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Posted on April 12, 2021

An Introduction to ACL Injuries

 

 

Do I Need Knee Surgery? What Do I Do Now?

The rupture or stretch of the anterior cruciate ligament is one of the most common injuries to the knee. Athletes who play sports with high physical demand, such as football or basketball, have a higher chance of experiencing anterior cruciate ligament injuries.

When the anterior cruciate ligament is injured, surgical intervention will most likely be necessary to restore the knee’s function. It will depend on several factors, including the severity of the injury and the patient’s activity level.

A Basic Anatomy of the Knee

The knee joint is formed by the meeting of three bones: the thigh bone (femur), the leg bone (tibia), and the patella. These bones are connected to our tendons, and the kneecap is on the front side of the knee joint to protect it. There are four main ligaments inside the knee joint. They act as resistant fibres that grip the bones to each other, keeping the knees stable.

Lateral ligaments

These ligaments are located on both sides of the knees. The middle collateral ligament is situated towards the inside, whereas the lateral one is located towards the outside. Hence, collateral ligaments are responsible for controlling lateral knee mobility and prevent them from making any improper movements.

Cruciate ligaments

Within the knee joints are the cruciate ligaments. They are arranged in a form taking the X shape; the ACL (anterior cruciate ligament) is located at the front. The PCL (posterior cruciate ligament) is located in the backside. The cruciate ligaments are responsible for controlling knee mobility back and forth.

The anterior cruciate ligaments cross the knee center longitudinally. It inhibits the shin bone (tibia) from moving ahead of the thigh bone (femur), in addition to providing rotational stability for the knee.

The Different Classes Of Injury

Injuries, such as damage to articular cartilage, menisci, or other muscles, occur in nearly half of all ACL injuries.

Partial rupture of the ACL is rare; in most ACL injuries, total rupture occurs.

Ligament injuries are called “stretches” and are classified according to their severity.

Minor strains: In a minor stretch, the muscle is slightly damaged. Although the muscle is slightly strained, it still manages to maintain the stability of the knee joint.

Mediocre strains: In a mediocre stretch, the ligament is stretched to the extent of loosening. It is usually called a partial ligament rupture.

Serious strains: This category of stretch is often called a total ligament rupture. The ligament is separated into two pieces, resulting in an unstable knee joint.

Fractional ACL ruptures: This injury is not common; as most ACL injuries result in total or almost total ruptures.

Symptoms of an ACL Tear

Some patients can hear a crackling or popping sound at the time of the injury. The cruciate ligament rupture causes excruciating pain. Several patients have identified the feeling of their knee breaking or moving. With time, the pain becomes more evident, particularly during physical activity or exercise. Because of the swelling in the knee, the joint’s motion is limited.

Tiny blood vessels are usually damaged as a result of the cruciate ligament eruption, resulting in a scar in or around the joint. Apart from that, the leg seems to be disoriented.

A cruciate ligament tear can go undetected in some cases. The only signs that an accident has happened are shaky posture and knee weakness. In addition, if the cruciate ligament cracks under low stress, the knee will collapse while walking.

The pain is usually severe, but it goes away after a brief period and rests. If pressure is applied to the knee again, the pain can worsen. The knee remains unstable.  The thigh moves downward compared to the lower leg, particularly when going down a flight of stairs, and causes discomfort.

Physical and historical examination of the patient

During the initial appointment, the doctor will go through your symptoms as well as your medical history. He will evaluate all injured knee structures and compare them to those of the contralateral (healthy) knee during the physical examination. A careful physical examination of the knee can help diagnose most ligament injuries.

Imaging Exams

Other tests that can help the doctor confirm the diagnosis are:

X-Rays: Although radiographs do not reveal the anterior cruciate ligament lesions, they can show whether the lesion is associated with fractures.

Magnetic Resonance Imaging (MRI): This exam provides better images of the soft tissues, such as the ACL. Nonetheless, it is not usually necessary to perform an MRI to complete a torn ACL analysis.

Cause of Injuries

The ACL can be injured in several ways:

  • Quick change of direction
  • Abrupt stops
  • Quickly reducing speed while run
  • Landing incorrectly after jumping
  • Direct contact (i.e. while playing football)
  • Collisions (i.e. if you’re involved in an auto accident)

The most frequent causes of an anterior cruciate ligament rupture are sports injuries and car crashes. In sports, the rupture is often caused by an abrupt stop with the knee extended, such as after a leap. A fall like this can cause the leg to flex, rotating it outwards unintentionally. An ACL tear is also frequently caused by an unexpected braking action combined with knee rotation.

Treatment

The treatment for ruptured ACL will vary according to the needs of each patient. For example, young athletes involved in highly demanding sports are likely to need surgery to get back into the sport. Less active people, usually older people, can resume calmer lifestyles without surgery. There are two treatment types for ruptured ACL: Non-surgical treatment and Surgical treatment.

