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fbahrami61
04-08-2008, 08:45 PM
Dear All,

Many thanks to all of you who have answered my question. I have forwarded all the answers to our student. I have also attached a summary of answers to this message.

Once again many thanks for your quick responses and concerns about the situation of our student, and

with best regards

Fariba Bharami

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In my opinion, I would got with optino #2, with repsect to rehabbing

the knee first for a month or so, adn then going onto surgery to repair the

ruptured ACL. I am a chiropractor and a sports chiro resident and I work with

our Ontario (canada) soccer athletes, adn I have seen many ACL ruptures

amongst our athletes. All those who have ruptured their ACL have undergone rehab

to strengthen the knee as much as possible because after the surgery the

knee will undergo atrophy a bit, so it is best to strengthen the knee as much as

possible.I would not advise the casting method, as I have never even heard of

That method. I would anticipate a great amount of muscle atrophy by having

a cast on for such a long time.



i hope that gives you some help,

Melanie Lopes


I believe the nature of the injury should be described in details.

However, if as you indicated: ACL was raptured! In such a case, unless you

see still some fiber attachment, the surgery perhaps is necessary and best option. Casting it perhaps is the worst approach since the ligament(s) becomes stiff and patient

will lose muscle strength which is important for further proper activity.



Regards,

Alireza Abouhossein M.E.Sc., PhD Candidate

EMPA

Duebendorf, Switzerland


Sounds like this is an active student, sine he was injured in a

sporting accident. There are a couple of things to consider:

1) state of the art of local surgeons 2) short term versus long term consequences

I will address the latter first. If this person wants to remain active

it would probably behoove them to have a surgical repair, although

there are some that suffer full ACL tears and return to normal function. In

the literature they are referred to as "copers". However, this person

is at greater risk of early onset Osteoarthritis in the knee due to the

subtle lack of stability. If they want to take up a less strenuous

activity level that does not require a lot of running, cutting and

jumping; such as jogging surgical repair is even less necessary. If

the person wants to even become sedentary there is probably no need for

surgery, but as you know this student will lose any health benefits

associated with regular exercise.

Now the former... I believe it takes equal part effort by the patient,

physical therapist and patient to succeed following surgery.

Therefore, the surgeon must have adequate skill, technique and experience to

minimize any complications following surgery; he must also advocate

immediate post-op care to facilitate the healing process by referring

for physical therapy. If you have good working relationships with

these surgeons and are confident of there surgical skill and follow-up care

it would lead me to be more comfortable with a surgical intervention. If

not I usually refer patients outside a geographical region for a second

opinion, this will ensure that there are no "turf" wars, or cooperative

agreements between competing clinicians. I do not mean that in a bad

way it is just that the field of orthopaedic surgery is pretty small

and it is pretty assured that most local clinicians will know each other.

Another avenue to explore is get the opinion of the local physical

therapist, either within your university (if you have a program) or a

neighboring university for referrals or opinions.

I hope this helps.

Tim Brindle PhD, PT, ATC

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If he want to continue with the sports is better the second option,

he's young, I have a LARS ligament in my left knee and I recomended

too, again the second option for him!


if the ACL is ruptured then as far as I understand the ACL won't heal

so the option of plastering the leg will only delay his recovery by resulting

in a stiff knee. My recommendation is that of your second option if this is

a physically active student. Physio then surgery is the much preferred

option. If the student is not physically active normally then a longer

period of physio may mean they could manage without an operation -

though if they have any instability signs after the rehab then an operation would

be warranted

Hamish Ashton MHSc (Physio)

NZ


I couldn't help but reply to your email. My name is Massimo Barcellona

And I am a physiotherapist by background now working in research related to

The ACL and knee stability. I have a large amount of experience working

With those who have injured their ACL.

A torn ACL is a torn ACL. The likelihood of 'repair' by putting the

knee in to a cast is almost non-existent. However, the negative repercussions

of putting the knee into a cast are huge. These will include loss of

function, muscle strength, proprioception and probably most importantly a long

term loss of joint motion. I have no doubt in saying that compared to an

immediate and progressive rehabilitation protocol, casting would prove

to be a poor option for management. Whether surgery to repair the injured

ACL is then necessary would depend on a variety of factors. These include the

activity level of your student and whether they are having repeated

episodes of 'instability'. Some would say that at such a young age the sensible

thing would be to repair the ACL. To add to this, there is much

evidence to suggest that the better individuals are, in terms of joint range of

movement, muscle strength and function pre-operatively, the better the

post surgical outcome will be.

I hope this helps. I am sure you will get so many more similar

responses.

Kind Regards

Massimo

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Regarding your friends ACL injury--option 2 would be advised.

