Posted October 31, 2002.

Note: Joint posting with Sue Barber-Westin of Cincinnati Sportsmedicine

Two postings from Pam, re cracking sound in knee six months after ACL recon:

http://www.factotem.org/cgi-bin/kneebbs.pl/read/180141 (Oct 17/02)

http://www.factotem.org/cgi-bin/kneebbs.pl/read/180279 (Oct 18/02)

6 Months and Trying Volleyball

Posted By: Yorkes11 <yorkes@mountaincable.net>

Date: Thursday, 17 October 2002, at 10:27 a.m.

Its been awhile since I posted. I just started back to a bit of volleyball this past week. The first week it was fine, with a little ache. This week, it swelled up a bit and is hard to bend. It almost feels like cartlidge problems when I bend it cause it is cracking quite loudly. I had my surgery last April 2002, ACL reconstruction. Am I pushing it. There is absolutely no pain when I am playing, and I wear my brace to play. But when I take it off, my knee feels weak and today it is cracking and grinding and is very stiff. Any suggestions.

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Re: 6 Months/Volleyball - Now Bruising

Posted By: Yorkes11 <yorkes@mountaincable.net>

Date: Friday, 18 October 2002, at 11:34 p.m.

My previous message explained what was happening since playing volleyball this week. I have now noticed bruising coming through the back of my knee and on the left side. Is there possibility that I have torn it again. It hasn't given out, and still feels strong to walk on, it just hurts when I straighten it out, and of course the pop and crack that goes with it. Maybe too much even though it felt great playing, still trying to get control of the swelling too. Any suggestions.

Messages In This Thread

RE: 6 Months/Volleyball - Now Bruising (views: 102) -- Yorkes11 -- Friday, 18 October 2002, at 11:34 p.m.

Re: 6 Months/Volleyball — Concerns raised by grinding, cracking, and swelling…. (views: 146) -- Michael Frind, with Sue Barber-Westin -- Thursday, 31 October 2002, at 11:18 p.m.

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Response to http://www.factotem.org/cgi-bin/kneebbs.pl/read/180279

(6 Months/Volleyball - Now Bruising)

Re: 6 Months/Volleyball — Concerns raised by grinding, cracking, and swelling….

By: Michael Frind, with Sue Barber-Westin

Dear Pam,

Although the cracking you report in your six-months-post-ACL-reconstruction knee might merely be indicative of scar tissue being broken up, there is cause for concern.

In your previous posting (http://www.factotem.org/cgi-bin/kneebbs.pl/read/180141), you noted that the cracking (or crackling) occurs while you are playing volleyball, and that this cracking is accompanied by swelling. You also noted a grinding sensation in the knee. Granted, grinding can be a sign of patellofemoral problems…but it can also be a sign of problems in the tibiofemoral compartment.

I asked Sue Barber-Westin, a seasoned knee researcher at the Cincinnati Sports Medicine Centre. Sue wrote that the swelling you report is a worrisome sign. She recommends you refrain from playing volleyball, and that you consult your OS at once. She notes that your symptoms could be due to any of numerous factors. A rigorous, thorough examination (i.e. re-examination) of the knee, including both manual drawer testing and MRI scans, is warranted.

In your correspondence, you pondered whether your OS’s 9-months-to-1-year-post-op moratorium on knee-strenuous sports is too conservative. Indeed, this is significantly more conservative than what most OSs seem to profess (i.e. return to sports at 5-6 months post-ACL-reconstruction). My view is that your OS probably has a very good reason for recommending such a delay in returning to knee-demanding sports.

Sue Barber-Westin also believes that your OS is not being overly conservative. She adds the following:

“I think going back to very strenuous sports at 6 months post-op is pushing it for most patients. In this era of little formal physical therapy and lack of a supervised program in the later stages of rehab, patients really don’t know if they are ready to return to activities that involve jumping, twisting, pivoting, and cutting.”

Additionally, Sue notes that it is risky to impose a “one-size-fits-all” approach to return-to-sports timeframes. A better approach is to test the knee regularly, thereby enabling rehabilitation progress to be recorded objectively. (Angular-acceleration tests, as done on Cybex and Biodex machines, are two examples.) Such a quantification-based system ensures that the knee (indeed, the person) is ready to the rigorous demands of ACL-intensive sports. Because everyone progresses through rehab at a different rate, and also because everyone’s knee injury is different, this approach demonstrates an inherent prudence and efficiency—qualities that are extremely desirable for any programme pertaining to a ligament-injury-history knee.

Sue writes: “We don’t believe in just giving a blanket time post-op when one can resume sports. Rather, we put patients through various functional tests prior to release. Whenever possible, patients go through a progressive program of plyometric training, and then a running program is done prior to resuming athletics. Of course, there are always patients who do their own rehab and think they don’t need any supervision.”

Please keep in mind that the process of conversion of your sliver of tendon into a bona-fide ligament is not complete at a mere 5-6 months post-op. Granted, ligamentization (i.e. revascularization and reinnervation of the graft) usually is sufficiently complete by 5-6 months post-op to enable the person to participate in many sports. (This assumes that the surgery was limited to ACL reconstruction, that no other injuries were present, that no complications [e.g. scarring, infection] took place, and that rehab progressed normally and was done under the supervision of a knee-experienced physiotherapist.) However, it must be remembered that the graft-ligamentization process takes at least 2-3 years to run to completion. So, at a half year post-op, your new ACL is still very different from its natural counterpart. Most notably, this ACL graft will be lacking tension-sensitive nerve endings…hence there will be no proprioception (i.e. no position-in-space sensory feedback from the knee to the brain) from the ligament, as well as no ACL-protective hamstring reflex.

Sue also noted that ligamentization is not the only defining factor with regards to a person’s readiness to return to sports. In fact, once the 5-6-month mark has passed, the decision of whether or not to return to sports now or later will be predicated mostly on the regainment of normal strength, proprioception, and coordination. (Since the aforementioned nerve endings require in excess of two years to regrow, during the interim period the person must make do with the proprioception from other parts of the knee.) Because good co-ordination (which in turn depends on proprioception) can only be developed through the appropriate training (e.g. proprioception exercises, including ballistic jumping and sport-specific exercises), the importance of a well-planned rehab programme (including on-going exercises that must be continued long after the final physiotherapy session) is clear.

So, I suggest you hold off on the competitive volleyball until your OS has had the opportunity to check your knee carefully. Although it may seem probable that the recently reported cracking and grinding and swelling are not cause for concern, these signs could be harbingers of further (or future) problems.

Keep me posted with regards to what your OS indicates.

Yours truly, Michael Frind.