Curovate

A blog about everything related to physical therapy, rehabilitation, ACL injury, ACL surgery and recovery!

More than ACL rehabilitation. Any questions?

Since I started this blog on December 11th, 2016 with my first blog about how to use crutches I have been focused on ACL rehabilitation. This made sense since I have helped to create an app for ACL injuries! For 3 reasons the blog will now include more than just ACL topics: 1. My patients and our blog users have been asking questions about things related to physical therapy and rehabilitation for other injuries, 2. I work with patients who have other injuries, 3. the excellent blog contributors I work with (Alenna, Nicole, Prateek, Tashkin) have expertise in a variety of areas besides ACL injuries.

This blog will still include information about ACL injuries but it will also include information about rehabilitation for other injuries.

I am now asking anyone who has a question related to physical therapy, rehabilitation or injury to email me (meetcura@gmail.com) with your question. If it is a really good questions that could help others we will answer the question in a future blog and publish your name! On the other hand if you are a physical therapist or an expert in the area of injury prevention or rehabilitation and you wish to contribute to our blog please email us (meetcura@gmail.com) and let us know what you wish to blog about.

Do knee braces work? What does the research say?

What is a knee brace?

Knee braces are external devices which can be soft or rigid and are prescribed by some healthcare providers after knee injury or surgery. In this blog I will focus on knee braces prescribed after an anterior cruciate ligament (ACL) surgery.

How is a knee brace used? Are there any issues with bracing?

Knee braces are recommended by some healthcare providers for one to two months after an Anterior Cruciate Ligament (ACL) surgery1. According to a survey done on American Orthopaedic surgeons, 63% report prescribing functional bracing after ACL surgery. Additionally, 71% of them prescribe these braces for up to 1 year after surgery2.

What are the different types of braces for the knee?

There are two kinds of braces used after ACL surgery:

  1. Functional knee braces - are worn after an ACL surgery to reduce improper knee movements such as excessive rotation, sliding side to side or front to back (translation) and the knee caving inwards.3 They are designed to substitute for damaged ligaments and are often prescribed for people who have torn their ACL and are not planning to get surgery.4

  2. Prophylactic knee braces - are designed to protect people from sustaining a knee injury without causing limitations in knee movement.5

What does research say?

Researchers found that people under the age of 30 experience muscle weakness with long term use of braces (1 to 2 years), compared to short term uses (3 months).6

Prophylactic Knee brace Functional Knee brace
1. There was no significant difference found among 31 healthy college athletes in single leg vertical jump, cross-over hop, and average power between wearing a prophylactic brace and not wearing a brace. Average power output was measured using isokinetic testing. Isokinetic testing involves a piece of equipment that allows the knee to be resistance tested while the person bends and straightens their knee at a specific speed. The speeds used were 60, 180 and 300 degrees per second.5 1. Researchers found a substantial reduction in quadriceps muscle (muscles at the front of your thigh) strength with long term use (1-2 years). There were no differences in the amount of knee movement (range of motion) and a persons awareness of their knee position (proprioception). Researchers did find wearing a brace improved knee stability by reducing excessive lower leg rotation and translation, as well as decreasing excessive knee bending or straightening. This study was a literature search of 15 research articles using PubMed and Embase databases to compare functional bracing to no bracing 3 months after ACL reconstruction.3
2. There are no significant differences in the amount of pressure and force on the knee between wearing a prophylactic brace or not. But wearing the brace significantly reduced rotation (inward and outward rotation) of the knee. For example, lower leg rotation reduced from 19.76 degrees to 15.91 degrees, when wearing the brace. Additionally, participants found that wearing the brace gave them a sense of stability while running. This study tested 20 female netball university athletes (20 years old) who were asked to do running, jumping and cutting movements on a force plate in a lab.7 2. 100 patients, all with a torn ACL, underwent a Bone-Patellar-Bone ACL reconstruction and were randomized into a braced and non-braced group. They were followed for 12 months. Patients in the unbraced group returned to work 1.84 months after surgery, compared to 2.28 months in the braced group. Additionally, 96% of the unbraced patients said they have no difficulty in climbing stairs compared to 93% of patients who used a functional brace.8


Do you need some more information and assistance after your ACL injury? Check out our ACL app!

