In recent times the world of football has certainly become very familiar with the term or phrase anterior cruciate ligament (ACL). There has been a regular occurrence of this particular type of knee injury which is potentially terminal to a professional footballer’s career. The injury is as such that many who have suffered it could not reignite their careers to get back to the heights they enjoyed before falling victim to such misfortune. The nature of this injury reportedly damages all the other the ligaments in the knee which makes rehabilitation complicated and lengthy.

Stars of the beautiful game such as Roberto Baggio, Brazil’s Ronaldo, Kaka, Alessandro del Piero and Ruud van Nistelrooy have all been down that road. Most recently the numbers have increased massively with Radamel Falcao perhaps the most high profile victim of this horrible phenomenon. The Colombian superstar seems to be struggling to find any sort of form while Sami Khedira is on the other end of the spectrum as he seems to be rediscovering his best form at Juventus. There are several other players who have sustained the injury, namely Theo Walcott, Kevin Strootman, Victor Valdes and Sergio Canales.

Over the weekend, the curse of the ACL struck again and this time it seems more significant with the 2016 European Championships right around the corner. Juventus, and Italy midfield maestro and star Claudio Marchisio fell victim as well as Portuguese playmaker Danny of Zenit St Petersburg. With both players missing out on the Euros and already in their 30s, Beyond 90 Minutes examines the ACL injury.

 

What is the anterior cruciate ligament?

The ACL is one pair of cruciate ligaments found inside the knee. The anterior cruciate originates deep inside the notch of the distal femur and is arranged in a cross pattern from the underside of the femur (thigh bone) to the top of the tibia (the bigger bone in the lower leg). It is quite broad and thick perhaps the size of your index finger with long collagen strands woven together in such a way that it allows the knee to withstand up to 500 pounds.

The anterior cruciate is one of the main stabilisers in the knee and to also keep its flexibility and movement in one plane. It is very important in terms of movement as it allows the knee to glide easily through a wide range of motion. Stability is perhaps its most primary function as science has shown that stabilisation occurs primarily from ligaments in the knee. Should the ACL be removed, the back and forth motion of the knee would be significantly affected, and certainly its range of motion.

 

How does the ACL get damaged?

The development of sports science in the past two decades in particular has been a driving force for the level of treatment available today. After deep research on the knee, particularly on the anterior cruciate, scientists have been able to prove that the ACL injury is not due to impact, which would be a nightmare for the medical personnel. Most physiotherapists will tell you that its better to treat impact injuries than muscle or joint problems without any contact. Even more unfortunately for the athletes is the fact that other structures in the knee such as the meniscus, articular cartilage and other ligaments gets ruptured whenever the anterior cruciate gets damaged.

The examination of such injuries have led scientists to conclude that the major causes of this phenomenon are:

  • Changing direction rapidly
  • Stopping suddenly
  • Slowing down while running
  • Landing from a jump awkwardly or incorrectly
  • Overextension of the knee after collision or contact
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Symptoms of the ACL injury

The detection of this injury is normally confirmed after an X-Ray examination or a Magnetic Resonance Imaging (MRI) scan. However, many scientists and experts have concluded that a ‘popping’ sound can be heard when the ligament gets damaged and athletes may also feel their knees give way from under their body weight. Another immediate sign is the severe pain in the knee when attempts are made to put weight on it. However other symptoms of the injury may also be seen from:

  • Pain along with swelling within 6 hours after occurrence
  • Loss of full range of motion
  • Tenderness along the joint line
  • Discomfort in the knee while walking

 

Treatment

After suffering the injury, the most important thing is to reduce the swelling. The first aid treatment includes raising the knee above the level of the heart, placing ice on the knee as well as the use of anti-inflammatory pain relievers. It is also very important to keep any sort of weight or pressure off the injured leg as to not aggravate the area. However further treatment is dependent on the severity of the injury. In most cases surgery is required to rebuild the ligament as the ACL cannot be stitched back together. The ligament is often replaced with a tissue graft which acts as a scaffolding for a new ligament to grow. Grafts can be obtained from several sources but the most common is from the patellar tendon which runs between the kneecap and the shinbone.

