3. INTRODUCTI
ON
Anterior cruciate ligament (ACL) injuries are common severe
traumatic knee injuries
Annual incidence 81 per 100,000 persons aged between 10 and 64
years
There are an estimated 80,000 to 100,000 anterior cruciate ligament
(ACL) repairs in the United States each year.
Most ACL tears occur from noncontactinjuries.
Women experience ACL tears up to nine times more often than men.
Past two decades have seen a significant increase in the number
of ACL tears inadolescents.
7. ANATOM
Y
ACL originates on the medial wall of the lateral femoralcondyle,
courses anteriorly and medially across the knee joint and insertsinto
the tibial articular surface.
It consists of two functional bundles, anteromedial (AM) bundle and
posterolateral (PL) bundle.
Primary role of the ACL is to provide primary anteroposteriorstability
and secondary rotatory stability
8. Multiple type III collagen–positive fibrils form a collagen fiber that is
bundled together and ensheathed by a thin layer of connective tissue
named the endotendineum.
Bundled fibers + endotendineum subfascicular unit.
Subfasciculi are collected in another connective tissue layer called the
epitendineum, a much thicker layer than the endotendineum.
The ligament is surrounded by the paratenon, which blends in with the
epitendineum.
9. ANATOM
Y
Blood supply to the ACL is primarily the middle genicular, inferior
medial and lateral genicular arteries.
Ligamentous branches form a periligamentous plexus
The innervation of the ACL comes from theposterior
Nerve supply is from articular nerve, a branch of the tibial nerve
Mechanoreceptors have been described on the surface of the ACL ,
located at the femoral insertion site.
They have proprioceptive qualities.
10. Biomechanics
The main function of the ACL is restraint of anteroposterior translation
of the tibia relative to the femur.
It also acts as a secondary restraint to tibial rotation and valgus or
varus stress.
Older ACLs fail with lower loads than do youngerACLs.
With passive range knee extension, the ACL experiences forces of
about 100 N, whereas walking produces about 400 N of force.
Activities involving acceleration, deceleration, or cutting maneuvers
can produce up to 1700 N of force on theACL.
The ACL has a maximal tensile load of 2160 157 N and a stiffness of
242 28 N/mm.
11. It is able to withstand strain of roughly 20% before failing.
Important variables that influence ACL strain are the position of the
knee and the dynamic interaction of muscle activity.
As shown by Beynnon and colleagues, increasing knee extension
increases strain on theACL.
Position and length of the bundles vary with changing angles of knee
flexion and extension , the ligament has been shown to elongate by
up to 3 mm with extension.
12. From 0 to 300 of flexion, the AM bundle shortens from its baseline
length. With continued flexion from 30 to700, the AM bundlelengthens
back to its baseline length. Beyond 700 of flexion, the bundle continues
to elongate, beyond the baseline length, until it reaches maximal strain
at about1200 offlexion.
The PL bundle is at maximal length and maximal strain when the knee
is at full extension.
As the knee is flexed, the PL bundle shortens, achieving minimalstrain
at about 1200.
13.
14. Typically, injury to extra-articular ligaments leads to hematoma,
organizes into a fibrinogen mesh, inflammatory response, inflammation
wanes, granulation tissue forms and reorganizes into fibrous tissue.
Fibrous scar tissue restores function to the ligament.
ACL, however, is intraarticular.
ACL is encased in only a thin envelope of synovial lining
Synovial lining is compromised, bleeding dissipates throughout the
joint space and is unable to organize into fibrous tissue.
Fibrous scar tissue never occurs, and the ligament remains functionally
incompetent.
15. Mechanisms of Injury
Common MOI’s
Slight knee flexion with/
tibial external
rotation/internal rotation at
foot strike
Excessive valgus, varus,
hyperextension or rotation
Quads active
Skiing
Phantom Foot
Knee hyperextension in
ski boot
Valgus rotation
Other Sports
Sudden deceleration
Abrupt change of
direction (fixed foot)
Single leg landing
16. Mechanisms of Injury
The skier falls back, trying to pull himself up, the boot
levers the knee forward in conjunction with a forceful
quadriceps contraction
Deceleration
with change
of direction
Landing from a jump
Sudden stop on
extended knee
17. CLASSIFICATIO
N
There is no standardized system widely used in the evaluation ofACL
injuries.
