Massage Therapy and Post-Surgical ACL Injuries
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The anterior cruciate ligament (ACL), is a ligament in the knee that has a primary role in the stability of the knee. Preventing the shinbone from sliding forward and the knee from twisting excessively.
Massage Therapy and Post-Surgical ACL Injuries
There is a wide spectrum when it comes to the ACL injuries, from a minor tear to the dreaded O’Donoghue unhappy triad. Named after Dr. DH O’Donoghue the American orthopedic surgeon who first described the injury (O'Donoghue 1950).
The unhappy triad is described as:
• Anterior cruciate ligament (ACL) tear
• Medial collateral ligament (MCL) tear/sprain
• Medial meniscal tear
Epidemiology
Some sports carry a higher risk of suffering a devastating ACL injury. Of the four sports with the highest ACL injury rates, three are women's – gymnastics, basketball and soccer (Hootman et al. 2007). These are followed up by American football, with running backs and wide receivers are most likely to suffer an ACL injury. In elite athletics roughly 90% of athletes are able to return to their sport within a year or two after an ACL reconstruction. To further break this stat down, some sports have higher return to play rates - with hockey players ranking highest on their return to play stats whereas snowboarders rank lowest.
Mechanism of Injury
The Anterior Cruciate Ligament functions primarily as a stabilizer of the knee, limiting anterior movement of the tibia and excessive twisting at the knee. ACL injuries are most often the result of an awkward landing or “cutting” type movement. There is often a popping sound at the time of injury followed by swelling within a couple of hours followed by severe pain when bending the knee.
Biomechanically the mechanism of injury can be described as anterior tibial translation, internal tibial rotation and abduction. A quick search of ‘ACL Rupture’ on YouTube will give you a visualization of the injury mechanism. Whether it is on the field or in your office that you may suspect that someone has ruptured their ACL, best practice dictates referring out for a proper diagnosis. This may include Family Physician, Sports Medicine Physician or Orthopedic Surgeon.
Risk of ACL injury is associated with restricted hip internal rotation
Biomechanical variables can be risk factors for certain injuries, risk of ACL injury has been shown to be associated with restricted hip internal rotation. Another part of this research showed that as hip internal rotation increases the odds of suffering from an ACL tear decreases (VandenBerg et al. 2017).
Orthopedic Testing
Orthopedic surgeons use the tests to assess the severity of an ACL tear
• Lachman Test
• Pivot-Shift Test
• Anterior Drawer
The clinical exam is then backed up by an MRI to see the extent of damage. This imaging has greatly lessened the need for diagnostic arthroscopy and also has a higher accuracy than clinical examination. It may also permit visualization of other structures that may have been co-incidentally involved, such as a meniscus, or collateral ligament, or posterolateral corner of the knee joint. Orthopedic surgeons recommend that once an ACL injury has been ruled in, you should limit the amount of orthopedic testing on the knee, in order to limit stresses applied to the injured tissue.
Surgical Considerations
Due to swelling, patients may wait 4-6 weeks after the initial injury before they have reconstructive surgery. That being said, not all ACL injuries will require surgery; there are many factors surgeons use for selecting surgical candidates. One of the primary selection criteria is the severity of the tear and the patient's’ ability to follow through with the 6-12 months of post-surgical rehabilitation.
A number of replacement material for ACL reconstruction are commonly utilized:
• Autograft (tissue harvested from the patient's body) - An accessory hamstring or part of the patellar tendon are the most common donor tissues used in autografts . Hamstring autografts are made with the semitendinosus tendon either alone, or accompanied by the gracilis tendon for a stronger graft.
• Allograft (tissue from a donor's body) -The patellar tendon, tibialis anterior tendon, or achilles tendon may be recovered from a cadaver and used as an allograft in reconstruction. The achilles tendon, due to its large size, must be shaved to fit within the joint cavity. There is a slight chance of rejection, which would lead to more surgery to remove the graft and replace it.
• Synthetic (Prosthetic) grafts - Several synthetic ligaments have come and gone but none have met the qualifications needed for a lasting ACL substitute. The main issue has been that grafts may break down over time which can lead to the joint became perpetually swollen and eventually most of these grafts have to be removed.
The ‘New’ Ligament in The Knee - ALL
This Anterolateral Ligament (ALL) is an independent structure in the anterolateral compartment of the knee and may serve a proprioceptive role in knee mechanics. It is hypothesized that the ALL functions to control internal tibial rotation thereby affecting the sensation of giving out during activity, often referred to as the pivot shift phenomenon. The anatomical research has shown that a tear in the ALL increased the amount of pivot shift present with an ACL tear. Currently surgical techniques are now being developed using the ALL to augment ACL reconstruction in patients with complicated or recurrent ACL injuries.
