Anterior Cruciate Ligament (ACL) Injuries

This is an extremely common injury in athletically active young people especially in sports with a lot of high pressure twisting and jumping such as netball, basketball and football.
There will almost always be a history of a dramatic giving way episode of the knee with lots of pain and subsequent swelling (but not always!). The injury may initially seem to settle well (perhaps with physiotherapy) but the knee feels weak or unreliable and a subsequent return to sport results in giving way of the knee.
It is usually fairly easy to diagnose this injury by a careful history and physical examination by an experienced sports medicine practitioner. Any history of a sudden giving way with a pop and swelling of the knee should raise a strong suspicion of this serious injury.
There can sometimes be other associated injuries to other important knee structures such as cartilage tears, other ligament tears or sprains, loose bodies, kneecap damage. These can usually be detected and treated at the same time as the anterior cruciate ligament reconstruction.
Treatment should include the option of immediate anterior cruciate ligament reconstruction. It is not necessary to delay the operation 'to prevent stiffness' and a preliminary arthroscopy 'to check the damage' is also not necessary. Sometimes if the diagnosis is not certain an MRI scan can help prove the diagnosis.
The use of strapping or a brace will not usually allow a safe return to sports such as football/basketball/netball, but may be successful for less demanding sports.
Reconstruction is the only realistic option for a young sportsperson keen to continue in their high demand sports. This is particularly true with recent dramatic advances in simplifying the surgery to rebuild torn anterior cruciate ligaments. Every attempt should be made to stabilize the knee before secondary damage to the cartilages and joint surface occurs. 1-2 days in hospital are required. A successful reconstruction will not require the use of a brace and immediate full weight bearing is optimal for healing tissue and joint nutrition.
Non operative management can be successful in some patients but will definitely involve quitting most vigorous sports. Intensive rehabititation and the use of a stabilizing brace are also involved.
There are really only 2 reliable modern methods of reconstruction. Research has shown that the patella tendon technique is definitely superior to the alternative hamstring tendon technique in maintaining tightness of the new ligament (and hence joint stability) and in rates of successful return to high level sport. More surgeons use the patella tendon technique than the hamstring technique particularly for high demand sports. In the Spring 2001 American Journal of Knee Surgery a survey of 740 top knee surgeons was published. 78% of surgeons commonly or exclusively used patella tendon and 82% occasionally or never used hamstring tendons for their ACL reconstructions.
Prolonged recovery is essential after anterior cruciate ligament reconstruction and the specialised rehabilitation should be supervised by an experienced sports physiotherapist, as the rehabilitation is as complex and detailed as the surgery. Full strengthening and maturing of the graft for a safe return to sport will take a minimum of 6-12 months. There is very recent evidence from a major study of AFL footballers by Dr Hugh Seward, that a return to AFL football in under 12 months was associated with a much higher reinjury rate than a return in under 12 months.
The success rate of reconstructions is high and in the 90% category if measured in terms of a successful and safe return to sport with a stable knee. There will often be minor aching or tenderness around the operation site but usually these do not interfere with function. The reinjury rate for ACL ACL injury to the opposite normal knee is also about 10%. These facts emphasize the importance of a proper supervised ACL Rehab program as these programs have been shown to reduce these risks.