Treatment of Combined ACL and MCL Tears in a Knee Joint

Anterior cruciate ligament (ACL) tears are commonly associated with medial collateral ligament (MCL) injuries.  This is due to the common mechanism of ACL injury involving the knee going into valgus with rotation.

Most medial collateral ligament tears have the potential to heal over the initial 6 weeks after the injury.

However in some type 2 to 3 tears of the MCL associated with ACL ruptures, the knee remains unstable to valgus stress due to permanent laxity of the MCL.

In these patients, reconstruction of the ACL alone may predispose to early reconstructed ACL graft failure due to MCL incompetence.

This is a patient who sustained both ACL and MCL tears in his left knee 3 months ago.  He continues to experience severe laxity of his left knee that affected his daily life.

This is a video of the examination before surgery.

In order to re-establish stability in his left knee, I decided to reconstruct both the ACL and MCL in one sitting.

This is the intra-operative surgery video:

It can be seen that the left knee’s ACL and MCL were stable after the reconstructions.

This patient’s left knee was placed in a knee brace for 1 month and he was asked to avoid placing weight on the left leg by using crutches for 1 month.

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Quick Facts About ACL Injuries

Facts About Anterior Cruciate Ligament Tears:

  • The anterior cruciate ligament (ACL) provides almost 90% of the stability to the knee joint.
  • More than 11.2 million visits are made to physicians’ offices because of a knee problem in the States. It is the most often treated anatomical site by orthopedic surgeons.
  • Of the four major ligaments in the knee, the anterior cruciate ligament and the medial collateral ligament are most often injured in sports.
  • Reconstruction of a torn ACL is now a common procedure, with over 50,000 hospital admissions per year.
  • ACL ruptures occur at a rate of 60 per 100,000 people per year. With society’s increasing interest in physical fitness, primary care physicians are seeing more athletic injuries. Along with these injuries are the commonly experienced ACL ruptures in athletes and non-athletes alike. Today’s athletes have greater than a 90% chance of returning to their pre-injury level of sports participation.
  • ACL reconstruction is a highly successful operation. With good rehabilitation, 90% to 95% of individuals who undergo this surgery can expect to return to full sports participation within six months.

FAQs on Anterior Cruciate Ligament Tears

What is the Anterior Cruciate Ligament?

The anterior cruciate ligament (ACL) is one of the most important of four strong ligaments connecting the bones of the knee. It is often injured.

Ligaments are strong, dense structures made of connective tissue that stabilize a joint. They connect bone to bone across the joint.

What Does The Anterior Cruciate Ligament Do?

The function of the ACL is to provide stability to the knee and minimize stress across the knee joint:

  • It restrains excessive forward movement of the lower leg bone (the tibia) in relation to the thigh bone (the femur).
  • It limits rotational movements of the knee.
  • Hence it holds the knee together during twisting or pivoting movements.

How can it be injured?

Usually from a twisting injury to the knee.

Common sports include: football, basketball, badminton, netball.

Other activities: skiing

Other causes: motorcycle accidents

The injury can be caused by a contact or non-contact injury

About 80% of sports-related ACL tears are “non-contact” injuries. This means that the injury occurs without the contact of another athlete, such as a tackle in football.

What Do I Feel?

Pain pretty much.

The hallmark of ACL injuries are:  POP sound, immediate swelling inside the knee and inability to continue with the sporting activity.

Swollen Left Knee

How to Apply First Aid?

1. Stop playing.

2. Ice the knee.

3. Get a pair of crutches if possible.  Avoid twisting the affected knee.

4. See a doctor.

Can a Torn Anterior Cruciate Ligament Heal on It’s Own?

No.  Once torn, it’s history.

When Will I Start To Feel Better After the Acute Injury?

Most patients have pain and swelling in the injured knee together with limitations in movements for the first 3 to 7 days.  They generally improve and can walk better after a few days.

Can I Live Without the ACL?

There are some patients who are able to function without an intact ACL. These patients modify their lifestyle by eliminating sporting activities that require pivoting and cutting.  However, sometimes during everyday activities the ACL-deficient knee can buckle or “give way” resulting in painful episodes with swelling.

There is a real risk of injury to the menisci (the cartilage shock absorbers) and articular cartilage (the smooth gliding surface on the ends of the bones) with each giving way event. This damage can lead to degenerative arthritis and subsequent meniscus tears.

Due of these reasons, a majority of active patients choose to undergo ACL surgery when the ligament tears.



Allograft ACL Reconstructions

Allografts refers to human tissues from another person.  For a sports surgeon like myself, the common allografts used are tendon allografts for knee ligament reconstructions.

