Bodyworks: Anterior Cruciate Ligament Injury

How to recognise it, how to overcome it


Posted: 5 June 2000
by Patrick Milroy

The majority of people possess both anterior and posterior cruciate ligaments, which form an X-shaped structure through the middle of the joint, their function being to prevent fore and aft movement of the tibia on the femur. Injury, in the form of a rupture, may be due to an accident in everyday life, or as a result of sporting trauma. If a tear occurs, nine times out of 10 it will be in the anterior cruciate ligament (ACL).

Symptoms
You are likely to have twisted your knee pretty severely or bent it backwards in a dramatic fashion to tear your ACL. There is no question of carrying on in the majority of cases, as the knee gives way, becomes painful and will swell with blood on the day of injury. It will be difficult to walk on, let alone run.

Signs
Comparison with the other knee will allow your doctor to confirm the swelling of blood within the joint, and they may or may not draw this off before using other tests on the knee’s stability. When a knee is freshly swollen following injury, it is notoriously difficult to be sure of the exact diagnosis by simple examination, though tests to pull the tibia forward of the femur may be strongly positive if the excess fluid is first removed.

Medical investigations
X-rays are going to give scant help in demonstrating what is soft-tissue damage, though arthrography, in which the knee is filled with opaque fluid, will often be helpful. Scanning techniques, which have been refined over the last 20 years into a really effective diagnostic aid, have made X-rays largely redundant, though if an orthopaedic surgeon has any doubt about the injury, visualisation through arthroscopy will provide the ultimate proof.

What else could it be?
Any condition that fills a knee joint with fluid, be it blood or excess lubrication from the lining synovium must be considered in the differential diagnosis. The injury will limit movement of the knee, as may damage to the cartilages, the collateral ligaments that allow the joint to hinge, the patella, or the formation of a bursa. On occasions, even the most experienced surgeons have got the diagnosis wrong!

Self-treatment
Sometimes the ACL is merely stretched and becomes lax, rather than ruptured; sometimes the patient does not realise the severity of the injury and does not obtain treatment; and sometimes the knee settles down and you can return to sport. Part of the function of the ACL is replicated by the hamstring muscles, so if these are strong and you work hard to maintain power and tone, you might get away without surgery. It is said that six out of the 30 touring All-Black Rugby players last autumn did so without ACLs, though their hamstrings are reminiscent of the trunks of the Giant Sequoia!

Medical treatment
Twenty years ago ACL reconstruction was not really an option, but giant strides have been made in the use of human, animal and mineral substances to rebuild the ligament. Not only is the tissue used important, but the angle at which it is inserted is crucial, and the operation now resembles precision engineering to ensure that the biomechanical integrity of the joint is maintained. Rehabilitation under the watchful eye of a physiotherapist should ensure that a full range of movement is obtained and that those all-important hamstrings are developed to further support the artificial ACL.

Can you run through it?/Recovery time
ACL rupture is a severe trauma to the knee and even attempting to run through it invites the knee to give way and cause further damage to the menisci and articular cartilage. Luckily, it is likely to be far too painful for you even to attempt it, though even professional sportspeople should prepare for the best part of a year off if their ACLs need reconstruction.


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Anterior Cruciate Ligament, ACL
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Discuss this article

Having undergone an ACL rebuild in Sep 02 physio is going well but I wonder what others have found in trying to get back to running, especially fell/hill running - will it take a year or even longer ?
Posted: 05/11/2002 at 23:58

Hi Neil,
I had my ACL reconstructed end of June. Approx. 6mths ago. I have been running on it for a couple of months now but have it is still not 100%. I am trying to build up gradually but knee still feels strange, sometimes sore or swollen after runs. I saw my consultant a couple of weeks ago and he said, it will be 12 mths b4 we can tell if it is fully ok to run on. I was running 15-20miles per week b4 op.


Rgds
Neil

Posted: 06/01/2003 at 17:09

Not direct experience but a mate of mine took 12 months to get back to playing football - and he reckoned another 12 before he felt he could really trust it 100%. But having said that football is far harder on the ACL than running. What does your physio advise re. strengthening the hamstrings - I understand (possibly wrongly) that strong hamstrings can help support the ACL (not sure about that one - I'm sure it was strong something though.)

