ACL Injury

The ACL

By Peter Shaw

The Dreaded ACL

I write to you from my hospital bed in the world class Santry Sports Clinic in Dublin. Having suffered the injury I always feared. I’ve unfortunately torn my left anterior cruciate ligament. It has been one month since I sustained the injury during a club level hurling match. In this article, I wish to provide insight to the mechanism of injury, some brief research on the ACL, my thoughts on prevention and ultimately my rehabilitation plan for the coming year. I’d like to take this as an opportunity to verify I am not an expert in the pathology of the knee nor am I a rehab specialist; this is merely a means for me to exercise my thoughts and maybe help some people in a similar situation.

Anatomy and Function

The anterior cruciate ligament begins at the underside of the femur and runs across to the top of the tibia. It is accompanied in the knee with the Posterior Cruciate Ligament , Medial Collatarel Ligament and Lateral Collateral Ligament. In my case, all the listed ligaments were intact along with healthy cartilage.  I found myself very lucky only sustaining an ACL tear and Tibial Plateau bruising which is consistent with this type of injury. The ACL plays a vital role in rotational stability which is essential in multi-directional field sports.

There are different types of orthopaedic treatment .The first utilising ipsilateral hamstring tendons to graft the ACL. The second is less common, is a LARS graft (Ligament Augmentation and Reconstruction System) . This basically an artificial graft. Also an allograft maybe used by cadaver from a deceased donor.  Finally, I opted for a Patellar Tendon graft which seemed far less invasive in comparison with the hamstring graft or cadaver option. Conor McGregor, Georges St. Pierre and Tom Brady have opted for the patellar bone graft in the past.  Couple this with the fact I had suffered hamstring trouble on that same leg before ; the decision made itself.

Protocols and Prehab

My first consultation was with Damien Sheehan and the team at Carlow Sports Rehabilitation Centre. The Lachmanns test, pivot shift test and anterior drawer test portrayed a poor image for my knee. I was immediately referred for an MRI which revealed a torn ACL. I then consulted Dr.Ray Moran who I had heard was the most proficient surgeon in the country at the patellar graft. He confirmed my greatest fears and I was provisionally booked in for an ACL reconstruction. 

Following the appointment , I worked tirelessly on regaining 0 degree knee extension (ability to straighten the knee).   I engaged in a heavy cycle of maximal strength once the knee was pain free and fully extended. It consisted of 5 reps and 5 sets of exercises such as a trap bar deadlift, single leg squat, single leg RDL’s , rear foot elevated split squats and step ups. The initial block was heavily prescribed with unilateral lower extremity strength. This was followed with 5 sets of 3 reps for a shorter period of time. The 5x3 cycle was based around bilateral exercises and building as much raw strength as possible before my surgery date.

Once you injure your ACL your knee will become inflamed and will swell dramatically. It takes just 10cc of fluid for your Vastus Medialis to switch off. .The VMO is a huge contributor to knee stability and strength. My whole quadriceps complex became atrophied due to the nature of the injury. Once I began strength training again , I prescribed some Blood Flow Restrictive training to stimulate some hypertrophy . This training involves in placing a Velcro strap around the musclotendon junction to restrict or occlude the muscles. It is a fantastic method to utilise with ACL patients because it can elicit hypertrophy using loads of just 20% of a 1 repetition maximum but placing little stress on the joint in question.

Surgery

Today I had my left knee reconstructed by Dr. Moran. The procedure lasts about 90mins in total. The surgeon will remove a piece from the middle third of the patellar tendon. The piece is inclusive of a piece of bone from both ends. An incision is made to allow an arthroscope (camera) to inspect the knee structure. At this stage the surgeon will alleviate any issues with torn cartilage. For example, Conor Mcgregor had damage to the posterior horn as well as having a torn ACL and discontinued MCL  : these would be repaired at this stage . A guide pin is then drilled through a portion of the tibia where the ACL would have been situated previously. It is guided through to the Femur where again the ACL would normally attach. The guide pin will allow the patellar graft to be placed in the appropriate position. Finally, an interference screw is passed through the femoral tunnel. The surgeon will extend the knee and place a second screw in the tibia.

Once I woke up I was immediately in pain. The knee felt heavy and stiff. I was prescribed some medication which eased the pain and I was then transferred to the overnight ward. Dr. Moran then arrived to chat about some exercises I needed to begin as soon as possible. Many people focus on flexion (bending of the knee) rather than extension (straightening the knee) . He advises gaining full extension within 6 weeks of surgery. Terminal deep flexion may not ever be regained full but it is possible to have sufficient flexion to return to sport.  

Prevention

So what are my thoughts on how this can be avoided for you or a team you work with? Firstly, contact ACL injuries are very hard to prevent. Non- Contact injuries are far more preventable. My first option is always assess. This can be done through a functional movement screen or even  the star balance excursion test. A coach should always be able to detect a high risk athlete or client during dynamic movement also. A simple squat in a warm up can trigger several athletes to knee valgus (Knee falls inwards /collapses) . These athletes need extra control to stabilise their knee. Some strides have been made in the industry with warm up designs such as FIFA 11, the Gaelic 15.) and IT Carlow have very recently launched an injury preventative warm up.

