11 Responses

  1. Dan
    Dan July 27, 2012 at 2:44 PM |

    Good stuff man. I believe most athletes injure their ACL during wrestling practice, because it’s quite the strain on your knees.

    Reply
    1. fightmedicine
      fightmedicine July 27, 2012 at 3:33 PM |

      Thanks for adding your comment, Dan. Hopefully this starts up one of many future conversations on here.
      As far as when you injure your ACL, you can divide it into traumatic vs atraumatic events. The traumatic events are similar to when a football players dives at someone and hits there knee from the outside. The other is when you plant your foot and the your knee and body twist away from it like when you are skiing and you get a ski caught in the snow.
      Because the ACL runs from the femur to the tibia at an angle, usually there needs to be some sort of twisting motion to cause the ACL to rupture.
      This certainly can happen during wrestling or grappling, but usually it would have to involve some sort of twisting motion on the knee. Whether this is more likely to happen during grappling where someone can grab your leg or when you are setting up a kick and planting your foot is hard for me to say.

      Reply
      1. Brian
        Brian July 27, 2012 at 10:23 PM |

        Great article and very timely for me; as luck would have it, I torn my ACL sparring Muay Thai two weeks ago. I am having conversations with my ortho surgeon right now to determine the best course of action – he is strongly recommending a patellar tendon replacement, as his belief is that up to 40% of allografts eventually fail.

        Reply
  2. Brian
    Brian July 27, 2012 at 10:25 PM |

    Forgot to add – my ACL tore when I low kicked my opponent. It was my pivot knee that went, the kick landed cleanly, but when it landed my pivot knee must have torqued from the sudden weight transfer and the ACL pulled completely off my femur (according to the MRI). Again, great post and I look forward to reading more from you!

    Reply
    1. fightmedicine
      fightmedicine July 27, 2012 at 10:30 PM |

      Hi, Brian.
      Thanks for the compliment and getting involved with a question/comment.
      It sounds like your mechanism is pretty standard for the non-contact ACL tear. Its usually a twisting motion where the foot is planted and the knee/body twists like a skier getting his ski caught. The other is a traumatic way like a football player hitting the outside of another player’s knee.
      As far as graft selection, its something you and your surgeon need to discuss and hopefully this article gave you some insight. Each surgeon has his or her own ideas and also how and where they trained may affect what kind of graft they choose. A surgeon may not feel comfortable doing a different type of graft.
      He is right to think that allografts don’t do as well as autografts (your own tissue). Your own tissue integrates better.
      However, there are other allograft options like hamstrings which avoid the knee pain from Patellar tendon aka bone-tendon-bone aka BTB.
      If your muy thai activities represent a concern about graft choice, make sure to have a thorough discussion with your doctor, seek a second opinion if necessary, and find a doctor that is comfortable with you and you are comfortable with him.

      Reply
  3. Kmillionaire
    Kmillionaire July 27, 2012 at 11:04 PM |

    What precautions should I take during training to avoid tearing my ACL a third time? This first time I tore my ACL, I used an allograft for reconstruction. The second time, I used my hamstrings. I completed physical therapy and am now back in thr gym doing strength training and some boxing drills.

    Reply
    1. fightmedicine
      fightmedicine July 28, 2012 at 12:14 AM |

      Thanks for your question.
      Preventing ACL injuries is difficult. Most pro athletes focus on plyometric training because keeping good form during sports training helps prevent non-contact ruptures. These kind of drills help you keep your knee in a good spot unconsciously during sports.
      There is some thought that since the hamstrings are on the back of the knee they pull the tibia backwards which helps prevent the tibia from moving forward and stressing the ACL. Keeping the muscles around the knee like the hamstrings and quads strong help keep the bones aligned which helps protect the ligaments. Sudden twisting motions where your foot is planted can stress the ACL. Doing quality strength exercises (not powerlifting) and plyometrics can help train your body to uncosciously keep everything where it is supposed to be when you land from jumping or other sudden movements in sports.
      I hope that helps!
      @Fightmedicine

      Reply
  4. TheFilt
    TheFilt July 28, 2012 at 2:20 PM |

    I started training muay thai and submission wrestling about 1 year ago. I’ve been an athlete my entire adolescence and adult life and currently own my own personal training business.

    Last week, I had my left ACL replaced by one of the best sports medicine facilities in Oregon.

