You heard a pop in your knee while twisting it skiing or playing soccer. You went to your family doctor and/or physiotherapist and they suspect an ACL tear. What are the next steps?
The steps following a suspected ACL tear can differ depending on if you have a family doctor, the symptoms you're experiencing and current wait times for imaging and surgery. The pathway below is one example of that you may follow but some variation doesn't necessarily mean you're off track. The most important thing is that you're not completely sedentary. Improving your knee range of motion pain free and strengthening your quadriceps will be important regardless if surgery is an option. Check out the ACL Prehab blog here for more details.
Step 1 - Initial Assessment
If you went to your family doctor first, they will likely recommend a physiotherapist first to help assess your knee and see how you improve with non-surgical care.
If you saw a physiotherapist first and they suspect an ACL tear then they will recommend you go back to your family doctor if you haven't already. They would likely provide a note highlighting their findings so that your physician is up to date with your rehab.
At the same time, your physio will provide you with education around the suspected injury, provide some hands on therapy to improve your knee range of motion in addition to early exercises targeting your hip and knee strength. These are paramount to start early!
Step 2 - Imaging and Specialist Referral
The family doctor can take a couple steps here depending on the severity and how suspect the injury is. They will likely first order an x-ray of the knee to 1) qualify you for an MRI and 2) rule out any potential fractures which need to be dealt with immediately.
After the x-ray they may order an MRI right away or they may wait until you see a specialist doctor. X-rays can be done fairly quickly with results within a week or two in Vancouver, BC, Canada. An MRI through the public system is where the time can vary a lot. It can take as quick as a month or upwards of 9 months depending on your schedule flexibility and current wait times. A private MRI can speed up the process at this stage but may not always been needed and can cost over $1000 in some cases.
The specialist that your GP will refer you to might either be a sports medicine doctor or an orthopedic surgeon.
Step 3 - Specialist
What is the difference between a sports medicine doctor and an orthopedic surgeon? Sports med doctors usually have a base level training in Family Medicine or Emergency Medicine (work in the ER) and have gone on to specialize in sports medicine. Sports medicine doctors can be faster to see depending on their waitlist and can have better diagnostic skills to diagnosing the likely injury versus the family physician. If they don't suspect surgery being warranted they may provide alternatives or at least other options before surgery is considered. Ultimately they may refer you to an orthopedic surgeon if they suspect a full ACL tear or meniscus injury that is preventing your knee range of motion from returning to normal. If this is the case, they will recommend you continue physiotherapy treatment aimed at strengthening your knee once the initially swelling reduces.
An orthopedic surgeon is a doctor who is capable of performing an ACL surgery which may use your hamstring, patellar or quadriceps tendon to rebuild a new ACL. You can read about those ACL surgeries and the rehab here. They can go other the pros and cons of the different types of surgeries, what they recommend and expectations. They would also give you a rough time estimate. You can also view the current ACL surgery wait times here for Vancouver, BC, Canada.
Both specialists will want to see the results of the MRI to determine the appropriate next steps in consultation with your goals and how you are currently managing your daily life activities and with physiotherapy treatments.
Step 4 - Prehab / Rehab
If you opt for the surgical approach, your surgery might be booked right then or told you'll receive a phone call in a few weeks to do this. Surgery is not always the option but depends on how your recovery is going and what your goals are. Your choice of whether you want surgery or not may even change as you go through the prehab / rehab before your surgery. This is completely normal as not everyone will want or need to reconstruct their ACL. The progress made during the rehab process leading to surgery might provide enough stability and strength where you can modify your activities enough to enjoy a healthy, active lifestyle with sports. This can be an ongoing process with your physical therapist over 1-2 years depending on the surgery waiting period. It is not uncommon to feel like your knee is strong enough to resume some sports depending on your level of activity but will not happen for many months after the injury.
Step 5 - Surgery
This step can be optional even with a full, uncomplicated ACL tear. You may even opt to wait a full year or 2 before making the decision to see how your physical therapy is going. This decision should be made with input from your physiotherapist and especially your orthopedic surgeon or sports medicine doctor. Regardless of which path you take, exercise will be the most important aspect of the rehab process to improve your outcomes.
The steps provided above shouldn't be used for personal medical advice but rather a guide to knowing which steps may occur through your rehab journey. You should consult a family doctor and/or physiotherapist to discuss the steps specific to your needs. If you've recently experience a knee injury and need a physiotherapist to assess it, you can book online here for appointments in the Crosstown / Gastown neighbourhood of Downtown Vancouver.