Oh snap! My cruciate is gone

Oh snap! My cruciate is gone

In the sporting community, this must be one of the biggest, if not the biggest, topics to discuss. This is because the cruciate ligament is a main stabilizer of the knee when undergoing tackles, cutting, changing of direction while running, and even when winding up to kick.

Injuries to the anterior cruciate ligament (ACL) occur most commonly during sports, particularly football. This commonly happens when the effected knee undergoes rotation with the same foot planted on the ground such as in kicking a ball forcefully. It is therefore a torsional or twisting injury of the knee and does not normally occur from being tackled – although tackles may also result in cruciate injuries!

Prevention primarily stems from being aware of how you can injure your ACL. One must try not to pivot forcefully on the planted leg. Secondly, and this is particularly important when playing on synthetic turf, careful consideration must be paid to the footwear that is being used. Most synthetic turfs have a sort of mesh underneath to keep the ‘grass’ rooted – if you use deep large studded shoes, such as you would on real turf, this can easily get caught in the meshwork and will result in the leg getting caught while the body is still rotating in the pivoting direction. The net result is a twisting effect between the two bones making up the knee with the eventual result of a torn meniscus (cartilage) and ACL.

The obvious question then is: OK, now that we have a torn cruciate – do we really need to operate it? And this is where the controversy kicks in. Unfortunately, there isn’t a simple answer. My guestimate is that two in three injured cruciates will eventually need reconstruction (surgery). This largely depends on the person’s activity level and ability to cope with the injury. Not all ACL deficient (injured) knees will be unstable. A recent study has shown that in a group of elite footballers with injured ACLs, fifty percent of them returned to same level sports with a good rehabilitation (physiotherapy) regime. This is quite a good number considering that only sixty percent of reconstructed knee patients return to the same level of sports.

Another myth that some proponents of surgery use as an argument is the relationship of early arthritis and cruciate injuries. While it is true that an ACL deficient knee develops arthritis more readily than a normal knee, cruciate surgery in the form of reconstructing the ligament hasn’t shown to prevent the onset of arthritis.

So why, I hear you ask, do we operate?

By and large I categorise patients into three:

The low demand, no symptom knee. If my patient has no symptoms, that is, his or her knee are not giving way and they do not partake in any high intensity sport, then I would leave that knee alone as in my opinion, and this is my opinion here, the chances of making that patient much better is slim.

Then there is the symptomatic knee. Even if the patient has no intent of performing sport, but his or her knee keeps buckling under, then I would advise surgery as the risk of further knee injuries is increased and the rate at which arthritis will develop is greater here; Not to mention that it is pretty disabling to have a buckling knee that is not functioning properly in simple daily activities.

Finally, there is the athlete. I think that people who partake in regular moderate to high activity or sport should get their ligaments rebuilt as it will reduce (not eliminate) the rate at which new injuries develop in the knee. My view on this is slightly changing as more evidence of good short-term outcomes with rehab is emerging. The question remains however… What are the long-term outcomes of surgery versus good ongoing rehab? We know that arthritis will eventually set in, but a lot of questions remain unanswered as good long-term evidence is lacking.

There you have it folks, this is the low-down on cruciates and the need for surgery. At the end of the day it is entirely up to you, the patient, whether to proceed with surgery or not but at least if this concerns you, you are a bit better informed on what to expect and can therefore make a better judgement and set more realistic expectations. It is important to understand that it is not a cruciate injury but a knee injury in an individual – and one has to evaluate that knee’s performance in that particular person; and that is why there isn’t a one size fits all answer to the question of whether you should get your cruciates done or not.

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