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ACL Ligament - Overview by Dr. Vikram Sharma

However, in understanding ACL Injury, Knee Anatomy has to be known. Knee anatomy constitutes three bones encompassing the femur, known as the thigh bone; the upper end of the shin bone or tibia; and a small bone, the kneecap, also referred to as the patella.

There are four main ligaments that hold the Knee in place: The anterior cruciate ligament (ACL) is on the front side of the knee, the Posterior cruciate ligament (PCL) lies at the back side of the knee, the Medial collateral ligament (MCL) is found over the inner side of the knee; and Lateral collateral ligament (LCL) On the outer side of the knee, apart from this smooth covering over bone ends known as cartilage, two necessary cushion-like structures known as Meniscus are also found inside the knee joint.

Injuries to the Anterior Cruciate Ligament (ACL)

A common mechanism of PCL injury would be a direct blow to the front of the knee or a fall onto a bent knee and often would be a football, soccer, or basketball injury. Other contributing mechanisms include car accidents and slips and falls, among other trauma to the knee.

Knee Anatomy Diagram

The ACL is one of the strongest stabilising ligaments of the knee; an injury to it is a tear or sprain of that ligament, a very common injury in any activity, including sports, particularly those with quick changes of direction, jumping, or contact. It's both due to contact and non-contact sports.

These are types of torsion injuries with greater propensities in soccer, basketball, wrestling, Kabbadi, skiing, or similar games.

Besides, in routine, injuries caused by slipping on stairs, injuries while dancing, two-wheeler accidents, and so on may be ACL injuries. Watch our Master Video with all the details about ACL.

How ACL Breaks

These injuries are primarily caused by non-contact mechanisms, i.e. sudden change of direction or stop, or landing while attempting to jump in a wrong way. The common causes of this ACL injury are

  • Sudden twisting of the knee
  • Swelling, which usually occurs within hours of injury, though swelling is late and also almost insignificant compared to an ACL injury
  • Direct contact, like when someone is tackled in football

Such injuries occur with twisting or rotation of the knee and simultaneously with an attempt to plant the foot firmly on the ground. Examples are sudden turning on the court or field or jumping or landing with a twisted knee.

Hyperextension is when the knee is over-extended; in some games, an athlete throwing a jump lands on the knee, stretching beyond its normal range of motion. A direct contact type of Injury, such as football with a tackle, can cause a tear in the ACL.

Sudden symptoms of ACL damage are

This is because understanding ACL signs and symptoms is very important; the symptoms are very specific, and you can predict an ACL tear even before an MRI only with the help of these symptoms.

  • Usually very bad, especially at the knee.
  • Swelling will typically begin a few hours after the time of Injury.
  • Pain or a popping sensation or noise at the time of Injury.
  • Another mentionable symptom is limited knee mobility.
  • The instability or feeling of the knee is going to give way.
  • Intolerance to weight-bearing on the affected limb.
  • Bruising and swelling at the knee.

Late or Chronic Signs and symptoms

  • Weakness in the gracile thigh
  • Cyclical instability.
  • Knee pains in chronic cases.

Clinical Trials

Normally, an evaluating doctor will perform both a physical and imaging test, such as an X-ray or MRI, to diagnose an ACL injury.

The physical examination test may include-

  • Lachman test
  • Pivot-shift test
  • Anterior Drawer Test
Diagnosis of ACL injury
  • A general physical examination is utilised to detect the ACL injury diagnostically.
  • Relying on an X-ray, an osseous injury is usually always ruled out.

An MRI is more of a gold standard investigation and is accurate in affirming the ACL tear and assessing the extent of Injury. Damage to soft tissue can be represented by an MRI, as well as bones, along with their ligaments, tendons, and cartilage.

Treatment protocols for ACL injuries

This Injury is treated differently in different people due to variations in the extent of damage in addition to patient needs.

Minor Injury and less demanding knee- this is the type of Injury and condition where the tear of your ligament is minor and only minor Injury with no symptoms, especially in low demand knee, which means if you are a simple office goer and old age person.

Non-surgical treatment can be attempted - This includes physiotherapy, bracing, and pain management. Physiotherapy in the case of partial Injury and low-demanding knee focuses on specific muscle strengthening and proprioception. In this method, a gradual return to sports and activity is tried.

Surgery: Most patients with an ACL tear will require surgery. This can involve reconstruction of the ACL with one of the grafts described in the treatment section. In the operating room, a piece of your body tissue will be used to replace or enhance the torn tissue to create a new ligament.

These surgical procedures can be done using an arthroscope and have a very good chance of success.