Grade I: A mild injury that causes only microscopic tears in theACL.
Grade II: A moderate injury in which the ACL is partially torn. The
knee can be somewhat unstable and can "give away" periodically when
you stand or walk.
Grade III: Asevere injury in which theACL is completely torn
through and the knee feels very unstable.
18. ACL Injury Open Growth
Plates
Classification
Non - traumatic
Congenital ACLabsence
Post - traumatic
- Tibial eminence avulsion
- Mid-substance tear
(common in age<12)
( common in age>12 )
- Femoral avulsion (rare, repair )
20. EVALUATIO
N
and treatACL
A thorough patient history is the initial step to diagnose
injuries.
Mechanism of injury, initial symptoms, previous injuries, time since
injury, and any late sequelae, including reinjuries.
Sensations such as popping or tearing at the time of injury.
Inability to bear weight on the injured leg and instability or the sensation
of the knee “giving out.”
Unable to participate after sustaining an acute injury.
Post-traumatic swelling of the knee joint which is manifestation of
hemarthrosis, seen within 12 hours after injury.
21. Physical Examinationand
Testing
Examinations performed immediately after an injury are more accurate
than after the injury response has been initiated.
If the examination is delayed and the initial symptoms have manifested,
decreasing the accuracy of the examination.
Repeat the examination in a few days.
Malalignment can be indicative of a fracture or a sign of knee
dislocation
Depending on the time frame of the examination, an effusion may be
detectable.
22. Palpation
Swelling
To detect injury to surrounding knee structures.
Medial and lateral joint line tenderness may in concomitant meniscal or
chondral injury.
Functional testing.
Active and passive range of motion ,check for loss of motion.
Factors that may cause loss of motion
incompetent extensor mechanism, or a
- pain in the knee
- a large
effusion, an
23. Stability testing (anterior stability, posterior, varus, valgus, and
rotational stability).
Anterior stability testing Lachman and anterior drawer’s test.
Lachman test is performed while the knee is flexed at 20 to 300. In this
position, a manual anterior force is applied to the proximal tibia while
the distal femur is stabilized with the opposite hand.
Assess the degree of anterior translation of the tibia relative to the
femur and in the firmness of the end point at which translation is
halted.
24. Compare between the injured and the contralateral normal knee.
The degree of translation is categorized in grades of laxity.
Grade I laxity describes 1 to 5 mm of increased anterior translation.
Grade II laxity is 6 to 10 mm.
grade III is more than 10 mm.
Arthrometers employed to provide objective instrumented laxity
measures of ACL laxity. The KT-1000 (MED metric,San Diego, CA) is
the mostly commonly cited device.
Anterior drawer test
- knee is placed in 900 of flexion, and the foot is held in place
throughout the examination.
25. Pivot shifttest
The test begins with the knee in full extension, and the patient is asked
to relax the musculature of the limb being tested. A valgus stress is
placed on the tibia, while an axial load and internal rotation are
simultaneously applied. The knee is then slowly flexed with these
applied forces.
During this motion, the lateral side of the plateau subluxates to a
greater extent than the medial side. With further flexion, the lateral tibia
reduces, producing the pivot shift.
This test is graded on the degree of subluxation and reduction of the
lateral compartment of the knee, with grade 0 having no detectable
shift, grade I having the tibia in a smooth glide during reduction, grade
II having an abrupt reduction, and grade III having the tibia
momentarily lock in the subluxated position before reduction.
26.
27. IMAGIN
G
Plain radiographic imaging plays a primary role in the exclusion of
associated injuries in the evaluation of theACL.
