Knee Ligament Injuries ACL

Mark: Hi, it's Mark from TLR. I'm here with Wil Seto of Insync Physio in Vancouver, multiple time winners, their whole crew of best physiotherapists in Vancouver and in North Burnaby, they have two offices. And we're going to talk about things that break in your body. How are you doing Wil?  

Wil: I'm doing great. 

Mark: This isn't so much a break, this is more of a tear kind of a thing. The knee ligament injuries. What kind of symptoms that people have when they come in with knee ligament problems? 

Wil: Well, what I wanted to actually discuss a little bit more today was major ligament in the knee, called the ACL. Now the ACL stands for anterior cruciate ligament, and the whole purpose of the ACL is that it's actually the main stabilizer in terms of ligament in the knee.

So you have several ligaments in the knee. You have your ACL, your PCL, and your LCL and you MCL. And so with the ACL quite often you also injure it in conjunction with a couple of other structures in the knee. So with your MCL, which is your medial collateral ligament, and then also your medial meniscus.

So quite often with the three injury, they call it the evil triad, so to speak. So quite often with sports, it's very, very common, you know, when you have like a sport that involves running with cutting and a lot of fast changing directions.

Particularly hockey, any kind of field sports, like football, soccer, ultimate Frisbee and rugby. Even like, believe it or not like tennis and squash. Anything that involves like fast changes in movement, but particularly the other ones that I mentioned because they involve contact. So you can kind of add that factor into it. 

Quite often, what happens is if you have contact, then you have sort of this initiation of force on the knee, and so this is where it involves all three parts. Like I called the evil triad. Where you can injure the ACL, MCL and the meniscus where you get this blunt force on the outside of the knee where it causes it to buckle and also hyperextend. And that's where you get the injury to all three. 

Now in another case where you can get just the ACL isolated, it could just be like a hyperextension type of injury, because the main function of the ACL is it actually stops like, so your knee, if you think of your knee is a hinge joint. And so the purpose of that ligament is, so say this is your lower leg and then this is your femur or your thighbone, so when you go to extend your lower leg or your knee, it actually prevents it from hyperextending or straightening out beyond what should be. And that's the protective, normal check and balance for protecting the knee.

 And so what ends up happening too is you've got a lot of nerve endings in that ligament, that basically when that happens, muscles will kick in and stop, like your hamstring is the biggest one. And so when you hyperextend it, and especially if you have your foot planted, then that can cause a tear in that ACL. 

And there's different degrees of tearing. So there's basically three classifications. So they have a grade one, grade two and grade three, and those are the three classifications.

And in grade one, it's a very mild injury to the ACL where basically you still have a good portion of the ACL, but it's either been slightly torn or stretched. And when you assess it and you diagnose it and you feel for it, and there's a battery of different tests that you want to do to kind of test it. But a couple of main ones and you can still feel that there's still ligament there intact. 

And a second degree, that's where you feel like a lot more give and it feels, it definitely has more of this like unstable kind of feeling, but it still has a little bit of that ligament left where, you know, it's still kind of holding it in place.

Whereas a grade three tear classification is that, that ligament is completely torn. And when you do specific tests on it, then that's not holding at all. And it's just basically, you know, pretty unhinged.

Mark: So how would, other than pain, swelling, what other symptoms would people have? Is it more about how it feels, whether how stable that knee feels for certain actions or you're just not capable of doing those actions anymore? What am I going to notice if I have a tear? 

Wil: So well, first off, if it's an acute injury or a trauma, there's going to be swelling right off the bat. Particularly because there's the way the blood supply is and how it connects and everything like that, then you're going to know right away that you've injured most likely your ACL, if you've done those sort of directions of movement that may cause the injury. The swelling happens automatic, like pretty instant.

And so the other thing to also consider too, is like, what I was talking about in terms of the movement is that you're going to have this feeling unstable. So your knee will feel like it gives up because it's just basically, especially with a grade three tear, you know, like I said before now it's like unhinged. I mean, it's got a bit of a weird term, but like the stability in your knee is no longer as good.

And so when you walk, you're going to feel like it gives out. And so that's a big problem. Like your knee will literally give up. Like it'll feel like it sort of just like glides out of joint and out of place. So that that's another thing to look for.

Now is you have other things that are happening, like if it locks, then it could be a meniscal injury as well. So when I talked a little bit earlier about how it could be this triad, this evil triad, and you have a bit of meniscal stuff going on, then that could be a part of it too. So you want to get it properly diagnosed to see if it's just the ACL, if it's possibly, you know, two or all three of them.

