot the normal range of motion all the time - i.e when i am walking

I have been recommended to a physio at an NHS hospital - i'll assume theyre pretty good!

[physiobob]

The partial ACL cannot heal properly right? but can it still send signals back?

I have felt a difference and slight instability in my knee (i.e no confidence to play football/soccer) so that must mean the partial tear is fairly significant - the Dr wouldn't say how much though.

Any info on arthritis on surgery v no surgery scenario? i am thinking long term effects here. should i give up footy?

Hard to say what fibers are torn and therefore how much that relates to the signals going to the brain. The feeling of laxity often increases with time but in terms of the early onset of arthritis that is more related to intact menisci (knee cartilages). Surgery is likely to involve trimming or removing some of that which if possible is best avoided as we are making steady progress in the medical fields or tissue replacement, growth, repair etc so the longer the joint surfaces are protected the better.

As for "footy", this is something hard to play without an intact ACL due to the pivoting and side to side movements. If the knee is unstable and you continue to play chances are you will progress to a full tear and the likelihood of injuring the menisci at the same time.

[mouk786]

I suppose the essential questions are can I :

a) go back to a near normal knee without surgery but with physio
b) can i get back to some sort of level of playing football without surgery

The Dr/specialist at the hospital seemed confident and kept say that I don't need surgery to get back to what I want.

[physiobob]

I suppose the essential questions are can I :

a) go back to a near normal knee without surgery but with physio
b) can i get back to some sort of level of playing football without surgery

a) Depends on the extent of the tear and which fibers are damaged
b) This is possible although you will always be at more risk of further injury than prior to the recent tear. Surgery will provide perhaps a reduced risk or reinjury but the functionality and dynamic movement "might" be better without.

As I read in another post somewhere a surgeon wrote "The is no condition so bad that cannot be made worse with surgery". This is something worth thinking about.

[physio.smith]

I hope since you last posted that you are making good progress.

One of the key things is regain the strength at your knee before doing anything too dynamic. You really need 80-90% strength in your injured leg (compared to your non injured) before doing anything too dynamic.

You must ensure however that you have full range of motion at your knee before embarking on too much else. If you are lacking full extension (or hyperextension) compared to the other side you are more likely to cause long term damage and not full trust the joint and will struggle to regain strength. Also if you are lacking full range you may still have swelling, this can take a long time to settle and range may change if you over do the exercises and stir up the joint, so do monitor.

You may find that due to NHS constraints that you are not taken as far as you need to in terms of rehab (not sure if this is true...as not worked in NHS for a long time). They should however ensure that you regain full range of movement and start you on a program, with specific goals and targets to meet. You may need further input as you progress.

Please seek the advice of a physio who has assessed you (as these may not be appropriate for you and technique is important), however below are a few tests that you may find useful to help you monitor your progress....

*Single leg press (1 Rep max) assertain limb symmetry
*Star excursion balance test
*Step down test
*Figure of 8 shuttle runs
*Cross over hop tests
(obviously there are much more basic tests and many more others out there)

The Lower Extremity Functional Scale (Brinkley et al. (1999) Physical Therapy. 79: 371-383) may help you monitor how your knee is feeling.

Good luck.

[glog1066]

I suppose the essential questions are can I :

a) go back to a near normal knee without surgery but with physio
b) can i get back to some sort of level of playing football without surgery

The Dr/specialist at the hospital seemed confident and kept say that I don't need surgery to get back to what I want.

hi there im new to this forum and have viewed your post, i know you had the problem a while ago but im wondering how your knee is, the reason im asking is im goining through exactly what you did i have a partial tear to my right acl and dont know weather to push for surgery or try the physio route, i did this playing football and would love to get back playing again, many thanks russ

[mouk786]

hi there im new to this forum and have viewed your post, i know you had the problem a while ago but im wondering how your knee is, the reason im asking is im goining through exactly what you did i have a partial tear to my right acl and dont know weather to push for surgery or try the physio route, i did this playing football and would love to get back playing again, many thanks russ

Hi

Its been ages since that post

Effectivley I rehabbed hard and got the strengh back up in my knee. I amanged to play 5 a side football for about a year - playing upto 2 games a week sometimes with no problems.

The knee itself wasnt bad, no pain and fairly stable but not as rock solid a joint as my normal knee

unfortunatley after about a year of playing i somehow managed to tear the rest of the ACL whilst twisting.

I have since had the ACL reconstruction and the knee feels more solid, although I managed to tear some cartialge as well which has caused me more problems

so my advise is push for the surgery if you want to play footy again.

[glog1066]

hi thanks for the speedy reply, you sound like youve had a tough time, i think after speaking to a few people including you i think surgery will be the best option for me,if they will do it of course, thanks very much for yiur help, cheers russ

[John Ross]

Let us know how you got on. Any kind of future sporting life (contact or non-contact) suggests you should have surgery...

