Episode 212 | Can You Prevent A Cyclops Lesion in ACL Rehab?

What is up team and welcome back to another episode on the ACL Athlete Podcast. Today, we were talking cyclops lesions. I’ve done a podcast episode on this before, diving into all the details around the cyclops lesion. But today, we’re answering the question: can you prevent a cyclops lesion in ACL rehab?

Now, let’s take a step back and just understand what a cyclops lesion is, which is still a question mark. We don’t fully know. But what we do know about this in a sense is that it is a wad or just this ball of scar tissue in the anterior aspect of the new ACL in the intercondylar notch. Let me break this down a little bit more. 

You have your new ACL and in the front of that ACL, there is some scar tissue that is building in the intercondylar notch, essentially, think about the end of your femur or your thigh bone. There’s a notch in there where those ligaments set, especially the ACL and the PCL. With that said, in that notch, that’s where the ACL will move and do its thing. They will see that the cyclops lesion or that ACL, that whole bundle, if you will, will be in that intercondylar notch, and then that is the issue that the athlete is dealing with.

There’s different theories around what a cyclops lesion is. One, it is a remnant of a previous ACL stump that had remained during surgery. Now I think most surgeons go in and clean that out, but different surgical procedures and maybe depends on how thorough this is. But, that’s one thing that can potentially contribute to this.

Another theory says that the fibrocartilage as a result of drilling the tibial tunnels. We think about the inflammatory process that is involved in there. And what ends up happening is the end result is arthrofibrosis, which is essentially scar tissue. It is scarred-down tissue that is in that knee joint. It is something that is like a physical block within there. 

Now, it can happen to what the research says somewhere around 2% to 11% of ACL reconstructive patients, but it’s a range, of course. And most probably, say around 2% to 4% is probably the average statistic. It can present anywhere from post-surgery to six months after, or even longer. Honestly, we’ve seen it across the board. But what we’ll typically see is a persistent loss of extension in the first two months or so. And what we need to do is keep an eye on this and keep it on the radar. And if it persists longer than three months, four months, then we need to make sure we roll this out.

This is super important to take into consideration. If you are someone who is dealing with an extension issue, I would not just go run or don’t run (bad joke for an ACL podcast). I wouldn’t go to the surgeon and say, “Hey, I have a cyclops lesion.” We want to make sure we do our due diligence from a clinical exam standpoint, assess what you’ve been doing, compliance of the work you’re doing, are you doing the right stuff. And if you’ve been really pushing it, then yeah, of course, this could be a conversation, if extension is still an issue or you’re getting some clunking as you go into extension or maybe you regain extension and then it regresses back. But we do see this and it is something that exists. And we tend to see this more in quad tendons, actually. They happen across the board. It’s not necessarily any specific tendon, but we tend to see, anecdotally, that quad tendons might be contributing to this as well. But I don’t have any research to back this up. This is just more of our own personal experience and mine, especially. We’re talking with other colleagues who see a lot of ACLs as well. Could be the thickness of that graft, it could be where it’s taken from, it could be from the intercondylar notch, having a notchplasty, so that’s cut down a little bit. So that could maybe fuel a little bit more inflammation or remnants, if you will, and could lead to scar tissue or a cyclops forming. 

In general, I think it happens more often than what the research shows and that’s just my personal take on this. I don’t think that is 4%, I think that that is a little bit higher. I know it’s a 2% to 11% range. Maybe more on the higher end of that range. I just don’t think it’s always caught and you just take the research. It’s not there are a ton of studies on cyclops lesions. But for the ones that exist, it did find this range. And I think, especially as quad tendons, for example, become more prominent in this space that we might even see an increase in that. But don’t think just because you have a quad tendon, you have a cyclops, it’s just something that we see has a correlation a little bit more. It’s also a little bit stickier with just getting the extension back, the quad doesn’t want to activate as much. There are a lot of factors in play here. But just sharing what we see from working with hundreds and hundreds of ACLers, that’s something that we want to share our stories and anecdotes and experiences with working with just the different graft types, different populations, different procedures all over the world. So that’s important that you guys are able to experience that or understand that from your own end as well. 

We have had things where the surgeon is refusing to get an image or denying that it’s there. They do a clinical exam. The extension might be in a little bit of gray area. It’s not like it’s in plus 10 or plus 15 degrees, but it might be plus five degrees, plus seven degrees. And with extension, we’re working with small degrees. We’re not working with flexion where it’s like 90 degrees or 130 degrees. You have just more degrees that you’re going through versus extension. You’re going in this like zero into the negatives. Even plus two versus a minus three—massive difference in quad activation, what you feel and especially when you’re comparing it to the uninvolved side. This is something that we often see with ACLers is that sometimes the surgeon will refuse that or deny it. Therefore, go get a second opinion, go get a third opinion and see if we can get an MRI and see if it’s there or not.

