It is one of the most serious injuries that an athlete can sustain and is particularly common in soccer players and skiers: the cruciate ligament rupture. As the name already describes, it is a tear of the (anterior and/or posterior) cruciate ligament caused by force. If you do not treat the damage completely, you may risk irreparable long-term consequences. FITBOOK spoke to experts.
In the summer of 2019, FC Bayern was about to sign Man City star Leroy Sané when he tore a cruciate ligament. FCB boss Karl-Heinz Rummenigge then refrained from a transfer and commented on his decision with the words: «No, people, everyone knows what cruciate ligament surgery means and what downtime is concerned.» A year later, Sané has it now as is well known, made it into the Bayern squad after surviving an injury. His teammate, the German national soccer player Giulia Gwinn, was caught fresh in a European Championship qualifier against Ireland.
It happened here: Leroy Sané suffered a cruciate ligament rupture in the English Supercup against Liverpool in August 2019Photo: Getty Images
It is not without reason that sports reporters also like to speak of a nightmare diagnosis. A cruciate ligament rupture is often not over even when the treatment has already been completed. FITBOOK asked a sports doctor the most important questions about the injury.
How does a cruciate ligament rupture occur?
By twisting trauma. «You lose control, you fall and your foot is trapped, for example because of a twisted position on the field or in stuck, high ski boots.» medical Thomas Teichmüller, specialist in orthopedics and sports medicine from Frankfurt am Main, a possible course of events. If a force is applied – due to a foul in contact sports or your own weight shifting during a fall – the cruciate ligament is quickly torn.
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What to do if it happened
Immediately after the injury, you should immobilize the affected leg, ideally put it up, and cool it with ice or something similar. Then please have it examined by a specialist as soon as possible, who can make a preliminary diagnosis after a magnetic resonance imaging. In this way, it is possible to see whether and, if so, where a rupture, i.e. a tear, has occurred. With a bit of “luck” only one of the cruciate ligaments is torn, with bad luck both are completely torn. And unfortunately it can get even worse.
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Why is a cruciate ligament tear particularly feared?
Largely because the injury is so long-lasting, Dr. Teichmueller. It can be a huge setback for professional athletes when they have to adjust to not being able to fully return to training until many months after surgery and the start of therapy. «In addition, a cruciate ligament tear is often accompanied by concomitant injuries,» explains the orthopaedist. He speaks, for example, of the «unhappy triad»: the unfortunate but frequent event that the collateral ligament tears in addition to the cruciate ligament and the medial meniscus is damaged. Here you can hardly get back on your feet without an operation.
How is the operation going?
like dr Teichmüller explains, the exact extent of the injury cannot always be seen clearly with magnetic resonance imaging. The patient is therefore examined again in detail after he has been put under anesthesia. Then the actual surgery begins. The arthroscopy shaft and trocar (an instrument commonly used in minimally invasive surgery to initially create access) are inserted into the joint via a small incision on the side of the kneecap. The trocar is then exchanged for the arthroscope and this is fixed to a digital chip camera. The camera transfers the images “live” from the body to an LCD monitor. In this way, the structures within the knee joint can be examined and, if necessary, recorded with photos. For a better overview, water is pumped into the joint so that it unfolds.
The cruciate ligaments can be examined for strength with a probe hook, which is inserted into the joint via another small incision on the other side of the kneecap. It is also possible to understand whether, for example, the meniscus has also been torn off and whether an operation may also have to be carried out. If the condition within the joint is clear, the damaged tendon tissue is removed, leaving only its stump in any case – «so that the surgeon knows exactly where the new tendon is to be inserted.» Identifying the right place on the corresponding side in the joint is requires according to Dr. Teichmüller has many years of surgical experience. The tendon he is talking about is endogenous tissue that is usually removed from the back of the thigh during the procedure. It is used in place of the damaged cruciate ligament and is often fixed with self-dissolving screws.
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What should be considered after the operation?
«That you start straight away with rehabilitation,» emphasizes Andre Scholz, managing physiotherapist at Physion in Frankfurt. The therapy is primarily about bringing stimulation and pressure back into the joint. «It is important that the patient gets up as quickly as possible and puts some weight on the operated leg», i.e. not with full body weight, but a controlled 20 kilograms. Likewise, in the first phase of therapy, stretching must be actively controlled in order to promote mobility. Weight bearing exercises come much later. «If you overstrain the cruciate ligament and put stress on it too early, it doesn’t have enough blood yet. You have to proceed in stages so that the inserted tendon can gradually learn the properties of a real cruciate ligament.”
The therapy takes place in phases. After the knee has been slowly brought up to the feeling of a partial load in the first week, «isometric strength exercises» can be started between weeks two and four, «passive and active, light exercises to improve mobility», says Scholz. From the fifth week it is important to increase the range of motion and to integrate coordinative exercises into the rehabilitation. Between the ninth and twelfth week, the patient is usually ready for more complex movements and light endurance training. «Specific training and contact sports can only be resumed from the fifth or sixth month.»
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Does a cruciate ligament rupture always have to be operated on?
no However, not operating also means saying goodbye to the corresponding ligaments, as Dr. Teichmüller explains that «the cruciate ligament does not heal again.» That is not necessarily a problem: According to the expert, many people live without a cruciate ligament, which does not have to be noticeable in everyday life, nor when jogging or cycling. The situation is different with contact sports and more complex movement sequences that cannot be performed without a cruciate ligament. In general, the trauma surgeon is a big supporter of the intervention, which he regularly performs at the Red Cross Hospital in Frankfurt am Main. It is not only worthwhile for active professional athletes, but also for older and less physically active people.
It is usually advisable to operate immediately. However, many cruciate ligament ruptured patients rely on conventional physiotherapy for months, only to realize that the operation is the better decision. «Unfortunately, they lost a lot of time unnecessarily,» says the orthopaedist.
What complications are possible?
«Cruciate ligament surgery has made great progress in the past seven or eight years, and very good results are achieved in 95 percent of the cases,» assures Dr. Teichmueller. Of course, it is important to put yourself in capable hands. A less experienced surgeon may be able to insert an incorrectly sized implant, which could lead to mechanical failure, or place it incorrectly. In very rare cases, there are also rejection reactions to the new tissue.
Neglecting rehabilitation after the procedure or ending it prematurely is definitely the most unfavorable decision, which is very likely to take revenge with arthrosis. Going to a physiotherapist for a few months vs. suffering from painful joint wear and tear into old age is out of all proportion.