|The experience and recovery of an ACL tear
Tearing the ACL is a horrible injury to experience, and with my luck it happened to me twice….to the same knee. The amount of shear force required to tear the ACL is pretty severe, as the tearing mechanism is dependent on the thickness of the ligament and the playing surface an athlete is performing on.
Females are more prone to ACL tears because of the way that they are anatomically structured and their playing stance or dynamics they perform on the field. I am one of those people who, when asked about their injury, can talk for days about the entire process, starting from the initial injury occurrence, to the pain felt and the body’s defense mechanism response to the long rehabilitation process afterwards.
Due to the fact that it is my second time re-tearing the ACL, I have been able to gain much more insight, knowledge and overall experience with the injury and the needed therapy to recover. I will start off talking a little bit about myself and my injuries and then I will discuss the rehab portion of the injury, and returning to sport.
First of all, I am that soccer player who has had almost every injury in the book – yes I have played with a splint on both arms and a knee brace all at the same time and still performed like a rock star – well a least I thought so. My first ACL tear happened when I was playing for Aurora, in the sports dome on artificial turf. I was wearing cleats and collided with another player mid sprint.
I guess the way we impacted sent my knee in an awkward angle and I remember hearing a loud “pop” travel from my knee to my head. It instantly blew up like a marshmallow and I was sent to the emergency, where they told me I would be fine in 3 weeks. Well, they were wrong. After 4 months of seeing doctors, physiotherapists, and receiving x rays and an MRI, it was confirmed that I had torn my ACL right off of the bone.
I had surgery to repair the ligament in August 2007 (Left), where the surgeon took my hamstring to make the new graft. I went through a successful recovery, exceeding the expected 9 month wait to return to sport, and waited a whole year to officially return to play because of fear. Once I got back on the field, I was able to play with no problems or knee pains and surprisingly that initial fear went away for 6 years of play, until last year at the end of November 2013.
At the end of November I was playing indoor soccer at the Soccer Centre in a dome on artificial turf with cleats. There was a slight divot in the turf and I planted while decelerating to prevent the ball from going out of bounds, and felt my knee slide out of place. I knew that at that very moment I had done it again, and went straight to emergency room. From there I began physiotherapy right away because of my previous experience, I became an expert regarding an ACL tear and I knew what I had to do this time around.
Through different connections, I was lucky enough to get an MRI in January 2014, and met with a surgeon a couple weeks after my injury happened. I was scheduled for surgery on February 7, 2014 (Right) and had it repaired with a donor graft using the tibialis posterior tendon. I am currently still in the recovery process, coming up to my 2 month post operation mark.
Throughout these two experiences, it has definitely, if anything, made me a stronger person, in realizing that everything in life doesn’t go the way you plan it to. I have met so many people, especially throughout my internship, both males and females, who have torn their ACL in soccer and I have noticed that every player has the same outlook on life and has the same attitude towards soccer.
I think with major injuries like this, and with athletes like us, it only makes us strive farther and want to fight back stronger, creating a tough player to beat inside and out. Call me crazy, but the people who have gone through this experience, who have the best spirits about it, are all soccer players. They all have the right attitude and personality, keeping it positive throughout the entire process, and that’s exactly what this type of rehab needs.
The best part is when you compare scars and understand that there is more to it than just a mark – it describes a whole part of your life story. Having done this twice it has set me back, and I will need to rehab my knee to the full extent again before I even consider returning back to sports. I need to take it slow and steady as it is a second graft repair, which has its challenges when people keep telling me to quit soccer.
But my argument is that this injury can happen anywhere during any sport and I am not going to quit something I love because of another potential injury (knock on wood), as much as that might anger people, especially family members. Telling me to quit soccer is like telling an endurance runner they can’t run anymore. I have been playing since I was 5 and nothing is going to keep me from playing this beautiful game.
Now to talk about the rehabilitation process that has to occur after the extremes of an ACL injury. I have broken it down by weeks and months of rehab, and have summarized everything in a chart at the end. A lot of it is my own experience, mixed in with research. Take into account I have had two different surgeons and different protocols given to me, but generally, the main bulk is the same, but very dependent on the graft type and if it’s a re-tear (Allograft).
At this time, the client is in Phase I of recovery and is quite limited to mobility. Here it is recommended that during the inflammation stage a client should work on strengthening the hip and ankle, maintaining their knee immobilized at 0° when not performing the rehabilitative exercises.
