Last week I wrote about my experience as an athlete that had an anterior cruciate ligament injury. This week I’d like to cover the importance of the ACL and why the mere mention of an ACL injury strikes fear into many athletes. The ACL is one of the four major ligaments of the knee. The medial and lateral collateral ligaments are located on the inside and outside portion of the knee, respectively. The oft-injured ACL and its neighbor the posterior cruciate ligament are located inside the knee joint.
Even though ACL injuries are not thought of as a common hockey injury, at any pont in a season there are usually a few players on injured reserve thanks to an ACL injury. Goalie Josh Harding of the Minnesota Wild and New York Rangers left wing Alexander Frolov come to mind at present. They will both be out of action for the forseable future this season.
If you were able to look inside the knee joint with the knee cap out of the way, you would see the ACL and the PCL behind it. If you cross your middle finger over your index finger, looking at the back of your hand, the middle finger would be the ACL and the index finger would be the PCL.
The ACL is there to keep the lower leg from sliding forward, while the PCL keeps it from sliding backward. The ACL is key and important in keeping the knee joint stable with side to side movement, cutting, shuffling and sidestepping. The ACL is a ligament, so injuries to it are generally called sprains and will range from a mild stretching to a complete tear or rupture of the ligament. Without an ACL, the knee becomes very unstable.
ACL’s are commonly non-contact injuries, meaning they are usually injured during deceleration and twisting that can happen when a player is cutting or in hyper-extension. They may also be injured during contact when a blow to the outside of the knee forces it inwards or from a blow to the back of the knee.
Most athletes will feel or hear a pop immediately when an ACL is torn. There will be swelling and pain. There may be a sensation of the knee “giving out” or instability. The ability to straighten the knee may be impaired and it will be tender to touch.
The initial goal after a knee injury is to manage the swelling and pain. You guessed it: RICE! A medical professional or athletic trainer may do some initial tests to determine which ligament may be injured. Ultimately, an MRI will determine if the ACL is intact, how much or it is damaged or torn and if there is injury to other components of the knee. The MCL and medial meniscus are common co-injuries of the ACL.
Prehabilitation is important after any injury, and there is often a program designed that focuses on swelling and pain management in the initial days after an ACL injury. Regaining full range of motion is very important prior to surgery. Basically, the better shape the leg and knee are in before surgery, the better chance of not running into complications
If the ACL is significantly or completely torn, an athlete will almost always have surgery to reconstruct the ligament. Remember, ligaments have very poor blood supply and this one in particular will not heal itself. Surgery is called an ACL reconstruction and consists of replacing the ligament with a graft.
Options for a graft are: the patellar tendon, which is the tendon that connects the kneecap to the shin bone, a hamstring tendon or a cadaver tendon. When the patellar tendon is used, a portion of bone from either end of the middle 1/3 of the tendon is taken, so there is a piece of bone that is taken from both the knee cap and the shin. Think bone saws and chisels for this! Residual pain at the front of the knee is commonly seen after this type of graft. The hamstrings are the large muscles on the back of the thigh and portions of this tendon may be used to create a new ACL. Allografts or cadaver tendons can also be used and may come from a variety of tendons.
Surgery is performed with the help of a camera or arthroscope. The old tendon is cleaned out and a new tunnel is drilled into the thigh bone and shin bone. The new ACL is then secured into place using anchors for the tendon grafts and screws to secure the bone-patella-bone grafts into place. There are usually 2-3 incisions, depending on the type of graft used.
Rehabilitation will most likely begin the day of the surgery as long as there was no repair of the meniscus that was done. Most patients will be up and on crutches after surgery. Rehab usually is a “back to the drawing board” concept at first with simple actions such as increasing range of motion (most time ROM is limited immediately following surgery) and muscle strengthening (most athletes will have trouble even lifting their leg up). Over the next 5-9 months, rehabilitation will progress to weight-bearing exercises and more sports specific training.
Disclaimer: Information on found in RICE & MICE on flyersfaithful.com is not intended to be medical advice. Any information or materials posted on the web site are intended for general informational purposes only, and should not be construed as medical advice, medical opinion, diagnosis or treatment. Any information posted on the web site is NOT a substitute for medical attention. See your health-care professional for medical advice and treatment.