Tears of the anterior cruciate ligament (ACL) are among the most common sports injuries – especially among children and adolescents involved in competitive sports that require a lot of running, jumping and quickly switching directions. ACL surgery and rehabilitation in a child or teen should account for the fact that the bones are still growing. In this video, a young athlete shares her story, and doctors at Children’s Hospital of Philadelphia (CHOP) talk about CHOP's approach to care.
0:01 Molly’s ACL injury
2:35 Why ACL injuries in youth are different than adults
2:55 Growth plates and why they matter
3:54 CHOP’s ACL experience
4:20 ACL reconstruction techniques
4:46 How we avoid disturbing the growth plates
5:19 Importance of mental recovery and coping
5:47 ACL rehab and other support services
6:35 A focus on young athletes
ACL Surgery for Children and Teens Where You Seek Treatment Matters
Molly: A competitive cheerleading routine is 2 minutes and 30 seconds of non stop, really hard work.
You're either tumbling, stunting, jumping, doing dance, doing the pyramid, performing. And you don't stop and don't cheer at all. You don't talk. And we don't have pom poms or anything like that. And we practice a lot. We practice 15 hours, sometimes a week.
At the day of my injury, we were probably 20 minutes into practice, and I just did round off back handspring double full, and I landed, and I just felt a pop in my leg.
Bridget: So Molly had called me. I literally just dropped them off at the gym, and she's oh, I got hurt. So then we drove down to CHOP.
Molly: I was just waiting for my results, and then my dad came in my room crying, and I was like, what is happening? And he was like, you tore your ACL and your meniscus.
J. Todd Lawrence, MD, PhD: So the ACL stands for anterior cruciate ligament. It's a crucial ligament for controlling the stability of the knee and how the knee works.
Brendan A. Williams, MD: It also helps with rotational forces about the knee. But the primary and most important function is it protects the knee from more significant knee injuries.
Kathleen J. Maguire, MD: It's a vital structure in terms of maintaining the stability of the knee with normal day to day activities, but more particularly with athletic activities that do require that cutting and pivoting kind of shifting motions through the knee.
Theodore J. Ganley, MD: So as kids get bigger and stronger and faster, they generate more force and then they can tear their ACL.
Molly: I met Dr. Ganley two days after I got my MRI results in, and he was basically telling me that I have to get surgery, but we have to wait six weeks because I had a torn meniscus, torn ACL and a sprained MCL and LCL.
Theodore J. Ganley, MD: When I first met Molly, she was certainly down and out, as anyone who's so dedicated and committed to a sport can be, but she knew the path forward and she was very committed to address every step required to get her back to full, peak performance.
J. Todd Lawrence, MD, PhD: At CHOP we tend to think about these injuries differently in kids who are growing and that's probably the main reason that people kind of seek out care here.
Some of the standard techniques that people use to address or fix ACL tears in adults can actually interfere with the normal growth of the knee.
Kathleen J. Maguire, MD: Right at the ends of each of the bones is a special cartilage that's essentially what we call the growth plate and that's cartilage that helps to make the bones longer and also wider over time.
We've developed different techniques that we can use to spare the growth plates, to kind of work around the part of the knee that's still growing, and to hopefully reduce the risk of causing long term issues with growth or deformity at the knee joint in the future.
J. Todd Lawrence, MD, PhD: During that preoperative evaluation and experience, we really like to make sure that patients understand the full extent of their injury and the full extent of what it's going to take to get them fixed up and back on their feet and back out there doing sports again.
So the ACL's a fairly predictable time frame for us. We're expecting to find meniscus tears both on the inside and the outside of the knee. We will take great care of you like you're one of our own. And come find us when we're done. Very good.
Provider: What if you try to straighten your knee out?
Theodore J. Ganley, MD: Children's Hospital is certainly among the highest volume centers for pediatric ACL reconstruction and repair.
We've had patients coming locally, regionally, nationally, and at times internationally, because we've developed less invasive ways to treat these injuries.
Kathleen J. Maguire, MD: The best way to really diagnose an ACL injury is using MRI. That's really our gold standard to visualize not only the ACL, but also the other structures inside the knee.
Brendan A. Williams, MD: The ACL can be reconstructed in a variety of ways. There's a variety of different tissue grafts, which include tendons and ligaments around the knee that can be used to reconstruct and create a new ACL ligament to function and stabilize in the knee for future return to sports and activities.
Theodore J. Ganley, MD: I've worked with my colleagues to develop unique surgical procedures such that a graft that is harvested is stronger than the native ACL.
We've developed procedures that specifically avoid the growth plate with placement of tunnels. So, an ACL can be reconstructed now with four incisions the size of a paper cut and one incision on the front of the knee that's two and a half finger breadths in length.
Brendan A. Williams, MD: Each of these options have various risks and benefits that we discuss with patients and families in order to optimize and make sure that they're fully informed about post operative expectations for these grafts.
Ultimately, the decision, it comes down to patient and family preferences, in addition to the recommendation of the treating surgeon.
Kathleen J. Maguire, MD: The other thing I think, not only just are kids and adolescents physically different, I think mentally they're different than adults. So I think having the tools and the resources to manage the psychosocial mental part of the injury, is just as important as having the techniques for the physical part of the surgery.
Brendan A. Williams, MD: As a former athlete, I understand the stress involved with injury and being out of sport, but as a physician, I also recognize that there's important steps we need to take to optimize their return and get them back there safely. At Children's Hospital of Philadelphia, we offer both the surgical services, the physical therapy and recovery and rehabilitation services, as well as mental health services that some patients require.
J. Todd Lawrence, MD, PhD: For a lot of these kids, sports is their world. Sports is their identity. And to not be able to participate in their sport, which is not only just their identity, but sometimes their whole peer group, that can be very, very challenging for them.
Molly: About probably two months in, I was thinking I may never compete again, I don't know, like this is really hard work.
I have to go to physical therapy two times, three times a week. And it's just so much hard work. It feels like I'm never gonna to get better.
Theodore J. Ganley, MD: With a sports medicine and performance center centered around young athletes getting the return to their peak fitness and their peak levels of activity, our athletes have every resource available to reach their goals and their milestones and reach heights that they hadn't reached before.
We can get them stronger then before their surgery, and we'd like their resilience to be better than ever and their grit and determination to be better than ever.
Molly: At six months, I was just starting to do like normal things like running in like gym class. So I was like, okay, there is a light at the end of this dark tunnel.
J. Todd Lawrence, MD, PhD: Once we've cleared patients for return to sports, we have a very structured return to play program. We really care about these patients, and so we like to keep tabs on all these kids through our research programs, too.
Bridget: So her first full competition was at Worlds. And it was the best feeling when I saw her out there doing what she was doing, I just started crying. I was like so excited for her.
Dan: Molly has this inner thing that just drives her to be the best. It's just amazing.
Molly: CHOP has been amazing throughout this whole experience. Every time I would go in for like my three month or my six month, they would just remind me, you're doing really well.
Just keep it up, keep going. And Christine has been the best part of this all because she was there every step of the way.
Kathleen J. Maguire, MD: As a former athlete, I get it. I get where these kids are coming from. I know how important their sport is to them. And I know how much work it takes. I think that really shaped who I am and gives all of us those important life skills. Teamwork, perseverance, hard work, picking your head up when things don't go your way. I think all those things are vital, not just as an athlete, but moving forward in life.
Topics Covered: ACL Injuries in Children and Teens