The initial step in conservative therapy for a cruciate ligament tear is to immobilize and stabilize the knee in a splint. The immobilization cycle lasts a few weeks. After that, you will have to go through a lot of physiotherapies. To balance the knee joint, it is essential to reinforce the muscles of the thighs. The patient must steadily increase the amount of movement and pressure on the damaged knee. After a cruciate ligament rupture, consistent physiotherapy is critical for the knee joint’s stabilization and work. Knee instabilities can happen due to improper care.

Non-surgical treatment

The ruptured ACL does not recover without surgical treatment. But non-surgical treatment can be beneficial for older patients or those who have a lower level of physical activity. If knee stability is still present, a doctor may advise simpler non-surgical options.

In non-surgical therapy, step-by-step physical treatment and recovery can reconstruct the knee to its original state and teach the patient how overcome and control the unstable condition.

This might be enhanced by using the knee brace with hinges. However, numerous individuals who decide to avoid a medical procedure may encounter further knee injury because of frequent instability issues.

If there are multiple injuries associated with the ACL injury, surgery is the most appropriate treatment form. However, non-surgical therapy can also be effective in some patients. It is particularly advisable in the following cases:

  • Patients without any instability signs and having partial ruptures.
  • Patients showing no instability signs during light sports activity and having complete ruptures. However, they must be willing to stop heavy sports activities.
  • Patients performing light manual activity
  • Patients who choose to carry on with an inactive way of living
  • Patients with open growth plates (kids).

 

Orthosis: A doctor may recommend the use of an orthosis to protect the knee from instability. To give additional protection to the knee, it is also possible to use crutches to prevent the body weight from being supported on the injured knee

Physiotherapy: When the swelling subsides, a cautious rehabilitation program will begin. Precise exercises can restore your knee functions and help in strengthening the muscles surrounding the knee.

Surgical treatment

Ligament reconstruction

In most cases, ACL ruptures cannot be sutured (joined with stitches). The ligament needs to be reconstructed to repair the ACL via surgical treatment to restore knee stability and mobility. The doctor uses a tissue graft to replace the damaged ligament; it acts as a platform for the development of a new ligament.

Grafts are likely to be acquired from various sources. These are usually detached from a patellar hamstring that extends between a leg bone and the patella. Usually, the hamstring lying on the backside of the thigh is used for obtaining the grafts. The quadriceps muscle, which stretches from the thigh to the kneecap, is occasionally used. Finally, the allograft is used infrequently.

All graft sources have their advantages and disadvantages. The graft options should be discussed with the orthopedic surgeon to determine which is the best.

Since the ligament needs time to integrate, it can take an athlete six months or longer to resume athletic activity following surgery.

The Procedure

Surgical therapy to restore the ACL is performed by inserting an arthroscope through small cuts. Arthroscopic operation is less intrusive. The advantages of less intrusive methods include reduced pain from the operation, shorter hospital stays, and shorter recovery times.

Unless it is the treatment for an injury associated with ligament injuries, ACL reconstruction is not usually performed immediately. Before surgery, the inflammation is expected to cease, and movements return. ACL reconstruction preformed early reduces the danger of scars which form in the joint, called arthrofibrosis, which may result in the loss of knee movements.

Rehabilitation and Returning Back to Activities

Regardless of whether treatment needs surgery, rehabilitation plays a vital role in resuming day-to-day activities. A physical therapy program will help in regaining strength and knee movements.

Rehabilitation Goals

The goals for ACL rehabilitation includes a reduction in knee swelling and maintenance of kneecap mobility to prevent anterior-knee pain issues, regaining full mobility of the knee, as well as strengthening the hamstring and quadricep muscles.

The patient’s balance and control sense related to the leg should also be re-established through various exercises designed for improving neuromuscular control. It normally takes around four to six months to bring about this improvement. While wearing a well-designed brace when resuming sports activity is not necessary after a successful ACL reconstruction, some patients may find that it provides them with a greater sense of safety and security.

What happens after surgery?

Following surgery, physiotherapy will concentrate on regaining mobility of the knee joint and surrounding muscles. Then, to preserve the new muscle, a reinforcement program would be introduced. Reinforcement gradually raises the effort in the tendon’s regions. The athlete’s sport decides the final phase of recovery, which helps to regain functional mobility.

Physical therapy is an important element of effective Anterior Cruciate Ligament treatment, especially following post-surgical procedures. However, the effectiveness of ACL rehabilitation medical procedures relies upon the patient’s commitment to uncompromising physical therapy.

With the latest surgical procedures coupled with effective graft affixation methods, physical therapy can further speed up ACL recovery.

Postoperative Course: The laceration is kept clean and dry for the first ten to fourteen days after surgery. More focus is placed on regaining quadriceps function and being able to fully straighten the knee joint.