References

  1. Hiemstra, L. A., Veale, K., & Sasyniuk, T. (2006). Knee immobilization in the immediate post-operative period following ACL reconstruction: A survey of practice patterns of canadian orthopedic surgeons. Clinical Journal of Sport Medicine, 16(3), 199-202.

  2. Marx, R. G., Jones, E. C., Angel, M., Wickiewicz, T. L., & Warren, R. F. (2003). Beliefs and attitudes of members of the american academy of orthopaedic surgeons regarding the treatment of anterior cruciate ligament injury. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 19(7), 762-770

  3. Lowe, W. R., Warth, R. J., Davis, E. P., & Bailey, L. (2017). Functional bracing after anterior cruciate ligament reconstruction: A systematic review. Journal of the American Academy of Orthopaedic Surgeons, 25(3), 239-249.

  4. Cluet, J. (2017). Types of Knee Braces for Support and Injury Prevention. VeryWell.

  5. Mortaza, N., Ebrahimi, I., Ali, A. J., Abdollah, V., Kamali, M., Wan Abu Bakar, W. A., & Noor Azuan, A. O. (2012). The effects of a prophylactic knee brace and two neoprene knee sleeves on the performance of healthy athletes: A crossover randomized controlled trial. PLoS One, 7(11), e50110.

  6. Risberg, M. A., Beynnon, B. D., Peura, G. D., & Uh, B. S. (1999). Proprioception after anterior cruciate ligament reconstruction with and without bracing. Knee Surgery, Sports Traumatology, Arthroscopy, 7(5), 303-309.

  7. Sinclair, J. K., Vincent, H., & Richards, J. D. (2017). Effects of prophylactic knee bracing on knee joint kinetics and kinematics during netball specific movements. Physical Therapy in Sport, 23, 93-98.

  8. Nazem, K. A., Mehrbod, M., Borjian, A., & Sadeghian, H. (2006). Anterior cruciate ligament reconstruction with or without bracing.

Physical therapy advice after knee surgery to keep up with your exercises! – Part 2

In my last post I discussed how fear and pain make it challenging to do your exercises after knee surgery (see Part 1 here). In this blog, we outline two more reasons why people struggle with their rehabilitation exercises after surgery. We also include physical therapy advice to help you overcome these barriers.

Perceived lack of time

Let’s face it; we live in a fast paced society with many personal and professional commitments. These commitments take a toll on the amount of available time for attending physical therapy appointments and doing daily exercises at home. When it comes to doing the things you need to do to recover, a busy daily routine and a perceived lack of time are significant barriers.1 When people were asked after surgery about why they find it difficult to complete their exercises at home, they mentioned work, holidays, family and social commitments all tend to take precedence over their exercises.1

Physical therapy advice - Recovery after ACL surgery is a huge time commitment for 8-12 months. After surgery is when all of the hard work starts. In the first month after surgery, rehabilitation can take 3-4 hours per day. In the later stages it can take at least 1 hour per day. Keeping an agenda (either on paper or electronic) is a great tool to keep track of all your responsibilities! Make your appointments or at-home exercise sessions a priority by scheduling a block of time during your day, as you would your other important life events! Here are some tips to help:

  • Do your exercises at the same time every day
  • If there is equipment you need have it in an easy to access place
  • Seeing your list of exercises either on a piece of paper or electronically is a very helpful reminder for you to do your exercises. If you haven't already, try our ACL app to help you do your daily exercises.
  • Ask friends and family to remind you to do your exercises or to check in on you every few days or weeks
  • If you know people who have gone though the same surgery ask their advice or exercise with them
  • Set reminders on your phone to do your daily exercises
  • Most importantly make time for these crucial exercises so that you can return back to your normal physical activity and daily activities.
Lack of availability of equipment

Doing your home exercises often requires some sort of equipment such as exercise bands, light dumbbells, or an exercise ball. When attending physical therapy appointments at a clinic all the necessary equipment is provided and completing the exercises is not an issue. However, when patients are given exercises that require the use of equipment at home, some patients report not having access to the appropriate equipment.1 As a result, instead of independently completing the exercises, patients opt to wait until they go to see their physical therapist. If you do not have access to the equipment necessary for the exercises given to you by your physical therapist, be sure to tell them so they are able to prescribe exercises that you can do at home.

