Cruciate Ligaments

Mehar Sheoran (1817034)
Anisha Singh(1817107)
Nitin Bansal (1817112)

These are very thick and strong fibrous bands, which act as direct bonds of
union between tibia and femur, to maintain anteroposterior stability of knee
joint.
They are of 2 types :
 ACL (Anterior Cruciate Ligaments)
 PCL (Posterior Cruciate Ligaments)
They are named according to the attachment on tibia.

 Anterior cruciate ligament
begins from anterior part of
intercondylar area of tibia,
runs upwards, backwards and
laterally and is attached to the
posterior part of medial
surface of lateral condyle of
femur.
 It is taut during extension of
knee.

 Posterior cruciate ligament
begins from the posterior part
of intercondylar area of tibia,
runs upwards, forwards and
medially and is attached to the
anterior part of the lateral
surface of medial condyle of
femur.
 It is taut during flexion of the
knee.

 Ligament injuries occur most frequently in individuals between 20 and 40
years of age as the result of sport injuries (e.g., skiing, soccer, football) but can
occur in individuals of all ages.
 The anterior cruciate ligament (ACL) is the most commonly injured ligament.
 Often, more than one ligament is damaged as the result of a single injury.
 A woman is three times more likely to tear the ACL than a man is because of
some biomechanical risk factors, neuromuscular risk factors, structural risk
factors and hormonal differences between males and females.

ACL injuries can occur from
 Contact mechanisms
 Non-contact mechanisms
The most common contact mechanism is a blow to the lateral side of the
knee resulting in a valgus force to the knee.
 This mechanism can result in injury not only to the ACL but also to the
medial collateral ligament (MCL) and the medial meniscus. This injury is
termed the “unholy triad” or “terrible triad” injury because of the
frequency with which these three structures are injured from a common
blow.

 The most common noncontact mechanism is a rotational mechanism in which
the tibia is externally rotated on the planted foot.
 Literature supports that this mechanism can account for as many as 78% of
all ACL injuries.
 The second most common noncontact mechanism is forceful hyperextension of
the knee.
 Other mechanisms includes changing direction rapidly, stopping suddenly,
landing from a jump.

 Injury to the posterior cruciate ligament (PCL) most commonly
occurs as the result of a forceful blow to the anterior tibia while the
knee is flexed, such as a blow to the dashboard or falling onto a
flexed knee.(38.5%)
 Followed by a fall on the flexed knee with the foot in plantarflexion
(24.6%), and lastly, a sudden, violent hyperflexion of the knee joint
(11.9%).

 Grade 1 – The ligament is mildly damaged. It has been
slightly stretched, but is able to keep the joint stable.
 Grade 3 – This type of sprain is most commonly referred to
as complete tear of the ligament. The ligament has been
split into two pieces, and the knee joint is unstable.
 Grade 2 – The ligament is stretched to the point where
it become loose. This is often referred to as a partial tear
of the ligament.

 Clinical Examination –
• Occurs after either a cutting manoeuvre or single leg standing, landing or
jumping
• There may be an audible pop or crack at the time of injury
• A feeling of initial instability which may be masked later by extensive swelling
• Episodes of giving way especially on pivoting or twisting motions. Patient has
a trick knee and predictable instability
• A torn ACL is extremely painful, particularly immediately after sustaining the
injury

• Swelling of the knee, usually immediate and extensive, but can be
minimal or delayed
• Restricted movement, especially an inability to fully extend the knee
• Possible widespread mild tenderness
• Tenderness at the medial side of the joint which may indicate cartilage
injury
Physical Examination :
 Lachman Test
 Anterior Drawer Test of the Knee
 Pivot Shift test
 Posterior Drawer Test
 Posterior Sag Test

 Radiological examination - A plain X-ray may be normal, or a chip of bone
avulsed from the ligament attachment may be visible. It may be possible to
demonstrate an abnormal opening-up of the joint on stress X-rays. MRI is a
non-invasive method of diagnosing ligament in juries, and may be of use in
doubtful cases.
 Dynamic Ultrasonography - Ultrasound can be used to objectively measure the
degree of laxity when combined with functional testing (ie, Lachman and anterior
drawer tests)
 Other investigation - Arthroscopic examination may be needed in cases where
doubt persists.

