Introduction
The purpose of this case report is to display the dynamics of a complete tear on an anterior cruciate ligament that required surgical intervention with a graph (cadaver) insertion via arthroscopy surgery and the chiropractic care and rehabilitation technique/procedures used to benefit and expedite the recovery process. In addition, the need for the routine narcotic medications prescribed for this type of surgery by the orthopedic surgeon was reduced.
Mechanism
A typical mechanism of an ACL injury is a non-contact twisting movement, usually due to abrupt deceleration and change of direction. Sidestepping (cutting), pivoting and landing from a jump are examples of events that may cause an ACL tear. An audible pop or crack, pain and the knee giving way are typical initial signs, followed by almost immediate swelling, due to bleeding inside the joint. When an ACL injury occurs, the knee becomes less stable. The ACL injury is a problem because this instability can make sudden, pivoting movements difficult, and may make the knee more prone to developing arthritis and cartilage tears. Epidemiological and frequency studies have demonstrated that the vast majority of acute ACL tears occur without any contact or direct trauma to the athlete’s knee. Landing at foot strike with the knee extended or a slight flexion (less than 20 degrees) and internally rotating the tibial in relation to the femur is by far the most commonly described incident which results in injury of the ACL.
Case Report
A 31-year-old male presents with knee pain, discomfort and limited range of motion due to swelling that began the previous night. Since that time, the swelling has become worse with extreme difficulty in walking. His pain is located at the medial and lateral aspect of the left knee and deep to the patella. He has no significant left knee history, with no known congenital conditions or symptoms.
Examinations
Plain film X-rays were taken of AP and Lateral views of the left knee with right knee comparisons. Initial analysis revealed no evidence of fracture or dislocation of the patella, distal femur and proximal tibia tuberosity and fibula. He consumed 600 mg. of ibuprofen the night after the incident and again in the early A.M. Physical examination included a thorough physical, orthopedic and neurological examination, which did clinically indicate an anterior cruciate ligament compromise. The palpatory exam revealed significant gross swelling at the lateral, medial and inferior patella.
Following the MRI, and due to the confirmed tear, an initial consult was made with an orthopedic surgeon. The patient chose to have surgery with a graft insertion, due to the severity of the ACL, which revealed a complete rupture. It was four weeks before the surgery was performed. Therefore, it was imperative to provide proper acute techniques to promote the injury healing process and reduce the potential deconditioning syndrome of the patient. Special attention was geared to reducing swelling and pain.
Treatment pre-surgery
Immobilization and protection of the injured tissue area during the first one to three weeks was initiated. In the early phase of healing, immobilization allows undisturbed fibroblast invasion of the injured area that leads to unrestricted cell proliferation and collage fiber production. Protection (such as with a cast or brace) prevents secondary injuries and early distention and lengthening of injured collagen structures, such as a torn ACL. The patient was provided an immobilization brace to wear until surgery. He was also fitted at the orthopedic surgeon’s office for a custom fit brace for post-operative activities, to prevent adduction and abduction of the left knee. He was seen at the chiropractic office three times per week for four weeks up until the day before the surgery. Treatment provided consisted of acute settings (advanced to subacute settings) on the ultrasound, ice, electrical muscle stimulation, activator adjustment to the left knee and diversified spinal adjustments to the bilateral lumbar spine and pre-surgery rehabilitation. The pre-surgery rehabilitation consisted of isometric exercises to strengthen the muscles of the quadriceps and biceps femoris muscles. In addition, strengthening and stretching exercises were also performed and instructed for the gastrocnemius, soleus and tibialis anterior muscles to support and maintain any muscles which could potentially affect the gait.
Treatment post-surgery
Following the surgery, he was at home and on bed-rest for two days, until he returned back to the chiropractic rehabilitation office and started post-surgical rehabilitation. The patient returned on crutches non-weight bearing. He was instructed to be non-weight bearing on crutches for two weeks or until further notice following the first post-operative office visit. The frequency for this was four times per week for the first two weeks, then three times per week for the next six weeks.
Following surgery, one week post-operatively, an in-office rehabilitation program was continued with positive response. He was eventually released to continued home therapy and supported care continued with extremity adjustments, nutritional advice, and monitoring exacerbations and functional performance. This patient was also able to take less than the prescribed and recommended pain medication of Oxycontin and Percocet.
Conclusion
No firm conclusion can be made from a single retrospective case study to ascertain that chiropractic manipulation and rehabilitation can reduce the average post-operative narcotic regimen following ACL surgery. However, this case does suggest and brings attention to the fact that the patient did fully recover, return to work and require very little of the controlled substances of Oxycontin and Percocet. Chiropractic intervention with manipulation of the involved extremity and lower spine along with pre- and post-surgical rehabilitation should be considered.
Mark S. Matvey, D.C., D.A.C.R.B., practicing chiropractor for 11 years, has been in private practice near the north side of Columbus, Ohio since graduating Cleveland Chiropractic College, Summa Cum Laude (Kansas City, MO) in 1994. He was originally a registered nurse, prior to becoming a chiropractor, and worked in orthopedics, neurological and medical surgical units, while at Research Medical Center, Kansas City, MO. He recently earned Diplomate status for the American Chiropractic Rehabilitation Board. Contact Dr. Matvey at [email protected], or Dimensions Health Plus, 2615 East Dublin-Granville Road, Columbus, OH, 43231; phone 614-899-9933.