Anterior Cruciate Ligament: My ACL Injury and Reconstruction
Anterior Cruciate Ligament
The anterior cruciate ligament (ACL) is the major stabilizing ligament of the knee. The ACL is located in the center of the knee joint and runs from the femur (thigh bone) to the tibia (shin bone). This is an all too common injury in athletes, especially women.
A Polio Survivor
- Poliomyelitis and Polio Deformities: I am a Polio Survivor
When I was about seven months old in late 1954, early 1955, I was a very sick little girl. We lived in Norfolk, VA at the time because my Dad was in the Navy. It was not until about four years later when we...
The ACL Injury
I was very athletic growing up despite having polio as a baby. I grew up in a neighborhood full of boys and few girls so we were always playing baseball, basketball, football, etc. I admit it… I was a tomboy. Back in the middle 70’s when I was attending college my roommate and I were playing racquetball. We both enjoyed the game and we went to the racquetball courts frequently. I went back for a shot, my right shoe caught and stopped suddenly but my body did not. That force was too much for my ACL and down I went with a pop and excruciating pain. When I was able to get up, I could walk but it didn’t feel very stable. I was taken to the emergency room but they just sent me home and told me to RICE (rest, ice, compression, elevation). No mention whatsoever of an ACL injury.
The ACL Diagnosis
For a long time after the injury, I would be walking and it would go out on me for what seemed like no reason at all. I would either have to immediately get off of it or end up on the ground. Occasionally, I would fall hard enough to cause more pain and/or swelling than usual and I would go to the doctor. They all just said I had a ‘loose kneecap’. Of course it was loose. My ACL was ripped. This pattern went on for 25 years and eventually I stopped trying to participate in any sports or physical activities. Then one day in the summer of 2001, I was out in the yard walking to the neighbor’s house when my right foot hit a hole and twisted and down I went. This time it felt very different so I knew I had better go to a doctor again. I decided to go to the doctors at the local university orthopaedic clinic. I had used their clinic before for my knee but it was a different problem then. They did the usual x-rays and then decided to do an MRI. That is the first time in 25 years I was told the problem was my ACL, or rather my lack of one. It was almost completely gone. And I also had a meniscus tear from the fall. First we had to fix the meniscus tear so they scheduled arthroscopic surgery. Then after that was healed they wanted to put me in a physical therapy program to strengthen up the muscles so I could deal better without an ACL. My first question was why can’t you give me a new ACL? I was tired of being so inactive and not doing the things I liked to do. It was even getting hard just walking! The doctor had the same problem and had learned to just deal with it so he thought at my age (I was 47 at the time) and the fact I had gotten along without one for 25 years, I could get along without an ACL reconstruction. So he talked me into trying the eight weeks of therapy and training. I had to go twice a week. At the end of the eighth week, I was no better off than before I started even though I did all the exercises faithfully. So the doctor finally said he would do the reconstruction if I still wanted to. There was no way I was going to have him work on me with his attitude so I went to a knee doctor I had seen once before who used to be at the university but left to join a private group of doctors. He immediately said he would fix it and he didn’t think I was too old to have the surgery. I knew it was going to be a long rehabilitation but it was going to be worth it to be able to be active again. We scheduled the surgery for January of 2002.
The ACL Reconstruction Surgery
When the ACL tears, you must either put up with it or it must be replaced. It cannot be repaired. There are two options for replacement. They either use a graft from a cadaver or harvest a piece of tendon from either the hamstring tendon or the patellar tendon. Mine was harvested from the hamstring. The reconstruction was done by arthroscopic surgery and under general anesthesia. It amazes me how they did all they needed to do through a couple of small holes and a larger cut of a little over an inch (this was needed to harvest the hamstring tendon). After the incisions are made, they pump saline solution through one of the holes to expand it and clean up the blood and enable the doctor to see the knee structures more clearly. They insert an arthroscope through another hole which has a camera on it. It transmits pictures from the inside of the knee to a TV monitor in the operating room. The doctor gave me some printouts of those pictures – very cool. Surgical drills are then inserted through other small incisions. They drill small holes into the upper and lower leg bones where these bones come close together at the knee joint. The holes form tunnels through which the graft will be anchored. Then it is time to harvest the tendon. The graft is pulled through the two tunnels that were drilled in the upper and lower leg bones. The doctor secures the graft with screws or staples (mine were screws) and then closes the incisions with stitches or tape. The knee is bandaged, and you are taken to the recovery room for 2 to 3 hours. The doctor pumped my knee full of an anesthetic so when I awoke the pain was not too bad. My knee was bandaged from thigh clear down to the calf. I had compression stockings on and running to keep my legs from forming blood clots. My surgery was classified as an outpatient surgery, but they were able to keep me overnight without being classified as an inpatient stay. In the morning they put a brace on my leg and with the use of crutches I went home.
The ACL Reconstruction Rehabilitation
The brace had a locking device at the knee which was movable to different angles. For the healing period it was locked to keep my leg straight. It was hard to maneuver with the leg totally straight but the first two weeks are basically lying around with your leg elevated to keep the swelling down and allow the graft to heal when you are not at physical therapy or doing the exercises they give you to do at home. The rehab schedule was: once the first and second weeks. After that they were:
2-10 weeks post-op—3 times per week
10-12 weeks post-op—2 times per week
12+ weeks post-op—1 time per week or as needed
After the initial healing period and gentle stretching exercises the next few weeks of rehab are very grueling. The new graft needs to stretch so you can begin to regain your range of motion but you have to do it in small steps. They start applying gentle pressure on your leg to get the knee to bend. They push until you can no longer stand it, measure the progress and then release it. After you are able to get to a certain degree of motion on your own, then the knee brace is moved to a different angle allowing you to bend the knee to that point. They also put you on a stationary bicycle which at first all you can do is pedal gently back and forth. You are not able to go all the way around. Curiously, I was able to go all the way around backwards before I went forwards. They gradually add in a few strengthening exercises and eventually you get to the point where you no longer need the brace. Then the emphasis switches to strengthening up the knee and leg muscles. I was using crutches for about 3 weeks and then they had me use just one crutch for another week, then it was a cane for a little while until eventually I was totally on my own. I also could not drive the whole time. Not that’s a hardship! I did manage to talk the doctor into letting me go back to work after two weeks, even though I was still on crutches and had to ice the knee four times a day. He wanted me to stay home until I was off the crutches but I was getting too restless. My physical therapist was totally amazed at how fast my rehabilitation progressed. She said I did better than most of her younger patients! I have always been a fast healer. Typically, it takes the reconstructed ligament approximately 9 months to heal. Depending on the individual, you are not allowed to return to the level of pre-injury activity for at least 4-6 months.
Was it Worth It?
A resounding YES! After everything was healed, my knee was so stable that not only was I able to walk again, I was able to participate in sports activities again without worrying that my knee was going to give out. I regret I was not able to find a doctor to make the correct diagnosis after the injury happened, but everything worked out well in the end. I am now much more proactive when it comes to my health.