2. The anterior cruciate ligament (ACL) is a band of
dense connective tissue which courses from the femur
to the tibia.
The ACL is an important ligament for the proper
movement of knee joint.
ACL injury commonly causes knee instability than
injury to other knee ligaments.
Over 200,000 ACL reconstructions performed annually
in US.
ACL tears may occur in isolation or in combination
with meniscal articular cartilage , and MCL .(1)
3. The ACL is attached distally to tibia on
lateral and anterior aspect of medial
intercondyle.
It extend superioly, laterally, and
posteriorly, to attach posteromedial
aspect of lateral femoral condyle.
Two components of ACL, the smaller
anteromedial bundle (AMB) and the
larger posterolateral bundle (PLB).
The ligament is 31-35 mm in length
and 31.3 mm in cross section.
Major blood supply is Middle
genicular artery.
4. Nerve supply by posterior articular branches of
tibial nerve.(2),(3)
Mechanoreceptors at surface of ACL and they have
proprioceptive qualities also.
Primary function is restraint of anteroposterior
translation of the tibia relative to the femur.
Secondary restraint to tibial rotation and valgus or
varus stress.(4)
5. With passive range knee extension, 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 the ACL.
The ACL has a maximal tensile load of 2160±157 N and
a stiffness of 242±28 N/mm.(5)(6)
6. Many noncontact injuries occur while landing from a jump, or while quickly
and forcefully decelerating, cutting, or pivoting over a single planted lower
limb.
Three factors of MOI is:-
(1) strong activation of quadriceps muscle over a slightly flexed or fully
extended knee,
(2) Marked “valgus collapse” of the knee, and
(3) Excessive external rotation of the knee (i.e., the femur excessively rotated
internally at the hip relative to a fixed Tibia)
Most ACL tears involve a transient subluxation of knee, causing secondary
trauma to bone, articular cartilage, menisci, or MCL.(4)
8. An ACL injury is classified as a grade I, II, or III sprain.
Grade I Sprain:
The fibres of the ligament are stretched, but there is no
tear.
There is a little tenderness and swelling.
The knee does not feel unstable or give out during
activity.
No increased laxity and there is a firm end feel.
9. Grade II Sprain:
The fibres of the ligament are partially torn or
incomplete tear with haemorrhage.
There is a little tenderness and moderate swelling with
some loss of function.
The joint may feel unstable or give out during activity.
Increased anterior translation yet there is still a firm end
point.
10. Grade III Sprain:
The fibres of the ligament are completely torn
(ruptured); the ligament itself is torn completely into
two parts.
There is tenderness, but limited pain, especially when
compared to the seriousness of the injury.
There may be a little swelling or a lot of swelling.
The ligament cannot control knee movements. The knee
feels unstable or gives out at certain times.(7)
11. A thorough patient history is initial step to diagnose.
Sensations such as popping or tearing at the time of
injury.
Inability to bear weight on the injured leg.
Hemarthrosis, seen within 12 hours.
Palpation follows inspection and should begin with
the uninvolved extremity. Palpation confirms the
presence and degree of effusion and bony injury.(1)
12. Diagnosis can be made by the following procedures:
Physical assessment
o Tests:
- Lachman Test
- Anterior Drawer Test of the Knee
- Pivot shift
Radiographs
– X -ray including AP (anterior to posterior) view, lateral view, and
patellofemoral projection.
– MRI :- Acute injury ligament fibers disrupted.
Also representing local oedema and haemorrhage
– Instrumented laxity testing/arthrometric evaluation of the
knee.(1)
14. The same characteristics for an ACL injury can be
found with;
knee dislocations
Meniscal injuries
Collateral ligaments injury
Posterolateral corner injuries to the knee.
Other problems that have to be considered are:
Patellar dislocation or fracture
Femoral, tibial or fibular fracture.
15. Acute Stage
o Whether surgery will
take place or not:-
o PRICE :- Reduce
swelling and pain, to
attempt full range of
motion and to decrease
joint effusion.
16. o Exercises should encourage range of movement,
strengthening of the quadriceps and hamstrings, and
proprioception.
o Neuromuscular Electrical Stimulation (NMES)
combined with exercise.
o Taping to provide stability and to encourage reduction
in swelling.(1)
17. PRE –OPERATIVE PHYSIOTHERAPY
MANAGEMENT.
o Immobilize the knee
o Control Pain and Swelling
o Restore normal range of motion
o Develop muscle strength
o Mental preparation
18. General principal
o Restore stability
o Maintenance of full active range of motion
o Isometric ligament function
Techniques for ACL reconstruction
o Extra-articular
o Intra-articular
19. Autografts:- Patellar tendon,iliotibial tract,
semitendinousus tendon, gracilis tendon and menisci.
Allografts: Grafts taken from cadavers.
Xenografts: Grafts taken from animals.
