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ACL Injuries

When the ACL tears, the person often describes hearing a pop and feeling the knee "giving out" or buckling. A torn ACL often results in swelling and a loss of stability in the knee, sometimes referred to as "feeling loose."

There are several different types of ACL tears: a partial tear of the ligament, a complete tear of the ligament (rupture), and rarely the very end of the ligament remains attached to a small piece of bone which breaks or separates from the lower leg bone (avulsion).

Treatment Options

Treatment for ACL injuries depends on the severity of the tear and whether other parts of the knee are injured. The patient's activity level and overall health are also considered before treatment begins.

Depending on the activity level of the patient, minor ACL tears are usually treated with physical rehabilitation, which will help build strength and increase flexibility in the knee. Rehabilitation normally lasts a few weeks, at which time most patients return to normal activities.

Complete ACL tears, called ruptures, normally require ACL Reconstruction surgery followed by several months of rehabilitation. ACL Reconstruction is the most common form of treatment for patients who require the use of a stable knee for athletic sports, walking, or other low-impact activities.

It is important to get a timely diagnosis of an ACL injury to avoid potentially damaging the knee further. Typically, surgery may be delayed until several weeks after the injury. The delay allows swelling to subside and enables the injured knee to regain some strength, stability, and range of motion. Delaying the surgery also decreases the risk of permanent stiffness or decreased motion following surgery.

Procedure

There are several options available when treating an ACL injury. The most common treatment is to replace your native ACL with a new ligament. Typically, the new ligament material (graft) can be taken from one of the patient's own tendons (autograft), or the graft can be taken from a tendon in the knee of a tissue donor (allograft). You and your doctor will decide which option is best for your particular situation.

ACL Reconstruction is usually performed as an outpatient procedure and rarely requires an overnight stay in the hospital. The entire procedure requires approximately 1-2 hours to complete and is typically performed under general anesthesia, spinal or epidural.

ACL Reconstruction is most often performed arthroscopically. Arthroscopy is a surgical technique that uses long tube-like scopes that are inserted into the body through very small incisions. These scopes display the inside of your knee joint on a monitor, allowing the surgeon to precisely manipulate the surgical instruments. The benefits of arthroscopic surgery are a shorter recovery period, smaller incisions (one-quarter to one-half inch in length), minimal scarring, and less potential for infection.

The graft is passed through specially designed instruments into the tunnels and fixed inside the tunnels. The new graft is fixed inside the tunnels with screws made out of materials that resorb or dissolve with time and are replaced with bone by the body. The graft crosses the joint in the position as the original ACL after it is fixed with these devices. The small incisions are then closed and a knee compression bandage is applied. We also prefer to use a long leg brace postoperatively.

Graft Options

The ACL Reconstruction procedure creates tunnels in the thigh bone (femur) and the shin bone (tibia) to make a path for the new graft (tendon).

Graft options to build a new ACL include grafts taken from your own leg called autografts and grafts taken from a donor called allografts.

Allografts were formerly used in revision surgery situations where previous tissue may have already been taken from the leg. Now, these grafts are becoming the preferred option for first time or primary ACL reconstructions simply due to the main advantage of decreased pain in the early postoperative period. 

The two most common autografts include: 1) a portion of the patellar tendon with attached pieces of bone and 2)two of the smaller hamstring tendons, the gracilis and semitendinosis. Results are very good for both of these grafts as well. However, the patellar tendon graft has been associated with a higher incidence of pain in the front of the knee (patellar tendonitis), and some hamstring graft recipients have reported post-operative weakness in the hamstring muscles that both resolve with rehab.

All graft options as well as deciding which graft is right for you will be discussed with you and your surgeon during consultation pre-operatively.

Recovery

As you and the doctor may have discussed before surgery, extensive rehabilitation is the key to your recovery from ACL reconstruction. Recovery normally requires five to six months or until the graft is transformed by soft tissue healing into a strong and durable ligament. This can require the better part of one year. If the graft is ruptured or stretched drastically during the recovery, a second surgery will be required.

Phase I of rehabilitation emphasizes range of motion, which is critical to avoid knee stiffness.

1. •    Crutches are used for the first 7 -10 days after surgery for comfort.
   

2. •    Riding a stationary bike without resistance and pool exercises to increase motion usually begin about 2 weeks after the surgery.
   

3. •    Driving is allowed when the patient is comfortable and has mobility, often as early as 2 weeks after the operation.
   

4. •    The patient returns for an office visit about 2 weeks after the surgery so the incision and range of motion can be checked.
   
   Phase II of rehabilitation incorporates strengthening and usually begins about 6 weeks after surgery.
   

5. •    A sports cord (an elastic resistance strengthening tool) and the treadmill are initially used.
   

6. •    Use of a stair-stepper or elliptical trainer is added at about 8 weeks.
   

7. •    Strengthening using weights is allowed at 2 - 3 months.
   

Phase III of rehabilitation adds sport-specific exercises.

1. •    Running is allowed at 3 months.
   

2. •    Pivoting and twisting activities can begin at 4 to 5 months.
   

3. •    This phase is usually customized for the patient's sports and activity level.
   

The final phase of rehabilitation involves a supervised return to sports. This usually occurs approximately 6 months after reconstructive surgery.

The results of your ACL Reconstruction are based to a great extent on your discipline, motivation, and perseverance in performing the physical therapy program. With your cooperation and dedication, you have an excellent chance to regain the strength, stability, and confidence in your knee that you had before your injury.

Maximum medical improvement should be restored to your knee after two to four months of following your physical therapy treatment plan. Once your doctor clears you, most patients typically return to unrestricted recreational activities.

Healthy ACL

Injured ACL

1. *All literature found within this article has been abridged from the following sources: