Causes, symptoms and treatment
When it comes to movement – getting from A to B – the knee joints are the body’s lynchpin. Without knee joints, movement quite literally comes to a standstill. You need your knees not only to perform everyday activities but also for virtually all types of exercise and contact sports.
Muscles and ligaments play an important role in helping your joints do their job. In your knees, your cruciate ligaments play the lead role. If a cruciate ligament tears, it can no longer provide support – which can lead to a whole string of very unpleasant symptoms. Read on to find out more. We’ll also take a closer look at the causes of cruciate ligament tears and how they can be treated.
Ottobock supports and orthoses
What is a cruciate ligament?
Four ligaments connect your thigh bone (femur) to your lower leg bone (tibia). They include the two collateral ligaments that stabilise the inner and outer sides of your knee joint and the posterior and anterior cruciate ligaments located inside your knee. Your cruciate ligaments are crossed like the letter X and run diagonally through the cavity of the knee joint. Cruciate means cross-shaped, which is how they got their name.
What job do cruciate ligaments do?
Your cruciate ligaments serve as central stabilisers. They centre the articular surfaces of the knee joint and keep your knee in position at all times, whether at rest or with force or strain acting on it. Your cruciate ligaments support and guide your knee during flexion, at which point they are tensed. During knee extension, the collateral ligaments take over and are tensed. In this way, your ligaments control your movements and also set physiological limits to your range of motion. They protect your knee from sprains and keep it stable even when the surrounding muscles are not even tensed yet. Ligaments are able to provide natural, “passive” protection because they are not as elastic as muscles, which means they always offer a basic level of stability.
The anterior cruciate ligament (ACL) prevents the femur from slipping forwards over the tibia (this is known as the “anterior drawer”). The posterior cruciate ligament (PCL) prevents the tibia from slipping backwards under the femur (this is known as the “posterior drawer”).
What is a cruciate ligament tear?
A cruciate ligament tear in the knee – also known as a cruciate ligament rupture – is a complete tear of one or both cruciate ligaments. If a ligament is not completely torn, this is called a partial tear or rupture to a cruciate ligament. The anterior cruciate ligament in the knee joint is affected in a majority of cases, because the ACL is typically subjected to a higher level of stress in many accident situations. The posterior cruciate ligament only ruptures in about ten per cent of all cases.
When the anterior cruciate ligament ruptures, it can no longer prevent the femur from slipping forwards over the tibia. A ruptured PCL can no longer prevent the tibia from slipping backwards under the femur. As long as the medial and lateral ligaments are intact, your knee joint will still have a measure of lateral stability.
Statistically speaking, a cruciate ligament rupture occurs every five to six minutes in Germany. That adds up to some 100,000 cases per year. Eighty percent of these injuries occur during sports.
How can you rupture a cruciate ligament?
As ligaments are not particularly elastic, they can easily be overstretched if placed under too much strain. A cruciate ligament will generally tear if it is strained beyond its maximum tearing strength. There are various situations where this can happen. Most tears are caused by traffic accidents or sustained in contact sports or sports with a lot of movement. Sports that involve sudden changes of direction or speed have a higher risk factor. A cruciate ligament can also tear if it is twisted, sprained or hyperextended. This can happen due to a fall, collision or impact. Classic scenarios include hitting your knee on the dashboard in a car accident, battling for a ball in sports or landing after a jump. It can also happen if you fall when skiing and your ski does not release automatically, in which case the leverage effect can twist your knee. And the list goes on.
However, cruciate ligament tears can also occur in numerous everyday situations. All it takes is one wrong step – twisting your knee, slipping on the stairs, or falling off a ladder or chair when you’re doing DIY or hanging a picture is often enough to overextend a cruciate ligament and cause it to tear partially or completely.
What are the symptoms of a cruciate ligament tear?
In most cases, the symptoms of a cruciate ligament tear are very clear. They include pain, swelling and haematoma around the knee joint. You will no longer be able to extend or flex your knee fully. Some people don’t realise immediately that they’ve torn their cruciate ligament. It’s not until they try walking or bearing weight on the leg that their knee feels unstable and “wobbly”. The slightest pressure on the joint will then suffice to make the knee buckle and give way.
Many people report hearing a clear snapping sound and/or a crackle or a pop in the moment when the accident occurs. This is followed by acute and intense pain inside the knee. Another of the first symptoms can be a feeling of something tearing or moving suddenly inside the knee joint. Over the next few hours, the knee swells up. This, in turn, can result in throbbing pain caused by steady expansion of the joint capsule.
In many cases, the acute pain will subside relatively quickly if you rest, but will return as soon as you use the leg again. Blood vessels around the joint are often damaged during the injury as well. A haematoma can then develop, restricting the joint’s range of motion even further.
How can a cruciate ligament tear be treated?
It’s important to find suitable treatment that stabilises the knee and prevents further wear and tear to the joint (arthrosis of the knee). Experts are in agreement here on these aspects. The excessive range of motion in the knee joint following a cruciate ligament tear can be a direct cause of increased degeneration. However, experts have different opinions on the best course of treatment for this.
Some medical professionals believe that surgery is always the best option. In surgery, an orthopaedic doctor will either sew the ruptured cruciate ligament back together or graft in tissue from one of your thigh tendons in a procedure known as cruciate ligament reconstruction.
Other medical professionals do not consider an operation essential in all cases. Depending on the type of tear, they believe a torn ACL can heal with conservative treatment in many cases. This may be the case, for example, if the synovial sheath (a stretchy membrane around the cruciate ligaments) has not been destroyed completely and is able to hold the ends of the torn ligaments close together.
There are also many cases where special exercises to increase muscle strength can stabilise the joint enough to cope with the stress of sports, work and everyday life. If the knee joint is subjected to excessive strain, however, muscles may not provide enough stability on their own to compensate for a missing cruciate ligament. In general, operations on sporty and young people are more common compared to older patients.
Conservative treatment generally involves the use of a rigid knee orthosis that is worn for around six weeks and restricts the knee’s range of motion in a targeted manner. This prevents you from straining your knee or moving it improperly, both of which can put the success of your treatment at risk. A stabilising brace may also be used following cruciate ligament surgery.
How long does it take to heal?
Cruciate ligament tears always take several months to heal. If surgery is performed, this normally takes place two to four weeks after the rupture occurs. Until then, a suitable orthosis is used to stabilise the knee. Orthoses are also used after surgery. Patients will also need around four months of rehabilitation for the graft to heal properly and provide long-term stability. During this time, the body transforms the grafted tendon into a ligament. With conservative treatment, on the other hand, rehabilitation begins as soon as the injury has subsided. This can also take several weeks. So at the end of the day, both forms of treatment take a similar length of time. Rehabilitation therapy will primarily start with physiotherapy that moves the knee passively and focuses on building up muscle and doing coordination exercises.
The right exercises make all the difference
Professor Wolf Petersen, senior consultant in the orthopaedic and trauma surgery clinic in Berlin’s Martin Luther Hospital, is very clear about one thing: surgery can succeed only in combination with aftercare. In order to return to normal life, physiotherapy is not the only important factor. You will also need to play an active role yourself in the recovery process. Doing the right exercises at home makes all the difference to the success of your treatment and helps improve your symptoms.
This is exactly where the Genu Move exercise programme comes in. Developed by doctors, this programme covers a wide range of exercises designed for patients who are recovering from an ACL tear. The exercises support aftercare and are ideal for building up muscle strength. This enables you to actively contribute to your rehabilitation at home and increase the load-bearing capacity, mobility, strength and coordination of the affected leg.
Genu Move – phase 1
Your knee will be sore immediately after surgery. There will be pain and swelling. The aim of the first phase of healing (weeks 1 and 2) is to alleviate and manage these symptoms. At this point, patients can already start exercises to extend their knee joint.
Exercises you can do at home – Genu Move
Frequently asked questions about cruciate ligament tears
Word of mouth is always a good and reliable way to find a good specialist for knee surgery. Ask your friends, family and acquaintances about their experiences. If they are unable to help, your only other option will be to do some detailed research. First of all, you should find out as much as you can about how knees work and the tasks they perform. Your goal at this stage is to feel comfortable with important medical terminology and to understand your own information that you find.
