Football season is upon us. Two-a-days. Ankle Taping. Water Jugs. Helmets. Pads. Whistles. Sweat. Turf. The list goes on and on. I’ve written before about being a trainer in high school and how that sent me to where I am now. But August….August meant football practice. It’s one thing to be out there in pads practicing and getting ready for the Game. It’s a whole other to sit there on the sidelines watching the practice. That was what I did. Waiting for something to happen. Watching for someone to overheat. Waiting on an immanent injury. We knee it was coming. Someone was gonna go down. We just didn’t know when: would it be a game? Would it be practice? Two things pop into my mind: shoulder and knee injuries. At the shoulder: the acromio-clavicular joint will become separated if hit just right. Today we talk about the knee. Most have heard of the ACL even if they don’t know what it does.

The ACL is the anterior cruciate ligament. The phrase “ACL” rolls off the tongue easy for announcers of college and professional sports. They turned it into the celebrity it is now. You can hear the announcers and color commentators now if you listen:

“Oh Bob, someone’s down on the play.”

“Yeah Frank. It’s Smith. He’s not getting up. He’s holding his knee.”

“Gee Bob, you think it’s his ACL?”

You’re likely to hear that conversation weekly somewhere on televised football this fall. I will say that if it wasn’t for football and the popularity of the sport, ACL injuries wouldn’t be as researched or repaired and rehabilitated as easily. Money, even in medicine and research, follows glamour.

The ACL is one of 4 major ligaments at the knee joint. If you were to pull the skin back from the knee, pull back the muscles, and look just at the structure of the knee, you’d see the femur (the thigh bone), the patella (kneecap) sitting on top of the groove at the bottom of the femur, and the tibia (the leg bone). The knee is held together by ligaments on either side of the knee. Ligaments connect bone to bone and provide stability to a joint. They don’t move like muscle. The lateral collateral ligament connects the outside (away from midline of the body) of the femur to the outside of the tibia. The medial collateral ligament connects the medial (towards the midline of the body) side of the knee together (femur to tibia). The ACL (anterior cruciate ligament) and the PCL (posterior cruciate ligament) cross each other inside the knee joint between the joint surfaces of the tibia and femur. There’s cartilage in there also, but that’s another story.

The ACL’s function is best described in that it keeps the tibia (the leg bone) from slipping forward on the femur (the thigh bone). What I mean by that is if you were to walk downhill, the tibia would want to shift forward. The ACL’s job is to hold it back and prevent that slippage. There are other things it does, but this implies a good description. It also helps prevent this same slippage when you stop running.

Knee braces provide some stability as does strengthening, but if one were to take a hit just right that ACL will pop in-two. There are a few tests that can be done on site to test the integrity of the ligament and many times they work. However, many times they don’t give the truest picture of what’s happening inside the knee. I tell my clients that I don’t have x-ray vision; the only way to know for sure is an MRI.

If an ACL is torn, what then? Surgery? Well, maybe. Not necessarily though. A fellow in the Salt Lake City Winter Olympics was a competitive ski-jumper and tore his ACL 2-3 months prior to the games. No surgery. He still won the gold.

As a therapist, I’ve patched someone back up and rehabbed the client back to the point that he was playing football with a torn ACL while wearing a brace. He had full strength, full speed, and had good control of his leg. That’s not to say that it didn’t hurt. But that client was able to finish his senior year playing football. He had the repair done just days after completing the football season.

The over-under is this: if you plan on getting back to being competitive and playing sports, you’ll probably need the ACL repaired. If you’re active sporting days are over, you might elect not to have the surgery and just rehab it. That’s fine. Physical therapy can make excellent in-roads on that goal as well.

I do recommend this: prehab. When possible, delay the surgery for a month or maybe 2-3 months and do pre-rehabilitation on the knee. The better that knee moves before surgery, the stronger that knee is before surgery, they better the knee does after surgery. Give a physical therapist 4-6 weeks before an ACL surgery and you’ll be running and jumping again.

ACL rehab after surgery starts with getting the quadriceps strong and getting the knee outstretched. Most people worry about how much bend they get in their knee. Overall, the bend is going to come. But the longer it takes to get the knee straight, the harder it becomes to get the knee totally straight. If the knee doesn’t get straight, that’s when you get a limp.

As weight bearing is allowed (that is somewhat physician dependent) the exercises get more and more functional and mimic real life activity. Don’t get in a hurry to run after surgery, depending on your doctor you probably won’t be able to do this until 8-12 weeks after surgery. The ACL repair simply isn’t strong enough to support running until at least 6 weeks after surgery.

When the time comes the therapist begins some return to sport activities to return a client to their function. Rehab-wise, ACL’s are fun for the therapists because they get to assign a lot of exercises that don’t normally get to be done by other clients. ACL surgeries, in my experience, do well in physical therapy for a variety of reasons, but chief among them: those that have an ACL repair tend to be in good shape or athletic to begin with. Those that have an ACL repair can usually expect to return fully to their sport, although it may take 8-12 months to get back. You’re limited by the speed of healing and determination.