ACL Injury Case – Functional Knee Strength

Building Functional Knee Strength

The knee is the largest joint in the human body and is a mobile weight bearing joint. This mobility makes the joint susceptible to injury as the knee’s stability depends almost entirely on associated ligaments and muscles. The surrounding muscles are the most important supporting mechanisms; therefore many knee injuries are preventable through appropriate conditioning and training.
In an effort to prevent injury and maintain stability there needs to be a focus on strengthening the major muscles supporting the knee joint. More specifically, it is important to use functional exercises that are similar to the movements involved in everyday activities.

ACL Injuries
The Anterior Cruciate Ligament (ACL) is one of the major ligaments of the knee and is the most commonly injured knee ligament. A complete tear of the ACL can cause instability problems, and often leads to reconstructive surgery. Surgery is not always necessary though, as one of my clients “GH” is an example of someone who rehabbed such an injury to the point surgery was no longer warranted.

Degrees of ACL Injury

Case Example
 One of my clients GH suffered a complete ACL tear as a result of a skiing accident in March of 2008. He consulted with me in September of 2008 for an exercise program to build leg strength and work on knee stability in an effort to be in top condition for his upcoming surgery. In developing his program an emphasis was placed on performing closed chain kinetic exercises using body weight as resistance, and until additional weight could be added.
 
After 2  months of consistent workouts focused on overall conditioning and building functional strength around the knee he went back to visit his surgeon for a check-up. Upon re-examination, GH’s Dr. decided the knee had been strengthened to the point that surgery was no longer necessary. He was also given the clearance to go back to skiing with the use of a knee brace.

This was a great success story from one of my clients and it was rewarding to see an individual take an active role in their healthcare and have such a positive result. It is now 2 years later and he still has not had any problems with his knee and regulary lifts weights, runs, bikes and skiis.

When is Surgery Needed?
 Although this case was succesfull with a rehab program alone and did not require reconstructiove surgery, the standard treatment for such injuries is reconstruction, usually using patellar or hamstring tendon autograft. There are 200,000 of these surgeries performed annually in the US, despite poor evidence of benefit beyond that of rehabilitation therapy.

In a recent Swedish trial of immediate versus delayed reconstruction, 121 athletically active adults (mean age, 26) with total acute ACL tears received standardized structured rehabilitation. Participants were randomized to reconstruction within 10 weeks of injury or to delayed reconstruction, with the option of surgery in the presence of continued serious instability and dysfunction.

At 2 years, roughly a third of patients in the delayed group had undergone ACL reconstruction, usually after 6 months of initial rehabilitation. On standardized testing, knee stability was significantly better in the early reconstruction group than in the delayed group; however, no between-group differences were noted in several functional and quality-of-life assessments specific to knee disability. Notably, most patients in both groups also underwent meniscal repair at some point during the study.

The general consensus seems to be that elite athletes with ACL tears who perform intense cutting and pivoting maneuvers usually will need early ACL reconstruction, but nonelite athletes might do well without reconstruction. It was added that “Ultimately, the most important predictor of the long-term outcome may not be instability due to ACL deficiency but rather the presence of articular-cartilage or meniscal lesions, which may lead to premature arthritis.”

 References
Frobell RB et al. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med 2010 Jul 22; 363:331. (http://www.nejm.org/doi/pdf/10.1056/NEJMoa0907797)

Levy BA. Is early reconstruction necessary for all anterior cruciate ligament tears? N Engl J Med 2010 Jul 22; 363:386. (http://www.nejm.org/doi/full/10.1056/NEJMe1004397)

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