ACL Tears are one of the most devastating injuries in a Soccer Player. There is a still a big number of patients that never return to play or they return to play to a much lower level than before the injury. In this post we outline all the components of an ACL injury. The more you know the better decision you'll make when recovering from this condition
ACL - Anatomy
The knee is a hinge joint where the thigh bone (femur) connects to the shinbone (tibia).
The quadriceps muscles in the front of the thigh and the hamstrings in back help to stabilize the knee, but stabilization occurs primarily from the knee ligaments.
There are 4 ligaments that keep the knee stable and moving in the proper direction.
The medial and lateral collateral ligaments keep the knee from shifting 𝐬𝐢𝐝𝐞 𝐭𝐨 𝐬𝐢𝐝𝐞, while the anterior and posterior cruciate ligaments keep the knee from sliding 𝐟𝐫𝐨𝐧𝐭 𝐭𝐨 𝐛𝐚𝐜𝐤.
The ACL attaches the lateral femoral condyle to the tibia just in front of the anterior tibial spine. Some of its fibers also blend into the medial meniscus.
There are actually two bundles of fibers that make up the ACL and allow it to help stabilize the knee in flexion (bending), extension (straightening), and rotation. It works as a passive stabilizer that with the assistance of the Muscles (active stabilizers) helps maintaining the bones of the knee joint (femur and tibia) from moving too much, keeping the knee stable for jumping , cutting , changing direction, and decelerating during high level sporting activities. The ACL resists forward ( anterior ) translation and inward ( internal ) rotation of the tibia in relation to the femur.
Mechanism of Injury
The 2 most common mechanisms for an ACL tear are:
1. Non-contact Injury
Rapid deceleration with the knee slightly bent and the tibia rotated internally or externally . For example landing from a jump , pivoting, changing directions.
2. Extreme hyperextension or from a direct impact to the outside of the knee.
Knowing the most common mechanism is very important for treatment and especially for prevention. Soccer teams around the world work on extensive balance exercises , landing from a jump exercises , single leg coordination exercises to maintain a healthy knee.
All this mechanism must also be reproduced during the last stage of the rehabilitation program to assure patient is ready to safely manage these demands to the knee and the ACL.
ACL Tear Facts
In non contact injuries, the person is usually changing direction quickly, making a sudden stop or landing from a jump.
In contact sports, the foot is usually planted and the blow causes knee hyperextension. High-risk sports include football, basketball, soccer, and skiing.
The use of cleats also increases the risk of an ACL injury.
Women are at higher risk of sustaining an ACL injury than men.
Potential reasons for this increased risk may include differences in anatomy, training, and activity experience.
Genetic differences in how muscles contract may also be another reason for the increased risk in females. Furthermore, women have a wider pelvis than men to accommodate childbearing, and this can cause an increased angle where the femur meets the tibia at the knee joint (Q angle). A wider angle increases the stress on the ACL, increasing the risk of injury. The male's larger quadriceps and hamstring muscles bulk tend to protect and stabilize better a women's quads and hamstrings, if the same stress is placed on the knee joint.
Symptoms of an ACL Tear
The patient usually can notice a loud popping sound as the ligament tears.
Pain is almost immediate.
Knee swelling occurs within an hour or two as blood from the ruptured ligament fills the knee joint.
Walking is difficult, and the knee feels unstable or like it will give out because of the fluid within the joint, it may be difficult to fully extend or straighten the knee.
The initial treatment may include ice for pain and inflammation management, and due to the instability of the knee and problems walking athletes need to use crutches and a knee brace for protection.
ACL Treatment Options
There are 3 options when it comes to fixing your ACL for your injured knee.
Most patients will require surgery if the want to return to long term high level sports
The most common surgical procedure is the ACL reconstruction. ( see below for reconstruction surgery options)
ACL repair is a good option but it’s only for a slightly torn ACL which is a less common type of injury . Usually the ACL tears completely in the middle of the ligament causing damage beyond repair and needs to be reconstructed
3. Rehabilitation without surgery
Finally there are certain patients that the will “cope” very well with the rehabilitation process and the knee feels stable enough to do “less risky “ physical activity or sports and can avoid the surgery altogether. See Picture below for more "facts" about non-surgical rehabilitation of complete ACL tears
ACL Surgery - Reconstruction and Graft Options
There are several options that surgeon will choose for an ACL reconstructions surgery
BONE- PATELLAR TENDON - BONE
QUADRICIPITAL TENDON ( YOUTH )
ALLOGRAFT ( CADAVER )
The different types of ACL reconstruction options require using a “graft” as the replacement for the completely torn ACL.
A graft is a living piece of tissue that is transplanted surgically.
The different types of ACL grafts one can choose from are: the two most common are hamstring tendon graft, patellar tendon graft from your own muscles and tendons.
Another option could be a graft from a cadaver called allograft and the 4th option is the quadriceps tendon graft ( mainly for youth athletes).
The rehabilitation of these types of graft is very similar and the outcomes are very similar as well in term of success to return to play and re-injury rates.
Patellar Tendon graft are associated with a higher patella and patellar tendon issues than hamstrings or cadaveric graft
ACL tear is a devastating injury for any Soccer player, most common in female soccer players
There are a few specific cases that will cope well with rehabilitation without surgery
It will require surgery in most cases using a graft to reconstruct the ACL and a long rehabilitation process ( + 9 months ) to return to play.
A good amount of patients ( 25-50 % ) will never return to their previous level of activity reason why the rehabilitation process is crucial in this patients.
Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries.
With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages
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Board-Certified Sports Specialist
Owner of White Bay Physical Therapy