Injury to the Anterior Cruciate Ligament:

By: Brit York

Injuries happen to everyone at some point in their life, however Injuries are more
common in athletes. One of the most common injury is a sprain or tear of the ACL. In one year
there could be anywhere from 150,000-200,000 ACL injuries reported (OrthoInfo, 2014). ACL
stands for anterior cruciate ligament. The ACL connects the femur to the tibia and controls the
back and forth motion of your knee. The ACL provides 85% of the stability in the knee, keeping
the tibia from shifting behind the femur (McCulloch, 2012). ACL injuries can take up to 6
months to fully recover, and if the ligament does not scar down on its own, surgery is required if
the individual relies on their leg for work or activity. If surgery or other medical care is necessary
health insurance will usually cover the cost of the procedure.

ACL injuries are caused when too much stress is put on the ligament to the point
where it is sprained or torn. Primary causes are twisting while the person's foot is planted,
hyperextension, suddenly stopping when running, shifting weight suddenly, or landing on an
already flexed knee. An ACL injury can be diagnosed by symptoms such as; swelling, pain along
the joint line, sudden severe pain, looseness within the joint, and popping or snapping sounds.
An injured ACL will be hard to put weight on and will also have a loss of full motion. Also about
half of ACL injuries that occur cause damage to other structures within the knee. When
diagnosing an ACL injury whoever is inspecting your knee will first begin with a physical
examination. During a physical examination the injured knee will be compared to the non-injured
knee by checking each structure by pulling on the leg. Most injuries can be diagnosed from the
physical examination. To confirm the diagnosis the patient will be subjected to X-rays and a MRI
scan. X-rays use radiation that passes through soft tissue such as skin or muscle and produces
an image of hard materials inside the body. Even though an X-ray cannot see the ligaments it is
still useful when diagnosing an ACL injury because there could be damage to the bone from the

initial injury or even a damaged bone could have influenced the wound. The final step to
confirming the diagnosis is an MRI scan. MRI stands for Magnetic Resonance Imaging and
produces images of soft tissue such as the body's ligaments. Injured ligaments are classified by
three grades of sprains. A grade 1 sprain is the least severe only resulting in a slight stretching
of the ligament but it is still able to keep the knee joint stable. A grade 2 sprain is more severe
than the grade 1 resulting in looseness within the joint and can also be diagnosed as a partial
tear. Lastly the most severe sprain is a grade 3 sprain or complete tear, this is when the
ligament is split into two separate pieces and the knee joint is unstable. When it comes to ACL
injuries it is rare to have a grade 1 sprain or a partial tear. The most common type of ACL injury
is a complete or near complete tear.(OrthoInfo, 2014)

The course of action when treating an ACL injury depends heavily on the type of
lifestyle the individual has. Non surgical treatment is usually chosen by older sufferers that may
not be as active in their everyday life, on the contrary, a younger person who participates in
physical activities or relies on his physical performance for his career will most likely have to go
through surgery before returning to normal activity. If the patient has a low activity level the
patient could get by with only a brace to correct the instability in the knee joint. Once the knee
joint swelling has gone down and weight can be applied to the joint the patient can begin
physical therapy. If the injured person wants to participate in sports or lives a high activity
lifestyle the best option for that type of patient would be surgery. Surgical treatment for a torn
ACL calls for the rebuilding of a new ligament for the patient, this is because ligaments can not
be stitched together. In order to reconstruct the ACL the surgeon must replace the damaged
ligament with a tissue graft. Grafts can be taken from many different sources. These sources
include; the patellar tendon, which connects the patella or kneecap to the tibia or shinbone, the
hamstring tendons which are located at the back of the thigh, even the quadricep tendon, which
runs from the kneecap to the thigh can be used. Another source for a new ACL is a cadaver

which means replacing the patients injured ligament with a persons ligament who has passed
away. Unfortunately the cadaver grafts are the most probable to re-tear which means the best
bet for a new reliable ACL will be a graft from the patient's own tissue. While in surgery the
surgeon will drill holes into the joint to remove the damaged ACL then once the injured ligament
is removed the surgeon will insert the graft and secure the graft with screws in the cavity left by
the drill when removing the patients torn ACL. Once the graft is secured all incisions are
stitched or stapled together.

After surgery the timeline for recovery is still about six months until the patient is able to
return to athletic activity, although recovery could be shorter or longer depending on the level of
functionality the patient desires. Rehabilitation of the knee joint begins with the patients focus
on regaining the full range of motion of the joint. Once the knee joint is functioning properly the
aim of the physical therapy is to strengthen the area of the knee to protect the new,
reconstructed ligament. As the new ligament is strengthened the final goal is the ability to return
to the patient's normal activity as they were before they tore the ACL. The average time it takes
to return to sport or other intense physical activity is from six to twelve months. It is safe to
return to high intensity activity once there is no longer pain or swelling, the quadriceps strength
is at 90% and the patient is able to one leg hop as the uninjured leg can. Once these goals are
reached the individual can return with the same abilities they had before the injury (APTA,
2011).

When faced with an ACL injury, the two most important factors when deciding a route for
treatment are, the patient's activity level and the stability in the joint. When dealing with an older
patient it could be more beneficial to choose a non-operative treatment plan if the joint is stable
enough to get through the patients daily activities without any problems. If the patient is
younger and more active or the joint is unstable, then the best option would be ACL

reconstructive surgery. Not only is the ACL reconstructive surgery a better option because of its
effectiveness, it is also the most cost effective given that the joint is unstable. When compared
to non-operative treatment, ACL reconstruction was less expensive in both short and long term
when compared to the cost of rehabilitation. The average cost to society for ACL reconstruction
is an estimated $38,121 compared to $88,538 for rehabilitation. These values were estimated
on effects of the ACL injury in terms of; work status, earnings, and disability (Value of
Orthopaedic Treatment, 2013).

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