Rehabilitation: Very important in the recovery of strength and/or range of motion and stability of the affected knee.

However, most of what will draw your eye is that the specific treatments or choice treatments would depend on the personal factors existing among the patients, such as their age, activity level, occupation, general health, and personal preferences.

Chapter 9: Choosing the Graft in Anterior Cruciate Ligament Surgery

ACL Reconstruction Surgery Replacing the damaged ACL with a new ligament called a graft. Some of the most commonly used grafts are:

  • Hamstring graft
  • Bone-tendon-bone (BTB) graft Patellar tendon autograft Peroneus Longus Graft Click here to know Graft Option and detailed understanding.
Implants used in ACL reconstruction

A significant number of metal or biocomposite implants are put into use for the graft to get fixed at its place. There are numerous varieties of implants, as follows-

What are implants used in ACL surgery- Detailed explainer about Implants and grafts

  • Suspensory Implants Two types of Loops are used as follows.
  • Fixed Loops implants Loop Implants Self-Adjusting
Screw Implants

Screw implants are designed to hold the position of the implant in the knee joint. The market offers two varieties of screws, that of metallic and bio-composite.Should another extraction of implants be done after so many years of surgery -I know it well.

Is it needed to remove implants years after Surgery – Understand it fully

Our Preference at SportsMed We usually put Adjustable loop implants on the Femoral side ( side of the thigh bone ), and on the tibial side, we use Bio composite of free loop adjustable implants; recently, we have advanced towards Free adjustable loop on the tibia ( leg bone side ), the advantage is that with this novel technique, we can create four-fold of graft so more robust and good sized graft we get.

Common Terms Used for the Classification of ACL Injuries

All the technical terms related to medicines, both in your reports and on the prescription by your doctor, are vast, and the understanding of those will give an idea of the magnitude of the problem, some of which are below.

Full-thickness tear- In this case, the ligament is completely torn. This type of injury may cause considerable instability in the knee and require more aggressive treatment by surgery.

Full-thickness tear: The ACL tears involve a full-thickness tear of the ACL. There is a rip right through the width of the ligament. This is an especially severe injury that might even necessitate surgery, in contrast to the partial thickness tear.

Almost complete The ACL ligament, in the case of a nearly complete tear, is almost completely torn. Such a tear can be accompanied by extreme instability of the knee and even requires surgical repair.

Partial tear - It is a partial tear of the ACL that is mild to moderate. It is an injury wherein the ligament is partially torn. This is the condition wherein treatment can be tried either conservatively or surgically based on the clinical examination and demand of the knee.

Some other words are
  • Anterior translation of the tibia
  • Bone contusion
  • Mucoid degeneration

Read below an in-depth video that explains your own understanding of an MRI report.

Grading of ACL tear

However, the grading of an ACL tear is required to help identify the degree of Injury and determine appropriate treatment.

Usually, the grading of an ACL tear is determined through physical examination, either through a Lachman test or through imaging studies, such as MRI.

  • Grade 1 ACL Tears: A minimum tear is described. The injuries need physical therapy and rehabilitation exercises to allow the knee to heal.
  • Grade 2 ACL tears These involve average extent; treatment measures for grade 2 ACL tears may include physical therapy, bracing and, in some surgery cases.
  • Grade 3 ACL Tears what is considered a very significant tear; the ligament is essentially wholly torn. Often, with this level of injury, such instability and pain are eventually present in the knee and can become extremely disabling. It is often surgically treated to stabilise the knee and prevent further damage.

Preoperative preparation and prehabilitation in ACL reconstruction.

ACL Ligament Surgery is an elective procedure, and proper preoperative preparation and rehabilitation will require the success of the process. Some of the fundamental guidelines are as follows.

How to prepare yourself for surgery-

Choose an experienced surgeon

Educate yourself on the procedure overall literature and explainers –( you can download our specifically made ACL booklet by clicking the link below :-

  • Prepare your home for recovery-
  • Follow preoperative instructions-
  • Optimise your health-
  • Plan for post-operative rehabilitation-

ACL reconstruction surgery is a planned surgery. Sometimes, you may be advised for a few physiotherapy exercises and this is called prehabilitation exercises.

