A “Q&A” about ACL & MCL Tears

6 Feb

A recent post from Bikram Yoga Vancouvers blog brought up a great response to a very common question- so we decided to share it here with you!

ACL-and-MCL-TearsThe Question

In March 2012 I experienced a minor tear in my ACL (anterior cruciate ligament) and MCL (medial collateral ligament). I have not been able to work out or play any sports since then. Recently, someone told me that Bikram Yoga could help, but I wonder if I should wait until after I see my surgeon in mid-October to try a class? I’ve tried Bikram Yoga before, but haven’t been in the hot room for over two years now.

We asked Roxy, a BYV teacher and a medical doctor, to provide us with some info about ACL & MCL tears. Here’s what she recommends …

The Answer

Of the two injuries you’ve experienced, it’s the ACL tear that’s most serious. The anterior cruciate ligament (ACL) is a tough band of tissue connecting the femur (thigh bone) to the tibia (leg bone) located deep inside the knee joint. Specifically, it functions to prevent forward movement of the tibia from beneath the femur, or similarly, backward movement of the femur over the tibia. Also, it serves to resist rotational and sideways forces to the knee. ACL tears are quite often accompanied by injuries to additional knee structures, most often one of the menisci (knee cartilages) and/or the medial collateral ligament (along the inner side of the knee). ACL injuries, by themselves, also vary in severity: they can be mild, moderate or severe (grade 1 microscopic; grade 2 laxity with slackening; or grade 3 full thickness tear with most instability). The more structures are injured along with the ACL, the worse the injury and the longer the recovery.

The medial collateral ligament (MCL), on the other hand, connects the femur and tibia on the inner side (between the knees) and resists forces acting on the outer side of the knee. Along with its counterpart on the lateral or outer side of the knee (lateral collateral ligament (LCL)), the ligaments provide stability and support to the knee in side-to-side movement. The MCL’s primary function is to prevent the leg from overextending inward, but it also is part of the mechanism that stabilizes the knee and allows it to rotate.

ACL tears, especially the most severe ones, may require surgical treatment, while MCL tears most often heal on their own without surgery (with symptomatic treatment). Initially, in the acute phase of injury, icing, elevation and non-steroidal anti-inflammatories are recommended with limitation of physical activity (minimizing weight-bearing) followed by physical therapy – which Bikram Yoga is – to strengthen the knee soft tissues and supportive structures and regain flexibility.

With ACL tears, the recommendations are no sudden movements (e.g., do not play sports like soccer, basketball, tennis, etc.), no planting (as in running and planting feet), no pivoting and no deep squatting.

Bikram Yoga & Recovery

Bikram Yoga – with some modifications – will be quite healing for a variety of reasons. Since often ACL tears have other soft-tissue injuries associated (e.g., meniscus tears), the increased irrigation of the circulatory system to the synovial fluid will provide better nutrition to the soft tissues. In Bikram Yoga, we do not do sudden movements and everything is held still, so there are no worries in that department.

Deep knee flexion, such as in Awkward Pose, can be avoided (gradually increasing the intensity bit by bit if tolerated). The other deep knee flexion, namely Fixed Firm Posture, has to be performed with utmost care with very little depth: start by keeping your weight forward on the arms and not fully flexing the knees, keeping the knees wide apart to minimize the intensity (feet still apart at hip-width).

There is no pivoting in class, but extreme care should be taken with rotations of the knee: namely Tree Pose (not bringing the knee back too far down or back, keeping it up toward the ceiling and forward toward the mirror), Toe Stand (most likely, you will need to avoid this one) and head to knee in the floor series (for the leg that rotates out and bends in, the heel may not reach anywhere near the costume nor the foot the inner thigh, so a very loose flexion). Likewise in Spine Twisting Pose, on the side of the injured knee, keeping the leg straight on the ground rather than bending the knee.

The general recommendations of sports medicine for ACL tears (no sudden movements, no planting, no pivoting, no deep squats) can be put in the context of the postures to achieve the desired improvement. Extra caution should be taken when restarting the practice but, in time, favourable results can be achieved and accelerated by Bikram Yoga as a form of physical therapy. In the acute phase of injury, I would suggest taking it extremely easy, but the practice can be particularly helpful as it is ideal for strengthening the supportive soft tissues of the knee, in particular the musculature, which will help with sustaining the architectural support of the knee joint that is lacking ACL support.

Summary of Specifics to Bikram Yoga Practice for ACL Tears

1. Deep knee flexion should be avoided initially, then gradually increased in intensity if tolerated (gauged by the student):

  • Awkward Pose: Minimize knee bend; may need to avoid third part with knees together (given the rotation).
  • Fixed Firm Pose: Stay high, keep knees wide apart and even brace body weight partially by leaning forward on arms.

2. Extra care in rotation:

  • Tree Pose: Keep bent knee up toward ceiling and forward toward mirror; with one hand holding the foot, the other hand can be used to support and hold the knee to minimize effect of gravity of pulling the knee down, which would increase rotation.
  • Toe Stand: Avoid.
  • Head to Knee Pose:(referring to floor posture that is accompanied with stretching): The leg that is normally bent and brought in for the foot to touch the inner thigh with heel on the costume may be bent slightly and loosely without bringing the foot in all the way to inner thigh (in very extreme cases, the leg may be kept straight).
  • Spine Twisting Pose: The leg that is usually bent on the floor may be kept straight.

This post originally appeared on the Bikram Yoga Vancouver blog.

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