The Anterior Cruciate Ligament – or the ACL is the most commonly injured ligament in our knee. Surgery for an anterior cruciate injury has unfortunately become commonplace. An ACL tear and resulting anterior ligament surgery can challenge the toughest young athlete. Anterior cruciate ligament surgery is far from routine for many surgeons. Now more than ever before you need to know as much as possible about your ACL surgery options. At the bottom of this post are the essential questions you will need to ask if you or your child are considering ligament reconstruction surgery.
There are many reasons why ACL tears are increasingly more common.
- Loss of seasonality of sports
- Single sport specialization
- genetics
- poor training and biomechanics
We have a loss of seasonality in sports prone to cruciate ligament injuries. Our sports are no longer seasonal. Our soccer and lacrosse players now play year round. There’s no rest and their knee ligaments are not getting a chance to recover.
Single sport specialization is a creation of modern times. Our athletes were not meant to play only one sport year round. Most elite athletes today specialized in many sports when they were young. By concentrating on a single sport year round we are causing a lot of stress on some of the weakest links in your body. Anterior cruciate ligament tears are more common in children who focus on a single sport.
We also know that many people are predisposed to tearing their ACL because of their landing,jumping and pivoting mechanics. Women are predisposed for many reasons. Some of these can not be modified. Many women have a different anatomy that sets them up for ACL tears.
What is the ACL?
The ACL is one of the four strongest ligaments in our knee. It sits in the center and is made of a very tough tissue we call collagen. The ACL keeps our knee stable for sports involving pivoting, turning and twisting at rapid speeds. The ligament is actually made up of two pieces or bundles of ligament tissue. Sometimes an injury to your anterior cruciate ligament only involves one bundle and we refer to that as a partial ACL tear. More on partial ACL tears.
Why Did My ACL Tear?
Most ACL Injuries occur as a result of a non-contact twisting injury. You pivoted, you heard a pop, and likely fell to the ground. Get the ice… and the crutches. The swelling can be impressive. In athletes under 25 years of age, a twisting injury, feeling a pop and noticing a swollen knee a little while later carries a 75% chance of an ACL injury.
Do I Need an MRI?
Does a good sports doc need an MRI to prove that you have suffered an ACL tear? No. Our exam of your knee can tell us that. But we do obtain an MRI following ACL injuries. We obtain an MRI because 1. you expect it.. and 2. to make sure that you have not injured anything else- such as a meniscus or the cartilage on the ends of the bones.
Do I Need ACL Surgery?
If you are an athlete who participates in sports involving cutting, pivoting, turning and twisting there is a strong likelihood that you will require ACL surgery. If you’re older, and you’re willing to modify your lifestyle to suit your limitations, then you may get by without it. Children almost always end up having ACL surgery. The scientific literature shows that children are very likely to suffer secondary injuries to the knee if their knees are not stabilized prior to return to activities.
ACL Surgery Questions to Ask:
Why are you recommending ACL surgery? There is very little debate about how to treat an anterior cruciate ligament tear in a young athlete. Most doctors would recommend an early reconstruction. Many studies show that children are at a high risk of causing more damage to their knee if ACL surgery is not performed and the knee remains unstable.
- For those of you beyond 30 you may have a difficult choice to make. It is clear that all tears do not require ACL surgery. Are you being told that you need it fixed simply because it is torn?
- What about lifestyle modifications, activity modifications, therapy and bracing?
What is the anatomical method of ACL Surgery? : As you read about ACL surgery you will see references to many different techniques. Our thoughts about how to fix an ACL are changing. Surgery to replace a torn torn ligament have evolved A LOT over the past 5-7 years. Older methods did not place the ligament where nature intended it to be. Many sports docs are very knowledgeable about these latest technique modifications. This is an area of much interest. You should feel open to talk with your surgeon about what type of reconstructive surgery they perform.
- single bundle vs double bundle (probably doesn’ matter)
- anatomic versus traditional ACL surgery. Most surgeons have transitioned to an anatomic reconstruction.
How many ACL reconstructions do you perform in a year? VOLUME MATTERS! Do not use a surgeon who performs a only few reconstructions a year. Find a surgeon who performs a few per month or more. Click here to learn more about how to choose your ACL surgeon
What ACL graft would you recommend and why? We need to use something to reconstruct your new ACL with during surgery. See our video discussion below on graft choices. We have two broad options:
1. Allograft – tissue from a cadaver, and
2. Autograft – tissue from your own body.
The literature surrounding the use of allografts, especially in young patients has demonstrated a failure rate approaching 40% in some series. Bottom line, unless there is a strong reason why you can not use your own tissue (autograft) then you should probably not use allograft. Click here to learn more about ACL graft choices.
