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Rehab for Partial ACL Tear

Hi all. A few years ago, I injured my left knee doing bench step-ups and never had it looked at. About a year ago, I injured it again when I jumped and landed in an awkward manner. The cycle of events from there is as follows: Dr. visit (started taking Naproxin), 5 P.T. visits for active stretching and ionto, back to the Dr., MRI, appt. with a non-surgical orthopod, 2nd appt. with same ortho guy, appt. with knee surgeon who said it isn’t bad enough to merit surgury. What the MRI said is that I have a partial thickness tear in the acl and some tendonopothy in my quad tendons. I can’t do normal squats without pain and weakness anymore, however I can manage front squats with about 135 for several sets of 10. Even doing that though results in swelling and some pain. Do any of you all have any ideas for me as to what my next step should be? I am certainly not happy with the way things are and I regularly feel pain even walking around. I probably have at least a half a dozen times a day where I get that buckle in my bad knee where it feels like someone just gave you a little kick to the back of the knee. Thoughts??

I had a complete tear in my ACL playing rugby 2 years ago.

You don’t need an intact ACL, but that looseness in the knee will come back to haunt you when you get older as you will likely be doing further damage to your meniscus and other ligaments.

Recovery from ACL surgery is a long process.

Do you play sports? Do you lift just to look good?

You have some tough decisions.

This is the standard protocol for most othropedic injuries.

  1. Control your pain and inflamation. Take your NSAIDS if tolerable. Ice after activities i.e. training sessions. If swelling is present, consider wearing a compression sleeve and elevate your knee when possible.

  2. Restore your ROM. This means stretch everything in the lower extremity, (quads, hams, calves, hip flexors, adductors). Before you start a detailed restrengthening program you should have close to full ROM in your knee. Also, take a look at the flexibility of other major joints/muscles (lower/upper back, shoulders). Take a special look at your contralateral shoulder motion (shoulder opposite of your injured knee). I’ve seen patients lose motion in this limb after major injuries (I’m not quite sure why).

  3. Restore strength. The standard protocol is closed kinetic chain training (movements where the foot is in contact with the ground or fixed), leg press, squats, lunges, stepups. Avoid open chain movements for the quads (leg extension), for the hamstrings it’s okay. Emphasize posterior chain training to increase the hamstring strength because these muscles will now have to dynamically stabilize the knee to a greater extent. Rehabilitation is the one time I feel balance and stability training is indicated (wobble boards, foam, dynadiscs etc.)

  4. Return to function. After the pain is controlled, motion is restored, and strength and stability is regained to adequate levels you can progress to more functional and explosive movements. Introduce plyometics, running, possibly olympic movements, or what sport movement you participate in.

Obviously there is some overlap in these phases just be smart. You didn’t mention a derotational brace (defiance, CTI, etc.) this might be something to discuss with your doctor. Find a PT or ATC that can oversee your progress.

Good luck

See another orthopedic surgeon who specializes in athletes and micro-surgery. Consider this: the partial tear is allowing improper movement mechanics in that knee, which is what is causing the pain and swelling, especially in rotational, and supportive movements. Over time, this can cause abnormal wear patterns on the bone structures surrounding the knee, resulting in acute arthritis. I speak from experience, get that sucker repaired! If you need references, contact the SOAR clinic in Palo Alto, CA.

I can vouch for SOAR in Palo Alto. I’ve rehabed quite a few of Dillingham’s patients and never had a bad outcome.

Definitely go the rehab route first and really do your best to get that thing strong and recovered. Avoid surgery if possible is my advice. Your knee(s) will never be the same.

check out this site for any ligament problem. i will be trying this out very soon. www.getprolo.com

Go see an ART–active release practitioner.

Also “partial ACL tear”…anything is possible, but this is very unlikely–if it tears, it tears. Get a second opinion.

If the MRI says its a partial then that is what it is. An ART, or whatever their called, will not fix a torn ligament. This problem has nothing to do with soft tissue tightness, fascial tightness, muscle imbalance, or all the other bullshit hocus-pocus snakeoil chirosmack they sell. A ligament tear is a concrete black and white condition with a specific intervention.

Thanks everyone for the advice! To answer a question, I basically train for health and to look good. I do not participate in any sports currently. I have considered taking martial arts classes though and have not because of all the stability stuff that would no doubt affect my knee. I will be away from my computer access for the next three days, but will check back into this thread on Monday. I very much appreciate all the help. You all are the greatest!

I’m not an expert…but i know people have a relatively long recovery from surgery…
Weeks 1-4 walking on crutches
Months 2 and 3…slowly walking w/ knee brace
Months 3 to 6 getting back up to speed…

Lots of rehab…but the knee would be just about 100% after that. The way I am, I would just as soon do the surgery, you’ll possibly end up tearing it anyway.

[quote]cheesehead wrote:
I probably have at least a half a dozen times a day where I get that buckle in my bad knee where it feels like someone just gave you a little kick to the back of the knee. Thoughts??[/quote]

This is what is most troubling about your condition. This is either due to a lack of strength particularly in the quadriceps or due to a lack of ligamentous stability - i.e. your “partial” tear of your ACL.

