ACL & Ligament Tears
Injuries to the Anterior Cruciate Ligament (ACL) in the knee are common. ACL injuries send more athletes to the bench for longer periods than almost any other acute injury. ACL injuries occur most often in people who participate in high impact sports like tennis, basketball, football, skiing and soccer, which requires abrupt changes in direction. Injuries occur when the athlete plants the foot to change direction and the knee buckles. In contact sports, the injury results from being clipped from behind. In skiing, the ACL tears when the ski catches in the snow or twists the leg.
Every time the knee buckles it does damage to the cartilage which can lead to early arthritis.
Female athletes suffer more ACL tears than male athletes. 50% of these injuries also damage other parts of the knee joint.
The cruciate ligaments in the knee are located inside of the knee joint and cross each other to form an X. The anterior cruciate ligament (ACL) is in front and the posterior cruciate is behind. These ligaments stabilize the knee for rotational movement.
Tears in the ACL are usually complete tears or ruptures. During sports, the ACL can be injured by:
- Rapidly changing direction- cutting, pivoting and sidestepping
- Stopping suddenly
- Awkward landings from a jump
- Direct impact as in a football tackle.
70% of ACL injuries occur without contact, 30% are the result of direct impact.
Athletes with partial tears can recover with progressive rehab in about 3 months, and patients can learn what causes instability and how to avoid it. However, instability is always a risk.
Complete ACL ruptures will prevent sports participation or even walking. Repeated episodes of instability can further damage the knee.
- You may hear a popping sound when the knee gives out.
- There will be pain and swelling within 24 hours of the injury, which may resolve on its own. But, any attempt to return to sports with instability increases risk of more damage to the knee.
- Loss of range of motion
- Tenderness at the joint
- Discomfort while walking
Your South County Orthopedic Specialists (SCOS), orthopedic expert will conduct a physical exam and patient history, at which point the patient will describe what caused the injury, symptoms and medical history. The physical exam will compare the patient’s uninjured knee range of motion, and the like to the patient’s injured knee. Most ACL tears can be diagnosed with a physical exam.
X-rays and imaging tests may help confirm the diagnosis and show if there is a broken bone. An MRI will provide images of the ACL.
Conservative treatment includes rest, anti-inflammatory medications and activity modification.
Once the swelling resolves, pain and dysfunction can be treated successfully with physical therapy.
A torn ACL will not heal without surgery. Nonsurgical management can be successful for patients with:
- Partial tears and no instability
- Complete tears with no knee instability and low activity levels. These patients must be willing to give up high demand sports
- People who do light manual work or live sedentary lives
- Children in whom the growth plates are still open
When knee stability is good, your doctor may recommend a hinged knee brace to protect against instability. You may need to use crutches to avoid putting weight on the leg. Physical therapy will restore function and strengthen the leg muscles.
When conservative management is unsuccessful, and there is recurrent knee buckling, ACL reconstruction may be the best option to restore full function and allow the patient to return to an active life.
ACL Reconstruction Surgery
The goal of surgery is to create a stable knee, and allow patients to return to their chosen sports. The ACL will not hold stitches so it must be replaced for the patient to achieve stability.
Before surgery, a patient usually undergoes physical therapy, because if the patient has a stiff, swollen knee and poor range of motion at the time of surgery, it can create major problems in regaining motion after surgery.
- Replacing or reconstructing the ligament. The torn ligament will be replaced with a tendon tissue graft. The graft tissue may be obtained from the patient’s own ligament tissue (an autograft), or from a cadaver (an allograft). It takes about 6 months before an athlete can return to sports.
- The surgery is delayed until the inflammation resolves and motion returns.
- Replacement of the ACL offers long term success rates of 82-95%.
ACL reconstruction is accomplished with arthroscopic knee surgery. The surgery begins with an arthroscopic exam of the knee to verify the tear and check for other tissue that may require repair, such as other knee ligaments. Once a complete diagnosis has been made, the surgeon will proceed to replace the torn ACL ligament.
This is minimally invasive surgery accomplished with a few small incisions, less pain, less joint stiffness, and has a shorter recovery time to allow the patient to return to sports.
Rehabilitation with physical therapy is critical for a successful outcome, and often begins immediately after surgery.
A patient may return to sports when there is no pain or swelling, full range of motion and muscle strength have been restored, and endurance and function have been fully restored. Balance will be restored through specific exercises.
- The patient must decide whether he or she is wiling to give up sports and activities that involve hard turns, pivoting, and heavy manual labor. These patients are often encouraged to have surgery if they want to continue with their sports or jobs.
- If considering surgery, the patient must commit to dedicate themselves to rigorous physical therapy for 4-6 months.
- A patient with significant instability has a high risk of secondary knee injury, and should consider surgery.
- When an ACL tear is combined with other injuries, surgery will often provide the best outcome.
Surgical complications are the same as with all surgeries:
- Bleeding and numbness
- Blood clots
- Recurrent Instability
- Loss of motion and knee stiffness
With arthroscopic surgery, proper strengthening and rehabilitation, 96-98% of patients return to their sport of choice. Each patient will determine a personalized course of treatment with their SCOS surgeon.
At SCOS we are fortunate to have three sports medicine knee specialists, with fellowship training and extensive experience in ACL repair and knee ligament reconstruction. Specifically, Dr. Scott Graham, Dr. Chris Veneziano and Dr. Nimish Kadakia have been treating the active and athletic population of Orange County for years, with exemplary skills and dedication to getting athletes back to play after ACL injuries. They are specialized in arthroscopic knee surgery and knee ligament repairs of all types with continuously high patient satisfaction reports and return to play success.
Sports Medicine Specialists
Scott Graham, MD
Dr. Graham is our Sports Medicine specialist, providing advanced and minimally invasive care for all sports medicine injuries. Read Dr. Graham’s biography.
Christopher Veneziano, MDS
Dr. Veneziano sees Orange County, CA patients for general orthopedic problems and injuries, and specializes in sports injuries. Read Dr. Veneziano’s biography.
Nimisha Kadakia, MD
Dr. Kadakia is a fellowship trained orthopedic surgeon who specializes in the care of sports injuries at SCOS. Read Dr. Kadakia’s biography.