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Ask Dr. Rick – November 2010

November 3, 2010

All About The ACL

Now that we are entrenched in the NFL season as well as the college football season, one of the most common dreaded injuries in sports medicine is damage to the anterior cruciate ligament. To give our readers an idea of the severity, approximately 400,000 anterior cruciate ligament reconstructions are done annually in the United States. The ACL is generally torn with a decelerating rotation injury to the knee. The athlete commonly feels a pop. The knee generally swells. The knee tends to be unstable and other structures including the meniscus and articular cartilage can be damaged. Once there is a suspected ligament injury, the knee needs to be immobilized immediately, iced and no weightbearing should occur until the joint has been evaluated by an orthopedic surgeon.

The athlete should be seen by an orthopedic surgeon who will x-ray the knee and generally order a MRI in trying to make the diagnosis of torn anterior cruciate ligament, as well as possible meniscal and/or joint surface pathology. Physical therapy might occur for one to two weeks to get full range of motion and resolution to the swelling resolved prior to surgery. Surgical treatment is generally an anterior cruciate ligament reconstruction. This means taking a structure from elsewhere and making a new anterior cruciate ligament.

Tissue can either be taken from the patient’s same knee and that would be the central third of the patellar tendon, or the hamstring tendon or tissue to be taken from an alternate source which is usually a cadaver or called an allograft. Holes are drilled through the tibia and femur and the ligament is placed in the position of the native anterior cruciate ligament fixing it at both ends with a screw to stabilize the new graft. Any ancillary surgery, including meniscal repair or debridement, is carried out and the patient is generally started on physical therapy two to three days after the reconstructive procedure.

Physical therapy generally lasts four to six months, and the athlete can expect to return to full unrestricted activities in about six months. Brace wear after an anterior cruciate ligament reconstruction is generally recommended for the first three months and after that it is up to the athlete whether he wants to wear a brace. Bracing after anterior cruciate ligament reconstruction is not a necessity and is decided upon by the surgeon and discussions had with the patient. The incidence of reinjury of the anterior cruciate ligament is very low and full return to competitive sports can be expected

Ask Dr. Rick

“Dr. Rick: I was trying to catch a pass at football practice four days ago and the ball hit the tip of my finger. Now I am unable to straighten my ring finger on my right hand. I went to the doctor and he took the x-ray and said nothing was broken, but I still cannot straighten my finger. Could you please explain what has happened? Thank you very much.”
– Larry R., O’Fallon, MO

Dear Larry: This injury is commonly called a mallet finger and occurs either when the extensor tendon or piece of bone pulls off the extensor tendon not allowing you to straighten the tip of your finger. After this injury, the finger swells and becomes uncomfortable. It should be iced, and after seeing the physician, it should be placed into an extension splint holding the finger straight for six weeks. The splint cannot be taken off at any time, allowing the finger to bend in those six weeks. Following the six weeks of complete extension, the splint should be worn only at night and physical therapy should be instituted. If the finger bends within the first six weeks, then the clock starts all over again and the finger needs to be extended with no bending for six weeks allowing the tendon to heal. You can expect full function and minimal result if it is treated in this manner. Thank you for
your question.

“Dr. Rick: I recently had arthroscopic surgery on my knee, and I was told the doctor repaired my meniscus. What is the difference between repairing my meniscus and removing my meniscus? I never miss a chance to read your article.”
– Karen L., St. Peter’s, MO

Thank you very much for your support, Karen. When the meniscus is torn, there are two options. One is to put stitches in the meniscus to try to get the meniscus to heal, which occurs if the meniscus has blood supply, or to remove a portion of the meniscus. A portion of the meniscus is generally removed when the meniscus has no blood supply and has no ability to heal. If the meniscus is sutured with an attempt to get it to heal, you will be non-weight bearing for a period of time and although the recovery will be longer, you will be able to maintain your meniscal tissue, decreasing the chance of future arthritis. If the meniscus is removed, this increases the chances of having arthritis years later. That was an excellent question; thank you.

Dr. Rick’s Medical Tip: When playing winter sports, layer your clothing. Start out with excessive layering to stay warm. You can peel off the layers as you warm up. Do not start your activity cold, which increases your chances for injury.

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