If you have ligamentous instability it doesn’t matter if your ACL is partially torn or not, it functionunally unstable and you probably should have surgery. That said, I would give rehab a shot for a month or so to try to strenghten the quads to eliminate weakness as the culprit of your “episodes of instability”

Good luck

Hey Gastrocnemius, as a fellow ATC myself, where do you practice? Your advice about his knee buckling is right on. Its either a weakness issue, or a protective reflex of the quadricep muscle not firing optimally because of effusion. The whole partial tear vs. complete tear is a mute point. I’ve had this discussion with other ATCs and our high schools orthopod. You’re exactly right the knee is either stable or unstable, thats all that matters. I don’t grade my Lachman’s tests like my valgus or varus test. The Lachman’s is either positive or negative. The knee is either stable or unstable, period. If its unstable you will battle the buckling and giving away episodes for the rest of your life, that is until there is so much degenerative joint disease that you need a total knee replacement.

Keep up the good life.

Crow

Crow,

I completely agree with your point about “grading” a Lachman. A partial vs complete tear is a non-issue if the partial tear causes instability functionally or via a Lachman’s, either way it needs to be fixed.

I have seen many instances where a kid comes back from a physician cleared to play with a “partially torn” ACL only to go out and have another episode of instability or buckling of the knee. Too often it seems that some physicans will trust the diagnostic testing too much instead of trusting the physical exam and what they feel with their hands.

Check out some of the work done by Bruce Kola and Cindy Endicott (I’m note sure it is published - don’t have time to check right now) at Colorado College regarding ACL prevention / rehab - thought provoking stuff.

I am in Arizona at a JC. You?

Gastroc, I’m in Corning/Red Bluff, California. I am in a PT clinic, and work with two local high schools.

Crow and Gastroc,
I’m curious if you guys have ever had a knee surgery. Also, are/were you involved in any athletics(besides weight training) before/after surgery?

I’ve never had knee surgery, but have a torn mensicus in my right knee currently. I’m not electing for surgery because it is not a porblem at this time as long as I make sound exercise choices. I’ve been involved in the rehab of 100s of post-surgical knees though, as I’m sure Gastroc has also.

What sound exercise choices do you recommend for someone with a history of knee trouble, ie. partially torn ligament, etc. that would like to avoid surgery?

That all depends on your history, which ligament is involved, age, athletic/performance goals, training experience, etc. For me, split jerking is probably the hardest on my involved (mensicus knee), so I switched to squat jerking and I’m fine. I don’t play basketball much anymore, so my knee is fine for relatively straight-up-straight-down motions. If I were a skiier, baller, or somebody that needed to rotate on it, then I would probably elect for surgery.

As for ACL, if you over 40 and have no need for rotational ability (i.e. cutting sports) there is no need for surgery. I would avoid OKC quad work. I would hammer your posterior chain.

For PCLs, the opposite is true for training. Avoid OKC hamstrings, and hammer the quads.

For MCLs, avoid rotational movements initially and hip adduction with the resistance below the knee.

For mensicus, avoid rotational movements, possibly very deep squating if painful, and let pain be your guide.

For the ligament injuries consider a derotational brace.

Apayne,
To answer your questions: I have never had knee surgery. I played DIII college baseball. I currently work with college (JC) athletes.

As far as your knee is concerned: as Crow said:

That all depends on your history, which ligament is involved, age, athletic/performance goals, training experience, etc.

I think I recall seeing that you had a “partial ACL tear” as well - right?

If so here are a few suggestions:
A) Like Crow said - hammer posterior chain. Your glutes and hamstrings can not be strong enough.
B) Do lots of single leg work (at least 1-2 exercises per leg training session). Lunges, Single leg squats (with opposite leg supported and unsupported), Step ups, Single leg deadlifts w/ dumbells (CT desribes this one in one of his articles), single leg gastroc/soleus work. My favorite exercise in this category is single leg squats with opposite leg free (some may call these pistol squats) get as deep as you can (pain free) - this is great because of the strength and proprioceptive demands. As you get stronger add an X-vest.
C) Add in some stability training or balance work - some may disagree with this but we are talking about rehab here. I would rather you do this on a stable surface and challange the balance by closing eye(s), or moving your upper body - for example catching a ball (again these are examples and you would have to follow a sound progression in order to advance to some of these activites. I do not like unstable surface traiing as it is not realistic training stimulus.
D) After achieving strength gains it would be important to do some strength endurance training (high rep) especially if you aspire to return to some level of athletics - isn’t rugby your sport?
E) Decelerating (sp?)(planting and cutting) will be the toughest activity for you to perform and will put the greatest amount of stress on the ligamentous stability of the knee. So during skill sessions (after building the strength back up) make sure you emphasize practicing stopping from a run or a sprint and also planting and cutting - obviously start at a slower speed before progressing to game speed.
F) During the rehabilitation phase I would consider performing leg training 3x/week and cutting back to 2x/week while/if you are participating in a sport.
G)Lastly, hammer the core/abs 3x/week. Research by Sahrman and others shows athletes with greater core stability have a reduce rate of injury.
Good Luck