The knee-joint is treated with ice regularly to reduce swelling and pain. The doctor may advise using the postoperative brace and using the machine for moving the knee to gain full mobility. Moreover, crutches are recommended to keep the operated leg free from weight and stress. It is also determined by physician preference, as well as other injuries addressed at the time of surgery.

Treatment/Techniques

When a cruciate ligament fracture is expected, the RICE concept must be implemented (rest, ice, compression, elevation). Stop doing your exercise, lift your leg, cool the knee-joint with the help of ice, cryo-spray, etc.) and wrap it in a compression bandage. Painkillers can be used to relieve extreme pain.

A cruciate ligament tear may be treated surgically or conservatively. This is based on the form and extent of the damage. Specific considerations such as the patient’s maturity, athletic interests, and the extent of knee-stressing exercises are all taken into consideration while preparing treatment.

In most cases, the operation is done on young patients for cruciate ligament tears who are more active in sports than in older patients who are less active and are not exposed to as much knee pressure. In patients with low levels of physical effort and low levels of stress, a cautious approach to care is appropriate.

Short term effects of ACL surgery

 

Viral transmissions

Allografts expose patients to the danger of viral transmission (i.e. it is possible to acquire a bone-allograft from an Hepatitis C contaminated benefactor) despite cautious screening and preparation.

Blood loss/impassiveness

Rare dangers such as blood seeping from intense wound to the popliteal artery. It may result in weakening or paralyzing the leg/foot. It is not unusual to have deadness in the upper leg’s external portion close to the cut, which might be brief or lasting.

Blood clotting

Although uncommon, blood clots in the calf/thigh veins can be fatal. This clotting may affect the circulatory system, move to the lungs, create a pulmonary embolism, or, in a worse scenario, travel towards the brain and cause a stroke.

Instability

Lingering instability is possible after an operations due to surgical methods.

Knee Stiffness

Rigidity in the knee or the loss of movement is common for patients after surgery.

Failure in the extensor mechanism

Rupturing of the patellar ligament (patellar ligament autograft) or fracture of patella (patellar ligament or quadriceps ligament autografts) can also happen because of weakness at the point of graft joining.

Injury of the growth plate

In youths with ACL ruptures, early ACL surgery can create a potential danger of damaging the growth plate, resulting in bone development issues. The ACL medical procedure may be deferred until a patients’ skeletal development is about to mature. The specialist might then have the option to change the ACL recreation method to diminish the danger of any damage to the growth plate.

Pain in the Kneecap

Postoperative front knee pain is a common aftereffect of patellar ligament autograft ACL surgery. Pain occurring behind the kneecap differs significantly in examinations, while the frequency of pain while kneeling becomes higher after patellar ligament autograft ACL surgery.

What are the possible long-term effects of an ACL injury?

This injury can cause shakiness in the knees when performing twisting motions. Participating in high intensity contact sports such as football, handball, and basketball would be complicated. Furthermore, sports requiring participants to use their legs for control, such as golf, skiing, and paddle tennis, would be difficult to play.

Is a return to sports possible?

The patient can resume sports activity when there are no signs of pain and swelling, as well as achieving full knee mobility and full restoration of the leg’s functional mobility, endurance, and muscle strength.

Cyclists and swimmers may continue with minimal restrictions because these sports require the least amount of knee rotation. Although there are less complications with these sports, patients may still experience pain or any other discomfort in certain movements, like breast-stroke in swimming and sprinting in cycling.

For sprinters, it is possible to run a nonstop race. However, cruciate tendon injuries limits an athletes running ability if there are lopsided floors or race-tracks with sharp bends.

For regular day-to-day existence, ACL injuries may cause issues while climbing the stairs or bending/twisting around. Persistent instability can cause further damage to the menisci and ligaments. These can result in the early and sped-up osteoarthritis of the reconstructed knee.

Conclusion

Total ACL ruptures sometimes result in long-term disruption. As a result, many patients may undergo joint-stabilizing surgery to return to their former level of active daily living. Moreover, the decision should be taken on a case-by-case basis.

There is a chance of secondary injury to the meniscus and articular cartilage where there is no muscle compensation. As a result, children and teenagers are also given the green light for stabilizing surgery. Osteoarthritis cannot be avoided in many cases, even with well-established surgical procedures.

Complications such as swelling, infections of joints, thrombosis, nerve, and vascular damage are uncommon after a cruciate ligament rupture. In most cases, both surgical and proactive care for a cruciate ligament tear yields successful long-term outcomes.

In the majority of cases, regular physiotherapy treatment is crucial to keep the joint from burning out prematurely. It is essential to exercise the muscles daily overtime to see consistent outcomes in the future (especially the thigh muscles).

The outcome of cruciate ligament replacement surgery is influenced by appropriate postoperative therapy. Both Physiotherapy and Massage Therapy are effective forms of post-op therapy. Goal setting is also key during rehabilitation, as creating targets will help develop positive habits.