Non Surgical Method
Surgical Method

 Acute sprains, partial ligament tears, and sometimes complete rupture
of a single knee ligament can be treated conservatively with rest, joint
protection, and exercise.
 In the acute stage of healing PRICE protocol will be followed to
decrease pain and swelling.
 If possible, examine before effusion sets in, utilize cold and compression
with rest and elevation.
Carolyn Kisner, Lynn Allen Colby; Therapeutic Exercise Foundations and Techniques 7th Edition -F.A. Davis Co. (2018)

 Teach protected weight bearing with use of crutches and partial
weight bearing as tolerated.
 Initiate quadriceps-setting exercises. The knee may not fully extend
for end-range muscle-setting exercises, so begin the exercises in the
range most comfortable for the patient.
 As the swelling decreases, initiate ROM within tolerance and start
exercises to improve muscle performance (strength and endurance),
normal ROM, balance, a normal gait pattern, functional status, and
cardiopulmonary conditioning.

 Joint mobility - Use supine wall
slides, patellar mobilizations, and
stationary cycling; encourage as
much movement as possible.
 Protective bracing - Bracing may be
necessary for weight-bearing
activities to decrease stress to the
healing ligament or to provide
stability when ligament integrity has
been compromised.

Improve Muscle Performance
 Strength and endurance - Initiate isometric quadriceps and hamstring exercises,
and progress to dynamic strength and muscular endurance training. Quadriceps
strength is important for knee stability.
 Neuromuscular control - Emphasize neuromuscular reeducation (proprioceptive
training) with stabilization, acceleration, deceleration, and perturbation training
in weight-bearing positions. Begin with low-intensity, single-plane movements
and progress to high-intensity, multiplane movements.

Improve Cardiopulmonary Conditioning
Utilize a program that is consistent with the patient’s goals, such as biking (begin
with a stationary bike), jogging (begin with walking on a treadmill), or swimming.
Progress to Functional Training
Develop activity-specific exercises and drills that replicate the demands of the
individual’s outcome goals.

Although there are no rigid criteria for patient selection, the most frequently cited
indications for ACL reconstruction include the following :
 Disabling instability of the knee due to ACL deficiency caused by a complete or
partial acute tear or chronic laxity.
 Frequent episodes of the knee giving way (buckling) during routine ADL as the
result of significantly impaired dynamic knee stability despite a course of
nonoperative management.
 High risk of reinjury because of participation in high demand, high joint-load
activities related to work, sports, or recreational activities after non-operative
management.

 Ligament surgeries are classified as intra-articular, extra-articular, or combined
procedures and can be performed using an open, arthroscopically assisted, or all-
arthroscopic approach.
 Initially, intra-articular procedures were performed through an open approach
and involved a direct repair of the ligament. Postoperatively, a long period
(usually 6 weeks) of immobilization and restricted weight bearing were required
because of extensive tissue disruption.
 Post-immobilization contractures, patellofemoral dysfunction and muscle
weakness were the unacceptable outcomes.

 ACL tear are not generally repaired using suture to sew it back
together, because repaired ACL have generally been shown to fail over
time.
 Therefore the torn ACL is generally replaced by a substitute graft made
of tendon.
 The graft, commonly used to replace the ACL are
 Autograft (the patient’s own tissue)
 Allograft (donor tissue)
 Synthetic

 Patient treated with surgical reconstruction of the ACL have long term
success rate of 82% to 95%
 In younger children or adolescents with ACL tear, early ACL
reconstruction creates a possible risk of growth plate injury, leading to
bone growth problem. The surgeon can delay the acl surgery until the
child is closer to skeletal maturity or the surgeon may modify the ACL
surgery technique.

 In general terms,
reconstruction involves the use
of a tissue graft to replicate the
function of the damaged
ligament and act as an inert
restraint of the knee.

