Returning to Play After an ACL Tear

Returning to Play After an ACL Tear Dr. Rahman Kandil

Each year, as Mother Nature blankets the mountains with snow, hundreds of thousands of ski enthusiasts head to the slopes. For most skiers, a day of fun is followed by a relaxing evening by the fire or a night out on the town. Unfortunately, an injury to the anterior cruciate ligament (ACL) in the knee will cut the day short for some and ruin the ski season entirely for others.

Of course, the ACL is prone to injury in other sports, as well. Basketball, in particular, lends itself to ACL injuries that occur when landing from a jump, cutting, pivoting, or with sudden deceleration. ACL tears often occur when a player forcefully plants his or her foot during a high-speed, high-impact stop and change of direction, or during a routine jump-stop that players do dozens of times in a game.

In one NCAA tournament game, University of Connecticut’s former standout Shea Ralph recalls, "My teammate gave me a lead pass, but it was going out of bounds. I tried to stop on my right leg and reach out of bounds to get the ball, spin, and get a lay-up. When I planted my foot, my leg below my knee stopped, but the rest of my body kept going. I felt my knee shift. [The pain] was continuous and sharp. It felt like somebody stabbed me in the leg and was moving the knife around."

Anatomy and Function of the ACL

Ligaments are strong connective tissues that help connect bones at the joints. The ACL is the ligament in the middle of the knee that connects the front of the thigh bone (femur) to the back of the shin bone (tibia). Along with the posterior cruciate ligament (PCL), the ACL helps provide stability for knee rotation and protects the thigh bone from sliding forward and backward on the shin bone.

Symptoms of an ACL Tear

Damage to the ACL ranges from a minor tear (grade 1 sprain) to a full rupture (grade 3 sprain). Symptoms vary by the grade of the sprain, but may include:

• Pain
• A popping noise when injury occurs
• Swelling in the knee within 24 hours
• Loss of full range of motion
• Instability—a wobbly feeling that will make it difficult to stand or walk

These symptoms are good indicators of an ACL injury, but your knee will be examined to see if there is instability. You also may have an x-ray of the knee to rule out a fracture to the bone. If a definitive diagnosis is still unclear, other imaging tests like an MRI may be necessary. In some cases, an arthroscopic examination may be performed by inserting tiny cameras into your knee to show any damage inside the joint.

Treatment and Return to Play

If you suffer a torn ACL, your treatment will depend on your age, activity requirements, and the extent of your injury. The most common treatments are:

Conservative

For a minor injury to the ACL, home remedies may be enough:

• Rest and stay off the knee as much as possible.
• Keep the knee iced and elevated.
• Take anti-inflammatory medications, like ibuprofen, to help with pain and swelling.
• Wear a knee brace to stabilize the knee joint.

If these methods do not work, or if you are more active, there are surgical treatments to help repair your knee and get you back on your feet as soon as possible.

Surgical

ACL surgery is an elective procedure. This means that surgery is not always necessary, depending on your lifestyle and age. Surgery may be recommended if you have:

• A complete tear of the ACL
• A high degree of joint instability
• Injury to the knee that affects more than 1 ligament
• A need to return to a sport that require pivoting, turning, or sharp movements
• No improvement with rehabilitative therapy

Surgical treatment involves repairing, rebuilding, or replacing the ligament. In the past, this surgery required opening the knee to reconstruct the ACL. It was performed with success, but the rehabilitation process was slow. Today, doctors usually perform arthroscopic surgery to make repairs.

A graft, from a tendon in the knee, is used to rebuild or replace the ACL. This procedure is effective because it uses your own tissue and allows the knee to retain its normal range of motion. The knee can heal back to its original degree of strength with a low risk of infection or graft rupture. The reconstruction usually lasts a lifetime, but repeat tears can occur with sufficient stress.

ACL Rehabilitation

Physical therapy (PT) programs help to restrengthen the knee. In addition, PT will help to:

• Regain range of motion
• Strengthen the muscles around the knee
• Improve balance
• Protect the ligament from further damage
• Provide physical training to get you playing sports again

An ACL brace that stabilizes the knee while it strengthens should be used with any physical activity for some time after surgery.

Potential Complications

Problems from ACL surgery are rare, but all procedures have some risk. Your doctor will review potential issues, including:

• Infection
• Excess bleeding
• Blood clots
• Reaction to anesthesia
• Not getting the desired improvement in function
• Instability of the knee
• Numbness or stiffness in the knee
• Kneecap pain after surgery

Before your procedure, talk to your doctor about ways to manage factors that may increase your risk of complications, such as:

• Smoking
• Drinking
• Chronic diseases like diabetes or obesity

Preventing ACL Injuries

Treatment for an ACL injury is effective, but your best bet is to prevent an ACL injury in the first place. The most effective way to do this is to strengthen the muscles around the knee, especially the hamstrings and quadriceps. These 2 sets of muscles are crucial to regaining balance and control. Strengthening hamstrings and quadriceps also helps prevent twisting and hyperextending the knee, which can cause the ACL to tear.

Strength training is an important way to help prevent injury. Others include:

• Staying in control when playing sports like skiing and basketball.
• Bending your hips and knees when landing from a jump.
• Warming up before exercising.
• Plyometrics, a type of jumping exercise, used to train and strengthen the leg muscles.
• Strength training for your quadriceps and hamstrings.
• Stretching exercises for your legs.

Shea Ralph has made some adjustments to try to prevent another ACL injury while playing basketball, like distributing her weight more evenly on both feet when jump-stopping. Because of her body type, she has taken even more precautions. "I worked on turning my feet outward and being conscious of it," she explains. "I also worked on keeping my knees faced out, how to jump and land, how to collapse if I fall, and how to position my leg if people are about to fall on it."

If you would like to make an appointment with Dr. Rahman Kandil to discuss ACL injuries that may need to be addressed, go to Dr. Kandil's physician page or call (703) 665-2720 and we will be happy to assist you.

Sources:

• American Academy of Orthopaedic Surgeons
• American Orthopaedic Society for Sports Medicine