Along with strengthening these muscle groups, increased attention to range of motion is beneficial to help regain movement within the joint. A good exercise that will utilize and improve the range of motion (ROM) are wall slides. These involve the client laying supine on a bed, with their feet on the wall, and a towel under their surgical foot. The goal is to slide the heel away from the wall and toward the body, flexing as far as possible.
More exercises have also been added to this stage to target the muscle groups indicated previously. The first is the straight leg raise. This strengthens the quadriceps by lying supine and raising the surgical leg off of the bed to a 45º angle, maintaining 0º at the knee joint, keeping the foot in a dorsi flexed position (opposite leg remains bent with foot in contact with the bed). If this becomes too easy in the later stages, added weight around the ankle is prescribed. An exercise band or bed sheet may also be used to assist with this movement if necessary.
The second exercise to target the hip abductors and gluteus medius as recommended for the Phase I stage of rehabilitation are lateral leg raises. To do these, the client will lift the surgical leg straight into the air toward the ceiling, away from the body. For variation, the client can add weight to the ankles or use an exercise band.
The third exercise is the medial leg raise. The client is to lie on the opposite side, and lift their leg towards the ceiling, across the body. Variation of this would be to add weight to the ankles or through the use of an exercise band. It is also recommended that there should be focus towards ones aerobic fitness post ACL surgery.
According to an online journal article by Dr. Jonathan Cluett titled “Rehabilitation After ACL Surgery”, a good way to safely allow a client to work on their cardiorespiratory fitness during the earlier stages of rehabilitation is through the use of a stationary bike (Cluett, 2012). In using this, the client is encouraged to sit on the bike and test their range of motion by pushing themselves to get further in range (as the angle will increase over time). In this phase, depending on the type of graft and amount of damage, the patient should start to weight bare as tolerated, with the use of crutches for support.
The final exercise for this timeframe would be hamstring curls in a standing position. According to results found and documented in a journal titled “Knee Surgery Sports Traumatology Arthroscopy”, the only indicator of ones likelihood to experience a greater chance of knee injury is weakness within the hamstrings (Tsepis, Vagenas, Giakas & Georgoulis, 2004). With this exercise targeted to work the hamstrings, the patient can choose to use no weight, weight around the ankle, or an exercise band to add resistance. The client will stand, holding onto supports, such as the ends of a table or wall, as the knee will be flexed as far as possible to the gluteal muscles, at a tempo of 3:3(static hold). This has been included to prevent injuries which may come in the future.
In week’s four to five, the goal has become to transition the patient from Phase II to Phase III in ACL recovery. More use of the stationary bike has been included for this time frame, to continue to work on cardiorespiratory system. The walking phase during this stage is important to focus on the stride lengths so that the motion required for further rehabilitation in Phase III can be accomplished, which will require more substantial work in the future. Because of this, light walking without crutches would beneficial to the client.
Having said that, the earlier the patient is able to apply pressure and walk without crutches, the more effective it is towards their recovery. In this time frame, it is also recommended to imitate quadriceps activity’s to get working and ready for increased weight bearing or resistance. The exercise selected to target this muscle group is named the Short-Arc Quadriceps Exercise. This involves the client lying supine with a tight roll under both knees. They will then lift their leg and attempt to straighten it, maintaining contact between the roll and knee. For variation, the client may add weight to the ankles in the further advanced stages, or use a can or towel in-between their knees to squeeze for more exertion and addition to firing of the vastus medialis.
An article by the University of California San Francisco states that it is beneficial to use a leg press at a light weight within the first three months after surgery (After acl surgery, 2002). For this reason, two to three sets of light weight during the leg press have been selected to further develop the quadriceps.
One final exercise has been selected for this time frame using a wobble board. This is typically recommended in Phase I, to strengthen the leg muscles as well as the proprioceptive system responsible for balance, however, if the patient is delayed within their weight bearing ability, and it is still a recommended step to recovery, it has been added to this section prior to the more advanced phases.
In order to continue cardiorespiratory exercises, combinations of the elliptical machine, and running on a treadmill have been selected. After the 6 weeks mark post-surgery, walking on a treadmill is most beneficial, while trying to slowly work up to a jog by the end of this time frame.
It is also beneficial if the patient is having trouble in full extension to have them walk backwards on the treadmill and focus on full extension and flexion. To supplement the more intense exercise of walking and running, an elliptical machine has been added, which will remove stress from the joints, but allow for greater movement. Because the client is able to fully weight bear, exercises utilizing quad sets are able to be implemented.