 Surgical approach, graft selection, and harvesting
 The most common ACL reconstruction procedure today is an
arthroscopically assisted or endoscopic procedure using an autograft. If a
bone-patellar tendon-bone graft is selected, it is harvested through a
small, longitudinal incision over the patellar tendon from the patient’s
involved knee or occasionally from the contralateral knee. The central one-
third portion of the tendon is dissected along with small bone plugs
attached to the tendon.

 After the graft is harvested and
prepared for implantation, the
arthroscopic instrumentation is
reinserted to drill femoral and
tibial bone tunnels. Graft
placement is achieved by passing
the graft through the tunnels to its
final position in the tibia and
femur.

 Precise, anatomical graft placement is crucial for restoration of
joint stability and mobility. Improper graft placement can lead to
loss of ROM postoperatively. A graft placed too far posteriorly may
result in failure to regain full flexion, and a graft placed too far
anteriorly may limit extension.

 Extra-articular reconstruction procedures, which involve the transposition of
dynamic musculotendinous stabilizers or inert restraints around the knee, such as
the IT band, were designed to provide external stability to the knee joint.
 Extra-articular procedures, in common use in the past, particularly for MCL and
LCL injuries, are used rarely today as primary procedures because they do not
restore normal kinematics to the knee as effectively as intra-articular procedures.

When to have a surgery?
Currently, it is recommended that almost all patients and athletes who sustain a
grade 3 PCL tear should consider a reconstruction.
Patients with grade 2 PCL tears should consider reconstruction if they have trouble
decelerating, going down inclines, going down hills, or if they start to develop pain
in their kneecap joint or along the inside (medial joint line) of their knee.

 PCL reconstruction is a double bundle reconstruction with allografts.
 PCL reconstruction technique involves the creation of a closed socket tunnel in the
femur for both the anterolateral and posteromedial bundles of the PCL. The graft is
fixed in that location and pulled distally down the tibia.
 The anterolateral bundle is fixed at 90° of knee flexion. After the anterolateral bundle
is fixed to the tibia at 90° of knee flexion, the posteromedial bundle is next fixed in full
extension.
 Double-bundle PCL reconstructions have been found to be equal to the outcomes for
ACL reconstructions. Thus, most studies can successfully reconstruct the PCL 85-90%
of the time.

Week 0 - 2
 PRICE: (protective bracing, rest, ice, compression, elevation)
 Gait training: crutches, partial weight bearing to WBAT
 PROM/A-AROM (range-limiting brace, if prescribed
 Patellar mobilization (grades I/II)
 Muscle setting, isometrics: quadriceps, hamstrings, adductors at multiple angles (may augment with E-stim)
 Assisted SLRs—supine
 Ankle pumps

Week 2-4
 Continue as above
 Progress to full weight-bearing; begin closed chain squats; heel/toe raises
 SLRs in four planes
 Low-load PRE: hamstrings
 Open-chain knee extension (range 90˚–40˚)
 Trunk/pelvis stabilization
 Aerobic conditioning: stationary cycle

Week 5-6
 Multiple-angle isometrics
 Closed-chain strengthening and PRE
 LE stretching program
 Endurance training (bike, pool, elliptical trainer)
 Proprioceptive training in single-leg stance: balance board, BOSU
 Stabilization exercises, elastic bands, band walking
Week 7-10
 Advance strengthening (include PNF), endurance, and flexibility exercises
 Proprioceptive training: high speed stepping drills, unstable surface challenge drills, balance beam
 Initiate a walk/jog program at the end of this phase

Week 11-14
 Continue LE stretching
 Advance PRE/initiate isokinetic training (if desired)
 Advance closed-chain exercise
 Initiate plyometric drills: bounding, jumping
 Initiate plyometric drills (bouncing, jumping rope, box jumps: double-/single-leg)
 Advance proprioceptive and balance training
 Progress agility drills (figure-eight, skill-specific patterns)
 Simulated work or sport-specific training
 Transition to full-speed jogging, sprints, running, and cutting

