eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Anterior Cruciate Ligament Injury: Treatment & Medication

Author: Tarek Souryal, MD, Head Team Physician, Dallas Mavericks; Former Chief, Department of Surgery, Division of Orthopedic Surgery, Las Colinas Medical Center; Clinical Professor, Departments of Orthopedic Surgery and Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center
Coauthor(s): Kenneth Adams, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Texas Southwestern
Contributor Information and Disclosures

Updated: Jan 2, 2009

Treatment

Rehabilitation Program

Physical Therapy

The key to successful treatment of an anterior cruciate ligament (ACL) tear is proper and early rehabilitation. Preoperative and postoperative rehabilitation programs are similar initially. Swelling control and restoration of motion and strength are the goals of each.

The postoperative rehabilitation program begins as soon as the patient awakens from anesthesia, especially because patients are discharged earlier now than they were in previous years. Quadriceps co-contractions make up the first exercise that patients should be taught for the maintenance of terminal extension.

Passive motion is emphasized with active flexion and assisted extension in the sitting or prone position to ensure good leg control (ie, ability to flex the hip and lift the leg against gravity without assistance.) A continuous passive motion machine (CPM) can be used to establish 0-30° of motion immediately postoperatively and to progress to 60° of knee flexion by the morning following the operation. The patient then begins gait training with crutches (weight bearing as tolerated), with the knee in an immobilizer. The patient usually can be discharged on the first postoperative day and should be encouraged to avoid crowds, keep the leg elevated when not ambulating, use the crutches at all times for protection, and continue frequent icing.

A number of different programs are used by different physical therapists. The therapy program chosen depends on the activity level of the patient and the type of surgery performed, coexistent injuries (meniscal or other ligamentous injury), the surgeon, the insurance policy, and time constraints.

Goal-oriented rehabilitation for patellar tendon grafts
The following rehabilitation program is an accelerated program for patellar tendon grafts. Note that the other grafts rehabilitate slightly differently. This rehabilitation program is classified as a goal-oriented approach. The dates listed are not meant to be followed strictly and can be varied by a day or 2, depending on the physician or the patient's schedule.

On day 3 following surgery, have the patient return to the surgeon for evaluation. Begin therapy on an outpatient basis, concentrating on gait training and other ambulation-oriented activities. The goal is to maintain terminal knee extension and progression toward 90° of flexion. The therapist emphasizes a normal heel-to-toe gait pattern, and the patient may weight bear as tolerated on the involved leg. Continue passive flexion ROM exercises. Have the patient increase quadriceps activity, introducing the partial squat with progression from bilateral to unilateral, placing increased body weight on the extremity involved at no more than 45° of flexion. Continue these exercises for 1 week. Continue the knee immobilizer when ambulating and continue regular icing of the knee.

On day 10 following surgery, have the patient return to the surgeon for evaluation. Advance therapy to include wall slide-squats and a stationary bike as tolerated. Place emphasis on terminal extension, progressive flexion, and full weight-bearing ambulation with normal heel-to-toe mechanics. In a controlled environment (no pets, children, or distractions), have the patient begin practicing crutch ambulation while out of the knee immobilizer. The patient should achieve full terminal knee extension and approximately 90-100° of knee flexion.

Three to 4 weeks after the surgery, the aggressive patient is ambulating with normal gait mechanics. At this point, the knee immobilizer can be removed. Advance the patient's activity to include loaded squats, swimming, eccentric quadriceps strengthening, bridging with a physioball, and a stair stepper. During this time, if the therapist is not observant, the patient can develop tendonitis of the quadriceps tendon or other repetitive use injuries of the lower extremity. Application of ice after each therapy session is very important.

Six weeks after surgery, release the patient to light jogging or bicycling. If the patient is older and has concomitant degenerative joint disease, encourage bicycling. The graft is still very weak at this stage, so advise the patient that it is important not to fall. The patient should jog only on a track or other flat protected surface. At this point, active ROM should be approaching 0-125° with minimal or no joint effusion. Work on balance and proprioception with activity drills.

At 3 months, recommend that the patient begin a gradual return to normal activities. At this point, most people do not require bracing, but occasionally, some athletes request a brace to increase their own comfort level when competing.

