3. INTRODUCTION
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 noncontact injuries.
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 in adolescents.
7. ANATOMY
ACL originates on the medial wall of the lateral femoral condyle,
courses anteriorly and medially across the knee joint and inserts into
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 anteroposterior stability
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. ANATOMY
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 the posterior
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 younger ACLs.
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 the ACL.
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 the ACL.
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 bundle lengthens
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 of flexion.
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 minimal strain
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
Skiing
Slight knee flexion with/
Phantom Foot
tibial external
Knee hyperextension in
rotation/internal rotation at
ski boot
foot strike
Valgus rotation
Excessive valgus, varus,
hyperextension or rotation Other Sports
Quads active 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
Sudden stop on
extended knee
Deceleration
with change
of direction
Landing from a jump
17. CLASSIFICATION
There is no standardized system widely used in the evaluation of ACL
injuries.
Grade I: A mild injury that causes only microscopic tears in the ACL.
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: A severe injury in which the ACL is completely torn
through and the knee feels very unstable.
18. ACL Injury & Open Growth
Plates
Classification
Non - traumatic
Congenital ACL absence
Post - traumatic
- Tibial eminence avulsion (common in age<12)
- Mid-substance tear ( common in age>12 )
- Femoral avulsion (rare, repair )
19. Tibial Eminence Avulsions
Classification
Type I: minimal / no displacement
Type II: anterior hinging (1/2 to 1/3 eminence)
Type III: avulsed fragment displaced
Type IV: avulsed and fragmented
20. EVALUATION
A thorough patient history is the initial step to diagnose and treat ACL
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 Examination and
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
- pain in the knee
- a large effusion, an incompetent extensor mechanism, or a
mechanical block.
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 shift test
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. IMAGING
Plain radiographic imaging plays a primary role in the exclusion of
associated injuries in the evaluation of the ACL.
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 native ACL
28.
29. GENDER ISSUSES
Female athletes have a 4 to 6 fold greater incidence
The reasons for this gender disparity in ACL injuries are likely
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. ELDERLY
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
tears.
Lately lateral meniscal tears are more commonly seen in
association with combined ACL and MCL injuries.
32. Treatment for ACL injuries
Immediately after injury
P. R.I.C.E
Non surgical treatment
Exercise (after swelling decreases and weight-bearing
progresses)
Braces
Surgical treatment
33. BRACES
Range of motion control.
FUNCTIONAL BRACE have rigid metal
supports down the sides of the brace to
reduce knee instability following injury.
34. Non surgical Treatment
Isolated ACL tears
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 surgical Precautions
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 reconstructive procedures,
to an arthroscopic two-incision technique, to an arthroscopic one-
incision technique
Timing of Surgery
There has been ample debate surrounding the ideal timing of ACL
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 Site Complications
and Graft Harvest
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. REHABILITATION
CONSIDERATIONS
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. PREVENTION
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 Up
Warm up is designed to get ready for practice activity and to help
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
not jog flat footed.
63. Stretching
Calf Stretch Correct Incorrect
Incorrect Quadriceps Stretch
Instructions: Stand tall with
Things to look
for: bending at
your weight evenly distributed.
Correct Bend your left knee, reach
the waist, or
Things to look for: bending behind with your left hand and letting your
the stance leg, leaning grab the front of your left ankle. knee “wing”
Instructions: Stand on your forward in the pushup Bring your heel up to your out to the side.
right leg, bend forward and position, arching the back, buttock and keep your left knee
put your hands on the or raising up on your toes. pointed towards the ground.
ground in a V-form. Keep Keep your left leg close to your
your right leg straight and right leg. Hold for 30 seconds
your right foot flat on the and repeat on your right side.
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.
64. Hamstring Stretch Inner Thigh Stretch Hip Flexor Stretch
Instructions: Lunge forward leading
Instructions: Sit on the ground with Instructions: Sit on the ground, and with your left leg and kneel on your right
your left leg extended out in front. Bend spread your legs evenly apart. Keeping knee. Rest your left arm on your left
your right knee and place the sole of your back straight, reach overhead with thigh, and lean forward with your hips.
your shoe on your left inner thigh. Keep both hands. Then, slowly reach towards Keep your balance, reach back for your
your back straight and try to bring your your right foot with both hands. Hold right ankle and pull your heel to your
chest to your left knee. Reach towards the stretch for 30 seconds and then buttocks. Hold the stretch for 30 seconds
your left toes and pull them towards repeat the stretch on the left side. and repeat the stretch leading with your
your head. Hold for 30 seconds and right leg forward.
repeat with the right leg.