Synthetics: Classified into 3 categories, devices.
biogradable (carbon fibers)
permanent prostheses (Gore-Tex and Dacron).
ligament augmentation. (1)
20. After Surgery –
• 0 -2 week
- Cryotherapy, electrotherapy, compression.
- Gentle flexion and extension ROM to 0°.
- Quadriceps/VMO setting
- Supported (bilateral) calf raises
- Hip abduction and extension
- Hamstring pulleys/rubbers
- Gait drill
21. 2-12 Weeks
- Cryotherapy, electrotherapy, compression.
- ROM drills
- Quadriceps/VMO setting
- Leg press (double, then single leg)
- Step-ups
- Bridges (double, then single leg)
- Single-leg calf raises
- Gait re-education drills
- Balance and proprioceptive drills (single leg).
22. Mini squats and lunges
Hip abduction and
extension with rubber
tubing
23. 3-6 Months.
- Increase difficulty,
repetitions and weight
where appropriate
- Jump and land drills
- Agility drills.
- Optimize neuromuscular
control with plyometric
exercise.(1)
Plyometric jumps over
block—lateral.
Plyometric
Agility drills in
ladders.
24. Proposed four stages of advanced rehabilitation
protocol of athletes after ACL-reconstruction:
Stage 1: Dynamic stabilization and core strengthening.
Stage 2: Functional strengthening.
Stage 3: Power development.
Stage 4: Sports performance symmetry.
25. Goals of this stage:
Improving single-limb weight-bearing function to tolerate
greater knee flexion angles.
Improving symmetry of lower extremity in running.
Enhancement of closed chain single-limb postural
balance.
Single leg dead lift
"Bridge on BOSU Wall squat
with stability
ball
26. Goals of this stage:
Increasing lower extremity non weight-bearing strength.
Improving load distribution pattern over both lower extremities
in activities requiring double-leg stance.
Improvement of single-limb landing force attenuation strategies.
Single leg squat BOSU
Single Leg Bridge on
Ball
Table-top crunches Lateral
lunges
27. At this stage, power production of lower extremity is the main aim.(8)(9).
Nordic hamstring curls. Lateral crunches
Back extension swiss ball
Barbell back squat.
28. Return to sport criteria in many studies and concluded
that in order to give clearance to return to sport an athlete
must have:
Less than 10% deficit in strength of the quadriceps and
hamstring on isokinetic testing at 180°/s and 300°/s .
Less than 15% deficit in lower limb symmetry on single-leg
hop testing (single hop, triple hop, crossover hop, and timed
hop).
Less than 3 mm of increased anterior-posterior tibial
displacement on Lachman or knee arthrometer testing.
29. - Greater than 60% normalized knee separation
distance on a video drop-jump test,
- Absence of effusion
- Full knee ROM
- Normal patellar mobility,
- No or only slight patellar crepitus,
- Painless activities without swelling.(8)(9).
30. The components of neuromuscular training are:
Balance training: balance exercises
Jump training – plyometrics: landing with increased
flexion at the knee and hip
Strengthening that emphasises proximal hip control
mediated through gluteus and proximal hamstring
activation in a close kinetic chain
Stretching
Skill training: Controlling body motions, especially in
deceleration and pivoting manoeuvres
Movement education and some form of feedback to the
athlete during training of these activities
Agility training: agility exercises.(1)(10).
31. 1. Peter Brukner and karim khan, Clinical sports medicine, Tata McGraw Hill 5th ed. 2017:737-
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2. Dodds JA, Arnoczky SP: Anatomy of the anterior cruciate ligament: A blueprint for repair
and reconstruction. Arthroscopy 10:132, 1994.
3. Kopf S, Musahl V, Tashman S, et al: A systematic review of the femoral origin and tibial
insertion morphology of the ACL. Knee Surg Sports Traumatol Arthrosc 17:213, 2009.
4. Donald A. Neumann, Kinesiology of Musculoskeletal System, Elsevier 2nd ed. 2010:533,535.
5. Woo SL, Debski RE, Withrow JD, Janaushek MA (1999) Biomechanics of knee ligaments.
Am J Sports Med 27:533–543.
6. Woo SL, Hollis JM, Adams DJ et al (1991) Tensile properties of the human femur-anterior
cruciate ligament-tibia complex.
7. William E.Prentice, Rehabilitation techniques for sports medicine and athletic training;
fourth ed. McGraw Hill publications.
8. Myer GD, Paterno MV, Ford KR, Hewett TE. Neuromuscular training techniques to target
deficits before return to sport after anterior cruciate ligament reconstruction. The Journal
of Strength & Conditioning Research 2008;22(3):987-1014.
9. Padua DA, Marshall SW, Beutler AI, DeMaio M, Boden BP, Yu B, Garrett WE. Predictors of
knee valgus angle during a jump-landing task. Medicine & Science in Sports & Exercise
2005;37(5):S398.
10. Sugimoto D. et al. Compliance With Neuromuscular Training and Anterior Cruciate
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