Anterior Cruciate Ligament Strain (ACL Strain)

The Anterior Cruciate Ligament otherwise more commonly referred to as the ACL is the ligament found in the centre of the knee. This important ligament of the knee controls the rotation of the knee and the forward movement of the tibia (also known as the shin bone).

This ACL has been reported to be the most commonly injured ligament in sport. Minor tears may not be noticed immediately but rather appear a few hours later with pain and swelling. More serious tears or ruptures of the ACL ligament are often accompanied by a popping sound. You may feel as though something has snapped or simply feel like your knee has given out.

Causes The tearing or rupturing of this ligament often results from sudden twisting and turning of the knee. Changes in direction or over stretching the knee can also cause the ACL to tear. Pain and tenderness as well as swelling will accompany the ACL injury. The knee may feel unstable to walk upon and may lock during movement. Movements of the knee can also place a great strain on the ACL causing damage to the ligament.

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Hyperextension of the knee, that is, if the knee is straightened more than 10 degrees beyond its normal fully straightened position, is a very common cause of an ACL tear. This position of the knee forces the lower leg excessively forward in relation to the upper leg.

Pivoting injuries of the knee with excessive inward turning of the lower leg can also damage the ACL. Basically any movement where the knee is forced into hyperextension and/or internal rotation may result in damage to the ACL. There does not always need to be impact to cause damage to the ACL, it can be injured without any contact from an outside force whatsoever.

The severity of the injury to the knee will depend on: The position of the knee at the time of the injury The direction of the blow The force of the blow

Most ACL injuries occur during athletic activity. Often those are noncontact activities with the mechanism of injury usually involving:

Planting and cutting - the foot is positioned firmly on the ground followed by the leg (and body for that matter) turning one direction or the other. Straight-knee landing - results when the foot strikes the ground with the knee straight. One-step-stop landing with the knee hyper-extended - results when the leg abruptly stops while in an over-straightened position. Pivoting and sudden deceleration resulting from a combination of rapid slowing down and a plant and twist of the foot placing extreme rotation at the knee. About 40% of all individuals experience a "popping" sensation at the time of the injury, which is actually the tearing of the ligament tissue. At least half of all anterior ligament tears also cause injury to one of the menisci of the joint, which may also produce a tearing sensation.

Non-Athletic-Related Injuries Non-sport related injuries to the ACL result from similar contact and non-contact stresses on the ligament. Examples vary from being struck

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on the outer side of the knee to landing on the knee forcing it into an over-straightened position with the knee turned inward. Motor vehicle accidents in which the knee is forced under the dashboard may also cause rupture of the ACL. Repeated trauma and wear and tear can be a knee problem at any age causing small tears in the ligament, which over time become complete tears.

Treatment
Immediate treatment of the ACL injury include the application of cold or ice packs to the affected area, and elevation of the knee. Resting the injured knee and avoiding use of the knee is also important to healing. Light compression of the knee joint with the use of an elasticized support bandage may also be beneficial. Individuals with severely torn ligaments often require surgery as part of their healing process. More often though, individuals with mild or moderate tearing require physiotherapy. A common technique used in the treatment of ACL injuries by physiotherapists is ultrasound. Ultrasound is a healing technique that has been in existence around the world for many decades. Ultrasound increases the blood supply to the affected area stimulating tissues and providing the optimal environment for healing. Not only does ultrasound aid in the duration of healing, but it helps to prevent long term complications. Scar tissue build up, pain, arthritis, and lack of mobility are some of the more common long term complications from an ACL injury. If you suffer from long term complications of existing ACL injuries, ultrasound can also help. Ultrasound is may be used to break up scarring and fibrous tissue in the affected area. The initial goals of treatment immediately after injury are; to reduce pain and swelling, regain range of motion and increase strength. Even if surgery is likely, achieving as much knee motion and strength as possible pre-operatively can greatly reduce complications following surgery.

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Immediately After The injury Immediately after an ACL injury, the so-called R.I.C.E. treatment is recommended.

Rest - The individual is advised to rest the knee from weight-bearing activities allowing the swelling to settle. Ice - Placing a cold compress or ice pack on the knee is helpful in controlling inflammation as well as helping to reduce pain. Compression - Utilizing an ace wrap for compression around the knee is beneficial to control the swelling. Elevation - Lying down with the leg elevated higher than the level of the chest is helpful in controlling and reducing swelling. The physician may request very gradual weight-bearing exercise immediately after the initial ACL injury. Braces used early after the injury are called rehabilitation knee braces and are off-the-shelf designs used for conservative treatment of the ligament tear. This type of brace is also used for postoperative care of the injured ACL. The rehabilitation brace, also called a post-operative brace, is used immediately post-injury in an effort to put the joint at rest and help protect it, while still allowing appropriate but limited motion. This form of bracing is available in two particular types:

Straight immobilizer - Made of foam with two metal rods down the side that is secured with Velcro and prevents all motion. Hinged brace - Allows range of motion to be set by tightening a screw control.

Post-Injury Exercises
As the swelling in and around the joint decreases and weight-bearing progresses, mild strengthening exercises are started. The exercises prescribed following injury are aimed at improving the strength of the quadriceps and the hamstrings muscles as well as restoring pain free range of movement at the joint. The exercises prescribed by your physiotherapist are specific to the individuals needs as care is taken not to cause further trauma to the ligament.

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Prevention
To reduce the risk of injury to the knee regular exercise is an important component. Gradually increasing the intensity of exercise under the guidance of your physiotherapist is important in preventing recurrence of the injury It is important to avoid sudden movements such as twisting or overstretching of the joint which will assist in keeping the knee stable.

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