The recent injury to Washington Redskins quarterback Robert Griffin III has sparked a lot of discussion and speculation about anterior cruciate ligament (ACL) tears in athletes at all levels.
RGIII sustained a minor LCL (lateral collateral) sprain when he was tackled on December 9. He sat out one game then returned in the last game of the season without apparent health concerns–though not performing up to his usual potential. Controversy ensued when, during his team’s first and only playoff game against the Seattle Seahawks on January 6, RGIII was tackled–reinjuring his leg and requiring surgery for both his LCL and ACL. Washington Redskins coaching staff and physicians disagree over who said he was healthy enough to play. Fans and teammates wonder if he’ll ever be the same player again after surgery.
ACL tears are common knee injuries that occur most frequently during such high-demand sports as football, soccer, basketball and skiing. Cruciate ligaments are found deep, centrally inside the knee joint. They cross each other to form an “X,” which gives them their name. The posterior cruciate ligament is in the back and the ACL is in the front. The ACL prevents the bottom bone of the leg (the tibia) from sliding out in front of the top bone (the femur). It also prevents the knee from rotating out of its central steadiness. This is called rotational stability.
The mechanism that often results in ACL tears is noncontact deceleration, which typically occurs when the athlete lands on the leg and then sharply pivots in the opposite direction. This produces a twisting injury that can tear the ACL even if it has already been successfully reconstructed in the past. Complete ACL tears do not heal without surgical intervention.
Collateral ligaments are on the sides of the knee and control the sideways stability of the joint. The medial collateral ligament is on the inside and the lateral collateral (LCL) is on the outside of the knee joint. Tears to the collateral ligaments occur from direct impact to the knee or by sudden extreme contraction of the muscles supporting the knee, such as in a sudden change in direction while running.
Complete LCL tears are serious (particularly for highly competitive athletes) because the LCL is the primary restraint against oblique angulations towards the midline of the knee joint. The LCL is thin and narrow, so complete tears frequently do not heal without surgical intervention.
LCL tears often coincide with posterolateral instability, which is the disruption of the complex layers of ligament and tendon structures on the outer and back portion of the knee joint. Patients with posterolateral instability may demonstrate a limp that exhibits excessive extension when taking a step (recurvatum).
When an orthopedic surgeon evaluates a high-level athlete with the above injuries, it is important to factor in all details of the mechanism of injury and any previous surgery, the physical exam and all diagnostic tests (such as X-ray and MRI). Next the orthopedic surgeon discusses a detailed discussion about diagnosis and all treatment options with the patient.
If surgery is necessary and there are injuries to both ACL and LCL, it is important for the surgeon to determine which type of instability affects the patient. Isolated ACL reconstruction corrects instability in one plane but will not correct rotatory instability. Rotatory instability occurs in multiple directions, causing the joint to rotate out of its fulcrum. This is an important consideration prior to surgery, because in the presence of multiple ligament instability, reconstructing only the ACL may actually increase the patient’s feeling of rotatory instability.
Even for those of us who are not professional athletes, it’s important to pay attention to twinges and pains and consult a physician to diagnose injuries. “Toughing it out” or “playing through pain” may look dramatic in a sports movie, but in the real world it could cause you to wind up in an operating room.