Good news is my mate reckons it is now effectively 100%
Posted: 06/01/2003 at 17:56

There was a footballer down my gym. He got back into playing for the reserves after 9 mths but was still not trusting his knee 100%. He was transferred to another club so not sure how he is doing know.

Re hamstrings - doing lots of hamstring curls etc. Also do lots of exercises on quads, calves etc (squats, presses, calf raises etc). You need to build up all the leg muscles because they weaken after injury and op and also they help support and protect the knee.
Posted: 07/01/2003 at 10:03

had my knee reconstructed after continuing to run on a damaged acl; put me back months. after the operation it took me 8weeks to get back to swimming but at least 8 months to get back to running. if you have a good physio they will point you in the right direction. front crawl is good for building up the quad muscle but also do as suggested above squats, ;leg raises (with weights) and alike. my knee still swells up now 2 years after the operation so it may continue to do so. you do as much as you feel you can as it can vary for times of healing. i was back at work and going to the gym within 3 months but obviously not everyone heals at the same rate.
Posted: 10/06/2004 at 11:37

My husband chose not to have reconstruction (not so important he is not a runner) but work on his hamstrings instead for normal strength when his consultant said the recovery would be a minimum of 9 months.


Posted: 10/06/2004 at 12:50

Hi guys, i had a knee injury about a year and 2 months ago while playing soccer. the first few minutes after the injury i couldn't step on the leg because the knee was twisting in every direction and could not support my weight. anyways the same night i could step on it, but when i went to a knee surgeon he told me that i have partially torn my ACL and my inner ligament. now i've been jogging for few weeks now and doing excercises but can you please recommend me anything more. i am planning to try to play indoor soccer in about 2 months. do you think this is a good idea or no. plese let me know what you think. thank you
Posted: 07/11/2004 at 15:49

How partially torn is it? From what I know if you want to get back to playing football or anything that requires pivoting then any significant tear is going to require repair. You'll probably find this out when you start playing but it might be easier to repair a partial tear now than a complete tear once you start playing. I know a couple of people that have had theirs reconstructed now and both have got back to playing football.

The trouble with building up the muscles to support it is what happens when you are old and naturally lose muscle. Also if the knee is unstable that could lead to other problems long term - stretching other ligaments, cartilage problems, osteo arthritis etc - that's not to say you knee is unstable just that a partial tear might make it so - should be easy enough for anyone with knowledge of sports injury to test in comparison with the other knee.
Posted: 07/11/2004 at 17:18

thank you for the quick reply. the surgeon said that he doesn't recomend surgery at this time since i guess it is not that bad. i personally don't feel any pain while walking or after jogging or other exercises, i've tried jumping two steps at a time up or down and there is no pain. only sometimes there is slight twist when lifting my leg while walking (it's hard to explain). however though the surgeon gave me 3 options: one do the surgery if i want (but then i'll have to pay for the knee bracelet $1500), two to play soccer and if something happen then have the surgery (he mentioned that the more muscle i have in the legs the less the ligaments are strained and the smaller the probability of something happening is), and three which is not an option to me is to never play soccer again. as far as for a surgery i don't know what to do. here in Canada they cut you and so on. i heard that in my home country Bulgaria they do it with a laser and cutting is not necessary. thats why i haven't taken any steps towards a surgery. how do they do it in England?, and what do you think for the 3 options?
Posted: 07/11/2004 at 17:29

Hi neil I had my recontruction June 3 2003, and was back running the bristol half 2.5 months later. I think this was a bit exceptional tho. I did a LOT of strength work before the op.

Most important thing I can say is to do exactly what the physios say - do all the exercises, but only push as hard as they advise. Doing too little or too much is a bad idea.

I've had no problems at all with it since then, just run my first marathon last weekend. Occasionally on training runs it can feel a little more tired than the other one, but otherwise I don't know it's there.

