Anterior cruciate ligament (ACL) tear

The anterior cruciate ligament (ACL) is one of the most commonly injured knee ligaments, with approximately 80% of cases occurring without direct contact with the knee. Anterior cruciate ligament (ACL) strains occur especially in sports such as soccer, basketball, tennis, netball, and snow skiing that involve rapid starts, stops, and turns. Where is the cruciate ligament located? We all may have heard the name of the cruciate ligament, and you should always know that it plays a very important role in your health and movement. In general, there are 4 main joints in the knee, one of the most important of which is the cruciate ligament. The cruciate ligament is located in the center of the knee and controls the rotation and movement of the leg and bones. Note that the forward movement of the leg will be the responsibility of the cruciate ligament. Of course, other robots are also responsible for rotating the leg to other parts, but one of the most important and of course the most vulnerable is the cruciate ligament, which they must always take care of. Many athletes, especially those who perform certain activities with their feet, may be exposed to more injuries. Anatomy of the anterior cruciate ligament (ACL) The anterior cruciate ligament (ACL) is located inside the knee joint and connects the lower leg (tibia) to the thigh bone (femur). ACL consists of three distinct categories, which are: - Internal front - anterolateral - Posterior lateral All these categories have a lot of blood and nerve resources. It is believed that the medial posterior and anterior bundles provide more stability by straightening and bending the knee, respectively. The ACL is thought to provide the knee with structural stability and functional stability by providing information to the nervous system about the position of the knee joint (proprioception) through a direct connection between the bones. Anterior cruciate ligament (ACL) tear symptoms Classic symptoms of an ACL tear include pain and a popping sensation at the time of injury, immediate and subsequent swelling, and instability of the knee when rotating or twisting. About half of people with an ACL tear can manage without surgery, but people with recurrent instability usually undergo ligament reconstruction. 81% of patients return to their sports after ACL reconstruction. 65% return to pre-injury level, but only 55% return to competitive sports. After ACL surgery, the risk of a second ACL injury is greater in both knees, but it is more likely to occur on the unoperated side. Osteoarthritis changes are common after ACL injury, whether the ligament is reconstructed or not. Other symptoms of an anterior cruciate ligament (ACL) tear include: - Initial inability to bear weight that improves in a short time. - Apprehension by attempting non-linear movements, a combination of Lachman, Pivot Shift and anterior drawer tests are used for clinical confirmation of the diagnosis. ### Symptoms secondary to an anterior cruciate ligament (ACL) tear Secondary symptoms include 7 cases as follows: - Bone contusion in the lateral condyle of the femur and the posterolateral tibial plateau - More than 7 mm of anterior translation of the tibia, which is also known as the tibial anterior displacement sign or the anterior drawer sign. - The posterior horn of the lateral meniscus is not covered - Segond fracture, and to a lesser extent the arcuate sign - Decreased PCL angle due to PCL buckling - Positive PCL line sign - Damage to the medial or lateral collateral ligament Causes of anterior cruciate ligament (ACL) tear You may be interested to know that any double pressure, impact and sudden changes in the knee can cause irreparable damage to the cruciate ligament. One of the main reasons for a rupture in the cruciate ligament is a sudden decrease in speed and a sudden change of direction. While running and walking, if you suddenly increase or decrease your speed, your cruciate ligament may be damaged or torn. On the other hand, sudden jumps or jumping from very high heights will be a very important factor for tearing the cruciate ligament, which is why many trainers in various fields advise people to never stop suddenly when exercising and performing heavy and intense activities. If your knee is subjected to any direct pressure or impact, your cruciate ligament may be damaged and torn, which is more common in athletes who play soccer. The cruciate ligament will play a very important role in your mobility, and damage to this sensitive area can cause you various problems for a very long time. Approximately 80% of ACL injuries occur without direct contact with the knee, usually when decelerating to change direction or when landing on one leg. Recent studies suggest that non-contact ACL injuries are