Our anterior cruciate ligament, also known as the ACL, is a very strong ligament in the center front of our knees (there is a back one too, called the posterior cruciate ligament).

This ligament is pretty strong, and are typically injured (mild to full tears) to individuals who are very sporty, especially those who participate in

• football or soccer
• basketball
• skiing
• baseball
• gymnast
• etc

That being said, nonathletes and anyone can also get an anterior cruciate ligament tear. Unfortunately, I also tore my left ACL when I was 14 years old, in a playground accident. It changed my sports life drastically, because

1. me and my family didnt know what it was
2. saw an incompetent orthopedic surgeon who sent me home with painkillers, telling me and my dad that “it’s nothing”

What a pain – my knee kept buckling and it was unstable, and I never knew what it was. Sad.

I realized what I had only when I started my occupational therapy class, and we were learning about sports and orthopedic conditions and injuries, and after testing, the teacher confirmed what I had was a full rupture of my anterior cruciate ligament.

Okay, enough about me. Just in the United States itself, there’s about 250,000 of ACL injuries diagnoses every single year, and this is estimated about $2B in medical expenses. From this source here.

For anterior cruciate ligament tears in the world of sports, it’s interesting to see that

• 70% of ACL tears are NON-CONTACT sports (imagine that! One would think it’s contact sports that causes more ACL injuries but not according to research)
• 30% are due to contact sports where there is player-to-player interaction and contact

Women are 2-8X more likely to get an ACL injury and tear and there’s a biological/mechanical reason for this: The groove in the femur, which is where the ACL passes, is smaller in females than males. A woman’s anatomy also makes her jumping stance different than a man’s. When women land after a jump, their knees tend to bend inward, which puts more strain on the ACL and increases their risk of injury.

Let’s find out what’s an anterior cruciate ligament tear

So the anterior cruciate ligament is one of the major bands of tissue (ligaments) that connects our thigh bone (femur) to our shin bone (tibia) at the knee joint.

If you can imagine the ligament within the knee joint, then you can consider how easily our can tear with:

• Twist your knee while keeping your foot planted on the ground
• Stop suddenly while running
• Suddenly shift your weight from one leg to the other
• Jump and land on an extended (straightened) knee
• Stretch the knee farther than its usual range of movement
• Experience a direct hit to the knee

My ACL tear happened because I fell on my knee and the momentum pushed my femur forward, popping it almost instantaneously =(

What does an ACL tear feels like?

I hope that you and your loved ones and friends NEVER ever has to experience this. What we experience when our ACL tears:

• feel a sharp, intense pain
• feel / hear a loud snap or pop
• immediate swelling
• immediate knee instability and unbuckling with pressure (eg unlock, unhinge)
• not able to put weight or load on it
• not able to pivot or turn on the injured leg

How is ACL tears diagnosed?

Immediately after you injure your knee (specificly if it’s an anterior cruciate ligament injury), you may be examined by physiotherapists or orthopedic surgeons (or maybe a sports physician too).

The physio will ask:

• What you were doing when the injury occurred.
• If you felt pain or heard a “pop” when the injury occurred.
• If you experienced swelling around the knee in the first 2 to 3 hours following the injury.
• If you felt your knee buckle or give out when you tried to get up from a chair, walk up or down stairs, or change direction while walking.

They may perform gentle “hands-on” tests to determine the likelihood that you have an ACL tear, and may use additional other tests such as the anterior drawer test to assess possible damage to other parts of your knee.

The orthopedist / orthopedic surgeon may order tests such as magnetic resonance imaging (MRI), to confirm the diagnosis and rule out other possible damage to the knee.

If you need knee ACL reconstruction or repair surgery

Not everyone needs an ACL repair or reconstruction – only those

• whose ACL is very damaged or fully torn (100% rupture) and/or
• would like to go back to competitive or knee intensive sports such as football

Many people who are mostly sedentary and mildly active can even live without repairing or reconstructing their torn ACL! I didnt get mine repaired when I tore it at 14 years old, and repaired it at 26. The #1 reason why I chose to repair it (other than because I was working at a hospital so there was better rates for me) is because my knee started to develop osteoarthritis grade 2.

So yes, pros and cons to surgery and not surgery.

Research shows that a select group can actually return to vigorous physical activity following rehabilitation without having knee surgery following an anterior cruciate ligament tear.

How does physiotherapy help with anterior cruciate ligament tears?

Once your ACL injury has been clearly diagnose, then you need to decide if you want to correct/repair it or not. Regardless, you will definitely need physiotherapy be it if you choose not for operation or for ACL reconstruction.

If you opt for surgery

Pre-surgery ACL physiotherapy

If your orthopedic surgeon determines that surgery is necessary, our senior physiotherapist can work with you before and after your surgery.

Some surgeons refer their patients to us for a short course of rehabilitation before surgery (increasing fitness and strength pre-surgery can improve the wound, muscle and discharge timing). We will help you

• decrease your swelling
• increase the range of movement of your knee
• strengthen your thigh muscles (quadriceps)

Post-surgery ACL physiotherapy

Your orthopedic surgeon will provide post-surgery instructions to us, and then we will design an individualized ACL physiotherapy treatment program based on your specific needs and goals. Your treatment program may include:

• Bearing weight. Following surgery, you will use crutches to walk. The amount of weight you are allowed to put on your leg and how long you use the crutches will depend on the type of reconstructive surgery you have received. Typically you will get a customized knee physio treatment program to meet your needs and gently guide you toward full weight bearing.
• Icing and compression. Immediately following surgery, control your swelling with a cold therapy, such as an ice sleeve, that fits around your knee and compresses it.
• Bracing. Some surgeons will give you a brace to limit your knee movement (range of motion) following surgery. The physio can help fit you with the brace and teach you how to use it safely. Some athletes will be fitted for braces as they recover and begin to return to their sports activities.
• Movement exercises. During your first week following surgery, physiotherapy help you begin to regain motion in the knee area, and teach you gentle exercises you can do at home. The focus will be on regaining full movement of your knee. The early exercises help with increasing blood flow, which also helps reduce swelling.
• Electrical stimulation. You may undergo electrical stimulation to help restore your thigh muscle strength, and help you achieve those last few degrees of knee motion.
• Strengthening exercises. In the first 4 weeks after surgery, your knee program will help you increase your ability to put weight on your knee, using a combination of weight-bearing and non-weight-bearing exercises. The exercises will focus on your thigh muscles (quadriceps and hamstrings) and might be limited to a specific range of motion to protect the new ACL. During subsequent weeks, your physical therapist may increase the intensity of your exercises and add balance exercises to your program.
• Balance exercises. Expect to be guided through exercises on varied surfaces to help restore your balance. Initially, the exercises will help you gently shift your weight on to the surgery leg. These activities will progress to standing on the surgery leg, while on firm and unsteady surfaces to challenge your balance.
• Return to sport or activities. As athletes regain strength and balance, they may begin with exercises that involve running, jumping, hopping and other exercises specific to their individual sport

Non-surgical ACL management

Current research has identified a specific group of ACL knee patients (termed as “copers”) who have the potential for healing without surgery following an ACL tear.

These patients have injured only the ACL, and have experienced no episodes of the knee “unlocking, unhinging or knee giving out” following the initial knee ACL injury (I would liked to have experience this instead of my prior ACL history)

If you fall into this category, based on the specific tests your physical therapist will conduct, they will design an individualized ACL knee physical therapy treatment program for you which may include treatments such as

• gentle electrical stimulation applied to the quadriceps muscle
• pain management
• swelling / edema management
• range of motion restoration
• gradual strengthening, balance training
• back-to-sport physiotherapy

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