The knee is one of the most frequently injured joints in many sports. The complexity of the anatomy and the mechanical reliance on other joints, added to the extreme stresses of twisting and turning which occur in sports such as football, basketball, skiing and rugby increase the vulnerability when loading. Ligaments, meniscus (cartilage) and tendons are the most common structures damaged. In particular, injuries to the anterior cruciate ligaments (ACL), inside the knee joint, are increasingly common and account for a considerable amount of lost time from sport and activity, so require careful attention.
The anterior cruciate is one of four main ligaments within the knee that help connect the femur (thigh bone) to the tibia (lower leg), and it is the second strongest ligament in the knee with a maximum load of 5OOIb.
The knee joint is held together by all these ligaments as well as the strong groups of tendons on the outside of the knee allowing great stress forces to be controlled and directed to perform complex movement patterns. This allows us the ability to be incredibly mobile and change direction rapidly. Injury to the ACL changes the whole dynamics of the knee and increases the instability and the chances of further damage to other structures.
Mechanism of injury
There are two types of injury: isolated twisting injuries increase the rotation of the knee, and combination injuries where there is impact from the outside or inside the knee.
An ACL injury should always be suspected if there is any kind of extreme rotation or flexion injury. Very often patients may injure their knee and the swelling settles and many months later they start to complain of ‘giving way’, ‘instability’ or feeling apprehensive.
Signs & symptoms
During activity, a patient may have a sudden pain or hear a ‘pop’.
Severe pain may occur, but often the patient can still walk.
Significant swelling and heat from the joint may develop within hours, causing discomfort and further pain.
The patient, with time, may develop a recurrent ’giving way‘ due to the absence or damage to the ACL and resultant instability of the joint.
Active and passive ranges of motion are limited.
Various tests can be performed to test the integrity of the ligament. But these are not always conclusive and further diagnosis may require an MRI. An explanation of the mechanism of injury and a good history usually leads you in the right direction for correct diagnosis.
Sometimes patients present with a simple knee issue, are not sure why, and may complain of occasional swelling and ‘giving way’, but no real pain. This is usually because they have injured their knee many years before and not really associated the two. This can make diagnosis difficult without the full history, even with physical examination.
Treatment
Treatment for a ruptured ACL can take the form of ‘operative‘ and ‘non-operative’ approach. Usually very young or elderly patients may consider the non-operative option but some may require further intervention in the future. However, this is not always the case and they have a normal active lifestyle.
Conservative treatment of the swelling and pain using a brace is usually the physiotherapy approach. Progressing on to local and ‘chain' progressive isolation and functional exercises programs to help restore good function, strength and co-ordination. Many patients make very good recovery with the conservative approach and I can think of two or three international athletes we have treated who returned to sport without surgery. It must be remembered, though, that there is always an instability issue, sometimes even after surgery.
Surgery involves replacement of the ruptured ACL, usually using the hamstring graft as a replacement. Post-operative care is similar to that of the conservative approach and if the surgery and physiotherapy rehabilitation programs go well, a good recovery is very common.
As with all of these types of injuries, we would always take into consideration lower limb biomechanics, and look at the footwear the patient uses, which may have increased the chances of injury. Careful functional rehabilitation is imperative to restore and refine quality chain (limb) movement and coordination.
If you would like to discuss any issues that you may have then call Ashleigh Clinic on 0116 270 7948 to discuss any injury prevention or rehabilitation issues. Liaison with your coach and physiotherapist is always advisable for improved and sports-specific biomechanics programmes to reduce the risk of injury.
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