Anterior Cruciate Ligament (ACL) Injuries - What Happens

What Happens

If you have a sudden (acute) anterior cruciate ligament (ACL) injury, you generally know when it happens. You may feel or hear a pop and the knee may give out, causing you to fall. The knee swells and often is too painful or unstable to continue any activity.

An ACL injury can cause small or medium tears of the ligament, a complete tear of the ligament (rupture), a separation of the ligament from the upper or lower leg bone (avulsion), or a separation of the ligament and part of the bone from the rest of the bone (avulsion fracture). When any of these occur, the lower leg bone moves abnormally forward on the upper bone, with a sense of the knee giving out or buckling.

When the ACL ligament tears, the blood vessels around the ligament tear and blood fills the knee joint, causing swelling. If you see a health professional immediately, he or she may not be able to examine the knee thoroughly because of the swelling.

Other parts of the knee can be injured at the same time. These may include one of the pads that act as cushions between the two leg bones (menisci), another knee ligament (medial collateral ligament or lateral collateral ligament), or the dense tissue that covers the ends of bones (cartilage). The bones of the knee joint may also be broken (fractured).

Diagnosis may not be done at the time of injury. Sometimes people think the injury is not serious, especially if the knee gets better in a few days. In this case, or if the diagnosis is missed during the initial examination, the injury may develop into a long-lasting and recurrent (chronic) ACL deficiency, in which the knee moves abnormally and gives way occasionally. This can potentially cause progressive damage to the joint, including osteoarthritis. However, not everyone with an ACL injury develops a chronic ACL deficiency.

The course of an ACL injury depends on:

• The condition of the ACL before this injury, including prior injuries, partial tears, ACL deficiency, and degenerative changes due to age.
• The general condition and health of all of your knee structures prior to this injury.
• The amount of damage or injury to the ACL. Injuries to the ACL are usually grouped into grade I, II, or III sprains (tears) according to the amount of damage.
• Additional injuries to the knee joint, such as to the cartilage or menisci, or to bones in the knee.
• Your age, how active you are, and how committed you are to treatment and rehabilitation.
• The time of diagnosis. If the ACL diagnosis is not made soon after the injury, the knee may be further damaged with use.

People with minor ACL injuries usually begin treatment with a physical rehabilitation program. Rehabilitation exercises build strength and flexibility in the muscles on the front of the thigh (quadriceps) and strengthen and tighten the muscles in the back of the thigh (hamstrings). You may use crutches for a short time. Although knee braces may be used to stabilize the knee immediately after injury, they are not usually used long-term. Most people return to their normal activities after a few weeks of rehabilitation.

More serious ACL injuries may require several months of rehabilitation or surgery followed by several months of rehabilitation to regain your knee strength, knee stability, and range of motion. You may use crutches or special knee braces, and it may take several months to a year until you can return to your previous level of activity. The rehabilitation program is intensive—many people think of it as having a second job.

Surgical techniques and rehabilitation programs used today generally are successful. Between 80% and 90% of people who have ACL surgery have favorable results, with reduced pain, good knee function and stability, and a return to normal levels of activity.² Unfortunately, 3% to 10% of people who have ACL surgery still have knee pain and instability.³ Athletes and those who participate in sports generally can return to their sport within months, depending on how intense and sports-focused the rehabilitation was.

Not all ACL injuries require surgery, but whether you have surgery or not, you need to start strengthening your knee and regaining motion soon after you injure it. This prepares you for your rehabilitation program if you choose not to have surgery and also helps prepare the knee for surgery if you choose to have it.