A cruciate ligament tear is also known as a cruciate ligament rupture in medicine. It is a tear caused by external force. A cruciate ligament tear often occurs as a sports accident in soccer players or while skiing. Typical signs of a cruciate ligament tear are pain in the knee, as well as visible bruising and swelling.
What is a cruciate ligament tear?
Schematic diagram of healthy cruciate ligaments and the different types of cruciate ligament tears. Click to enlarge. A cruciate ligament tear usually affects both cruciate ligaments, since they function in the knee almost like Siamese twins: the cruciate ligaments lie inside the knee between the joint bones, crossed over each other. There, on the one hand, they stabilize the knee against the dreaded cruciate ligament rupture, and on the other hand, they provide lateral three-dimensional mobility, which is important for sitting, walking and standing. In addition to the cruciate ligaments, the outer and inner ligaments on the knee are equally important, because without this fixation, the knee would fall out of its forward plane, especially in the case of a cruciate ligament tear, and the affected person would no longer be able to move forward. The cruciate ligaments themselves, consist of collagenous muscle fibers and are cushioned by a mucosal sac, the synovial sac towards the joint bone. They may be reinforced by other ligaments, such as the meniscofemoral ligament and the Humphry ligament, but not everyone has them to the same degree. The cruciate ligaments are 18.5 to 33.5 mm long and are usually formed of three fiber bundles, the anterior, posterior, and medial bridges. Together with the external and internal knee ligaments and the connection to the anterior meniscus ligament, they form the bridge between the thigh and lower leg. The combination of the ligaments at the knee prevents the tibia from hyperextending forward, as well as hyperextending backward. With a healthy structure, the cruciate ligaments optimally regulate the movement of the knee on all axes and the symmetrical alignment of the upper and lower leg.
Causes
Unfortunately, a cruciate ligament tear occurs relatively frequently, although the cruciate ligaments are particularly protected against heavy stress due to their crossed position. A torn ligament usually results only from extreme overstretching of the ligaments in one direction. The cruciate ligaments can hardly tear under normal physical stress, unless someone moves their knee in a lurching motion with quite a bit of force. This usually only happens in accidents and during sports. Cruciate ligament rupture is a typical athlete injury, because it occurs most often due to the high load on the knees during soccer and skiing. If the soccer ball is kicked from the side with force, causing rotation in the forward motion, this can lead to overstretching of the cruciate ligaments, resulting in a cruciate ligament tear under stress or if the other foot also slips on the turf. When the anterior cruciate ligament is torn, the rolling-sliding mechanism of the femoral head is severely disrupted. This causes damage to the meniscus and wear to the cartilage in the knee joint. In the bending position of the knee, the lateral knee ligaments are relaxed and thus most accidents with cruciate ligament rupture occur in this position, since the full force of the movement is transmitted unhindered to the inner ligaments. Slalom driving with the ski sport, in bent position start as with the toboggan or also with the ice hockey can be triggers. If the knee is moved out too far to the front, the anterior cruciate ligament can tear, while a blow to the tibial plateau endangers the posterior cruciate ligament. If both cruciate ligaments tear, which occurs in most cases when there is a lot of force from the motion, the rotation of the lower leg backward inward is no longer limited. The stability of the cruciate ligaments is a prerequisite for the health of the knee joint. Destroyed cruciate ligaments also jeopardize the meniscus in its healthy function. When the ligaments are taut, they can absorb the force of an unexpected blow, as in soccer, and pass it on to the muscles. When they are slack, the risk of an accident is much greater, because jerky stretching increases the risk of small tears in the fibers or complete rupture of the ligaments.