Also, few important things:

1) If a complete rupture of the ACL -- should ensure that that is no

cartilage and MCL damage. If a partial ACL injury – then if you

friend is not planning on participating in sports it may not be beneficial to

have surgery—this depends on the amount of laxity of the knee joint and

how well he is able to function.

2) If possible get surgery done asap. While waiting for surgery

Perform exercises to keep the thigh and lower leg muscles as functioning as

possible. Also, during the waiting period, a knee brace may be of

assistance as it will protect the knee joint structures from further

damage—the cartilage, MCL, etc.

3) Also perform exercises for the uninjured limb as your friend may be

In danger of injuring the non-injured limb post reconstruction of the

Injured limb.

4) Post surgery—extensive rehabilitation on the reconstructed knee

joint – especially the hamstring muscles, balance exercises, etc. Again

perform exercises for both limbs. If you would like a sample program please

advise.



Hope this helps.



All the Very Best.

Most sincerely,

Neetu Rishiraj, PhD Candidate, ATC

ACTIN Health & Rehabilitation Inc.

5767 Oak Street

Vancouver, BC

V6M 2V7

CANADA

604-244-3614 (Tel)

604-263-0477 (Fax)

For sure in case of disagreament between two surgens you have to ask for the opineon of the other one or two experts. I remember Dr. Madadi in Tehran who is expert in lower limbs injuries. I don't know where he is now. I also suggest to contact Medical Federation of Iran in Tehran (Federasion Pezeshki) who have well experiences about knee injuries because of the socure players injury. They will introduce you an expert who have already treated few similar socure players.
I wish this will help our student.

Best wishes,

Nader

Having a torn ACL is the sad part of the recreation.
First of all we should be certain about the amount of tear: whether it is a total tear or partial. the only undoubted way is arthroscopy, even MRI sometimes gives misleading results let alone physical exam (drawer test).
Second we should be notified about his level of activity: a professional sportsman or a recreational.
But generally speaking, if it is a partial tear and he is a recreationalist, most probably he can benefit from conservative treatment and waive the surgery. The best center of ACL rehabilitation is Esteghlal PT clinic (affiliated to Esteghlal footbal team) I know the staff there.
Also i would like to mention that total immobilization seems to be not suitable in any case. he needs some kind of Range of Motion (ROM) exercise for sure. Now i cannot exactly remember if he will benefit more from a closed kinematic chane exe or open one (I will ask and let you know). the most important thing is that he should do muscle setting exercises as frequently as possible: contract the quadriceps muscles and keep them for 10s. no resistance will be applied this is a kind of isometric exe. this will help keep the muscle strength. and also prevents swallowing (edem0 of the joint). edema is a serious hazard.
at this moment he can use knee brace for walking but should open it and do some exercises that i have mentioned.
About the surgery: in the case of total tear, it is recommended by most of experts but not always, even with a good rehabilitation (Isokinetic exe) he will be fine.
methods include:
bone-patellar-tendon-bone graft (BPTBG): a very strong graft but some side effects such as patellar tendinitis. Cadaver Graft: not performed in Iran. Semimemberanus-semitendinusus Graft: graft from hamstrings.

I am also interested to know others perspectives!
Sincerely
Behdad Tahayori
Graduate Student
Department of Kinesiology
Louisiana State University
Baton Rouge, LA, 70803
225-578-4395


cast treatment will definitely not help an ACL rupture. If anything it

will make the knee stiff, but still leave it unstable.

If he has no other ligament injury, I would suggest do physio for a

period, and if he is doing well, he might not need any other surgery.

If he still has symptoms, reconstruction of the ACL.

If he has multiple ligament injury, the situation is a bit more

complex.


I talked to a colleague of mine who is an orthopedic surgeon. There is

No place for casting of a legamentis injured knee. It only causes

stiffness and disability that can never be overcome. So the doctor recommended

casting should be avoided.

The best thing to do is six weeks physiotherapy to regain the knee's

Range of motion. Then the patient should slowly resume regular activity if at

That time he is having symptoms of knee instability. That means the knee

Giving out going up and down stairs or with side cutting movements during

sports he should then consider ACL reconstruction.



