Learning About Ligament Injuries
If you or someone you love has a ligament injury in the knee, it’s important to learn about the injury, causes, repair options, and preservation. Being well informed about your ligaments and anatomy will help you choose the best recovery treatment.
Ligament tears, such as ACL (anterior cruciate ligament) tears are common and increasing every year as sports become more popular. Each year, between 125,000 to 200,000 patients in the U.S. require surgery to repair injuries to the knee. Fortunately, surgery and rehab have improved dramatically in recent years, so people who suffer a ligament tear in the knee can look forward to effective outcomes.
This guide is a collaborative effort between the doctors, nurses, and rehabilitation team at Glenwood Orthopedic Center to answer your questions about knees, common injuries, surgical procedures, and the five phases of recovery. In this guide, we’ll discuss:
- Ligaments Of The Knee
- Common ACL Injuries
- Surgical Options for ACL Tears
- The 5 Phases Of Recovery
Read on to learn about ligament tears of the knee and make informed decisions about your care.
Your Knee Ligaments
Ligaments are like ropes that provide stability to the knee by holding the three bones of the knee joint together–the thigh bone (femur), the shin bone (tibia), and the kneecap (patella).
Each of your knee joints is supported by four unique ligaments. There are two types:
Collateral — Two ligaments are collateral, which means they are around the joint.
Cruciate — Two are cruciate, which means they’re inside the joint. They’re about 2 cm long and can only be stretched about 1.7 mm before they’ll tear.
The ACL (anterior cruciate ligament)
Your ACL controls the stability of the knee, preventing it from sliding forward or twisting too far. This important ligament is also responsible for your sense of balance. Your ACL attaches to the front of the shin bone and the back of the thigh bone and is one of the most common knee ligaments to tear.
The MCL (medial collateral ligament)
Your (MCL) connects the femur and the tibia and is on the inside of the knee. A tear in the MCL is the second most common knee ligament tear we treat.
The CCL (cranial collateral ligament)
Your CCL connects your femur with your fibula (the smallest bone in your lower leg). Located on the outside of the knee, both of these collateral ligaments work together to prevent too much sideways movement of the knee.
The PCL (posterior cruciate ligament)
The PCL is attached to the back of the shin bone and the front of the thigh bone. Operating behind the knee, the PCL prevents the shinbone from moving too far back. This ligament is shorter and much stronger than the ACL, so it doesn’t get injured often.
All four of these ligaments work together to keep your knee strong and functioning properly. But sometimes collisions happen or you move suddenly the wrong way, and the knee is injured. Various problems can occur as a result, but this guide focuses specifically on tears to the ACL.
Find out how you can injure the ACL in the next section.
Common ACL Injuries
Injuries to the ACL can happen from a blow to the knee or awkward movement. It happens most often during sports, such as basketball, soccer, tennis, football, downhill skiing, volleyball, and gymnastics.
- These are the most common ways to cause ACL tears:
- Non-contact twisting movement
- Sudden stopping when the foot is firmly planted on the ground
- Planting and pivoting
- Landing from a jump with one leg too far from the body
- Hyper-extending the knee (bending it too far back)
When one of the events above happen, you may experience the following, which will indicate that an ACL injury is likely.
- Audible crack or pop – About half the time, you can hear a noise at the time of injury.
- Pain — Often, you won’t be able to put weight on the knee or bend it.
- Knee giving way — Frequently, the knee will feel unstable and buckle.
- Immediate swelling – When a full tear happens, the swelling usually occurs within six hours. The swelling is caused by bleeding inside the knee.
- Restricted movement — It’s likely you will have limited mobility when you tear your ACL.
Some ACL tears can heal with a rigorous rehabilitation program. This is often possible when the ACL is only partially torn. If your ACL is completely torn, your best option is surgery.
Explore what’s involved in ACL reconstruction surgery in the next section.
Surgical Options for ACL
Surgery is the preferred method of treatment if your ACL is completely torn or if your knee continues to buckle. This is because every time your knee gives way, you can damage other structures in the knee, such as the cartilage or meniscus, and increase your risk of developing arthritis.
You might also consider ACL surgery if you’re an athlete who wants to return to sports that involve sudden changes of direction, pivoting, and jumping.
