The knee joint is the joint most vulnerable to trauma among the joints in the human body. The anterior cruciate ligament is the most injured structure after the meniscus in knee injuries. The most common cause of anterior cruciate ligament rupture is sports trauma. It is common among athletes and also in sedentary individuals. Especially in athletes, anterior cruciate ligament rupture seriously affects their sports life. The return period of athletes who have surgery is quite long (6 months on average), and with the recently developed therapy methods, this period has been shortened and is being tried to be shortened.
After ACL injuries, the person's activity level is restricted, and as a result, both social life and work life may be affected. For this reason, after an ACL injury, the person suffers material and moral losses. In order to eliminate these negative effects on human life, ACL injuries should be treated with the most appropriate method.
What Does the Anterior Cruciate Ligament Do?
Knee joint; femur (thigh). It consists of 3 bones: tibia (shin) and patella (kneecap). The structures that hold these bones together are called ligaments or fibers. There is no bony stabilization in knee joint stabilization; in short, ligaments and muscles play a major role in knee joint stabilization. Ligaments are strong structures that hold the bones together and provide stability (stability of the knee);
* Lateral (Collateral) Ligaments; They extend parallel to the leg on the inner and outer sides of the knee. It prevents the knee from angling to the side and ensures that the knee remains in an optimal position.
* Cruciate Ligaments; These are the intra-articular ligaments located on the inside of the knee and cannot be felt by palpation. There are two pieces, front and back, and they are named because they extend diagonally. These structures control the forward and backward movement of the knee (they prevent the knee from sliding forward and backward) and provide the stability of the knee to rotate around its own axis. ) long and approximately 10 mm (11mm – 18 mm) thick.
How Does Anterior Cruciate Ligament Injury Occur?
Although it is interesting for many of us, 80% of anterior cruciate ligament injuries are non-contact. It is caused by unnecessary traumas. ACL injuries usually occur during sudden turning movements on a fixed foot. Most often it happens during a reverse movement made by the athlete himself. For example; While shooting on artificial turf, an athlete's body may rotate excessively or unbalanced on the foot that carries the weight of the whole body, rather than on the shooting foot. More rarely, the anterior cruciate ligament may rupture or partially tear after direct blows to the knee, traffic accidents, falls from height, and work accidents. The sports equipment used is not suitable for the athlete (shoes, skates, etc.), the field and ground conditions are not suitable, the individual has insufficient muscle strength according to the activity, the weak balance-coordination, which we call proprioception, and muscle and joint contraction and positioning during dangerous movements. Many conditions, such as the individual being anatomically prone to anterior cruciate ligament injury, may be effective in the occurrence of anterior cruciate ligament injuries.
Frequency of Anterior Cruciate Ligament Injuries:
In our country, Although the number is unknown, an average of 80,000 – 100,000 ACL injuries occur annually in the United States. ACL surgeries are the 6th most frequently performed surgery in the United States. Anterior cruciate ligament injuries are more common in female athletes than in men.
Evaluation of Anterior Cruciate Ligament Injury:
The anterior cruciate ligament is usually not injured alone, but the posterior cruciate ligament is not injured on its own. , lateral ligaments, menisci and cartilage can be injured along with the anterior cruciate ligament. While the ligament injury in adults occurs in the body of the ligament, in children the injury may occur by tearing the bone from the place where it attaches to the bone. History is very important in the initial approach to the patient with ligament injury. With anamnesis, very important information can be obtained about the trauma suffered by the patient and the force applied to the knee. This trauma may vary from sports injury or traffic accident. During the injury, the individual says that he/she hears a snapping sound along with extreme pain as a result of the rotation of the knee, and that the knee comes out as if it did not belong to him/her. After the injury, either immediately or a day later, the patient's knee swells painfully and it becomes difficult to bend and unbend the knee. lives and has difficulty walking. Rarely, especially in partial injuries, pain occurs with impact on the knee, the patient feels as if his knee was in and out, but the knee may not swell much and may not hurt. However, if the activity continues and strains the knee, swelling and pain may occur.
The most sensitive radiological test in evaluating ACL lesions is Magnetic Resonance Imaging (MRI). In addition to MRI, Direct Radiographs and Ultrasonography help in diagnosis.
Many orthopedic tests can be used by physiotherapists and doctors to diagnose ACL (Lachman test, Anterior drawer test, Pivot – shift test).
In patients with ACL injuries. Generally, hemarthrosis (intraoperative bleeding) occurs in the knee. If an ACL tear occurs during sports, the patient usually cannot continue sports. Before considering a ligament injury in a patient with hemarthrosis, a possible fracture should be kept in mind and excluded. Physical examination and radiological examinations can be very helpful in diagnosis.
Findings in ACL Rupture:
Pain, swelling, loss of movement and tenderness throughout the joint are observed in the acute phase of the knee.