Rehabilitation and Return to Sport
Treatment is determined based on the severity of the tear on the ligament. Small tears in the ACL may just require several months of rehab in order to strengthen the surrounding muscles, the hamstring and the quadriceps, so that these muscles can compensate for the torn ligament. The ACL ligament has relatively poor vascularization so whether or not there is surgery recovery will take a while. Generally speaking, rehabilitation is six months, with an athlete returning to play after twelve months. Though early activity is encouraged, returning to sports too early will often result in pain, swelling and risk of reinjury. The risk of reinjury of the ACL ligament is high; it is best to be cautious of progressing through rehab. Ultimately, a proper balance of commitment and patience will greatly improve chances of a successful and timely recovery.
The more proactive a patient can be immediately following ACL surgery, the better the results. It is recommended that patients start the following soon after surgery:
• Walking
• Weight bearing
• Doing safe quadriceps exercises several times a day
Massage Therapy Considerations
In an integrated multidisciplinary program, massage therapy may be used as a specific hands-on technique to promote tissue healing and restore normal movement patterns. As part of the assessment process it is important to find out what the patient's’ goals are. Some athletes may have the goal of returning to their sport after an ACL reconstruction and some may just want to regain daily active living. The main focus early on is to improve range of motion in the knee joint. Later, therapy shifts towards regaining strength in the weakened muscles around the knee that have atrophied since the surgery from disuse.
Post-surgical muscle atrophy is common after ACL surgeries and patients with dedicated physical therapy patients will generally regain post-surgical quad strength before twelve months. There is evidence to suggest that patients who sustain an ACL rupture have a four fold increase of chances to develop osteoarthritis (OA) of the knee later in life (Muthuri et al. 2011).
Strength deficits at 6 and even 12 months postoperatively are quite common, speed bumps athletes may encounter during ACL rehabilitation include:
• Patellofemoral pain syndrome
• Infrapatellar saphenous neuralgia (Trescot et al. 2013)
• Joint swelling
Structures to be Aware of When Treating ACL Injuries
It is important to keep this concept of soft tissue continuity in mind when developing a treatment plan. Hamstrings and their antagonist the quadriceps function as a good foundation for any treatments plans. Building on that you can move up the kinetic chain to work on tensor fascia latae, gluteus maximus, medius and minimus. Progress medially to work on the adductors and their fascial attachments to the hamstrings and quads. Within the adductor group the adductor magnus is a high value muscle, contemporary anatomy texts describe the adductor magnus as having a hamstrings portion (described as the 4th hamstring) and an adductor portion.
Saphenous nerve - An often unappreciated contributor to medial knee pain is irritation of the saphenous nerve at the adductor canal (Porr et al. 2013)
Adductor magnus - may be involved in the compression of the femoral artery, due to the interconnection between the adductor magnus and vastus medialis by the vastoadductor membrane (Tubbs et al. 2007). Working the vastoadductor membrane (the adductor magnus tendon & the vastus medialis), may yield good therapeutic results. This band can create a notch with a venous stenosis at the outlet of the Hunter's canal, usually located 12-14 cm above the femoral condyle. Contraction of the adductor longus closes the hiatus, while the adductor magnus opens it.
Vastus lateralis - An expansion from the vastus lateralis tendon blends with the lateral aspect of the capsule of the knee joint and the iliotibial tract, before attaching to the lateral tibial condyle. The vastus lateralis also extends posteriorly and forms a groove with the biceps femoris, the IT band overlies both muscles.
Alterations in the Vastus Lateralis Muscle as the Result of ACL Injury and Reconstruction
“The persistence of the increase in extracellular matrix and decrease in satellite cell content despite surgical reconstruction and rehabilitation demonstrate the need to intervene early following an ACL tear to prevent changes at the cellular level that may ultimately limit muscle adaptation during rehabilitation. " (Noehren et al. 2016)
Lower leg and Ankle - Other soft tissue structures that can be included in treatment plans are popliteus, gastrocnemius and the soleus. As for bony articulations; joint mobilizations at the proximal tibiofibular joint and the ankle joint (the talocrural joint, subtalar joint and the inferior tibiofibular joint) will strengthen the therapeutic input.
Upper body - The first four weeks patients rely on the use of crutches to get around. This may result in patients presenting with the complaint of headaches as well as neck and shoulder discomfort. As a wholistic treatment approach it is important to address these complaints as well. Including active release treatments is a time effective way to manage these upper body symptoms.
Whether the injury is acute or chronic massage therapy is a valuable addition to any ACL rehabilitation plan. For any therapist who would like more information on ACL injuries I recommend reading Robert G. Marx -The ACL Solution: Prevention and Recovery for Sports’ Most Devastating Knee Injury.
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