Anterior Cruciate Ligament (ACL)

[phillyp369]

hi all, 4 weeks ago i was playing football, i turned my foot stayed planted in the groung and my right knee turned. I heard a very loud pop as did half the field, immediatly my knee swelled right up. I was whisked away to hospital where i had 180ml of blood taken and advised to come back the following day. I went back up the next day and the surgeonadvised me that i had almost certainly damaged my side ligaments. 4 weeks later ( today) i went for a follow up and am still in pain , my knee still very hot and still swollen, the dr thinks that i have snapped my ligament because of the swollen knee still. I have been booked in for an MRI scan to see. He advised me that if thats the case then i will need surgery, how probable will this be?

I still cant walk on it albeit iam trying but just more a limp and a drag of the right leg. i cant climb the stairs without a lot of pain. Touching the left side of my right knee is really sore as is the knee cap at times. Iam still badly swollen.
I have been off work since the 4th of oct and my line up 15th nov how much more time off does it require.
I have found the docs talking big spangled words i dont understand. Any help would be great.Cheers in advance

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[SigMik]

Dear Phillyp369,

hope you are doing well in despite of your knee. Your mechanisms of injury, the clearly audible pop and the immediate and considerable swelling are the three main predictive factors of a full ligament tear. Since you don't report an increased feeling of instability, the left side ligament (medial collateral ligament - MCL) is probably intact. The location of your soreness, together with the rotational nature of injury do nevertheless suggest either a partial tear (painful) or a sprain (less painful) of the MCL. Also since you don't report of locking sensations or giving away either, the likelihood of a full meniscus tear is substantially reduced. This leaves us with a full ACL tear as main cause of the audible pop and immediate swelling, a minor injury to the MCL and possibly no medial meniscus involved. I hope you see that these are only general predictions from my part. If you do feel considerably unstable and actually have had some locking sensation, then you'll have to reconsider the information above accordingly.

I'll shortly sum up some basic information about considerations of ACL tears. It's usually a question of surgery or conservative management. My take on this is that most of all, it depends on what level of activities you want to return to and probably more importantly your motivational drive in the rehabilitation.

First scenario - If your knee feels stable and your motivation is very high to return to pre-injury level of activity, then I'd generally advice conservative management.

Second scenario - Again, if your knee feels stable, but your motivation for rehab is less than maximum and your ambitions of return to pre-injury level is moderate and can live with a knee that will handle most activities of daily life, and you can live with a "grumpy" knee when you occasionally go hiking/running/kick a few balls, then I'd also advice conservative management.

Third scenario - If your knee feels UNstable, shows a slow progress (not able to bend knee 90 degrees 6 weeks post-injury), you are in a lot of pain, not motivated to live with a "grumpy" knee, then maybe consider surgery...

There are a lot of other scenarios as you might imagine, but you can use the aspects as mentioned to play around with the possible other scenarios...

The typical advice for people wanting surgery, is to do an ACL reconstruction after 4-8 weeks when full range is established and there is no joint swelling. The most important range of movement is actually to be able to stretch out your knee fully, rather than full bending as strange as it might sound. You want to do this whether you operate or not, as it is associated with long-term prognosis for either scenarios. There are two common surgical techniques for ACL reconstruction and that is either taking a graft from your patellar tendon or your semitendinosus (on the medial side of your hamstring), drill holes for it within the knee, and smack it in. From what I've heard, the choice of technique depends largely on surgeon preference. Either way, short term studies shows excellent knee function whether patellar or hamstring grafts are used. The same studies also confirms that about 65-80% of these patients are able to fully return to sports within the first year. These are studies done on "sporty" people, so remember the motivational aspect influencing such a high success rate. However, many athletes are also able to return to a high level sports even with conservative non-surgery management.

The next question is, what is the prognosis of the conservative management vs. athletes treated with surgery in regards to sports? One large follow-up study of semi-pro handball players in Norway concluded that 60% of the players treated with surgery and 80% of the conservatively treated players were still active after 10 years post-injury. This suggest that conservative management is at least and maybe better than surgery, and also comparable to findings from other studies. Hence, surgeons (at least in Norway) are very conservative when considering surgery vs non-surgery. In addition, most studies show that ACL injured athletes are considerably less represented in high level activities 10 years post-injury, whether they operated or not.

It is difficult to transfer these findings to the "normal" population due to many factors. The main factor being pre-injury level and fitness (obviously higher than in normal population), in addition to the fact that they are a part of a study, etc...

Take home message - you don't HAVE to operate, even if you have a full ACL-tear, but maybe you knew this already... My apologies if all the information is a bit too much. But at least then, you can consider the issues I've mentioned and be a part of the decision yourself when and if the question of surgery comes up.

I wrote another post in response to another acute knee-injury that might be of help in terms of what to do in the earlier stages, I've copied it in below to give you some tips of how to decrease the swelling, hopefully you've started some of this already. In terms of exercise, get it moving! Especially aim for full knee extension and worry less about the bending...

Kind regards,
Sigurd Mikkelsen

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First of all, apply these principles.

Ice it, several times a day. I usually suggest my patients to wrap a cold, moist towel around an icepack. You can keep the moist towel in the fridge, so that it is easily available and you won't need to soak it every time you are about to ice it. I go for sessions of 20 minutes on, 20 minutes off, and 20 minutes on again, 3-4-5 times a day, but especially within the first 48 hours. The icing is generally for easing pain, decrease the bleeding and to hinder excessive edema. You are beyond the 48 hrs time-frame, but it might do you good to decrease the swelling since you are telling that it is not that painful anymore, especially if you feel the swelling is warm. I also suggest this procedure if my patients easily swell up after exercise.

Try to put some compression around it. Elastic bandage is good for this. This is to give some support to the knee, but mainly to control the swelling. Not too tight, not too loosely... Keep it on the whole day, but take it off for a few minutes and rewrap a few times a day. Also elevate the knee whenever possible. Elevation is simply to limit the gravitational forces acting on the swelling. Excessive swelling is believed to compress the blood vessels, and you want to avoid this because the blood vessels carry nutrition and agents that is important for the healing process. Excessive swelling will also often be painful as it might compress sensitive nerve endings and complicate movement due to increased internal pressure/edema in the joint.

In general, with such traumatic events, all research points towards early mobilization being of short- and longterm benefit for your rehab. With that being said, everything within pain limits! Your body starts the healing processes within a minute after such injuries and there is ongoing discussion of how much we should interfere with these natural healing processes through such advices that I give now. Some advice early and active use of non-steroideal anti-inflammatory drugs (such as Ibuprofen/Naproxen), but there is emerging good evidence that this actually delays healing processes to such an extent that the long-term rehab end results are actually poorer than for those not taking them post-operatively. So I'd advice, if you can do without, let them be. I'd try Paracetamol for simple pain control, before going on to the "stronger" meds in any case.

A very general exercise I often give for early knee and ankle injuries is to sit on the tip of a chair and slide your injured foot geeeently back and forth. Use your hip muscle actively to adjust how much weight the knee joint will be taking. If it swells up right after the exercise, you've been doing too much - use ice. There are heaps of other exercises you probably could do (move your ankle a lot to keep your calf muscles active, tighten your gluts while sitting and so on), but these better be given by a professional who have assessed you first.