Understanding the ACL Injury

The ACL

Injuring the ACL (anterior cruciate ligament) is one of the most dreaded injuries that an athlete can sustain in the course of their lifetime. It is a debilitating injury that can literally sideline an athlete for months and in addition to excruciating pain, it is also a fairly difficult injury to recover from. Since the ACL is one of the four major ligaments in the knee, it is crucial to the overall movement of the leg. It is the most common injury among athletes, usually torn during sudden dislocation, torsion, or hyperextension, and is often accompanied by a loud popping sound as well as moderate to severe pain and severe swelling. The most common sports in which this injury occurs include skiing, gymnastics, basketball, and football.

The ACL is a relatively unique ligament because of its position within the knee, joining the upper leg bone with the lower leg bone and maintaining stability in a normal environment. Injuries can be mild, such as a slight tear or sprain, to sufficiently severe that the ligament completely tears away from the bone, or separates in half. The worst part about an ACL injury is that if it is not treated properly the individual is likely to lose control of the knee, resulting in reduced movement and the potential for bone on bone friction, which is otherwise known as chronic ACL deficiency. Since abnormal bone movement can damage the surrounding tissues and cartilage that covers the ends of the bones, it can directly lead to development of osteoarthritis, sometimes at a frighteningly young age.

Causes

There are three common causes of ACL rupture that doctors associate with the injury: environmental causes, anatomical causes, and hormonal causes. Environmental causes are those which specifically involve sports where running and jumping pose the greatest potential for injury to the athlete, and contrary to popular belief the risk for rupture does not increase with contact sports. It simply depends upon whether or not the individual is running or jumping. The ACL can be torn if the knee joint is bent backwards, twisted, or dislocated in any manner.

Meanwhile, anatomical causes of ACL injuries are most commonly prevalent in female athletes, primarily because they land on their feet in a more straight-legged manner as compared to men, which results in significantly greater shock placed upon the knee because a woman is less reliant upon her quadriceps to absorb the impact. If the knee cannot withstand the shock, it literally bends sideways instantaneously. In addition, estrogen is one of many hormones which have been associated with an increased risk of ACL rupture, which is yet another reason why women are at a higher risk for the injury than men.

Why Women More than Men?

In addition to the reasons noted above, there are a variety of studies that detail women’s greater susceptibility to ACL injuries due to hormones, ligament dominance, quadriceps dominance, as well as the biomechanics, anatomy, asymmetry, and physiological differences between men and women. One of the primary reasons that women are more susceptible is due to the angle formed by a woman’s hips and knees, which in and of itself places greater pressure on the ACL. This phenomenon does not occur until puberty, the time at which the hips begin to widen.

The shape of woman’s body requires that the ligaments be used with greater frequency than the muscles, while the direct opposite occurs in a man’s body. Since ligaments often compensate for muscles in the female form, it can make the muscles more susceptible to damage. For example, male athletes use their hamstrings instead of ligaments for stability, while women use their quadriceps, which compresses the joint and pulls the tibia forward, placing stress upon the ACL. This is why strengthening of the quadriceps muscles is so crucial for most women..

In addition, the biomechanics of a woman’s body are such that their knees are likely to bend inward during any form of jumping, pivoting, or landing, which distributes weight unevenly throughout the body. Scientists have shown that the femoral notch, which is the space at the bottom of the femur where the ACL runs, is narrower in women than in men.

Diagnosis and Treatment

The best way to avoid an ACL injury is to regularly engage in strength training to prevent the injury from occurring in the first place. However, accidents can happen, and it is important to properly diagnose and treat the injury as quickly as possible. As a general rule, a clinician will diagnose an ACL injury by applying anterior force to determine the flexibility of the knee, with any abnormal motion suggesting a tear. In addition, an MRI is usually taken to confirm the diagnosis.

Treatment will depend entirely upon the extent of the injury. A doctor may simply recommend physical therapy and a knee brace. Physical therapy is used to strengthen the muscles around the knee to help compensate for the absence of a healthy ACL, specifically focusing on the hamstring, quadriceps, calf, hip and ankle, with an overall goal of establishing a full range of motion for the knee.

Most patients will be able to resume normal activities within a month after the injury. More severe treatments require surgery, with the most extreme cases requiring reconstructive surgery, both of which will involve subsequent daily physical therapy for several months. Fortunately, with proper rehabilitation, full range of motion is generally restored.

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