The ACL (anterior cruciate ligament) is one of four ligaments stabilizing the knee joint. Ligaments are tough bands of tissue that connect the ends of bones together. The ACL is located in the center of the knee joint where it runs from the backside of the femur (thighbone) to connect to the front of the tibia (shinbone).

The ACL is the main controller of how far forward the tibia moves under the femur. This is called anterior translation of the tibia. If the tibia moves too far, the ACL can rupture. The ACL is also the first ligament that becomes tight when the knee is straightened. If the knee is forced past this point, or hyperextended, the ACL can also be torn. Other parts of the knee may be injured when the knee is twisted violently, as in a clipping injury in football.

The anterior cruciate ligament (ACL) is probably the most commonly injured ligament of the knee. In most cases, the ligament is injured by people participating in athletic activity such as basketball, football, skiing, and soccer. The ACL injury occurs when the player tries to tackle from the back, his knee twists and he falls to the ground in football, and a blow to the knee from the front in basketball, cricket, skiing and hockey and a sudden decelerating injury during running. It is common to also see a tear of the medial collateral ligament (MCL) on the inside edge of the knee, and the lateral meniscus, which is the U-shaped cushion between the outer half of the tibia and femur bones, which is termed O’Donohue’s triad.

However, ACL injuries are very commonly seen with road traffic accidents. The commonest mode of injury in Chennai and other cities of India are scooter/motor cycle accidents where the scooterist brakes suddenly, and plants his leg to the ground to balance himself.
Anterior cruciate ligament injuries are more frequent in females with between 2 and 8 times more females suffering a rupture than males, depending on the sport involved and the literature reviewed. The reason for this is as yet unknown, however areas of current research include anatomical differences; the effect of estrogen on the ACL and differences in muscle balance in males and females.

The symptoms following a tear of the ACL can vary. Some patients report hearing and/or feeling a pop. Usually, the knee joint swells within a short time following the injury. This is due to bleeding into the knee joint from torn blood vessels in the damaged ligament. The instability caused by the torn ligament leads to a feeling of insecurity and giving way of the knee, especially when trying to change direction on the knee. The knee may feel like it wants to slip backwards. There may be activity-related pain and/or swelling. Walking downhill or on ice is especially difficult. And you may have trouble coming to a quick stop.

The pain and swelling from the initial injury will usually be gone after two to four weeks, but the knee may still feel unstable. The symptom of instability and the inability to trust the knee for support are what require treatment. Complete ACL injuries result in instability of the knee joint. Whenever the person runs or comes downstairs rapidly the tibia slides off the femur. This can lead to repeated falls. These can result in injuries to the semilunar cartilages or menisci. Meniscal tears can lead to mechanical symptoms like locking or unexpected falls. A combination of persistent ligamentous laxity and meniscal tears can result in the development of secondary osteo-arthritis.

Diagnosis of an ACL Tear
A careful physical examination, combined with x-rays and MRI, will determine the extent of the damage and whether or not other tissues such as the meniscus are torn.

Nonsurgical Treatment
Once there is an acute injury to knee joint, immediate care is necessary - Rest, Ice pack application, compression bandage and limb elevation (RICE) will relieve the acute pain and swelling. An ACL injury is a serious one which needs medical attention immediately. The surgeon may aspirate the blood inside the joint if it is very severe, to provide comfort.

An ACL brace may be suggested. This type of brace is usually custom-made and not the type you can buy at the drugstore. It is designed to improve knee stability when the ACL doesn't function properly. An ACL brace is often recommended when the knee is unstable and surgery is not planned.

Nonsurgical rehabilitation for a torn ACL will typically last six to eight weeks. Therapists apply treatments such as electrical stimulation and ice to reduce pain and swelling. Exercises are used to help you regain normal movement of joints and muscles. Range-of-motion exercises should be started right away with the goal of helping you swiftly regain full movement in your knee. This includes the use of a stationary bike, gentle stretching, and careful pressure applied to the knee by the therapist. Exercises are also given to improve the strength of the hamstring and quadriceps muscles. As your symptoms ease and strength improves, you will be guided in specialized exercises to improve knee stability. You can return to your sporting activities when your quadriceps and hamstring muscles are back to nearly their full strength and control, you are not having swelling that comes and goes, and you aren't having problems with the knee giving way.

If the symptoms of instability are not controlled by a brace and rehabilitation program, then surgery may be suggested. The main goal of surgery is to keep the tibia from moving too far forward under the femur bone and to get the knee functioning normally again. Even when surgery is needed, most surgeons will have their patients attend physical therapy for several visits before the surgery. This is done to reduce swelling and to make sure you can straighten your knee completely. This practice also reduces the chances of scarring inside the joint and can speed recovery after surgery.

Arthroscopic ACL Reconstruction
Arthroscopic ACL Reconstruction is now done on an outpatient basis, and many patients go home the same day as the surgery. Some patients stay one or two nights in the hospital if necessary. The advantages of Arthroscopic ACL Reconstruction are that the incision is cosmetic as only tiny key hole incisions are used to visualize and repair the tear. Recovery is faster as there is less postoperative pain.

Patellar Tendon Graft: One type of graft used to replace the torn ACL is the patellar tendon. This tendon connects the kneecap (patella) to the tibia. The surgeon removes a strip from the center of the ligament to use as a replacement for the torn ACL.


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