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050 | Cyclops Lesions in ACL Rehab · The ACL Athlete Podcast

• 0:19
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:23
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:33
  SPEAKER_00: I'm your host, Dr.
• 0:34
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:04
  SPEAKER_00: What's up, ACL athletes, and welcome back to another episode on the ACL Athlete Podcast.
• 1:10
  SPEAKER_00: Today we are talking about cyclops lesions.
• 1:14
  SPEAKER_00: So you've maybe heard of this term, maybe not.
• 1:17
  SPEAKER_00: It's something that can come up, especially more in the early phases of ACL rehab, and we're gonna dive into all things related to a cyclops lesion.
• 1:27
  SPEAKER_00: So let's talk about what it is.
• 1:29
  SPEAKER_00: It was first described in 1990 by Jackson and Schaefer in their patients after ACL reconstruction.
• 1:38
  SPEAKER_00: The lesion itself is a focal anterior arthofis.
• 1:43
  SPEAKER_00: Arthrofibrosis means scar tissue.
• 1:46
  SPEAKER_00: It occurs in the anterior portion of the graft and protrudes between the femur and the tibia at the intercondyler notch.
• 1:56
  SPEAKER_00: So just think about your two bones together and where that notch, where that ACL comes up into, uh there can be this cyclops lesion that forms in the front of the graft.
• 2:08
  SPEAKER_00: And so this can happen between two to eleven percent of ACL patients.
• 2:14
  SPEAKER_00: It's a little bit of a range, and so most suggest around two to four percent.
• 2:19
  SPEAKER_00: Depending on the studies you're looking at, it's still a very low number, but it is still prevalent, so it's something to keep on the radar.
• 2:27
  SPEAKER_00: In terms of timing, it could present anywhere from early post op to six months after or even longer.
• 2:34
  SPEAKER_00: And what you'll see typically is a persistent loss of extension in the first two months, and you need to keep this specifically on the radar, loss of extension repeatedly, and we'll talk about this in more detail about symptoms.
• 2:49
  SPEAKER_00: But that's one of the things that you will see as a hallmark classic sign of what this is, and so if it's persistent through three months, then there might need to be a conversation with the physio or with the surgeon about if there is a cyclops lesion present.
• 3:05
  SPEAKER_00: Now, hear me out.
• 3:06
  SPEAKER_00: A lot of people will have some extension deficits further along, and this can be just one of those factors.
• 3:13
  SPEAKER_00: So it doesn't automatically mean if you're losing extension or don't have your extension at three months, then that means you have a cyclops lesion.
• 3:21
  SPEAKER_00: Just make sure you're working with someone who can help you to figure this out.
• 3:25
  SPEAKER_00: And then if it persists and you've been working really hard, and some of these things that you'll see whenever I talk about the symptoms align as well, then maybe it is something to have that conversation and then talk with your surgeon and physical therapist.
• 3:40
  SPEAKER_00: But let's go through this first so then that way you have a good framework to understand okay, is this something relevant to you or someone that you're working with?
• 3:49
  SPEAKER_00: And a lot of the times it happens after an ACL reconstruction or surgery, but there have been cases that have shown with people non-operative ACL as well.
• 3:59
  SPEAKER_00: So people who have had an ACL injury and just did not have surgery.
• 4:03
  SPEAKER_00: It has been reported that people with that can still go on to have a potential cyclops lesion, but it's less often.
• 4:10
  SPEAKER_00: So why do they happen?
• 4:12
  SPEAKER_00: So these are just theories.
• 4:14
  SPEAKER_00: We do not have a conclusive, this is exactly why it happens, almost similar to why an ACL injury happens, it's multifactorial.
• 4:22
  SPEAKER_00: So when we're talking about cyclops lesions, there are certain theories that are at play.
• 4:26
  SPEAKER_00: One is that we think it's a possible remnant of a previous ACL stump that had remained during surgery.
