Episode 119 | Going to the ER/Urgent Care After A Suspected ACL Injury

What is up guys? And welcome back to another episode on the ACL Athlete Podcast. Today’s episode 119, we are talking all about going to the ER or emergency room, urgent care, whatever the emergency place that you go to after you have a suspected ACL injury or just any type of really big knee injury. Let’s say that you have injured your knee. It hurts like hell, and you’re worried about it. You’re not sure what’s going on with it. And you’re trying to figure out what’s wrong. People usually go in three different routes. They play the wait-and-see game, they either go to some sort of emergency center or schedule an ortho appointment and wait for that to come. Those are typically the three routes that most people will fall into. 

And today, I want to specifically talk about going to the emergency room, urgent care, I’m just going to call this the ER, just for simplicity’s sake for this episode. But just think about it as whatever it is that people go to whenever they do have an injury of some sort or some sort of emergency and they have to go to a doctor to help them figure out what it is. Typically, because they’re worried, they’re in pain, they’re concerned about what is actually happening in that place or area, sickness or joints. But today, we’re talking about ACL injuries because this is in an ACL podcast. And this has come up enough times with ACLers I’ve talked to, that I want to make sure I bring this to light and have this conversation and allow you guys to know what to expect, especially if you do decide to go to the ER or the urgent room. I just said I was going to say ER. I’m going to stick with ER for you guys.

The injury has happened to your knee. You want to go to the ER because you want to get it checked out, and that’s totally normal to do. You had a major injury. You’re typically in bad pain and you want to get things checked out just to make sure they’re okay. The ER will take account of what happened, so you might see your doctor. They’ll take your history and then they’ll make some judgments. Maybe we need to do some imaging. Typically, it’s only an X-ray. They’re not going to do an immediate MRI for something like this. And so then they do that. They might not do that if they don’t suspect anything bone-wise or any issues. But a lot of times they will. And then they’ll do a clinical exam as well to test the knee. And that is basically for you to move it or for them to move it with their hands on the table. There are different variations of what aspects you would get if you go to an ER to get your knee tested. And we’re talking here probably in the first hours, the first day, maybe two days. Usually, people don’t go to an ER if it’s not within the first 24 to 48 hours. Sometimes they do later on. But for a knee injury like this, you’re probably the person who’s a wait-and-see-type person, or you’ll go and get it scheduled with an ortho. But a lot of times people will just go in that first 24 hours and just make sure everything’s okay.

Today’s episode focuses on the considerations of what that ER doctor is going to look at and just the status of the need going into that visit to make sure you understand the information you gain from it and also the advice or guidance you’re given based on that. The things that are important to consider are the expertise of the emergency care or the ER doc. And this is really important. And I think this gets missed often, that we think that a medical doctor or anyone with a doctor in their name, or someone who is a healthcare provider, maybe is a physician assistant, whoever is helping you in the ER room that is qualified to do so. We got to understand their medical background. And this is where it’s important to know, okay, I’m walking into an ER or an urgent care. The goal is to make sure you’re good, get out of the urgent situation, and rule out any red flags or life-threatening issues. That’s the main goal there. And then, of course, make you feel better. Usually, you’re in a panic mode, you’re in pain, and something is miserable in your body, so that’s what they’re trying to do to make you feel better. And so that’s the goal of these types of situations. 

The other thing that’s important here is the training of that medical professional. And this is not to take a hit at any professional, their background, or anything like that. It’s just the context. It’s understanding you’re walking into an ER-type location. This is what you’re going to get. And so what it is is that these people are trained in emergency medicine. And whenever you go in with a knee injury, these are not specialists in orthopedics, they are not someone who is going to be able to diagnose very clearly. This is an ACL injury. Their backgrounds aren’t specialized in this and even in medicine. There’s not a ton of emphasis on orthopedics unless you’re going in that direction. 

When you think about the world of medicine, there are so many things about our human bodies that people study. And when an ER doc is not so hyper-focused on musculoskeletal injuries, unless that’s their background or specialty, but typically you need to go in the orthopedic route or physical therapy or athletic trainer, people who are very hyper-focused on musculoskeletal care and anything related to bone, muscle, and joint. And those are the things that we’re looking for in terms of helping to find a more accurate diagnosis if you will. But guess what? Even immediately after an A C L injury or a knee injury, it’s hard for anyone in this field to truly diagnose that. 

