Dr Karl Zippelius runs a private medical clinic in Florence (Italy) since 1998. He specialises in traditional orthopedics and traumatology, where the basic approach of Western medicine is combined with Traditional Chinese Medicine (TCM) as well as natural procedures of diagnosis and treatment. The following conversation is on ACL injuries and is aimed at providing vital information for better treatment ideas and outcomes.
Introduction – Anterior Cruciate Ligament (ACL) injuryis a debilitating musculoskeletal injury of the knee mostly found in athletes. The ACL can be injured ranging from small to severe tears, to the ligament completely torn. It’s recommended that as a practitioner a range of tests are to be performed in order to diagnose an ACL injury. A detailed analysis of the situation will assist in deciding if the patient should opt for surgery. Physical examination may consist of the pivot-shift test and the Lachman test to confirm diagnosis of ACL injury. The MRT gives further information about the severeness of ligament tear.
Question 1: Do you think it’s important to perform any of those test to confirm the diagnosis?
Yes, the most important step of diagnosis is the physical examination. The aim is to get a first valid impression about the stability of the knee joint. We will see during this interview why stability of knee joint is of utmost importance.
Question 2: If so, what test would you mostly perform and why?
The Lachman test is the most useful clinical test to do because you can examine the acute injured knee without any risk to create secondary damage to the injured knee through examination. Potentially, this could occur during the pivot shift test. Here is how to perform the Lachmann test: in a 30 degree flexion of the injured knee, the examiner pulls on the tibia to assess the amount of anterior motion of the tibia in comparison to the femur. An ACL-deficient knee will demonstrate increased forward translation of the tibia. In evaluating the of injury, you will have to consider that the anterior movement of the tibia maybe increased not only due to cruciate ligament tear but also due to haemathrosis and swelling. So do the test carefully again to confirm your first impression, once swelling and hemarthrosis has been eliminated.
Question 3: Why is stability of knee joint an important factor?
The stability of the knee joint determines the ability to continue with high level sports and to develop efficient movements. The relation between stability and movement behaves like yin and yang: One does not exist without the other. Besides, the risk of post traumatic arthrosis over time is correlated to instability. Thus, one of the main aims of therapy is to stabilise the knee joint. Chirurgical reconstruction of the ACL seems to be the first choice. However, according to recent studies (and the evaluation of the Swiss Medical Board, which is an constitutional consultant board for the public health system in Switzerland), in the long term, statistically there is no difference between conservative and chirurgical treatment as far as arthrosis and pain syndromes of the knee joint after an ACL injury. As a consequence, the Swiss Medical Board recommends to decide case by case and not to automatically favour surgery.
Question 4: How to decide whether chirurgical treatment or conservative treatment is indicated?
The decision for one of those two treatment strategies is based on two factors, clinical examination and the degree of instability during the patients or athletes daily activities. In normal activity patterns, even a middle grade instability may be compensated, however during high level sports, even the slightest instability maybe not tolerable. Furthermore, we have to consider that a spontaneous healing of a ruptured ligament may occur under certain circumstances. I will talk about this later on.
Question 5: In your experience, which TCM pattern would you mostly see in ACL injury?
We have to distinguish between internal and external factors as a cause to injury. General or temporarily qi deficiency (tired muscles do not to protect ligaments), liver qi stagnation (movement is not smooth but aggressive or not coordinated) and kidney deficiency (ligament and bone is easy to be injured even after a soft impact) may be the primary patterns. According to Western medicine, the risk of ACL injuries depends on the gender as well. Women are at greater risk to obtain an ACL injury. Also the following scenarios are to be considered:
- muscle imbalance between the quadriceps and hamstrings (weaker hamstrings)
- weak quadriceps and hamstrings
- tight, inflexible quadriceps and hamstrings
- incorrect technique for cutting, planting, pivoting or jumping
- external forces during contrast with other players or sudden turning or stopping
Question 6: How does your treatment and rehabilitation plan look like?
As for every acute trauma and without distinction if it is bone, ligament, or muscle injury, you will have to target mostly the blood level. Most importantly during the first few days is to move blood and break (blood) stasis. The best method to do this is to apply herbal packs and massage gently with herbal tinctures. You may also add acupuncture as a pain reducing method. In the second phase, acupuncture becomes more important especially constitutionally for example to tonify kidney energy and relax liver qi and locally to accelerate and initiate healing processes. The aim of the third phase is to bring the patient or athlete back to normal daily or sports activity. Thus, it is most important to open meridians with acupuncture treatment, enhance flexibility with soft tissue and/or Tui Na massage as well as using warming and smoothing Chinese herbs topically. Naturally a specific rehabilitation program to achieve normal muscle strength and balance is necessary. Another important aspect of rehabilitation is that patients must experience stability of the knee joint during movement so that they develop confidence about using their knee during specific sports activities.
Question 7: What else is important to consider with an ACL injury?
As I said before, an interesting aspect in discussing the topic of an ACL injuiry is that completely ruptured ligament may spontaneously heal. In scientific literature, a number of documented case reports on such spontaneous ligament healing can be found. How to explain it? First of all, if you get a MRT based diagnosis of a completely ruptured ligament, it is not excluded that there are still single continuous fibers left. Along those fibers, healing and stabilisation of the ligament can still occur. What can we do to promote the healing tendency of a ruptured ligament? According to my experience, the healing of the rupture depends mostly on how long swelling and hemarthrosis persist. The longer it remains, the less probable it is that the ligament will heal. If blood stasis and swelling remain for a long time, an aggressive absorption processes – as a natural response of the body – will damage and worsen the ligaments tissue and healing will no longer take place. To give healing a chance, we must quickly eliminate swelling and blood stasis and start with specific and intelligent /intuitive physiotherapy and movement. Qi gong is very helpful and promotes qi flow, provides bio-mechanical input to ligaments and initiates healing.
Question 8: Can ACL injuries be reoccurring and what best to do to prevent?
Statistically, up to 30% of athletes who return to sport after an ACL repair, re-injure or tear their ACL on the opposite knee. This is due to a number of factors, neuro-muscular weakness and asymmetry. To lower the risk: adapt training and rehab program to obtain strong and balanced muscles, also encourage to use physiological proprioception. As part of a warm up program, apply regular self massage with warming and meridian opening herbal ointments which will guarantee the best flow of energy in meridians and muscles.
In essence, it is not only the ligament healing status that must be considered but also the importance of open meridians, a good condition of surrounding soft tissue and the function of muscular chains.