Lateral capsular avulsions (Segond’s fractures) and tibial eminence
avulsion fractures seen in younger patients or those with osteopenia.
MRI is a highly useful tool for confirming the diagnosis of ACL
disease. It is highly specific and sensitive and is able to provide
information on the other intra-articular structures in the knee as well as
evaluate both bundles of the nativeACL
28.
29. GENDER
ISSUSES
Female athletes have a 4 to 6 fold greater incidence
The reasons for this gender disparity in ACL injuries arelikely
multifactorial.
- anatomic
- hormonal
- neuromuscular
- biomechanical differences
Increased activation of the quadriceps relative to the hamstrings (Q/H
ratio) as well as decreased ratio of firing of medial to lateral quadriceps
and hamstrings.
30. ELDERL
Y
ACL reconstruction for those patients who wish to remain active,
Remain involved with high-risk activities
“physiologically” young
31. Associated Injuries
Knee
O’Donoghue coined the phrase “the unhappy triad” in referring to
the association of ACL injury with MCL and medial meniscal
seen in
tears.
Lately lateral meniscal tears are more commonly
association with combined ACL and MCLinjuries.
32. Treatment for ACLinjuries
Immediately after injury
P. R.I.C.E
Non surgical treatment
Exercise (after swelling decreases and weight-bearing
progresses)
Braces
Surgical treatment
33. BRACE
S
Range of motion control.
FUNCTIONAL BRACE have rigid metal
supports down the sides of the brace to
reduce knee instability following injury.
34. Non surgicalTreatment
Isolated ACLtears
With partial tears and NO instability symptoms
With complete tears and NO symptoms of knee instability
during low-demand sports who are willing to give up high-
demand sports
Who do light manual work or live sedentary lifestyles
Whose growth plates are still open (children)
35. Non surgicalPrecautions
Modification of active lifestyle to avoid high demand activities
Muscle strengthening exercises for life
May require knee brace
Despite above precautions ,secondary damage to knee cartilage &
meniscus leading to premature arthritis
36. Operative Management
Knee
Early surgical treatment of ACL injury involved attempts at primary
repair.
Augmentation procedures intra-articular and extra-articular
Autogenous reconstruction
Thus, both primary repair and augmentation procedures fell from favor.
37. Prosthetic ligament reconstruction devices became popular in the
1980s. Carbon fiber, polylactic acid (PLA)–coated carbon fiber, and
polytetrafluoroethylene (PTFE) were all introduced during this period.
The most popular device, the Kennedy ligament augmentation device
(LAD) introduced in 1980, was a flat 6-mm diamond-braided
polypropylene device.
A gradual transition has occurred from open reconstructiveprocedures,
to an arthroscopic two-incision technique, to an arthroscopic one-
incision technique
Timing of Surgery
There has been ample debate surrounding the ideal timing ofACL
reconstruction surgery.
38. Graft Selection
The optimal graft material for ACL reconstruction remains an area of active
debate.
The ideal graft should have structural properties similar to the native ACL that
are present at implantation and persist throughout the “ligamentization” process ,
secure fixation, good biologic incorporation, and minimal donor site morbidity.
Autograft ACL graft options include bone–patellar tendon–bone (BPTB),
quadriceps tendon, and quadrupled semitendinosus and gracilis hamstring (HS)
tendon.
Allograft options include quadriceps, Achilles, tibialis anterior or posterior,
BPTB, and HS.
BPTB is the graft of choice (ease of harvest, comparable structural properties to
native ACL, rigid fixation, bone-to-bone healing, and favorable track record,
considered the gold standard against which other grafts are compared).
39. Graft Healing
Biologic graft healing encompasses both the graft attachment site
healing as well as the healing process of ligamentization or graft
revascularization and incorporation.
Attachment site healing in grafts containing bone, particularly
autografts, closely resembles fracture healing with graft bone–to–
host bone healing occurring within 6 weeks.
Purely soft tissue grafts typically take 8 to 12 weeks to heal into
host bone.
