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The anterior cruciate ligament (ACL) runs diagonally between the tibia (shin bone) and femur (thigh bone), aiming to prevent the forward sliding of the tibia on the femur and providing stability for rotational movements of the leg. |
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Most commonly ACL injuries occur without direct contact from another player/the ball.
This often happens in sports involving sudden change of direction/cutting movements. |  |
- Muscular imbalance (quadriceps dominance over hamstrings).
- Fatigue/lack of concentration
- Anatomical variations eg a larger Q angle – which is the measurement of the line of pull of the quadriceps muscle group relative to the knee; a larger Q angle is associated with a wider pelvis body-type; therefore often women are at more risk of these injuries than men.
- Playing sports that involve a lot of sudden change of direction.
- Environmental conditions
- Commonly a “popping” sound will be heard with sudden intense pain deep in the knee.
- Immediate swelling
- Inability to continue playing/instability with weightbearing.
- Loss of range of motion at the knee.
Surgery vs Conservative Management:
When deciding whether to have surgery or not following ACL injury there are a few things to consider. The ACL does not have the capacity to heal completely if it is ruptured, and so surgery involves the use of usually either a hamstring tendon or the patella tendon to form a graft to act as the ligament. Sometimes there are other injuries which occur alongside an ACL tear eg a fracture or damage to the menisci in the knee (specialist cartilage in the knee joint), which could be the reason for having surgery as fragments of these structures are blocking range of motion and need to be removed.
Excluding this – we can live without an ACL or a partially torn ACL so long as we strengthen the muscles surrounding the knee to avoid ongoing instability, and many people have good results from conservative management alone. If wanting to return to similar sports involving the sudden changes of direction again, it is often advisable to have surgery to improve the stability of the knee joint for these high loads. Either way rehabilitation will be involved and return to sport takes between 9-12 months – too early and sufficient neuromuscular patterns will not have been corrected and we can leave ourselves exposed to reinjury.
What does Prehab involve and what are the benefits?
If the decision you have reached after consulting your Physio and Knee Specialist are to go ahead with surgery, it is highly recommended to undergo some prehabilitation prior to your operation and there is evidence to support better outcomes vs those who go directly for surgery.
Prehab prior to surgery needs to be a minimum of 3 weeks’ worth focusing on the following aspects:
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Many people are also able to progress towards hopping/plyometric drills even before they have the operation!
Rehab and Criteria for Return to Sport:
Rehab will cover the same aspects mentioned in the prehab section, but this occurs post-operatively. Early aims are to reduce swelling and pain, restore knee range of motion and improve strength and stability.
In order to be able to return to your sport testing is undergone to demonstrate:
- Sufficient muscle strength return; particularly in single leg-type exercises eg squats, calf raises and bridging.
- Excellent neuromuscular control eg single leg balance and control even under conditions of fatigue.
- Agility testing after gradual return to running program has been completed; testing often involves hopping/change of speed and direction.
- Psychological readiness to return to sport and confidence in the limb post-injury as hesitancy can be a risk factor in re-injury.
We have sports-specific screenings available which can help determine if you are at risk and we can provide strengthening/mobility programs to help address any deficiencies. Come in before the season kicks off to avoid an injury that would keep you out for the whole season!
Author: Lou Marmion, Physiotherapist (B. ExSc, M. Phty)