The Goal of ACL Surgery – Your surgeon’s goal is to improve the stability of your knee. Surgery allows you to resume routine activities and eventually return to playing the sports you love.
Surgical Options for Your ACL Tear
If the tear is not a complete rupture, it’s possible to simply repair the ligament.
It’s more common to experience a complete rupture. In this case, the ligament must be replaced by a substitute ligament. The surgeon will remove the damaged ACL and replace it with a section of tendon that connects muscle to bone. This is called a graft.
There are two types of grafts: an autograft and an allograft. An autograft is when other soft tissues around your injured knee are used as a substitute for the torn ACL. An allograft is when donor tissue is used.
What Happens During Surgery?
- Anesthesia. Whether you are put under general anesthesia or have local anesthesia depends on your surgeon and the factors involved in your surgery.
- Incisions. Your surgeon will make a few small incisions for the instruments needed.
- Tunnel creation. After removing the damaged ligament, your surgeon will drill sockets or tunnels into your thigh and shin bones where the ends of the graft will be secured.
- New ligament attachment. The graft is then threaded through a tunnel and attached as close as possible to the original ACL’s location.
Finding the Right Doctor
Don’t rush this process, even though you may be impatient to get started on the road to recovery. Most surgeries are performed a few weeks after the injury so that swelling can subside, you can gain strength, and you can regain a full range of movement. As a result, you have plenty of time to plan your next move. The more research you do, the better your outcome.
You Have Options – You may want to seek multiple opinions from specialists in your area. Your potential surgeon must have a full understanding of the damage done to determine the right thing for you to do.
Experience – You should look for a doctor with extensive experience performing ACL reconstruction. The following qualifications are good benchmarks:
- Perform at least 2 ACL reconstructions per month
- Low re-tear rate
- Recommendations from other physicians and previous patients
Pre-rehabilitation – Pre-rehabilitation, or prehab, is what you should do before surgery. It is critically important to prepare your knee for surgery. Plus, studies have shown that proper prehab can lead to a faster recovery.
Prehab also introduces you to the type of exercises you will do in rehab after surgery, and it can increase your chance to regain full function of your knee.
Exercises should be started as soon as you can tolerate them to preserve the function of the knee and to minimize stiffness.
RICE (Rest, Ice, Compression, Elevation) — For the first 48 – 72 hours after injury, you should stay off your leg as much as possible, ice the joint frequently, wear a compression sleeve, and prop your leg up on some pillows.
- Knee extension – You should work to be able to lock and straighten your knee for an extended period of time.
- Knee flexion – Use a bicycle or do heel slides to maintain the ability to bend your knee.
- Increasing hamstring mobility – Do hamstring curls.
- Improving quad strength – Do lunges and squats.
Fundamentally, you want to get as strong as you can before surgery because your strength and mobility will play a big part in your recovery.
Find out what’s involved in recovery and typical timelines in the next section. However, keep in mind that your timeline may vary, especially based on how much effort you put into the rehab process.
The Five Phases of Recovery
Rehabilitation is designed to help you regain normal knee motion, muscle strength, balance, coordination, and neuromuscular control. How long the recovery takes depends on your age, fitness level, and the structure of your knee. The timeline to complete recovery varies quite a bit, so listen to your body and move through the process according to how you feel.
Phase 1: Recovery from Surgery
The first two weeks after surgery set the foundation for a successful recovery. Getting it right will make returning to full functionality much more likely. The primary goals of Phase I are listed below:
- Reduce inflammation and swelling/rest, etc. — As soon as you awake from surgery, your medical team will be focused on reducing inflammation and swelling. Swelling causes pain, restricted movement, and decreased muscle strength.
Often an inflatable cuff filled with ice will be placed around your knee after surgery. For the first 6 hours, drain tubes will be inserted to prevent excess blood and swelling from accumulating. You should elevate your knee as much as possible when lying down.
- Return to normal range of motion/knee extension — Being able to move your knee is critical to recovery. You should be able to fully straighten your leg by week two. Any lag in this can affect your gait, and may result in a buildup of scar tissue that prevents you from extending your knee permanently. Straighten your knee and hold the position for increasing amounts of time. Begin straight leg raises to build your endurance.