Mohamad Zoghi-Moghadam, PhD

Dept. of Mechanical Engineering

City College of the City University of New York

zog2725@me.ccny.cuny.edu

I am a certified athletic trainer in the Southeastern region of the United States. In trying to answer your question as objectively as possible without actually seeing the amount of damage to the knee.
In the first scenario, sometimes if there is not a lot of anterior tibial translation of the knee it is recommended that the athlete undergo rehabilitation and wear a brace during activity if that activity is not going to include a large amount of deceleration of the lower extremity and cutting motions (typically this may occur if there is part of a season left to play) but... we have not fully immobilized patients with ACL ruptures since the 1980's. We found that even with those individuals that are not going to go back to playing a sport (recreational athletes or just regular individuals) the full immobilization caused too many adhesions to form within the joint (amongst other problems~reduced circulation slowing healing process, etc.) making it virtually impossible to have the person gain full range of motion back to the joint for a longtime (if ever). I would not recommend the first option for my athlete.
The second scenario is the option that most sport medicine orthopedics would recommend here in the states. We would perform some physiotherapy (rehab) to strengthen the quadriceps muscles, reduce the swelling and try to restore some of the range of motion prior to surgery. We usually begin non-weight bearing rehab immediately following (2-3 days) surgery with limitations on extension and flexion activities identified in a brace until the graft healing in which the "standard" healing time is about 6-8 weeks but varies based upon the individual, surgeon, type of grafting, etc. This is usually recommended in order to reduce the stress placed on the other structures of the knee joint (meniscus, PCL, MCL, LCL) and slow the process of arthritis occurring in the later years. I would recommend this option for my athlete.
Having said all of this, I do not intend to offend anyone particularly someone that has spent many years in Medical school. Research has indicated that at this point, the latter option is best for the long term. Hope this helps with your question.


Kathleen S. Thomas, MS, ATC
GTA -PhD, Human Movement Sciences
ESPER Department Spong Hall 113
Old Dominion University
Norfolk, VA 23529
(757) 683-5676 (lab office)
(757) 683-4270 (fax)
kthomas@odu.edu


While I am not an expert on ACLs from a clinical standpoint, I have had

a few ACL replacement surgeries myself. I can, almost with certainty, say

that ACLs will not heal themselves. Surgical practices which do not involve

reconstruction are being developed, but most have not been used on

humans. However, these procedures still use something to bridge the gap. The

fluid in the joint dissolves the clot that is formed from the injury; therefore,

healing on its own is a very difficult process for the ACL to accomplish.

Therefore, I would HIGHLY recommend NOT getting the leg casted. It doesn't take

much time for the body to recognize that the muscles which flex and extend the

knee are not being used, thus atrophy will occur quickly. The knee is a joint

in which its stability is highly dependent on the health and strength of the

musculature crossing the joint.

>From someone who has had three replacements, I would also offer that

there is no reason to shy away from surgery. I have never felt as if it were the

wrong decision. If he intends on continuing playing sports I would also

suggest having surgery because the longer the ACL/knee remains lax the more

risk he has of developing arthritis.

Hope this helps. Please remember that I'm not a clinician, but someone

who has had this decision to make.

Lex Gidley, MS

University of Massachusetts,

Amherst, MA

Totman Bld, 155C


A ruptured ACL will generally not heal on its own, particularly if it

Is completely ruptured. The body will instead clean up the damaged tissue

until no traces of the ACL are left. Casting does not change this and

may exacerbate the problem through atrophy of muscles and bones and

restriction of range of motion.

Physical therapy before surgery is a good idea to reduce swelling and

recover range of motion. If the individual is planning on returning to

high activity, he should have the ACL reconstructed. There are several

techniques used and each has advantages and disadvantages. I would

suggest contacting an orthopedic surgeon in your area for further

evaluation.

Gary A. Christopher

Assistant Professor

Health & Physical Education

University of Great Falls

1301 20th Street South

Great Falls, MT 59405

Office: (406) 791-5383

Fax: (406) 791-5993

gchristopher01@ugf.edu

I'm not sure you have access to surgical repair, but that does appear to be the current treatment of choice for complete ACL ruptures, either with either hamstring donor (easier recovery, but some evidence for slightly lower failure strength) or patellar tendon bone-tendon-bone donor site (more difficult recovery, but ultimately high strength). There is some work recently published using a double-bundle technique with one portion used to control tibial rotation and the other to restrain translation.
Casting for any length of time will just lead to a joint contracture and is currently contraindicated, I believe.
I hope that someone will respond who has more experience than I do. Best of luck.
Cheers
Michael Orendurff
Division Director
Movement Science Laboratory
Texas Scottish Rite Hospital for Children
Dallas


No to the cast...immobilizing can result in poorer outcome...casting

was an approach years ago and it leads to all sorts of problems, not the least

of which is a capsular (frozen) knee joint...

If the injury is isolated to the ACL, and an age of 24, surgical

reconstruction has very good outcome...

Daniel Cipriani, PT, PhD

School of Exercise and Nutritional Sciences

San Diego State University

5500 Campanile Drive

San Diego CA 92182-7251

(office) 619.594.1922

(lab) 619.594.5625

(fax) 619.594.6553

http://www-rohan.sdsu.edu/dept/ens/ens_web/faculty/cipriani.htm

In my clinical experience, the chance for regeneration of a completely ruptured ACL is quite small (I think the literature states less than 5%). The more typical treatment is one month of physio followed by surgery and then more physio. If these patients wish to return to sport, it often requires the use of a brace to protect the joint from future injury. Hope this helps...

