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ACL Injuries in Athletes

ACL injuries or anterior cruciate ligament tears have historically been one of the most feared and most common injuries to the athlete’s knee. These injuries occur in all major sports and once were significant career-altering, if not career-ending injuries. Some of us remember athletes like Gale Sayers and Billy Sims whose greatness was extinguished prematurely, or Joe Namath and Mickey Mantle who struggled to maintain their greatness despite being hobbled by their knees throughout their careers.

The ACL is a strong ligament - about the size of your fifth finger - and it spans the center of the knee between the thigh bone (femur) and shin bone (tibia). It’s considered the primary stabilizer of the knee, holding the knee together against the tremendous forces applied to the knee during athletics, especially when one plants a foot and cuts in the opposite direction.

When the ACL is torn, the knee becomes painful and swollen. Over time with rest, ice and therapy, the knee settles down and could conceivably return to feeling normal. The problem, however, is that the forces that would ordinarily be borne by the ACL are now distributed to the other ligaments and soft tissues around the knee and aren’t built to take the load. An ACL-deficient patient might actually be able to return to their sport without surgery, but over time these “secondary constraints” stretch out and become lax. Episodes of buckling or “giving way” develop and other structures in the knee, such as the cartilage, can be damaged. Ultimately, the end result is arthritis.

For these reasons, the younger the patient with an ACL tear the more likely the orthopaedic surgeon will advise ACL reconstruction. The younger the patient is, the more mileage is expected out of their knee and the greater the likelihood of later difficulty if the ACL tear isn’t fixed.

In my career I’ve seen a fascinating evolution in the treatment, rehabilitation and outcomes of ACL tears. During my training years, I remember receiving a phone call on Easter Sunday morning from Dr. Gerald O’Conner, the team physician for the University of Michigan. He asked me to go to the hospital to prepare for surgery one of the offensive linemen on their football team who had torn his ACL in Saturday’s spring game. At that time, arthroscopic surgery was not done. During surgery we literally took apart his knee and rebuilt it piece by piece, much like taking apart a car engine, laying all of the pieces on the garage floor and meticulously reassembling it. Dr. O’Connor’s magic helped that young man win four Super Bowl rings with the 49ers but not without a full year of rehab and always wearing a brace when he played.

Now, ACL reconstructions are almost always done through the arthroscope and always involve tissue grafts either from the patient or from a cadaver. Many different grafts can be used, with patellar or hamstring tendons being the most popular. There are pros and cons to each of these grafts and the surgeon will explain these to the patient beforehand. I personally prefer patellar tendon grafts because they seem to hold up best in most studies. But the downside is that it requires a somewhat larger incision to harvest the graft.

For most young athletes, aggressive rehabilitation protocols have shortened the time away from their sport with most returning to the sport at the pre-injury level of performance by six months. While it’s never easy for a young athlete to hear the diagnosis “torn ACL,” the fact is that orthopaedic surgeons have made treatment of the injury perhaps the greatest sports medicine advance in the last 50 years. Reconstructing the ACL prevents episodes of instability, protects the knee from further damage, and minimizes the chances of arthritis.

Current players like Adrian Peterson, Tom Brady and Derrick Rose all at one time or another had ACL reconstruction and continue to have very successful careers.

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