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Anterior Cruciate Ligament

ACL injury

The Anterior Cruciate Ligament, or ACL, is one of the major ligaments in the knee. It is easily injured, torn, or sprained and you don’t have to play sports to injure it. An ACL knee injury causes severe knee pain, which can be due to simple injury, partial tear or complete tear; the good news is that there are many knee injury treatments options available to help you care for your ACL strain all the way to the complete tear.

Where is ACL?

I have written a blog on the knee joint that you can check out but this joint is the largest joint in the body made up of several bones and ligaments: the thigh bone (femur), the shinbone (tibia), a non-weight-bearing bone called fibula and your kneecap (patella). These bones are connected or held together by many ligaments such as the medial collateral ligament (MCL) and Lateral Collateral Ligament (LCL). The MCL is located on the inside of your knee and the LCL ligament is found on the outside of your knee. The ligament we are discussing today, the ACL, is found on the inside of your knee joint. Its main purpose is to stop your shinbone (the tibia) from sliding out from under your thigh bone (the femur). There is a specific way of grading the type of tears or sprains that a ligament can sustain. Based on the grading, we are able to map out a specific treatment plan.  The grading scale is as follows:

  • Grade 1 Sprain:

The ligament is mildly stretched but is still able to keep the knee joint stable.

  • Grade 2 Sprain:

The ligament is damaged to the point where it becomes very loose and we refer to it as “a partial tear”.

  • Grade 3 Sprain:

This type of sprain is also known as a “complete tear of the ligament.” A grade 3 sprain results in the knee joint being highly unstable and requires surgery.

What are the symptoms of the ACL injury?

Most patients coming to my office with an ACL injury complain of swelling and weakness in the knee, wanting to “give away”; many times they hear a loud popping sound before feeling the pain. These are the classic symptoms of an ACL injury. Since many ACL injuries come with other injuries, depending on the severity of the injury other ligaments or muscles may be involved or damaged as well. This increases pain in the knee joint and decreases movement or range of motion (ROM). The most common example of in involved injury of the ACL and the surrounding tissue is the so-called “terrible triad”. It involves the medial collateral ligament, the anterior cruciate ligament, and the medial meniscus mostly seen in football players. Here, the player gets tackled while in a standing position and hit on the outside of the knee. This injury requires some major reconstruction and there is no way to dodge surgery.

How to tell if I have an ACL injury?

The obvious clues to an ACL injury depend on the extent of the injury itself. With the example of Terrible Triad, it is a no-brainer and the person ends up in the hospital more than likely. More subtle cases require specific tests in the office but the definitive answer comes with an MRI where the soft tissue is best seen. I have seen cases of ACL injury were the tests were negative but because of the pain persistence or a very slow progression, I ordered an MRI and the injury was THEN confirmed.

What are the treatments for an ACL injury?

There are many types of treatments that work well with ACL injuries. With the exception of surgery, which I recommend seeing a Knee surgeon for instead of an orthopedic surgeon, treatment can take a few sessions or rather extensive. At times, I have recommended PRP injection which is essentially your own blood plasma, ran through a centrifuge and reinjected in the area. This is my choice of medical intervention for which I refer my patients out; I am not a fan of a cortisone shot for many reasons including the fact that it is damaging to the cartilage itself. Working with active and professional athletes, my goal is to not only get the patients out of pain but to bring them back in full circle with a proper posture of the whole body and a strong knee joint itself.

  • Acute Phase:

During this phase, when the injury has occurred less than forty-eight hours, the protocol the gold standard is PRICE. PRICE is an acronym that stands for the following: Protect, Rest, Ice, Compress, Elevate, and Stabilize.

I recommend cartilage repair supplements, olive leaf extract to boost immunity (injury lowers immunity), ginger and natural gelatin soup (bone broth) for this phase.

  • Sub-acute Phase:

This phase which is between 2 days or 2 weeks is the phase to assist the body to heal itself.

This is the phase of contrast therapy when you ice the area for about 15-20 minutes, followed by heat. Icing should not be more than once every hour and not over 20 minutes at a time. Contrast therapy starts with ice and ends with ice.

Cold Laser Therapy also known as Low Level Laser Therapy (LLLT) is where I apply the laser to the injury to stimulate healing, reduce pain and resolve or reduce inflammation in the joint to provide maximum pain relief. Cold Laser Therapy is an excellent system in treating muscle, ligament, tendon, bone, connective tissue, and nerve injuries.  

Therapeutic ultrasound is a wonderful tool to use with regards to knee injuries because it sends out continuous sound waves to generate heat to help, encourage more blood flow to the area to exchange CO2 for Oxygen, bring more necessary nutrients to the area for the healing to take place.

Once the pain is diminished, I like to start moving the close by joints so exercises involving seated flexion/extension, inside/outside ankle movements as well as lying down hip flexion are a good start. I like seated torso extension/flexion and side-bending and rotation to both sides. I recommend removing any movement that causes pain the knee joint from the list.

Kinetic Taping the knee is crucial during this phase but the goal of taping is to stabilize the area while the joint is moveable.

Nutritionally, add vitamin C and protein intake (powder) during this time to facilitate the healing process while continue taking the cartilage repair supplements. I do like natural gelatin soup as the food of choice during this phase.

  • Chronic Phase:

 Active Release Technique or ART: is a type of rehabilitation technique that focuses on restoring normal function and movement between the muscles, tendons, ligaments, fascia and nerves. In case of knee injuries, all agonist and antagonist muscles need to be addressed. This means the inside, middle and outside of the thigh muscles (vastus medialis, rectus femoris and vastus lateralis), TFL and IT band and the hamstrings. I typically a few minutes of focused treatment on each area and move to the next group of muscles to a break. ART is always finished with ice and patient drinks plenty of water that day.

Foam rolling the IT band is a must in all knee, hip and ankle injuries at my office and my recommend method is explained in this video.

Working on the pelvic floor is an absolute must to get the progress going and conditioning the patient to start the exercise protocol for the knee joint itself without worrying about re-injury. DNS or Dynamic Neuromuscular Stabilization is my choice of the best method to achieve this goal.

I do continue with the kinetic taping only this time, it is more focused to provide support to the specific area so the patient is able to be more proactive with strategic movement exercises like the one shown in this video.

Brain-Based Neurology and Posture is explained in detail. In short, we know that there are different parts of the brain that in charge of movement and balance. When a joint is immobilized, or due to minor pain, we shift our walking and posture to accommodate the injured area, the part of the brain responsible for for that area start shrinking. This is referred to as neuroplasticity. This means that if we perform strategic exercises for the brain to activate the part of the brain that has decreased in size (with regards to posture) while working on the injured area (the knee joint here), then we approach the failed posture comprehensively. This is fully necessary to avoid future injuries. In this video, I show how I test the balancing component of the hearing nerve which provides great value to the brain so it can determine how to balance you. Brain-Based neurology exam is consisted of up to 79 different tests to determine how well your brain is handling your posture!

How do I prevent an ACL injury?

Saying to stay away from the activity that causes the injury to someone who is active or plays sports at a higher level is not even an option. To best prevent any injury, ACL or not, is to maximize the posture while strengthening the whole body, watching the form when performing the actual sport and while performing specifically focused exercises at the gym.

Brain-based neurology exam comes is the most helpful way to discover where the posture fails and DNS is the perfect way to train the muscles, joints and tendons to work together while performing a sport. These are my 2 go to paradigms that train the brain and the body to perfect their movement to the closest biological pattern that the body movement is to follow.

Remember, you are the Director and the Designer of your own life so direct and design it the way you wish to live it.

Dr. Shakib