The process of graft revascularization and incorporation proceeds
through well-defined phases starting with an
- inflammatory phase
40. Host revascularization, lasts from about day 20 to 3 to 6 months after
surgery.
Final phase collagen maturation.
Allografts proceed at a slower rate, leading to a potentially increased
rupture rate.
41. Donor SiteComplications
and GraftHarvest
Although donor site complications are infrequently reported overall,
most of the complications arise from autograft BPTB grafts.
Patellar fractures, patellar tendon ruptures, localized numbness, and
tendonitis, patellar tendon rupture rarerly.
Closure of the patellar tendon after harvest may cause shortening of the
tendon.
Anterior knee pain after BPTB harvest has been reported to occur in up
to 50% of cases,
42. Graft Tension
Appropriate graft tensioning remains a difficult quantifiable task.
Adequate tension is necessary to restore adequate anteroposterior
stability at the time of ACL reconstruction, whereas too much tension
may lead to graft stretching, fixation failure, and capture of the knee.
Multiple variables that affect graft tensioning, knee flexion angle and
rotational position of the knee during tensioning and the specific graft
type used.
43. GRAFT
FIXATION
Mechanical fixation to host bone can be categorized as either
-direct fixation (interference screws, staples, spiked washers), which
compresses the graft against the host bone,
-indirect fixation (cross-pin, screw and post, Endo Button), which
suspends the graft within a bony tunnel.
For BPTB grafts, the most commonly performed and reported fixation
is direct fixation using interference screws on both the tibial and
femoral sides
44.
45.
46.
47. POST OPERATIVE
REHABILITATION:
Early range of motion
Immediate weight-bearing
Early return to sport, in the shortest time possible withoutcompromising the
integrity of the surgically reconstructed knee.
Rehabilitation protocol for ACL reconstruction has changed dramatically
during the past several years.
Instead of conservative rehabilitation with limitation of range of motion,
delayed weight-bearing (8 to 10 weeks), and delayed return to sports (9 to 12
months)
Current ACL reconstruction rehabilitation protocols emphasize immediate
ROM, immediate weight-bearing, and earlier return to sports(4 to 6 months)
48. Open and Closed Kinetic Chain
Exercise
Closed kinematic chain (CKC) exercises are safer than the open kinematic
chain(OKC) exercises
CKC exercises apply less anteriorly directed forces on the tibia, increase
tibiofemoral compressive forces, increase co-contraction of the hamstrings,
mimic functional activities more closely than OKC exercises, and reduce the
incidence of patellofemoral complications, especially at low knee flexion angles.
CKC exercises are defined as those in which the foot is in contact with a solid
surface GRF is transmitted to all of the joints in the lower extremity, and muscles
spanning all of the joints of the lower extremity are used
Squat and leg press.
49. OKC exercises are defined as those in which the foot is not in contact
with a solid surface.
One segment of the limb is stabilized while the other segment moves
freely, and only the muscles spanning the knee are required to perform
the exercise.
Leg extension machine.
Many activities cannot be clearly classified as CKC or OKC.
Daily activities like walking, stair climbing, and jumping are
combinations of OKC and CKC movements
50. REHABILITATIO
N
CONSIDERATIO
NS
Pain and Effusion
cause reflex inhibition of muscle activity
PRICE principle, protection, including rest, ice, compression, and
elevation.
Narcotic and anti-inflammatory pain medications
Muscle activities like quad sets and ankle pumps can help to reduce
swelling by improving venous return muscle stimulation of the
quadriceps
51. Cryotherapy
Ice packs, ice baths, and continuous flow cooling devices.
Lowers joint temperature.
Motion
Loss of motion is one of the most common complications.
common causes include arthrofibrosis, inappropriate graft placement or
tensioning.
Leads to anterior knee pain, abnormal gait, muscle atrophy, and early
degenerative changes of the joint.
Usually, the loss of extension is more commonly seen and more poorly
tolerated than the loss of flexion.
