I live in a rural area and am planning to have my knee replaced soon. There is not a good option for in home physical therapy, but my doctor has recommended a clinic that will set up tele rehabilitation sessions. Is this as good as having a therapist come to my home, or should I try to get into town to see one?

This is a problem for many people in all areas of medicine and with improvements in internet access telemedicine is increasing. There haven’t been too many studies on comparing the quality of these services as far as physical therapy is concerned. However there has been on recent study by Moffat et al, published in July 2015. In this study they were able to have two large sample sizes for two groups, one receiving at home face to face PT following knee replacement and the other receiving at home video based PT. The results of their study are promising that there is very little to no difference between the outcomes for these two groups. This results of this study indicate that if you have the option for tele rehabilitation it can be a good option.

I am considering having therapy following my total knee replacement be through video conferencing, what is the difference from face to face, and are there any down sides?

I have good news for you. According to a recent study conducted by Moffat et al there is good evidence that there is no down side to having your at home physical therapy provided via the internet and video. They showed no significant difference at four months after hospital discharge between face to face and video therapy after total knee replacements. They also described that the treatments provided were exactly the same. They included individual evaluation, supervised exercises, instruction in exercises to complete on days without a session, advice about pain control, use of walking aids and return to activities. The intensity and difficulty was based on each individual patients progress. This is good news for patients and therapists looking for the benefits of physical therapy following a total knee replacement, but do not have the resources to access at home face to face treatments.

My daughter is 16 years old and has recent torn her ACL. I have been doing research on the different graft options, and what is the best choice?

One of the most important things to consider when having an ACL reconstruction is what tissue to use as the graft. In a recent article out by Lynch et al there is some data about this from the Multicenter Orthopaedic Outcomes Network, which is a large, multi-center, collection of data from thousands of ACL reconstructions. In this article they discus the importance of choice of graft with successful outcomes. They found that the choice of graft and the patients age were the most predictive variables. Use of an allograft (donor or someone else’s tissue) had a four times greater risk of re-rupture than when an autograft (patients own tissue) was used. Re-rupture was more likely in the age group ten to nineteen and then every ten years the risk decreased slightly. The take home message is that for younger patents the best choice is autograft, with the least chance for re-tear. They did not discuss any differences between the two most common autograft choices; patella tendon and hamstring tendon, so on this point I would recommend you discuss this further with your surgeon.

I tore my meniscus and ACL, should I try to have the meniscus repaired?

Borchers et all studied meniscus and cartilage injuries in primary ACL and revision surgeries through the Multicenter Orthopaedic Outcomes Network and the Multicenter ACL Revision Study. This research found that meniscus injuries are the most common additional injury found in both primary procedures and revision. Having history of meniscectomy is also the most important factor associated with cartilage damage. This indicates that in the presence of a meniscus injury the best course of treatment, if possible, to to repair the meniscus injury. Roman et all reviewed a different study of 437 ACL reconstructions with 82 meniscus repairs and found that the repair had a ninety-two per cent success rate at a two year follow up. So it appears that meniscus repairs are quite successful and that this is the best way to maintain the integrity of the structures in the knee which protect from future wear and tear.

Why do my knee caps hurt when I run, squat or descend stairs?

The causes for pain behind the knee cap can be coming from any number of problems or multiple issues combined. Getting your legs assessed by a trained movement assessment specialist for possible faulty alignment issues in the leg joints,insufficient muscle strength, sport training errors, and overly tight muscles is a good start. As the knee cap is often overstressed and thus giving you a pain message to change your movement or sport training.

I recently tore my ACL and have been attending physical therapy for strengthening for the past month with good results.  My therapist brought it to my attention that I might not need an ACL reconstruction.  I thought if you tore it you needed to fix it.  Is this true?

Just because you tear your ACL does not mean you need surgery.  There is a percentage of the population that are able to “cope” and use their muscles to stabilize their knee during activities.  The decision to have surgery or not have surgery is ultimately yours to make, but you should take into consideration your age (the younger the more likely you might  want to consider surgery), your activity choices (pivoting sports like soccer?), the number of incidences of your knee giving out, and your dedication to your rehabilitation (much more work following ACL reconstruction). This would be a good discussion t o have with both your physical therapist and your surgeon.

After I have my ACL repaired how long will it take me to return to playing soccer?

The type of repair and coinciding damage as well as how well you do with rehabilitation all ties into how long a full recovery will take.  Surgeons recommend physical therapy for a minimum of three months and as much as six months following reconstruction.  They also do not recommend full return to pivot-type sports (i.e. soccer) for nine months.  That being said, however, sometimes people do get back to full activities more quickly.

I am a soccer coach for a girls’ competitive soccer team. I am interested in putting together a ACL injury prevention program for our soccer club. What is the most effective program?

There have been many ACL injury prevention programs and screening tools developed in the past decade as participation in youth sports is on the rise and the number of ACL injuries is also on the rise, particularly with young females. Some research estimates that return to sport after ACL rupture and repair is as low as 50% in young athletes, while epidemiological studies estimate that females are four to six times more likely to suffer and ACL injury compared to their male counterparts. Universal ACL injury prevention programs are more beneficial than screening programs for young athletes as they are a cost effective strategy for reducing the physical, psychological and financial burden of ACL injury.