A landing error scoring system could be utilised to reveal and stability issues during dynamic movements. Simply, have an athlete step off a 1ft high box and then jump into the air once they hit the ground. I would advise each athlete to be videoed. This will allow a Biomechanist or expert to assess and score the athletes jumping and landing mechanics and red flag any glaring issues.  An anterior view here is paramount while a lateral view could add some benefit also. Anterior will reveal and knee valgus while lateral view will determine amount of knee flexion utilised and ultimately the force absorption mechanics.

As mentioned earlier, a warm up should incorporate preventative measures while still being specific to the sport in question. Drills I tend to use are some mini band glute activation exercises. These may vary depending on each athletes asymmetries. I incorporate a significant amount of jumping and landing. Throughout the warm up I am constantly cueing the landing mechanics of the athlete. I try to reinforce good control as much as possible. Some dynamic movement preparation is a staple of my warms ups. My personal favourites are the World’s Greatest Stretch, Inchworm, Superman Y Scapula retraction and many more. As most of my recent coaching has been in a female domain, I include a lot of hamstring recruitment exercise and I will discuss the reason why later in the article.

One area I feel that is thoroughly neglected in particular the GAA world is decelerating mechanics. I try get some deceleration work done in every warm up. An anecdotal concept I use is including some decelerating and landing mechanics in the cool down too. I feel this may ingrain some control while under fatigued conditions.  

My favourite exercises in a warm up for a field sport are jumping and landing drills. I use some neural activation drills such as pogos, ankle hops and fast feet while also working through exercises that require high neuromuscular control. I tend to use Countermovement Jumps with a stick landing, altitude landings (gym setting) , lateral hop and stick, left-right-left hops with a stick and also have the athlete stand on their left leg and perform two forward quick hops and stick on the third contact. Constantly during this I am screening for knee valgus and poor balance. With smaller groups I can begin to see left to right asymmetries during these drills also.

Strength Cures Everything

A comprehensive strength programme should be prescribed for an athlete who you deem high risk for an ACL tear. Proper coaching and supervision during this type of training can alleviate a lot of risks.

Unilateral training (single leg training) can teach the athlete proper neuromuscular control . Most sports occur on one leg so teaching the athlete how to stabilise their knee during these dynamic movement is crucial.

If you have an athlete who tears an ACL they should be referred to a medical professional. Most athletes will want to take a break once they receive the dreaded news but this is an opportunity to gain some strength that will pay dividend on the other side of the surgery. Also used as a chance to improve in other aspects and take a holistic approach to movement flaws or discrepancies.

Females and The ACL

It is common knowledge in our industry that females are highly susceptible to ACL tears. For the ordinary skill coach or athlete it may not be known.There are many  factors predispose females to ACL tears.  Dr. Gregory Myer has dedicated a lifetime of work on ACL tears and in particular women ACL tears. I had the great privilege of meeting and listening to Gregory speak three years ago on this subject.

Some risks are :

·         Wider Pelvis (Q Angle) and Knee valgus

·         Anatomically have a smaller ACL

·         Poorer core control compared to men

·         Poor posterior musculature recruitment (Land more upright)

·         Glute Medius activation (Knee instability)

·         Hamstring firing sequence may be a risk factor

There have been some studies completed in the affects of puberty in females and the correlation to ACL risks. It has been noted that females gain less hamstring recruitment during puberty and therefore are higher risk when landing from a jump.

ACL Problems

What should you expect in the future if you have ruptured your ACL? Firstly, you should return to play. Sadly there are some unavoidable repercussions . The risk of osteoarthritis is drastically increased and seems to be almost unavoidable . The younger you suffer the injury the earlier you will suffer degenerative changes in your knee. If you have got a hamstring graft and you are female you may suffer as this hamstring will be significantly weaker. However, it appears most surgeons will avoid undertaking a hamstring graft on a female with a history of hamstring injury.

Final Advice

Firstly, have a great physiotherapist. I highly recommend Damien Sheehan who I have been with my whole career. I would advise you to get it as strong as possible prior to surgery and avoid getting lazy. Anyone who coaches or participates in sport should engage in a strength programme. This programme should be heavily prescribed with unilateral work, require high neuromuscular and trunk control. Athletes should work on plyometric elements, in particular eccentric jumping. 

Positivity is key when dealing with any injury. This extended lay off is an opportunity to become a stronger version of yourself both mentally and physically. Once you have returned to play the rehabilitation of your knee needs to continued and your movement refined even further. I would advise you not to fear this injury but to embrace it if it god forbids occurs. Get that knee straight, get lifting heavy and get some muscle back into that leg. I’ve set myself the target of 7 months to return to performance and to surpass all my previous performance markers such as CMJ height, drop jump height, landing forces, speed tests and strength markers.

Finally I would like to thank, my friends in particular Andrew Morrissey for his help, family, team mates, physiotherapist Damien Sheehan, Dr. Ray Moran and Dr. Tom Foley and all the staff at Santry Sports Clinic.

Thanks for reading.

Do everything better.

Peter Shaw

Performing Supermans into Overhead Reverse Lunge 3 weeks post surgery.