Everyday People: Rehabbing Major Knee Injuries with AZOPT

Minnesota Vikings running back Adrian Peterson. Chicago Bulls point guard Derrick Rose. Washington Redskins quarterback RG3. Most recently, snowboarder Lindsey Vonn. What do these professional athletes have in common? They have all had surgery to repair a torn ACL. If you are a sports fan, you will read about an athlete tearing their ACL almost too frequently. Not to downplay this horrific injury, but ACL injuries have become so commonplace, that we expect an athlete to recover quickly from ACL surgery, and in some cases, perform even better. Just look at what Adrian Peterson accomplished this season in Minnesota, winning the NFL’s MVP award. Athletes are privy to top doctors, top physical therapists, and top rehabilitation equipment, right?

But what happens when a young, otherwise healthy, person tears his ACL? Can they expect the same doctors, same level of physical therapy, and ultimately, the same return to normal activity? To answer these questions, we will examine Arizona Orthopedic Physical Therapy’s patient Josh H., who is in the mist of rehabbing his left knee after surgery from suffering a grade 3 tear of his ACL and MCL, along with torn meniscus and bone bruising.

On November 7, 2012, Josh was enjoying a Judo class with his son. While practicing with another adult, their legs became entangled, and the sparring partner fell onto Josh’s fully extended left knee. It was one of those fluke injuries that could happen during any activity. Josh knew it was bad right away. He heard a loud, audible snap that sounded like celery when you break it in half. His leg felt like a peg, there was total instability. Josh immediately called his primary care physician, who referred him to an orthopedic surgeon. There, Josh was given a physical exam and an MRI, which revealed the tears.

A ligament is a tough band of fibrous tissue connecting two bones. The ACL (anterior cruciate ligament) and PCL (posterior cruciate ligament) are inside the knee joint connecting the femur (thigh bone) to the tibia (large bone of the lower leg). The ACL and PCL form an “X” inside the knee that stabilizes the knee against front-to-back and back-to-front forces.

ACL injuries are sprains, in which the ligament is torn or stretched beyond its normal range. Almost always, when the ACL is torn, it’s due to a sudden stop, twist, pivot or change in direction at the knee joint (like a running back, point guard, or skier), extreme hypertension of the knee (like Josh’s injury or a gymnast landing a vault), or through direct contact to the outside of the knee or lower leg. A grade III ACL injury is the most severe form of injury in which the ACL is completely torn through and the knee feels very unstable.

According to Health A-Z, a Harvard Health Publication, “most ACL injuries are severe Grade IIIs, with only 10% to 28% being either Grade I or Grade II. Currently, between 100,000 and 250,000 ACL injuries occur each year in the United States, affecting approximately one out of every 3,000 Americans. Although most of these injuries are related to athletic activities, especially contact sports, about 75% occur without any direct contact with another player.”

Prior to this injury, Josh was a generally active person. As a 35 year old, Josh participated in CrossFit 3 or 4 times per week, and also enjoyed Judo, bike riding, and golf. He had intended to participate in the Toughmudder run this February. This father of 3 was not prepared for the substantial change in lifestyle caused by this injury – not being able to carry his kids or even tie his shoes. Initially, Josh felt a sense of loss from doing the activities he once enjoyed, but his faith (Josh is a Pastor) guided him through this difficult period.

Immediately following the injury, Josh was placed on crutches and told to rest and heal, allowing the swelling to go down in the knee. This is common practice in Grade III tears known as RICE – Rest the joint, Ice to reduce swelling, Compress the swelling with an elastic bandage, and Elevate the injured area. Josh followed this regimen through the month of November.

Once the swelling and pain subsided, Josh began seeing AZOPT’s Ryann Roberts, DPT, on December 5, 2012. Throughout the next few weeks, Josh and Ryann worked on basic strength, flexibility, and range of motion. Physical therapy consisted of range of motion stretching, hamstring stretching, quadriceps strengthening, balance training and knee stability training – all with the purpose of preparing for surgery and the rehabilitation that will follow. In three weeks, Josh met all of his pre-surgery goals.

The next step in Josh’s recovery was surgery. On January 14, 2013, Josh underwent a surgical procedure known as auto graft to repair the torn ACL. Dr. Douglas Hartzler performed the surgery, in which he uses a section of tendon taken from Josh’s hamstring to replace the torn ACL. Dr. Hartzler also shaved down the torn meniscus. The MCL healed on its own during Josh’s pre-surgical physical therapy. Currently, almost all knee reconstructions are done using arthroscopic surgery, which uses smaller incisions and causes less scarring than traditional open surgery of the past that left large scars.

As Josh said, “after surgery is when the real work comes in play.”

Two weeks after surgery, January 23, Josh was back at AZOPT with Ryann to begin the long and tedious process of rehabbing the knee allowing Josh to get back to regular life and exercise, but more importantly, reducing the risk of reinjuring the knee or injuring the other knee. At the time, Josh was icing the knee and resting. Dr. Hartsler had given the green light for easy isometric exercises with the goal of returning to light jogging in three weeks.

To track progress, Ryann recording these initial measurements:

Active Knee Flexion – 85° (normal is 120-125°)
Passive Knee Flexion – 98° (normal is 130-135°)
Passive Knee Extension: -6° from full extension
Inability to maintain full knee extension during straight leg raise

Girth measurements (circumference of knee):

  • Mid patellar – R: 39.1 cm L: 44 cm
  • 5 cm below patella – R: 35.7 cm L: 40.8 cm
  • 5 cm above patella – R: 44.9 cm L: 46 cm

In his first physical therapy session with Ryann after surgery, Josh received manual therapy on a table to increase his range of motion. The plan was to begin no resistance bike pedaling at the next session if his range of motion allowed. Josh was instructed to continue using ice at home and to elevate his leg for several hours each day.

In the short term, 2 to 6 weeks, Josh will look to improve his range of motion to within normal limits. The goal over the next 12 weeks is for Josh to be able to walk with some light jogging while reducing the swelling by 90% and returning to light fitness activity. At physical therapy, Ryann will supervise therapeutic exercises geared to correct specific strength deficits. Ryann will also administer manual therapy including joint mobilizations and soft tissue treatments. Josh will have physical therapy two or three times each week for the next 12 weeks.

Josh has reasonable expectations for his recovery. He understands that each individual is on a continuum and heals differently. While there is not a general timeline for recovery, Josh fully expects to get back into all the activities he loves – CrossFit, bike riding, golf, etc. – except Judo. Josh is finished with Judo. When asked what kind of advice he would give someone in his situation, Josh said “be pragmatic. It may take a while to rehab – a month, 8 weeks, sometimes longer – to significantly heal, so be patient. And remember, suffering is good for us, it perfects our character, teaches us how to be useful and content, and helps us remember to be thankful for what we do have.”

We will check back on Josh in March to report his progress. In the meantime, let us know what questions you have about your injuries or rehab process. The team at AZOPT is available to answer your general or specific questions. You can ask your questions in the comments section below, or live tweet with a therapist @AZOPTTherapy.