Treatment for ACL Injuries: Is Surgery Required?

Anterior cruciate ligament (ACL) is what connects your shinbone to your thigh bone to stabilize your knee joint. It works with the posterior cruciate ligament (PCL) to control knee motion. An ACL injury occurs when the anterior cruciate ligament in the knee gets overstretched or tears.

Usually, this happens when you abruptly stop or suddenly change direction while running, or land incorrectly while jumping. Overextending of the knee joint could cause it too. As a result, these injuries are more common when playing sports like basketball, soccer, and football. In order to reduce swelling and pain from an ACL injury, try elevating the leg or using ice. In addition, one can use the help of crutches for the first few days, but not for too long. Otherwise, lack of activity can cause the muscles to become weaker. 

An ACL injury sometimes comes alongside damage to other parts of the knee. For example, the meniscus, the articular cartilage or other ligaments could also have been affected. Consult a doctor, who will offer methods of treatment accordingly. Undoubtedly, choice of treatment depends upon the patient’s condition and needs.

Typical symptoms of ACL injury include:

• A “popping” noise and the knee giving out when the injury occurs
• Swelling within 24 hours of the injury
• Pain that intensifies when putting weight on the injured leg
• Discomfort while walking
• Joint line becoming tender
• Loss of movement

If any of these symptoms occur, do not return to sports. The knee is still unstable and further damage to it can be caused; consult a specialist as soon as possible.

An ACL injury can be diagnosed through a variety of methods:

• A physical examination – The patient’s symptoms and medical history will be evaluated. The doctor will compare the patient’s injured knee with the non-injured knee, checking all the different structures. Most ligament injuries can be diagnosed through this method.
• X-Rays – An x-ray can show the association between an injury and a broken bone. However, an x-ray will not show the damage done to the anterior cruciate ligament.
• Magnetic Resonance Imaging (MRI) scan – Creates better images of the anterior cruciate ligament and other soft tissues. However, in most cases, an MRI scan is not necessary for the diagnosis of a torn ACL.

There are two types of ACL treatments:

• non-surgical
• surgical

Non-surgical treatment means using a brace, a crutch or a physical therapy program. Generally, these are not recommended for ACL tears. This is because it’s unstable nature could lead the patient to experience secondary injury to the knee. Mostly, non-surgical treatments are used for young children or patients with: 

• partial tears and no severe symptoms
• complete tears, but are willing to give up sports
• very low activity level
• no clinical instability

ACL surgery has a long-term success rate of 82 to 95 percent. It is especially suitable for patients suffering from a combination of other knee injuries or complete tears. Moreover, surgery is recommended for athletes and those who wish to avoid the issue resurfacing in the future. By undergoing surgery, the knee becomes stable again. As a result, the function of the ligament is restored.

The goal is to repair or reconstruct the ligament. During the procedure, the doctor replaces the torn ligament with a tissue graft. In this case, the graft becomes a scaffolding on which the new ligament will grow. Doctors obtain the graft from either the patellar, hamstring or quadriceps tendons. In some cases, they use tissue from a donor.

Arthroscopic surgery is the most effective form of surgery for ACL treatment. In this procedure, an arthroscope (a small instrument with a camera) will be inserted through a small incision. Then the surgeon will use the arthroscope to reconstruct the ligament. Most prefer this minimally invasive surgery (MIS) to open surgery because it means:

• only one-centimeter incisions in front of the knee
• less scarring and pain to the patient
• faster recovery time
• the surgeon gets a better image of the knee structures
• fewer risks than open surgery

Learn more about minimally invasive surgery here. 

What happens during arthroscopic surgery?

The doctor might recommend physical therapy for patients who are planning to undergo surgery. Once the patient’s knee is ready for treatment, the following procedure is carried out:

• First, the patient is administered either regional or general anesthesia.
• After that, the doctor examines the patient’s ACL and other ligaments in case they need repair too.
• Next, he/she prepares the graft. If an allograft (tendon from a donor) is to be used, it will be thawed before the procedure. For other types of grafts, the doctor will harvest the tendons from the selected body area.
• Post that, the doctor makes small incisions of one-centimeter each in the knee front.
• Then, he/she inserts the arthroscope. Simultaneously, he uses any other necessary equipment to inspect the knee condition.
• Following that, the doctor removes the stump of the torn ACL. At the same time, other ligaments are also trimmed and repaired.
• After which the torn ACL is replaced with the selected graft. The doctor then holds these in place using posts, staples and screws. Generally, we will not need to remove these devices.  
• Finally, the doctor removes the equipment and closes the incisions.

Whether the patient has undergone a surgical or non-surgical, rehabilitation is vital for a full recovery. A patient’s physical therapy should focus on:

• Regaining motion and strength in the knee
• Strengthening the surrounding muscles and the new ligament

Samitivej Hospital has two testing machines; Isokenetic muscle and Biodex (Balance testing) to further aid the rehabilitation process. Moreover, sports physiotherapists and trainers are at hand to provide training and rehab programs tailored to each individual patient.

• The Isokinetic machine improves muscle strength. Along with that, it assesses muscle function during different intervals of exercise. Therefore, it can be used to evaluate the patient’s joint arthritis and physical impairments pre and post-surgery. 
• On the other hand, the Biodex machine is used for athletes and elderly patients. It improves balance and stability post surgeries or sports-related injuries. 

The rehabilitation process can last six months. The muscles in the injured leg must be as strong as the uninjured leg before resuming normal activities. Besides, completion of physical therapy can prevent the injury from recurring in the future. For athletes, the therapy might also include endurance activities, coordination training and adapted sports programs. Thus, engaging in physical therapy can help these athletes return to their chosen sport on schedule.

Here are the complications that might occur during or after arthroscopic surgery:

• Bleeding
• Numbness
• Blood clots
• Infection
• Knee stiffness
• Pain in the kneecap
• Recurrent instability of the knee due to the reconstructed ligament rupturing or overstretching

These complications rarely occur; however if they do, consult a doctor immediately.

The Sports and Orthopedic Center also reaches out to anyone suffering from orthopedic injuries, or from acute or chronic damage to bones and joints. Our center brings together a highly accomplished team of 38 orthopedic surgeons, physical therapists and sports injury and physical rehabilitation experts. We pair these experienced experts with the latest orthopedic and physical rehabilitation equipment, ensuring all patients receive the best possible care. 

Samitivej has a team ready to help and provide services for: 

• Treatment Plan Consultation with a doctor via online video-call (second opinion)

• Treatment Planning if you have medical records or a price estimate from another hospital 

• Cost Planning by our Appraisals Team with price guarantee (only for procedure packages without complications)
• Check Initial Coverage Eligibility with Thai and international insurance companies (only for insurance companies in contract with the Hospital)