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Classification of Anterior Cruciate Ligament Injuries:
Anterior cruciate ligament injuries are classified according to their severity;
Stage 1: Mild tension in the ligament. It is in the form of knee pain, but stability is good.
Stage 2: There is a partial tear in the anterior cruciate ligament and nearly half of it is torn.
Stage 3: ACL It is completely torn (full thickness tear). There is a loss of stability in the knee. Loss of stability manifests itself as a feeling of insecurity in the knee while running or descending stairs, as well as loss of balance.
Anterior Cruciate Ligament Treatment
Conservative treatment:
Treatment options for ACL rupture are either conservative ( preventive) or surgical. If patients with ACL rupture lead a sedentary life and do not have an active sports life, conservative treatment can be tried. While surgery was previously considered for young patients, a conservative approach was more prominent for older patients. However, the age criterion is no longer considered among the conservative treatment criteria. In short, patients are advised to decide whether to undergo conservative or surgical treatment. It is necessary to look at more than one criterion when giving treatment.
The aim of conservative treatment in the acute period is to reduce the effects of inflammation on the joint and prevent muscle atrophy that may develop. In the acute period, the patient is given cold application, anti-inflammatory drugs for inflammation, and braces that partially restrict knee movements. Appropriate rehabilitation programs should be started after the patient's inflammation symptoms and pain complaints in the knee disappear.
Muscle strength should be increased by giving the patient closed chain exercises (such as standing and squatting). In this way, the range of motion and flexibility of movement of the knee is tried to be ensured before the injury. He/she is asked to press without giving full load until the three weeks are up. After three weeks, the patient is told to bear full weight. Since closed chain exercises will tighten all the muscles around the knee and strengthen the hamstring muscles, the tibia (shin bone) will be prevented from sliding forward. While doing the closed kinetic chain exercise on the knee, the hamstring (Back leg muscle) and quadriceps (Front leg muscle) muscles contract together in a coordinated manner. Coordinated contraction of the quadriceps and hamstrings minimizes the load on the ACL. Finally, proprioceptive exercises are started on the patient to ensure coordinated work of the muscles. (Consult a doctor or a physiotherapist for these exercises).
The patient starts sports exercises after the sixteenth week. However, it should not be forgotten that in conservative treatment, the patient must be told that there is no ACL and that they need to get used to this lifestyle. Otherwise, conservative treatment may fail. The aim of conservative treatment is to strengthen the quadriceps-hamstring muscles and restore neuromuscular control and proprioception.
Surgical Treatment in Anterior Cruciate Ligament Injuries:
In addition to ACL injury, meniscus tear, internal There is a consensus that if there is one or more of the external collateral ligament tears and capsule tears, the treatment should be surgery.
If the patient with an ACL injury is an athlete and will continue this activity in the future, if a meniscus tear accompanies the ACL injury, the patient If the ACL tear accompanies multiple ligament injury and is an active young patient, this disease Surgical treatment should be considered first in these cases.
Studies have shown that between 6th and 12th months. It has been shown that the results of ACL surgery performed between weeks and weeks are better than the results of surgery performed at other times.
The surgeon repairs the patient's anterior cruciate ligament with the appropriate graft and timing and then moves on to the rehabilitation part completely.
Rehabilitation after Anterior Cruciate Ligament Surgery:
One of the most important factors affecting the success of ACL reconstruction (repair) surgery, apart from the surgical technique, is the rehabilitation of the patient. While in previous periods, rehabilitation programs were started in the late stages, today the idea that early rehabilitation is more effective has begun to be accepted. The aim is to avoid early complications and to ensure more effective preservation of joint functions in the long term. It is necessary to start rehabilitation in the pre-surgical period for the patient who is considered for ACL reconstruction, because the control of joint range of motion and quadriceps (front leg muscle) control in the acute post-surgical period. It will be difficult to win. Rehabilitation started before surgery provides a significant advantage in terms of post-operative rehabilitation. Post-surgical rehabilitation consists of four stages: phase 1, phase 2, phase 3 and phase 4. Our main goals in Phase 1 are; The aim is to reduce the negative effects of immobilization, to protect the graft (the piece of tendon replaced by the ruptured ligament), to control the inflammation that will occur in the joint, and to achieve flexion close to 90º as well as full extension. At this stage, the patient is given in-bed exercises, quadriceps and hamstring isometric exercises, sitting flexion (knee bending) exercises, hamstring (hind leg muscle) and gastrosoleus (calf muscle) stretching and proprioception exercises, straight leg lifting exercises, CPM (Continuous Passive Motion) device. Passive joint movements are made with Phase 1 includes the first week after the operation. Depending on the patient's condition, weight can be given as much as tolerated with the help of crutches while in full extension (straight knee). After a successful phase 1 phase, phase 2 is started.
Phase 2 is performed between the 2nd and 4th weeks after ACL surgery.
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