most likely caused by a combination of knee movements when the knee is slightly bent. ***Dr. Majid Ghorbanzadeh*** is one of the biggest and most experienced orthopedic doctors in Tehran, who has experience with anterior ligament tears and can treat you in a very short period of time. Does an anterior cruciate ligament (ACL) tear hurt? At the time of injury, a person usually experiences significant knee pain, although some mild ACL tears may not be painful. Often after the injury there is a feeling of instability of the knee during the movement of the joint and then returning to the position. This may be indicated by the person using their fists (the "two-fisted" sign). When an anterior cruciate ligament (ACL) tear occurs, a person is usually unable to continue activities or even bear weight and notice immediate swelling in the joint (ie, within 2 hours of the injury). Swelling that occurs during this time period indicates bleeding in the knee joint (hemarthrosis) due to damage to a blood-rich structure. Approximately 50% of patients presenting to accident and emergency with haemarthrosis have an anterior cruciate ligament (ACL) tear. X-rays are indicated to confirm or rule out a knee fracture if there is severe hemarthrosis. Patients with a tibial crest fracture cannot fully straighten their knee (true locking), which may cause the bone to separate and "get stuck" in the joint when the tibial crest is injured and fractured. A torn ACL may also get stuck between bones, causing a physical obstruction to movement or the stomp reflex. In fact, anterior cruciate ligament (ACL) rupture causes the hamstring joint to contract and prevent the knee from fully straightening. ACL tears often occur with traumatic meniscal tears, which may cause true locking if the tear is displaced. Once the initial pain and swelling have resolved, the main complaint is instability of the knee during rotational or twisting movements. Although approximately 50% of patients with an ACL tear do not have recurrent instability with appropriate physical therapy. Patients with an ACL defect who do not have knee instability are referred to as "coopers," while "nondisplacers" typically describe a lack of confidence in their knee or feel that the knee is giving out or giving way during some of their usual daily activities. Diagnosis of anterior cruciate ligament (ACL) tear Based on the findings MRI and surgery separate anterior cruciate ligament (ACL) tears in 12-23% of ACL injuries, with most injuries occurring in conjunction with a traumatic meniscal tear or injury to other ligaments. ACL injuries often occur when the knee is dislocated. 18% of knee dislocations include vascular damage. As a priority, it is important to perform a thorough vascular evaluation in cases of known or suspected knee dislocation. Clinical tests that determine anterior translation of the tibia or attempt to reproduce the phenomenon of axial shift are used to assess ACL integrity. The most commonly used tests are described below. ### Luckman test: Lockman test is the most sensitive diagnostic test for anterior cruciate ligament (ACL) tear. For this, the athlete should lie on his back and be comfortable. The knee should be bent 20 to 30 degrees. Then, while holding the thigh with one hand, slowly pull the leg forward with the other hand. If the degree of anterior instability increases and there is no clear end point, the test is positive, and a positive test indicates a tear of the anterior cruciate ligament. is The test should always be repeated relatively on the opposite knee. In addition to the Lockman test, there are other tests to diagnose an anterior cruciate ligament (ACL) tear, which include: - Pivot shift test - Anterior sliding test Treatment of anterior cruciate ligament (ACL) tear The treatment method for cruciate ligament rupture depends on the severity of the injury, and some of its treatment methods are mentioned below: ### primary care Immediate care measures play a role in reducing pain and swelling caused by knee injury: - Rest**:** To improve the condition and limit the pressure on the knee, rest is necessary. - Ice**:** During waking hours, put ice on the knee for 20 minutes every two hours. - **Compression:** Close the knee tightly with a bandage. - **Lifting:** Lie down and put the knee on the pillow. ### Drug treatment Taking over-the-counter pain relievers such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce inflammation and pain. The prescription of these drugs by the doctor is to reduce the inflammation around the knee joint and to improve the effect of physiotherapy. In cases of severe pain, the doctor may recommend injecting steroid drugs into the knee, but this injection should only be done with the doctor's opinion due to the possibility of weakening the injured