In the autograft category we have two main choices- a portion of your hamstring tendons, or the center of your patella tendon. Both grafts work well and stand the test of time in a properly performed surgery. A patella tendon graft certainly hurts more, but that may be worth it in certain individuals. Research is starting to show that a hamstring harvest in women may not be a good thing for a high level athlete. Women tend to be quadriceps dominant… so the front of their thigh is stronger than the back where the hamstrings are. It stands to reason that we do not want to make them even more quadriceps dominant by harvesting their hamstring tendons. In some people, especially elite athletes, a hamstring graft can produce weakness. While barely perceptible to most, some will notice the difference. Over my career the pendulum has swung from patella tendon grafts to hamstrings and it appears to be swinging back once again to patella tendon grafts. Have a long discussion with your physician.. question why they suggest a certain graft. This is especially true if considering ACL surgery with an allograft.
Should I start therapy before my ACL surgery? Yes.. prehabilitation can get your knee ready for the procedure and start the muscle reeducation process. Early research shows that PT before surgery improves your results after surgery. A flexible strong knee going in eases some issues following surgery.
Read on :
4 tips to prepare you for your ACL surgery
Dr. Luks, my 15 year son tore his ACL during a football during his freshman year of High School. His surgery was done 12/31/2013. He started PT immediately after his surgery. He ended his PT however works out 3x a week at at performance training facility. 2015 during 2.different. Lacrosse gameshis knee gave out while wearing his custom brace (which is suppose to correct the motion). He had am MRI the ACL is not torn. The orthopedic is recommending another surgery because it’s “loose”. I’m not to happy about this. I would thinking strengthing his quad and continue his performance training would be better for him. His orthoapdic said he will make it Stronger using a different type of screw. My question is if it’s not broke why fix? He is 16. I know of plenty of athlete who have played sports with ACL injuries. Your thoughts? He is scheduled April 9 2015 and I’m not feeling good about this
Dana
Hi Dana …
An ACL graft that is put in loose or mal-positioned is just as bad as having no ACL at all. If the ACl is not functional then it will not stop your son’s knee from giving way as it did. Braces, sadly, do not prevent buckling during sports and can lead to weakness due to the compression of the muscles around the knee. Every time the knee gives way, it risks tearing a meniscus or injuring the articular cartilage on the end of the bones.
I would consider another opinion or two… revision ACL surgery is trickier than the initial surgery. You would like to be under the care of someone who performs many revision procedures per year.
Good Luck to you and your son.
My son is 15 and he had a parcial ACL tear and he did not get surgery because his growth plates need to grow he was wondering if he still needed to wear a Bracehe dosent fell no pain he can run good and he’s doing Great he already tried not using the brace and he felt good playing soccer and his shin guards don’t fit him. Does he need to ware the brace or can he stop using it?
Thank You
Probably not… but you should discuss this with his doctor since I can not examine his knee.
Good Luck
I play soccer and hockey, I’m a goalie in both, and I’m actually on my way to get my surgery,… To get back on the ice… What can u help me with?
I am a very active 57 year old that feel of a ladder and injured my knee. MRI showed a partial to complete ACL tear, bone bruising of my femur and tibia, lateral and medial menisci tears. My Dr tells me I need the meniscus repaired for sure but that I need to decide on the ACL surgery. I am a very active individual who does not really know how to slow down and relax, but am totally undecided if I want to go through the ACL repair. Help
HI Jane … Being “active” is very subjective :-) If you run, garden, cycle etc that is all great– and might not need to consider an ACL reconstruction. If you climb mountains, play in an adult competitive soccer team, etc then you might have an issue with stability. Bust course of action following an ACL tear, with or without meniscus tears is physical therapy. Get the leg strong, allow the inflammation to go away, use a brace only if the knee feels unstable. Consider using a cane or crutch if it unstable all the time. The only people who need to consider ACL and or meniscus surgery are those with symptoms (pain and instability – which persists after PT).
Good Luck
Hi Dr. Luks,
Your comment about “Bottom line, unless there is a strong reason why you can not use your own tissue (autograft) then you should probably not use allograft.” Does this hold true for a 47 year old female that runs, cycles, does crossfit and occasionally practices soccer with her sons? Is the hamstring of a 47 year old strong enough to overcome the trauma and act as a substitute ACL?
Thanks!
An allograft is an appropriate graft in those circumstances… As long as it hasn’t been terminally irradiated (weakens the graft).
Thank you for your reply. I am tempted to go with a hamstring graft, because it is my understanding that they are stronger than an allograft (and I would like to return to skiing, which is how the injury occurred in the first place). Would age alone exclude someone from this option? Or is it really only a matter of preference?