Something that we just want to make sure that we just keep in mind if you’ve done everything right and your extension just still seems to be stuck after three to four months. And if it seems signs earlier of it, not budging and you’re in this plus five, plus 10, then maybe it’s something that is impacting your rehab and worth rolling out, in my opinion. I think in certain systems it can take a while, or maybe it’s the cost associated. Sometimes we have people where they come in and it’s eight months later or 11 months later, and they’ve been dealing with this issue and they just were never educated on it. Or they’re just like, this is just your knee. But in reality, there was a cyclops there. 

With that said, I think it’s just important to make sure you have someone with you who can help tease through this stuff and has the experience. Never hurts to get a second opinion, even with physical therapists. And any good physical therapist should put their ego aside and say, “Hey, yeah, let’s bring someone else in,” especially if there’s low ACL experience, even if it’s high ACL experience. If someone came to me and was like, “Hey, Ravi, I think I’m going to go get a second opinion. I would respect that because there are things I haven’t seen and there are situations where I might be looking through things in a certain lens and someone else comes in with their own lens and they look at it differently and are able to provide a different perspective. And that goes across any profession, y’all, any profession, any experience—surgeon, physical therapist, medical provider, think about teachers, think about financial advisors. You think about any domain of profession, there’s going to be the way that we learn things, the way that we assess things, the way that we critically think about things. And there’s a lot of “not” critical thinking going on. I think it’s important to just be able to make sure that you are getting the right care and attention and the right opinions about where you are in this process because it is an opportunity cost. You’re tackling a cyclops lesion at three months versus eight months can make all the difference in your life and all the frustrations of those five months where you almost felt gaslit in a way.  You’re like, “I’m doing everything I can.” And we’ve had athletes share this. They felt like they were gaslit by their PT, their surgeon. They’re like, “Oh, you’re just not doing your stuff, or it’ll get better with time, and oh, it’s getting better.” But you feel like it’s not getting better. I think that’s important to share with you guys that we want to make sure that you are looking out for yourself and making sure that your team is also looking out for you.

The reason for this episode today, the most important point of this episode is, can you do anything to prevent the cyclops lesion from happening? The scar tissue formation and this thing that we want to avoid. Can you do anything to prevent it? In short, no. It’s probably not what you guys want to hear. But based on current research, current science available on this topic, even just experience in general, guys, this is challenging because we don’t really know what exactly causes a cyclops lesion or the timing of it. This is something that I wanted to bring up because I sometimes see ACLers—and I feel like I’ve heard this more recently, just blaming themselves and can sometimes blame others too, maybe other people in their care. Whether it’s the physical therapist they were working with, maybe it was the surgeon who often can get the blame for this. But with that said, they are blaming themselves most importantly. And I think this is just something that we need to take a second to process this. Essentially, what they’re doing is they think that they’re not doing enough or rushing the process and so then they start to point the finger inwards at themselves. While sometimes this can be the case, I’m not going to deny sometimes, people do rush into it too fast, or maybe they just didn’t do enough and they just provided the right environment and lack of compliance for scar tissue to form and that’s why it happened. But we can’t pick and choose who those people are going to be, so that makes it really challenging. But I will say not doing the rehab and rushing into surgery isn’t going to be the 

But here’s the thing, y’all. Even with people who do everything perfect, getting the most attention and care, it still happens. So what gives here? And as I was alluding to before, we don’t know. I think it’s important to be transparent about this. If someone gives you a rhyme or a reason, you just want to take it in stride and just question a little bit. In current day, as this podcast is being released, we don’t know 100% why.  I suspect there are so many factors here, just like with a non-contact ACL injury. When it happens, we don’t necessarily know the reasons why specifically. And with cyclops lesion, I imagine there are some factors in play that we might not know about. But some things that just come to mind are even just a person’s genetics, the injury they had themselves, the timing between the injury and the surgery. Think about the concomitant injuries themselves, whether that’s meniscus, MCL, did they have tibial plateau fracture, was there any type of chondral damage. There are a lot of things that can also coincide with an ACL injury and not just the ACL itself. So that will trigger a potential inflammatory process that makes it a little bit worse. What about the graft type that an athlete gets, the rehab process itself, whether you’re working on the right things or not.

