Frequently Asked Questions: Knee

Anterior Cruciate Ligament (ACL) Injuries

Diagnosis

How does an Anterior Cruciate Ligament (ACL) injury occur?

Injuries to the ACL can occur in several ways, usually without contact. High speed twists, bending or extending the knee beyond its normal range, or landing "wrong" from a jump may result in an ACL tear. Basketball, volleyball, tennis and soccer players, as well as skiers and snowboarders are particularly vulnerable. Female athletes are more prone to ACL injury than males.

What are the signs and symptoms of a possible ACL tear?

The famous "pop" is the most telling symptom of an ACL injury, although you may have a tear without ever experiencing the pop. The injury is usually followed by considerable pain and swelling within the first several hours. You may develop a feeling of instability in the knee or "giving way", making walking difficult.

What should I do if I think I have an ACL tear?

Immediately after an injury think RICE: Rest Ice Compression Elevation. Then see your doctor.

How will my doctor diagnose an ACL tear?

There are several steps to making the diagnosis. First is your story, the what, when and how of your injury and what symptoms you are having. Second is a physical exam that includes both looking at and feeling the knee, and putting it through some non-painful moves to check for looseness and clunks. Third, an MRI (Magnetic Resonance Imaging) may occasionally be done to look for an ACL tear. While very good, these methods arenít perfect. Sometimes a tear will be missed and other times a suspected torn ACL will turn out to be ok. The physician will utilize all aspects of the history, physical exam, X-rays and MRI to confirm the diagnosis.

Treatment Decisions

Will I need surgery?

It depends. ACL tears can be partial or complete. With stretching and strengthening exercises and often a good knee brace, it is possible to live with a tear. If you find you can not lead the life you wish and are unwilling to modify it, then surgery is for you. "Modify your life to fit your knee or modify your knee to fit your life" is the standard quote. However, surgery is frequently recommended for very active patients, particularly those involved in sports.

Are there risks in deciding not to have surgery?

Long term instability may lead to arthritis. If you opt not to have surgery itís important to minimize the giving way episodes by restricting your activities, strengthening your leg muscles and wearing a brace if necessary.

Who should not have surgery?

Rehabilitation after surgery is just as important as the surgery itself. It takes time and effort to restore range of motion (how far your knee will bend and straighten) and strength. If you are not willing to do daily exercise for several weeks then surgery may not be for you. Those with very sedentary lifestyles or those with no other injuries may be candidates for non-operative approval.

Can you use someone elseís tendon for the graft as a donor? Do you recommend this procedure?

Yes, this can be done and the graft is called an "allograft." Your surgeon may recommend this graft depending on a number of factors associated with your injury and other aspects of your overall knee condition. This decision needs to be made in personal discussion with your surgeon.

Would a maleís donor tendon be stronger than a femaleís?

No.

Is taking a large piece of my patella, or patellar tendon dangerous?

No. We will bone graft the patella and the therapist will work with you to decrease the chance of long term issues.

After Surgery

What should I expect after surgery?

  • You will need crutches for several weeks.
  • Ice and elevation will become your mantra.
  • Swelling and bruising as far down as your ankle and foot is normal.
  • You will need to keep your dressing dry until the stitches are removed.
  • Driving is OK when you are off prescription pain relief and when you feel up to it.
  • It will be several weeks before you will walk normally.

How many of the postoperative exercises should I do?

Do what you can. Try two to three of each at first. A few hours later try some more. Itís better to do a few, several times a day than to do too many once a day. Listen to your body. If you get increased pain and swelling, back off a bit.

Can I shower?

Yes, but you need to keep your dressings dry. You can cover them will plastic wrap. If you have a longer dressing it may be easier to step into a tall kitchen trash bag, then secure it with an elastic. If this doesnít come up high enough, cut a hole in the bottom of a second bag and pull it up and over the first bag until everything is covered, then secure with an elastic.

An anti-skid mat is a good idea.

How about a bath?

Once your stitches are out and your incisions are fully healed itís OK to take a bath. This usually requires three weeks. Donít go too hot or too long, as this can lead to more swelling. A warm bath is a good place to do some range of motion exercises. Follow up with ice and elevation.

What about stairs?

The first day or two after surgery you may find it easier to do stairs in a sitting position, using your arms and good leg to push off. The other leg just goes along for the ride.

Up with the good and down with the bad is the key to doing stairs with crutches.

Once off crutches you will do stairs the baby way for quite a while, that is, always leading with the same leg. Again itís up with the good and down with the bad. Stepping up and down is part of the rehabilitation process and you start off with the height of a phone book. So, donít push it!

How can I control swelling?

RICE = Rest Ice Compression Elevation

Rest - just what it says.

Ice - as often as 20 minutes on, 60 minutes off.

Compression - use as much as you need. Options include: an elastic bandage wrapped from the ankle to just above the knee, elastic stockings, support hose, i.e., Sheer EnergyTM, or snug fitting leggings.

Elevation - Ideally, lie down and use enough pillows to support your whole leg and get your foot 12" to 18" above the rest of your body.

How can I minimize scarring?

See the compression options above. Once the incisions have healed, use lotion to gently massage along each side of the scar and across it. Many people believe using vitamin E will minimize scarring. While there is no scientific evidence for this, there is no harm in using topical vitamin E.

When can I add other activities?

Follow the guidelines in the knee rehabilitation protocols that apply per your physician. If possible, it is good to only add one new exercise or activity per day. Often you will feel fine when doing an exercise, only to have increased pain and swelling later in the day or the next day. If you have done several new things, it can be difficult to pinpoint which activity caused the pain.

Is there any kind of aerobic exercise I can do?

Once your incisions are healed and you feel up to it, you can go swimming usually after three weeks. Only do a gentle freestyle, flutter kick, face up or face down. If this bothers your leg you can support both legs with floats and just do the upper body.

Doing upper body weight training with lighter than usual weights and many, fairly quick reps might get your heart rate up.

High Tibial Osteotomy

What is the purpose of a high tibial osteotomy?

A high tibial osteotomy distributes the stress of weight bearing across the knee more evenly. It relieves excessive pressure on the diseased (or arthritic) side of the knee joint.

What is the recovery time for a high tibial osteotomy?

Six weeks of no weight bearing, followed by six weeks of minimal weight bearing with crutches and 12 weeks of rehabilitation with physical therapy. Most patients are able to fully recover to full activity by six months.

What evaluation do I need before a high tibial osteotomy?

You will need full length X-rays and a physical examination.