• 4:34
  SPEAKER_00: Another theory is fibrocartilage or bone is in the joint as a result of drilling the tibule tunnels, and formation occurs of this cyclops lesion.
• 4:45
  SPEAKER_00: And then other theories are an anteriorly positioned graft, partial torn anterior graft fibers, graft hypertrophy from impingement.
• 4:55
  SPEAKER_00: So when the knee flexes and extends, it could be because it's getting impinged.
• 5:00
  SPEAKER_00: So we do not really know what is the exact reason.
• 5:03
  SPEAKER_00: The first couple theories are probably the ones that are the most prominent that we have seen in the research and literature, but there are other factors that could potentially be at play or theories as to why they happen.
• 5:16
  SPEAKER_00: Can you do something to prevent it?
• 5:19
  SPEAKER_00: Not really.
• 5:20
  SPEAKER_00: It's very multifactorial, as I said before.
• 5:23
  SPEAKER_00: And this is something that you don't want to blame yourself, your physical therapist, or even the surgeon you're working with.
• 5:30
  SPEAKER_00: Some suggest that the most significant risk factor for this potentially forming is not being able to get your full knee extension early in the post-operative period.
• 5:41
  SPEAKER_00: And that's what's really important here.
• 5:43
  SPEAKER_00: When you look across all the research and what's going on, what can you do to help prevent this or help to minimize the possibility of this?
• 5:51
  SPEAKER_00: Is get your knee extension range as early as possible from ACL injury or after surgery.
• 5:58
  SPEAKER_00: And this is also a very important thing to consider why prehab is so important.
• 6:03
  SPEAKER_00: Because if you go into surgery lacking extension, then there's a good strong chance that that will be something tough to come out of surgery with and making sure that you regain that knee extension.
• 6:14
  SPEAKER_00: So make sure you focus on prehab, getting the kneecal, getting the swelling down, and getting that extension.
• 6:20
  SPEAKER_00: And then if you are post op, getting your extension range as early as possible can help to make sure that this cyclops lesion doesn't show up.
• 6:29
  SPEAKER_00: Now, how do we know if you have one?
• 6:32
  SPEAKER_00: What are you feeling?
• 6:33
  SPEAKER_00: What's going on?
• 6:34
  SPEAKER_00: So let's talk about this from the physical aspect and the functional, and then some of the symptoms.
• 6:40
  SPEAKER_00: So this cyclops lesion will be located in the front of the knee.
• 6:45
  SPEAKER_00: Think about right behind the kneecap, uh, where that graft is in the front of the graft, ACL graft, and that's where it will typically form as this wad or this lump.
• 6:56
  SPEAKER_00: And when the knee is placed into a straight position or extension, the nodule becomes impinged between the ACL graft and the femur and the tibia.
• 7:05
  SPEAKER_00: This impingement leads to the limitation in your range of motion, especially extension.
• 7:11
  SPEAKER_00: And so when we're talking about what it is, it's a physical block that prevents the knee joint from locking out into full extension.
• 7:20
  SPEAKER_00: You may feel an audible clunk or a snap while walking.
• 7:24
  SPEAKER_00: It's common to feel anterior knee pain, maybe some posterior knee soreness.
• 7:29
  SPEAKER_00: So maybe at the hamstrings and the calves and the back of the knee, it could be a bit sore.
• 7:33
  SPEAKER_00: Uh your patella mobility might not be the best where you can kind of move it around and make sure that it's grooving appropriately.
• 7:40
  SPEAKER_00: And then you'll also see some weak quadriceps that won't necessarily come back.
• 7:44
  SPEAKER_00: Maybe everything is done within your power and the quadrus will not come back because of that lack of extension.
• 7:50
  SPEAKER_00: And clinically, when I'm assessing into extension and pushing that knee down to see, okay, what is the athlete feeling?
• 7:58
  SPEAKER_00: If they feel something in the back side, it could be capsular or muscular tightness.
• 8:03
  SPEAKER_00: Uh if it's on the front side, then that's where we start to look into okay, what are the other details?
