What You Need to Know:
An ACL injury is common in athletes of all levels but is more common among girls than boys.
An ACL injury is especially common in activities and sports with a lot of cutting, pivoting, jumping, and change of direction. Examples include football, hurling, soccer, basketball, and rugby to name a few.
The severity of ACL injuries is classified by grades 1, 2, and 3.
Either non-operative or surgical treatments may be recommended depending on the grade of ACL injury, the patient’s level of sport, age, and goals.
What is the ACL?
The anterior cruciate ligament (ACL) is one of the four major ligaments found inside and around the knee joint.
A ligament is a structure in a joint that holds the bones together and helps control movement or motion at a joint.
The ACL helps to make your knee stable and prevents the shinbone (tibia) from rotating and sliding in front of the thighbone (femur). In other words, the ACL works to prevent the shin from moving too far forward.
What are the symptoms of an ACL injury or tear?
- A “pop” in the knee at the time of injury
- Swelling of the knee
- Warmth and redness around the knee
- Inability to bear weight on leg (though some have little or no pain)
- Instability or buckling of the knee
What to Expect After Injury
The ACL can be injured or torn in several different ways. The ACL is particularly vulnerable to injury during sporting activity involving a sudden pivoting or cutting manoeuvre, or from impact when the foot is planted on the ground. The ligament can also tear due to work injuries or automobile accidents.
When an ACL injury occurs, you may hear a “pop” or feel a “popping” or “snapping” sensation in the knee. The amount of pain experienced during the injury is somewhat variable but can be severe. Some may have little or no pain.
Normally, the person is unable to continue playing their sport or activity and has the impression that a significant injury has occurred. It is typical for your knee to swell immediately afterwards, feel unstable and become too painful to stand and walk. Immediate swelling of the knee often develops at the time of injury. This usually starts within the first several hours after injury. The extent of swelling can be limited if the knee is immediately iced or splinted using a compression bandage. The severity of the injury varies and can range anywhere from a partial thickness tear to a full rupture.
Your Next Steps
Elevate the injured leg and ice the knee immediately after injury. This will help to reduce the amount of pain and swelling you might experience. Avoid taking anti-inflammatory tablets where possible to allow your body to start its natural healing process.
After injuring your knee, it is very important to book an appointment at a clinic you trust and have your knee properly assessed by a qualified health professional such as a Physiotherapist or an Athletic Therapist. At your initial appointment, one of our therapists here at the Pain and Performance Clinic Lucan will talk to you about what happened when the injury occurred and will use a series of clinical tests and measures to test the available movement and the structures in the knee. Your physio will either rule out the possibility of an ACL injury or confirm the suspicion of an ACL injury.
If your physio believes an ACL injury is likely, it is common to be referred for an MRI scan to confirm the diagnosis. Your therapist will start you off with a rehabilitation and treatment plan before you leave your initial physiotherapy appointment. Many individuals believe they need to rest completely until they receive the results of the MRI scan, but it is very important to start working on regaining the range of motion and movement in the knee joint even while the knee settles from the injury.
Frequent icing for 10-15min at a time during the first 24-72 hours is often recommended. Exercises used in this first phase of rehabilitation focus on regaining the ability to fully straighten the leg as well as improve your ability to bend your knee. A few examples of exercises used in this initial phase are included in the video titled “Early Stage ACL Exercises” which can be found on our Pain and Performance Clinic YouTube Channel.
We Discuss Your Options with You
Once the MRI results confirm the diagnosis and the severity of the injury, your therapist will discuss your treatment options with you. Surgery, known as ACL reconstruction (ACL-R) is a very common treatment for ACL injuries, yet it is not the only treatment option. ACL injuries, especially partial-thickness tears, can be treated without surgery.
The recommended treatment depends on the severity of the injury, your level of sport or activity, age, and your goals. For instance, individuals who tend to not require surgical repair and can rehabilitation their injury using only physio would typically be those who are older, not involved in any sport and are not experiencing instability at the knee (e.g., they do not feel like their knee is unstable or will give away).
In some cases, young, active individuals can rehabilitate the knee and recover from an ACL injury without surgery, yet this depends on the type of sport they play and if their injured knee feels stable. If surgery is recommended, your therapist will refer you to a sports medicine or orthopaedic consultant to seek their professional medical opinion.
Types of ACL Injuries
ACL tears are sprains and are graded by severity and are called sprains. A sprain is a stretch or a tear in a ligament.
A ligament is a structure in a joint that holds the bones together and helps control movement or motion at a joint.
Grade 1 (Mild)
A Grade 1 sprain of the ACL occurs when your ACL is overstretched, but not torn. If your knee is still stable, you likely have a grade 1 injury and will not need surgery. If no loss of function, recovery time can take as little as a few months before returning to sport fully.
Grade 2 (Moderate)
A Grade 2 ACL sprain is a partial tear. If you have a grade 2 sprain, your ligament is damaged. It is common to experience instability and pain at the knee, however, some individuals may not experience instability. Partial, or grade 2, ACL tears are the least common of the three types of ACL tears. Recovery time for a grade 2 ACL injury takes longer compared to a grade 1 injury. Return to sport and activity follows a phased return. Progression is dependent on when certain goals and outcome measures are satisfied.