My training, after the op, was lots of swimming (crawl), lots of cycling, and lots of running.
Posted: 08/11/2004 at 16:16

PS should have said, I had a lovely winter of off-road running in the 5-10 months after the op, and my recent marathon was snowdonia, so yes I think hill/fell running is definitely possible!
Posted: 08/11/2004 at 16:17

I had a repair done a year after the injury by which time my carteligdge was damaged too and half was taken out. That was in 1192!
I run about 20 miles a week but my knee is always a bit achey and swollen at the back.
Posted: 09/12/2004 at 07:01

Hi all had ACL done Aug 03.Back to running after 6 mnths.Now doing 30-40 miles a week.Doing FLM 05.Follow what physios says
try not to get dishearten it just takes time
to get back.Good luck.
Posted: 09/12/2004 at 11:35

Just recently had my ACL reconstructed from Hamstring Tendon (the pref method these days) and also medial meniscus tear taken away.

This was 7 weeks ago and after just a few weeks I was able to swim again, but i built up to quickly to about 10km swimming per week and now i am on a rest week as the damn thing has swollen up again.

Everyone recovers at different speeds, but there is quite a good timetable which states running after 3 months post Op and I am on target for that

The My left knee post is truely remarkable running an event after just 2.5 months... WOW.
Posted: 09/12/2004 at 14:17

I had my left ACL reconstructed 6 weeks ago using the hamstring from the same leg . the swelling has now virtually gone and I'm starting to get a few aches and pains every now and then which I presume is part of the healing process . I'm having physio twice a week at the moment and the knee and leg are getting stronger by the day . I'm desperate to start running again or even to get out on my bike but I really don't want to rush things . I believe that between weeks 8 & 10 in the recovery the ligament actually weakens as the graft stabilizes so walking is about as much exercise as I'm doing at the moment . I've also been told that I'm likely to pull my hamstring at some point during the recovery as it is now severely weakened after the op . It really is all about being patient.
Posted: 22/04/2005 at 13:32

Apologies for dragging an old thread back to the surface but there are quite a few on ACL reconstruction and it seemed silly to add another.

I had an ACL reconstruction using my patella tendon back in Jan of 92 or 93.

I was playing cricket within 5 months and football in 6. I have played regularly each season ever snice without having any probs. In fact, it's probably more stable.

However, I never really did much running except on the football pitch (and, some would say, not much there either. Since starting running recently I have noticed three things.

There is a certain amount of soreness in the patella area especially after long runs. There is also some soreness also in the areas where the ligament was attached to the bone. Finally, I occassionaly get a twinge similar to (but not as strong) as the pain I experienced when I had the original injury.

Is it normal for the patella tendon to still be weak after all these years and is it possible that the replacement ligament has ruptured or become detached, or is just the effects of running on the road?
Posted: 30/08/2005 at 11:22

All, I have read this with interest and feel a little inspired and glad to hear peole have managed to get back to fitness. Thanks.

I had left knee ACL reconstruction (ruptured it playing rugby) using a bit of my hamstring on 4 Aug 05. Tore my hamstring when I banged my leg into a car door 2 weeks ago. However, I did a lot of leg strengthening prior to the op. Hamstring well on the way to being post-op 'normal' and knee is improving all the time. I have some physio exercises to do and I am walking as normal.

Anyone looking to get a reconstruction, I strongly recommend you do the max possible to strengthen your leg muscles prior to the op.

Post-op, patience is key. My physio reckons light jog/walk on treadmill by Novemember, jog/running at 6 month point. Full strength can take up to 2 years. At the one year point, for those who need to, you can run with rucksacks/weight bearing, but surface is key - no twisting, so choose your routes carefully throughout the rehab process.

Ultimately, I am looking to run a marathon, ski again and lose some of the weight I have put on since I stopped running post-injury ! All of which, I am assured by my surgeon, doc and physio are achievable. However, I reiterate, patience is key. As normal, some discipline and dedication to regaining full fitness are required !

I am not a doctor, so this is not a cure, or me recommending you should take supplements, but I am taking Glucosimine with chondroitin, normal vitamin supplements, including Cod Liver Oil and you might want to check out a supplement called Serrapeptase on-line. (As I don't want to have legal action taken against me (!), please speak to your doctor if you are going down the supplements route.)