These programs typically involve an altered warm up and inclusion of certain fitness drills in practice that include core work, stretches, plyometrics, strengthening and sport-specific agility drills. The end goal is to optimize muscle balance and improve the athletes biomechanics, particularly with jumping and cutting type movements that typically stress the ACL. Two programs that have the most research supporting their effectiveness and the Sportsmetrics and Prevent Injury and Enhance Performance (PEP) Programs. It is advisable to look at these programs online and also look around your local community of physical therapists and athletic trainers to see if any programs currently exist in your area.

I am a young athlete who has seen many friends tear their ACL. I do not want to have this happen to me. Is there anything I can do to prevent ACL injury?

There is never a guarantee that you can prevent any injury, but there are certainly steps that you can take to minimize your risk. As an young athlete, there are screening tools available that include specific jumping and cutting tests to identify if your biomechanics are such that you are at risk for ACL injury. Most of these screens are conducted by researchers in the areas of physical therapy, biomechanics or kinesiology. If you live near a University or have some contacts in the field of physical therapy or orthopedic medicine, ask around to see if any screening centers are in your area. If not, there are other options. Several ACL injury prevention programs have been developed in the past decade as the incidence of ACL injuries has risen with the rise in youth sport participation.

These programs typically involve an altered warm up and inclusion of certain fitness drills in practice that include core work, stretches, plyometrics, strengthening and sport-specific agility drills. The end goal is to optimize muscle balance and improve the your biomechanics, particularly with jumping and cutting type movements that typically stress the ACL. Two programs that have the most research supporting their effectiveness and the Sportsmetrics and Prevent Injury and Enhance Performance (PEP) Programs. It is advisable to look at these programs online and also look around your local community of physical therapists and athletic trainers to see if any programs currently exist in your area. You could even get your team mates or a group of friends on board to train with you. It is best to have a qualified coach, personal trainer, or physical therapist to help guide you through these programs the first few times through, as there are specific things to look for with your movement that can be difficult to identify on your own. For the programs to be effective, form is the most important component.

How do you measure anterior laxity of the knee?

A machine called a KT2000 arthrometer is used. The machine can be set to output a certain amount of force (in this study 134 Newtons, which is about 30 lbs. of force). It slides the tibia (lower leg bone) forward in the knee joint and measures the amount of movement.

If I think my knees hyperextend will I have an ACL tear?

Just because you have hyperextension in your knees does not mean that you will tear your ACL. THe research shows that you are at a higher risk for sustaining an ACL tear than a person who does not have knee hyperextension. If you are concerned about your knee hyperextension, speak with your primary doctor or a physical therapist about exercises to help you improve strength and balance to protect your knee to try and reduce the risk of ACL tear.

If I have a bad knee and my doctor is suggesting that I have it replaced, would platelet rich plasma help me?

There is no guarantee of success, and not all physicians are using this technique yet, but it might be something to suggest if you are trying to avoid or delay an invasive surgery. PRP is hypothesized to improve the bodies’ own natural mechanisms for healing cartilage. So if the reason for your pain is due primarily to worn cartilage this may be an option for you. It is certainly a much less invasive procedure, and although still a little experimental, is quite affordable and might be worth considering a trial before surgery. It wouldn’t hurt to ask your doctor if he or she does this procedure, or if there is someone in your community who does, and if they feel you are a candidate for this procedure.

My physical therapist is suggesting I try a valgus knee brace to help with my knee OA.  Is this recommended and will it help me?  They are very expensive.

OA knee valgus braces help to alleviate the compression that occurs at the inner knee joint line that results in a lot of knee pain typical of OA.  Sometimes patients see good relief with these braces and sometimes not. The current treatment guideline for knee OA found evidence to be inconclusive regarding the effectiveness.  While they are expensive, most companies give you a 30-day trial period to let you figure out if the brace will benefit you.

I am 50 years old and generally active however have been limited lately by my knee pain.  My doctor says I have osteoarthritis.  What are some things that I can do to keep my pain to a minimum and keep moving as long as I can?

The current treatment guideline for OA, based on a recent literature review by the American Academy of Orthopedic Surgeons, strongly suggest that you keep up with a good gym program to stay strong, keep unnecessary weight off, maintain heart health with a low-impact aerobic activity (like biking), and correct any faulty biomechanics or strength discrepancies.  You can manage your pain with NSAIDs or tramadol.

What is the difference between an autologous chondrocyte implantation and an osteochondral allograft transplantation? I have a large cartilage tear that goes clear down to my bone and my surgeon is suggesting I have an osteochondral allograft transplantation.

An autologous chondrocyte implantation is a two-step procedure. The first portion involves harvesting cells from cartilage in your body and then growing them in a lab until there is enough for the repair site. The second step involves the actual placement of that tissue. An osteochondral allograft transplantation (OCA) is a one step procedure that involves using cartilage from a cadaver and placing it in the area of damage in your knee. A recent review of the evidence suggests that the OCA is the better of the two procedures as far as long-term effectiveness and success with full return to sport activities.

I am a 25-year-old competitive kick boxer. Six months ago I tore my medial meniscus and some of the cartilage under it. I have been strengthening and getting ready for surgery but am trying to figure out what surgery will be best for me. I want to be able to get back to my previous level without having to worry about having arthritic knees when I’m 40.

It sounds as though you have a deep cartilage tear along with your medial meniscus tear. Based on a recent review of surgical options for someone like you (a high end athlete, young, and a big chondral tear), you might look into getting an osteochondral allograft transplantation (OCA). This involves taking a size-matched piece of cartilage from a cadaver and transplanting it into your damaged knee. Rehabilitation takes about one year before you’ll be at 100% however long term studies show that it will be worth the work.