Because of the potential for injury associated with loading weight beyond the injured joint at the ankle, the article “Anterior Cruciate Ligament Strain and Tensile Forces for Weight-Bearing and Non–Weight-Bearing Exercises: A Guide to Exercise Selection”, explains that exercises such as leg extensions may not be as beneficial to improve quadriceps strength due to the increased risk of dangerously loading the knee joint (Escamilla, Macleod, Wilk , Paulos & Andrews, 2012).
In order to accommodate the intent of quadriceps rehabilitation, five exercises have been selected, which do not require weighing in that method. The second are lunges which ensuring proper alignment is of the utmost importance for considering the potential for knee strain if done incorrectly.
The third exercise is step-ups followed by the fourth exercise of step-downs. Here it is important to decrease the height of the step if knee pain occurs. Finally, the continuation of wobble board proprioception is included in this section with the intent of decreasing reaction time, as well as recovery time in comparison to that which has been done in weeks 4 and 5, and increasing stability and balance.
It is recommended, after being cleared by the surgeon, that a patient may run and eventually transition into sprinting at this timeline in the clients’ recovery. To satisfy this goal, treadmill running has been selected as the primary form of maintaining ones cardio.
Along with this running, wind sprints will be added to get the client used to more intense running, at their own pace. Because at this stage the knee is starting to function at a Phase III transitioning to Phase IV level, some light plyometric exercises have been introduced to improve leg function.
Three exercises are always highly recommendable. The first exercise is the jump in place. Here, the client stands on the ground and both jumps into the air and lands on two feet. Secondly, the hip-twist ankle hop was selected. In this exercise, the client is to jump and twist 90° to the right, followed by a second jump to move them to the left. The final plyometric exercise at this time is the front box hop. This involves the client jumping with both feet onto a box which is raised one foot off the ground. The client will then step down and return to the start position.
All of these jumping motions work various parts of the leg, but equally, place a controlled amount of stress on the newly created ACL to help direct them into more advanced plyometrics in the weeks to come. In addition to the plyometrics, the leg press has been added to supplement any short comings the client may come across upon the introduction of this advancement, to aid in strengthening their quadriceps should they fatigue too early in order to safely finish the set routine.
4 Months +
The goal after the four month mark is to train the knee and accompanying muscles to respond to athletic type stress in attempt to gain clearance from the surgeon to return to sports. For this reason, the plyometric work done in months 3-4 are still implemented, but the repetitions are increased per set. The reason for this increase is to begin to reach the recommendation of sport specific movements at an athletic training level.
A single leg hop exercise has been added to this plyometric section at this level as well, to increase the difficulty of the exercise. Because the client has now also had training with plyometric jumping, stair jumps have been added in small quantities to further stress the muscles. Because of the delicate potential for muscle fatigue, and the risk associated with jumping on stairs too early, this exercise was chosen to be introduced after a proven level of balance and control has been met, to carry out this exercise safely.
These two additions place considerable strain on the ACL and muscles and are part of the final exercises prior to being cleared to return to sports. To work cardio, the continuation of wind sprints will remain a useful training technique, but this time for a longer duration. The use of a treadmill may also be useful to aid in speed control for the client.
Some sport related drills have also been added to ensure the client will be able to handle the stress when returning to sports. The first exercise is burpies. The reason for this is because it is quite practical for an athlete to be able to stand up quickly from the ground level in a contact sport such as soccer.
Sport specific movements are then trained/practiced from here on out, such as dribbling, ladder drills, 360˚ runs, etc. Soccer also involves much pivoting, the client will benefit from sprinting and changing direction to 180°, to then sprint back to the starting point through pivoting sprints. Soccer offers much reaching to both make and receive passes. For this reason, the final test is advanced proprioception involving a wobble board and 3 pound medicine ball. The client is to stand on the wobble board and the therapist will throw the ball to various eccentric areas for the client to catch and throw back.
Another test that is generally done is a one legged triple jump onto a trampoline, followed by a one legged squat on the trampoline, being able to look in both directions without losing balance. After all of these exercises are done successfully, the goal is to clear the client to return to sports.
**Note: that this exercise plan is all dependent on degree of injury (ex. meniscus tears as well), which type of graft was used, and whether it is a revision. The timeline to recovery will vary to a certain extent, all specific to individuals.
Melissa Koteff is an intern with SoccerFitness. Soccer Fitness Inc., is a soccer-specific strength and conditioning company located in Toronto. For more information about Soccer Fitness, please visit www.soccerfitness.ca.