Common sports injury: Torn ACL (anterior cruciate ligament)
with Rosemary Schultz, M.D
The ACL (anterior cruciate ligament) is located in the center of the knee joint. This strong band of connective tissue supports the knee, keeping the tibia (the inner and larger of the two bones in the lower leg) from sliding forward on the femur (thigh bone). It is frequently torn in sports injuries.
An ACL tear will not repair itself, but a person who has suffered a minor injury can strengthen the knee through rehabilitation. Athletes, however, require special surgery to reconstruct the knee when the ligament tears completely.
Rosemary Schultz, M.D. - Orthopaedics, Fellowship Trained, Sports Medicine, who is with Advanced Healthcare, sees the problem often, particularly in young athletes.
Who is at risk?
Risk for ACL injuries is highest for athletes in soccer, basketball or downhill skiing where the feet are planted one way and the knees are turned another.
Also, women who play basketball or soccer are usually three to five times more likely to have the injury than men in the same sport. The reason why is not clear. "Part of this could be training, muscle coordination or the way a woman's body is built," Dr. Schultz said.
ACL tears also occur by direct impact to the knee in those who have suffered a fall in a non-athletic situation.
While sports training exercises help strengthen the muscles surrounding the knee, anyone can suffer an ACL injury. It is very common among well-trained, professional athletes.
"People usually think of an ACL injury as happening when a player gets hit on the field but more often it is due to a non-contact injury. A person lands wrong from a jump or injures the knee coming to a quick stop or pivoting," Dr. Schultz said.
The Symptoms
In layman's terms, an ACL tear is aptly called "blowing out the knee." A person feels or hears a popping sound in the knee followed by a feeling that the joint has given way. Later there will be pain or swelling throughout the joint.
In time, the pain and swelling will go down, but the knee will likely be less stable. When a person stresses the knee, it may give way, causing further pain and swelling. The popping is a one-time symptom caused by the tear.
Giving way is a problem because in time, the ligaments can get looser. This was the "trick knee" people used to walk around with in the days before surgery became an option. But constant damage takes a toll on the joint. "A patient who comes to me and says my knee only gives way once or twice a year is at risk for early traumatic arthritis," Dr. Schultz said.
A look at ACL surgery
ACL surgery is usually done on an outpatient basis, though some of Dr. Schultz's patients stay overnight to recover. For the two-hour procedure, either general anesthesia or a spinal anesthetic to make patients drowsy and comfortable is used.
"First, we examine the knee under anesthesia to determine the laxity in the joint. Then we use an arthroscope to look inside the knee and examine all parts of the joint, the cartilage and ligaments. Finally, we do the reconstruction. We don't put stitches in the ligament, we make a new one, using grafts," Dr. Schultz said. The grafts may come from the patients' patellar or hamstring tendons or from donated tendons.
In her surgery, Dr. Schultz commonly uses a part of the patellar tendon, attaching the bone segments to the tibia and femur. "In time this heals bone-to-bone," the doctor said.
The tissue taken for the graft heals itself, usually in about six months. While it is healing, the patella (kneecap) or patellar tendon could be damaged if enough stress is put on the knee.
"Jerry Rice (NFL wide receiver for the Oakland Raiders) was a good example. He came back from reconstruction early, at about four months, landed on his knee and sustained a patellar fracture because the kneecap was not quite healed…only a temporary setback," Dr. Schultz said.
Post-op recovery and physical therapy
Physical therapy is crucial to the success of an ACL repair. It begins within a day of surgery, with the patient getting up on crutches and putting as much weight on the leg as is comfortable.
Most of Dr. Schultz's patients stay on crutches for about two weeks and wear a brace on the knee for six weeks, though the time can vary depending on how well physical therapy progresses.
Exercises will include simple straight leg raises and stretches to increase range of motion and progress to functional activities. These are done at home and in physical therapy. Patients will likely be in physical therapy several times a week for the first few weeks.
"In addition, if patients belong to a gym they can go and do such things as riding a bicycle. It's a lot of hard work, but usually my patients are athletic anyway so for them it's no big deal," the doctor said.
Read more about
ligament injuries.