And if you’re a PT, athletic trainer or healthcare professional listening to this, you’re probably shaking your head. Yeah, it’s, it’s really hard after this injury to have any accuracy, to know for sure that your ACL is torn, especially immediately after the injury. And we’re going to talk a little bit about the details here in a second. But this is just some background to understand the expertise of who you’re going to is going to matter in the decisions or advice they give you. They’re not specialized in this. They’re just trying to make sure you get out of this, feeling safe and good, and give you some good idea of hopefully what’s going on. This is not to discredit any of the value of their education is just more so of understanding. 

This is where I’m going, what’s their background, and also how am I coming into this place? And that’s what’s going to lead me to the next point, the status of your knee going into that emergency care place. If you’ve injured it, it’s likely that the knee has swelled up a bit. Now, you might fall into the category where people’s knees don’t necessarily swell up too much. But there’s a strong likelihood that your knee has some swelling in it. Mine puffed up, especially minutes after, and then progressive minutes after that, like 30 minutes, an hour in the first one to the two-day window. It swells up and it’s like a balloon, to varying degrees. It’s angry. The joint is like what just happened. And what happens with this situation is that it gets blurry of any type of clinical testing we do. That means putting you on a table and trying to move it around. With my two ACLs specifically, I was apprehensive to let anyone touch them because I had just injured them. It was painful. And of course, the swelling that I had just mentioned. I didn’t even want to move it myself. 

When you think about that first window of the first day, especially if you go to this ER and you want to get this tested, do you think that anyone who is painful and has a swollen knee and does these clinical tests on the table would give a false positive? You bet. We have special tests that can help us lock in certain areas to see if we suspect an ACL injury, some with better specificity and sensitivity than others. For the ACL specifically, we have the Lachman, anterior drawer, and pivot shift tests are typically the three go-tos. Sure, there are other ones out there, but those are the three. You go to an orthopedics office, and you come and see me. These are the clinical tests we would do on your knee to see if we can get any sense of whether the ACL is torn or not. But if it’s not typically within the first few minutes of that injury, it’s going to be a bit harder in that first one to the two-day window to get an accurate read, if not longer than that. If the knee is swollen and painful with swelling, probably being more of that limiter than anything. And you’ll see whenever someone injures their knee in a game. 

If we’re watching a game on TV and someone injures their knee, and especially if there’s a little bit more trauma to it. Or, I’m sure that as the trainer gets on the field and checks out the athletes, they ask them questions and they’re like, all right, what did you feel? They go through their series of assessments and then they’re going to start checking the area potentially on the field. A lot of times you’ll see if it’s a knee, they’ll go down there and they’ll check, and they’ll do that Lachman test. They’ll grab that end of the thigh and then they’ll grab the higher part of the shin and they’ll pull it forward and back. And that’s the Lachman’s test. And they’re testing to see, do they get an increase in laxity to basically see if the ACL is torn or not. You can get a good idea of it before the body starts to do its thing after the injury. And the swelling kicks in and more of the pain kicks in. You try to get that within those first couple minutes of the injury.

And then after that, once the pain and swelling sit in, then you start to get a little bit more blurry, it’s fuzzy, it’s hard to really say because that swelling in that joint is going to blur the lines, especially with any type of clinical testing. Two of the main things that people will report, and I can confirm this from my own experiences, is that you’ll feel the pop. And then that you can feel some instability or the knee kind of giving out. And I will say that whenever swelling starts to set in too, there’s probably less instability, at least from my own personal experience, and asking other athletes because that joint starts to fill a little bit. And then it almost locks in the joint a little bit more versus whenever the swelling is not present and you have a torn ACL.

Of course, there’s other factors like muscle strength and other things that go on in the knee that could get injured. But with that said, the pop and the instability tend to be two big factors that help to give us an idea. All right, maybe it is the ACL. But with that said, that’s not our goal to cover today. It’s just some pieces of that puzzle. It’s just one of those things that I think is important to mention as we do have this injury and we do go to this emergency room. And that’s the thing that I want to make sure we bring to light today is that I’ve had ACLers where they’ll walk away and they’ll think that it’s like an MCL sprain or a meniscus. And it’s not too uncommon for people to go with this assumption and then later find out that they’ve had an ACL tear.