Symptoms, complaints and signs
A cruciate ligament tear is clearly felt. The moment the ligament tears, a rapid or cracking sound may be heard. After that, the affected knee swells and pain sets in.The pain is described by sufferers as dull to stabbing, with recurrent pain peaks during which the stabbing increases sharply. In addition to the pain, bruising develops in the joint. The hematoma usually runs down quickly and may spread to the entire joint as it progresses. The bruise may appear immediately after the cruciate ligament rupture, but sometimes it presents with a delay or not at all. The ligament injury causes instability in the knee, which in some cases results in further symptoms and discomfort. Typical is the feeling that the thigh and lower leg are wedged into each other. In addition, there is a pronounced unsteadiness of gait, often associated with spontaneous bending away in the joint. After a few days, there is a loss of power and an inhibition of extension and flexion or pseudo-blockade in the knee joint. Depending on which cruciate ligament is affected, the type and severity of symptoms can vary greatly. In isolated cases, a cruciate ligament rupture occurs without further injury.
Complications
Time and again, patients with cruciate ligament tears may experience complications and disorders after surgery. If treatment of a cruciate ligament rupture fails completely, instability is to be expected, since a healed cruciate ligament would provide good fixation of the thigh and lower leg in the knee joint. The instability leads to an increased mobility of the knee. With this, possible damage to the knee, possible wear and tear damage or further consequential damage to the body can occur in further consequence. Since there is no spontaneous healing in the case of a cruciate ligament tear, professional treatment in the form of surgery is recommended in all cases. If the result after surgery is not satisfactory, the procedure is often repeated. The specialists divide the possible disorders after surgery into early and late complications. Early complications, which occur immediately after surgery, include wound healing disorders, bacterial infection of the knee joint, or thrombosis in the leg. The likelihood of occurrence of early complications is rather low compared to late complications. Late complications include residual instability of the knee joint or residual limitation of motion. Restriction of motion often results in a lack of full extension and flexion of the knee joint. A reaction to incompatibility with bone expansion is also possible.
When should you see a doctor?
Anyone who has suffered a torn cruciate ligament should see a doctor quickly. A tear of the cruciate ligaments is an injury that definitely requires medical attention and medication. Otherwise, a full recovery cannot be guaranteed. The cruciate ligaments provide stability and mobility inside the knee, so a tear of the cruciate ligaments severely restricts and hinders the entire range of motion. Affected individuals will experience severe pain even at rest, making a trip to the doctor essential. Anyone who completely forgoes medical treatment must reckon with considerable complications. Even irreparable consequential damage can occur, since a healed cruciate ligament ensures the overall stability of the knee. Full extension and flexion of the knee can also no longer be guaranteed if a visit to the doctor is missed. Thus, the following applies: a cruciate ligament tear should always be treated by a doctor, medication and surgery, otherwise serious consequential damage can occur that can no longer be healed.
Treatment and therapy
A cruciate ligament tear, which is the injury or severing of one or both cruciate ligaments at the knee joint, is diagnosed by the physician by carefully examining the movement of the knee. The knee may be swollen up to twice its size. In this case, the doctor, preferably a sports doctor or orthopedist, must proceed with caution. In the case of cruciate ligament rupture due to violent falls during sports with twisting of the knee joint, other ligaments are often affected. The patient experiences extremely severe pain from the bruising normally associated with the tear. If the physician’s puncture of the knee reveals blood and bright fluid, this indicates a tear of the cruciate ligaments. If, in addition, it is noted in the medical history that the lower leg and thigh can be shifted against each other like drawers, this is a sure indication of cruciate ligament rupture.However, the extent of knee injuries with cruciate ligament rupture can only be specified by a knee endoscopy. During endoscopy, the doctor will not only determine the injury, but also immediately place a cruciate ligament suture to reconnect the severed fibers. If the cruciate ligaments are so fibrous and unevenly torn that they cannot be repaired with a suture, the surgeon will replace them from a strip of fibers taken from the thigh muscles. In older people, the doctor likes to forgo surgery and immobilize the knee with a knee brace to allow the fibers to heal on their own.
