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Sports Medicine

ACL tear/stretch confusion

09/10/2008

Question:

About 6 months ago injured my knee skiing. I have (foolishly) only recently had it seen to professionaly (although I did RICE). My physiotherapist diagnosed a ACL Grade 2 tear and some damage to the MCL, however I just went to get a referral for an OS from my GP, and he said I have only stretched NOT torn my ACL. While he agrees with the PT that there is some laxity in the ACL it is certainly not enough to warrant surgery & advised I can resume normal activities (of relevance: skiing & social tennis). The physio maintains it was at least a Grade 2 tear and that you cannot stretch ligaments without tearing them. I am happy to opt out of surgery if its unnecessary, but am wondering a) can I stretch but not tear my ACL, and b) can I confidently resume normal activities as suggested by GP. My knee was painful and swollen immediately post accident however I didnt hear any popping as I tumbled down the steep slope! From about 4 months post accident I have had no pain or instability (knee was only unstable immediately after the fall) in my knee, but less ROM than before. Further, I have started serious quad and hamstring stretches. Will building up the surrounding muscles be enough to prevent further injury and arthritis later in life. Looking forward to your thoughts.

Answer:

If your physical examination has revealed laxity of the ACL in your injured knee which is not present in your uninjured knee, you've injured your ACL... the difference between "stretch" and "tear" is semantics - both terms describe an injury. If ligament fibers are stretched to the point where there's residual laxity, some have been torn. A Grade 2 ligament injury is an incomplete injury, meaning not all fibers have been completely torn. Surgery is not typically performed for an isolated Grade 2 ACL injury, although you mentioned your MCL was also injured, and you may or may not have additionally sustained cartilage injury (to a meniscus, and/or the articular cartilage coating on the end of your femur) - which an MRI would usually reveal.

The fact you've been without persisting knee pain nor instability symptoms is certainly a good sign, and if you remain without those symptoms, your chances of developing significant knee arthritis in the future are less. To this end, optimal rehabilitation is certainly advisable, which includes not only strengthening exercises for trunk, hip, and lower leg muscles - in addition to thigh muscles, but also, appropriate flexibility exercises, balance re-training, attention to technique, and cross training. Progressive resumption of desired activities, with guidance from a physical therapist or athletic trainer, will hopefully allow you to become confident with again engaging in desired activities, at the appropriate time.

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Response by:

Brian L Bowyer, MD Brian L Bowyer, MD
Clinical Associate Professor
Physical Medicine & Rehabilitation
College of Medicine
The Ohio State University