And I’ve evaluated a lot of swollen knees immediately post-injury. And you have to piece these specifics of their story, the mechanism of how they tore it, and then try to do the clinical testing to see what we get. And if there’s an MRI available, then that’s awesome. Of course, then that helps us to make a decision. But a lot of times when people acutely injure their knee, they don’t have this information yet, especially not an MRI. And then we have to take the information we have so far and make a judgment. And there’s really no one who can say with 100% certainty in that one to two-day window that, oh, your ACL is torn. Maybe there are some clear-cut signs based on the swelling and some of these other pieces that are not there. But for the most part, if it swells up and you’re doing some of the testing, there could be some false positives with this, whether you’re an orthopedist, a physical therapist, athletic trainer. If you just don’t get the right timing, or it just depends on the type of injury, then it can be hard to figure out.

I want to give a little bit of transparency in that, that it’s not straightforward and that’s why we need to make sure we have all these pieces lined up. And of course, the more your expertise is in this area, the better you can give better advice and guidance on what potentially did happen and what those next steps are going to look like. And let’s just say that you did get a diagnosis from the ER and they said it’s an MCL tear or a sprain, or maybe it is a meniscus or something of that nature. You got that diagnosis and you’re still wondering, well, did I tear my ACL or did I not? Well, usually they’ll say, okay, see how it goes for the next two to four weeks. They might give you a brace or they might give you some medicine to help with the pain. They might say, hey, schedule an orthopedic visit if it doesn’t improve, which is great guidance. And the thing to think about here is that if you go to the ER and you’re told this, maybe it is very much an MCL tear or a meniscus tear. And oftentimes that can be the case.

I think the thing that is important to be cautious about is that if things don’t improve over, let’s say a two to four-week window and/or you feel instability, or maybe your gut is telling you something feels off. Listen to it. This is after having conversations with ACLers we’ve worked with or other ACL athletes wanting consultations. And the thing that happens is that they go and do this thing and then they’re told, ah, you’re fine. Go back and do your thing. After maybe two weeks, four weeks, six weeks, whatever that is, they go back to do the thing, and then things don’t feel right, or they end up injuring the knee again. And this is where I just want to throw caution to this and just make sure that when you take that window of time, assess it and see how it feels. And if your gut’s telling you it’s off, as I said, listen to it. And what we need to do is sometimes give it that window of time to settle down. And get out of the acute phase of this. And then that gives us a more accurate representation of how the joint actually is. Then we might be able to do better clinical testing because there’s less swelling or pain or your range of motion is improved. And therefore, we could do better testing to see, okay, if is this torn or not.

And then of course, the MRI will also help, and that’s usually what most offices will utilize in order to confirm that there is an ACL tear or anything else going on, or maybe you don’t have one. Maybe the ER did get it right. And so that’s the point of this episode, it’s not to not believe the ER or the urgent care doc you’re working with that has helped you. It’s just more so to be cautious and understand that given the information that you’ve been provided, the state of the knee when it’s being evaluated, we can’t have 100% accuracy. We have human error. At the end of the day, we can’t see into the knee, unfortunately. And even in MRIs, there’s some degree of error. So with that said, it’s just putting all these pieces together and getting the best understanding, and trying to figure out what’s going on. 

And so to sum up, if you’ve injured your knee and you are going to an ER, or you have gone to the ER, you’ve gotten a diagnosis, and you’re like, okay, that’s cool. Let’s see how it goes. That’s totally fine. Let it wait out, maybe two to four weeks. If you’re feeling a little antsy or if you’re not sure about it, then schedule a visit with an orthopedist and see if they can check it out. And then it might warrant an MRI. But let that knee calm down, and then let’s see where that goes. If someone does get it wrong, don’t blame them for it. It’s just a matter of medicine and it’s just a matter of the information that they have. It’s just more of making sure that you double-check. If you fall into this category and you don’t find yourself three months, six months later, and find out, oh wow, my ACL has been torn all this time. And you go to do things and your knee keeps giving out or something like that. So that’s something to look out for my ACLers. I want to make sure that you guys feel equipped if you’re in this situation. 

If you have any questions, please feel free to reach out to our team@theaclathlete.com. Until next time, this is your host, Ravi Patel, signing off.