Understanding Anterior Cruciate Ligament (ACL) Injury

Anterior cruciate ligament (ACL) is one of the most important ligaments in the knee joint, playing a crucial role in stabilizing the joint. ACL injuries are common among athletes and active individuals, particularly those involved in sports that require sudden stops, jumps and directional changes like basketball, badminton, skiing and also the contact sports such as football, rugby, etc. In India, one of the leading causes is road traffic accidents (RTA). These injuries can be debilitating in the long run and need to be addressed on time.

Where is ACL located?

ACL is one of the four major ligaments in the knee, connecting the femur (thigh bone) to the tibia (shin bone). It prevents excessive forward movement of the tibia relative to the femur and helps control rotational movements of the knee. The ACL, along with the posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL), ensures stability and functionality of the knee joint.

How does it get injured?

ACL injuries typically occur due to excessive stress on the ligament, leading to a tear or rupture. Some of the leading modes of injury include:

1. Sudden stops / change of direction: Sports like football, basketball, tennis involve quick pivots and changes in movement, which can put immense stress on the ACL.

2. Jumping and landing improperly: High-impact landings, especially with inadequate knee control, increase the risk of ACL injury.

3. Direct trauma: A direct blow to the knee, such as during a football tackle or road traffic accident, can result in ACL damage.

4. Hyperextension of the knee: Excessive extension caused by a sudden force or incorrect movement can strain or tear the ACL.

5. Weak muscles and poor conditioning: Insufficient strength in the muscles supporting the knee can lead to instability and increase the risk of ACL injuries.

6. Gender Differences: Studies suggest that female athletes are more prone to ACL injuries due to anatomical differences and hormonal influences.

When should you suspect an ACL injury?

The symptoms of an ACL injury can vary depending on the severity of the tear. Common ones include:

Immediate symptoms:

1. Popping sensation or sound: many individuals report hearing a "pop" at the time of injury

2. Severe Pain: immediate pain in the knee, often preventing weight-bearing walking

3. Swelling: Knee swells up rapidly due to internal bleeding

4. Restricted range of motion: Difficulty fully extending or bending the knee

Delayed symptoms:

1. Instability: the knee feels wobbly or gives way during stair climbing, pivoting movements

2. Frequent falls

3. Inability to walk or run fast due to apprehension of a fall

How is it diagnosed?

If you suspect an ACL injury, seeking medical attention is crucial. Diagnosis typically involves:

1. History: typical mode of injury

2. Physical Examination: Your orthopaedic doctor will assess the swelling, range of movements and stability of the joint

- Lachman Test: A specialized physical test used to evaluate the integrity of the ACL.

- Anterior Drawer Test: Another manual test to detect instability in the knee joint.

- Pivot-Shift Test: Used to assess the knee’s rotational stability.

3. Radiology:

- X-rays: Necessary to rule out bony fractures, ligament avulsion injuries

- Magnetic Resonance Imaging (MRI): Provides detailed images of soft tissues, confirming the type and grade of ACL tear, rules out associated injuries such as meniscus tears

What are the treatment options?

Treatment varies based on the severity of the injury, patient’s activity levels, functional demands and long-term goals. The two long-term approaches are non-surgical and surgical treatments. Irrespective of this, the initial management of the injury remains the same.

A) Immediate Care:

- R.I.C.E. Protocol:

• Rest: Avoid activities that put stress on the knee

• Ice: Apply ice packs to reduce swelling and pain

• Compression: Use an elastic crepe bandage and a long leg knee brace for support

• Elevation: Keep the knee raised over pillows to minimize swelling

- Consult an orthopaedic surgeon at the earliest

- First priority is to reduce the pain, swelling, restore the normal knee movements and functionality.

- Bracing and supervised rehabilitation are the keys to get back to your daily routine quickly

B) Definitive treatment:

It consists of conservative (non-surgical) and surgical options. Treatment best suitable for you can be decided based on your age, type of lifestyle and involvement in sports or pivoting activities.

