the sports doctor

Professional and college sports may finally be getting up to full speed, and with that comes an increase in sports injuries. One of the most common injuries in both contact and non-contact sports is a tear of the Anterior Cruciate Ligament (ACL). Listed here are ten not the most frequently asked questions about the ACL.

１ What is the anterior cruciate ligament?

Ligaments connect one bone to another. The ACL sits in the center of the knee just in front (anterior) of the PCL and connects the femur (thigh bone) to the tibia (shin bone). When you plant your foot and rotate your trunk, your ACL causes your body to stop as your weight shifts. In most people, if your ACL does not function, your knee will “give way” and you will fall down.

２ Is this the same as a torn cartilage?

The answer is no. In the knee there are two types of cartilage: the articular cartilage and the menisci. The articular cartilage is the Teflon coating on the end of the bones that keeps them gliding and the menisci are the shock absorbers. The ligaments – there are four including the ACL – act more like seat belts. Even though these are all separate structures, they are often injured at the same time.

３ How is the ACL usually injured?

Typically, the ACL is torn in two ways – through contact and non-contact injuries. Contact injuries occur in sports such as football, and surprisingly are not as common as in non-contact injuries that occur in sports such as basketball or soccer. Both contact and non-contact injuries occur when the knee is twisted or bent on a fixed foot. A “pop” and immediate swelling often accompany the injury. Usually, the athlete cannot continue to play after an acute ACL injury. Non-contact ACL

tears are much more frequent in women than men playing the same sport. This is usually due to the way women land after they jump, and this difference can be corrected with a series of instructional exercises.

４ What is the best thing to do when an

On the field, after an initial evaluation by a qualified trainer or team doctor, the answer is RICE: Rest the knee with splinting to prevent further injury; Ice to reduce inflammation and prevent further swelling; light Compression to reduce swelling; and Elevation to control bleeding in the joint. Once this is done, evaluation by an orthopedist or sports medicine specialist is recommended.

５ What happens at the doctor’s office?

First, the doctor will ask questions about how the injury occurred. He or she may also ask about your age and activity level, both at work and during recreation. Your general health is also important. Next, the doctor will examine you. This is a hands-on evaluation to determine what the injuries are and their severity. If your knee is very swollen, the doctor may drain it with a needle and syringe. X-rays can be very useful at this point, serving to check for injuries to the bones, the status of growth plates or, in older patients, the presence or absence of arthritis.

６ What about an MRI?

MRIs are very useful for the evaluation of ACL injuries, as well as the other injuries that accompany them. The ACL is a ligament and, therefore, cannot be seen on an X-ray. Even though the injury may be strongly suspected after an examination and X-rays, it can be reliably confirmed with an MRI. In addition, an MRI can detect injuries that were not originally appreciated.

７ Is surgery always necessary?

Treatment for an ACL tear will vary depending upon the patient’s individual needs. For example, the young athlete involved in agility sports will most likely require surgery to safely return to sports. In a limited number of patients, surgery may not be the correct solution the less active, usually older, individual may be able to return to a quieter lifestyle without surgery. However, it is important to realize that a torn ACL will not heal without surgery. Also, the ACL may scar into nearby structures, regaining some function and providing some stability to the knee. In addition, strengthening the muscles around the knee may, in some cases, compensate for the loss of stability caused by a tear in the ACL.

Non-surgical treatment may be effective for patients who are elderly or have a very low activity level. If the overall stability of the knee is intact, your doctor may recommend simple, nonsurgical options. Remember, many people who initially opt for non-surgical treatment, require surgery in the future as they do more damage or as their knees become unstable over time. This process can take several years. In a young and active individual, who has an unreasonable amount of instability in the knee, surgery is necessary to give the best and most reliable result to allow for continued safe participation both in sports and daily activities.

８ What are the options for

Most ACL tears cannot simply be sutured (stitched) back together. To surgically repair the ACL and restore knee stability, the ligament must be reconstructed or replaced. Your doctor will replace your torn ligament with a tissue graft. This graft acts as scaffolding for a

new ligament to grow on.

Grafts can be obtained from several sources. Often, they are taken from the patellar tendon, which runs between the kneecap and the shinbone. Hamstring tendons at the back of the thigh are also a common source of grafts. Sometimes a quadriceps tendon, which runs from the kneecap into the thigh, is used. Finally, a cadaver graft (allograft) can be used. Cadaver grafts can use even stronger tendons from other parts of the body besides the knee.

There are advantages and disadvantages to all graft sources. To help determine which is best for you, you should discuss graft choices with your orthopedic surgeon. As with all surgical procedures, you should confirm that your doctor feels comfortable doing the procedure and performs the procedure frequently.

９ How is ACL surgery done?

The surgery is performed arthroscopically and as an outpatient procedure. This means that the surgery is done with small incisions and uses a TV camera the size of a ballpoint pen and minimally invasive techniques. The TV camera is inserted in the knee and any remaining blood is flushed out. Any other injuries are thoroughly addressed and repaired. The remaining stump of the original ACL is removed, and small tunnels are drilled at the attachment sites of the ACL on the femur and the tibia. Regardless of which ACL graft has been selected, it is fashioned to fit exactly in the tunnels and to be the correct length that corresponds to the patient’s anatomy. The graft is carefully fitted in the previously drilled tunnels and secured in place with non-metallic screws. Finally, the incisions are closed, a dressing is applied, and the patient is sent to the recovery room for home discharge after several hours.

１０ What happens after ACL surgery?

Physical therapy is a crucial part of any successful ACL surgery. Many orthopedic surgeons strongly suggest that physical therapy begins immediately after the surgery. Much of the success of ACL reconstructive surgery “Physical therapy is a crucial part of any successful ACL surgery.”

depends on the patient’s dedication to the rigorous physical therapy regimen. With new surgical techniques and stronger graft fixation, current physical therapy techniques use an accelerated and aggressive course of rehabilitation. Weight bearing and range of motion exercises are started extremely early and progress rapidly.

The patient may return to sports when there is no longer pain or swelling, when there is full range of motion in the knee, and when muscle strength, endurance, coordination and functional use of the leg have been fully restored.

The patient’s sense of balance and leg control must also be restored using exercises designed to improve muscular control. This usually takes six to nine months. With an allograft, it may take up to nine months until the graft is strong enough to allow for full participation in sports. Ideally, use of a functional brace when returning to sports is not necessary after a successful ACL reconstruction. While some patients may feel a greater sense of security by wearing one, they are generally not needed or helpful.

Michael L. Gross, MD, is the founder and director of Active Orthopedic and Sports Medicine in Hackensack. He is the section chief of sports medicine at Hackensack/Meridian University Medical Center, the chairman of the department of Orthopedic Surgery at New Bridge Medical Center, the clinical director of Orthopedics for Summit Health and an assistant professor at Hackensack Meridian School of Medicine. He can be reached by at drgross@activeorthopedic.com or at 201-343-2277. ■