 The brace is locked at 0˚ for 6 weeks to allow healing of the graft without
allowing it to be overstretched.
 Day 1 – 14
 Ensure good quality isometric quadriceps activation is achieved and practised
4–5 times daily, Patella mobilisations, Hamstring and calf stretches, Hip
abduction/extension exercises

Weeks 2 – 6
Remove brace and ensure knee can gently flex to 60˚passively.
Weeks 6 – 8
Brace unlocked to 90˚ flexion, Static cycling, lunges, Proprioception exercises e.g Calf
raises, Leg press 60˚ - 0˚, light weights.
Weeks 8 – 12
Gradually progress proprioceptive challenges, Aim for full range of movement by 12 weeks

3 – 4 Months
Begin active hamstring exercises no resistance, Progress strengthening and
fitness training, By end of 4th month running on the treadmill
4 – 6 Months
Start resisted hamstring exercises Start low intensity plyometric – jumping,
skipping , jogging and begin sprints, Progress as able to shuttle runs, high level
proprioception exercises
6 – 12 Months
Continuation of advanced sports specific skills, Monitor for signs of swelling,
pain, increased laxity / instability.

To Increase Knee Extension
To Increase Knee Flexion
To Increase Mobility of IT band

 Decreased extensibility of the hamstring musculature and periarticular tissue
posterior to the knee can restrict full knee extension.
 Increasing knee extension is a two-step process.
 First, full extension of the knee is obtained without placing tension on the
hamstrings at the hip (the hip is maintained at or near 0° extension). After full
knee extension has been at tained, a stretch is applied to the two-joint hamstring
muscle group by progressively flexing the hip while maintaining the knee in
extension (SLR position)

1. PNF Stretching Techniques
Patient position –
Supine, Hip and knee extended as much as
possible
Procedure –
 Ask patient to perform isometric contraction of
the knee flexors and resist by placing the hand
proximal to the heel.
 Ask patient to hold the position and then relax.
 The therapist will passively extend the knee in
the newly gained range

2. Gravity-Assisted Passive Stretching Techniques
Use a low-intensity, long-duration stretch to ensure that the patient
stays as relaxed as possible.
 Prone Hang
Patient position : Prone, hips extended with the patient’s foot off the
edge of the treatment table.
To increase the stretch we can put weight cuff which wil increase the
stretch, therefore help in knee extension.
 Supine Heel Prop
Patient position : Supine, knee extended as much as possible
Towel roll placed under the distal leg to elevate the calf and knee off
the table
This provides stretch on the hamstring muscle.
Weight cuff can be used proximal to the knee joint

3. Self-Stretching Technique
Patient position and procedure:
Long-sitting, with the distal leg supported on a
rolled towel.
Have the patient press down with the hands
against the femur just above (not on) the patella
to cause a sustained force to increase knee
extension.

Before stretching to increase knee flexion, be sure the
patella is mobile and is able to glide distally in the
trochlear groove as the knee flexes.
1. PNF Stretching Techniques
 Patient position and procedure: Sitting at the edge of
treatment table
 Knee flexed as much as possible
 Procedure : ask the patient to contract knee extensors
and apply resistance just proximal to the ankle
 Ask patient to relax
 Passively flex the knee or say the patient to actively
flex through the newly gained range of motion

2. Gravity-Assisted Passive Stretching Technique
 Patient position – high sitting, knee flexed (as
possible), legs hanging in the air
 Instruct the patient to relax the thigh muscles
and let the weight of the leg create a low-
intensity, long-duration stretch.
 To increase the stretch a light cuff weight around
the distal leg can be used.