Grade 3 (Severe)
A Grade 3 ACL sprain is a complete tear. This is the most severe type of ACL injury. In most cases, if you have a grade 3 ACL sprain, it is common to experience severe pain and instability in the knee. Recovery time and return to sport and activity follow a phased return and are dependent on when certain goals and outcome measures are satisfied. Recovery time can take roughly 9-12 months in most cases.
If your knee is unstable, surgery is often recommended. Should your knee feel stable, non-surgical options can be an option. If you suffer an ACL injury, it is important to seek medical care immediately regardless of the grade of your sprain. Your Physiotherapist or Athletic Therapist will evaluate your injury and provide you with the best course of treatment.
Surgical reconstruction of the ACL is usually recommended for those who are younger (aged 30 years old or less) and active – either through playing sports, other forms of exercise, or physically demanding jobs.
Other factors that may lead to surgery being recommended would be the feeling of instability at the knee or a complex injury to the knee where other structures in the knee, such as the cartilage and/or collateral ligaments (e.g., the ligaments on either side of the knee such as the MCL or LCL) are also injured. With ACL tears, it is common to also have an injury to other structures within the knee.
Surgery is Not the Only Treatment Option
If surgery is recommended, your therapist will refer you to a sports medicine or orthopaedic consultant to seek their professional medical opinion. Many individuals that opt for ACL reconstruction (ACL-R) surgery often want to have the operation as soon as possible, however, it is VERY important to allow the knee to settle from the injury and regain both a good level of strength and function before surgery. Doing so can help make the surgery less painful as well as speed up your recovery post-surgery.
Despite ACL-R surgery being a very common treatment for ACL injury, it is not the only treatment option.
A common goal for the typical patient after ACL injury is to return to their pre-injury level of sport or activity, and there is a widely held belief that the patient requires an ACL-R to do so. Unfortunately, ACL-R does not guarantee a return to the pre-injury level of sport and activity.
There are consistent findings across several research studies that show that non-operative ACL patients (even elite athletes) do just as well, and in some cases, better than ACL-R patients in short-term and long-term outcome measures, including function, quality of life and return to pre-injury levels of sport and activity.
The Rehabilitation Process
The rehabilitation process for an ACL injury can be long regardless of the treatment route chosen. Rehabilitation needs to be thorough and you need to put in a lot of work – both in the gym and at home. The typical time to recover from a full rupture ACL injury ranges between 9 to 12 months.
The ACL rehabilitation protocol is broken down into 6 phases. Each phase has a list of goals and outcome measures that need to be satisfied at the end of each phase to move on to the next one.
The first phase is the Pre-Op/immediate post-injury phase. The pre-op/immediate post-injury phase focuses on injury recovery and readiness for surgery if opting for surgical reconstruction.
The second phase is the Post-Op phase. This phase focuses on recovery from surgery if surgical reconstruction was done.
The third phase focuses on regaining strength and neuromuscular control of the muscles at the knee as well as at the joints above and below (hips and ankles).
The fourth phase is when we start working on running, agility, jumping and landing. These are crucial skills that need to be mastered before returning to activity or sport.
The fifth phase is where we allow you to gradually return to sport and activity fully.
Many think the fifth phase is the final stage, however, the sixth phase focuses on reducing the risk of reinjuring your ACL.
All athletes with a history of ACL injury should continue with an ongoing ACL injury prevention program even while they continue to play sports. This final phase aims to improve neuromuscular control during standing, cutting, and landing tasks. This phase is ongoing and is done before playing any sport.
Parts 2 and 3 of this ACL blog series outline Phases 2 to 6 further.
Pre-Op Phase of Rehabilitation
If opting for surgery, it is important to allow the knee to settle from the injury and regain a good level of strength and function.
According to recent research, people who attain full range of motion, good quadriceps (muscles in front of your thigh) and hamstring (muscles at the back of thigh) strength, and minimal swelling before surgery have better outcomes up to 2 years post-surgery than those who do not.
Your Physiotherapist or Athletic Therapist will give you exercises and activities during this phase. These typically include regular icing of the knee to reduce swelling, range of motion exercises, low-impact aerobic exercise such as cycling, and a progressive strengthening regime.
Strength exercises should progress depending on your symptoms and the severity of your ACL injury.
As the pain and swelling reduce and the range of motion increases, strength exercises progress to include weighted exercises in the gym, such as step ups, deadlifts, squats, etc.
Exercises may also include jump and landing activities such as various hopping drills. Aggressive change of direction and activities involving rotation is avoided.
The 3 most important goals of the Pre-op Phase are:
- Eliminate swelling
- Regain full range of motion (straightening and bending)
- Regain 90% strength in the quads and hamstring compared with the other side
Examples of exercises used in this Pre-Op phase are included in the video titled “Early Stage Exercises After Surgical ACL Reconstruction (ACL-R)” which can be found on our Pain and Performance Clinic YouTube Channel.
Should you suffer an ACL injury, it is important to seek medical care immediately regardless of the grade of your sprain. One of our Physiotherapists or Athletic Therapists will evaluate your injury and provide you with the best course of treatment.
If you think you’ve injured your ACL, call or email our Physio clinic in Lucan, County Dublin right away for an appointment.
Where You Can Find Us:
Pain and Performance Clinic Lucan
Hills Industrial Estate, Unit 3,
Lucan, Co. Dublin, K78 VA06
Phone: 086 787 6358
Appointments can be booked online through our website, by phone or by email.