Tendon allografts are commonly used by me for ACL (anterior cruciate ligament) reconstructions.

My first choice graft is still the patient’s own hamstring tendons.  For various reasons, some patients may request or may require allograft or donor tendons.

I prefer to use the tibialis anterior tendons for such purposes.

Some examples of patients who need allograft/donor tendons are:

  1. Revision cases. A reconstructed ACL can rupture a second time. It is useful to have the option of using a donor tendon for such patients.
  2. Multiple ligament reconstructions.  In such cases, the patient may not have enough tendons  for reconstructions.  Sometimes we take the tendon from the patient’s normal leg but this may not be ideal.
  3. Patients who are older or people who prefer to have less post-surgery pain.  Allograft ACL reconstructions can be much less painful compared to reconstructions using the patient’s own tendons.

The advantages of allograft ACL reconstructions are:

  1. Less pain.
  2. Shorter surgery time.
  3. Smaller incision.
  4. Quicker recovery to walking.

There are disadvantages though:

  1. Small risk of disease transmission.
  2. Higher costs.
  3. Healing time for tendon to bond well with bone is longer.

Common questions answered:

  1. One can still return to sports at 6 to 9 months after surgery using allograft tendon.
  2. There is no tissue rejection.

An example of a famous footballer who had ACL reconstruction using allograft tendon is Michael Owen.

Allograft ACL Reconstruction

Michael Owen sustained an ACL tear in his knee during the World Cup game against Sweden in June 2006.   He seeked treatment with Dr Richard Steadman of Vail, Colorado, USA.

Dr Steadman reconstructed Michael Owen’s right knee ACL using an allograft.

The following PDF file carries the story of one of my S-League player who underwent ACL and medial collateral ligament MCL reconstructions using tendon allografts.

The pros and cons of autografts versus allografts  tendons for ACL reconstructions are discussed.

click —>   Allograft ACL Reconstructions to read.

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How To Diagnose ACL Tears?

Diagnosing torn anterior cruciate ligament (ACL) of the knee joint is not difficult.

Most patients have some form of twisting or pivoting injury to the knee. This usually happens during sports such as football or basketball.  There may or may not have been contact during the injury.

A typical story is twisting injury to the knee associated with a ‘pop’ or ‘crack’ sound.  There is immediate onset of severe pain and the injured person is not able to continue playing.  If one can continue playing after the injury, it is highly unlikely to be an ACL injury.  The injured knee becomes swollen within the next 1 to 2 hours.

The ACL injured sportsperson will be limping over the next 3 to 7 days.

With such a story, I am 70% confident that this patient has an ACL injury. The other 30% is confirmed by clinical examination of the knee joint.

Other things that he or she may notice is that of giving way of the knee when walking or jamming/locking of the knee.

During the physical examination of the ACL-torn knee, we look for increased laxity in the knee joint.

The anterior drawer test is shown in this short video clip.

The Lachman’s test is shown next.  This is a very sensitive test for this condition.

The Pivot Shift test is confirmatory of rotatory instability of the injured knee but may be difficult to elicit in a person who is guarding or tensing the knee muscles.

MRI scans of the knee is not usually needed in order to diagnose an  ACL tear. It is, however, useful to assess the status of other structures in the knee joint that may be injured as well.  These include meniscus tears and tears to other ligaments such as the medial collateral ligament.

If you want to have your knee assessed for ACL injuries, please call us at 683 666 36 or email us at

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ACL Tears – What Can Happen If Left Untreated?

The anterior cruciate ligament (ACL) provides anteroposterior and rotatory stability to the knee during activities such as pivoting.  An example of a pivoting activity is the sudden change in running direction during football or basketball.

Loss of the function of the ACL in the knee leads to sensations of the knee “buckling” or “giving way“.   The knee may become unstable.

Some patients with very strong thigh and hamstring muscles may not experience this problem.  However, many other patients will, at one point or another, have sensation of the ACL-deficient knee giving way.

There is convincing evidence that an active individual with a nonfunctional ACL is susceptible to meniscus injury.  There is also the risk of more tears occurring with time. In a study by Satku et al on the “Natural History of ACL Injuries”, 68% of their study cohort lost at least one meniscus after more than 5 years of follow-up.  The loss of meniscus increases the load per unit area on the cartilage surface as the contact area reduces. This resulted in increased cartilage wear with strenuous activities or sports. Satku et al showed only 11% incidence of radiographic changes in patients with ACL-deficient knees with no evidence of meniscus tears compared with 100% in those having meniscectomy more than 5 years previously. Hence ACL-deficient knees over the long-term tends to have meniscus tears which will lead to radiological evidence of osteoarthritis.