3. Self-Stretching Techniques
A. Gravity-Assisted Supine Wall Slides
 Patient position and procedure: Supine, buttocks
close to the wall and lower extremities resting
vertically against the wall (hips flexed, knees
extended).
 Ask the patient to slowly flex the involved knee
by sliding the foot down the wall until a gentle
stretch sensation is felt.
 Hold the position for a period of time
 Then slide the foot back up the wall

B. Self-Stretch with Uninvolved Leg
 Patient position : Sitting with legs dangling over the edge
of a bed and ankles crossed.
 Apply force on the affected leg with the uninvolved leg,
just above the ankle.
C. Rocking Forward on a StepSitting
 Patient position : Standing, with the foot of the involved
knee on a step.
 Rock forward on the foot stabilized on the stepper by
flexing the knee to the limit of its ROM.

D. Sitting
 Patient position : Sitting on a chair, with the
involved knee flexed to the end of its available
range and the foot firmly planted on the floor.
 Ask the patient move forward on the chair and
don’t allow the foot to slide.
 Hold the position for a comfortable, sustained
stretch of the knee extensors

 The IT band is a strong fibrous band of connective tissue that is not easily
stretched, although mobility of its distal attachment at the knee is necessary for
proper patellar tracking and knee flexion
 The distal attachment of the TFL and approximately one-third of the gluteus
maximus insert into the proximal IT band and therefore affect its mobility

1. Foam Roller Fascial Release
 Patient position - Side-lying with the
involved thigh on a foam roller
(dense foam cylinder) positioned
perpendicular to the femur.
 Maintain the hip of the involved side
in extension, flex the top hip and
knee (uninvolved side), and plant the
foot on the floor.
 Have the patient on the forearm or
hands to lift the trunk and adduct
the hip of the involved leg
 Then roll the lateral thigh
proximally and distally on the roll
along the IT band or maintain a
sustained pressure against the IT
band

Open chain exercises
Closed chain exercises

1. To Develop Control and Strength of Knee Extension (Quadriceps Femoris)
A. Quadriceps Setting (Quad Sets)
 Patient position and procedure: Supine, sitting in a chair (with the heel on the
floor) or long-sitting with the knee extended (or flexed a few degrees) but not
hyperextended. Have the patient contract the quadriceps isometrically, causing
the patella to glide proximally; then hold for a count of 10, and repeat.
 verbal cues to the patient- to push your knee back and tighten your thigh muscle”
or “Try to tighten your thigh muscle and pull your kneecap up.
 Have the patient dorsiflex the ankle and then hold an isometric contraction of the
quadriceps

B. Straight-Leg Raise
 Patient position and procedure: Supine, with the knee extended.
 To stabilize the pelvis and low back, the opposite hip and knee are
flexed, and the foot is placed flat on the exercise table
 First, have the patient set the quadriceps muscle, and then lift the
leg to about 45° of hip flexion while keeping the knee extended.
Have the patient hold the leg in that position for a count of 10 and
then lower it.
 To progress, have the patient lift to only 30° and then to only 15° of
hip flexion, and hold the position.
 To increase resistance, place a cuff weight around the patient’s ankle

C. Straight-Leg Lowering
 Patient position and procedure: Supine. If the patient cannot
perform an SLR because of a quadriceps lag or weakness, begin by
passively placing the leg in 90° of SLR position (or as far as the
flexibility of the hamstrings allows), and have the patient gradually
lower the extremity while keeping the knee fully extended
 Be prepared to control the descent of the leg with your hand under
the heel as the torque created by gravity increases.
 If the knee begins to flex as the extremity is lowered, have the
patient stop at that point, then raise the extremity upward to 90°.
 Have the patient repeat the motion and attempt to lower the
extremity a little farther each time while keeping the knee
extended.
 When the patient can keep the knee extended while lowering the leg
through the full ROM, SLRs can be initiated.

