How a ligament breaks
Most ruptures occur without a direct blow to the knee. A typical picture: the foot is fixed on the surface, the body turns, the knee goes inward, and the lower leg moves forward - the ligament is stretched beyond its limit and breaks. This is why football players, basketball players, skiers, wrestlers and dancers suffer so much. A person usually hears or feels a click, experiences sharp pain, often falls and cannot continue playing, and in the next few hours the joint bursts from the inside.
- Sharp braking and change of direction of movement on the supporting leg
- Unsuccessful landing after a jump with the knee going inward
- Rotation of the body with a fixed foot
- Hyperextension of the knee
- Direct blow to the outer surface of the knee - less common, usually also damaging the medial collateral ligament and meniscus
- Ski injury when the boot fixes the shin and the body continues to rotate
How does it manifest itself in the acute period and then
On the first day, the picture is clear: pain, rapidly increasing swelling due to blood in the joint, limited movement, inability to put weight on the leg. After two to three weeks, the inflammation subsides, the swelling subsides, the pain goes away - and a deceptive calm sets in. The man walks, climbs the stairs and decides that everything went well. The problem manifests itself later, when trying to return to activity: the knee begins to buckle when turning around or on an uneven surface.
This explains why a torn anterior cruciate ligament is so often detected months and sometimes years late. A person goes to the doctor not with an injury, but with a complaint that the knee is “failing”, and only upon examination it turns out that the ligament has been missing for a long time. By this point, many already have a concomitant meniscus tear, resulting from one of the episodes of breaking. Therefore, it is wise to be examined immediately after an injury, even if after three weeks the knee seems completely healthy: early knowledge of the diagnosis allows you to choose a lifestyle consciously, and not retroactively.
- A clicking or tearing sensation inside the knee at the time of injury
- Rapid swelling of the joint in the first hours
- Inability to continue playing or practicing
- Limitation of full extension and flexion in the acute period
- Later - a feeling of instability, knee buckling when turning
- A feeling of uncertainty in the leg, which the person describes as "I don't trust my knee"
It is the episodes of breaking that are more dangerous than the rupture itself: each such episode is a new microtrauma, which damages the menisci and articular cartilage. A patient with an unstable knee who continues to play sports with rotations accumulates damage over several years that cannot be corrected by plastic surgery of the ligament. Therefore, the question of treatment is primarily a question of whether the knee will be subjected to loads under which it is unstable.
Survey
- Расспрос о механизме травмы и о скорости появления отёка — это важные диагностические сведения.
- Тест Лахмана — main клинический тест на переднюю крестообразную связку, самый чувствительный of всех. Врач оценивает смещение голени вперёд при слегка согнутом колене и, что не менее важно, характер конечной точки этого смещения.
- Проба переднего выдвижного ящика и ротационный тест — дополняют картину, но в остром периоде из-за боли и напряжения мышц могут быть неинформативны.
- Рентген коленного сустава — исключает переломы и выявляет косвенный признак разрыва: отрыв небольшого костного фрагмента по наружному краю большеберцовой кости.
- МРТ коленного сустава — подтверждает разрыв и, главное, показывает сопутствующие повреждения: мениски, боковые связки, хрящ, костный отёк.
- Повторный осмотр через 1–2 недели, когда стихнут боль и отёк: клинические тесты в это время гораздо информативнее.
To operate or not: how the decision is made
This is the only truly difficult question when it comes to an ACL tear, and there is no one-size-fits-all answer. The ligament will not heal, but some people live well without it: their knee is stabilized by powerful thigh muscles and good neuromuscular control. Such patients make do with rehabilitation. For others, this is not enough for everyday life, and any careless movement ends in breaking.
It is impossible to predict in advance which group a particular person belongs to - this is determined in practice. Therefore, a common and reasonable approach is: first three months of quality rehabilitation, and then an assessment. If during this time the knee has never failed during normal activities, the strength of the hip has recovered symmetrically, and the person does not intend to play football, the operation can be postponed and observation continued. If the breaking is repeated or reversal loads are imminent, the indications for plastic surgery become obvious. Such a delay does not spoil anything: the quality of the result of the operation does not suffer from it, and the preparation of the knee itself improves the outcome.
- In favor of surgery: young age, sports with turns, jumping and contact, physically difficult or traumatic work
- In favor of surgery: repeated episodes of knee breaking at home
- In favor of surgery: a concomitant tear of the meniscus requiring a suture - the ligament is repaired so that the suture does not collapse due to instability
- In favor of conservative management: sedentary lifestyle without turning loads
- In favor of conservative management: partial rupture with preserved stability according to clinical tests
- In favor of conservative management: advanced age, severe arthrosis, severe concomitant diseases
The issue of timing is particularly important. Operating in the first days after an injury, while the knee is swollen and does not straighten, is a bad idea: the risk of developing cicatricial stiffness of the joint is much higher. The standard approach is to first return full extension, relieve swelling and restore function of the quadriceps muscle, and only then operate. The exception is a blocked knee due to a meniscus tear similar to a watering can handle, when intervention is not delayed.
Ligament plastic surgery: what exactly is done
The torn ligament is not stitched - it is replaced with a graft. Through arthroscopic punctures in the femur and tibia, channels are formed, the graft is passed through them and fixed. Over time, it is rebuilt and overgrown with its own tissues, turning into a new ligament. It is this restructuring that takes months of rehabilitation: the strength of the graft is temporarily reduced in the first weeks after surgery, and this must be remembered when the temptation arises to speed up the return to sports.
- Semitendinosus and gracilis tendon grafts are the most common option.
- Graft from the middle third of the patellar ligament with bone blocks - strong fixation, but pain in the anterior part of the knee is possible when kneeling
- Quadriceps tendon graft - gaining popularity
- Donor graft - used in certain situations, more often during repeated operations
- At the same time, associated damage is eliminated: suture or resection of the meniscus, if necessary, additional external stabilization
The choice of graft is discussed with the surgeon: it depends on the type of sport, age, presence of previous operations and what kind of loads are expected. No one option is best for everyone, each has its own strengths and price.
Rehabilitation and return to sport
Rehabilitation after anterior cruciate ligament surgery is not an addition to the operation, but half of it. Even a flawlessly performed operation, if recovery is neglected, results in a weak, unstable knee. The program is built in stages, and the transition to the next stage is determined not by the date, but by the achieved criteria: full extension, absence of swelling, symmetrical hip strength, high-quality knee control when landing.
- Первые недели — восстановление полного разгибания, борьба с отёком, включение четырёхглавой мышцы, ходьба с постепенным увеличением опоры.
- С 6–12-й недели — велотренажёр, силовые упражнения в безопасном диапазоне, работа с мышцами задней поверхности бедра и ягодичными.
- С 3–4 месяцев — беговая нагрузка при выполнении критериев по силе и отсутствию отёка.
- С 5–6 месяцев — прыжковые и разворотные упражнения, обучение правильному приземлению.
- Возвращение к контактному спорту — как правило, не раньше 9–12 месяцев и по результатам функциональных тестов на симметрию силы и прыжка.
- Профилактические нейромышечные программы после возвращения — обязательная часть, а не факультатив.
Two points deserve special attention. The first is full knee extension in the first weeks. This is the most common missed detail: if extension is not restored immediately, scar tissue forms in the joint, and then it has to be eliminated with a separate intervention. The second is the muscles of the back of the thigh. They work together with the ligament to keep the tibia from moving forward, and their weakness overloads the graft. If the graft was taken from these tendons, restoring their strength becomes an even more important task, and it takes longer than usual.