Anterior Cruciate Ligament Injuries

There are four major ligaments in the knee. Two in the center of the knee are the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). The anterior cruciate ligament (ACL) is an important structure that provides stability to the knee. The ACL when injured is responsible for what most people call a "trick" knee. It is commonly injured when an impact or blow is sustained to the outer knee. Sometimes you can "blow out" your ACL without getting hit.

What happens when you tear your ACL?

When the ACL is injured you know it. It can happen when your knee is hit. It can even happen when the knee is twisted and does not get hit. When the ACL is torn the foot is usually planted while the rest of the leg and body is twisted.
You and everyone around you hear a loud POP!!!
You can't walk on it. You can't "shake it out." You are unable to continue playing. The knee swells up immediately and can get to the size of a grapefruit.
Immediate medical treatment includes ice, ace wrap compression, elevation, splinting. X-rays should be done to make sure there are no dislocated or broken bones. After a few days, if nothing is broken you can walk on it a little with crutches or a brace.
Next there are generally three alternative treatment options. Your knee function can determine whether or not you need to have surgery. I tend to place patients into one of three groups.

Treatment

• Group One - Athletic, active individuals will experience episodes of what they describe as "giving way." Activities like twisting to get in or out of a car, walking on uneven ground, stepping off a curb the wrong way makes the knee give out. When this happens it is disabling. The knee swells up again for a day or two. The knee slowly feels better. But eventually the knee pivots again. For some athletes, slowly returning to sports can help determine if it needs to be fixed. In the course of practice or play if the knee pivots, then it probably should be fixed. Football, basketball and soccer players always need knee surgery to return to these sports. Episodes of pivoting that occur more than 2 or 3 times a year indicate an unstable knee that should be fixed.
• Group Two -  “Weekend warriors” that modify their sports or activities. The knee gives out once or twice a year and they are OK with that. They have stopped or changed sports so that the knee does not give way.
• Group Three - The functioning ACL tear group. The ligament is torn but the knee rarely gives way. This group has no limitation with knee function. They know the feeling of pivoting and can actively "control" of the knee.
  If the knee gives out more that a few times a year then the ACL should be surgically reconstructed. Reconstructing the ACL can prevent ongoing cartilage, ligament and bone injury. In the non-surgical group, treatment includes bracing, physical therapy, and activity modification.
  Some patients come to my sports clinic and want immediate surgery. This may be a bad idea if the knee is still swollen stiff and sore (what I call a “hot knee”). Surgery done while the knee is still “hot” can cause permanent loss of knee movement. When surgery is done after the knee has “cooled down” the results are much better.

Surgery

There are several surgical techniques that are used. All of them require use of new tissue to create a new ligament. Surgery to shrink the ligament does not stabilize the knee.

• Technique One- A new ligament is carved out of the knee using a sliver of bone from the front of the kneecap along with a sliver of the tendon below the knee cap and a sliver of bone from the top of the shin bone. This surgical technique is called a bone –patella tendon – bone graft. It is carved out of the front of the knee, fashioned into a cylinder and this slides inside the knee in the same direction and with the same attachments as the original ACL.
• Technique Two - Use of the hamstring tendon. Part of the hamstring tendon is removed front the inner side of it's attachment at the knee. It is shaped into a tube like structure and it is secured inside the knee in a similar fashion to above technique.
• Technique Three -The use of a cadaver ligament is also common. This tissue is checked and sterilized. I use a reliable bone bank to obtain the graft. The tissue is shaped into the appropriate size and is inserted into the knee similar to the above methods. After Surgery physical therapy is the key to successful ACL surgery.

 

Post-operative goals should include:

1. Pain Management
2. Swelling Control
3. Regaining Full Movement
4. Thigh Muscle Strengthening and Retraining

Dedication to physical therapy is the difference between a great ACL reconstruction and an OK one. It's up to you. It usually takes six months to return to contact sports such as soccer, football and basketball. It takes three or four months to get back to heavy work.  Most athletes and patients that do heavy work wear a brace for up to a year from surgery.
In the past a torn ACL was a career ending injury. Not anymore. Careful timing and preparation can get you back “in the game.”