Soccer ACL Injuries
SOCCER PLAYER – ACL TEARS
David M. Lintner, MD
Team Physician: Houston Texans and Houston Astros;
Former Head Team Physician Houston Dynamo and Houston Hotshots soccer teams
If you play soccer, you probably know someone who has injured their ACL (anterior cruciate ligament) This ligament is crucial for those in agility sports. For those of you who have injured the anterior cruciate ligament in your knee, the following is a list of common questions and answers that I have compiled with the help of patients whom I’ve treated in the past. I know it’s sometimes difficult to ask questions of doctors or to remember to ask all the questions you had planned. I hope this will help you. If there’s anything else you’re wondering about, please feel free to ask and I’ll be glad to answer and probably add your question to this handout.
What is the ACL?
Ligaments are like cables that hold the bones together. They can bend, but don’t stretch. This allows the knee to flex but keeps it stable during twisting maneuvers. There are two large ligaments inside your knee each about the size of your little finger that cross deep inside the joint. They are called the ACL (anterior cruciate ligament) and PCL (posterior cruciate ligament) and go from the femur (thigh bone) to the tibia (shin bone). They serve to stabilize the knee and allow it to glide through a smooth range of motion as you bend and straighten the leg. The ACL is the ligament in the front and the one most commonly injured.
Why is it important?
Without the ACL the knee is less stable. Without its stabilizing influence, the knee can buckle suddenly as it is used and this leads to cartilage damage and eventually to arthritis. This is usually not a problem for “straight-ahead” activities such as walking or jogging. However, it can be a big problem for activities involving twisting, pivoting, jumping, or suddenly changing direction. Examples of these activities include most sports (especially basketball, football, volleyball, soccer, skiing, etc.) and many jobs (such as carpentry, warehouse, refinery, etc.). If you plan to continue vigorous activities such as soccer, you will probably need your ACL reconstructed surgically.
Is anything else damaged inside my knee?
About half the time when the ACL is torn there is also damage to the meniscus cartilage inside the knee. If present, this is something that can be taken care of at the same time ACL surgery is performed. You can usually tell whether there is a torn cartilage on examination but sometimes this is difficult. Occasionally, an MRI study can help but this is expensive and time consuming and sometimes not necessary.
What would happen if I did nothing about this injury?
Usually within weeks of tearing the ligament, the pain and swelling go away and the knee starts to move well. The knee usually starts to feel nearly normal. The problem comes when you try to cut, pivot, or twist on the knee. Without the stabilizing influence of the ACL it will likely buckle and give way. Patients usually end up with a “trick knee” that gives way unexpectedly. The problem with this (beyond the embarrassment) is that with each episode of buckling, the joint gets scuffed and cartilage often tears leading to arthritis. Some people who elect to live less active lives (no jumping, cutting, pivoting, running sports) can get by without this ligament. Currently, the conservative way to treat the injury is with reconstructive surgery, if you plan to remain active in agility sports (soccer, basketball, football, volleyball, skiing, etc).
How is the ligament fixed?
Older techniques consisted of sewing the torn ends of the ligament back together. This relatively simple operation didn’t work and the ligament almost always tore again. The standard operation is now reconstruction of the ligament where a tendon from your own body is used as a replacement for the anterior cruciate ligament. There are two main choices for this substitute tendon. I frequently use the central third of the patellar tendon (the tendon which runs from the knee cap to the shin bone) for competitive athletes. This has the best track record in this group as far as knee stability. Using the hamstring tendons from behind the knee is just as strong and less painful and provides an excellent graft as well. The early stage of recovery is quicker and there are fewer complications of anterior knee pain. However there is some evidence that in teenage girls this graft may stretch out a bit compared to patellar tendon. Donor tendons ( allograft) can be used in the adult population. Using an allograft does not cause any additional trauma to the knee, but in young patients has a higher tendency to stretch out than either the patellar tendon or hamstring grafts. This is true for teenagers but not in older adults. I am frequently asked if the new ACL can be torn again. The answer is of course! The surgery doesn’t make you bullet proof. If you tore the ligament God gave you, you can tear a man-made one!