Things to look for: rounding your Things to look for: maintaining your
Things to look for: rounding your back back, leaning forward too fast or balance and keeping your hips square
or bouncing. bouncing with your shoulders.
65. Agility Drills
Single Leg Touches
Single Leg Sport Specific
Instructions: While standing on
Instruction: Stand on one leg and
one leg with ball on the ground in
balance while performing soccer kicks
front of you, slowly reach down with
with the other or dribbling basketball
one hand and touch the ball, then
while balancing. Perform 1-2 minutes
perform using other hand. Repeat
each leg.
10 times on each side.
Things to look for: Do not allow
Things to look for: Do not allow
balance knee to fall in towards mid line of
balance knee to fall in towards mid
body- keep knee in a slightly bent
line of body- keep knee in a slightly
position
bent position
66. Single Leg Sport Specific
Instruction: Stand on one leg and Things to look for: Do not allow balance
balance while performing soccer knee to fall in towards mid line of
kicks with the other or dribbling body- keep knee in a slightly bent
basketball while balancing. position
Perform 1-2 minutes each leg.
67. Squat Jump With Hold
Correct Landing
Incorrect landing
Instruction: Stand on ground with Things to look for: When landing
feet approximately shoulder width- make sure to land softly on balls of
perform a quick squat and then explode feet keeping knees slightly bent and
into a jump- hold the landing for a 2 pointing straight forward- No landing
count Perform 20 times.
on heels with knees straight!!
68. Single Tuck Jump
Instruction: Stand on ground with feet
Things to look for: Off balance landings-
approximately shoulder width apart- should land on balls of feet with
jump into air while bringing knees up knees slightly bent and pointing
toward chest and hitting knees with forward
hands- Be sure to land softly on balls of
feet with knees slightly bent- try to bring
thighs parallel to ground. Perform 10
times.
69. Lateral Jumps
Things to look for: Explosion at
Instruction: Stand with feet slightly
take off with plant leg making sure
apart- Push off ground with plant leg
knee does not fall in to midline of
while moving in a sideways direction
landing on opposite foot- hold 2
body and on landing make sure knee
seconds- repeat with other leg Perform stays in a forward direction with a
10 times each leg. slight bend
70. Strength Exercises
Front Plank Side Plank
Instruction: Position yourself in a “push- Instruction: Lie on either side, legs
up” start position, with your elbows on outstretched, lower elbow on floor in line
the floor in line with shoulders. Tighten with shoulder. Tighten your stomach
your stomach, lift your hips off floor till muscles, lift your hips off floor until your
your legs and upper body are in line with legs and upper body are in line.
shoulders over elbows. Things to look for: Make sure shoulder
Things to look for: Make sure to keep is positioned over elbow on the floor.
legs and torso straight. Make sure back is Keep legs and torso straight and place
not arched or curved downward. Hold 20 upper arm against side. Hold 20 seconds,
seconds, Repeat 2 times. repeat 2 times each side.
71. Assisted Russian Hamstring Curl
Instruction: Start on knees with
Things to look for: Be sure
arms crossed resting on chest and
your partner holding your feet. to tighten your stomach
Keeping your body straight, slowly while moving forward and
lower self towards floor and return back. Make sure not to arch
to upright position. Repeat 20 back when returning to start
times. position.
72. Single Leg Calf Raise
Correct Incorrect
Instruction: Stand on one Things to look for: Be sure to
foot and slowly raise up on move up and not forward (as
to toe and then back down. shown above in picture 2).
Repeat 10 times each side.
73. Forward Lunge
Correct Incorrect
Instruction: Take large step Things to look for: Make
forward and slowly lower self sure to keep your knee over
towards ground keeping your your toes when performing
knee directly over your toes. lunge.
Repeat 10 times each side. Make sure to keep your torso
straight when lowering self.
74. Paediatric ACL INJURY
The increased number of pediatric ACL injuries reflects the increased
participation seen in youth sports.
Most injuries are mid substance ACL tears or tibial avulsion
fractures.
Femoral avulsion fractures of the ACL attachment are rare.
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 the ACL.
75. Type I fractures can be managed with cast immobilization in 200
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 is controversial.
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 also controversial.
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 Human Anatomy
Campbell_s_Operative_Orthopaedic
DeLee and Drezs Orthopaedic Sports Medicine
Pub med online articles
David IP Orthopedic Rehabilitation, Assessment, and Enablement.
Therapeutic excercises 3rd edn, John v Basmajian
DeLisa’s - Physical Medicine Rehabilitation 5thedn