- Regain full quadriceps activation/function of your quads — Quads can be knocked out of commission by the surgery, and their support keeps your knee in the right position. Do isometric exercises by contracting the quadriceps on your injured leg and holding the contraction for 10 seconds.
- Put weight on your leg — You will use crutches until your knee can bear weight. You may not be asked to put weight on your leg if you have additional injuries, such as meniscus damage.
By the end of this phase, you should have regained about 70 degrees of the normal range of motion in your knee.
Phase 2: Building Strength, Stability, Neuromuscular Control
Two to six weeks after surgery, you’ll begin physical therapy to help you regain full strength, flexibility, and mobility. Working with the right physical therapists will help you regain maximum use of your knee and greatly reduce the risk of re-injury.
Your physical therapy program during this phase will have three goals:
- Activating your quadriceps and hamstrings
- Working to re-establish your sense of balance
- Starting to move around
It’s important to note that you must monitor pain and swelling after physical therapy sessions. If swelling occurs, use ice and a compression sleeve.
Phase 3: Strength Training, Agility, Running
Six to 12 weeks after surgery, your ligament graft is still vulnerable so take extra care as you increase the complexity and degree of difficulty of your exercises. Avoid any side-to-side movements or pivots that put stress on the new graft.
The goals for this phase are to:
- Regain full strength and balance
- Increase intensity and drills
- Begin to jog for cardiovascular health
Phase 4: Preparation for Return to Sport
At about four to six months, as you continue to gain mobility, strength, and balance, your knee may feel back to “normal.” However, you are not yet ready to resume play. You need to carefully start performing the movements your sport requires, easing into the movements that are typical for your sport.
- Agility drills
- Sport-specific drills
- Maintenance of strength/endurance/balance/agility
Phase 5: Return to Sport and Prevention
The timeline for returning to playing sports is highly individualized. You must progress at a pace that is comfortable for you. Your recovery timeline may be different than others depending on your fitness level, age, and a host of other factors. Pay attention to the level of pain as you progress. It’s important not to push yourself too hard or too soon.
Injury prevention program
As you return to normal activities and the intensity of sports, staying injury-free is of paramount importance. Doing the following activities before walking onto the field or court will help prevent re-injury.
- Warm-up – Warming up the muscles helps them to perform at top function once the first whistle is blown. You can warm up by jogging, doing shuttle runs, and running in different directions.
- Stretch – Many studies have shown that stretching before strenuous activity can help you to prevent injury. You will want to stretch your quads, glutes, hamstrings, calves, hip flexors, and inner thighs, holding each position for at least 20 seconds.
- Strengthen – Many muscles work together to support the knee. Exercises to strengthen your quads, glutes, hamstrings, calves, and trunk will help you keep proper alignment so your knee moves in the correct position.
- Plyometrics – These neuromuscular training exercises help you to learn how to jump, pivot and change direction without putting too much force on the knee.
- Balance – Being aware of where you are in space (proprioception) helps you to make small adjustments to keep you stable.
Glenwood Orthopaedic Center at Valley View
Your ability to regain full function of your torn ACL depends both on your faithful dedication to a well-planned physical therapy program, and the skill and experience of your medical team.
Of the many places you can choose, Glenwood Orthopaedic Center has earned a reputation in the region for their excellence in repairing joint injuries. Staffed by board-certified orthopaedic surgeons, every professional in the center–from anesthesiologist to physical therapist–is committed to getting you back in action quickly and safely.
Our board-certified hip and knee specialists use the latest treatment options to return you to optimum function. We provide a full spectrum of care with state-of-the-art techniques proven to achieve maximum benefit to your bones, joints, muscles, ligaments and tendons.
We evaluate, diagnose, and perform non-surgical as well as surgical interventions needed for the most efficient path to recovery. With you as our partner in decision-making, we make sure you have all the information and support possible to help you make the treatment decisions that will provide you the best outcome.
You can expect to continue to improve for several months as long as you keep up your exercise program while your new graft gains strength. Staying diligent with therapy and strength training can allow you to come back even stronger than before. With the right medical team in your corner, you can step onto the field, ready to take on whatever the competition throws your way.