52. The goal is to achieve full extension right after the surgery and regain
10 degrees of flexion per day.
By 7 to 10 days post op the knee should achieve 900of flexion.
Bracing in slight hyperextension, an easy way to ensure full knee
extension.
Early passive and active range of motion using continuous passive
motion machine.
Prevention is the key to achieving range of motion.
- control of pain and swelling,
- early reactivation of quadriceps
- patellar mobilization,
- early return to weight-bearing
53. Weight-Bearing
Weight-bearing was prohibited earlier rehabilitation protocols
Current trend is immediate weight-bearing
Helps to improve cartilage nutrition, reduce disuse osteopenia, and
hasten quadriceps recovery.
Muscle Training Issues
To prevent muscle atrophy and weakness.
Muscle activation and strengthening, voluntary exercises, electrical
muscle stimulation, and biofeedback.
Electrical stimulation can help to initiate muscle activation , when
reflex inhibition can not be overcome in patients who are suffering
54. Quadriceps muscle strength is correlated with good outcomes after
ACL reconstruction.
Strengthening of the quadriceps is the focus of many rehabilitation
programs.
Appropriate H- Q ratio.
Electrical Muscle Stimulation and Biofeedback
Electrical muscle stimulation is used as an adjunct to voluntary
exercises in an effort to recover muscle strength after ACL
reconstruction.
The effectiveness of this method is controversial in the literature.
55. Proprioception
Proprioception is defined as the culmination of all neural inputs originating
from joints, tendons, muscles, and associated deep tissue proprioceptors.
Mechanoreceptors are specialized nerves located in skin, joints, tendon,
ligament, and skeletal muscle.
After ACL reconstruction, patients continue to have deficits in proprioception
and neuromuscular joint control for at least months and as long as 1 year after
surgery.
It is important to incorporate beginning, intermediate, and advanced
proprioceptive training exercises throughout the postoperative rehabilitation
protocol.
56. STAGE
1
Begin immediately post op upto 6 weeks
Goals
Protect graft fixation
Control inflammation
Achieve full extension and flexion
Education
Therapeutic excercises
- Heel slides, quadriceps sets
- Non weight bearing gastro soleus and hamstring streches
- Straight leg raises with knee in full extension
- Isometric quadriceps at 60 and 900
57. STAGE
2
6 to 8 weeks
Goals
Restore normal gait
Maintain full extension and progress with flexion range
Graft protection
Therapeutic excercises
Wall slides 0 to 450
Stationary bike
Closed chain terminal extension with resistance tubing
Toe raises
Balance excercises
Hamstring curls
Aquatic therapy
Weight bearing streches
58. Stage 3
8 weeks to 6 months
Goals
Achieve full ROM
Improve strength, endurance and proprioception
Therapeutic exercises
Continued flexibility excercises
Stairmaster
Advanced closed chain(one leg squat, leg press 0 to 500
Proprioceptive excercises (slide boards, Ball excercises with balance
activities
Progress aquatic therapy- pool runing, swimming
59. Stage 4
6 months to 9 months
Goals
Achieve progress strength, power, endurance, proprioception
To prepare to return to functional activities
Therapeutic excercises
Continue flexibility and strengething excercises
Initiate plyometric program
Functional progression walking, jogging, forward and backward
running at half and three fourth speed; cutting and cross over
Sports specific drills
60. Stage 5
9 months post op
Goals
Safe return to athletics
Maintenance of strength, endurance, proprioception
education regarding possible limitations
Therapeutic exercises
Gradual return to sports
Maintenance program
61. PREVENTIO
N
Components Of Program
Warm up
Stretching
Agility drills
Practice
Strength exercises
Cool Down
Warm up and stretching are to be done at the beginning of practice
followed by the agility drills
Then, the athlete would be ready for a normal practice session
At the conclusion of practice, a brief strengthening session followed by
the cool down
62. Warm
U
p
Warm up is designed to get ready for practice activity and tohelp
prevent injury.
