The piv­otal role of the an­te­rior cru­ci­ate lig­a­ment

201 Health - - News - WRIT­TEN BY RYAN GREENE

The piv­otal role of the an­te­rior cru­ci­ate lig­a­ment

“Any­thing in life [could in­jure the ACL]. It could hap­pen at work. It could hap­pen with nor­mal daily ac­tiv­i­ties.” DR. MICHAEL GROSS, BOARD-CER­TI­FIED SUR­GEON WITH HACK­EN­SACK UNIVER­SITY MED­I­CAL CEN­TER AND AC­TIVE ORTHOPAEDICS & SPORTS MEDICINE

Asoc­cer player out­ma­neu­vers the last defender on her way to score the win­ning goal – and sud­denly feels some­thing go wrong in her knee. A quar­ter­back plants his feet to send a laser to his wide re­ceiver when a low sack catches him in the knees. A run­ner fin­ishes his first 10K, and as he slows down just past the fin­ish line, his knee gives out. Each one of them hears the same thing.



ACL in­juries rank among the most com­mon – and loathed – in­juries in sports for pro­fes­sion­als and am­a­teurs alike. The ex­tent of the in­jury and the treat­ment re­quired can vary widely, but there isn’t a whole lot any­one can do to pre­vent them.

The an­te­rior cru­ci­ate lig­a­ment, or ACL, is one of the four main lig­a­ments in the knee. It grows out of a notch deep in the lower end of the fe­mur, con­nects it to the tibia and con­trols ro­ta­tion. The ACL and its coun­ter­part, the pos­te­rior cru­ci­ate lig­a­ment, or PCL, form an X in­side the knee.

Dr. Michael Gross is a board-cer­ti­fied sur­geon with Hack­en­sack Univer­sity Med­i­cal Cen­ter and Ac­tive Orthopaedics & Sports Medicine. He says the ACL’s job is pretty sim­ple. When you set your foot on the ground and ro­tate your body on it, the ACL makes sure your shin bone and thigh bone stay con­nected.

“Oth­er­wise you’d twist right off,” he says.


Some­times an ath­lete will get about as close as any­one to twist­ing right off. ACL in­juries can strike seem­ingly out of nowhere, and from a num­ber of causes. Ac­cord­ing to the Amer­i­can Acad­emy of

Or­thopaedic Sur­geons, the main sources of in­juries in­clude: chang­ing di­rec­tion rapidly stop­ping sud­denly slow­ing down while run­ning land­ing in­cor­rectly af­ter a jump di­rect im­pact or col­li­sion That sounds – well, un­fair, frankly. You can hurt your­self not by run­ning, but by slow­ing down af­ter run­ning? More than that, Gross says you might not even re­al­ize you’ve in­jured your ACL.

The worst ACL dam­age is clear from the mo­ment it hap­pens. The ath­lete will hear a pop from their knee just be­fore it gives out. Pain and swelling are usu­ally im­me­di­ate.

But some­times, ACL dam­age isn’t so ob­vi­ous. Dr. Gross says years can go by be­fore some­one no­tices any­thing amiss, es­pe­cially if the ACL doesn’t tear com­pletely. That’s be­cause other parts of the knee, or sec­ondary sta­bi­liz­ers, can com­pen­sate. “Giv­ing-way episodes,” when the leg gives out, will be­come more fre­quent as those sta­bi­liz­ers can no longer make up for the dam­aged ACL and suf­fer dam­age them­selves.

Ob­vi­ously, seek­ing treat­ment if you sus­pect even mi­nor ACL dam­age is vi­tal.

“Let’s say you have bad brakes,” Gross says. “You don’t drive around with bad brakes and say let’s wait and see if I get into an ac­ci­dent.”


Th­ese days, ACL di­ag­no­sis and treat­ment are straight­for­ward: Gross says pa­tients will see their doc­tor for an X-ray and MRI, wait a few weeks for surgery, then spend a few months re­ha­bil­i­tat­ing the knee.

Isn’t wait­ing to fix the knee coun­ter­in­tu­itive? Not quite. While you don’t want to let an ACL in­jury linger for months or years, a pa­tient needs three to six weeks for the swelling from a fresh ACL in­jury to sub­side be­fore surgery is pos­si­ble.

Cur­rent ACL surgery is quick and min­i­mally in­va­sive, though it took decades of trial and er­ror to reach that point. Dr. Gross says in the ’60s, for ex­am­ple, doc­tors tried to re­pair the torn ACL. That didn’t work be­cause it short­ened the ACL, im­pair­ing the knee’s func­tion, and re­quired sur­geons to match the pieces of count­less torn strings of lig­a­ment.

“It’s like try­ing to sew to­gether two mops,” Gross says.

Later doc­tors tried to aug­ment the re­paired lig­a­ments with ten­don grafts, un­til they re­al­ized the re­pairs still gave out while the grafts held. Now surgery in­volves the rel­a­tively sim­ple mat­ter of a ten­don graft, per­formed arthro­scop­i­cally (us­ing small in­ci­sions rather than open­ing up the whole knee).

A sur­geon has two op­tions: us­ing pieces of the pa­tient’s ten­don, ei­ther from the ham­string or patella, or us­ing do­nated ten­dons. Gross, who per­forms about 150 ACL surg­eries a year, says sur­geons pre­fer the for­mer in younger pa­tients, be­cause do­nated ten­dons rup­ture more of­ten in pa­tients younger than 30.

Also, a pa­tient’s own ten­don in­cor­po­rates more quickly through lig­a­men­ti­za­tion. In mod­ern ACL surgery, the piece of trans­planted ten­don an­chors deep in the fe­mur and acts a scaf­fold for grow­ing a new lig­a­ment. Gross says doc­tors aren’t sure how yet, but cells “just know” to grow a lig­a­ment where it needs to be, even though a ten­don is there now.

Af­ter surgery, the pa­tient can usu­ally leave the hos­pi­tal the next day. Ath­letes un­dergo four to six months of re­hab be­fore go­ing back to “cut­ting” sports like ten­nis, vol­ley­ball or bas­ket­ball, and pa­tients can usu­ally get back to bik­ing or jog­ging much sooner.

Be­cause there isn’t a whole lot any­one can do to pre­vent an ACL in­jury, Gross says aware­ness is the key to treat­ing such a com­mon knee in­jury.

“Any­thing in life [could in­jure the ACL],” he says. “It could hap­pen at work. It could hap­pen with nor­mal daily ac­tiv­i­ties.”

An­te­rior and Pos­te­rior Cru­ci­ate Lig­a­ment

Knee Lig­a­ments

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