Physical therapy advice - There is always an alternative that can be provided for most equipment that you do not have at home. You do not have to have access to a gym or any fancy equipment to recover fully after surgery. Ask your physical therapist how you can modify exercises that require equipment. Almost all of the exercises in our ACL app can be done with no special equipment. Here are some simple examples of things that can be substituted for equipment:

  • A folded pillow or couch cushion can be used as a balance disc or balance board for balance exercises
  • A water bottle filled with water or sand or rocks can be used as a weight
  • A few books can be used to replace a step for step up and down exercises
  • A water bottle can be used as a pylon for running drills, clock lunges and squat touch down exercises. All of these exercises are included in our app.
  • An office chair with wheels can be used as an exercise ball
  • Resistance bands (which can cost $5-15 per band) are a cheap alternative to using cable machines found in gyms and other forms of resistance equipment that you may not have

References

Physical therapy advice after knee surgery to keep up with your exercises! – Part 1

Fear, frustration, discomfort… These are a few things you may feel after a knee surgery.

If you have ever undergone an anterior cruciate ligament (ACL) surgery, you know the lengthy rehabilitation that is required for a successful recovery. For some people, a full recovery can take up to one year!1 Not only will this require a positive mindset to remain committed to recovery, but there are several other factors that influence your ability to complete all of the necessary rehabilitation. Full commitment to doing all of your exercises after surgery for 6-12 months can be challenging.

This challenge often leads to people not doing everything they need to do, which is called low rehabilitation compliance, some of which you may relate to. After each of the barriers I discuss below I have included "physical therapy advice" from our physical therapist Nirtal Shah who has helped patients overcome these barriers after ACL surgery for the past 17 years. Hopefully, the process of recognizing these barriers, realizing that you are not alone in your challenges and being provided with some helpful tips will allow you to successfully rehabilitate your knee!

Fear

The number one reason why people don’t return to their sport after ACL reconstruction is because of fear!2 Most people fear re-injury and because of this they are hesitant to return to their usual sport, physical activity, or exercise. In fact, only one third (about 33%) of people return to their previous levels of activity after ACL surgery.2 Some people delay their progress and limit their long term knee function by simply not doing any exercises due to this fear.3 The likelihood of actually sustaining another injury is very low when rehabilitation programs are effective and done consistently.4 Knowing this, you are limiting your progress by not attending your appointments or by avoiding your exercises, both of which are crucial for regaining functional strength in your knee!

Physical therapy advice - Recognize that fear is normal after surgery. Even if you have decided you will never return to a sport it is still important to do all of the rehabilitation that involves jogging, running, cutting, changing directions, etc at the appropriate stage. Meaning you would not do these things in the first month but when you are ready and your physical therapist determines your knee is ready for these activities. Once you have done these movements and also sport specific movements you can decide if you and your knee feel ready to return to sports. I never force my patients to return to sports but I do strongly encourage them to return to their prior level of physical activity and exercise. The health consequences of never returning to physical activity are far worse than re-injuring your ACL. My biggest concern for my patients who are fearful is that they do not regain the full function of their knee. This is a serious problem and leads to more knee joint issues in the future. I also do not deny that there is risk associated with sports. We have a blog on the risk of ACL injuries with various sports which can be found here. In the end it is a personal decision that the patient makes to return to sports. I try to help by providing information and an objective opinion on the health of their knee. In addition our ACL app can also help by overcome this fear by guiding you through your rehabilitation.