The risks for the three graft choices can be summarized as follows:
Patellar tendon: pain at the front of the knee with kneeling or crawling. This occurs about 10-20% of the time. But this is usually the most stable graft.
Hamstring: Stretching / loosening of the graft slightly, weakness with deep knee flexion such as pulling your foot all the way to your buttock. This is an issue for hurdlers, wrestlers/MMA fighters, and those that sprint backwards like defensive backs in football.
Allograft: Stretching of the graft when used in younger patients ( under 20 years). But you are back on your feet faster after surgery because there is less trauma to the knee.
Using arthroscopy, I place the tendons where the ACL used to be, secure them with screws, and this becomes the new ligament. Cartilage tears are repaired at the same time. Shortly after the surgery, your knee will be in a continuous passive motion machine (CPM). This is essentially a hammock for your leg which gently bends and straightens the knee. Most patients use this for approximately one week after the surgery.
Will I have to stay in the hospital?
This is an outpatient surgery and you can go home the day of surgery. Everything is done arthroscopically (through small poke holes) except for harvesting the patellar tendon or hamstring graft which requires a short incision on the front of the knee.
Do the screws ever come out?
Almost never. They are actually inside the bone and rarely cause any discomfort. While I often use screws that turn into bone over a few years, sometimes metal screws work best. This is determined case by case.
Does this weaken the patellar tendon/hamstrings?
There are five hamstring tendons. I use two. The remaining three compensate by getting stronger and there is some evidence that the two tendons regrow so you won’t miss them unless you depend on power in the deepest knee flexion ( see above). This only applies to athletes in certain sports such as hurdling, defensive back in football, and grappling sports.
For the patellar tendon I take the central third of the tendon. The gap fills in with a strong fibrous tissue so weakness of the tendon is not an issue.
Will I need a brace?
This reconstruction is strong enough that you rarely need a brace for more than a few weeks to a month. There are a couple of exceptions. The most common is when the MCL (along the inner aspect of the leg) is torn at the same time. Patients need a brace for four to six weeks when the MCL and ACL are torn together. I often recommend a “sport brace” during the early phases of physical therapy, much like many football players wear on the field.
When can I walk on my leg after surgery?
You walk the same day as the surgery. You are given crutches but should put your weight on the leg right away. People frequently end up carrying the crutches by the end of the first week but I want my patients to use them until they can walk without a limp.
Will I need rehab or physical therapy?
Yes, this is very important. Your chance of achieving normal knee function after the surgery is greatly increased by the proper rehab. In fact, it takes a great commitment from the patient to get to the therapist and do the exercises with the appropriate diligence. It is also important to do only the correct exercises, as doing the wrong exercises can be more damaging than doing none at all. Unless otherwise instructed, you should start supervised physical therapy 1-2 days after your surgery. At first, PT emphasizes obtaining your full range of motion and some strengthening exercises. As your motion improves, more emphasis is placed on strengthening. Usually within a week you are on a stationary bike and gradually progressed to a stair climber. You will also be doing some weight lifting exercises such as mini-squats and leg press. I usually recommend therapy 3-5 times a week for the first 1-2 weeks and 3 times a week for 2-4 weeks and gradual transition to a home or gym-based program. Jogging is usually allowed at approximately 2-3 months if your motion and strength allow.
Can I play soccer again?
The odds are very good that you can play again after you have recovered from your injury and surgery. Usually you can be doing ball drills by three months after surgery, with return to play 5 or 6 months after the surgery if your strength has returned. Some players wear a brace, but this is optional.
Tearing your ACL can be a frightening experience, but most athletes are pleasantly surprised how well they do after surgery. Yes, you can play soccer again if it is treated properly and you are diligent with the rehabilitation afterward. It takes a well-performed surgery and a lot of work in PT to re-gain your strength, agility and confidence. But you can do it!