This is a case study presenting a 69 year-old man complaining that his right knee hurts and has been gradually getting worse over the last two years. He complains of pain with descending a slope and prolonged walking. He has a history of twisting of his knee with an unexpected step into a hole at the work site. On examination he has a mild effusion of the right knee and positive anterior drawer test. The rest of the exam is negative. He has a partially torn Anterior Cruciate Ligament (ACL).
This orthopedic condition brings the skilled Prolotherapist special challenges. The cruciate ligaments are almost two inches long. They are located in the center of the knee, rather than on the outside. Also they are intra-capsular but extra-synovial.
We all know that we see more ACL than Posterior Cruciate Ligament (PCL) injuries. This is for two main reasons. First, the ACL stabilizes the knee in multiple places. This means it is vulnerable to injury from traumatic forces from several directions. Secondly, the blood supply to the PCL is more generous than the supply to the ACL. This leaves the ACL more vulnerable to injury and less able to heal after injury.
Since the cruciate ligaments are not in the synovial fluid, simple Prolotherapy intra-articular injections will not lead to strengthening of the cruciates. We must therefore identify the anterior and posterior insertion sites, and carefully inject the proliferant there.
Let’s review the ACL anatomy. The proximal end (posterior portion) of the ligament is located posteriorly on the medial superior aspect of the lateral condyle of the femur. From there the ligament runs distally, slightly medially and anterior to its attachment (anterior portion) on the tibia. It attaches on the tibial plateau between the tibial eminences just anterior to the coronal midline and slightly medial to the sagittal midline. The origin is about 20mm by 10mm. The insertion is about 10mm by 30mm, with the long axis running anterior/posterior.
Continue reading Prolotherapy for the ACL at the Journal of Prolotherapy.
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