Indy surgeons, rehab help patients return to action after an ACL tear
Though it’s been a couple years, northwest Indianapolis member John Ruggles recalls the precise moment when he tore his ACL. A Boy Scout leader for his son’s troop, he’d joined kids and adults in a basketball game on an outing. “I got the ball, planted my foot and my knee just buckled,” says Ruggles, 46. “I screamed I was in so much pain, but after that it was more shock.”
Ruggles completely tore his ACL — or anterior cruciate ligament — one of four major ligaments in the knee. In April 2012, highly rated orthopedic surgeon Dr. Peter Sallay at Methodist Sports Medicine on Indianapolis’ northside, reconstructed the ligament.
Surgeons see high success rate for ACL reconstruction
Orthopedic surgeons say thanks to continued advances in technique and technology, the success rate for reconstructing a torn ACL usually exceeds 90 percent. “Most patients ... get back to their sports, and the activity level they had before the injury,” says Dr. Liz Matzkin, a spokeswoman for the American Academy of Orthopaedic Surgeons.
Ruggles says his knee was “back to normal” in about six months — roughly the average amount of time it takes patients to recover from ACL reconstruction, though recovery times vary considerably. “All the way through the surgery and the rehab and follow-up appointments, [Dr. Sallay has] been very encouraging,” Ruggles says. “The physical therapy I got there was amazing.” The active father of three also returned to hiking, biking and weightlifting. “I do everything I want to.”
ACL reconstruction patients typically regain complete function in their affected knee or very close to the function they had before surgery, experts say, but a small percentage don’t fare as well. “Recovery is most commonly limited by loss of full extension after ACL reconstruction,” Matzkin says. She adds that other issues include persistent pain in the affected knee and weakness in the quadriceps. Some patients experience so-called pivot shift, where the knee gives out periodically. “There’s still some persistent instability in the knee,” explains highly rated orthopedic surgeon Dr. Carlos Berrios at OrthoIndy, based in northwest Indianapolis.
Some patients suffer from "pivot shift"
A fully functional ACL usually keeps the shin bone from sliding in front of the thigh bone and helps stabilize the knee when a person cuts and pivots, as they would while playing basketball, football, soccer or skiing — common activities in which tears occur. “[With pivot shift] when you flex or extend the knee, one bone will move more than another bone,” Berrios explains, adding that it causes the knee to give out.
But recently published research identifying a new knee ligament may hold the key to reducing pivot shift in some patients. A study published in the Journal of Anatomy in October provides the first full description of a knee ligament not clearly or completely defined or delineated previously in medical literature, despite references to its existence. The finding may hold clues to reduce pivot shift in some patients, which can limit patient activity and increase risk of further injury, including an ACL retear.
Belgium researchers, orthopedic surgeons Dr. Steven Claes and Professor Dr. Johan Bellemans, used as the starting point for their search an article by a French surgeon in the 19th century that postulated a ligament’s existence at the front of the knee. They located the newly named anterolateral ligament, or ALL, in 40 of 41 cadavers they studied. Claes and Bellemans theorize that injury to the ALL, that occurs when a person tears their ACL, may explain why the knee continues to give out after an otherwise successful ACL reconstruction. “Maybe we should be supplementing our ACL reconstruction with a hard look at the ALL,” says Dr. Robert Klitzman, a highly rated orthopedic surgeon with IU Health Physicians who practices in Indianapolis, Fishers and Carmel.
Experts say more research on ALL ligament needed
Klitzman and other surgeons say we’ll need further study, however, before we know if fixing this ligament will help some patients whose knees give out after ACL reconstruction. “This is very early and there’s a lot of research [needed] in the lab and clinically,” Klitzman says. Matzkin reiterates that most ACL reconstruction patients enjoy stable knees post-surgery. But problems following surgery for some patients, such as persistent knee pain, weakness or loss of range of motion, continue to drive innovation.