I hope this helps anyone who is about to go through the process.
Posted: 14/09/2005 at 13:15

bit of advice needed really...i injured my knee a year and a half ago playing football and had to go to hospital and was unable to walk and on crutches for 6 weeks, basically my left knee went went inwards whilst making a tackle. A few months after seeing doctors, consultants and physios nobody actually told me what i had done to me knee! the consultant asked me if my knee had swelled up straight away and as i was unsure (and in agony at the time!) his immediate response was "no you would definitely have been aware of this therefore it is a strain and not a tear", i can actually run but im unable to play sports as i cannot twist or turn properly, after a number of falls in the past year ive realized its always on the outside of my left knee that gives way, do you think this could be my anterior ligament? and also whats the best way of getting this sorted as the hospital seemed glad to get rid of me, even though i still have problems every so often and am unable to walk for a few days after...any help would be appreciated...cheers...
Posted: 15/09/2005 at 01:36


KD
Guys, Anybody had an experience with NOT doing the reconstruction of ACL following a rupture? Can this realy be overcome by just strengthening the muscles? How about playing football or sking without ACL?
Posted: 15/01/2006 at 23:40

FAO- Sprinting toffee.
Just read you problem I ruptured my cruciate ligament a few yrs ago. It would dislocate reguarly swell up.& at times I l;itery couldnt walk at all.
.
My local hospital every time sent me home to rest telling me nothing was wrong just swollen...no explanation. eventually after one to many collapses.I saught a second opinion.
I went to another specailised hospital literly in under a minuite I was told what exactly what was wrong..I had a reconstruction operation...An thats another storie lol.
Posted: 13/03/2006 at 22:00

Im very pleased for you myra stephen, i can understand how frustrated you have been and am glad it has worked out for you. I havent had any major problems the last few months, its nearly went a few times but ive been lucky enough to keep my balance to prevent any serious damage. Im enjoying running, and started to play golf again, think im going to have to retire from football though and im only 22!

ah well, cheers for the feedback and info, if only the nhs could sort themselves out! they just dont seem interested, i had to go and see them on 3 or 4 seperate occasions during the first year, and each time they gave me pain killers and told me to rest!
Posted: 14/03/2006 at 02:35

sprinting toffee.
Are u really 22? u cant give up football well not if u really enjoy it. Ive given up so much. but im 40 odd. I think it well sad how your giving up things u enjoy coz u worrie about ur leg. ur so younge. But then again if you can run ok an your life isnt as active an crazy as mine was then I guess u cud maybe get away with it being a tad dodgie...One funny incident I had.. once I was up on a stool an my knee twisted slightly leg gave way.. I fell from the grabing the wardrobe to break my fall..that came tumbling on top of me..along with the tonker truck on the top of that.OW!!! hopefully ur leg may get better on its own????
Posted: 14/03/2006 at 22:31

ye im 22. Thats what im hoping for to be honest m8, nhs just kept on sending me to this physio and i was going for a few months doing exactly the same things with no progress, so i left it in the end. Im at undersity aswell, so as soon as my exams are over in may im going to work on my knee and see if i can build up strength in it etc. Im fine running its the twisting and turning at speed that i cant do when playing football and tennis. Only problem is if i did test it out in a football match and it went, it really would go badly so dont know whether its worth it. I might give it a try with a training session with my old footy team late summer see how it goes, cheers anyway m8...
Posted: 15/03/2006 at 00:11

I sometimes wish I neva had my op coz it aces so much alot of the time an I have neva had the guts yet to test it to see if it wud hold out an nt give way so wat was the flippin point of havin it really..? I rember the pain wen it did go an sadly the memory is still vivid. So im kinda were I was with the added greif of swelling at the bk of my leg on just standing!!!!!????? nuts isnt it.

Posted: 16/03/2006 at 19:19

If anyone had offered me a reconstruction, I'd have signed up on the spot!  I was told at the time that it was unlikely to help and offered painkillers, physio and strengthening exercises.  I did damage both my cruxiate and medial ligaments, so it was a fairly bad injury.