Pain

If you have ever gone through any type of surgical procedure, you have experienced the physical pain that comes with recovery. One of the reasons people don’t do the things they need to do to recover is because they are in pain. For most, being in pain is a negative experience and often leads to avoidance behaviours such as skipping appointments or not doing their exercises at home. In fact, patients report worsening pain during exercise as a barrier to rehabilitation compliance.5 They believe that exercises causing pain to their area of injury is harmful. As a result, patients will stop performing an exercise if they feel it is painful.5 However, exercise has actually been shown to reduce pain!6

Physical therapy advice - You will definitely have pain after surgery. In the early days after surgery it is very important that you take the pain medication prescribed to you in the correct doses. I have personally had a surgery and lived with the pain first hand and this guides how I help my patients with their pain. You can read about my pain experience and what to expect immediately after surgery here. Besides medication there are other things that help with pain such as ice, compression, elevation, (find a blog about how to do this here)and most importantly movement of the joint in the motions that you are allowed. This means you should move your knee as much as you can and have been instructed by your physical therapist and this will help with your pain. Even in the later stages of recovery often just sitting on a stationary bike (or lying on your back if you do not have access to a bike) and getting your knee to move without resistance (5 minutes of continuous movement) can help with knee pain. Movement is your friend, use it! Many of the exercises in the first month hurt. This is unfortunate but it has to be done. The pain is going to be temporary but the functional gains you make in your knee are going to be long term. There are many ways to help you manage your pain after ACL surgery which you can find in our ACL app.

References

Ice, compression, elevation and ankle pumps

After surgery or injury you will need to learn how to reduce swelling by using ice, applying compression using an elastic bandage, elevating and doing ankle pumps. All of these steps together will help reduce your pain and swelling.

Here are the basic steps:
1. Fill a sealable bag with ice cubes or use an ice pack
2. Place a plastic bag over the area and ice on top of the plastic bag
3. Wrap an elastic bandage over the ice. Learn how here
4. Use 5 pillows to create a wedge or ramp as shown in the video with your feet higher than your hips and your knees and hips straight
5. An ankle pump is moving your ankle all the way up and all the way down without holding either position. Do 50 of these every 5 minutes
6. Lie down with your head lower than your feet for 20 minutes

Our app, Curovate, has all of your daily exercises for ACL rehabilitation as well as built in reminders and timers for ice, compression, elevation and ankle pumps!

Here is a video (which can also be found in our app) of how to ice, compress, elevate and do ankle pumps.

ACL graft sites, what's the difference?

There are usually 2 areas where a surgeon can take a graft to replace your ACL. The two areas are your patellar tendon or your hamstring tendons. If this is new information to you, refer to our previous post on some details about ACL surgery here.
When reading the differences listed below it is important to remember that your surgeon will choose the graft site for your ACL surgery. The good news is that our app, Curovate, for ACL rehabilitation has a protocol for hamstring tendon or patellar tendon grafts here.

Hamstring Graft Surgery (HT) Patellar tendon also called Bone-Patellar-Bone Surgery (BTB)
1. The operation takes more time and the tourniquette, which is a device used during surgery to limit blood flow in the leg, is on for longer2 1. The knee is stiffer after surgery2
2. The knee moves more freely front and back, when tested using a KT-1000 Arthrometer machine2, which is a device that measures front and back movement of your lower leg compared to your thigh. 2. More knee pain when kneeling on the ground3
3. Over a period of 15 years after surgery there were more reinjuries reported.3 3. Over a period of 15 years after surgery more stiffness and difficulty straightening the knee was reported3.
4. The need to do another surgery to address issues with the first surgery is called a revision surgery. The revision rates, for hamstring graft surgeries increases by 0.65% within 1 year and by 4.45% within 5 years4. 4. Revision rate after 1 year is 0.16% and revision rate after 5 years is 3.03% for patellar tendon graft surgeries4.
5. Hamstring muscle power reduced by 15%1. Muscle power is the maximum force you can apply in as short a time as possible.
6. Muscle strength reduces by 11% when straightening the knee2. Muscle strength is how much force a muscle can produce in a maximal effort.
7. There is more instability in the knee when force is applied2. Instability is undesirable movement in a joint.



References

Who has the highest risk of ACL injury?