• 8:08
  SPEAKER_00: And could this actually be something related to a cyclops lesion instead?
• 8:12
  SPEAKER_00: And one of the biggest signs here is that you will lose extension constantly, no matter what the progress you make, you're gonna lose extension and it's not coming back no matter what you do.
• 8:24
  SPEAKER_00: And this can vary anywhere from 10 to 20 degrees, or it might even be that little bit, but usually it's a bigger range, and you will work on it, work on it, work on it, it'll go, and then it'll return back to what its normal extension is.
• 8:38
  SPEAKER_00: And that's something that I'll typically see with athletes, in addition to all these other signs that we're feeling and assessing.
• 8:47
  SPEAKER_00: When we look at how it's diagnosed, we can only truly know by an MRI.
• 8:51
  SPEAKER_00: So imaging needs to be done, and it has shown to be 84% accurate in detecting a cyclops lesion, and you'll typically see it.
• 8:59
  SPEAKER_00: It'll be that ball or that wad of scar tissue on the MRI.
• 9:03
  SPEAKER_00: So that's the only way to diagnose it truly, and then to get rid of it, the only option we know of right now is to have surgery.
• 9:11
  SPEAKER_00: You have to have a knee scope to go in there and to remove the cyclops lesion, to cut it away, and really nothing else can be done unless it's surgically removed.
• 9:21
  SPEAKER_00: And then you need to have aggressive PT to make sure you get that full extension back.
• 9:27
  SPEAKER_00: And a lot of times, what I will see is that athletes will get their extension back pretty quick and they won't have that issue of that anterior knee pain, and they'll be able to make the gains that they need to, but it's important to make sure you prioritize that early and be aggressive with it.
• 9:42
  SPEAKER_00: So that's a cyclops lesion in ACL rehab, so it can form in the anterior portion.
• 9:49
  SPEAKER_00: Loss of extension is a very big sign of it.
• 9:51
  SPEAKER_00: There are all these other things that we discussed in this episode in terms of signs and symptoms that you'll see related to a cyclops lesion, and then you got to get it diagnosed by an MRI, and then you have to have it surgically removed to get that full knee extension.
• 10:08
  SPEAKER_00: And like I said, have a conversation with your physical therapist and with your surgeon to make sure that this is something that's rolled out, especially if you're further in the process, and while also considering did you aggressively work on your extension early on and are still working on it and is still becoming an issue?
• 10:26
  SPEAKER_00: So don't go two weeks after your ACL surgery and you still don't have your extension and you're wondering if it's a cyclops lesion.
• 10:33
  SPEAKER_00: Give it some time, make sure you're communicating, and this is something that should be a team decision and an effort to figure out if a cyclops lesion is on the table.
• 10:44
  SPEAKER_00: Again, that percentage is very low for most people with ACL injuries and surgeries, but can happen.
• 10:51
  SPEAKER_00: So, my best recommendation of what you can do get your extension as early and as soon as possible, right after your injury, right after your ACL surgery.
• 11:02
  SPEAKER_00: It will do you tons of benefits besides just avoiding a cyclops lesion, but that should be number one priority along with the rest of the quiet knee.
• 11:12
  SPEAKER_00: So go do that.
• 11:13
  SPEAKER_00: If you can make me one deal right now, if you are someone who is coming out of ACL surgery, about to have it, just had your ACL injury, if you can make me a single deal, it's to achieve your quiet knee as quickly as possible and to put on the very, very, very top of that list is two things.
• 11:32
  SPEAKER_00: One is to get your complete terminal knee extension back and get your quadriceps active and going.
• 11:38
  SPEAKER_00: The rest of the ACL process will thank you so, so, so much.
• 11:43
  SPEAKER_00: Alright, guys, that'll do it for today.
• 11:45
  SPEAKER_00: Thank you all so much for listening.
• 11:47
  SPEAKER_00: This is your host, Robbie Patel, signing off.