acl tear bruising

Having an ACL injury is often seen as a catastrophic event for many athletes, especially those who are professionals and playing high tempo games involving a great deal of pivoting or jumping and landing. Indeed, having an ACL injury has ended many a promising individual’s athletic career.

“there have been examples of top tier athletes who have continued playing their game despite not having an ACL.”

This coupled with the fact that ACL injuries happen fairly commonly in sports makes it a dreaded injury to have.

But, there are some good news despite all these gloomy talk. Here are 3 things that you need to know about having ACL injuries.

1. Having a ACL injury does not mean you can no longer participate in the sport if you opt NOT to go for surgery.

It’s true that the stability of the knee with an ACL injury would be affected to a certain extent. For professional athletes or those who compete at a very high level, this compromise may be sufficient to force the athlete into retirement. However, there have been examples of top tier athletes who have continued playing their game despite not having an ACL!

“there is a good chance that even without surgery, the individual may be able to return to recreational level playing.”

acl tear bruising

Dejuan Blair (above) played basketball for the San Antonio Spurs in the NBA despite having no functioning ACL in both knees.

Photo credit: US Today Sports

DeJuan Blair played basketball for the San Antonio Spurs in the NBA despite having no functioning ACL in both knees. Similarly, Jimmy Hitchcock also managed to play American Football for the New England Patriots in the NFL for 8 years while having bilateral torn ACL ligaments. Just how can this be possible? I’ll elaborate on that in the next section, however, there have been many athletes who are still able to play the game that they enjoy, just at a lower level than before.

In other words, if one was playing competitively prior to injury, there is a good chance that even without surgery, the individual may be able to return to recreational level playing. And the reason for this is covered in the next section.

2. Muscular control can compensate for the missing ACL to a certain degree.

A human knee has 2 broad categories of stabilisers. The dynamic stabilisers (eg muscles) which stabilise the knee by changing their length and the forces that they transmit across the joint, and the static stabilisers (eg. Ligaments and bony anatomy) which are unable to change their length or shape. The ligaments basically work as fixed length tethers that control the degree of motion that one bone has over the other.

Together, the dynamic and static stabilisers work seamlessly to stabilise the knee across a huge spectrum of activities. However, in situations when the static stabilisers are injured or torn, the dynamic stabilisers need to compensate to a certain degree.

Of course, there is a limit to which the muscles can compensate. And there are usually 2 aspects to this.

Firstly, it depends on how many static structures are damaged. The greater the number of ligament injuries, the more difficult it is for the muscles to compensate. That means, if a knee has a torn ACL, posterior cruciate ligament (PCL) and medial collateral ligament (MCL), it would be very difficult for the muscles surrounding the knee to compensate for all these injuries. However, if the ligament injury is only isolated to the ACL, then with a good strengthening and physiotherapy program, it is possible for the muscles to compensate and stabilise the knee somewhat.

if the ligament injury is only isolated to the ACL, it is possible for the muscles to compensate and stabilise the knee somewhat.”

The second aspect to this issue is the endurance, strength and control of the muscles that are doing the compensation job. If the muscles are well conditioned, they would be able to voluntarily activate at the appropriate times to counteract the destabilising forces that may cause the knee to give way. This voluntary activation may be impeded when the muscles are fatigued.

acl tear bruising

if one has an isolated ACL injury, it is usually during the times when the muscles are tired and the person is attempting a pivoting action that the knee experiences episodes of giving way.

Hence, if one has an isolated ACL injury, it is usually during the times when the muscles are tired and the person is attempting a pivoting action that the knee experiences episodes of giving way. Individuals in this category would tend to report instability after playing a game for a while (Eg. In the second half of a soccer game). So being aware of this allows one to understand how some athletes can still perform at such high levels despite having an absent ACL. These athletes would have spent a lot of time in training their muscles to support and stabilise their knee joints.

For those who do not have a need to play at such intense levels, a good physiotherapy program, coupled with realistic adjustment of activity level may allow one to remaining playing their favourite sport (albeit at a lower level) without the need for going through surgery.

3. There are now means to repair certain types of ACL tears.

When discussing ACL repairs, most of the time, surgeons and patients are actually describing reconstruction. What is the difference?

Repair involves preserving the original torn ACL ligament and allowing it to heal while reconstruction involves replacing the torn ligament with a substitute graft (which can either come from the patient or from another donor). At this point in time, reconstruction is the accepted surgical means of treating a completely torn ACL or a non-functional ACL.

Overall results from reconstruction have been good and the outcomes fairly predictable.

In recent years, there has been greater understanding of the knee which extends beyond the mechanical understanding of how ligaments and muscles contribute to knee stability.

“results from reconstruction have been good and the outcomes fairly predictable.”

Research and insights into the biological and cellular nature of the ACL have revealed that the ACL is more than just a bundle of collagen fibres that act like a rope. Among these fibres, there are nerve receptors which help in proprioception (the sense of the relative position of one’s own parts of the body and strength of effort being employed in movement).

Preservation of the original ligament is thought to be more beneficial due to the preservation of these receptors. However, results of this hypothesis have not been demonstrated in large scale clinical studies yet. In certain ACL tears (those that peel off the femoral attachment), surgeons have attempted to repair them to the bone while placing a strong ribbon-like material (internal brace) across the ACL to reinforce the ligament while allowing it to heal.

While this is still a new development, there have been many patients around the world (including in Singapore) who have had this procedure done. Reports of early results have been encouraging.

However, as it stands, this technique is recommended for a particular category of ACL injury (those that occur from the femoral side and are identified early – within 6 weeks of injury). Other techniques of repairs (eg. BEAR – bridge enhanced ACL repair) are currently being developed to address other forms of ACL injuries. These new repairs incorporate biologically enhanced materials into the repair in order to bridge gaps present in certain patterns of injured ACLs.

Conclusion

While an ACL injury can possibly be devastating, there are many options available for treatment. The treatment protocol may not always need to involve surgery. Rather than a one size fits all type of treatment recommendation, a detailed and individualised plan can be developed for the affected individual taking into consideration unique requirements and expectations.

Together with application of the latest technologies and techniques, it is likely that outcomes from ACL injury treatment will continue to improve in the near future. Should you or someone you know injure their knee, it is best to have the knee evaluated early so that an individualised treatment plan can be developed right from the beginning.