The Anterior Cruciate Ligament (ACL) is a major ligament in the knee point that is responsible for preventing the tibia (shin bone) from coming forward from the femur (thigh bone). It also controls rotation in the knee and is essential for stabilising the knee during dynamic agility tasks, such as pivoting and cutting. It is located centrally within the knee joint and sits in front of the Posterior Cruciate Ligament (PCL). Whilst these ligaments have mechanically different roles, they work in conjunction to prevent any excessive forward, backward and rotational movement at the knee.
The anterior and posterior cruciate ligaments are named as such for the way in which the cross over one another, like a crucifix or cross.
ACL injuries are one of the most common serious injuries in football and frequently occur without any physical contact from another player. The specific movement of the knee moving inwards, as well as internal rotation of the knee, are tell-tale mechanisms for an ACL injury – this can occur when a player quickly changes direction, lands awkwardly when coming down from a jump, or plants the foot whilst turning. An awkward tackle to the knee from the outside, which forces the knee inwards, is an example of a contact-based mechanism of ACL injury.
During most ACL injuries, a player will feel a “popping” feeling in the knee and this is a sign the ACL has been injured or possibly ruptured. This may be heard by other players nearby. The knee will often immediately swell up and be very painful with weight bearing and active movement.
An ACL deficient knee typically feels very unstable and most players voice a sense of distrust or frequent episodes of their knee giving way soon after their injury.
At the initial stage, ice and elevation are essential to reduce the swelling around the knee. It is best to be seen by a Physiotherapist to determine the severity of the injury. An MRI scan is the best imaging technique to determine the grade of an ACL injury. If the ACL is partially torn or completely torn, it significantly influences your rehabilitation and overall treatment planning. In severe cases, surgery will be needed to repair the ligament, whereas for more mild cases, it can sometimes be managed conservatively with a knee brace and rehabilitation exercises.
Interestingly there is increasing discussion surrounding whether or not reconstruction is always required, and in time this subject will no doubt gather more attention and detailed research.
Essentially however each player is different and timelines to return to play can vary between 9 months to a more than a year. However, with the right management, and treatment from physiotherapy including exercises, most players can make a remarkable recovery.
Early treatment goals after having an ACL injury are to have reduced swelling and pain, as well as restoring normal flexion and extension range of movement. Soon afterwards, the goal is to restore normal strength, throughout this range of motion. Being mindful to keep the other leg, as well as the hip and ankle on the same side, healthy, is also essential. Early return to pain-free and low intensity exercise, such as swimming and cycling can be important milestones.
For early mobility, doing calf stretches against a wall or with the use of a towel to pull the toes up is helpful. To help with knee flexion and extension doing knee slides where the heel is placed on a towel or any slippery material to slide the knee to the chest and extend out straight.
Another exercise is a towel press down where you press down onto a rolled-up towel. Essentially the idea is to contract the quadriceps as well as the hamstrings by pressing the heel into the ground and press the back of the knee into the towel.
Hanging your leg off a chair or bed and working to extend the knee fully can help increase your strength early and return to basic exercise sooner.
Squats are a good exercise to build strength around the quadriceps and work the hamstrings and glutes. This can be done against a wall, using a chair, or with a band around the knees.
Exercises to strengthen the glutes, which assist in stabilising the knee, are also important. Side-lying leg raises, or banded hip abduction exercises, are quite beneficial.
The exercises lifted above are generally useful in the early stages of an ACL injury and are intended to restore motion and begin the rehabilitation process. Obviously, the specifics of an ACL injury and patient symptoms guide treatment, and all players with an injured ACL require an individualised rehabilitation program and potentially a combination of hands-on techniques, which will be provided by your Physiotherapist.
Although truly preventing ACL injuries is difficult, working on single-leg strength and power appears to be useful. Heavy single-leg lunges, step-ups, and leg presses are a great place to start. As we know that non-contact injuries are common mechanisms, spending time improving your agility and control of landing, cutting, and pivoting is also very useful.
As with any injury, it can be challenging to find accurate and trustworthy information on the internet.
Despite the information we have supplied being helpful in our experience it is always worth your while to speak to a qualified physiotherapist, to get an accurate diagnosis and treatment plan that’s tailored specifically to you.
If you would like to speak to one of our team then call us on 01324 227 370 or you can book yourself in for a physiotherapy appointment with us here
Written by Andrew Davidson, Student Physiotherapist 🇨🇦 and Jesse Coad, Senior Physiotherapist 🇦🇺