1.     Conservative Management:

This modality of treatment is suitable for patients who prefer sedentary lifestyle, are not involved in or ready to curtail pivoting activities such as running, jumping, dancing and those presenting with advanced stage of knee arthritis. It involves:

• Physical Therapy: Supervised rehabilitation to strengthen the core, hip and agonist muscles of ACL (hamstrings and soleus) to improve knee stability.

• Bracing: A hinge knee brace can provide additional support during initial phase

• Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) help reduce initial pain and inflammation

• Activity Modification: Limiting high-impact activities forever to prevent future episodes of buckling and probable damage to other knee structures, primarily the menisci

2.     Surgical Management:

In cases where the ACL is completely torn, surgery is often recommended, particularly for active individuals having symptoms of instability

ACL Reconstruction Surgery:

• The procedure is performed under spinal anaesthesia by arthroscopy (key-hole surgery)

• Minimises the risks of an open surgery, such as excessive bleeding, infection, and post-operative pain

• Surgery typically takes around 1.5-2 hours

• Graft is prepared using one of the tendons from the patient’s own body (hamstring, patellar tendon, quadriceps) and fixed inside the joint using two tiny titanium buttons.

• Once the graft heals well, the patient can perform all sports activities without any difficulty.

Rehabilitation:

• Immediate post-operative care includes pain management and swelling control.

• Patient can walk by putting weight on the leg right from the next day

• Hinge knee brace support is needed for initial 8-12 weeks

• Return to competitive sports usually takes 9-12 months

How is the recovery post-surgery?

Recovering from an ACL injury, whether through surgery or non-surgical means, involves a structured rehabilitation program. The key phases include:

Phase 1: Initial Recovery (0-2 Weeks)

• Focus on pain management and reducing swelling.

• Gentle range-of-motion exercises.

• Use of crutches or walker for support if needed.

Phase 2: Strengthening (2-6 Weeks)

• Begin weight-bearing exercises.

• Increase quadriceps and hamstring strength

• Improve balance and proprioception.

Phase 3: Advanced Strength and Conditioning (6-12 Weeks)

• Introduce low-impact exercises (cycling, swimming).

• Progress to resistance training.

• Improve agility and neuromuscular control.

Phase 4: Sport-Specific Training (3-6 Months)

• Gradual reintroduction to sports-related movements.

• Plyometric training (jumping, cutting drills).

• Focus on dynamic knee stability.

Phase 5: Return to Play (6-12 Months)

• Clearance from a medical professional.

• Full participation in sports with proper precautions.

• Ongoing strength and conditioning maintenance.

How to prevent ACL injuries?

Prevention is the key to reducing the risk of ACL injuries. Some effective strategies include:

1. Strength training: Developing strong muscles around the knee improves stability.

2. Plyometric and agility drills: Training the body to land safely and cut efficiently reduces stress on the ACL.

3. Proper warm-up and stretching: Enhancing flexibility and muscle activation before exercise.

4. Use of protective braces: Athletes with previous ACL injuries may benefit from supportive braces during the early rehab

5. Neuromuscular training programs: Exercises focusing on body mechanics, balance, and coordination.

To summarise:

ACL injury can be a life-altering event, particularly for active individuals and athletes. Early diagnosis, appropriate treatment, and a structured rehabilitation plan are crucial for optimal recovery. While surgery may be necessary in specific cases, non-surgical approaches can also be effective for individuals willing to alter their lifestyle.

With proper prevention strategies, the risk of ACL injuries can be minimized, ensuring long-term knee health and functionality. Continuing sports activities with an ACL tear and instability can be detrimental for the rest of the knee structures and may complicate things further. If you experience instability of the knee or suspect an ACL injury, consult an orthopaedic surgeon promptly to determine the best course of action suiting your needs.

Get to know the Doctor

Book a consulatation to know more!