Open kinetic chain (OKC) and closed kinetic chain (CKC) exercises

Significant discussion surrounds the difference between OKC and CKC exercises during ACL rehabilitation. The difference concerns the assumption that CKC exercises are safer than OKC exercises because they place less strain on the ACL graft, producing less patellofemoral pain. The second assumption is that CKC exercises are more functional and are equally effective in improving quadriceps muscle force production.

A study by Beynnon and colleagues showed no difference in ACL strain characteristics between OKC and CKC exercises.12,13 A report by Fleming and coauthors argues that, with improved anatomical placement of the ACL graft, the graft may respond more like the intact ACL during OKC and CKC exercises. Therefore, these 2 articles argue that both types of exercise can be performed safely.

With regard to safety, OKC and CKC exercises can be applied in a manner that minimizes the risk of excessive graft strain and patellofemoral compression. Using different knee joint motion excursions for each type of exercise is the key to risk reduction. When OKC knee extensions are performed, limit knee joint motion to more flexed positions. During CKC lower extremity exercises, limit knee joint motions to more extended positions.

Nonoperative treatment

Patients may for a variety of reasons— if, for example, they are not highly active or athletic or are minimally symptomatic —opt for nonoperative treatment. In these cases, after initial control of pain and effusion, start hamstring and quadriceps activation/disinhibition and protected weight bearing in a hinged brace. As swelling and pain slowly resolve, ROM should return to normal, or nearly normal, parameters. Start exercises that take place in an anterior/posterior plane (eg, stationary cycling). Exercises need to be nonballistic.

Medical Issues/Complications

  • The primary goals in the treatment of anterior cruciate ligament (ACL) rupture are restoration of function in the short term and the prevention of long-term pathologic changes in the knee. Nonoperative treatment is a reasonable approach in patients who are not athletically active.
  • Research has demonstrated that the natural history of untreated complete injuries of the ACL consists of the progression of symptomatic instability to recurrent injuries. These injuries damage the menisci and the articular cartilage, eventually leading to osteoarthritis and osteoarthrosis.14
  • Complications from ACL surgery generally arise during surgery (see Allograft Reconstruction, ACL-Deficient Knee). Complications include the following:
    • Extravasation of irrigation fluid during arthroscopy
    • Posterior femoral cortex compromise during endoscopic reaming of the femoral tunnel
    • Paresthesias along the lateral aspect of the knee
    • Improper handling of the graft (eg, dropping it on the floor)
    • Bruising and/or hematoma formation
    • Blood loss
    • Improper alignment of the tunnels, causing graft impingement
    • Improper graft placement, making the graft too short and thus not allowing the knee to reach full terminal extension
  • The main complication of ACL surgery during the postoperative period is rupture of the graft. Careful and conservative physical therapy (PT) during the first 8-12 weeks is important (see Physical Therapy).
  • Another complication that can develop after surgery is failure to achieve full knee extension (see Physical Therapy).

Surgical Intervention

Several options exist for the patient who elects to have surgery. For complete rupture, no local healing response is detectable at the injury site, and a graft must be used to replace the ACL.15 Today, 4 options are used. The first 3 types are autografts using the central one third of the patellar ligament (considered a bone-ligament-bone graft), the quadruple semitendinosus/gracilis tendon, or the quadriceps tendon.16,17 The fourth type of graft is a cadaveric allograft.

  • Autografts
    • The patellar ligament with its bony ends has been a popular ACL replacement because of its high ultimate tensile load (~2300 N), its stiffness (~620 N/mm), and the possibility for rigid fixation with its attached bone graft.
    • By comparison, the dimensions of a round, 10 mm quadruple semitendinosus/gracilis tendon graft (hamstring graft) are more comparable to those of the intact ACL, and its ultimate tensile load has been reported to be as high as 4108 N. The quadruple tendon graft also may provide a multiple bundle replacement graft that better approximates the function of the 2-bundle ACL. Disadvantages of this soft-tissue graft include concern over tendon healing within the osseous tunnels and a lack of rigid bony fixation. A 1998 study from Japan suggests that aggressive early rehabilitation after an ACL reconstruction using the hamstring graft has more risk for residual laxity than does the patellar tendon graft.18
    • The quadriceps tendon graft has been shown to have an ultimate tensile load of as high as 2352 N. This graft has become an alternative replacement graft, especially for revision ACL surgeries and for patients with multiple ligament injuries in the knee.
    • Cadaver studies have shown that the strength of fixation between the patellar tendon graft and the hamstring graft is equal to approximately 450 N, but the patellar graft can achieve fixation strength of as high as 1000 N. Grafts fixed to bone close to the articular surface (ie, patellar tendon grafts) undergo less strain and are stiffer than are those grafts fixed outside of drill holes (ie, hamstring grafts).
  • Allograft
    • Allograft tissues are harvested from human donors and typically include either the patellar tendon or the Achilles tendon.
    • Allografts are used for multiple ligament reconstructions and revisions of ligament reconstructions, as well as for the treatment of patients who are not high-performance athletes. However, the reduction of tensile strength that occurs with sterilization is a concern, as is the risk of inflammatory reactions.