But I think a big one that can often get overlooked or one that I think plays into this is the inflammatory process. Everyone’s got their own inflammation that happens whenever you injure something. We have a natural inflammatory process that is going on in our bodies to repair things and turn over cells and tissues. Especially when there’s an injury that happens, there is an acute inflammatory process that takes place. When you cut yourself, there is an inflammation process taking place to make sure that you are able to heal that area. Whenever something like an ACL injury happens, inflammation occurs when you are recovering, that inflammatory process taking place to heal. And then also when the surgery happens. Some people are a little bit more prone to having, whether it’s chronic inflammation or inflammatory process, in general, and swelling coincides with that to some degree can be a little different.

But with that said, we typically see those go hand in hand and stick around for maybe a longer time. In some people, it might go away very quickly. And I’m not saying that inflammation or swelling itself leans itself to a cyclops lesion, either. These are all factors that I’m just throwing out there that could be contributing. The main thing here is, do you have control over all of these? Some, yes, and some, no. Like you have control over the things you do in rehab. You have control over the timing of injury to surgery. You have the control of the graft type you choose. But some of this stuff, your genetics, the injury that happened itself, maybe even some of the other things that you might not necessarily have a choice about, could be influencing some of this stuff.

Again, even those who did every single thing right and the knee looked great, let’s say even three months out, extension looks great and awesome. We’ve had people regress backward and that’s because the cyclops presents itself and they can still get them, even with the most perfect situations possible. If you’re an ACLer listening to this or maybe a clinician or coach listening to this, control your controllables and that’s all we can ask for. That’s getting the knee quiet, managing your symptom profile, your swelling and pain, restoring range of motion, especially with an extension focused consistently throughout the day, getting those quads awake and activated, and don’t forget about the other important areas that influence your overall health and recovery.

Nutrition, getting in adequate amounts of protein. We need a lot of protein to make sure we can maintain and rebuild. And also nutrients that can have some natural anti-inflammatory effects. Sleeping well for at minimum 7 hours. And something that gets overlooked—managing your stress. Stress has a byproduct of cortisol and inflammation and whatnot. We want to make sure we manage our stress very well. Of course, you’re going through this process so it’s stressful, in general. You might not be sleeping as well. But when you can get these things in control and that’s going to be a huge byproduct of allowing yourself to move the needle and controlling the things that you can control. And if you’re doing this stuff and you get a cyclops lesion, give yourself some grace. It is going to happen to some people, even with the most perfect things in place, recovery, controlling for everything. And you know what guys shit happens. Don’t blame yourself unless you didn’t do anything. Maybe take some ownership for not doing something and who’s to say that even not doing something would have played into the cyclops or not. But with that said, that’s a controllable you had control over.

I always tell our athletes, even when this comes up and even with our team, can we control the controllables? If we can, then therefore that is all we can ask of our athletes and of our team to make sure that we set people up for success.But in most of these cases, ACLers are doing everything they can, especially when they’ve been pushing extension. We’ve been educating and encouraging around this and giving them all the tools possible to do it and it still happens. Then, it’s about game planning when that does show up, you decide. Is it severely impacting things like extension pain, quad activation and just activity in general to move forward? Or is it gray area where it’s impacting these things but it’s not very much? You can take it or leave it with some of the discomfort or extension, but overall functionally you’re doing okay. You just notice the difference. And that’s the one that’s honestly the most challenging and even surgeons themselves won’t necessarily operate on it. And some aren’t the most happy to operate on it anyways, because some believe that it’ll just come right back. I think that if it’s impacting things a good amount and it could put you in a position where you’re not able to extend your knee the proper way or get your quad strength up to a certain point, pains in the way, or positions don’t look really good, then I think it is very much worth it to make sure there’s a plan in place to tackle that thing. But then it comes down to talking with your team about it and whether you feel like something needs to be done about your specific context and situation. 

The takehome here is if a cyclops happens, give yourself some grace. Just know it happens to even the pro athletes, for example, where it’s their full-time job to do this and they have the best resources possible. We just don’t hear about it. This does exist though in the pro-collegiate space. It’s just some of this stuff is kept up tight. We’re not going to necessarily hear as much detail about these high-level athletes making millions of dollars and high profiles and issues that they’re dealing with. This is just something to keep note of, even for the best of the best, if you will. But the big thing here is to get a plan in place, keep doing the thing, stay focused in your ACL rehab, and just control the controllables y’all. 

I hope that this is helpful in terms of just understanding cyclops lesions. Can we prevent them or not? It’s just a very challenging question to answer. I think it is one that we need to continue to explore as time goes on in this space. Until next time team, this is your host, Ravi Patel, signing off.