FAQs on Ligament Injury

Posted by : Dr. Pradeep Moonot, 09 Feb 2013 12:26 AM
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What causes an Anterior Cruciate Ligament (ACL) injury?
ACL tear is the most common injury in the knee with around 3% of all athletic injuries. There are several ways in which an ACL injury can occur. Twisting of the knee or leg, landing "wrong" from a jump or extending or bending the knee beyond its normal range may result into an ACL tear. Sports like football, basketball, tennis and volleyball, and activities like skiing and snowboarding are more vulnerable. As compared to males, female athletes are more prone to ACL injury. Three - Four times more common in women than men (smaller ACL, tight notch, increase in the Q-angle, hormonal in women may be the factors causing increase in ACL injury)

What are the signs and symptoms of a possible ACL tear?
The famous "pop" is the most telling symptom of an ACL injury, although you may have a tear without ever experiencing the pop. The injury is usually followed by considerable pain and swelling almost immediately after the injury. You may develop a feeling of instability in the knee or "giving way", making walking difficult especially on uneven surface or while running or playing sports.

How does a doctor diagnose an ACL tear?
The what, when and how of the injury helps the doctor in diagnosing the tear. It is followed by clinical examination of the knee, and special clinical tests to check for looseness and clunks. An xray and MRI (Magnetic Resonance Imaging) helps in confirming the diagnosis of an ACL tear.

Is surgery necessary if ACL tear takes place?
An ACL tear can be partial or complete, and thus it depends on the severity of the tear, if surgery should be done or not. It is possible to live with a tear with strengthening exercises of the thigh and often a good knee brace.

Are there risks in not getting the surgery done?
Almost 1/3rd of the patients with ACL injury may not require surgery. However it is important for these patients to have appropriate physiotherapy and rehabilitation to strengthen their thigh muscles and work on core stability. A knee brace during sporting activities will help as well.
1/3rd of the patients do have symptoms of instability but by restricting their activities they may not require surgery.
The rest 1/3rd of the patients do have symptoms (giving way and cannot trust their knee) from the ACL tear which affect their day to day activities. These patients will benefit from ACL reconstruction surgery. If these patients do have anything done for their knees then there is increase risk of further damage to the knee which may cause arthritis in the long term.

How long after the injury will I need a surgery?
If you do have symptoms of instability like giving way and unable to trust your knee then surgery is the real option. However there should be a gap of atleast 6 weeks between the injury and surgery. Otherwise there is an increase risk of complications like stiffness of the knee which may lead to sup-optimal outcome from ACL reconstruction.
How do you repair the ACL?
The ACL cannot be repaired in adults. It is replaced and the surgery is called anterior cruciate ligament reconstruction. The two most common tissue used in the surgery is either the hamstrings or the bone patella bone graft. The outcome is similar for both the grafts. 

What is the outcome after ACL reconstruction/surgery?/Success after surgery
The outcome is very good after surgery and most of the patients go back to playing their pre-injury sport. The success rate is more than 90% at 3-5 yrs. However in patients who have a failed ACL surgery, the most common cause is either a malposition of the bone tunnels or rerupture of the ACL graft. 
Also around 15% of patients have other injury like posterolateral corner tear of the knee which is missed by the treating surgeon/physician.  

What should I expect after surgery?
The admission in the hospital should be for only a day or two. 
You should be able to go home walking, may be with one or two crutches. This can be weaned off in the next 2-4 weeks.
Regular ice and elevation will help alleviate pain
Regular paracetamol and some anti-inflammatory will help
Regular physiotherapy for the next 3 – 6 months (exercises can be done at home once confident)
In the first 2 weeks it is important to achieve the get the knee straight.
Swelling and bruising as far down as your ankle and foot is normal.
You will need to keep your dressing dry until the stitches are removed.
Driving is OK when you are confident and may take upto 6 weeks after surgery.
You should be able to feel confident on your leg after each session of physiotherapy.  It will take atleast 4 – 6 months to go back to gentle running and around 9 months to be back to playing sports. 
How many post-operative exercises should be done?
Try few exercises at first, then few more later. It’s better to do a few at regular intervals in a day than to do too many at once. Do what you can, do not exercise forcefully. If you get increased pain and swelling, discontinue or back off a bit.

Is it fine to take a shower?
It is required to keep the dressing dry. It can be covered with a plastic wrap. Kitchen trash bags can be used for the same if the dressing is long. Once the stitches are out and the incision is fully healed, taking a bath would be fine. It would require around 10 days but it should not be for long time or with too hot water.

What about stairs?
The first day or two after surgery you may find it easier to do stairs in a sitting position, using your arms and good leg to push off. The other leg just goes along for the ride.
Up with the good and down with the bad is the key to doing stairs with crutches.
Once off crutches you will do stairs the baby way for quite a while, that is, always leading with the same (good) leg. Again it’s up with the good and down with the bad. Stepping up and down is part of the rehabilitation process and you start off with the height of a phone book. So, don’t push it!

