Ask Mark…
Q: When can I return to running after an ACL tear?
Q: Mark, I keep reading about "Metatarsal fractures" and seeing it on TV, what does it mean?
Q: When can I return to running after an ACL tear?
A: In answer to your question, I think that it is vitally important to understand as much about the Anterior Cruciate ligament as possible.
What is the ACL?
The Anterior Cruciate Ligament connects the Tibia in the lower leg to the Femur in the thigh and lies within the knee joint.
What does it do?
As with all ligaments, its function is to protect the joint by preventing unwanted movements. It is an inert structure which, due to its position and length, prevents the lower leg being brought forward of the thigh. However, equally important is its function as a major stabiliser within the knee joint. The amount of stress being passed through the ligament causes signals to be generated which the body interprets to work out what position the knee joint is in at any time and therefore allow it to fire off the appropriate muscles to ensure that the joint is not put into an unstable position.
How do you injure it?
The ACL can be injured in a number of ways, and does not necessarily require a massive amount of force to achieve this. Excessive inward rotation of the lower leg with the foot fixed and hyper-extension (over straightening of the knee) are common positions in which a tear can be caused. Therefore the sporting environment, especially dynamic sports which require alot of pivoting (football, rugby, basketball etc), frequently result in participants sustaining this injury.
What are the symptoms of an ACL tear?
Not everyone will experience all of these symptoms but the most common are:
Sudden "giving way" of the joint
Hearing a "pop" from within the knee
Rapid joint swelling
Reduction in the knee joint range of motion
Pain on weight-bearing
What are the consequences of this injury?
The function of a knee without an intact ACL is significantly altered with instability the most frequent symptom. This instability is often both subjective (the knee always feels like its going to collapse under the patient) and objective (the knee frequently gives way). The knee gives way due to the increased sliding action between the Tibia and the Femur causing an increase in movement for which the knee joint is not designed to cater. This increased movement will also lead on to the early onset of arthritic changes within the joint surfaces, resulting in the likelihood of recurrent joint swelling and consequent weakening of the muscular structures supporting it. Therefore, if the patient is young then an ACL reconstruction is the treatment of choice, this is also true if the patient leads an active lifestyle. However, if the patient leads a sedentary lifestyle, they may be able to function adequately without the surgical intervention.
What are the treatment options?
Usually to describe an ACL operation as a repair is a misnomer as the two ends of the damaged ligament are not reattached, instead a replacement ligament is constructed. However, Dr Richard Steadman of the Steadman-Hawkins Clinic in Vail Colorado, has had some success with a procedure known as a Healing Response for partial ACL ruptures. If over 50% of the ligaments fibres are still intact, these fibres are stimulated to bleed and the resultant blood clotting and scarring is used to augment the remaining ligament fibres and restore the strength of the ligament. The vast majority of ACL operations are reconstructions with the "new" ligament being harvested from the patella tendon or the hamstring tendons. There are some slight differences with the surgical procedures depending on which surgeon is used (one prominent US surgeon always advocates harvesting the patella tendon graft from the unaffected knee whilst another renowned surgeon in France is prefers using a graft from the Ilio-Tibial Band). One other procedure consists of harvesting a graft from a dead body, either using Patella Tendons or occasionally Achilles Tendons or the Hamstring Tendons.
How long does it take to rehabilitate?
There are alot of variables to consider when working out the time needed to fully rehabilitate from an ACL reconstruction such as age and physical condition of patient, any post-operative complications (infections etc), level of activity to be returned to, compliance with post-operative rehab programme. This is by no means all but it gives an indication of the difficulty in being exact, however, rough time scales are as follows:
Walking fully weight-bearing limp-free - 2 weeks
Jogging - 3 months
Competitive sport requiring rapid direction change - 7-8 months
What are the results?
The latest research suggests that ACL reconstructive surgery is a successful procedure with around 90% of patients able to return to their previous level of activity. It is worth considering that well over 100,000 ACL reconstructions are performed in the USA alone each year. Somewhere between 3-5% of patients go on to require a further procedure on their ACL at a later stage.
Q: I have recently had a screw put in my 5th Metatarsal. I am wearing an aircast and have been told I can take it off to drive now. I forgot to ask if I could exercise in a swimming pool. What do you think?
A: Thanks for your email, I would certainly advocate hydrotherapy as a most valuable aspect of your rehabilitation. As long as your surgical wound is completely healed, water-based exercise can start immediately. If in doubt, always contact your surgeon.
Q: Mark, I keep reading about "Metatarsal fractures" and seeing it on TV, what does it mean?
A: The term Metatarsal fractures has recently entered the general public's vocabulary after some very high profile footballers have suffered the condition. From David Beckham through to Michael Owen, Steven Gerrard and Wayne Rooney, this fracture (involving a relatively small bone in the foot) has caused consternation for an army of football fans and a great deal of frustration for the players involved.
The metatarsals are 5 long bones arranged in a row within the forefoot. They form a joint at each of their ends, one with the phalanges (small bones of each toe), and the other with the tarsal bones just before the ankle joint. These bones are liable to two types of fracture, stress and traumatic.
Stress fractures are relatively common and occur mostly in the 2nd, 3rd and 4th metstarsal but the 5th can also be involved. They can be caused by overuse and also wearing inappropriate footwear over a prolonged period. Young athletes appear to be particularly vulnerable to this injury. Symptoms include a gradual onset of pain, pain specifically centred over the fracture site and localised swelling. These fractures are not always evident straight away on x-ray but MRI scans are very sensitive for picking them up. Treatment is REST and ice for the inflammation. If unable to weight-bear then an aircast protective boot and crutches may be indicated for the first 2-4 weeks. Gradual progressive weight-bearing exercise can be resumed when pain-free. Usually a period of 6-8 weeks is required before a return to full training/playing activities.
Traumatic fractures occur as a result of direct contact, i.e. The foot impacting the studs of an opponent's boot or indirect force via the foot rolling forwards and twisting onto the outside border. The symptoms are immediate acute pain, rapid swelling, inability to weight-bear, with the possibility of an obvious foot deformity. Treatment is to seek medical attention straight away. Diagnosis is confirmed by x-ray or MRI scan. The foot will be immobilised in a short cast from below the knee to the toes or in an aircast boot for at least 3 weeks. Or, if the bone on either side of the fracture are not in good alignment, a small screw may be inserted to ensure the bone heals in the correct position. Check x-rays are then often taken between 4-6 weeks. Either way, the athlete will be away from competitive competition for around 8 weeks.
Pro-actively, athletes should work hard on balance and proprioceptive exercises as this will improve their functional ability and may help to reduce the chances of this type of injury occuring.
Rehabilitation is centred firmly around exercising in a pain-free context. Each body will heal at its own rate and pain on weight-bearing is a sure sign that more time is needed. Non weight-bearing exercise such as swimming work and static cycling should be encouraged to maintain some cardio-vascular fitness during the initial phase.
