ACL Problems Discussion

Discussions from our Radio Show on ACL Problems:

A CALLER WITH ACL PROBLEMS

CALLER: I am a tennis pro and I have played tennis for years and I have also played soccer and I have had three surgeries and I have permanent pain in my right knee.

Dr. Darrow: The caller had a torn ACL, he had one surgery several years ago where they actually cut open (an incision), because I remember the scar on his leg, (that had) to be at least a foot long. Back then the surgery was very evasive, now they do it an arthroscope. But even then many of these ACL surgeries are unnecessary. Doctors are trained to think that the ACLs are pretty much necessary and any one who rips one can’t be an athlete. But we find that many athletes go on and compete without them. So we just stabilize the ligaments in the knee and people with deficient ACLs can still do their sport.

Dr. Gene: You are saying that if you saw this Caller a few years ago you obviously would not have suggested that surgery.

Dr. Darrow: I never suggest surgery unless it is absolutely necessary. Generally for an ACL I would like to wait a couple months and see if the injury calms down. There are many studies on the ACL, that the results are much better if the patient waits (on surgery). There are some who just jump right into the surgery and then the person has a longer rehabilitation period.

Dr. Gene: How long should someone wait, the caller is a professional tennis player, if he had to get back on the court in a hurry, how long?

Dr. Darrow: The problem is this. When someone tears an ACL or a big ligament like that. You just can’t go back and play tennis right away, the rehabilitation from ACL is long and extensive before that donor ligament is “matured” is at least nine months. Most of these people who have had them done, if they go and do any sports that have any degree of twisting of the leg before that time will rip it again. You have to be very careful.

ACL REVISION SURGERY
Researchers writing in the American Journal of Sports Medicine looked at “revision anterior cruciate ligament surgery (to) determine the association between stability and functional results”

What they found was “Revision (ACL) surgery allowed approximately 60% of patients to go back to sports, most of them at lower levels than their prerevision function,” and that “patients who undergo revision anterior cruciate ligament surgery should be counseled as to the expected outcome and cautioned that this procedure probably represents a salvage situation and may not allow them to return to their desired levels of function.”

Battaglia MJ 2nd, Cordasco FA, Hannafin JA, Rodeo SA, O’brien SJ, Altchek DW, Cavanaugh J, Wickiewicz TL, Warren RF.Results of Revision Anterior Cruciate Ligament Surgery.Am J Sports Med. 2007 Oct 11

MRI Reliability in ACL Ruptures
Researchers writing in the Korean Journal of Radiology say that MR imaging itself is not a reliable examination to predict stability of the ACL rupture outcome, even when the MR images show an intact appearance of the ACL.

Chung HW, Ahn JH, Ahn JM, Yoon YC, Hong HP, Yoo SY, Kim S. Anterior Cruciate Ligament Tear: Reliability of MR Imaging to Predict Stability after Conservative Treatment. Korean J Radiol. 2007 May-Jun;8(3):236-41.

An Alternative Solution to Preventing ACL Tears

Thousands of articles have been written on the various means an athlete can take to help prevent the most devastating of knee injuries – the complete tear of the ACL Anterior Cruciate Ligament. Unfortunately very few have been written on what can be the best remedy for knees at risk – Prolotherapy.

The ACL is the most famous of knee ligaments because of the frequency of injury – over 200,000 reported annually in the US. It is also the most infamous because the severity of the injury can end or derail the hopes of many young athletes.

The ACL is a strong connective band deep in the knee that helps prevent hyperextension and provides stability. Interestingly, tears of the ACL occur more without physical contact and instead are linked to the twisting of the knee while the foot remains planted. In a healthy ligament this twisting typically requires a great deal of force to cause a tear, especially a complete tear or rupture in such a strong ligament. The problem is many times the ACL is not a strong as we think it is – it does get weak with overuse.

Prevention
The internet is filled with articles on how to prevent ACL tears. They range from strength training, aerobic training, nutrition, coordination exercises, balance and posture, knee bracing, etc. But what about the high risk knee? The knee that has already been compromised by wear and tear and previous injury. How can ACL injury be prevented?

The Ligament
If you look at a picture of the human anatomy, you will see that muscles are big and red. They are red because of the abundant blood supply that runs through them that helps them grow and repair. Ligaments on the other hand are small and white and resemble thick rubber bands. They are small and white because they do not have an abundant blood supply run through them and because of this, usually do not heal well from injury and will in the case of tears – require surgery.

Over the course of an athlete’s season ligaments become weaker, they loss elasticity, and are prone to injury. This is when pain, soreness, and loss of strength appear in the knee.

The treatment causes the injury
It is about this time that icing, anti-inflammatory medications, and knee bracing or taping will be tried to get the player through the season. We have found in our practice that these remedies actually increased the risk of ACL tear rather than prevented it. This observation is supported in many medical papers citing the pros and cons of knee bracing and taping and circulatory and healing disruption by icing. In a future article we will discuss a rotator cuff tear in great detail as there is a lot of important information that needs to be conveyed regarding a rotator cuff tear.

Further, the player will begin to over compensate for the injured knee and in doing so puts the “healthy knee” at greater risk for severe ACL damage. In addition chronic ankle sprains have been cited as a cause of higher risk to ACL tear. So not healing an injury completely puts the athlete at risk for ACL tear.

The treatment that strengthens
One thing that the treatments described above have in common is that they weaken ligaments. Icing, as stated disrupts circulation needed to bring the healing cells to damaged ligaments, anti-inflammatory medications have been shown to increase the risk of ligament damage by suppressing immune function. Knee braces – there is no conclusive evidence they work and may only trick the athlete into a comfort level that their knee is protected.