How can I control swelling?
RICE= Rest, Ice, Compression and Elevation
Rest – don’t walk too much or keep your legs down for too long.
Ice - as often as 20 minutes on, 60 minutes off.
Compression - use as much as you need. Options include: an elastic bandage wrapped from the ankle to just above the knee, elastic stockings or snug fitting leggings.
Elevation - Ideally, lie down and use enough pillows to support your whole leg and get your foot 12" to 18" above the rest of your body.

How can I minimize scarring?
Once the incisions have healed, use lotion to gently massage along each side of the scar and across it. Many people believe using vitamin E will minimize scarring. While there is no scientific evidence for this, there is no harm in using topical vitamin E. Also Biofilm can also be used.

Are there any life style changes that will prevent these injuries?
There are various things one can do to prevent ligament injuries:
- Having a healthy lifestyle with some form of physical activity like swimming, cycling, yoga, pilates will help
- Keeping yourself fit
- Adequate warm up and cool down
- Use of knee brace may help
- Appropriate footwear 
Are there any exercises that will help with strengthening of these ligaments?
Knee and thigh strengthening exercises – achieved with cycling, swimming, walking but not running.
Core stability exercises
What are the other ligament injuries of the knee?
Medial collateral ligament can be injured with a valgus injury. Usually the patient does not require any surgery and can be managed by RICE and a brace for 2 – 6 weeks.
What does a high tibial osteotomy do?
If the arthritis is only in one part of the knee then the patient may benefit from high tibial ostetomy. In this surgery the stress of weight bearing across the knee is more evenly distributed by realigning the bone. It relieves disproportionate heaviness on the diseased (or arthritic) side of the knee joint.

What is the time required for the recovery of high tibial osteotomy?
For healing of high tibial osteotomy, there requires about six weeks of partial weight bearing, which is again followed by six weeks of full weight bearing with crutches and about 12 weeks of rehabilitation with physical therapy. Majority of patients fully recover to full activity by about six months.

What evaluation is needed before a high tibial osteotomy (HTO)?
Clinical evaluation along with full length X-rays are required for evaluating a high tibial osteotomy. Patients usually younger than 55 yrs old, only mild deformity, good movements in the knee and arthritis in only one part of the knee are the indications for HTO.

Ankle sprain
An ankle sprain (also known as a lateral ankle ligament sprain) is the most commonly occurring injury to the ankle. During weight bearing activity (walking, running or jumping) the ankle and foot move inwards, towards the mid-line of the body, more than the stabilising structures allow, thus resulting in injuries to these structures. Most commonly it is the lateral ankle ligaments and the lateral ankle joint capsule which are torn.
Bleeding into the joints itself is common after this injuries and this can lead to chronic inflammation setting up in the soft tissues within the ankle joint known as synovitis.
I have repeated ankle sprains or weak ankles. What is the cause?
If your ankle feels unreliable and gives way repeatedly, or if you have recurring ankle sprains, it is recommended that you have a full assessment by a foot and ankle surgeon.
Your foot will be examined for signs of swelling and tenderness. By stretching your ankle in different directions, the surgeon will be able to see whether the ligaments are abnormally weak. This is known as a stress view.
The surgeon may take x-rays to check whether there is any damage to the ankle bones. An MRI scan may also be taken.

Chronic ankle instability usually develops following an ankle sprain that was not diagnosed properly or has not healed. An ankle sprain stretches and tears the connective tissues, known as the ligaments.
Ankle instability makes you more prone to ankle sprains, which in turn exacerbate ankle instability. With each ankle sprain, the ligaments are increasingly weakened.

Other causes of recurrent ankle sprains are generalized ligament laxity and neurological disorders.

What is the treatment of ankle sprains?
There are four ways available to manage an ankle ligament sprain/rupture. These are 
either to do nothing and simply wait for the ankle to settle. 
Secondly, to immobilise the injured ankle in a plaster cast for a period of 4-6 weeks, walking as comfortable. 
Thirdly, to use functional rehabilitation to treat the sprained ankle (a graded physiotherapy programme, often combined with a removable ankle brace). 
The final option is to operatively repair the injured ligaments.

What is the treatment of recurrent ankle sprain or ankle instability?
Treatment depends upon the severity of the ankle instability and the patient’s own activity levels.
Physiotherapy should be tried as the first treatment and is effective for many patients. Physiotherapy is based on retraining the damaged proprioceptive nerves, enabling them to respond to the movements of the ankle. The strength of muscles around the ankle will also be increased by exercises and activities. If your foot shape makes you prone to extra stress on the ankle ligaments, a moulded insole may be advised for your shoe to reduce these stresses.
Surgery may be considered if ankle instability fails to improve following non-surgical treatment, and depending on the degree of weakness in the ligaments. There are two main types of operation for ankle instability.
1. The damaged ligaments may be tightened and re-attached to the bone. Known as the Brostrum’s procedure, this type of operation is highly successful and is appropriate for people with active lifestyles.
2. If all other options have been tried and are neither successful nor suitable, a tenodesis procedure may be carried out. This involves taking a strip of hamstring to recreate new ligaments. This approach should only be considered as a last resort, when the instability is severe and there is likely to be a great deal of stress on the ankle. This type of repair is a very durable treatment for ankle instability but frequently causes stiffness in the ankle.
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