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The Hockey Doc: Combined ACL and LCL tears

02/21/2018, 4:15pm CST
By Dr. Rob LaPrade

Having both your ACL and LCL reconstructed at the same time is a big surgery, but gives you the best chance to return back to full on-ice activities.

Question: I got hit on the inside of my knee and presently my knee feels like it wobbles side-to-side. I was told that I have  ACL and LCL tears.  What should I do about it?

Answer: What you describe does fit with a possible LCL (lateral or fibular (FCL) collateral ligament) tear. The LCL is the main ligament on the outside of the knee. The other thing that can make a knee feel like it wobbles side-to-side is a MCL tear (medial collateral ligament) on the inside of the knee. It is very important to make sure that one does have an LCL tear, instead of an MCL tear.  This is because LCL tears very rarely heal, while MCL tears often do heal. When one does have an ACL tear, it almost always needs to be reconstructed because the ACL is important in preventing twisting, turning and pivoting limitations with sports. When done well, and all other concurrent injuries are treated, an ACL reconstruction has an excellent chance of getting one back to full activities.

A tear of the LCL is totally different than having a tear of the MCL. A lot of research has gone into the fact that LCL tears rarely heal, and the side-to-side gapping of the knee that they cause almost always make an ACL, or even a PCL, reconstruction graft fail if the LCL is not reconstructed at the same time. Because a complete  LCL tear rarely heals, the residual side-to-side gapping of one’s knee causes the ACL graft to stretch out and fail. Thus, it would be strongly recommended that you have both the ACL and LCL tears reconstructed at the same time and then you would have an excellent chance of being able to return back to full activities.

Probably the other main thing to think about is having the surgeon use your own tendons for reconstructing your ACL and LCL. This is because cadaver ACL grafts have a very high risk of failure in people that are less than 25 years old, and also have a higher risk of failure even in patients up until age 50. Thus, using your own tissue for your ligament grafts has a much better chance of getting you back to activities. It may not be as important to use one’s own tissue for the LCL reconstruction because the LCL is not subject to the same harsh healing environment as the ACL is within the middle of the joint, but we still feel that using one’s own tissues are better than using a cadaver ligament graft when possible.

It used to be that one of the most common reasons of ACL graft failure was from surgeons failing to treat the LCL and other structures on the outside of the knee at the same time as the ACL reconstruction. Improved education and research have led to most modern surgeons recognizing this injury pattern and reconstructing them at the same time to ensure that you return back to full activities. Having both your ACL and LCL reconstructed at the same time is a big surgery, but gives you the best chance to return back to full on-ice activities. 

 
Robert F. LaPrade, M.D., Ph.D. is a complex knee surgeon at The Steadman Clinic in Vail, Colorado. He is very active in research for the prevention and treatment of ice hockey injuries. Dr. LaPrade is also the Chief Medical Research Officer at the Steadman Philippon Research Institute. Formerly, he was the team physician for the University of Minnesota men’s hockey team and a professor in the Department of Orthopaedic Surgery at the U of M. If you have a question for the Hockey Doc, e-mail it to editor@letsplayhockey.com.

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