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ACL Pain, Diagnosis, and Treatment – Should I See and Orthopedic Surgeon?
The Anterior Cruciate Ligament, or ACL, sits deep in the knee joint, connecting the thigh bone with the shin bone. Its function is to prevent excessive forward movement of the tibia relative to the thigh and also to prevent excessive rotation at the knee joint.
The ACL can be injured in a number of different ways, including landing from a jump on a bent knee and then twisting, or landing on an overextended knee. In collision sports, direct contact with the knee of opponents can damage the ACL. Due to the force required to damage the ACL, it is not uncommon for other structures in the knee such as the meniscus or medial ligament to also be damaged and require professional diagnosis.
A moderate impact against the inner side of the knee joint causes the lateral collateral ligament to rupture. A more violent impact also causes the rupture of the Anterior Cruciate Ligament. In severe cases, the posterior cruciate ligament ruptures.
ACL injuries have been reported to occur more often than ever before, which may be due to the increased intensity of athletic activity. In football, it is reported that for every 1000 hours of football played (training and matches), there are between 4 and 7 ACL injuries. Many top professional players have suffered this injury, including Paul Gascoigne, Alan Shearer, Gustavo Poyet, Roy Keane and Ruud Van Nistelroy.
Signs and symptoms
At the time of the injury, the person may feel a snapping sensation deep in the knee. There will be pain, proportional to the strength and degree of damage to other structures in the knee joint. In some cases, the person may feel able to continue playing, but as soon as the ligament is strained during sports activity, the knee joint becomes unstable. A classic example of this was Paul Gascoigne in the 1991 FA Cup final, who tried to play on before being stretched.
The reason the person is unable to continue is that the splinting function of the ACL is absent and there is excessive rotation and forward movement of the tibia relative to the thigh. After a few hours, the knee joint becomes painfully swollen due to what is called hemarthrosis – bleeding into the joint. This swelling performs a protective function by not allowing the person to use their knee.
During the acute phase of the injury (the first 48-72 hours), the exact diagnosis is very difficult due to the significant swelling around the joint. Once initial treatment to decrease swelling has taken effect, clinical diagnosis may be possible. This can be achieved by medical personnel performing stress tests on the ligaments of the knee – the degree of laxity in the joint will allow the clinician to estimate the degree of damage. In case of doubt, or to confirm the clinical tests, the patient is sent for additional examinations. Most often, an MRI is used to determine the level of knee injury. In some cases, the MRI may not give a clear picture of the damage and it may be necessary to examine the joint with an arthroscope. The combination of these findings allows the orthopedic consultant to get an idea of the extent of the damage.
Treatment of ACL injury depends on the extent of damage and subsequent functional impairment, patient age, and level of athletic activity. If diagnostic investigations reveal only a partial tear of some of the ACL fibers and there is minimal instability, a conservative approach with a physical therapist is usually indicated. This option is also more likely for teenagers and more sedentary people. In the case of individuals participating in high performance sport where a degree of instability is functionally unacceptable, surgical reconstruction of the ligament is the surest way to restore normal function.
Surgery to reconstruct the ACL has evolved beyond recognition since the first ACL repair in 1963. By 1980, Cambridge surgeon David Dandy had begun using an arthroscopic technique. Development has continued since then and the latest surgical technique is an arthroscopic procedure where a strip of the patellar tendon from the patient’s knee is removed and used as a graft to replace the ACL.
In addition to the progress of the surgical procedure, there is the progress of post-operative rehabilitation which has allowed the return to full activity in most cases in less than six months.
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