The ACL Tear.

As we approach the end of football season, there is one injury that we have heard of several times throughout the year (and past years as well). The ACL tear.  Most sports fans have seen this listed on the injury report and heard the announcers talk about concerns for this when a player goes down on the field, but what is it? Why is it a big deal, how does it happen, and what is typically done about it?  

First, knowing a little anatomy of the knee is important. The ACL – or anterior cruciate ligament – is an important structure inside your knee joint.  We have 4 ligaments in and around that area, named for where they are located. Anterior (front) and posterior (back) cruciate ligaments, and medial (inside) and lateral (outside) collateral ligaments.  Today we focus on the ACL because it is usually the most ‘tragic’ when injured in sports. By tragic, I mean the one that is the most worrisome for an athlete because of the long treatment and recovery process that often alters one’s career short and long term. 

The ACL connects the bottom bone in the knee (tibia) to the top bone of the knee (femur) from front to back.  It plays a key role in stabilizing the knee. In medicine we would say it “resists anterior translation of the tibia on the femur.”  Stick with me here… this means in regular language that it stops the bottom bone of the knee from sliding forward in relation to the top bone during normal movement, aka inside the knee joint where it bends.  This bending is what allows us normal knee motion needed for walking, running, jumping, playing.  But we need something to help keep the bones attached to one another or else the knee may feel unstable (jelly-like) when we put stress on it.  [Think of the knee as a door hinge where the ACL is the pin that connects the two pieces of the “hinge”; without this the door can swing open and closed gently, but if it’s pushed too hard the hinge may not line up properly and may become damaged].  Not an ideal situation if one is interested in getting back to doing higher impact activities like playing football. 

If the ACL is torn the knee becomes unstable because the bottom bone can shift away from the top bone.  The cool thing the human body is that there are often redundant systems.  For the most part (although not always for every person) normal walking and low-impact day-to-day life can still be achieved without the ACL because the other ligaments and muscles around the knee can pick up the slack to provide stability.  This means even without an ACL, for daily life activities, many people move about fine.  The problem is with any sudden or shifty movements, such as cutting in sports or in high-impact jobs like law-enforcement or firefighting where folks are required to do movements that aren’t straight forward or backwards. These types of movements are more complex and require more stabilization, so without an ACL the knee can feel unstable and even give out.  For football and other sport athletes, one also would not get the control or explosive power she or he needs to play.   

An ACL tear most likely occurs when the leg is forced in a way that stretches the ligament too far.  Remember, the ACL blocks forward movement of the bottom part of the knee.  Consider a  a football player whose foot is planted to the ground when his knee gets pushed backwards, pushing the top bone away from the bottom bone. Pop!  The ACL is overstretched and gives way.  This is just one example, and there are of course other ways this happens.  Sometimes it involves a collision with another player (as described above) and sometimes it involves getting the leg in an awkward position when a person is running or jumping with the knee buckling inwards/backwards due to the force of the jump or a bad landing.  In this case, it is simply the lack of control and force of the jump landing or cut that causes the tear.  We tend to think of these “non-contact” tears occurring most frequently in young female athletes (maybe a teenage basketball player) that hasn’t developed full hip/knee control. 

The tearing of an ACL is an abrupt injury and not usually subtle.  Sometimes people hear a pop (but not always), feel a pop, have sudden onset of significant pain, and usually fall to the ground.  Most of the time the injured can’t walk easily (if at all) and don’t usually keep playing the game after.  The knee swells up from the inside due to the trauma (effusion).  I usually ask patients if it swelled up like a water balloon as an analogy.  A former mentor of mine taught me when I was learning about knee injuries that a young person running or cutting during sports with a sudden burst of pain with a pop in the knee and large swelling is an ACL injury until you prove otherwise.  This still rings true for my patients today.  #mentor

To diagnose the ACL tear we first talk about what happened when the injury occurred in great detail.  Then, we do an office examination of the knee, as well as the hips and lower legs.   Looking at the other nearby joints is important! Just because it seems that it might be an ACL tear it doesn’t always mean that is our answer.  We complete a few special maneuvers that help clue us in to what possible problem could be happening inside your knee. These maneuvers are helpful to distinguish other injuries that present in the office like an ACL tear.  This exam also helps us determine what next steps to take or if there is concern for other associated injuries (ACL tears often occur with other injures such as MCL tears, meniscus problems, and bone or cartilage injuries).