I love running and hill walking so I have followed this regime for years, trained carefully and ran on.  It has been manageable with care, but in the long run (sorry for pun!) it hasn't helped.  My knee joint has now deteriorated and I've got bad osteoarthritis, as well as a wonky knee.  I've been told I can't hope to run again, ever, and I have to have a knee replacement.  

If ligament repairs give you less than perfect outcomes, the chances are so much more successful than knee replacements.  From what I've read since I got the bad news, I'll be lucky to walk up and down stairs, let alone run up and down mountains.

I think the human knee has a few basic design flaws.  Injuries happen when you run, but getting the best advice sounds really vital.  I wish I'd tried harder to get things fixed earlier.


Posted: 02/09/2007 at 18:28

I've torn my acl two months ago playing football and despite my best efforts couldn't get any help from my GP or the hospital I attended after the accident. After a month of trying to get the report for my MRI I finally had to get a friend that worked there to get me a copy so I could make an appt with a private consultant. I'm worried that because I have had no advice for two months and I still can't walk properly whether I'll ever be able to run as well again and I'm only 24. Now that I've seen him I am going to get surgery. Is there much chance this will get me back to normal eventually?


Posted: 04/01/2008 at 19:34

adam, I had acl surgery in mid sep 07 after tearing my acl and damaging meniscus playing football. I am now beginning to run again and my knee is improving literally on a daily basis. you are on the right track now that you are seeing a consultant and are going to have surgery. I'm not going to kid you, it's tough for the first couple of weeks post surgery and you are going to continue to have aches and pains in different parts of your knee. However, if you follow the advice of your surgeon and physio and work hard doing the rehab exercises you will start to see results.  hoepfully you'll be back running after 3 months. I would suggest that you wait 12 months to play footy though as from what I've read and from what my physio and surgeon have said you are at high risk of re-injury if you come back within this period. however, you should be back to normal after this period (stats suggest a 95% success rate for return to sport)

 good luck with the surgery


Posted: 10/01/2008 at 16:02

Hi

I've just had an arthroscopy to sort out a suspected meniscal tear but when I was in the recovery room post op they told me they found i'd ruptured my ACL. ( This is what the Italian doctors told me 6 weeks ago after I twisted my knee skiing) They didnt tell me anything else, like whether they had done anythingwith the meniscus or not. It was late evening and i guess they wanted to get home, i was also very woozy still.  So I'm back home and attempting to do the post arthroscopy exercises but not having a clue really how bad my ACL rupture is, whether I still have meniscal problems or not and what I should be doing to prepare myself for a ACL repair. I'm meant to be going back to the clinic in 2 weeks time.

Advice welcome


Posted: 01/04/2008 at 14:25

I damaged my knee  skiing at christmas and just let it recover. it was 99%  fine for running . however last week,  i stupidly agreed to try football after 4 months.while i was playihg , the pain told me  i should not be.  it went again with alot of pain and a couple of loud clicks. now i am going to see a specialist next week. I am scared what the outcome will be but i am heartened by some of the posts here that suggest a semi normal knee can be achieved after the reconstruction.


Posted: 22/04/2008 at 15:43

Reading peoples stories here, I think that there is a lot to be said for winning the mental battle to return to doing what you love. I had surgery last December for a ruptured ACL and a ruptured lateral collateral ligament / posterolateral corner after a high speed mcycle 'high side' on a race day. At 43 I maybe shouldnt be doing such daft things (I hear the missus saying) Anyway, 3 months post op in March I took my first steps in anger and by June I could run for 20 mins without stopping. Being reassured by my physio that the pain was not doing any internal damage, I have built up my miles to around 20 pw and I chose for my first race, a gentle re introduction to running this November 4th: Hellrunner! No point in settling for a 5k when you can go for it big style!

An hour 47 for 11 plus miles of bogs and hills has given me newfound confidence that my knee won't just collapse and I have 2 more race entries in the bag with a 1/2m due in mid January. Both I and my surgeon never thought that was possible this time last year, so set your sights high but take heed of professional advice before pushing to the limits. Mega thanks to my physio for pummeling me week after week and teaching me how to walk again!


Posted: 29/11/2008 at 18:57

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