Set up two markers about 10-20 yards away from each other and have
the players perform the following 3 warm up activities about 2 minutes
each:
Forward jogging- Hip, knee and ankle should be in alignment , the
knees are not falling in toward each other , the feet are not moving out
to the sides.
Side shuffling- maintain hip and knee in bent position and don’t travel
standing straight up.
Backward jogging-maintain hip, knee, and ankle alignment and not
allowing knees to fall inward. They should also stay on their toes and
63. Stretching
Instructions: Stand on your
right leg, bend forward and
put your hands on the
ground in a V-form. Keep
your right leg straight and
your right foot flat on the
ground. Bend your left leg
and place your left ankle
across your right calf. Hold
this position for 30
seconds. Switch legs and
repeat on your left side.
Incorrect
Correct
Things to look for: bending
the stance leg, leaning
forward in the pushup
position, arching the back,
or raising up on your toes.
Calf Stretch Correct
Quadriceps Stretch
Instructions: Stand tall with
your weight evenly distributed.
Bend your left knee, reach
behind with your left hand and
grab the front of your leftankle.
Bring your heel up to your
buttock and keep your left knee
pointed towards the ground.
Keep your left leg close to your
right leg. Hold for 30 seconds
and repeat on your rightside.
Incorrect
Things to look
for: bending at
the waist, or
letting your
knee “wing”
out to the side.
64. Hamstring Stretch
Instructions: Sit on the ground with
your left leg extended out in front.Bend
your right knee and place the sole of
your shoe on your left inner thigh. Keep
your back straight and try to bring your
chest to your left knee. Reach towards
your left toes and pull them towards
your head. Hold for 30 seconds and
repeat with the right leg.
Things to look for: rounding yourback
or bouncing.
Instructions: Sit on the ground, and
spread your legs evenly apart. Keeping
your back straight, reach overhead with
both hands. Then, slowly reach towards
your right foot with both hands. Hold
the stretch for 30 seconds and then
repeat the stretch on the left side.
Things to look for: rounding your
back, leaning forward too fast or
bouncing
Inner Thigh Stretch Hip FlexorStretch
Instructions: Lunge forward leading
with your left leg and kneel on yourright
knee. Rest your left arm on your left
thigh, and lean forward with yourhips.
Keep your balance, reach back for your
right ankle and pull your heel to your
buttocks. Hold the stretch for 30seconds
and repeat the stretch leading with your
right leg forward.
Things to look for: maintaining your
balance and keeping your hips square
with your shoulders.
65. Agility Drills
Instructions: While standing on
one leg with ball on the ground in
front of you, slowly reach down with
one hand and touch the ball, then
perform using other hand. Repeat
10 times on each side.
Things to look for: Do not allow
balance knee to fall in towards mid
line of body- keep knee in a slightly
bent position
Instruction: Stand on one leg and
balance while performing soccer kicks
with the other or dribbling basketball
while balancing. Perform 1-2 minutes
each leg.
Things to look for: Do not allow
balance knee to fall in towards mid line of
body- keep knee in a slightly bent
position
Single Leg Touches
Single Leg Sport Specific
66. Instruction: Stand on one leg and
balance while performing soccer
kicks with the other or dribbling
basketball while balancing.
Perform 1-2 minutes each leg.
Things to look for: Do not allow balance
knee to fall in towards mid line of
body- keep knee in a slightly bent
position
Single Leg Sport Specific
67. Instruction: Stand on ground with
feet approximately shoulder width-
perform a quick squat and then explode
into a jump- hold the landing for a 2
count Perform 20 times.
Things to look for: When landing
make sure to land softly on balls of
feet keeping knees slightly bent and
pointing straight forward- No landing
on heels with knees straight!!
Squat Jump With Hold
Correct Landing
Incorrect landing
68. Instruction: Stand on ground with feet
approximately shoulder width apart-
jump into air while bringing knees up
toward chest and hitting knees with
hands- Be sure to land softly on balls of
feet with knees slightly bent- try to bring
thighs parallel to ground. Perform 10
times.
