The document summarizes key information about the anterior cruciate ligament (ACL): - The ACL connects the femur to the tibia and stabilizes the knee joint, preventing excessive shifting. - ACL injuries are common in sports involving pivoting, cutting, and deceleration. Diagnosis involves physical exams like the Lachman and drawer tests along with imaging like MRI. - Treatment may involve rehabilitation or reconstruction surgery depending on severity. Post-surgery rehabilitation focuses on regaining range of motion and strength before returning to sport.

1. Submitted by
Neelesh kumar
Choudhary
MPT 1 YR
SPORTS
Submitted by:
Dr. Sneha Joshi
Associate Professor
MAHSI

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)

7. Deceleration with change in direction
Sudden stop on extended knee

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)

13. Pivot shift test.
Sensitivity: 24%
Specificity: 98%
Anterior drawer
test
Sensitivity: 93%
Specificity: 91%
Lachman test
Sensitivity: 85%
Specificity: 94%

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).

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