The painful side to play

A patient of mine recounted the moment he fell in a tackle by his opponent in a football match the night before.

"Can I still play?" he asks.

He wasn't so much concerned about whether he could walk properly after being pushed into the consultation room in a wheelchair.

After a bedside examination and magnetic resonance imaging (MRI) scans, he was told that he had sustained a ruptured anterior cruciate ligament (ACL).

He was advised to undergo arthroscopic surgery. "There will be a good chance you will play again after surgery, but of course I can't promise you will play better," I told him.

Despite the subtle sarcasm, his face brightened up.


In the 70s, ACL injury usually spells the end of a career for a sportsman. With more understanding of the function of the ligaments of the knee, plus the evolution of surgical techniques, a patient can return to meaningful sport after six months.

The anterior and posterior cruciate ligament cross each other in an "X", therefore the term "cruciate". Together with the medial and lateral collateral ligaments holding both sides of the knee, the cruciate ligaments are main stabilisers of the knee for all athletic pivotal activities involving jumping.


As the central pivot, ACL is the most vulnerable ligament in the knee. Eighty per cent of ACL injuries are non-contact and occur during jump landings, quick changes in direction while running or sudden deceleration.

An injury to a knee ligament disrupts the function of the joint, immediately destabilises the knee and may lead to degenerative arthritis in the longer term.

It is just like a maligned unstable wheel, which causes a car to shake and affect the chassis.

ACL reconstruction is the sixth most common procedure performed in orthopaedics, with approximately 100,000 procedures performed annually in the United States alone.

There is no official Malaysian statistics but its number can't be too low because we are keen on football. We love the game, but we don't necessarily kick very well. That makes a potent combination for sports injuries.

Price of injury


There is, of course, a price on the injury and an economic burden because it affects mostly productive young men and women.

In the year 2000, it was estimated that 50,000 ACL reconstructions were performed, costing about US$17,000 (RM51,000) per procedure, resulting in a total cost of US$850 million in the US.

Of patients who choose to continue to be athletically active five to 10 years after they sustain their injuries, two-third are affected with the rest having symptoms of pain.

Lack of ACL stability eventually leads to additional injury in the knee. For example, 80 per cent of patients may also sustain meniscus tear, or cartilage injury within two years. Losing of meniscus contributes significantly to knee pain and swelling, and may bring on premature osteoarthritis of the knee.


The modern treatment of ACL tear involves extensive knee rehabilitation before and after surgery. With the advent of arthroscopic (keyhole) surgery, and using patient's own tendon grafts to reconstruct the usually frayed ruptured ligament stump, it allows quick return to normal activities, and return to sport within six months.

While patellar tendon autograft is strongest, ACL reconstructions performed with hamstring tendon autografts have been shown to result in faster recovery of quadriceps muscle strength, less donor site pain and less interference with kneeling and crawling.

Hamstring tendon grafts are the autogenous graft of choice for patients whose occupation, lifestyle or religion requires kneeling or crawling.

The chance of successful ACL reconstruction is reportedly high. In cases of failure, it may be related to poor surgery, rehabilitation and re-injury. Proper follow-up and rehabilitation may reduce failure rate. If needed, re-operation can be performed.