Once this foundation is laid, you can visit hospital websites and read the doctors’ profile pages. These will give you an idea of their level of experience, fields of research and the types of surgery they specialise in. Different hospitals may offer different surgical procedures. In your search for the appropriate knee specialist, you can also check to see whether a doctor has published books or articles or completed further education in specialist areas. You should also pay attention to information about the hospital’s quality and hygiene management. If you have a very specific knee problem, you could also narrow down your search by referring to the lists of specialists that are published annually. Online forums, social networks and patient reviews can also help you obtain the information you need. However, the quality of information can vary considerably.
Once you’ve found a knee specialist, you should arrange an initial consultation to form a first opinion. In many cases, it can be wise to get a second or even a third opinion before you settle on a knee specialist.
Directly after surgery, the first priority is to reduce swelling. This can be done by elevating and icing the leg and performing lymphatic drainage. Many people need analgesics (pain medication) because the pain blocks the muscles and makes movement virtually impossible. Many of the physiotherapy exercises used in rehabilitation can be done at home. For example, you can lie on the sofa, lift your leg and write letters in the air. But always consult your doctor first and ask how soon you should begin with such exercises. For two to four weeks, patients should also practise walking with crutches for thirty to sixty minutes every day. This is another aspect that you should discuss in detail with your doctor first.
Thrombosis is a vascular/circulatory disorder in which a blood clot (a “thrombus”) develops in a blood vessel. At first, thrombosis does not have noticeable symptoms in many cases. However, it can potentially lead to a life-threatening pulmonary embolism. You should avoid sitting or standing for extended periods of time, because this is how blood clots generally develop. You can actively prevent thrombosis by walking, lying down and engaging in sports or stretching exercises for the feet and limbs, many of which are suitable even after surgery. Doctors will often recommend injecting anticoagulants for the first couple of weeks after surgery as a preventive measure. The injections contain heparin, a natural substance that inhibits coagulation. People who work in jobs that require them to stand for long periods of time should wear compression stockings.
After surgery, you can ideally slow or even reduce the swelling by icing your knee repeatedly and evenly. The cold also provides pain relief. Gel ice packs are ideal because they shape themselves to your knee and distribute the cold evenly over the affected skin surface. However, you should never place the gel or ice pack directly on your skin; always wrap it in a towel or waterproof bag first. If the ice pack touches your knee directly, it can damage the skin or even cause frostbite.
Cooling should be applied for a maximum of five to ten minutes. Follow this with a break of at least two hours. If you ice your knee too intensively or for too long, your body will go into protection mode and send extra blood to warm the area in question. This, of course, would be counterproductive, because more blood would only make your knee swell more. Also, the enzymes that trigger repair mechanisms in your knee work best at certain temperatures – not too cold and not too hot. The inflammation in your knee is the direct result of these repairs, which takes the form of heat development. This means that if you ice your knee too intensively or for too long, you hinder rather than help the healing process.
Good sleep is immensely important for the body’s internal repair processes, so it plays an important role in healing and recovery after a cruciate ligament tear. A good quality orthosis helps by preventing you from making undesirable movements – not just during the day, but even more so at night, when we can’t consciously control all of our movements. Your doctor may prescribe you analgesics that you can take at night before you go to bed for pain-free sleep. Often, icing the affected area will also bring pain relief.
Directly after an ACL tear, you will definitely be given a sick note for at least two to three weeks. The stitches will be removed after around two weeks. Most people are ready and able to work after around four to six weeks. This may take longer for people in physically demanding jobs.
There’s no one-size-fits-all answer to this question. It depends on the surgical procedure used and on your individual case. Doctors will generally advise their patients regarding this. If you’ve had an arthroscopy, there will be only minimal superficial wounds that will also be stitched cleanly. Aseptic wounds close within around 24 hours, after which microorganisms can no longer enter. At this point, you will generally be able to take a shower or wash with clear tap water without any issues. This is beneficial not only in terms of hygiene, but also for your sense of wellbeing. Small incisions can be safely covered with a waterproof plaster. Many patients will be allowed to shower between 24 and 48 hours after surgery so long as they don’t feel dizzy and their immune system is not compromised.
Open surgery is a different matter altogether. In this case, patients will usually need to wait until the stitches have been removed or will need to cover the incision securely (with a special plaster or film) before showering. If your knee is put in a plaster cast or splint after surgery, it will need to be kept dry at all costs. For the first six weeks following cruciate ligament surgery, you should not take long baths or go swimming as a rule, because prolonged contact with water will prevent the tissue from healing properly.
