ACL Injury (Tear)

Anterior Cruciate Ligament (ACL) injuries tend to occur due to a rotational injury to the knee and are especially common in twisting and turning sports (eg skiing, rugby, football and netball).

Overview

The anterior cruciate ligament (ACL) is one of several important ligaments that connect the tibia (shin bone) to the femur (thigh bone) across the knee. It is one of the key primary stabilisers of the knee.

ACL Tear Causes & Symptoms

When the ACL is damaged as part of a twisting injury, you may actually hear or feel a “popping” sensation. As the ligament has a blood supply, when torn the knee may fill with blood becoming swollen quite quickly. It is often impossible to continue sporting activity after ACL rupture and urgent medical review is generally required. 

When the ACL is damaged, the knee can feel acutely unstable and occasionally will give way completely.  Often the ACL is injured as part of a combination of injuries in and around the knee. These frequently include the medial collateral ligament (MCL) which may only be mildly stretched and occasionally fully ruptured. In addition the meniscal cartilages are also often damaged as part of the twisting mechanism.

Without an intact ACL it is very difficult to return to any sports that require twisting and turning, such as, rugby, football, squash and skiing. However, other “in line” sports such as running, cycling or cross training are often possible, despite ACL deficiency. 

Diagnosis of injury to the ACL

As with all surgical conditions, diagnosis of damage to the anterior cruciate ligament is made by a combination of:

  • listening to your history 
  • clinical examination
  • diagnostic imaging techniques e.g. MRI scan 

Once a definitive diagnosis has been made, your surgeon can discuss with you the best way to proceed.  

ACL Treatment & Surgery

Not all ACL injuries need reconstructive surgery. In some cases, the ACL can re-attach to surrounding structures and render the knee stable after a few weeks (approximately 10% of cases).

It may be possible to pursue many sports without a functioning cruciate ligament. However, more rigorous, high-demand sports that involve a lot of “cutting”, twisting and pivoting are much more dependent on an intact, functioning ACL.  

For most patients, the initial treatment centres around reducing the swelling within the knee whilst strengthening the muscles around the knee to act as secondary supports for stability. 

A specialist physiotherapist will often “Pre-hab” the parent so as to help reduce swelling, improve movement in the knee and let the soft tissue injury settle whilst optimising early recovery. 

If a second ligament (eg. MCL) is injured, you may need the knee braced for a few weeks until this heals, and this can slow the recovery down a little.

The stability of the knee is often assessed carefully once you have a pain free range of movement and if the knee is deemed unstable, a surgical reconstruction of the ACL is recommended. Essentially, achieving rotational stability prevents further damage to the meniscus and cartilage surface within the knee.

ACL reconstruction surgery

Due to advances in surgical techniques, what was once a major open operation is now a minimally invasive procedure, meaning it has become an increasingly popular operation over the last decade.  

Like most surgical procedures, there are many ways of achieving an excellent ACL reconstruction. Most surgeons across the world use a similar technique to restore a ‘new’ ACL, but the choice of graft material varies widely.

Your surgeon will discuss with you the surgical options available in terms of reconstruction and what they feel is the best technique in your individual case.  The following will be considered carefully:

  • The type of graft that can be used - such as your own tissue, hamstrings or patella tendon graft (autograft) or the use of donated cadaveric tissue (allograft).
  • The type of reconstruction ie isolated ACL reconstruction and/or the need for extra articular support with lateral tenodesis (particularly in the revision situation).
  • The fixation methods used to hold the graft .
  • ACL reconstruction involves undergoing a general anaesthetic and is now done as a day case procedure. The operation takes approximately 40-60 minutes.  

The operation is carried out under direct vision of the arthroscope (camera) inserted within the knee. Bony tunnels are drilled within the shin bone (tibia) and the thigh bone (femur) to allow the graft to be pulled across and held in place securely. This graft is, in effect, creating a ‘scaffold’ on which a new ligament can grow.  

ACL Surgery Recovery

In the immediate post-operative period, the priority is:

  • to reduce the swelling in and around the knee 
  • to regain the range of motion 

The post-operative programme is as follows: 

  • Crutches and a brace are provided for a two-week period, but you will be able to stand unsupported.
  • You will walk once awake and be able to climb stairs within 3-4 hours after surgery.
  • Physiotherapy begins the day after surgery.
  • The sutures are removed from the wounds after two weeks.

The surgeons at Schoen Clinic will work closely with the outpatient physiotherapist of your choice to optimise your recovery. You will be carefully monitored after surgery by both your surgeon and your physiotherapist to make sure that you are recovering well. 

As the wounds settle, the priority changes from the range of motion to muscle-strengthening and proprioceptive/balance work.  Naturally, every patient recovers at a slightly different rate and there is no “normal” with respect to returning to sporting activity post-surgery. We would, however, expect you to be able to cycle within the early months following surgery and run after five months.  

The speed of recovery from this operation is limited by the ability of the body to integrate the graft material into the bony tunnels and to become fixed. This integration takes a minimum of ten weeks, but the graft itself continues to strengthen internally for up to 18 months after the reconstruction. 

The surgeons at Schoen Clinic have an international reputation and regularly treat professional and amateur athletes from around the world. We also have some of the leading sports medicine consultants in the UK who can also advise on muscular optimisation prior to returning to competitive sport. 

Specialists

Mr Sam Rajaratnam
Head of Department - Knee

Consultant Orthopaedic Surgeon FRCS(Tr&Orth)

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Mr David Sweetnam
Head of Department - Knee

Consultant Orthopaedic Surgeon MBBS FRCS FRCS(Orth) DipSportsMed

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Mr Deepu Sethi

Consultant Orthopaedic Surgeon MBBS FRCS (Tr&Orth)

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Dr Philip Batty

Consultant Sport and Exercise Physician MB ChB, MRCGP, FFSEM

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Mr Paul Trikha

Consultant Orthopaedic Surgeon & Knee Specialist FRCS (Tr&Orth) MBBS

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Dr Roger Wolman

Consultant Rheumatology and Sport & Exercise Medicine MD (Res) FRCP FFSEM

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