Avoid always Some common mistakes that are made by many ACL injury patients – You must Watch Video

What is done in ACL surgery, and which technique is better

This is quite a common query of the patients – what is the best technique, and what needs to be used? We have narrated all common techniques for better understanding

  • Anatomical ACL Reconstruction-
  • Remnant-Preserving ACL Reconstruction
  • Double Bundle ACL Reconstruction.
  • Single Bundle Augmentation -
  • ACL Stump Repair All-Inside ACL Reconstruction
  • All-Inside with FiberTape
  • Bridge-Enhanced Anterior
  • Cruciate Ligament Repair (BEAR) 
Video in Depth on ACL Surgical Techniques Review

Our Preferred technique – We at sportsmed perform Anatomical remnant preserving ACL reconstructions; we use both conventional methods and all inside to make tunnels. The advantage of remnant preserving ACL is that the new ligament graft union will be faster, and the old torn ligament helps to develop this new graft. We follow anatomical guidelines, so we will try to copy native ACL attachment sites. As far as the issue of implants is concerned- we are using an adjustable loop at the femur ( thigh Bone ) and a free adjustable loop with a button at the leg bone tibia – this has the advantage of utilising graft best, and only a single muscle graft is needed. Sometimes, we use tape when there is high demand and graft size is less.

Why surgery was needed in complete ACL tears is the most common question, and with this explanatory video, we have tried to touch each part in detail. we believe well-informed and educated patients recover well as also-

Fibertape- Miracle or Just an Assistive Implant

Amongst the most frequently asked questions would be how to use fibre tape with ACL graft. Every second patient wants to know this, so we are trying to resolve this myth for you

What is Fibertape?

Fibre tape is a synthetic implant made up of polyester and polyethene fibres. Brand Fiberatpe is in common use, so we are using the same term, mentioning polyethene fibers tape as firetrap, although other implant companies are also making similar products. It is designed to provide extra support to the injured ligament. The implant is surgically placed along with the graft during the reconstruction procedure.

Know the concept of Fiberatpe or Internal Brace.

Indications and Advantages

Fibre tape is used in several conditions in orthopaedics, like ACL reconstruction. The benefit of fibre tape is that it provides extra support for the injured ligament. As long-term results are not available, its usage cannot be proved.

Disadvantages and Risks

This being an additional implant, care is required as sometimes this may lead to infection; over-tightening may create a problem in flexion and related complications.

Exploit Bust myths using video-detailed Fibertape.

ACL Revision Surgery and Retears

In some instances, the ACL may tear again or fail after the primary surgery. ACL revision surgery, also known as re-do ACL surgery, is an aggressive procedure that is used in the management of these failed or returned ACLs.

Causes of failure of initial surgery- There are many causes of retear or failure of surgery.

  • Inadequate rehabilitation - 
  • Overuse or returning to high-risk activities, too
  • Not suitable for the patient
  • Re-injury due to trauma
Challenges in Revision Surgery.

The challenges and risks of revision surgery are always high; the following points should be known about recovery after revision surgery.

  • Longer recovery time
  • Higher risk of graft failure
  • Surgical expertise required
  • Limited graft choice

Update your knowledge about the Retear of ACL and treatment options with our educational

Special emphasis in revision surgery

Tunnels formed for primary ACL at times can be expanded and if that belief is there by the surgeon, then at times further study through a CT scan may be needed and on this CT scan, the exact current diameter of tunnels formed during the prior surgery is measured, and planning for surgery is done accordingly. In revision surgery, the surgeon does not have enough freedom to create new tunnels but shall have to follow or modify previously created tunnels.

Women sports persons commonly suffer injuries in the ACL, often called the anterior cruciate ligament. It has been noted that females are more vulnerable to ACL injury than their male counterparts. The biomechanical, hormonal, and neuromuscular factors have been cited as reasons for such a scenario. In fact, females are very sensitive to Injury in some phases of their menstrual cycles that can change the levels of hormone and ligament laxity. Moreover, the narrower intercondylar notch increases the vulnerability of females to injury from the ACL.

Lastly, female athletes often jump and pivot on their ground and pivot on their ends more frequently than male athletes, and usually with a greater knee extension plus an internally rotated position of their hip activity that requires the ACL to absorb more stress.

Why Women Are More Prone to ACL Tear
Injury Prevention Strategies

Prevention is better than cure, and the same goes for the case of ACL tears. Injury prevention strategies, such as neuromuscular training, correct muscle imbalance, improve balance and proprioception and optimise movement patterns, specifically Landing Technique.

SportsMed – Injury prevention program for Female athletes- with this specific educational program, we create awareness among sports persons and coaches about preventable factors for ACL tears in females.

For customised treatment for female sports persons- surgical technique varies from graft choice, tunnel placements, Internal brace augmentation and many more small yet important considerations during surgery.

Common questions related to ACL

We are here to reply to your commonly asked questions about ACL injury – click the link here to open a specifically answered FAQ section.

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