Disruption of the ACL is one of the most common and debilitating injuries of the knee. The ACL functions to stabilize the knee while running and changing direction and during deceleration. It attaches inferiorly to the anterior aspect of the tibial spine and superiorly to the posterior part of the medial surface of the lateral femoral condyle.
6 A classic history of ACL tear includes hyperextension with rotation of the knee, usually during deceleration and with an audible pop and immediate swelling of the knee.
Injury to the ACL may lead to abnormal knee mechanics and possibly functional instability, especially during cutting and pivoting movements.
7 Because this type of injury is common, several surgical techniques have been developed to repair a damaged ACL.
8–9 In some cases, the patellar tendon, semitendinosis units, or iliotibial band may be used as an augmentation graft.
8 In other cases, an allograft may be used, or a torn ACL may be sutured.
8 The type of surgical technique selected is dependent on various factors, including the patient's age, activity level, and occupation, as well as the surgeon's preference. Surgery can restore the passive stability of the knee, and subsequent rehabilitation can restore the knee's functional stability.
9
The rehabilitation protocol for patients with ACL continues to evolve. Patients can return to full weight-bearing capability more quickly today than the standard protocols called for 10 years ago. The goal of any rehabilitation program should be the rapid return of the patient to complete preinjury strength and performance.
To optimize the rehabilitation program of the patient in the present case, osteopathic principles were applied to case management. One of these principles is that the body is a unit; another is that structure and function are interrelated.
3 George W. Northup, DO,
10 wrote, The proper function of any one joint area is dependent to a greater or lesser degree upon the proper function of the total musculoskeletal system. One cannot just “treat” a painful knee without considering the totality and interrelationship of body parts and physiologic systems.
Therefore, the physician must consider the knee; the surrounding ligaments, cartilage, and musculature; and the feet, fibula, patella, spine, and hip when treating a patient with a damaged ACL.
Northup
10 added, It is almost axiomatic that the knee joint is never in trouble by itself. If the pelvic and spinal structures are not involved in the initial stress, they most certainly are by the time the patient reaches the doctor. Commonly lesions are found in the low-back area and in particular around the second lumbar level.
Northup
10 also noted that lesions of the calcaneus, cuboid, and talus are common with knee injuries. Strachan
11 reported a reflex type of spinal muscle tension near L2 when the knee joint was irritated.
There are multiple sequelae that may occur after reconstructive surgery as the patient progresses through the post-operative period. These sequelae include changes in gait, posture, and weight-bearing capability. In addition, the patient may experience compensatory structural changes resulting from the injury.
With all of these changes in motor performance, somatic dysfunction is likely to result. Such dysfunction represents an impediment to the healing process. Dysfunction as represented by limited mobility and tension of muscular and myofascial components is known to decrease blood flow to, and lymph flow from, the healing area.
12 Additional physical stress to the healing area may result from the alteration of gait.
Management of the somatic dysfunction can reduce these impediments and optimize the rehabilitation process, returning the patient to levels of preinjury functioning and strength. In the present case, OMT led to increasingly stable mobility. This was a noteworthy result, especially considering the large area of preexisting dysfunctions in the patient's lumbopelvic region. Furthermore, the physical stresses that followed surgery were immediately accessible and readily resolved. These improvements made it possible for the patient to return to his regular sports activities 6 months after surgery.