Peter E. Pidcoe, PT, DPT, PhD
Associate Professor
Department of Physical Therapy
Virginia Commonwealth University
Phone: 804-628-3655
Fax: 804-828-8111

I believe complete or extensive ACL ruptures are reported to respond poorly to nonsurgical care, at least in terms of ligament repair. Function of the knee may well improve when muscular endurance and coordination improve; but in a 24 year old who intends (I would imagine) to continue playing sports after resolving this issue, that may not be good enough! An athlete needs an ACL or, in this case, a reconstruction of one.
MCL injuries are quite different--respond beautifully to bracing and physiotherapy. But I would guess that surgery is indicated here. (I should probably mention that I am a non-surgeon.)

Best,
Peter J. Stein, DC
Harvard Vanguard Medical Associates
Alternative Paths to Health
133 Brookline Ave.
Boston, MA 02215
(617) 421-6432
www.harvardvanguard.org
1093 Beacon St.
Brookline, MA 02446
(617) 232-3927
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I am a physical therapist and graduate student at Washington

University. I would suggest the physio followed by surgery route. If indeed the ACL

Is completely ruptured, a cast, in my opinion, will not heal the ligament.

If the ACL is partially torn only, a cast may help but there is still a

Greater chance of later rupture. People do proceed through life without an ACL

And do just fine. They MAY have increased risk of arthritis in the future,

But this is not for certain. My opinion would be, that because of the

person's age (young), and if they want to compete in athletic activities in the

future, the surgical option may be the best one.

Therapy to increase range of motion, reduce inflammation, and increase

strength before a surgery is a great option. Then the surgery can

repair the ligament, with the understanding that further therapy is needed after

surgery to complete the process. The post-surgical therapy would be to

again, decrease inflammation, increase range of motion and increase

strength, balance etc. This is a very important time point. Overall the

process is not a fun one, and recovery takes some time, but it can be

done, and is done frequently. I myself have had an ACL reconstruction and had

good results. The patient must work hard though to have a good outcome.

This is just my opinion, but if you have any other questions, please

Feel free to contact me.

Justin Beebe, PT

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I am an exercise physiologist, and work in the area of musculoskeletal

rehabilitation. Additionally, I have had three knee surgeries which

were the result of sports injuries. Based on my educational and experiential background I would agree more

closely with the second recommendation; immediate physiotherapy.

Keeping the injured area active will increase blood flow to the tissues

(assisting healing), and assist in maintaining range of motion and muscular

strength. I feel that the former recommendation will result in the

opposit effects, slowing recover.

Sincerely,

Dr. Robert Kell

Assistant Professor, Exercise Physiology

Dept. of Social Sciences

Augustana Campus, University of Alberta

4901 - 46 Ave.

Camrose, AB

Canada T4V 2R3

Phone: (780) 679-1651

email: rob.kell@augustana.ca


Your student can also post his question on this sports medicine online

forum:

http://asmiforum.proboards21.com/index.cgi?board=knee

Glenn S. Fleisig, Ph.D., Smith & Nephew Chair of Research

American Sports Medicine Institute

833 St. Vincent's Drive, Suite 100

Birmingham, AL 35205

(email) glennf@asmi.org

(tel) 205-918-2139

www.asmi.org


I've helped to rehabilitate many ACL reconstructions, and I have

personally had 2 ACL ruptures and repairs. A full rupture of the ACL

does not 'heal' per-se. Your second physician recommended a treatment

that is typically used in the United States.

Now, part of the decision as to whether to get reconstruction lies on

the age of the patient and their desired functional ability. If they

desire to be active and will be able to handle surgery, that is your

best option. If, on the other hand, they are a sedentary individual

who is older, we typically recommend physiotherapy and functional

bracing.

If you have any other questions regarding this please feel free to ask.

Matt Tenan, ATC

Teaching and Research Assistant

Department of Exercise and Sport Science

University of North Carolina - Chapel Hill

I would say the current treatment for ACL ruptures in North America are more in lines with the latter treatment you stated. That is, physical therapy for a time period to decrease swelling, increase strength and increase range of motion. Then surgery to repair the torn ligament. There are some thoughts on "copers" - those who can be pretty functional without surgery, but involves an extensive treatment regimen. If it was me I would opt for the therapy then surgery with a cadaver repair.

Hope all goes well.
nicole
Nicole Chimera, MEd, ATC, CSCS
PhD Candidate
Biomechanics and Human Movement Science
Spencer Laboratory
University of Delaware
Newark, DE
484-356-6578 (cell)
chimera@udel.edu



Fariba Bahrami
Assistant Professor
CIPCE, School of Electrical and Computer Engineering
University of Tehran
Tehran, Iran



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