The activity level of the ACL-deficient patient usually reduces after the injury. A study by Muadi et al from University of Sidney, conservatively managed ACL-deficient knees have a good short- to mid-term prognosis in terms of self-reported knee function and functional performance. However, subjects reduced their activity levels on average by 21% following injury.

A study by Nebelung et al published in Arthroscopy journal in 2005 showed the incidence and progression of osteoarthritis over a time period of 35 years following anterior cruciate ligament (ACL) disruption in high-level athletes. Their retrospective study looked at 19 athletes in the Olympic program of former East Germany who sustained an ACL injury  between March 1963 and December 1965 who were treated without reconstruction. The clinical results were evaluated for all patients from 1975 and 1985 and for 17 of the 19 patients in 2000; 18 of the 19 patients were examined arthroscopically in 1985. They found that all patients were able to return to sports after a period of 6 to 14 weeks. Ten years after the injury, meniscectomy had to be performed in 15 of the 19 patients (79%). The medial meniscus was affected in 13 patients (68%) and the lateral in 7 (37%); 20 years after the injury, meniscectomy was necessary in 18 of the 19 patients (95%). In 1985, in 18 of the 19 knees, arthroscopy was performed and 13 patients (68%) had a grade 4 chondral lesion. Ten total knee replacements had to be performed until the end of the year 2000. They concluded that, despite the possibility of return to high-level activity with a definitive unstable knee, this will lead in 95% of cases to meniscal and cartilage damage over the next 20 years. In addition, cartilage damage and progressive osteoarthritis will occur and patients will have a high risk of becoming a candidate for further total joint replacement.

Chronic ACL Tear Left Knee
Right Knee Acute ACL Tear | Left Knee Chronic ACL Tear

The left knee ACL has been torn for over 10 years while the right knee had an ACL tear just 1 month ago.  The above x-rays showed mild narrowing of the left knee medial compartment joint space compared to normal looking joint space in the right knee.

Knee Osteoarthritis from Chronic ACL Tear

This is an example of knee osteoarthritis from chronic ACL tear.

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ACL Reconstruction Rehabilitation Protocol

ACL Reconstruction Rehabilitation Protocol

ACL reconstruction surgery takes between 1 hour to 1 1/2 hours to perform.

The next 6 months is very important if the athlete wants to get back to high level sports.

A proper rehabilitation protocol is needed to allow the graft to heal, mature and strengthen while the knee becomes stronger.

The importance of post-ACL reconstruction rehabilitation cannot be over emphasized.



Stage 1 – Pre-surgery physiotherapy

Stage 2 – Week 1 to 2 immediate post-surgery

Stage 3 – Week 2 to 6 Hamstring and Quadriceps Control

Stage 4 – Week 6 to 12 Proprioception

Stage 5 – 3 to 4 months Sports-specific activities

Stage 6 – 5 to 6 months Return to Sports

Stage 1 – Pre-surgery
Goals Physiotherapy
Reduce pain and swelling Cryotherapy
Achieve full ROM Heel slides
Improve quads strength Isometric quads

Stage 2 – Week 1 to 2
Goals Physiotherapy
Reduce swelling & Pain ICE, Cryotherapy
Restore ROM: 0 – 90 Heel slides, active/passive knee flexion, prone hangs

Achieve full knee extension
Restore patella mobility Patella mobilisation
Hamstrings and quadriceps muscle control to 4/5 Isometric quads, electical stim on VMO, SLR, hamstring stretches

Watch out for: infection, stiffness, over-stretch graft, bleeding, DVT

Stage 3 – Week 2 to 6 Hamstring & Quadriceps Control
Goals Physiotherapy
Continue to reduce swelling and inflammation Cryotherapy
Increase ROM 0 to 130 Heel slides, active/passive ROM, prone hangs, heel prop
Normal gait pattern in FWB Gait training, pool exercises
Increase hamstring and quads control Quads/hamstrings co-contractions

Hamstring curls

Leg presses, hip strengthening

Step ups/downs

stationary cycling

Mini lunges

Wall squats up to 70 degrees knee flexion
Commence proprioceptive work Static balance exercises, progress to wobble board or balance pad, trampoline

Stage 4 – Week 6 to 12 Proprioception
Goals Physiotherapy
Full ROM Able to sit on heels pain free
Quads strength 85% of non-injured knee Progressive strengthening exercises in gym and poolBegin endurance training
Improved neuromuscular control and proprioception Start threadmill walking – flat and slowly increase to 12 degrees incline