So you tore your ACL, what now?  Since it is such a crucial ligament for knee stability, most highly active people or athletes should discuss surgery to repair or reconstruct the ligament in the knee.  It does not grow back. It does not scar into place or heal. That said, it is important to note that older patients or people who are less involved in side-to-side/cutting sports or activities may not need surgery.  Be sure you have a discussion with your doctor about what the benefits of surgery are for you, the associated risks of the procedure, as well as the expected long term outcomes.  We practice medicine using the guide of high quality research, and if the studies show that you may do just as well without surgery, that may be the best way to treat your specific injury. Most important is to have these discussions with an orthopedic sports trained surgeon.  They will discuss options, the optimal timing to have surgery if it is thought to be best for you, and also very importantly your rehabilitation and expectations for recovery.  

Whether one has surgery or is treated without operation, he or she will need extensive physical therapy/rehab.  It takes many months for one to get back on the field!  One has to be patient.  For professional athletes that have dedicated athletic trainers and rehab specialists, these are season ending injuries. Often with great rehab, they can return in 6 months (at the earliest) though it can take 1 or more years to reach the prior level of sport.  But these are gifted individuals with many many resources.  For the average injury, it will be at least 1 year before one may feel 100%. And keep in mind, once a person has had an injury, and then had surgery, it is quite possible the knee will never feel 100%.  [Stay tuned for my article discussing preventing injuries like ACL tears.]

Stay healthy-

I miss sports…

April 30. 

The fiancé and I took a long run tonight around our neighborhood.  I have been trying to get into the swing of exercise during the pandemic. But if you read my last post (linked here!) it hasn’t always been easy.  So, when offered a leisurely paced (aka Morgan’s pace, not his pace) tonight after dinner, I took him up on the offer.  When we were about 1.5 miles out, we happened upon the local high school sports fields.  Immediately I felt the need to reach out my hand towards the gate.  There was a pit in the bottom of my stomach.  Seeing that football field I was struck with so many emotions.  I really miss sports. 

My job sometimes isn’t easy, and it often weighs on me.  As an emotive person the weight of everyone’s pains and injuries can build up. The expectations of seeing volumes of patients, doing paperwork, and managing a staff can weigh on my sensitive being.   And when you have games to cover on countless weekends and evenings it can start to feel like a chore.  But that day I felt such a strong longing to stand on the sidelines on a fall Saturday covering a football game.  I could feel the cool breeze in the air, hear the fans cheering in the stadium, and see our team playing on the field.  I long for the day we are able to play sports again.  But this longing is mixed with the fear I have for the safety of our athletes. COVID-19 has changed everything, including my perspective.   

May 3.

My fiancé and I have jumped on the bandwagon and are watching The Last Dance on ESPN (ESPN Story linked here).  The story for those that don’t know is about the Chicago Bulls in the era of the great Michael Jordan.  And you know what, I’ll say it again, I really miss sports. While watching I couldn’t help but think about why I feel so strongly about it.  I am not just a fan.  There is something more to the desire I feel.  

You’ve have heard the saying, “if you can’t be an athlete be an athletic supporter?” Well I think we as team docs are the ULTIMATE athlete supporter.  Let’s be honest again, I am not larger than life. I will never be.  But these athletes are.  And when they stand in victory we stand on the sidelines or in the very far background.  The feeling that we helped, even in a just small amount, contribute something towards whatever it was that allowed them to get there… WOW. Even if we didn’t directly contribute anything aside from being there in case, even when we are just there to watch it from behind the scenes while it is all happening…. Same feeling. Still Wow. 

The energy of being around sports is irreplaceable.  I don’t have a championship ring, but I know what it is like to watch that end being achieved. Maybe that is in part why we do our jobs;  it isn’t for the ring itself in our case but to be a part of something greater than ourselves, to help the best of the best achieve her or his best, to help those larger than life characters to be the gladiators of today. 

Team doctors are always there.  Winning seasons or losing ones. Pandemic or not.  There is no real credit and most of us don’t care. All we want to be there to help the best achieve greatness. We want the gladiators of our time to shine. We want those who are larger than life to make magic.   

Bottom line, I am honored to go behind the scenes and play my very small role in the greater world of sports.  It is absolutely my honor to have stood in every tunnel in which I have been placed. It is my honor to walk into a locker room and help an athlete in need.  

I often joke that it is like going behind the curtain of the Wizard of Oz at times. You know what is back there now, and some of the spectacle of it all changes.  But what an honor it is to know the greatest of the greats. 

Dang, I miss it.