Things to look for: Off balance landings-
should land on balls of feet with
knees slightly bent and pointing
forward
Single Tuck
Jump
69. Instruction: Stand with feet slightly
apart- Push off ground with plant leg
while moving in a sideways direction
landing on opposite foot- hold 2
seconds- repeat with other leg Perform
10 times each leg.
Things to look for: Explosion at
take off with plant leg making sure
knee does not fall in to midline of
body and on landing make sure knee
stays in a forward direction with a
slight bend
Lateral Jumps
70. Strength Exercises
Front Plank Side Plank
Instruction: Position yourself in a “push-
up” start position, with your elbows on
the floor in line with shoulders. Tighten
your stomach, lift your hips off floor till
your legs and upper body are in line with
shoulders over elbows.
Things to look for: Make sure to keep
legs and torso straight. Make sure back is
not arched or curved downward. Hold 20
seconds, Repeat 2 times.
Instruction: Lie on either side, legs
outstretched, lower elbow on floor in line
with shoulder. Tighten your stomach
muscles, lift your hips off floor until your
legs and upper body are in line.
Things to look for: Make sure shoulder
is positioned over elbow on the floor.
Keep legs and torso straight and place
upper arm against side. Hold 20 seconds,
repeat 2 times each side.
71. Assisted Russian Hamstring Curl
Instruction: Start on knees with
arms crossed resting on chest and
your partner holding yourfeet.
Keeping your body straight,slowly
lower self towards floor and return
to upright position. Repeat 20
times.
Things to look for: Be sure
to tighten your stomach
while moving forward and
back. Make sure not to arch
back when returning to start
position.
72. Correct Incorrect
Single Leg Calf Raise
Things to look for: Be sure to
move up and not forward (as
shown above in picture 2).
Instruction: Stand on one
foot and slowly raise up on
to toe and then back down.
Repeat 10 times each side.
73. Correct Incorrect
Instruction: Take large step
forward and slowly lower self
towards ground keeping your
knee directly over your toes.
Repeat 10 times each side.
Things to look for: Make
sure to keep your knee over
your toes when performing
lunge.
Make sure to keep your torso
straight when lowering self.
Forward Lunge
74. Paediatric ACL INJURY
The increased number of pediatric ACL injuries reflects the increased
avulsion
participation seen in youth sports.
Most injuries are mid substance ACL tears or tibial
fractures.
Femoral avulsion fractures of the ACL attachment arerare.
Physical examination should focus on ligamentous instability, patellar
instability, and referred pain from the hip.
Comparison to the contralateral extremity is critical to rule out
ligamentous laxity or congenital absence of theACL.
75. managed with cast immobilization in 200
Type I fractures can be
flexion.
Type II fractures can be managed with cast immobilization of
ananatomic reduction can be maintained.
Type III fractures are generally treated operatively.
Treatment of pediatric midsubstance ACL tears iscontroversial.
Nonoperative treatment, however, has led to recurrent instability,
pain, and new meniscal and chondral injuries in a high percentage of
patients.
76. Operative treatment of pediatric ACL tears, is alsocontroversial.
Options include extra-articular reconstructions, intra-articular
reconstructions, and combined intra-articular and extra-articular
reconstructions.
No specific technique has demonstrated superiority.
Recently, the most popular techniques have included transphyseal tibial
tunnels with an over-the-top femoral placement and transphyseal tibial
and femoral tunnels with soft tissue grafts in patients nearing skeletal
maturity
77. References
Gray's Anatomy - 40th Ed
Acland's DVD Atlas of HumanAnatomy
Campbell_s_Operative_Orthopaedic
DeLee and Drezs Orthopaedic Sports Medicine
Pub med online articles
David IP Orthopedic Rehabilitation, Assessment, andEnablement.
Therapeutic excercises 3rd edn, John v Basmajian
DeLisa’s - Physical Medicine Rehabilitation 5thedn
