Torn Anterior Cruciate Ligament…..Is Surgery Required?

The Anterior Cruciate Ligament (ACL) is one of the most commonly injured ligaments of the knee. It is injured mostly in those who engage in sporting activities such as rugby, soccer, skiing, and snowboarding.

Approximately 50% of ACL injuries involve damage to other parts of the knee including the meniscus, other ligaments or the articular cartilage. Sometimes unfortunately, people can suffer from O’Donoghue’s Unhappy Triad, which involves injury to the ACL, medial meniscus and the medial collateral ligament.

Symptoms of Injury

Immediately after the injury, patients normally experience pain and swelling around the knee, which can also feel unstable.  Within a few hours patients can experience a large amount of swelling, pain, loss of range of movement in the knee and difficulty walking.

Diagnosis

Your osteopath will examine your knee and after some orthopedic testing a diagnosis of an ACL or meniscus injury can often be made.  To confirm the diagnosis your osteopath will often refer you for a scan (X-ray/ Ultrasound / MRI) of your knee.

Treatment Options

Not all patients with ACL injuries will require surgery.  The need for surgery depends on many factors; the degree of injury and instability symptoms, and the patient’s activity levels.

Non-Surgical Interventions

Non-surgical management of isolated ACL tears maybe suitable for patients:

• With partial non-complete tears and no instability symptoms
• Who do light manual work or live sedentary lifestyles
• With complete tears and no symptoms of knee instability during low-demand sports who are willing to give up high-demand sports.

Surgical Interventions

ACL reconstruction has remained the gold standard of care for ACL injuries, especially for young individuals and athletes who aim to return to high-level sporting activities.

Surgical management of ACL tears is likely to be suitable for patients who:

• Are young patients and wish to maintain an active lifestyle
• Are active and involved in sports or jobs that require pivoting and turning of the knee e.g. rugby, skiing, basketball, football , snowboarding, roofers, plumbers, police officers, firemen
• Experience instability (giving way) with activities of daily living
• Who have an ACL injury coupled with injury to other structures in the knee such as the meniscus and other ligaments

It is important to note that levels of activity rather than age is an important determinant on whether surgical intervention will be suggested.

Surgery

The goal of the ACL reconstruction surgery is to prevent instability of the knee and restore the function of the torn ACL creating a stable knee.  Patients who undergo reconstruction surgery of their ACL have long-term success rates of 82-95%. Recurrent instability and graft failure are seen in approximately 8% of patients.

The surgery is performed arthroscopically as an outpatient or during an overnight stay. The ruptured ligament is removed and generally replaced by a substitute graft made of tendon, taken from the patients’ knee, such as the patellar, hamstring, or quadriceps tendon. The graft is prepared to take the form of a new tendon and is passed through small 1 cm drill holes in the front of the knee. The graft is placed in almost the same position as the torn ACL. The new tendon is then fixed into the bone with various devices to hold it into place while the ligament heals into the bone, which usually takes 6 months. Any other damage to the knee such as a torn meniscus is repaired at the same time. The wounds are then closed and a dressing applied.

Rehabilitation

Physical therapy plays a critical role in rehabbing either a partial or complete ACL tear. A partially torn ACL may require a rehabilitation period of at least 3 months which involves mobilising and strengthening exercises. Surgery may not be required, however some patients may still have instability issues. Much of the success of ACL surgery often depends on the patient’s dedication to rigorous physical therapy. Treatment is usually recommended to start as early as possible.

Pre-operative Physical Therapy

Physical therapy is helpful to better prepare the knee for surgery. The early goal is to regain range of motion, reduce swelling and achieve full weight bearing. Osteopathic treatment can be used to achieve these goals before undergoing surgery.

Post-operative Rehabilitation.

The goals for rehabilitation of ACL reconstruction include:

• Reduce knee swelling
• Maintain mobility of the knee
• Regain full range of motion of the knee
• Strengthen the quadriceps and hamstring muscles
• Encourage neuro-muscular control (proprioception)
• As osteopaths we will also ensure that all other joints in the lower extremity and spine and mobile to further encourage a return to full mobility.

Professional athletes may return to sports when there is no longer pain or swelling, when full knee range of motion has been achieved, and when muscle strength, endurance and functional use of the leg have been fully restored. This usually takes around 6 months, provided the patient is fit and has adhered to the rehabilitation. Recreational athletes may take 10 -12 months to return to sports, again depending on motivation and time put into rehabilitation.

As your Osteopath we will work closely with your orthopedic surgeon to ensure the best possible recovery outcome for you.

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