Tears in the Anterior Cruciate Ligament (ACL)

• Sport injuries often cause ACL tears, particularly those from contact sports like football or other games that require a lot of twisting of the knee.  
• There are several ways to treat an ACL tear, meaning surgery is not necessary for everyone.

We often hear about professional athletes injuring their knee ligaments, especially in popular sports such as football. Some international football players have had to undergo a few surgeries on the anterior cruciate ligament (ACL) of the knee. 

The ACL is a ligament at the front of the knee, responsible for keeping the knee secure during movement. In other words, it steadies and controls our leg movements from the knee, and helps lock it in place. The ACL is especially crucial for twisting or rotating knee movements.

Sport injuries cause most of the ACL tears, especially those from contact sports like football, basketball and rugby. Participating in games requiring a lot of knee twisting, such as tennis and badminton can also lead to accidents that tear the ligament. Sports that entail a lot of jumping, like gymnastics are equally risky. Such injuries are, however, not limited to sportspersons. Ordinary, non-sporting activities including falling down the stairs, tripping or stumbling while walking, or other accidents can cause an ACL tear.

If your ACL is torn, within one to two hours, you will notice your knee swelling from the bleeding inside the knee. Mostly you will not be able to continue playing sports or other activities after the injury. Apart from the swelling, you will also experience knee pain and difficulty moving the knee. For patients who have severe symptoms, you may feel as if the knee has come loose.

If you experience immediate and severe pain, and notice a swollen knee within one to two hours of the injury, see a doctor immediately. It could mean a torn ligament or even a fracture. A torn ligament causes bleeding inside the knee, as would a fracture nearby the kneecap. Otherwise, it is usually just a simple soft tissue injury. In that case, rest the knee for one to two weeks for healing. If after two weeks, you do not see an improvement, consult a doctor.  Your doctor can prescribe the best treatment based on the cause of your prolonged symptoms.  

There are several ways to treat an ACL tear, meaning surgery is not necessary for everyone. The type of treatment required will depend on the symptoms of each patient and their lifestyle.

For elderly people who have single-strand ACL tear, surgery is not typically required. Medication and physiotherapy along with specific lifestyle changes can be sufficient to treat ACL tears. Additionally these therapies will also help to reduce the risk of reinjury. On the other hand, younger patients, and patients who cannot abstain from activities that require lots of twisting at the knee, or those whose work involves a high level of physical exertion may require surgery to continue working as before. Finally, regardless of age, if the patient has an ACL tear combined with an insecure or unstable knee, then the doctor will consider surgery.

Some patients may have multiple injuries in the same knee. For instance, one could have a torn ligament combined with a fracture, or a torn ligament combined with cartilage damage, or multiple torn ligaments. For such patients, the doctor will consider surgical treatment, so that multiple knee conditions can be treated simultaneously. Moreover, with surgery, the knee can be reconstructed as similar to normal as possible.

Arthroscopy is a popular procedure used to treat ACL tears, because it is minimally invasive, leaves only a small scar and is relatively pain-free. In addition, the arthroscope has a high level of magnification. This helps the surgeon see other abnormalities in the knee more clearly than with open surgery. 

The doctor may use reconstructed ligament that is suitable for the patient for more effective results. Alternatively, the doctor will keep the good part if the arthroscope finds that the ACL is only partially torn.  Building a whole new ligament will, then, not be necessary. An ACL augmentation can be done, in other words, the surgeon will only reconstruct the specific area required. During this procedure, the surgeon can create a new ACL that is almost as strong as before.

The knee will not return to its normal function from surgery alone, at least not as the patient might expect. Instead, the patient must practice using the knee post-surgery, to gradually strengthen it. The patient’s condition should be assessed and a suitable rehabilitation plan put in place to prevent recurrence. ‘Return to Play’ meaning the doctor will determine when the patient is ready to return to sports or other activities after the surgery. Weak muscles around the knee or atrophied, or injured ligament that is not fully healed are indications of high-risk of a repeat injury. In such cases, the doctor will recommend the patient to undergo further training. This will help rebuild muscle capacity before returning to sports or activities.

Post-surgery training programs like the FIFA 11 Plus, takes around 15 – 20 minutes per session and two sessions per week. Such programs help reduce the risk of repeat injuries by 30 to 50%. It is focused on the three parts outlined below:

1. Rebuilding body strength, especially in the muscles in the front of the torso, back, buttocks and both legs
2. Increasing coordination between the brain and the muscles required for balancing
3. Increasing muscle power, as well as flexibility

“Surgery alone is not enough to get you back to normal. It requires dedicated training and physical rehabilitation too.”

**As part of ‘Return to Play’, the doctor will conduct two tests to determine whether the patient is ready to return to sports or other activities:

1. Functional Testing for knee strength. This could be the Single-Hop Test or the Three-Hop Test
2. Isokinetic testing for muscle strength. This test measures muscle efficiency and retrains muscles affected by joint surgery, particularly knee surgery. Isokinetic testing measures muscle strength while the body is in motion as if to simulate the playing of a certain sport or the performance of an activity. The doctor must look at whether the body is balanced on both sides, right and left, and front and back to assess overall muscle strength.
3. If the test result is in the correct range, then the patient can return to sports or other activities. Otherwise, the patient must undergo further training to increase his muscle strength and the body’s fitness before returning to sports.

How to prevent ACL tears 

Patients who have suffered an ACL injury tend to have weaker joints than those who have not. The best thing is to prevent such injuries or tears. When the ACL is already injured or torn, then its surrounding cartilage is likely to deteriorate over time. Muscle strength and flexibility training are highly recommended to prevent ACL injuries. Such training also helps to improve the strength of the knees, balance and posture, so that the knee flexes and extends correctly. This training is called the ACL Prevention Program.

Playing sports and getting regular exercise is a great way to build strength and have fun. However, be aware that accidents can happen at any time. Go to see a doctor immediately if you get injured. Ignoring the injury may worsen it, and increase its possibility of developing into knee osteoarthritis.

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