2. To Develop Control and Strength of Knee Flexion (Hamstrings)
A. Hamstring Setting (Hamstring Sets)
 Patient position and procedure: Supine or long-sitting, with the knee in extension
or slight flexion with a towel roll under the knee.
 Have the patient isometrically contract the knee flexors just enough to feel tension
develop in the muscle group by gently pushing the heel into the treatment table
and holding the contraction.
 Have the patient relax and then repeat the contraction
B. Multiple-Angle Isometric Exercises
 Patient Position - Supine or high-sitting.
 Apply either manual or mechanical resistance to a static hamstring muscle
contraction with the knee flexed to several positions in the ROM

C. Hamstring Curls
 Patient position and procedure-
Maximum resistance from gravity
occurs when the knee is at 90° flexion.
Apply resistance with ankle weights or
a weighted boot. If the patient flexes
the hip, stabilize it by having the
patient place the anterior thigh against
a wall or solid object.
 Can be done in prone position also

 Initiation of closed-chain exercises - During rehabilitation, closed-chain exercises
can be incorporated in an exercise regimen as soon as partial or full weight
bearing is safe.
 In certain portions of the ROM, closed-chain strengthening exercises generate less
shear force on knee ligaments, particularly anterior tibial translation, than open-
chain quadriceps strengthening activities.
 Therefore, resistance can be added to closed-chain activities sooner after injury or
surgery than can be added to open-chain exercises while still protecting healing
structures such as the ACL.
 Clinically, closed-chain exercises enable a patient to develop strength, endurance,
and stability of the lower extremity in functional patterns sooner after knee injury
or surgery than do open-chain exercises.

 Partial weight-bearing and support techniques - If the patient does not tolerate or
is not permitted to bear full weight on the involved extremity, begin exercises with
upper extremity assistance, such as in the parallel bars or in a pool, to partially
unload body weight and avoid excessive biomechanical stress.
 Also consider use of supportive taping techniques or bracing to ensure proper
alignment during weight bearing.

1. Closed-Chain Isometric Exercises
A. Setting Exercises for Co-Contraction
 Patient position and procedure: Sitting on a chair, with the knee extended or slightly
flexed and the heel on the floor.
 Have the patient press the heel against the floor and the thigh against the seat of the
chair and concentrate on contracting the quadriceps and hamstrings simultaneously to
facilitate co-contraction around the knee joint.
 Hold the muscle contraction, relax, and repeat.
 Use biofeedback to enhance learning of the co-contraction
B. Alternating Isometrics and Rhythmic Stabilization
 Alternating Isometrics and Rhythmic Stabilization
 Patient position and procedure: Standing, with weight equally distributed through both
lower extremities.
 Apply manual resistance to the pelvis in alternating directions as the patient holds the
position.
 This facilitates isometric contractions of muscles in the ankles, knees, and hips.

2. Closed-Chain Dynamic Exercises
A. Scooting on a Wheeled Stool
 Patient position and procedure: Sitting
on a rolling stool or chair.
 Have the patient “walk” the feet forward
to use the hamstrings or “walk”
backward to use the quadriceps
 Be certain the knee is aligned vertically
over the foot to avoid hip adduction,
internal rotation, and subsequent valgus
alignment of the lower leg.

B. Unilateral Closed-Chain Terminal
Knee Extension
 Patient position and procedure:
Standing, elastic resistance looped
around the distal thigh and secured to a
stationary structure
 Have the patient actively perform
terminal knee extension while bearing
partial to full weight on the involved
extremity.

C. Partial Squats, Minisquats, and Short-Arc Training
 Patient position and procedure: Begin by having the patient flex both knees up to
30° to 45° and then extend them.
 Progress by using elastic resistance placed under both feet or by holding weights
in the hands.
 The patient should maintain the trunk upright, concentrate on maintaining a
posterior weight shift, and lower the hips as though sitting down before moving
the knees.
 The knees should maintain alignment with the toes to prevent valgus collapse and
should not move forward beyond the toes to ensure gluteal activation and
decreased forces on the patellofemoral joint.
D. Standing Wall Slides
 Patient position and procedure: Standing, with back against the wall.
 Flex the hips and knees, and slide the back down and then up the wall, lowering
and lifting the body weight

ACL & PCL
INJURIES
Anisha Singh(1817107) Mehar Sheoran (1817034) Nitin Bansal (1817112)

Cruciate Ligaments

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Cruciate Ligaments

Similar to Cruciate Ligaments (20)

Recently uploaded

Recently uploaded (20)

Cruciate Ligaments