The guidelines for riding a bike are the same as for driving a car and will depend on the progress of your recovery. You should not go out cycling until you are able to control your bike. Ask your doctor for advice. After six to eight weeks, many patients will be able to start practising on an indoor bicycle, provided they are able to bend their knee sufficiently and without pain or discomfort. Many people are able to cycle on flat roads after about two months. However, you’ll need to be careful not to put too much pressure or strain on the new ligament structure, and you shouldn’t attempt uphill slopes for at least three months after surgery. The above guidelines are not set in stone. You should always consult your doctor first to discuss your individual case.
Unfortunately, it’s impossible to give a blanket answer to this question. It will always come down to your individual case and the progress you make in recovery. Anyone who drives a car must be in complete control of the vehicle, without being restricted by any aftereffects from the cruciate ligament rupture. Doctors and insurers will generally advise you to wait at least four to six weeks after cruciate ligament surgery before driving a vehicle. Even then, it will depend on what your knee can cope with. We therefore recommend you consult your doctor before getting back behind the wheel – and possibly also check with your insurer.
Nowadays, surgery methods are fairly standardised, meaning that even “normal” patients are likely to receive the same quality of surgery as elite athletes. Recovery times are also comparable, though many people underestimate just how long it takes. After surgery for a cruciate ligament tear, you’ll need to allow sufficient time for the rehabilitation phase in particular before your knee is at full strength again. Two months of mandatory rehabilitation is not sufficient for this.
After their knee is surgically repaired, most people will need to do their exercises diligently and regularly for at least eight months to restore the strength in the affected leg. Talk to your doctor about the various exercises, sports or isolated muscle training routines – either at home or in the gym – that will best help your affected leg through each phase of recovery. These could include walking up slopes and doing sessions on a stepper. Both activities will build up your gluteus muscles, which play a significant role in stabilising your knees. Doing squats on one leg is also very helpful, but make sure your knee does not bend more than 60–70° in the process. Standing on tiptoes helps to build up your calf muscles, which also become weaker after surgery. Once you’ve recovered sufficiently to ride a bike, cycling in any form will help you stay mobile and will build strength in your knee.
You can even track your performance directly by measuring the circumference of the thigh. Is your sound leg larger? Then you still need to build up more muscle. Another positive sign is when your knee no longer swells up after using it. There are various classic cases in which cruciate ligaments are likely to tear, but you can reduce the chance of it happening to you by systematically building up your hip and gluteus muscles and exercising your thigh muscles (front and back).
The best way to avoid it is by training the right muscles. The stronger your muscles, the better they can relieve strain on your ligaments and stabilise your joints. In the event of an accident, strong muscles can – to a certain degree – protect your cruciate ligaments from tearing. Obviously, the muscles need to be tensed at the crucial moment. Athletes should always include special running, jumping, balance and strength exercises in their warm-up routines to stabilise their muscles.
This will always depend on your individual case and your doctor’s recommendations. There is no universal recommendation. But the fact is that if you engage in sports again too soon, you could injure the ligament again or damage your cruciate ligament reconstruction. Even when the rehabilitation phase is over, your knee will still be very sensitive and prone to reinjury. So don’t start too soon, and don’t try to do too much too quickly.
You should follow your doctor’s recommendations in each treatment phase. Once treatment has been completed successfully, you can start with slow exercise such as cycling cautiously on an indoor bicycle. After around two months, you can progress to cycling outdoors on a flat road. To protect your new ligament structure, you should avoid uphill slopes for the first three months or so. After four months, you can start running again, but cautiously. You should not engage in contact sports for at least six months.
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Patients talk about their symptoms and experiences
Jessica’s Genu Arexa story
Jessica’s anterior cruciate ligament was partially torn during a sudden braking manoeuvre when skiing. A few weeks later, she made a movement without thinking about it while dancing and ruptured the ligament completely. Since undergoing surgery, she has begun wearing the Genu Arexa knee brace. This allows her to move her injured knee in a controlled manner again and offers the best support for her recovery in combination with the "Genu Move" exercise programme.
Ottobock orthoses and supports for a cruciate ligament tear
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