[Kevoras]

I happen to be in the exact same position now, and stumbling on this post.

I recently on June, had my left knee ACL partially torn, and now doctors are recommending that I do physio, and they seem confident that I can return to my previous level of play. (but again, the doctors doesn't look like athletes.. not sure if they understand the roughness on the pitch.)

I am a near professional level Football player.
and for the last 2 months, I have been doing hardcore physio, trying to regain strength..
so far.. knee doesnt feel solid at all. And no confidence for football has returned yet...

I would really like to know if the original poster can return to football since his ACL reconstruction....
appreciated

[physiobob]

The ACL does NOT provide any direct structural support to the knee joint. What it does is send information about load and angular velocities to the brain so that the brain can then send messages to the muscles to support the knee during activity.

So if the partial tear is enough to reduce those connections to the brain the knee will feel more unstable. If you have done a lot of side to side movement rehab and change or direction etc and this has produced no results in terms of feeling more in control then perhaps you will need a reconstruction in time (mainly as you will probably reinjure and rupture it). It's a hard call - I am in favor of leaving what's still attached, attached as this something to connect to the brain. But then at a high level of sport like football that may not be enough to play at that level with confidence. The original poster was in 2007 so I am not sure if they will respond to this still.

[Kevoras]

thanks for the reply.

yea, pretty disheartening to have the ACL partially torn, and 2 months of rehab is not doing much at all.
Just Tuesday, I did a pivot test to check its stability, and it failed miserably.

I do notice if I concentrate heavily, and if I know what's coming, then I can hold the knee fine.
but otherwise, it just feels kinda weird. (and it crashes once a while... completely knocking off my balance.)

I am worried about further injuries damaging the Meniscus, which as of right now, are still in good shape.

I keep telling myself that rehab can bring it back to strength.
but I guess I have been disappointed with the results so far...

Guess I will try for another month first. and see where that leads.

any other advices, or recommended exercises will be very much appreciated. thanks.

[physiobob]

Yep, basically consider a lot more agility training and plyometric type work. You'll need a trainer or PT to work out a plan for you locally. If the brain is not sure about things it simple won't give more power to the muscles so you are weak through inhibition and that's something that strength training can only assist a little with. It is 'neural connection strength' you need. Best of luck in the coming month and let us know how you get on.

[Dolores]

Thanks a lot for the advise!
I stopped seeing the Physical Therapist because her approach seemed a bit too aggressive for me considering the extent of my injury and because my insurance stopped covering the sessions. I can't explain how much I've been struggling with this injury, it has affected all aspects of my life. I had to stop my career, lost my job, got evicted and haven't been able to get another job because I can barely walk with a cane, and the truth is that nobody wants to hire a crippled person. I'm actually in the process of filing a Disability claim because I'm afraid this is going to be permanent and I'm kinda worried about my future.

Luckily my one and only friend offered me shelter and has been helping me tremendously. I feel very fortunate in that regard but the situation is still frustrating because I used to be a self sufficient independent person and now I can't even handle my own grocery bags. However, I've been trying to remain positive just pushing trough the pain and doing mainly the leg raises that the PT showed me to strengthen the muscles but without overdoing it and I feel more comfortable going at my own pace. Unfortunately I can only do so much physical therapy because too many repetitions start producing an excruciating sharp pain directly on the ACL area, sometimes in the front of the patella tendon as well, so I have to stop myself and its been hard to work the quad muscles.
It's also very difficult to bear total weight on the knee, it just feels mushy and "very unstable" like its going to give out anytime. I can't even walk without a cane or a crutch, can't go up and/or down the stairs without holding on to the rail and the cane, I can't jump nor run....I have seen 3 orthopedist surgeons so far and have gotten an MRI which surprisingly showed all ligaments and cartilage to be "intact" but I still was diagnosed with a "Knee Joint Derangement" and "Patellofemoral syndrome" and was simply advised to continue with physical therapy.
I am very confused and beginning to question the accuracy of MRIs. Perhaps they are not good at detecting partial ruptures, so I am wondering if there are other ways of determining what exactly is wrong with my knee joint, and if its going to need to be repaired in order to be fully functional again. It's been 11 months since the accident and I don't see much progress,,could it be a slow healer or something more serious that is going to require surgery? From what I've read about ligaments, they don't heal on their own, so I don't know but there is definitely something wrong with my mine...I'm probably just going to get another MRI, it's been 3 months since the last one...any suggestions will be greatly appreciated....Good Luck to all of you and Dont give up.
This support systems are definitely what keep the faith alive!

[Dolores]

Yep, basically consider a lot more agility training and plyometric type work. You'll need a trainer or PT to work out a plan for you locally. If the brain is not sure about things it simple won't give more power to the muscles so you are weak through inhibition and that's something that strength training can only assist a little with. It is 'neural connection strength' you need. Best of luck in the coming month and let us know how you get on.

