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Summary about ACL injury

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  • Summary about ACL injury

    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


    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.


    Alireza Abouhossein M.E.Sc., PhD Candidate


    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


    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)


    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


    Kind Regards



    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


    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


    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,


    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!
    Behdad Tahayori
    Graduate Student
    Department of Kinesiology
    Louisiana State University
    Baton Rouge, LA, 70803

    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


    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

    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)

    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


    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

    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.
    Michael Orendurff
    Division Director
    Movement Science Laboratory
    Texas Scottish Rite Hospital for Children

    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

    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.)

    Peter J. Stein, DC
    Harvard Vanguard Medical Associates
    Alternative Paths to Health
    133 Brookline Ave.
    Boston, MA 02215
    (617) 421-6432
    1093 Beacon St.
    Brookline, MA 02446
    (617) 232-3927

    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


    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.


    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


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


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

    American Sports Medicine Institute

    833 St. Vincent's Drive, Suite 100

    Birmingham, AL 35205


    (tel) 205-918-2139

    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


    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 Chimera, MEd, ATC, CSCS
    PhD Candidate
    Biomechanics and Human Movement Science
    Spencer Laboratory
    University of Delaware
    Newark, DE
    484-356-6578 (cell)

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

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