Post-ACL Reconstruction Challenges: Pain, Instability, and Rehabilitation

Issues After Anterior Cruciate Ligament Reconstruction Surgery

I am currently 44 years old.
In December 1990, I underwent ligament reconstruction surgery for my left knee's anterior cruciate ligament (ACL).
After surgery and rehabilitation, I regained my original function, and I am very grateful to the surgeon for their skill.
However, in May 2004, while jogging, I heard a "pop" and experienced pain in my left knee.
An MRI at the hospital diagnosed a tear and rupture of the ACL, along with slight joint degeneration.
Subsequently, on December 5, 2005, I underwent another reconstruction using the patellar tendon.
I actively began rehabilitation after the surgery (and I am still continuing rehabilitation).
It has now been over 9 months, but I still have difficulty walking smoothly and occasionally limp.
There is slight pain in the joint, and I hear a "clicking" sound when fully extending my knee at about a 5-degree angle, along with a feeling of some looseness.
I am unsure if the reconstructed ligament is too loose; if it is, can a thermal shrinkage procedure be performed? Currently, I can flex my knee to 120 degrees, but there is muscle atrophy, and my recovery seems less than ideal.
Given my current condition, what treatment and rehabilitation should I pursue? I would greatly appreciate your guidance.
Thank you!

Jiànkāng, 40~49 year old female. Ask Date: 2006/09/27

Dr. Chu Baijun reply Orthopedics

What does "approximately" mean? I believe that the current rehabilitation treatment can focus on rebuilding the strength of your thigh muscles, which will help improve muscle atrophy and enhance protection for the ligaments, preventing re-injury.
Thank you for your message.
Please stay in touch if you have any questions.
Director Li Wei-Chiang, Department of Rehabilitation, Taoyuan Hospital, Ministry of Health and Welfare.

Reply Date: 2006/09/27

More Info

Post-ACL reconstruction challenges can be quite complex and multifaceted, especially for individuals who have undergone multiple surgeries and rehabilitation processes. In your case, having had two ACL reconstructions and still experiencing pain, instability, and functional limitations is understandably concerning. Let’s break down the issues you are facing and explore potential avenues for improvement.

Pain and Instability
After ACL reconstruction, it is not uncommon for patients to experience some degree of pain and instability, particularly if there has been a history of previous injuries or surgeries. The "popping" sound you heard during running, followed by pain, suggests that there may have been a re-injury or a complication related to the reconstruction. The presence of a grinding or "catching" sensation in the knee, along with a feeling of looseness, could indicate several possibilities:
1. Graft Laxity: If the reconstructed ligament is too loose, it may not provide adequate stability to the knee joint. This can happen if the graft did not integrate properly with the bone or if the surgical technique did not adequately restore the ligament's tension.

2. Joint Degeneration: The MRI findings of slight joint degeneration could also contribute to your symptoms. Degenerative changes in the cartilage or meniscus can lead to pain and instability, especially during weight-bearing activities.

3. Muscle Weakness: Muscle atrophy, particularly in the quadriceps and hamstrings, can significantly affect knee stability and function. Weakness in these muscle groups can lead to compensatory movements that may exacerbate pain and instability.

Rehabilitation Strategies
Given your current situation, here are some recommendations for rehabilitation and management:
1. Physical Therapy: Continuing with a structured physical therapy program is crucial. Focus on strengthening the muscles around the knee, particularly the quadriceps, hamstrings, and calf muscles. A physical therapist can design a program tailored to your specific needs, incorporating exercises that promote stability and strength.

2. Functional Training: Incorporate functional exercises that mimic daily activities and sports movements. This can include balance training, proprioceptive exercises, and agility drills. These activities can help improve your confidence in the knee and reduce the feeling of instability.

3. Pain Management: If pain persists, consider discussing pain management strategies with your healthcare provider. This may include modalities such as ice, heat, electrical stimulation, or even medications to help manage discomfort during rehabilitation.

4. Assessment of Graft Integrity: If you continue to experience significant instability or pain, it may be worthwhile to have a thorough evaluation by your orthopedic surgeon. They may recommend imaging studies, such as an MRI or X-rays, to assess the integrity of the graft and the condition of the surrounding structures.

5. Surgical Options: If graft laxity is confirmed and conservative measures do not yield improvement, surgical options such as a revision surgery or a procedure to tighten the graft may be considered. Discussing these options with your orthopedic surgeon is essential to determine the best course of action.

6. Gradual Return to Activity: As you progress in your rehabilitation, gradually return to activities that you enjoy, but do so cautiously. Avoid high-impact activities until you have regained sufficient strength and stability in your knee.

Conclusion
Your journey post-ACL reconstruction is understandably challenging, but with the right approach to rehabilitation and ongoing communication with your healthcare team, there is potential for improvement. Focus on strengthening, functional training, and pain management while keeping an open dialogue with your orthopedic surgeon regarding your concerns. Remember, recovery can take time, and patience is key in achieving the best possible outcome.

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