Injuries to the Anterior Cruciate Ligament (ACL) are relatively common in sport, especially in Australian football, basketball, netball and skiing.
The ACL prevents the femur from moving forwards during weight bearing. It also helps to prevent rotation of the joint.
Injury of the ACL most often occurs when an athlete is pivoting, decelerating suddenly or landing from a jump. The injury can also be caused by another player falling across the knee. Women are much more likely to suffer an ACL injury than men.
Studies indicate that after ACL reconstruction, on average 81% of people returned to any sport, 65% returned to their pre-injury level of sport and 55% returned to competitive level sports.
The decision to allow an athlete to return to sport (RTS) after ACL reconstruction is based on the elapsed time after surgery (a surrogate for biological healing) and the patient’s functional capacity. Incomplete rehabilitation and rushing back to sport can result in additional knee injuries and graft rupture.
An ACL rupture may be associated with an injury to other stabilising ligaments within the knee. Rupture of your ACL is commonly associated with tears that involve the shock absorbing cartilages (menisci) of the knee. Depending on the location and size of these tears, they may be surgically repaired or trimmed at the time of your surgery.
The first line of treatment following injury to the ACL should be those of the RICE principle (Rest, Ice, Compression, and Elevation). Early review by a physiotherapist is important to reduce swelling, improving movement and minimise wasting of muscles around the knee joint. Crutches are generally recommended to avoid excessive weight on the injured limb primarily during the early stages until you can walk without pain.
Goals Of Treatment
The treatment of ACL tears will vary across individuals based on their expectations, lifestyle, sporting aims etc. The major aim is to return the patient to their desired level of activity, both in regards to sport as well as other activities such as your occupation, whilst minimising the risk of injury to other structures within the knee.
Patients with an ACL tear who do not wish to return to pivoting sports can often be managed with this approach. Running in a straight line, swimming, bike riding and golf are activities that are suitable. Physiotherapy is critical in the recovery phase to restore movement and strength to the lower limb. The latter phase of your rehabilitation should focus on proprioceptive re-training. These are exercises that improve the protective reflexes around the joint to minimise further instability episodes and reduce the risk of further joint injury.
When is an ACL Reconstruction recommended?
Most patients who want to return to pivoting sports will require a reconstruction to prevent their knee buckling during these activities. Other indications for surgery include young patients with high activity levels and people who work in an environment where knee stability is critical for safety and function. If your knee is giving way regularly and this is interfering with your quality of life, you may want to consider an operation. This instability may occur during sport or during activities of daily living.
When should the surgery occur?
An ACL reconstruction is not an urgent or emergency operation. The best outcomes from reconstructive surgery have been shown to occur in people whose knees have had some time to stabilise and recover. In the majority of cases, it is preferred to rehabilitate your knee prior to undergoing surgery. For elite athletes, surgery will usually be performed after a shorter period of rehabilitation.
Physiotherapy prior to surgery is important to reduce the swelling, regain movement and limit the loss of strength in the muscles around your knee. It also teaches you the exercises needed for rehabilitation after the surgery.
Physiotherapy (rehabilitation) is critical to the success of the surgery. If you cannot strictly follow the necessary precautions and rehabilitation, then it is best off not having surgery as complications such as graft loosing, graft rupture, stiffness and chronic pain can result.
It is important to start physiotherapy within 2-4 days of your surgery. You will require physiotherapy twice a week for approximately 6 weeks then reducing the amount of visits after this. Rehabilitation after an ACL reconstruction takes approximately 12-18 months. During this period you will take part in a structured rehabilitation program with your physiotherapist, and gradually return to your normal activities. This process is designed to safely improve the strength, motion and balance (proprioception) in your knee whilst the ACL graft heals
Recent research has allowed therapists and clinicians to easily identify and target weak muscle areas (e.g., weak hips, which leads to knock-kneed landing positions) and identify ways to improve strength and thus help prevent injury. In addition, other risk factors such as reduced hamstring strength and increased joint range of motion can be further assessed by a physiotherapist to improve performance. Prevention programs such as FIFA 11+, Footy First and Netball Knee have been shown to reduce ACL injury rates.
Current studies also demonstrate that specific types of training, such as jump routines and learning to pivot properly, help athletes prevent ACL injuries. These types of exercises and training programs are more beneficial if athletes start when they are young. It may be optimal to integrate prevention programs during early adolescence, prior to when young athletes develop certain habits
To make a booking to see your local Melbourne ACL sports physiotherapist for treatment of your ACL tear or injury, please call your local clinic or book online.