Improvements in the reconstruction procedure allow surgeons to more closely locate the reconstructed ACL to mirror where the ligament had been — a seemingly small change that can make a big difference for patient outcomes, surgeons say. “If the placement is more anatomic, you’ll have more of a normal function,” Berrios says. Experts say patients should locate a surgeon with ample experience performing ACL reconstructions — and expertise in sports medicine, especially if one considers returning to sports a priority. Patients must choose between an autograft, which involves using a graft, like a tendon from a knee or hamstring, from their own body, or an allograft, which involves using a tendon from a cadaver, to reconstruct the torn ligament.
Research shows grafts harvested from a patient’s own body tend to have a lower failure rate than tissue taken from a donor, a deceased person who donated all or part of their body for medical use. “It is becoming increasingly clear that allografts do not perform as well in younger, active patients,” says Dr. Mark D. Miller, a professor of orthopedic surgery at the University of Virginia in Charlottesville, who has researched the pros and cons of graft types closely. One study found the failure rate was about 2.5 to four times higher for ACL reconstruction with an allograft than for surgery with an autograft. But harvesting tissue from a patient’s own body has its downsides too, including post-operative pain. Some surgeons prefer allografts, and a general consensus exists that they’re adept for complex cases involving multiple ligament tears.
Work with a surgeon to determine the best treatment
Experts caution that all surgery carries risks, from bleeding and infection during a procedure to a failure of the ligament to heal after surgery, and no technique works for all patients. After tearing an ACL, talk to orthopedic doctors experienced in treating this injuryto determine your options.
When Westfield, Ind., member Debra Wallace partially tore her ACL and hyperextended her knee while stepping awkwardly off a ladder in 2011, she saw Dr. Richard Johnston, a highly rated orthopedic surgeon at Parkcrest Orthopedics in St. Louis, where she lived at the time. He evaluated her injury and prescribed physical therapy.
“I don’t think anybody wants to go into surgery,” says Wallace, adding that she felt fortunate that physical therapy alone proved sufficient to make a full recovery.
Bypassing surgery may be an option for some patients with partial ACL tears and individuals with a full tear who want to walk but can live with otherwise limited activity. But for patients who’ve fully torn their ACL and wish to return to an active lifestyle — particularly sports that require pivoting, such as soccer — experts typically advise surgery.
Rehab profoundly impacts recovery
Still, for all the innovations in the field, orthopedic doctors and rehab specialists stress that patients’ post-operative rehab — from physical therapy to completing prescribed home exercises — profoundly impacts recovery. “The rehab process restores the range of motion and function,” says Jeff Sorg, director of therapy at OrthoIndy. Rehab may include exercises from lunges and squats to stretching.
That’s true for both weekend warriors and professional athletes like Indianapolis Colts receiver Reggie Wayne, who tore his ACL playing the Denver Broncos this season. Colts coach Chuck Pagano said in a recent press conference that after his ACL reconstruction surgery, Wayne has taken his trademark work ethic to rehab, and expects to return for the 2014 season. “That’s just Reggie being Reggie,” he says.
As with surgery, Klitzman recommends looking for a physical therapist experienced in sports medicine. “Talk to your doctor about getting with somebody who does the majority of rehab on athletes,” he says. In addition, independently evaluate therapists on their own merit, rather than relying solely on a doctor’s recommendation, experts say — and follow-through with recommendations, including home exercises.
To improve surgical outcomes, Klitzman and others also emphasize the importance so-called “pre-hab” — either undergoing physical therapy, doing moderate home exercises, or a combination of both, to reduce swelling, increase range of motion, and strengthen muscles around the torn ligament prior to surgery.
Teen aims to get back on the court after ACL surgery
After tearing her ACL in May, 16-year-old Danielle Klingensmith of Fishers worked to maintain function in the affected knee on the advice of Dr. Michael Thieken at OrthoIndy in Fishers, before undergoing reconstruction surgery in June. “At that time, [he] had me work on range of motion and walking,” she says.
Danielle hopes to return to playing organized basketball for the spring AAU season. The Fishers High School sophomore, who plays point guard, says her OrthoIndy rehab has included running, plyometrics, knee-strengthening exercises, and dribbling and cutting in preparation for getting back on the court. “The trainers make sure you feel confident,” she says. “I know I’ll be back and playing for the school team.”