ACL Tear: It Can Happen to Anyone

From the WebMD Archives

Bryan Vargo leapt into the air for a 50/50 header. It’s a common soccer scenario, two players going airborne to compete for the ball with their heads. But the landing changed Vargo's life.

“I came down, got bumped by the other player, landed, and twisted. I was told that you could hear the ‘pop’ from across the field,” says Vargo, an editor with the Arthritis Foundation in Atlanta. “It made a nasty sound, like when you’re eating chicken and you snap a piece of cartilage. I knew right away what I’d done.”

He tore the anterior cruciate ligament, or ACL, in his right knee. It’s one of four major connectors that link the bones that make up the joint. It helps your knee move and does the lion’s share of the work to keep it stable.

It’s Easy to Tear an ACL

Just ask NFL star Carson Palmer. The Arizona Cardinals quarterback reinjured his left ACL in November 2014 when he planted his leg at an awkward angle.

In fact, ACL sprains and tears are among the most common knee injuries. They happen to about 200,000 people a year in the U.S., racking up an annual health care cost of more than $2 billion.

They put weekend warriors and pro athletes side by side in the ranks of the walking wounded.

“We’re talking about a huge cross-section of society,” says Andrew Cosgarea, MD, an orthopedic surgeon who leads the Division of Sports Medicine at Johns Hopkins University, where he serves as head team doctor for the athletic department.

Cosgarea says he’s treated ACL tears caused by roughhousing with friends after school, dancing at a party on a Friday night, or jumping on a trampoline.

“The risk is highest for people involved in cutting and pivoting sports,” he says. “But basically, everybody who is involved in physical activity is at risk.”

Repeat Tears Are Common

Say you shred your ACL and go back to a sport, like soccer, that requires cutting motions. You’re six times more likely to tear one again -- and it could be either knee -- within 2 years.

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Rachel Schmitz, a former college soccer player, has had two ACL tears. Cosgarea has rebuilt ligaments in both her knees, but she’s still in the game. Her most recent injury came in a rec league in September 2014.

Why get back out there after the first one? “It’s hard to quit. I love playing too much,” says Schmitz, who’s now a grad student at the University of Maryland-Baltimore County. Her younger sister has also had surgery on both knees. The two are living proof that women are up to 10 times more likely to get ACL tears than men.

You Can Make a Comeback

Palmer also knows what it’s like to have two ACL injuries -- to the same knee. He tore his for the first time back in 2006.

The good news for pro athletes and regular guys alike? You can bounce back and do pretty much everything you did before. Palmer proved it by coming back to lead the Cardinals in the 2015 season.

“Full recovery is always the goal, and there are no shortcuts,” says Vargo, who uses “always” because, like Palmer, he tore the ACL in the same knee twice.

His ill-fated landing happened in 2008. Then in 2012, he tore it again while playing soccer, planting his knee wrong during a sideways move. “I misjudged a divot in the ground,” he says.

That injury was worse than the first time. Vargo also tore his meniscus, a piece of cartilage that cushions the ends of the bones in your knee, along with some other ligaments. Even so, he’s back to playing soccer, mountain biking a couple times a week, kayaking, doing some hiking, and going skiing and snowboarding every winter.

“You have to do the work if you want to get back in the game,” he says.

Will You Need Surgery?

Your comeback will probably start in the operating room. Most people need surgery to prevent further injury. But not everyone does. Those who don’t include:

  • People with severe arthritis
  • Older people with more inactive lifestyles
  • Folks whose knees are stable despite the injury, whether it’s a full or partial tear

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Surgery is a 75-minute outpatient operation. Most people have what’s called a tendon graft. The surgeon reconnects your torn ACL using a piece of tissue from another part of your body or from a cadaver.

In the "autograft" version of the procedure, the doctor uses one of your own tendons. It could be the patellar tendon, which connects your knee cap to your lower leg. This is considered the gold standard, and it’s the option Schmitz chose. You can also use hamstring tendons from the big muscle on the back of your leg, or the quadriceps tendon from the big muscle on the front of your leg.  

With an "allograft," the tissue comes from a cadaver. Your doctor will get it from a certified tissue bank. These rebuilds work just as well as autografts most of the time, though there is a higher risk that the graft will tear again if it’s used in young people. This is the option Palmer and Vargo chose.