    Most of what you said is pretty much correct but not necessarily set in stone. Overall, a good article but there are some key things you left out or kinda generalized.

    I’m still on a lot of meds so bear with me:

    1. The patellar graft is no longer the most used. The hamstring graft is used just as often, if not more, in athletes.

    2. An allograft is not an option for a young person or athlete. No surgeon would use only cadaver tissue in that circumstance. If the portion of patellar tendon or hamstring is not thick enough(around 9mm), they attach a small strip of cadaver tissue.

    3. The choice of graft is based more on the skill level of the surgeon. For example, if he is better at hamstring grafts vs patellar grafts, the go with the hamstring graft.

    4. For anyone with the hamstring graft, strengthening the quad is first. Along with the glutes. The VMO(vastus medialis oblique) actually fires first in the chain so it must be rehabbed first.

    5. The attachment point can vary from just inserting the new ‘ACL’ into a deep tunnel in the the bone to attaching it to screws.

    6. For ACL reconstruction alone, a brace usually isn’t necessary and you should be walking fine in a couple weeks to a month.

    This is all from my surgeon, his team and my physical therapists.

    Overall, good job laying it all out. Just wanted to add a bit.

    Reply
    1. fightmedicine
      fightmedicine July 28, 2012 at 8:26 PM |

      Thanks for your interesting comment. Its always welcome to hear what patients have to say, as this website is to promote conversations across the board from doctors to fighters to fans and in-between.
      I agree that I had to shorten some topics for the sake of brevity. However, much of the literature in orthopedics is controversial and not definitive. Here are some responses to your comments (your questions are italicized):

      1. The patellar graft is no longer the most used. The hamstring graft is used just as often, if not more, in athletes.

      Graft selection is and likely always will be one of the most debated topics in ACL reconstruction. The Patellar (or BTB) graft is considered the “gold standard” that all other graft outcomes are measured against. That being said, hamstring grafts are certainly making a comeback. The most recent articles on this show different results, which sheds some light on the variations regionally and nationally.

      In a February 2012 article in the American Journal of Sports Medicine (AJSM), the Kaiser Permanente health system looked at ACL graft selection in their hospital’s patients from 2005-2010. Of the 9849 patients included in the study, 2796 (28.4%) received BTB autografts, 3013 (30.6%) received hamstring autografts, and 4040 (41.0%) received allografts. Older and female patients with lower BMI (body-mass index) were more likely to receive allografts and hamstring autografts than BTB autografts. Cases performed by non-fellowship-trained surgeons, lower volume sites, and/or lower volume surgeons were also more likely to be performed with allografts or hamstring autografts than BTB autografts.

      In 2010, the Journal of Knee Surgery published the results of a 2006 national survey. A total of 993 responses were received. BTB autograft was most commonly preferred (46%), followed by hamstring tendon autograft (32%) and allografts (22%). Five years earlier, BTB grafts were even more frequently chosen and hamstring tendon and allografts were less frequent (63%, 25%, and 12%, respectively).

      As you can see, the most appropriate type of graft for any given patient population continues to be a debated topic in the orthopedic community. In fact, several systematic literature reviews and meta-analyses beyond these two studies have been published and no definitive conclusions reached.

      As far as performance in athletes or other high-demand patients, the literature is also variable from year to year, but it still seems that autografts do better than allografts because autografts are your own tissue.

      In a recent 2012 article in AJSM, a total of 120 cadets underwent 122 ACL reconstructions (2 bilateral) before matriculation into the United States Military Academy. A total of 20 failures occurred. Of the failures requiring revision, 7 were BTB (11% of all BTB), 7 were allograft (44% of all allograft), and 6 were hamstring (13% of all hamstring). There was no significant difference in the graft failure between the BTB and hamstring autograft groups. In contrast, those who entered the academy with an allograft were 7.7 times more likely to experience a subsequent graft failure.

      A 2011 AJSM article using a University of Mississippi database determined that hamstrings autograft and allografts had a significantly higher failure rate in the age group of patients 25 years and younger compared with the bone-patellar tendon-bone autograft. These data suggest that BTB autografts may be a better graft source for young, active individuals.

      The literature goes back and forth on this all the time, so it comes down to surgeon preference and a discussion with the patient on the risks and benefits of each type of graft.

