35-year-old Male – Knee Sprain including ACL tear
A 35-year-old male presented to Access Ortho. The patient had been playing Ultimate Frisbee on the weekend when he was running and stepped in a hole. As he fell, his ankle stayed still, and his knee twisted and gave way. He and his teammates heard a popping noise. He had to leave the field, which was an unfortunate end as they were in the finals for the tournament. Thankfully, his team went on to win!!
Injuring an ACL in a sidestepping/pivoting activity is more common than injuring it in a direct blow or “tackle” type situation.
The medic at the carnival noted immediate swelling, and he had pain on the outside of the knee radiating to the inside. Ice was immediately applied, and he went to the emergency department. X-rays done in the ED were normal. He was struggling to walk and was supplied with crutches.
The patient was told to follow up with their GP. The patient was grateful that his friend was a past patient at Access Ortho, and he recommended that he contact us for an appointment. He called Monday and made an appointment for that afternoon.
On assessment in the clinic, it was noted that he had mild swelling and slightly limited flexion and extension. He was now beginning to walk without crutches. On ligament testing, the ACL was noted to be lax, while the MCL and the other ligaments of the knee were stable.
An ACL tear was suspected, and an MRI referral was arranged to assess. The patient was advised to keep their knee moving, within the bounds of pain, and mobilise without crutches as confidence and comfort allowed. Medication was also prescribed – anti-inflammatories as a means of improving his pain and mobility.
An appointment was booked following the MRI scan.
3 days later:
The patient was lucky to get a rapid MRI and returned to the clinic to see the orthopaedic surgeon 3 days later.
The MRI showed a complete rupture of his ACL. The PCL was intact, and the MCL showed a possible partial injury at the tibial insertion.
This news was devastating for the patient.
As they were young and keen to maintain their active lifestyle, surgery would be likely the best option.
The recommended care initially was to continue ice, elevation, rest and pain medication. It was explained to the patient that this treatment is critical in the initial post-injury period. The other aspect of treatment discussed was the importance of regaining strength and movement in the knee before surgery. This is typically best done under the supervision of a physiotherapist. The orthopaedic surgeon assessed the MCL injury as stable; therefore, physio could commence immediately. A referral to his local physio was arranged.
The patient was immediately referred to the public hospital system for treatment as they did not have health insurance and chose not to self-fund surgery. They were seen in the Access Clinic on two further occasions to check their progress in regaining strength and movement in the knee and to ensure no other complications developed while waiting for their public hospital appointment.
The patient was in the clinic approximately 12 months later with their wife as she had an injury. He was pleased to let us know they had undergone surgery and were making excellent progress with their postoperative rehabilitation. Thankfully, his wife’s injury was minor and did not require surgery!
IMPORTANT TO NOTE:
Following an ACL tear, there is no urgency to have surgery. Early physiotherapy puts patients in the best position to undergo and recover from surgery. It often takes 6-8 weeks of physio to regain strength and knee movement after an ACL injury.
It is also important to note that just because a patient has an ACL tear, they do not always automatically need surgery. The ACL is important for twisting and turning at speed. Some patients who do not undertake these activities may not ever need surgery as they may find that following rehabilitation, they have a knee that is stable enough for all the activities they wish to undertake. Many patients even play moderate levels of sport after an ACL tear and no surgery, without difficulty, provided they have regained the strength and movement in their knee.
Patients who cannot trust their knee for their daily activities even after they regain strength and movement usually benefit from surgery. The higher the level of sports a patient is involved in, the more likely they are to undergo an ACL reconstruction because, typically, the knee will continue to give way, accumulating damage.