By: Dr. Rebecca Van Heuklon
Last month we published the ultimate guide to preparing for orthopedic surgery. The article contains all the info you will need to know to prepare really for just about any elective surgery, including a knee surgery such as an ACL reconstruction. This month, we hope to fill in the specific details of some other issues you may be considering if you are facing an upcoming ACL reconstruction surgery.
Once you have been diagnosed with an ACL tear, it is common for the first inclination to be a rush to schedule surgery right away; however, it is important that you feel comfortable with the surgeon you are working with and the surgical approach to be performed. There are three main approaches that can be used to reconstruct the ACL. Each surgeon may each recommend a different approach to surgically correct the problem based on their training, beliefs, and experience, even though one particular approach may be more ideal for you.
One choice is to use the middle one third of your own patellar tendon located in the front of the knee just below the knee cap. Pros of this option are that it has been a gold standard for athletes, showing excellent return to sport/activity; however, it has a slightly higher incidence of causing pain in the front of the knee, especially during the first year. (Although higher incidence certainly does not mean that every patient expeirences this.) Additional cons include that it can cause discomfort with repetitive kneeling due to tenderness in the area or with jumping activities due to quadriceps muscle weakness.
Another commonly used graft site is to use part of your own hamstring tendon. This option also has good success rates and is great for people who kneel a lot or are in jumping sports. Other advantages include smaller incisions and possibly less swelling and pain post-surgery. Cons of the hamstring graft include slower healing of the tendon due to not having bone to bone healing and the possibility of having long-term weakness in the hamstrings (although we generally do not see this when rehabilitating these injuries).
The final option is to use a cadaver graft, which is commonly performed in the aging population or in patients who have had multiple ACL surgeries or revisions. Pros of this approach is that there is less discomfort and quicker healing due to not having trauma and healing of a donor site; however, this approach tends to have higher infection rates and slightly higher failure rates of 4%, compared to around 2.8% for the patellar and hamstring grafts. One of the most important factors to consider when choosing a graft option is which approach your surgeon is most comfortable doing, as that will be the option the surgeon will be most successful performing, allowing for the best possible outcome for you. This is a primary reason why it is important to get multiple opinions, as the option your first surgeon provides may not be the best option for you.
Once you have found a surgeon and approach you feel confident in, you will need to prepare for your upcoming surgery. Feeling prepared can help ease some anxiety going into surgery. Some surgeons believe in using a brace after surgery to protect your knee and avoid damage to the healing graft, while others do not. If your surgeon wants you to wear a brace, I would encourage you to get fitted for the brace before surgery, so you aren’t having to adjust straps or trying to figure it out how to put it on when you are recovering. Each surgeon has different recommendations on how long to wear the brace, when to wear it, and if it should be locked at a certain angle or left open to bend, so follow the instructions given to you by your surgeon.
It is also likely that due to weakness, bracing, and discomfort, you will need to use crutches or a walker to help you move around after surgery. In my experience, it is commonly assumed that you have obtained your own assistive device, are properly fitted for the device, and know how to safely and effectively use it. If you are not comfortable and experienced in using crutches or a walker, it will be important to see a physical therapist to learn how to use your device for walking, getting into/out of a chair or car, and going up/down the stairs safely. This step should be done before surgery, so you feel confident in being able to move around and get where you need to go. The last thing you want after undergoing surgery is to have a fall that results in injuring the new graft, putting you back at square one. Remember to declutter your home, hallways, and stairs, and watch out for pets undercutting you in excitement as you attempt to walk upon returning home post surgery.
At home after surgery, you will likely be very tired and it will be important to rest. For the first few days, the main goal is to keep swelling and pain down through icing, elevating, using your compression wrap, and doing gentle exercises. These exercises commonly include ankle pumps and quadriceps and gluteal isometrics to help reduce swelling and prevent blood clots.
Most often you will begin physical therapy within the first few days after surgery, where your exercises will be progressed. It is common for each surgeon to have his/her own protocol that outlines the rehabilitation process. Your physical therapist will be able to educate and guide you in what activities and exercises can be performed at what point in the healing process. The most important factor determining how successful your surgery is will be how diligent and consistent you are in attending regular physical therapy and doing your home exercise program. Initially after surgery, expect to attend physical therapy 2-3 times per week. Your walking and independence from the crutches should improve over the first 2-3 weeks. As your mobility improves, the frequency of visits will likely taper down after the first couple of months to 1-2 times per week, depending on your specific needs.
The goals of physical therapy will be to slowly improve pain, swelling, knee range of motion, strength, balance and muscle endurance in order to improve your walking pattern, transfers, squatting, and stair ambulation, as well as ease getting you back to performing your daily activities independently without pain. Progression back to jogging and higher-level sport-specific activities is guided by your physical therapist and surgeon but heavily depends on your knee’s stability and functional strength. This timeframe varies greatly from person to person and varies based on the goal activity and physician protocol, but likely occurs no sooner than 4 months with full return to activity/sport around 6-9 months.
It is important to find a physical therapist that has worked with patients who have undergone ACL reconstruction surgery on a regular basis, who can best educate you on what to expect/what is normal and has experience with providing the manual and exercise skills necessary to get you back to doing the things you enjoy most. MotionWorks Physical Therapists have experience in helping athletes at all levels return to full participation in sports following orthopedic surgeries, as well as helping the weekend warrior get back in the game as well. Contact the Doctors of Physical Therapy at MotionWorks with any questions or to schedule an appointment at 920-215-2050 or Rebecca@motionworkspt.com.