Thanks Physiobob!

I truly appreciate your suggestions but I'm not sure if inhibition is what's causing my painful knee joint derangement symptoms although I really hope that's the case because it means that there's a chance I won't be needing an ACL reconstruction...and that it's simply up to me to regain full functionality of the joint.
However, I was looking at some lower body Plyometric exercises and the ones I saw require "Jumping" (even w/Low Intensity) which is one of the activities I have not been able to do since the day I injured the knee joint from running (11 months ago, almost a year) I just started to bear some weight in the knee about 3 months ago but I have to use a cane to walk because the knee still feels very unstable and it really hurts, in other words I cant stand on the injured leg for more than 20 seconds without some sort of support,,,otherwise I start getting a sharp shooting pain...
I'm also wearing a hinged knee brace for extra support because the joint feels kinda loose inside,,,,
so I don't think the jumping exercises are going to work for me because even if I try, I'm afraid that whatever is left of the ACL and patella tendon,
will fully rupture when I land....but I could be wrong,,,
I guess there's only one way to find out but it sounds way too risky....
Do you think its because I have some significant missing fibers in the acl and patella tendon and that's why my brain is getting mixed signals... hence the sensation of pain? I just don't understand why the pain? Is it a good sign or a bad sign?
that's what I'm not sure about,,,
does it mean that it's healing or that it's getting worse?
I guess that what I'm trying to understand is if the pain is part of the recovery process or if the reason for the pain is because am I injuring the ligaments even more by forcing myself to walk and work out. I know its a lot of questions ,,,its just so confusing.....any feedback would be highly appreciated!

Best regards,
Dolores

[Dolores]

Yep, basically consider a lot more agility training and plyometric type work. You'll need a trainer or PT to work out a plan for you locally. If the brain is not sure about things it simple won't give more power to the muscles so you are weak through inhibition and that's something that strength training can only assist a little with. It is 'neural connection strength' you need. Best of luck in the coming month and let us know how you get on.

The more I think about the partial ACL tear the more I realize that I'm wasting my life away by waiting for it to heal,,,
Surgeons will not try to repair it if its not fully torn they only suggest "Physical Therapy" which is totally useless because it's like a dead end road,,,
Perhaps the only alternative for this cases is to tear it completely in order to get it fixed,,,
what is the use of having a piece of useless tissue constantly sending pain signals to the brain? If I could at least walk on it, it would make sense but if it's making it impossible to move on and it's going to break eventually then why even hold on to it?
I know how radical this sounds but if that is the only way to get it reconstructed then it does make sense,,otherwise its just going to continue being a HUGE bump on the road...I can't even get a job and since the ligament is not fully torn it's not really considered a "disability" as disabling as it really is,,,
This is not about pain,,,its more about a tiny rupture that has ruptured my life completely,,,its starting to look like I'm just going to end up homeless living in the streets and unable to walk,,,

[Dolores]

Physical therapy has made my injury a lot worse,,,specially pedaling on the stationary bike ...leg raises w/out added pounds are fine but aftr more than 40 reps I start getting a sharp pain in the inside of the knee,,,its been very frustrating,, seems like the more effort I put into working it the worse it gets,,,,everybody tells me not be a baby and to just keep trying because pain is part of the recovery but the pain I get from physical therapy is more like injury pain...now I cant you bear any weight on the injured knee for more than 10 minutes without feeling an uncomfortable stretch in the back muscles...

Been going through this for the past 10 months,,,I was running and somehow ended up with a very strange left knee injury. I never fell so I must have just stepped wrong or hyperflexed the ligaments,,,its been hell though I lost complete support on that joint plus my job and my independence... it looks like my back is now compensating for that lack of joint,,,2 orthopedists said theres nothing wrong with it and recommended me to do physical therapy to strengthen the quads buttocks and hamstring muscles but like I sid it has not been very effective for me on the contrary it just makes the interior of the knee hurt a lot more i might have injured the pcl or acl,,,,im gonna see another dr next week hopefully Ill get more info! I know I have to stay positive and try not to overdo it...but this injury sucks...im actually considering a leg amputation but I dont know if Ill actually do it,,,does anybody know how long this type of injuries take to heal?
and is it better to get a knee join replacement or ligament reconstruction?

[mouk786]

Leg amputation is the last resort. Before that is a knee replacement and you are unlikely to get one if you are in your 30s. Its a significant operation.

ACL ligament reconstruction is pretty standard.

You ideally need an MRI scan to see what is happening inside.

My first prot of call woudl be a sports physio - but looks like you areseeing a Dr so maybe they will refer you to a specialist.

I also have problems with my hips compensating for my weak side - all my msucle have tighted on my good side.

If you do not have laxity(looseness) i nthe need then it may be cartilage damage.

Sharp pain is abd and need slooking at.