Anterior Cruciate Ligament (ACL) tear is the most common knee injury in athletes. Research in the United States approximately 100,000 to 200,000 cases of ACL rupture each year, with an annual incidence of 1 in 3500 population, although it may be higher (Gordon MD, Steiner ME , 2004).
dr. Andi Nusawarta, MKes, Sp. OT (K) Sports explained that the ACL has two bundles, the anteromedial bundle (AM) and the posterolateral bundle (PL). The AM bundle is tense in knee flexion and the PL bundle is tensed in knee extension. The AM bundle has an important role in protecting and keeping the knee in forward motion. The PL bundle protects and keeps the knee in rotational motion.
"Injuries usually occur due to jumping with an excessively straight knee (hyperextension), falling with the position of the fibula (tibia) pushed back against the femur, usually in football players who experience it when they are confronted by their opponents (tackling/tackle), jump then land with the position of the knee is rotated inwards (internal rotation) or when a ball player or athlete is running and suddenly stops and the knee rotates (twisted / pivoting style)," he explained.
In principle ACL injuries occur because the tibia and femur rotate in different directions while being totally supported against body weight. ACL injuries are rare due to direct contact. 70-80% of ACL injuries are non-contact mechanisms, only 20-30% of ACL injuries are through contact mechanisms (Holland hospital). The injury is usually accompanied by injuries to other ligaments and the meniscus (unhappy triad / O'Donoghue's triad / terrible triad / horrible triad” (combined ACL / MCL and Meniscus injuries).
In acute injuries, there will usually be a 'pop' sound and the knee will swell and the athlete can no longer continue the game.
"On special physical examinations such as the drawer test and the Lachman test, a typical examination will be found indicating an ACL ligament injury, and often the examination cannot be carried out because the patient is in pain and the knee is swollen," he said.
Dr Andi added that the examination should be postponed until the swelling subsides and the patient is not in pain.
After the physical examination, it is followed by x-ray and MRI radiological examinations. On x-ray radiological examination, it is usually normal, and from a new MRI examination, a torn or broken ACL is found.
"Even with MRI, other ligament injuries and meniscus tears are often found and cartilage damage is found," said Dr. Andi.
Operation action
ACL tears cannot heal on their own so they require surgery. Treatment of tears in the ACL depends on the severity of the trauma, age and activity level of the patient.
"In adolescent patients aged 20 years, surgery is highly recommended. Whereas in patients aged 30 to 40 years, surgery is recommended for active individuals or patients with other ligament injuries (eg ACL injuries accompanied by MCL injuries). In patients aged 50 years or more , operations are rarely performed except for those with combined injuries with other injuries (Holland Hospital)," he explained.
Grafts or grafts to replace a broken ACL can be taken from the patient's own body (Autograft) or from a source outside the patient's body (Allograft). Autograft is especially recommended for patients who are athletes or those who actively exercise regularly. The graft for this ACL can be taken from the Achilles tendon, hamstring tendon or patellar tendon.
"After the graft is taken, it is tidied up and sutured, then a tunnel is made in the tibia and femur. The tunnel that is made must be precise because it determines the success of graft placement. Then the graft is placed in the tunnel (reconstruction to replace the ruptured ACL)," said Dr. Andi.
The Key to Cure in Rehab
Dr Andi Nusawarta said that postoperative rehabilitation is very important because it determines the successful outcome of the operation. Rehabilitation plays an important role in preparing patients to return to their normal activities. There are regulated stages in the process of undergoing rehabilitation.
First day - Second Sunday
Postoperative day one to week two minimizing swelling and pain in the knee joint, the leg is elevated at rest, positioning the patient's knee in full extension (with a brace), mobility of the patella is restored.
"At this stage, passive flexion exercises are allowed (standing holding a chair while flexing the knee as best as the patient can passively or while sleeping on his stomach flexing the knee), the patient may walk on partial weight bearing using a stick (brace attached to the knee)," he said.
Third - sixth week
Furthermore, in the third to sixth week, the patient has started to learn to walk normally with the help of a stick (brace attached to the knee).
"Exercise can only be done without loading (bicycle without loading, fully extending the knee actively by pulling the leg using a rope, walking in a swimming pool)," he said.
Third - sixth month
Starting to focus on doing muscle strengthening exercises or open kinetic changes, namely flexion, extension of the knee with loading and the ankles of the feet are also free to move.
Then do more advanced proprioceptive exercises, namely walking on one leg alternately, catching and throwing the ball in different directions.
"Start also running exercises and doing specific sports activities," he said.
Seventh - ninth month
In the seventh to the ninth month, the patient has started doing exercises in the open (the exercises started to be increased more severely, the strengthening was increased and the proprioceptive exercises were further enhanced). The patient has practiced running in nature and started doing specific sports that he or she enjoys, to prepare himself so that he can be active again in that sport soon.
"Furthermore, the patient can return to being active as before the injury," said Dr Andi Nusawarta.
If you need consultation and treatment regarding a knee injury, you can consult directly with Dr. Andi Nusawarta, MKes, Sp. OT (K) Sports (Sports Medicine and Arthroscopy Consultant Bone and Joint Surgeon) at EMC Sentul Hospital.