Progress to jogging in straight line

Swiss ball exercises

Swimming – light kick, no breast stroke

Dynamic balance exercises with balance pad, wobble board
Increase hamstring strength Increase weight and repetitions of hamstring curlsCycling on road

Stage 5 – 3 to 4 months, Sports-specific activities
Goals Physiotherapy
Preparation for return to sportImprove skill level Functional sport-specific exercises in controlled situation (no pivoting)
Improve agility and reaction time drills More advanced agility drills (Figure of 8s, start-stops, change directions forwards and backwards, low speed cutting)

Plyometrics – hopping, jumping, skipping
Increase total leg strength and fitness Progress to strength and conditioning programme
Develop patient confidence Isokinetic test

Stage 6 – 5 to 6 months, Return to sports
Goals Physiotherapy
Return to full agilityFunctional test 80% of non-operative legPrioprioception 100% of non-operative leg Increase speed with figure of 8s, sprint stop-start, change surfaces, jumping bilaterally and unilaterally with increase height and surface
Return to Sport Sport specific training – drills with equipment on sport-specific surface

Unrestricted training, match play

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Double Bundle ACL Reconstruction – The Evidences

Tears of the anterior cruciate ligament (ACL) are some of the commonest conditions seen and treated in my practice.

The natural ACL is made up of 2 anatomically and functionally distinct bundles. They are named the anteromedial bundle (AMB) and the posterolateral bundle (PLB) based on the position of the fibres in the central part of the knee joint.

ACL reconstruction surgeons have traditionally reconstructed the larger and functionally more important bundle and that was the anteromedial bundle (AMB). The understanding of the role of the posterolateral bundle (PLB) was lacking and the ability to reconstruct this bundle was not well accepted until recent years.
Through cadaveric knee anatomical dissection studies as well as biomechanical studies, sports and knee surgeons now have a better understanding of the importance of the once neglected posterolateral bundle (PLB) of the ACL.

Criticism of Single Bundle ACL Reconstructions

Biomechanical studies with cadaver knees

  • 1 bundle ACL reconstruction cannot completely restore the normal anterior laxity
  • 1 bundle ACL reconstruction has no effect on the rotatory instability
  • Woo et al: JBJS, 84A:907, 2002
    Yagi, et al: AJSM, 30: 660, 2002

Kinematic analyses with patients

  • 1 bundle ACL reconstruction cannot improve the rotatory instability during walking or running, independent of the graft (BTB, Hamstring, etc)
  • Georgoulis et al: AJSM, 31: 75, 2003
    Ristanis et al: Arthroscopy, 21: 1323, 2005
    Chouliaras et al: AJSM, 35:189, 2007
    Tashman et al: Clin Orthop, 454: 66, 2007

What Are The Roles of Each ACL Bundle?

Posterolateral bundle (PLB) acted dominantly in extension, while the anteromedial bundle (AMB) mainly resisted against anterior tibial load in flexion. Hence each bundle have specific role in providing knee stability at different knee flexion angle.

Comparing Single Bundle to Double Bundle ACL Reconstructions

Comparing Single Bundle To Double Bundle

Double Bundle ACL Reconstruction Gives a More Stable Knee

8 papers showing Double Bundle ACL Reconstruction is Clinically Better than Single Bundle ACL Reconstruction

2006 Yasuda et al: Arthroscopy (level 2) n= 72
2007 Agllieti et al: CORR (level 2) n= 75
2007 Yagi, Kurosaka, et al: CORR (level 1) n= 60
2007 Jarvela: KSSTA (level 1) n= 65
2007 Muneta et al: Arthroscopy (level 1) n= 68
2008 Siebold et al: Arthroscopy (level 1) n= 70
2008 Streich et al: KSSTA (level 1) n= 50
2008 Kondo, Yasuda, et al: AJSM (level 2) n= 328

Double Bundle ACL Reconstruction

Double Bundle ACL Reconstruction

What Have I Found Out After Doing More Than 60 Cases of Double Bundle ACL Reconstructions?

  • The reconstructed knee feels more stable when examined.
  • The rotatory control or knee pivoting stability is superior to single bundle reconstructions.
  • Patients are generally more satisfied with their surgical outcome.

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Double Bundle ACL Reconstruction Video

Double bundle ACL reconstruction allows for a more anatomical reconstruction of the ruptured anterior cruciate ligament.

Studies have shown that it can provide up to 97% of the stability of the native ligament.

This is a surgical video of a double bundle ACL reconstruction done by me. The graft was using the patient’s hamstring tendons.

The video is divided into 4 parts.

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