Ultimately, the decision as to which graft is best is still a matter of contention. The agreement is that the patellar and hamstring grafts are superior to the quadriceps graft and the allograft; however, the decision as to which is the better of the patellar and hamstring grafts depends on which surgeon is operating.

With regard to osteoarthritis, the type of graft does not appear to influence the development of osteoarthritis. In spite of the type of graft, a certain percentage of patients develop osteoarthritis in the reconstructed knee, especially patients with concomitant or subsequent meniscectomy.

Consultations

In anterior cruciate ligament injury cases, presurgical consultations with other services generally are needed only in connection with surgical clearance. After surgery, it is important to consult with a specialist in physical medicine and rehabilitation (PMR) for initiation of a program to facilitate the patient's rehabilitation.

Other Treatment

Some patients, especially those who are minimally involved in sports, elect not to have surgery and instead choose bracing. Several custom and off-the-shelf, anterior cruciate ligament–specific braces are available. For patients who are involved in vigorous sports, the use of braces without surgical stabilization is not recommended.

Medication

The goal of pharmacotherapy is to reduce morbidity.

Nonsteroidal anti-inflammatory drugs

These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.


Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Adult

600-800 mg PO tid

Pediatric

Not established

Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Narcotics

Pain control is essential to quality patient care. If nonsteroidal anti-inflammatory drugs (NSAIDs) are not sufficient, then narcotics may be given. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial to patients who have sustained trauma or injuries.


Acetaminophen and codeine (Tylenol #3)

Indicated for the treatment of mild to moderate pain.

Adult

1-2 tab PO q4-6h prn

Pediatric

Not established

Toxicity increases with CNS depressants or tricyclic antidepressants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients dependent on opiates, since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

COX-2 inhibitors

These drugs can be used as an alternative if the patient has GI upset or a history of GI bleeding with NSAID use. Because of the cost, these medications are not always a first-line choice.


Celecoxib (Celebrex)

Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, being induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.

Adult

200 mg/d PO qd; alternatively, 100 mg PO bid

Pediatric

Not established

Coadministration with fluconazole may cause increase in plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, and conditions predisposing to fluid retention; severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction or in abnormal liver lab results

More on Anterior Cruciate Ligament Injury

Overview: Anterior Cruciate Ligament Injury
Differential Diagnoses & Workup: Anterior Cruciate Ligament Injury
Treatment & Medication: Anterior Cruciate Ligament Injury
Follow-up: Anterior Cruciate Ligament Injury
References
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Further Reading

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Keywords

anterior cruciate ligament injury, ligament, knee surgery, ligaments, knee injury, knee injuries, torn ACL, ACL injury, ACL reconstruction, torn ligament, knee ligaments, anterior cruciate ligament, anterior cruciate, ligament tear, ACL tear, anteromedial bundle, posterolateral bundle, hemarthrosis, Segond fracture

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Contributor Information and Disclosures

Author

Tarek Souryal, MD, Head Team Physician, Dallas Mavericks; Former Chief, Department of Surgery, Division of Orthopedic Surgery, Las Colinas Medical Center; Clinical Professor, Departments of Orthopedic Surgery and Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center
Tarek Souryal, MD is a member of the following medical societies: American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Kenneth Adams, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Texas Southwestern
Kenneth Adams, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine
Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, Physiatric Association of Spine, Sports and Occupational Rehabilitation, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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