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Knee Pain - ACL treatment Kingston surrey

ACL Rupture

Anterior Cruciate Ligament


The anterior cruciate ligament (ACL) is located on the knee starting from the femur and attaches to the top of the tibia bone. ACL is often at high risk for injury when the ligament is stressed at each angle of knee motion. The majority of ACL injuries are actually non-contact. Three common factors that are associated with ACL rupture include:

Strong contraction of the quadriceps muscle over a slightly flexed or fully extended knee,

A marked valgus collapse of the knee, and excessive internal rotation of the knee.

Hyperextension of the knee, while the foot is planted, is also linked to ACL injury.

Valgus collapse is a phenomenon commonly seen in female athletes.

Following landing from a vertical jump or lunge, the femur goes into adduction and internal rotation.

ACL is commonly classified in grades of I, II or III. During grade I, ACL suffers from mild damage where the ligaments are overstretches but they still provide adequate stability to the knee joint. In Grade II ACL is stretched and partially torn and finally in Grade III, there is a complete ligament tear in half where the knee joint is unstable and not supported any more.

ACL Common signs and symptoms

The individual will often report hearing/feeling a “pop" at the time of injury. Patient’s will also report the knee feeling “unstable," often presenting with quad avoidance during gait. Individuals with chronic ACL deficiency will frequently complain of having a “trick knee" that gives out. Usually patients present with loss of flexion and extension, secondary to knee effusion, and quadriceps inhibition. Upon suspicion of ACL rupture, an MRI is often ordered for confirmation. Along with identifying the integrity of the ligament, the MRI can aid in detecting the presence of bone contusions. It should be noted that females have been found to be at higher risk for ACL injuries compared to males. The proposed intrinsic factors that contribute to this difference include: increased Q-angle, decreased femoral notch size, smaller ACLs, and increased posterior tibial slope. The increased Q-angle places a significant valgus force on the knee and ACL, especially when landing from a jump. Whether or not there are gender differences in femur size is still under discussion, but a frequent component of ACL reconstruction is simultaneous enlargement of the femoral notch. To sum up, most common signs and symptoms of an ACL injury include rapid swelling, severe pain and inability to keep up with physical
activities, loss of range of motion, a feeling of instability with weight bearing and a ‘popping’ sensation in the knee.


Surgical management:

The general sequence of surgery is graft harvest/preparation, diagnostic arthroscopy, drill tibia tunnel, drill femoral tunnel, and fixation of graft at each end. The purpose of the diagnostic arthroscopy is to identify any additional injuries in the knee, such as meniscal tears, cartilage damage and more. Some of the most common graft selections for ACL reconstruction include autografts removing a part of hamstring tendon and attach it back to the damaged ligament. The pros of hamstrings include quicker post-op quad control, easier early rehabilitation
and less anterior knee pain. The cons include decreased hamstring activity (hamstrings are important restraint to anterior translation) and decreased hamstring strength in deep flexion. Following ACL reconstruction, one of the most important factors that should guide your treatment plan is the tissue healing time frame. As individuals are anxious to return to their prior levels of function, accelerated rehab protocols were developed. Unfortunately, an increase in graft failure rate was noticed and further research was needed to guide the aggressiveness of therapy. Overly, aggressive activities can loosen these attachments, prolonging inflammatory reactions and leading to false treatment.

ACL Rehabilitation:

Rehabilitation is often thought of as the time following an ACL reconstruction. With these patients, let us not forget the importance of “prehabilitation"– the time after injury but before surgery. While not all patients receive pre-operative rehab, several studies have demonstrated the importance of a good quadriceps strengthening and full knee extension range of motion. The swelling in the knee could impair the healing process following reconstruction and limit ROM. This leads to the next reason for waiting: regaining full ROM. Decreased extension is a significant complication following surgery that may be linked to further knee damage. By regaining the motion prior to surgery, the patient is more likely to return to higher level activity and decrease the chances of further knee injury. The final reason for delaying surgery is to strengthen the quadriceps. As we all know, there is a quadriceps strength deficit following joint effusion and surgery. As quadriceps strength is linked to function, it is desirable to regain as much strength as possible before surgery. Therefore, our goals prior to surgery include decreasing swelling, increasing knee ROM (especially extension) and increasing quadriceps strengthening.

Strand House, 169 Richmond Rd, Kingston upon Thames KT2 5DA 020 8546 6464