- History of Injury
- Indications for surgery
- Risks & Complications
The anterior cruciate ligament is one of the major stabilizing ligaments in the knee. It is a strong rope like structure located in the centre 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.
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.
The ACL is the major stabilizing ligaments in the knee. It prevents the tibia (Shin bone) moving abnormally on the femur (thigh bone). When this abnormal movement occurs it is referred to as instability and the patient is aware this abnormal movement.
Often other structures such as the meniscus, the articular cartilage (lining the joint) or other ligaments can also be damaged at the same time as a cruciate injury & these may need to be addressed at the time of surgery.
- Most injuries are sports related involving a twisting injury to the knee
- It can occurs with a sudden change of direction, a direct blow e.g., a tackle, landing awkwardly
- Often there is a popping sound when the ligament ruptures
- Swelling usually occurs within hours
- There is often the feeling of the knee popping out of joint
- It is rare to be able to continue playing sport with the initial injury
Once the initial injury settles down the main symptom is instability or giving away of the knee. This usually occurs with running activities but can occur on simple walking or other activities of daily living.
The diagnoses can often be made on the history alone.
Examination reveals instability of the knee, if adequately relaxed or not too painful.
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.
At times the final diagnoses can only be made under anaesthetic or with an Arthroscopy.
Not everyone needs surgery. Some people can compensate for the injured ligament with strengthening exercises or a brace.
- Episodes of instability can cause further damage to important structures within the knee that may result in early arthritis
Young patients wishing to maintain an active lifestyle.
Sports involving twisting activities such as soccer and football.
Giving way with activities of daily living.
People with dangerous occupations e.g., Policemen, firemen, roofers.
It is advisable to have physical therapy prior to surgery to regain motion and strengthen the muscles as much as possible.
Surgical techniques have improved significantly over the last decade, complications are reduced and recovery much quicker than in the past.
The surgery is performed arthroscopically. The ruptured ligament is removed and then tunnels (holes) in the bone are drilled to accept the new graft. This graft which replaces your old ACL is taken either from the hamstring tendon, the patella tendon or allograft. There are advantages & disadvantages of each with the final decision based on surgeons preference.
The graft is prepared to take the form of a new tendon and passed through the drill holes in the bone.
The new tendon is then fixed into the bone with various devices to hold it into place while the ligament heals into the bone (usually 6 months).
The rest of the knee can be clearly visualized at the same time and any other damage is dealt with e.g., meniscal tears.
The wounds then closed and a dressing applied.
Surgery is performed as a day only procedure.
You will have pain medication by tablet or in a drip (Intravenous).
A splint is sometimes used for comfort.
You will be seen by a physical therapist who will teach you to use crutches and show you some simple exercises to do at home.
Leave any waterproof dressings on your knee until your post-op visit.
Put ice on the knee for 20 minutes at a time, as frequently as possible.
Post-op visit will usually be at 8 days.
Physical Therapy can begin after a few days or can be arranged at your first post-op visit.
If you have any redness around the wound or increasing pain in the knee or you have temperature or feel unwell, you should contact your surgeon as soon as possible.
Physical Therapy is an integral part of the treatment and is recommended to start as early as possible. Preoperative physical therapy 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.
The remaining rehabilitation will be supervised by a physical therapist and will involve activities such as exercise bike riding, swimming, proprioceptive exercises and muscle strengthening. Cycling can begin at 2 months, jogging can generally begin at around 3 months. The graft is strong enough to allow sport at around 6 months however other factors come into play such as confidence, fitness and adequate fitness and training.
Professional atheletes often return at 6 months but recreational athletes may take 10 -12 months depending on motivation and time put into rehabilitation.
The rehabilitation and overall success of the procedure can be affected by associated injuries to the knee such as damage to meniscus, articular cartilage or other ligaments.
The following is a more detailed rehabilitation protocol useful for patients and physical therapists. It is a guide only and must be adjusted on an individual basis taking into account pain, other pathology, work and other social factors.
Acute (0 – 2 Weeks)
- Wound healing
- Reduce swelling
- Regain full extension
- Promote muscle control
- Pain and swelling reduction with ice, intermittent pressure pump, soft tissue massage and exercise
- Patella mobilization
- Active range of motion knee exercises, calf and hamstring stretching, contraction (non weight 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 progression of general rehabilitation. Resisted hamstring loading should be avoided for approximately 6 weeks
- Gait retraining encouraging extension at heel strike
Stage 2- Quadriceps Control (2-6 Weeks)
- Full active range of motion
- Normal gait with reasonable weight tolerance
- Minimal pain and effusion
- Develop muscular control for controlled pain free single leg lunge
- Avoid hamstring strain
- Develop early proprioceptive awareness
- Use active, passive and hands on techniques to promote full range of motion
- Progress closed chain exercises (quarter squats and single leg lunge) as pain allows. The emphasis is on pain free loading, VMO and gluteal activation
- Introduce gym based exercise equipment including leg press and stationary cycle
- Water based exercises can begin once the wound has healed, including treading water, gentle swimming avoiding breaststroke
- 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
- Bilateral and single calf raises and stretching
- 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 (6-12 Weeks)
- Begin specific hamstring loading
- Increase total leg strength
- Promote good quadriceps control in lunge and hopping activity in preparation for running
- Focal hamstring loading begins and is progressed steadily throughout the next stages
- Active prone knee flexion which can be quickly progressed to include a light weight and gradually increasing weights
- 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
- Single straight leg dead lift initially active with increasing difficulty by
With 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
- Gym based activity including leg presses, light squats and stationary bike which can be progressively increased in intensity as pain allows. It is important to monitor any effusions following exercise and if it is increasing then exercise should be toned down
- 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 off a step and in a quadrant
- Running may begin towards the latter part of this stage
Prior 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
- Increased proprioceptive manoeuvres with standing leg balance and progressive hopping based activity
- Expand calf routine to include eccentric loading
Stage Four-Sport Specific (3-6 Months)
- Improve leg strength
- Develop running endurance speed, change of direction
- Advanced proprioception
- Prepare for return to sport and recreational lifestyle
- 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
- Advanced proprioception to include controlled hopping and turning and balance correction
- Monitor potential problems associated with increasing loads
- 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
- Full training for 1 month prior to active return to competitive sport
- 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
- To improve running endurance leading up to a normal training session
- Full range, no effusion, good quadriceps control for lunge, hopping and hop and turn type activity. Circumference measures of thigh and calf to within 1 cm of other side