After surgery, rehabilitation plays a vital role for athletes to get back to competing at the highest level. A physical therapy program is normally organised based on the severity of the injury in an attempt to get back to the best physical condition. Firstly, therapy normally focuses on returning motion to the joint and the surrounding muscles. This is then followed by strength training that is designed to protect the new ligament. The strengthening normally increases gradually as the weeks go by which allows the new ligament to be strong enough to withstand pressure when applied in any situation. The final phase of rehab is normally geared at tailoring the athlete for his/her particular sport. For example the preparation, physical conditioning for basketball is different from that of football and as such athletes are prepared accordingly.

 

Is there any pattern related to the ACL injury? 

In recent times, the prevalence of the ACL injury has led many experts and scientists to question what has been the cause of the rapid increase in its occurrence. The type of footwear has been called into question as well as the pitches, match scheduling and even impact.

In the modern game, several manufacturers such as Nike, Adidas, Puma and Under Armour have customised the footwear for players to improve efficiency in terms of ball control, movement and to prevent slipping. Sports scientists knows the importance of having a suitable footwear on the surfaces today hence there is simply not enough evidence to support this claim. It is quite evident that many research goes into developing the footwear in the modern game and manufacturers will definitely seek advice from scientists to protect themselves against any potential scrutiny or lawsuit.

Most football clubs around the world invest millions to maintain their facilities and to improve the infrastructure including the condition of the pitches. The safety of the players are extremely important and as such the pitch conditions must be of a high standard in order for it to be deemed fit when examined. Again, this argument does not concur with science based on the causes of such an injury.

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Perhaps the scheduling of games may play a role in not just the ACL injury but other injuries as well. In the modern game there are several competitions and it is possible for players to compete in up to play up to 60+ games per season. In some cases, there are games every 3-4 days and some experts believes that this does not give players enough time to recover fully and leaves the body a bit tired. If the body is not fully recovered or tired then it becomes susceptible to injury especially in the muscles and joints. The physical demand of the modern game is as such that squad rotation is mandatory and the role of the medical staff as well as nutritionist and other experts have become more important.

The expertise of the medical staff becomes critical in determining when a player is in the red zone and needs to rest as well as how long a player should last in certain games. Recovery sessions are important as well and based on age the pattern of recovery is different which must be noted by the experts. With that said match scheduling may be a contributing factor but still not a foregone conclusion.

 

Based on the theory proposed by scientists and experts, the ACL phenomenon is perhaps one that cannot be prevented based on its causes. It is highly impossible for athletes to be prepared for an overextension of the knee, a sudden change of direction or even landing badly. These are instances that happen in the heat of the moment or action which is simply unfortunate. Football is a contact sport hence the coming together of players in inevitable. Players get knocked off balance and as such additional stress or pressure is placed on the knee when running at full speed, challenging for the ball in the air or a simple collision when challenging for the ball. In other situations players fall on each other in an awkward manner especially after challenging for the ball in the air which is simply an unfortunate situation.

Scientists and experts should perhaps be thinking that the pace of the game is increasing year after year and as such the need for players to be sharper, make sudden change of direction and stopping suddenly will increases. Changing direction and stopping suddenly at full speed places these athletes at a high risk. The demand on the human body to balance club commitments with international games which includes extensive travelling is already taking its effect on players which increases their susceptibility to injuries. With the tempo of the game getting faster the probability of collisions and other mishaps become greater and hence it is possible that the ACL phenomenon and other unfortunate situations will continue.

In the present moment there isn’t any scientific solution in an effort to eliminate or even minimise the risk of players suffering the ACL injury and other potentially terminal problems. Resting and nutrition may reduce the physical vulnerability however unless the beautiful game  a non-contact sport then the ACL injury in particular is likely to occur as the pace of the game gets quicker. Reducing the number of games, meaningless international friendlies in particular, could help reduce its occurrence however in the present day that may be a far cry due to the revenues generated from such fixtures.