Mark: So where's the line between rehab and the knife? 

Wil: That's a really great question. Now it's kind of interesting because prior to 2019 and 2018 if you were a very active individual and especially if you were involved in athletics and sports and you had a complete tear, then the rule of thumb was to get that reconstruction and get that repaired.

But they have done a lot of research and they came out with a consensus and a study. Some studies done in 2019 and they presented it at sport physiotherapy in the sports medicine conference, world congress in 2019, showing that it's actually 50-50. And so in other words, with a complete rupture of your ACL, there've been people that have had athletes, so this is going back to the athletic population, and were very active and depending on that stability. That if they've gone under the knife and they had the reconstruction done, they've done really well in terms of rehab. But then they've also seen half of that study group not do well. 

But then they took another group where they had individuals not do any surgery. And they did really well. They just did very specific rehab that was geared towards what they needed to get back to playing sport. And they were actually back playing competitive sports at the level that they could play with the full rehab, with a fully torn ACL.

So this has been interesting. So that's kind of where we stand now more recently in the last couple of years and that's kind of the direction that we're going. But either way, the rehab component of strengthening and really being sport-specific or activity specific dependent is a huge factor. So you always want to make sure that you're addressing whatever deficits are needed. Because that's ultimately the key to successfully return to sport or a successfully returned activity, whatever that is. 

Mark: Okay. I really don't want this ever. How do I prevent it? What are the actions I can take to help prevent other than a blunt force to the front of the knee kind of thing, that hyperextends it, what could I do to strengthen it? 

Wil: There's some specific things that you can do. Like you want to strengthen up your quadriceps. You want to strengthen up the hams, like all those muscles around the knee. And there's some specific exercises that you can do. We actually have a YouTube channel with a specific list of ACL prevention exercises.

So there's about seven to 10 exercises that you can do, but there's more. But those are the basics that you can start with. And then obviously as you get into like specific sports, like if its Ultimate Frisbee, even rock climbing, you want to do some specific things to work on strengthening the knee.

So that is very important because what you're doing is you're developing the what's called the muscle activation pattern, that will stop your knee from going beyond the range that it should be. Because I mentioned before that your ACL has nerve receptors. And so when it goes to the end range of extension, as it goes just even a little bit past that end range, your nerve receptors kick in right away. Now, if your muscles are trained and strong and you've been, and you've been really focusing on having a good sort of sense of muscle activation patterns with respect to also your balance and all that stuff and how everything activates properly, then that's a really great way of preventing injury.

Mark: Depends on the grade of injury, but what's a typical course of treatment? 

Wil: Yeah. So it can take anywhere from up to six to eight weeks for really, really mild someone that's just sprained it very, very gently. Where they're back on track and they're doing their sports to as long as a year. And the other interesting thing about that is that you're asking, you know, your actions, I never want this injury. Well I didn't mention that this injury can be something that can happen that you might not even be aware of. And then maybe because you're very active, I'll give you an example. 

One of our therapists is treating someone else right now who does not do any contact sports or running sports or whatever, but he is an avid golfer. Like super avid golfer. And he was complaining of like weakness and loss of range in like his hip and other areas. And he's like complaining about his golf game. And so the physiotherapists on our team assessed his knee and found that, well, this is the cause of your hip tightness and why you're compensating because you have, you have this deficient ACL and the best way to actually ascertain that is to compare that knee in question with the other knee. So you always want to do what's called a bilateral comparison. And so she found out that he had a total grade three ACL tear. And so they'd been doing rehab, working on it, and he's been doing simple things and he's like a very avid golfer. 

He's been really getting out there on the greens, but he's been like hitting balls and playing all summer long and his and his hip just started getting tight. So these compensation patterns started happening. His knee started feeling weird. But he didn't know why. And for life of our physio, who's been working with him you know, like there has been no trauma. So that's really interesting. So we think that it's his compensation pattern and he's been over stretching and over stretching and over stretching. 

So his timeframe for rehab you know, let's go back to your question, might take a little longer, because he's developed all these muscle patterns in his hip, in his back because of that ACL. And he didn't even know he had an ACL injury. 

Mark: Yeah, complicated. If you want help with your knees, the guys to see are Insync Physio. You can reach them at their website to book, insyncphysio.com. Both offices you can book there. It's really easy to use, or you can call them in Vancouver 604-566-9716. Or in North Burnaby, 604-298-4878. Get professional help. Keep going with your sports. Thanks. Wil.

Wil: You're welcome Mark.