ligament. ### knee brace A knee brace is a device used to support the injured joint after a cruciate ligament tear. This device can be used until surgery or during the recovery period after surgery. An ACL brace increases the stability of the knee and helps it heal, preventing further injury. ### Physiotherapy and rehabilitation The physical medicine specialist teaches the patient how to correctly perform therapeutic movements; These movements can be done both in the clinic and at home. A brace or crutch may be used to prevent pressure on the knee. In many cases, the patient must undergo rehabilitation several sessions a week. These exercises strengthen the muscles around the knee and restore its full range of motion. Sometimes a home exercise program is considered. We say these programs below: #### Passive knee stretch To do this exercise, place two chairs facing each other at the same height; Their distance should be a little shorter than the length of the leg. Sit on a chair and place your heel on the opposite chair. Release the leg until the knee is straight. several times a day, stay in this position for 1 to 2 minutes each time; This movement gradually stretches the hamstrings. #### Bridge This movement involves the muscles of the hamstrings, back and pelvis. Repeat 8 to 10 times and stop if it hurts. Lie on your back, bend your knees and ankles so that only your heels are on the floor and your knees are at a 90-degree angle. Contract the abs and draw the spine in, then press through the heels, contract the hips, and raise the hips until they are in line with the knees. Stay in this position for 6 seconds and breathe normally; Then slowly come down and rest for 10 seconds. #### Lifting the heel This exercise is useful for strengthening leg muscles and should be done 8 to 12 times a day. Stand straight with feet 10 cm apart, place your hands on a chair or counter. Slowly raise the heels while keeping the knees straight; Stay in this position for 6 seconds and then slowly return the heels to the ground. #### Lifting the leg while lying down This movement helps to strengthen the upper thigh and hip muscles and should be repeated 8 to 12 times. lie on your back, bend the healthy knee and place the sole of the foot on the floor; Keep the injured leg straight. (The back should have a natural arch, so that your hand fits between the back and the floor). Press the back of the affected knee into the ground, contract the thigh muscles and keep the knee straight. Raise the injured leg so that the heel is about 30 cm from the ground; Stay in this position for 5 seconds. #### Lifting the leg from the side This movement strengthens the pelvic muscles and should be done 8 to 12 times. lie on your side; Place the injured leg on top. Contract the front thigh muscles of the injured leg and straighten the knee. The body should be in a straight line and the knee should be forward; Do not step back. Raise the straight leg so that the heel is 30 cm away from the ground; Hold for 5 seconds and then lower. ### TENS Transcutaneous electrical nerve stimulation or TENS is a non-invasive method in which mild electrical waves are applied to the skin next to the affected area. These waves block the pain messages to the brain and reduce the feeling of pain. TENS is often used to control pain from cruciate ligament tears and increase comfort during rehabilitation. ### Ultrasound Ultrasound treatment is the use of high-frequency sound waves to generate heat in deep tissues. This heat increases blood flow and accelerates the delivery of nutrients to the affected area, as well as improves waste removal. The use of ultrasound is effective in reducing inflammation and relieving pain caused by cruciate ligament rupture. ### low power laser In the low-power laser method (LLLT), low-intensity laser light or LED is used to stimulate cell activity and accelerate tissue repair. This method helps to recover after cruciate ligament rupture, reduce inflammation and relieve pain. LLLT is a safe and non-invasive method, but its effectiveness is different for different people and for better results, it should be done under the supervision of a physical medicine specialist. ### cruciate ligament surgery The doctor recommends surgery in the following conditions: Athletes who are active in jumping, turning and sudden movements and intend to continue professional sports. Cases in which more than one ligament or connective tissue of the knee is torn. When the knee becomes empty during daily activities. In cruciate ligament repair surgery, the damaged part is removed and replaced with a part of the tendon called a graft. This tendon can be taken from another part of the knee or from the tendons of a deceased donor. After the surgery, the rehabilitation period begins; Successful ACL