Management of torn ACL
Author: Dimitrios Giotikas MD, PhD
The initial management of an acute ACL injury is the same as for any other knee injury and aims to relieve the symptoms of the acute phase of injury. It includes a knee x-ray to exclude the presence of a fracture, a knee brace, ice-therapy, non-steroid inflammatory medication, elevation and restriction of activities. At the same time, starts the detailed diagnostic investigation of the elements of the knee injury. This includes a careful clinical examination and an MRI scan of the knee. During the clinical examination, the doctor performs special movements of the knee in order to assess the integrity of various elements of the knee joint. Sometimes, the examination is not reliable because of patient’s apprehension and it has to be repeated a couple of weeks later.
The MRI scan is the test of preference to investigate ACL injuries and concomitant knee injuries.
When the diagnosis of ACL tear is confirmed the treatment options include non-operative treatment and surgical treatment.
Surgeons, used to be more aggressive in suggesting surgery for ACL injury in the past because we thought that chronic instability of the knee inevitably leads to osteoarthritis in the future. We know now that it is the damage on the cartilage cells, which happens on the moment of injury, rather than the chronic knee instability, which is responsible for the development of osteoarthritis years later.
Non-operative treatment consists of a specialized program of physiotherapy which sequentially, over the course of 6 weeks, aims to:
The only indication for surgical treatment of ACL injury is the presence of recurrent incidents of instability in the knee. This is usually felt as the knee “giving way” with sudden movements, especially those involving, knee rotation or change of direction of movement. The patients sometimes report that “they cannot trust their knee”.
The ACL doesn’t have significant self-healing abilities, so when it is torn it has to be reconstructed in its entirety. This is done by harvesting a tendon graft and putting it to the same anatomical position as the native ACL. The whole procedure is done through arthroscopic view of the joint. At the same time, other intra-articular conditions are treated (like meniscal tears, removal of loose bodies, and cartilage defects). The tendons that are commonly used as grafts are the hamstrings tendons or the middle third of the patellar tendon. They both have produced very satisfactory functional results.
After the surgery, a rehabilitation protocol follows which aims to:
Return to sports should not be anticipated before 6 months or even 9 months if we are talking about contact sports or sports which require many pivoting movements in the knee (tennis, volleyball).