Outlook and prognosis
The healing outlook of a cruciate ligament tear turns out to be very good in most cases. The different healing times of conservative as well as surgical treatment must be taken into account. In terms of conservative therapy, after a short period of immobilization, the treated person must immediately put weight on his knee again in the form of a detailed muscle-building program. If, on the other hand, a cruciate ligament tear has been surgically corrected, the patient may only resume full use of his knee after about three to four months. There should be no serious complications, such as bleeding of the nerves and vessels, joint infections or thrombosis. If physiotherapeutic therapy is started at an early stage, the risk of arthrosis is significantly reduced. This counteracts joint wear and tear. In order to increase the chances of healing, it is important during therapy to exercise the joint to a sufficient extent and, above all, regularly. Afterwards, full mobility and strength can be expected again. If the patient wishes to return to maximum athletic activity after the healing process, he or she should give this project at least six months to counteract a new cruciate ligament rupture. In all cases, it is advisable to treat a cruciate ligament tear as soon as possible. If no measures are initiated for treatment, the affected person has to expect reduced performance as well as wear and tear of the knee joint.
Prevention
The same exercises that orthopedic surgeons recommend for knee and muscle training to strengthen ligaments are also used to reactivate the knee after an ACL tear has healed. Knee exercises to strengthen all ligaments are also the best prevention for active athletes who play sports that put stress on the knee joints. Since a cruciate ligament rupture almost never occurs in ballet dancers, whose ligaments and joints are subjected to extreme stretching and stress, some exercises of training on the barre can be copied there for knee strengthening. All up and down movements, bending positions of the knee and climbing stairs should be performed symmetrically from the joints and slowly, so that the muscles can accompany the positions of the ligaments. Alexander Technique and a complementary medicine manual treatment method (e.g., Rolfing) are body therapies that can be used to strengthen ligament weakness in general. Athletes who make full use of their pelvic floor muscles and use their spine in optimal alignment with gravity will be less prone to accidents and unanatomical movements.
Follow-up
A cruciate ligament tear is a serious injury that can result in extensive secondary damage. Careful follow-up care is necessary to reduce the risk of osteoarthritis and other symptoms. Patients with cruciate ligament rupture are initially encouraged to attend all offered medical follow-up appointments during the first weeks and months. In addition, patients should also see their doctor if new complaints arise or if the healing process is delayed. An essential part of aftercare for a cruciate ligament rupture is physical rest. In particular, the knee must not be subjected to unnecessary stress, either during sports or at work. Nevertheless, muscles and ligaments around the knee must be exercised, so individually tailored exercise programs with a physiotherapist are necessary. Even if the symptoms of the cruciate ligament tear have subsided after a few months following conservative or surgical therapy, caution is advised. In principle, patients with a torn cruciate ligament should undergo regular examinations throughout their lives to check the condition of the ligaments and the knee joint in particular.This is because a cruciate ligament tear favors the development of arthrosis, which, however, often only becomes apparent decades after the accident. The doctor can therefore prescribe special sports, health shoes and insoles that prevent arthrosis and minimize the late effects of the cruciate ligament tear as much as possible.
What you can do yourself
In the case of a cruciate ligament tear, the first thing to do is to take it easy and immobilize the injury. Against the swelling and for pain relief, the affected leg is best cooled immediately with ice packs or cold accumulators and stabilized with a compress. A doctor should then be consulted immediately. Immediately after surgery, the injured cruciate ligament must continue to be cooled and rested – for at least a week. Stretching is also important. Here, the joint is passively moved and – if possible – completely stretched. Training can then be slowly resumed. In cooperation with the physiotherapist, physiotherapy and gentle sports such as swimming can be started. In the first few weeks, the focus should be on slowly improving the load-bearing capacity of the cruciate ligament through individual exercises. Light squats and training equipment such as the leg press or a bicycle ergometer are suitable for this purpose. Accompanying these physiotherapeutic measures, the injury must be checked regularly. Ideally, the cruciate ligament tear is completely healed after six to eight weeks and the patient may return to the original training program. In severe cases – such as when the cruciate ligament had to be replaced – strength and coordination exercises should be maintained permanently.