  • People who play sports where there is a lot of changing directions, pivoting and jumping are at a higher risk of ACL injuries.1
  • Females have a 2-8 times higher chance of injuring their ACL’s. With most ACL injuries occurring between the ages of 15 and 45.1
In what sports do the most ACL injuries happen?
  • Studies constantly list basketball and soccer as sports that cause ACL injuries.1,2
  • However, it is possible to injure the ACL in other sports that require a lot of pivoting, cutting (changing directions quickly), jumping and contact sports.1
  • Female athletes tend to be more at risk of ACL injuries.1
  • Using data from the National Collegiate Athletics Association (NCAA) Injury Surveillance System (ISS) 5000 ACL injuries were recorded from 1988 to 2004.
  • Based on this data sports are ranked below based on number of ACL injuries.
  • On the left side of this table the number of ACL injuries that occurred as a percentage compared to all other injuries in a sport.
  • On the right of this table the number of ACL injuries that were recorded per 1000 games and practices (also called exposures).
ACL injuries as a percentage compared to all injuries3 Injury rate per 1000 exposures3
1. Women’s basketball (tied) 1. Men’s spring football (tied)
1. Women’s gymnastics (tied) 1. Women’s gymnastics (tied)
2. Women’s Lacrosse 2. Women’s soccer
3. Women’s soccer 3. Women’s basketball
4. Men’s spring football 4. Men’s football
5. Men’s football 5. Men’s football
6. Women’s softball 6. Men’s wrestling
7. Women’s volleyball 7. Men’s wrestling
8. Women’s field hockey 8. Men’s soccer
9. Men's wrestling 9. Women's volleyball
10. Men's basketball 10. Women's softball
11. Men's soccer 11. Women's field hockey
12. Men's ice hockey 12. Men's basketball
13. Women's ice hockey 13. Men's ice hockey
14. Men's baseball 14. Women's ice hockey



References

I injured my ACL what should I do?

You can either manage your ACL injury surgically or non-surgically. Which form of treatment is right for you is determined by you and your health care provider.

Surgical treatment

Autograft and Allograft Surgery1,2,3,4
1. Autograft surgery means taking a tendon or a ligament from another part of your body, also called a graft, and replacing the injured ACL.
2. Allograft surgery is when a piece of ligament or tendon is taken from a cadaver, a deceased body, and used to replace the injured ACL.

In this post we will focus on the autograft surgery. There are two areas where the graft is taken from. The surgeon chooses the graft site for your ACL surgery (also called an ACL reconstruction).

a) Bone-Patellar Tendon-Bone Reconstruction (BTB)

  • The patella is the small bone that you can touch in front of your knee and the patellar tendon sits below this bone
  • The patellar tendon is an extension of the 4 upper thigh muscles called the quadriceps, which allow the knee to straighten
  • During this surgery, a piece of the patellar tendon is removed and used to replace the ACL5

b) Hamstring Tendon Reconstruction (HT)

  • The hamstrings are a group of three muscles (Semitendinosus, Semimembranosus, and Biceps Femoris) that are located on the back of your thigh.
  • They allow you to bend your knee and bring your hip back
  • During the Hamstring Tendon Reconstruction surgery, part of the Semitendinosus and Gracilis tendons are used to replace the injured ACL5

Prior to surgery it is essential to rehabilitate the knee to make sure you are ready for surgery. After surgery you will need at least 6 to 8 months of rehabilitation to return to your prior level of physical activity and sports. This rehabilitation is typically guided by a Physical Therapist but you will have to do at least 60 to 90 minutes of exercises daily. There is a huge time commitment to rehabilitation exercises after ACL reconstruction. Curovate offers a pre and post-operative app which has 6 months of video guided exercises to help you with your ACL recovery.

Non-surgical treatment

Progressive Physical Therapy is crucial for the treatment of ACL injuries. Weekly exercises are provided that will reduce knee pain, increase knee mobility, return to normal walking, and eventually return to running and jumping. How much you will be able to do after the injury is based on your particular injury, your knee health before and after the injury and what you and your Physical Therapist decide is appropriate for you. There will be more information on non-surgical management in a future blog post. Stay tuned!
Curovate has a non-operative version of their app which provides video guided exercises and progress tracking to help you recover from your ACL injury.

References

ACL social support

After an ACL injury or surgery social support is very important to help you recover. The ACL Recovery Club is a social network of people who are going through the same challenges as you.