      2. An allograft is not an option for a young person or athlete. No surgeon would use only cadaver tissue in that circumstance. If the portion of patellar tendon or hamstring is not thick enough(around 9mm), they attach a small strip of cadaver tissue.

      An allograft certainly is an option in a younger person or athlete. If the patient has any religious objections or other objection to using cadaver tissue in their body, the surgeon must honor that request. If the patient is older than 35, chances are the cadaver tissue is better than theirs since the donors tend to be younger males. If pain or lack of physical therapy is a concern, the surgeon may opt for an allograft to reduce post-operative pain in the patient as the harvest of the graft is the most painful portion of the procedure. That being said, in a younger, active patient, the surgeon would prefer an autograft but there are still plenty of valid reasons to use an allograft if necessary.

      3. The choice of graft is based more on the skill level of the surgeon. For example, if he is better at hamstring grafts vs patellar grafts, they go with the hamstring graft.

      This is true, but less about “skill level” and more about comfort level and where and with whom they trained.

      4. For anyone with the hamstring graft, strengthening the quad is first. Along with the glutes. The VMO(vastus medialis oblique) actually fires first in the chain so it must be rehabbed first.

      As far as physical therapy goes, protocols vary widely, but some things are for certain. When strengthening exercises begin, “closed-chain” exercises are performed first because they put less stress on the knee joint and repaired ligament. A closed-chain exercise is an exercise in which the extremity stays planted the entire time, such as a leg press machine. ; this is in contrast to the later “open-chain” exercises in which the limb is out in space such as a leg extension machine.
      The thoughts on strengthening hamstrings after ACL reconstruction is that they help pull the tibia posteriorly, or backward, and thus take stress of the ACL graft which is stressed when the tibia moves anteriorly, or forward. Quadriceps also must be strengthened, as they become weak after the injury and are the weakest post-operatively.

      5. The attachment point can vary from just inserting the new ‘ACL’ into a deep tunnel in the bone to attaching it to screws.

      This is a very complex issue. The area of insertion of the ACL, or footprint on the tibia has been debated. For a long time, it was measured 7mm from the back of the tibia. Today, most people use the posterior edge of the anterior horn of the lateral meniscus as their guide.

      As far as where on the femur the tunnel is drilled varies with surgeon and technique. Originally, the tunnel in the femur was drilled through the same tunnel in the tibia and thus a more “vertical” graft angle was created. Several antomic studies have shown that the ACL actually lies low on the femur and thus the technique of creating a low femoral tunnel through a separate skin inciscion was created to match the more “anatomic” graft angle.

      6. For ACL reconstruction alone, a brace usually isn’t necessary and you should be walking fine in a couple weeks to a month.

      Brace usage varies with surgeon preference and whether you receive a regional nerve block. Some surgeons don’t use a brace at all, others use a brace until your quads are strong enough to perform a straight leg raise, others keep it on for a month or 6 weeks; some lock the brace, some leave it hinges, and then there is everyone in-between.

      Again, thank you for your comments. It most certainly improves the discussion.
      Feel free to post more comments or ask questions at fightmedicine.net
      You can also follow me on Twitter @FightMedicine

      Reply
      1. TheFilt
        TheFilt July 29, 2012 at 6:04 AM |

        Thanks for the reply. It’s always good to get more info from a doctor.

        1. Very interesting data. Inconclusive, but interesting.

        2. I should have said an allograft is the very last resort for a young athlete. What are some reasons a young athlete could need one?

        3. Yes, ‘comfort level’ would have been a better word.

        4. I’m still in the closed-chain/isometric stage of rehab. My therapist is doing things differently, but I appreciate your insight.

        Thank you for all the info regarding the attachment point, too.

        To give you a little background on my particular injury:

        I tore my ACL 5 years ago. In that time, I’ve regained most of the strength and stability on my own. My hams, quads and glutes became my ‘ACL’. I learned to punch, kick, wrestle, run and jump without it. I could actually grab the rim from a standing jump at 5’9″ before surgery. I had my ACL replaced and my lateral meniscus repaired on Wednesday, so now I’m starting all over.

        I know I’ll be back training harder than ever in a year. I’ll let you know how it goes.

        Reply
  5. TheFilt
    TheFilt July 28, 2012 at 2:29 PM |

    Also-

    The level of strength that you lose/regain is GREATLY influenced by PT and how much time and effort you put in.

    Again, great job laying out all this info in a way people can understand.

    Reply

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