ACL (Anterior Cruciate Ligament) Anatomy
ACL (Anterior Cruciate Ligament) is one of the major stabilizing ligaments in the knee which is a strong rope like structure located in the center of the knee running from the femur to the tibia.
When this ligament tears, unfortunately, it doesn’t heal and often leads to the feeling of instability in the knee.
What are the causes of ACL injuries?
There are several factors which lead to the injury of ACL, such as:
- A sudden change of direction of knee e.g. while playing sports tackling, landing awkwardly
- overextend knee joint
Symptoms of ACL injuries
- Often there is a popping sound when the ligament ruptures
- There is a feeling of the knee popping out of joint
- Not able to continue playing sport with injury and feel pain and starts swelling
ACL injury diagnosis
ACL injury is diagnosed by the following:
- – Injury history
- – Nature of knee pain
- – Physical examination
- – Imaging tests
An MRI (Magnetic Resonance Imaging) can be helpful if there is doubt as well as to look for damage to other structures within the knee.
How ACL injuries treatment done?
Not everyone needs surgery, some people can compensate for the injured ligament with strengthening exercise or a brace.
ACL Reconstruction Surgery
The ACL reconstruction surgery is performed arthroscopically. The ruptured ligament is removed and then tunnels in the bone are drilled to accept the new graft. This graft will replace your old ACL and is taken either from the hamstring tendon or the patella tendon. The graft is prepared to take the form of a new tendon and passed through the drill holes in the bone.
ACL reconstruction is a commonly performed surgical procedure and with recent advances in arthroscopic surgery can now be performed with minimal incisions and low complication rates.
Risk of ACL Reconstruction Surgery
It is important you understand the risk and complications of the surgery, there are anaesthetic and surgical complications.
Deep vein thrombosis
Excessive swelling & bruising
Damage to nerves or vessels
Reflex sympathetic dystrophy
ACL Reconstruction surgery recovery
After the knee surgery is performed, you need overnight stay in the hospital. You will be seen by a physiotherapist who will teach you to use crutches and show you some simple exercises to do at home.
If you have any redness around the wound or increasing pain in the knee or you have a temperature or feel unwell, you should contact your surgeons as soon as possible.
Physiotherapy is an integral part of the treatment and is recommended to start as early as possible. Preoperative physiotherapy is helpful to better prepare the knee for surgery, the early aim is to regain range of motion, reduce swelling and achieve full weight-bearing.
Regarding the ACL reconstruction recovery time often professional sportsmen return at 6 months but recreational athletes may take 10 -12 months depending on motivation and time put into rehabilitation.
The following is a more detailed rehabilitation protocol useful for patients and physiotherapists. it is a guide only and must be adjusted on an individual basis taking into account pain, other pathology, work and other social factors.
1. Wound healing
2. Reduce swelling
3. Regain full extension
4. Full weight bearing
5. Wean off crutches
6. Promote muscle control
1. Pain and swelling reduction with ice, intermittent pressure pump, soft tissue massage and exercise
2. Patella mobilisation
3. Active range of motion knee exercises, calf and hamstring stretching, contraction (nonweight bearing progressing to standing), muscle control and full weight bearing. Aim for full extension by 2 weeks. Full flexion will take longer and generally will come with gradual stretching. Care needs to be taken with hamstring co-contraction as this may result in hamstring strains if too vigorous. Light hamstring loading continues into the next stage with the progression of general rehabilitation. Resisted hamstring loading should be avoided for approximately 6 weeks
4. Gait retraining encouraging extension at heel strike
Stage 2 – Quadriceps Control (Week 2 -6)
1. Full active range of motion
2. Avoid hamstring strain
3. Minimal pain and effusion
4. Normal gait with reasonable weight tolerance
5. Develop early proprioceptive awareness
6. Develop muscular control for controlled pain-free single leg lunge
1. Use active, passive and hands-on techniques to promote full range of motion
2. Progress closed chain exercises (quarter squats and single leg lunge) as pain allows. The emphasis is on pain freeloading, VMO and gluteal activation
3. Introduce gym based exercise equipment including leg press and stationary cycle
4. Water-based exercises can begin once the wound has healed, including treading water, gentle swimming avoiding breaststroke
5. Begin proprioceptive exercises including single standing leg balance on the ground and mini tramp. This can progress by introducing body movement whilst standing on one leg
6. Bilateral and single calf raise and stretching
7. Avoid isolated loading of the hamstrings due to ease of tear. Hamstrings will be progressively loaded through closed chain and gym based activity
Stage 3 – Hamstring / Quadriceps Strengthening (Week 6 – 12)
1. Begin specific hamstring loading
2. Increase total leg strength
3. Promote good quadriceps control in lunge and hopping activity in preparation for running
1. Focal hamstring loading begins and is progressed steadily throughout the next stages of rehabilitation
- i. Active prone knee flexion which can be quickly progressed to include a light weight and gradually increase weights
- ii. Bilateral bridging off a chair. This can be progressed by moving onto a single leg bridge and then single leg bridge with weight held across the abdomen
- iii. Single straight leg dead lift initially active with increasing difficulty by adding dumbbellsWith respect to hamstring loading, they should never be pushed into pain and should be carefully progressed. Any subtle strain or tightness following exercises should be managed with a reduction in hamstring based exercises
- 2. Gym based activity including leg presses, light squats and stationary bike which can be progressively increased in intensity as pain and control allow. It is important to monitor any effusions the following exercise and if it is increasing then exercise should be toned down
- 3. Once single leg lunge control is comparable to the other side hopping can be introduced. Hops can be made more difficult by including variations such as forward/back, side to side of a step and in a quadrant
- 4. Running may begin towards the latter part of this stagePrior to running certain criteria must be met
- No anterior knee pain
- A pain-free lunge and hop that is comparable to the other side
- The knee must have no effusion
- Before jogging start having brisk walks, ideally on a treadmill to monitor landing
- Action and any effusion. This should be done for several weeks before jogging properly
- 5. Increased proprioceptive manoeuvres with standing leg balance and progressive hopping based activity
- 6. Expand calf routine to include eccentric loading
Stage Four-sport Specific (3 – 6 Months)
1. Improve leg strength
2. Develop running endurance speed, change of direction
3. Advanced proprioception
4. Prepare for return to sport and recreational lifestyle
1. Controlled sport specific activities should be included in the progression of running and gym loads. Increasing effusion post running that isn’t easily managed with ice should result in a reduction in running loads
2. Advanced proprioception to include controlled hopping and turning and balance correction
3. Monitor potential problems associated with increasing loads
4. No open chain resisted leg extension exercises unless authorised by your surgeon
Stage Five-Return to Sport (6 Months Plus)
A safe return to sporting activities
ACL Surgery Recovery Treatment Guidelines
1. Full training for 1 month prior to active return to competitive sport
2. Preparation for body contact sports. Begin with low-intensity one on one contests and progress by increasing intensity and complexity in preparation for drills that one might be expected to do at training
3. To improve running endurance leading up to a normal training session
4. Full range, no effusion, good quadriceps control for the lunge, hopping and hop and turn type activity. Circumference measures of thigh and calf to within 1 cm of another side
For making an appointment regarding the acl reconstruction treatment, please make an appointment with us.