Anterior cruciate ligament rehabilitation

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The fast facts:

  • In the Netherlands, there are over 4000 anterior cruciate ligament injuries each year in soccer alone.
  • It is more common in young people (15-40 years old) who play pivoting sports, such as basketball, soccer, handball, and skiing.
  • In addition to physical recovery, the psychological reaction to the VKB rupture and the rehabilitation after the rupture (including fear of recurrence), appears to influence the extent to which a person resumes sports activities.
  • Annually, more than 3% of amateur athletes experience a VKB rupture; in elite athletes, depending on the type of sport, this can even exceed 15%.
  • Women are 2-8 times more likely to have a VKB rupture than men when playing the same sport.
  • Approximately 5% of all elite athletes sustain an anterior cruciate ligament injury.

Anterior cruciate ligament injury

An injury to your anterior cruciate ligament (ACL) is one of the most common injuries to the knee joint. Annually more than 860,000 knee injuries occur during sports in the Netherlands. A large proportion of these involve an injury to the anterior cruciate ligament. The ACL is very important for the stability of your knee during sport. When your anterior cruciate ligament is torn, we see a decrease in the stability of the lower leg in relation to the upper leg. This injury usually occurs without an opponent nearby where you need to brake explosively. Also, movements where you have to turn, cut or jump quickly put you at a higher risk of injuring your anterior cruciate ligament. In order to get back to your old level of sport, it's important to know what your options are.

Cruciate ligament injury

Anatomy and function of the anterior cruciate ligament

A joint is a place in the body where two parts of the bone meet. In the knee, this is the femur (upper leg) and the tibia (lower leg). Between these bone parts is cartilage which has a very smooth surface so that it can move smoothly. In order to steer the knee joint properly, there are different types of ligaments in and around the knee. On the inside and outside are the collateral ligaments. Between the femur and tibia is the inner and outer meniscus which acts as a shock absorber between these two bone parts. In the knee is the anterior and posterior cruciate ligament. The anterior cruciate ligament provides passive stability. Ligaments, bones, capsules and the position of joints provide passive stability you have no control over. Active stability is controlled by muscles and tendons. Here you do have control. The active and passive stability together determine how stable a joint is.

Damage to the anterior cruciate ligament

  • Of all VKB ruptures, approximately 70% are based on a "non-contact" trauma mechanism
  • This means that the cruciate ligament tears without contact with an opponent or other object.
  • 0.04 seconds is the time when the cruciate ligament tears after the moment of contact with the ground

An anterior cruciate ligament can tear partially or completely. There may also be a slight strain. The anterior cruciate ligament averages about 4 inches in length and is about the thickness of your little finger. These different injuries are classified into 3 degrees.

Grade 1 is only a strain. The knee is then usually sensitive but there need not be swelling in the knee, for example.

Grade 2 is a torn anterior cruciate ligament. Chances are the knee is swollen and sometimes feels unstable.

Grade 3 is a torn anterior cruciate ligament. Often the knee immediately becomes swollen and you experience instability. This is a feeling where you threaten to fall through your knee a lot or actually do. In 80% of all cases, the person also hears a distinct recognizable snap. It is quite possible that in this case there is also damage to the meniscus or cartilage.

Women have a higher risk of an injury to the anterior cruciate ligament. This risk is up to 6x higher. This has several causes. Changes in hormone levels may play a role in this. Women also have a wider pelvis which mechanically puts the knee in a more vulnerable position during high speed sports. The knee folds inwards more quickly.

Physical testing of the anterior cruciate ligament

There are a number of described tests to understand possible damage to the anterior cruciate ligament:

Lachman test

The lachman is a passive test in which the lower leg is pulled forward. When the anterior cruciate ligament is still intact, the examiner feels the tightening of the anterior cruciate ligament. The anterior cruciate ligament then inhibits further movement of the lower leg relative to the upper leg. When the anterior cruciate ligament is torn, this is not the case.

Front drawer test

In the front slide drawer test, the knee is in a more bent position. The examiner pulls the upper leg toward him. The degree of translation (shift) of the lower leg forward gives an indication of the integrity of the anterior cruciate ligament.

Pivot shift

The pivot shift is a more dynamic test of the knee. In addition to providing an indication of the integrity of the anterior cruciate ligament, the test also tests other structures of the knee. In addition to the anterior cruciate ligament, the outer ligament, posterolateral capsule and associated ligaments, and iliotibial band are tested for possible damage or instability.
When one or more tests are positive, it is possible to examine the knee further with an MRI to confirm specific injuries to the knee.

Surgical intervention or conservative treatment

  • In the Netherlands, more than 9000 VKB reconstructions are performed per year. Most primary VKB reconstructions are performed with a bone-patellar tendon-bone (BPTB) graft or hamstring (HS) graft. Both methods lead to good functional results and restoration of passive stability.
  • A better understanding of the structure and function of the anterior cruciate ligament has ensured that treatment, both operative and nonoperative(conservative) continues to evolve. Not operating can also be a responsible choice in some cases.

In people who are highly active and who like to play a sport where you have to jump, turn or cut, surgery is the best solution in most cases.

Knee Osteoarthritis
Kevin van Geel

Knee & Sport rehabilitation specialist Kevin van Geel

The different phases in the treatment of the anterior cruciate ligament

Successful rehabilitation consists of several phases and steps. Good strength, stability and control of the knee is necessary to safely return to your sport. Both after an operative procedure and with a conservative policy.

Acute phase:
In this phase, we focus primarily on symptom reduction. There is often swelling, pain and reduced mobility of the knee. In addition, it is important to regain good control over your quadriceps (thigh muscle). After injury to the anterior cruciate ligament or surgery on that knee, we often see a significant decrease in strength and mass of the quadriceps. It is therefore of crucial importance to quickly regain proper function of the quadriceps. In addition, it is important to get back to a normal walking pattern.

Strength and stabilization phase:
In this phase there is more of a build up in strength. Stabilizing exercises are also addressed. General fitness may also be worked on in between.

Sport-specific phase:
The final phase focuses particularly on maximum strength, jumping power and explosiveness. This is all necessary to be able to change direction quickly within your sport. We also work towards a competition condition so that you can continue to perform under fatigue. The quality of movement must remain good under these conditions. The chance of re-injuring your anterior cruciate ligament is many times greater under fatigue.

Rehabilitation at Fysio Fitaal

An anterior cruciate ligament rehabilitation takes a lot of effort and is quite intensive. It can take up to 15 months before you are back on a level that allows you to fully participate in your sport again. This takes a lot of willpower but also time. During the rehabilitation, there will always be small and sometimes big setbacks. Especially in certain phases, it will go slower than you had thought. Patience is necessary. Our specialists will guide you through this process as best as they can and motivate you where necessary. Fysio Fitaal works with specialists in the field of anterior cruciate ligament and sports rehabilitation. Because of this combination of expertise, extensive facilities and passion for sports, you have come to the right place.

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Have you been suffering for some time from a complaint described above? Then don't keep walking around with it! Make a appointment with our specialist Kevin van Geel. Together we will look at how to reduce your symptoms!

Kevin van Geel

Knee & Sport rehabilitation specialist Kevin van Geel

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