surgery, along with proper rehabilitation, will help restore knee stability and function. If a person skips surgery, the probability of re-injuring the knee will be much higher. Care after an anterior cruciate ligament (ACL) tear One of the common problems and injuries among people, especially athletes, is stretching or tearing of the cruciate ligament. This ligament is located in the knee area and affects other movement organs. In general, the largest and most complex joint of the human body is the knee joint, and any injury and disorder in this part of the body causes many problems and movement restrictions for other side organs. Experts believe that a sprain or tear of the cruciate ligament should be treated as soon as possible to prevent further damage. If the cruciate ligament is torn, it will not be treated with home care alone, and you must perform treatment methods along with home care. ### Primary actions when cruciate ligament rupture If for any reason you encounter a rupture of the cruciate ligament in different areas, it is better to do first aid so that you can get to medical centers as soon as possible. The rupture of the cruciate ligament is such that it will be accompanied by a lot of pain and pressure, so it is better to immediately stop any activity and rest as soon as this happens. Rest will prevent your knee from bearing extra weight and causing more damage. After this step you can put ice on the affected area, as this will prevent further bruising and inflammation. If you can wrap your knee with a tight bandage, you can reduce the pressure. Of course, until you reach the place of treatment, it is better to place your knee at a height in such a way that a small pillow is placed under the knee to avoid more pressure and higher swelling. Finally, you should immediately go to medical centers and specialists so that the necessary measures can be taken for you. ### home care The only solution that doctors offer to people for home care is more rest and reduced range of motion. For example, when walking or doing daily activities, it is better not to put any pressure on your feet and avoid lifting heavy objects. You should also know that a major part of the pain and injury should be improved by resting and shortening the range of motion, and for this condition, using knee braces will be a good option. By using these braces, you cannot bend your knee to a great extent or you will have a very small range of motion when moving, in this situation the knee ligament will heal at a higher speed. ### Medical care One of the effective methods to improve the cruciate ligament is to use various drugs that are used to relieve pain. Many medications are suitable for reducing inflammation and can improve the damage to the cruciate ligament in the short term. Doctors and specialists consider physiotherapy suitable for knee ligament injuries and believe that by strengthening the muscles, it can remove any additional pressure from the ligaments and joints. Many specialists consider the use of platelet-enriched plasma as a solution to this problem, which is known today as PRP and is particularly popular among other treatment methods. All these methods are simple and uncomplicated activities and you can use them to improve the cruciate ligament. Specialists take these methods according to the patient's physical conditions and can get the best results. When the cruciate ligament is damaged, all the mentioned methods are an effective process in improving this condition, but according to the severity of the injury, doctors will determine which treatment method is more suitable for improving the cruciate ligament. Possible consequences of cruciate ligament rupture In general, the cruciate ligament is one of the most important ligaments in the body, which is located in the leg area and can perform a very important task in your movement process. But the rupture of the cruciate ligament may bring risks and complications for you, the most common of which is bleeding or the presence of blood clots. Of course, with a rupture of the cruciate ligament, you may experience constant pain in the knee area for a very long time. Infections, dry joints and muscle weakness are all complications of cruciate ligament rupture. Complications that you may experience after a cruciate ligament tear is a decrease in joint range of motion. You should also know that after the rupture of the cruciate ligament, various disorders may occur in your immune system. Rupture of the cruciate ligament may cause more risks for you if not treated and attended to on time. —————————————————————– Ways of communication with Dr. Majid Ghorbanzadeh The Instagram page of Dr. Majid Ghorbanzadeh Aparat channel of Dr. Majid Ghorbanzadeh The show channel of Dr. Majid Ghorbanzadeh —————————————————————–