As an experienced Orthopaedic Sports Surgeon I have treated all types of athletes - young and old, world class and amateur, with ACL injuries. This article will help you make the most-informed decision possible regarding the management of an ACL injury.
What is an ACL tear?
Most patients I meet have heard of the ACL, and know athletes that have suffered an ACL tear, but are not exactly sure what or where it is. ACL stands for Anterior Cruciate Ligament. It is one of the main ligaments (rope like structure) in the knee.
The ACL sits in the middle of the knee and attaches the thigh bone (femur) to the shin bone (tibia). It stops the shin bone from sliding forward and rotating excessively. If your ACL is torn then your knee may buckle and give way during movements that require a sudden change in direction, like sidestepping or pivoting, e.g. during football, basketball, netball, rugby or martial arts.
Most patients that I see that I see with an ACL tear have had a non-contact injury that occurred when they were turning on their knee suddenly during training or a match. In footballers this can occur when they place excessive pressure on their standing leg when performing a crossfield pass.
Unfortunately for female athletes reading this, you are at greater risk for an ACL tear, due to differences in alignment, size and shape of your knees.
Athletes who tear their ACL often feel a ‘pop’ and their knee may swell suddenly (as the torn ligament bleeds). A key feature is that they are immediately unable to walk or continue playing due to pain. When the knee swelling eventually subsides their knee may feel unstable or even give way, and they are unable to play their favourite sports.
I always ask a lot of questions about how exactly the injury occurred and carefully examine the knee to make the diagnosis of an ACL tear. An MRI (magnetic resonance imaging) scan can swiftly be arranged to identify an ACL tear and rule out other injuries such as a meniscal tear.
Famous athletes who have suffered an ACL tear include Zlatan Ibrahimovich, Ruud Van Nistelrooy, Francesco Totti, Paul Gascoigne, Alan Shearer, Tom Brady, Tiger Woods, Jamal Crawford, and Derrick Rose to name but a few. So if you have an ACL tear then you are in excellent company, and the good news is that all these athletes were able to resume their playing careers successfully after an ACL reconstruction. With the right treatment so can you!
Can the torn ACL heal on its own?
The ACL usually does not heal well on its own because it does not have a good blood supply. I liken it to a rope, and if completely torn in the middle, it is difficult for the rope ends to come together to heal, particularly as the knee is moving all the time. However some athletes are able to return to sports if they only have a partial ACL tear, minimal instability or play sports that do not involve sudden turning movements (e.g. baseball).
Is ACL reconstruction surgery my only treatment option?
ACL reconstruction is when the torn ACL is completely replaced by a tissue “graft” (usually made of hamstring tendons which sit behind the inner thigh) to provide stability to the knee. It is the recommended treatment option for athletes who have knee instability following an ACL tear, and are unable to play sports.
It is worth seeing a good physiotherapist on the recommendation of your surgeon, and undergo rehab before considering surgery. This allows your knee to regain full range of movement and strength, as well as allow bone bruising to settle. Some doctors have also argued that ACL reconstruction is associated with a lower risk of early arthritis (degenerative change) on Xray.1
ACL repair is a newer treatment suitable for certain types of tears where the ends of the torn ACL are reattached to the thigh bone using a device called an internal brace. Most ACL tears are not suitable for direct repair and there can be a high rate of revision surgery with repair (1 in 8 patients in some papers). There are many studies on the use of stem cell and platelet rich plasma in ACL healing, but these technologies are still in an experimental stage and the “gold standard” treatment is still ACL reconstruction surgery.2
What are the different types of ACL reconstruction surgeries in Singapore?
All reconstruction surgeries use a ‘graft’ or transplanted tissue, to replace the torn ACL. These grafts include:
When is the best time to go for an ACL reconstruction surgery after an injury?
Within a few weeks of injury is ideal.6 Delaying surgery for more than 6 months is associated with a higher risk of injury to other structures in the knee like cartilage and menisci.7,8 Ideally you will have undergone physiotherapy to reduce swelling, regain full range of movement and strengthen your quadriceps (front thigh muscles) before the operation.
Some people recover quickly, some take a little longer. For a professional athlete it can be at least a year before they return to sports at a similar level. If you return to sport too soon you have an increased risk of your ACL graft retearing.
How much improvement can you expect after an ACL reconstruction surgery?
According to a large study involving 7556 patients undergoing ACL recontructsion, the majority were able to return to sports (81%). Two thirds of all patients were able to return to their preinjury level of competition, and 55 percent were able to return to elite level competition.
If you have torn your ACL and have knee instability, ACL reconstruction may be an excellent solution to your problems. At International Orthopaedic Clinic (IOC) we are dedicated to helping you find your way back to playing and enjoying sports.
Dr Alan Cheung is a Consultant Orthopaedic Surgeon specialising in Sports Injuries such as torn ligaments and tendons, and cartilage injury in the knee, hip and shoulder, Adult Joint Reconstruction including total and partial Knee Replacement and Total Hip Replacement for osteoarthritis, and Robotic Surgery (Makoplasty, Navio and Robodoc systems). He has also received extensive training in trauma (fixing broken bones) and musculoskeletal tumour (bone cancer) surgery.