In either case, the goal is to “create a structure that looks like an ACL,” Cosgarea says. Your surgeon drills tunnels through the bone to house the new graft. He threads the new ligament through the tunnels and anchors it on both sides. Over time it grows into the bone and becomes part of your body.

A Recovery Timeline

Physical therapy begins in the recovery room. You’ll do some exercises and get your crutches. You might or might not get a brace -- it’s up to your doctor. Here’s what you can expect over the next few weeks:

1-3 weeks: You’ll get your stitches out between 1 and 2 weeks. If your job isn’t active, you can probably go back to work after the first week. Rehab will focus on straightening your knee, strengthening your quad, and getting the swelling down. You may ride a bike, do toe and heel raises, and learn to walk with a normal gait. You’ll walk without crutches by the end of week 2, unless you had repairs to other parts of your knee. You can drive when you’re off the crutches.

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4-6 weeks: Your walk is back to normal. You’ll use weight machines to work your quad and hamstring. You may add lunges and step exercises, and work on your balance. You can go back to work if you have an active job.

7-12 weeks: Post-surgical stiffness and swelling should go down by 8 weeks. That will give your knee a full range of motion. You can slowly add activities as your doctor OKs them. This timeline works for most people:

  • Treadmill -- 7 weeks
  • Elliptical -- 9 weeks
  • Rowing and outdoor biking -- 10 weeks
  • Swimming, stair stepper, jogging -- 12 weeks

4 to 6 months: You can move without pain or stiffness. You’ll either be back to your favorite activities or just about ready to hit the field, track, or slopes again.

After 6 months: You’re fully active with no tenderness in the knee. Your doctor might not let you return to cutting sports for a few more months.

Rehab: An Insider’s Take

Vargo laughs as he likens it to torture. But then, he’s an action junkie who wanted back in the game as quickly as he could manage it.

“I tend to push myself hard, but I’ve never been in a room with more grown men where you can’t tell if that’s tears or sweat coming down their faces,” he says. “I’ve had injuries before, but nothing like this. It’s humbling.”

He rehabbed 4 months with a physical therapist after his first ACL reconstruction. The second one lasted 6 months, but it was a year before his surgeon released him from care and he was able to play soccer at close to full speed.

Will Your Knee Be The Same?

ACL reconstruction surgery has a 90% success rate in terms of knee stability and patient satisfaction. Surgery lowers your chances of arthritis and further damage to the cartilage in your knee, too.

How well you recover depends on how much work you put into the process. There are no guarantees.

“The truth is, you never fully recover, at least not 100%,” Vargo says. “The injury is always with you, whether you’re just taking a stroll with the kids or hitting the slopes hard with them. You definitely feel it from time to time.”

But it beats the alternative, he says, because sitting on the sidelines is not an option for him. “The key is finding that sweet spot. Being active enough, but not so active that it aggravates my knee into swelling and pain.”

WebMD Feature Reviewed by James Kercher, MD on September 3, 2015

Sources

SOURCES:

Department for Orthopaedic Surgery, University of California, San Francisco: “Anterior Cruciate Ligament Injury (ACL).”

OrthoInfo, American Academy for Orthopaedic Surgeons: “Anterior Cruciate Ligament (ACL) Injuries.”

CDC: “Injury Prevention and Control.”

Sports Illustrated: “Carson Palmer’s Out for Season With Torn ACL.”

AAOS: “Autograft or Allograft for ACL Reconstruction.”

National Center for Biotechnology Information: “Allograft versus Autograft Anterior Cruciate Ligament Reconstruction.”

ESPN.go.com: “Carson Palmer’s lasting connection.”

Andrew Cosgarea, MD, orthopedic surgeon; Chief, Division of Sports Medicine, Department of Orthopaedic Surgery; Professor of Orthopaedic Surgery, Johns Hopkins University.

Rachel Schmitz, ACL injury patient, grad student.

Bryan Vargo, ACL injury patient, editor, Arthritis Foundation.

Mayo Clinic: “Torn meniscus.”

AAOS OrthoInfo: “ACL Injury: Does it Require Surgery?”

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