The anterior cruciate ligament is a cruciate ligament which is one of the four major ligaments
of the human knee.
In the quadruped stifle, based on its anatomical position, it is also referred to as the cranial
cruciate ligament.
Structure The ACL originates from deep within the notch
of the distal femur.
Its proximal fibers fan out along the medial wall of the lateral femoral condyle.
There are two bundles of the ACL—the anteromedial and the posterolateral, named according to
where the bundles insert into the tibial plateau.
The ACL attaches in front of the intercondyloid eminence of the tibia, being blended with
the anterior horn of the medial meniscus.
Function These attachments allow the ACL to resist
anterior translation and medial rotation of the tibia, in relation to the femur.
Clinical significance Injury
ACL Tears are one of the most common knee injuries.
There are more than 100,000 ACL tears in the US alone every year.
Most ACL tears are a result of landing or planting in cutting or pivoting sports, with
or without contact.
Most serious athletes will require an ACL reconstruction if they have a complete tear
and want to return to sports, because the ACL is crucial for stabilizing the knee when
turning or planting.
Reconstruction is most commonly done by autograft, meaning the tissue used for the repair is
from the patient’s body.
The two most common sources for tissue are the patellar tendon and the hamstrings tendon.
The surgery is arthroscopic, meaning that a tiny camera is inserted through a small
surgical cut.
That camera sends video to a large monitor so the surgeon can see any damage to the ligaments.
In the event of an autograft, the surgeon will make a larger cut to get the needed tissue.
In the event of an allograft in which material is donated this is not necessary.
The surgeon will make holes in the patient’s bones to run the tissue through, and the tissue
serves as the patient’s new ACL.
Recovery time ranges between 6–10 months or longer.
Tearing the anterior cruciate ligament can sometimes be part of a knee injury known as
“the terrible triad”.
This consists of the simultaneous tearing of the anterior cruciate ligament, medial
collateral ligament, and medial meniscus.
Non-operative treatment of the ACL The ACL can be treated non operatively with
strengthening and rehabilitation and occasionally injections when the ACL is not completely
torn and the knee is still stable or if the patient is not doing activities requiring
cutting and pivoting or similar actions.
The mainstay of ACL non-operative treatment is strengthening of the muscles around the
knee, especially the hamstrings.
Focused physical therapy supervised by a knee doctor can be an effective way to accomplish
this.
Anterior cruciate ligament surgery is a complex surgery that requires expertise in the field
of sports medicine.
Many factors should be considered when discussing surgery including the athlete's level of competition,
age, previous knee injury, other injuries sustained, leg alignment, and graft choice.
Occasionally, stimulation of body's natural ability to heal the native ligament, called
a “healing response” surgery is resorted to.
More commonly the ligament needs to be replaced by a graft from the patient's own tissue or
tissue from a cadaver.
Graft choice could be confusing, requiring expert counseling from a doctor.
Rehabilitation is crucial to any ACL surgery.
ACL surgery typically takes 6 to 9 months for complete recovery and return to sports
or such activity.
Revision ACL surgery will often take 9 months to more than a year.
During this time, the doctor should guide the patient through the rehabilitation process.
The early rehab, usually lasting around 6 weeks, will focus on maintaining full knee
motion and preventing scar tissue.
The second phase of rehab will then be directed towards regaining knee strength.
Finally, sport or the patient's activity specific rehabilitation activities are administered
before the patient returns to the occupational activities like sports.
The rehabilitation program can also be composed of aggressive motions, weight bearing exercises,
and a speedy recovery for athletes to return to their sport.
If the doctor recommends surgery for ACL, he may prescribe rehab before surgery as many
studies have shown that having good motion before the surgery will benefit the patient
after surgery.
The ACL is quite commonly injured in athletes of varying sports.
These situations are often remedied by surgery followed by several months of physical therapy.
A 2010 Los Angeles Times review of two medical studies discussed whether ACL reconstruction
was advisable.
One study found that children under 14 who had ACL reconstruction fared better after
early surgery than those who underwent a delayed surgery.
For adults 18 to 35, though, patients who underwent early surgery followed by rehabilitation
fared no better than those who had rehabilitative therapy and a later surgery.
The first report focused on children and the timing of an ACL reconstruction.
ACL injuries in children are a challenge because children have open growth plates in the bottom
of the femur or thigh bone and on the top of the tibia or shin.
An ACL reconstruction will typically cross the growth plates, posing a theoretical risk
of injury to the growth plate, stunting leg growth or causing the leg to grow at an unusual
angle.
The second study noted in the L.A. Times piece focused on adults.
It found no significant statistical difference in performance and pain outcomes for patients
who receive early ACL reconstruction vs. those who receive physical therapy with an option
for later surgery.
This would suggest that many patients without instability, buckling or giving way after
a course of rehabilitation can be managed non-operatively.
However, the study points to the need for more extensive research, was limited to outcomes
after 2 years, and did not involve patients who were serious athletes.
Patients involved in sports requiring significant cutting, pivoting, twisting, or rapid acceleration
or deceleration may not be able to participate in these activities without ACL reconstruction.
The randomized control study was originally published in the New England Journal of Medicine.
ACL injuries in women Women have been known to suffer ACL injuries
more frequently than men; current research gives some explanations for this.
The joint through which the anterior cruciate ligament passes, along with the actual size
of the anterior cruciate ligament, is significantly smaller in women than in men.
This makes it more susceptible to damage.
Along with these aspects, women tend to not activate their hamstring muscles as much as
their male counterparts during certain cutting movements causing less stability in the knee
joint.
Additional images
See also This article uses anatomical terminology;
for an overview, see anatomical terminology.
Anterior cruciate ligament reconstruction Anterior drawer test
Lateral collateral ligament Medial collateral ligament
Posterior cruciate ligament Unhappy triad
References
External links Anatomy photo:17:02-0701 at the SUNY Downstate
Medical Center - "Major Joints of the Lower Extremity: Knee Joint"
Anatomy figure: 17:07-08 at Human Anatomy Online, SUNY Downstate Medical Center - "Superior
view of the tibia."
Anatomy figure: 17:08-03 at Human Anatomy Online, SUNY Downstate Medical Center - "Medial
and lateral views of the knee joint and cruciate ligaments."
lljoints at The Anatomy Lesson by Wesley Norman