Anterior Cruciate Ligament

(ACL) Tears

Submitted by : Under the guidance of:

Amandeep Singh(MPT 1st year) Dr. Mithilesh Kumar
Roll no.:4802
Anatomy
 The knee joint is formed by the
femur, tibia, and patella. The
ACL is one of the four main
ligaments in the knee that
connect the femur to the tibia.
The knee is a hinge joint that
is held together by the MCL,
LCL, ACL and PCL.
 The anterior cruciate ligament
runs posteriorly and superiorly
from its attachment near the
front of tibial plateau to its
femoral attachment at the
posterolateral aspect of the
intercondylar notch.
Contd…
When the ACL is injured, the shinbone can slide forward on
the thighbone causing the knee to “give way”.
 Mechanism of Injury
 When the knee is forced into an unusual position, the
ligaments in the knee can partially or fully tear.
 Stopping and changing directions suddenly can cause
the ligaments to do this.
 Cutting, pivoting and jumping in sports such as
basketball, volleyball, skiing & soccer are all causes of
ACL tears.
This diagram
shows the
twisting motion
that causes the
ACL to tear.
 Mechanism: Contact

 Hit on outside of leg

 Foot planted
 Twisting of knee
Mechanism: landing
 Knee slightly flexed on landing
 Quads pulls tibia forward
Risk Factors

 Poor landing + pivot style

 Stronger quads than hamstrings
 Shoe / playing surface interface
 Playing surface quality
 Female gender
Contd…
 Female Gender
 2-8x more common in
girls
 Poor ham:quad strength
 Activate hams more
slowly
 Land with knees slightly
bent
Boys land with knees
more bent
Hormonal Influences
 ACL have estrogen
receptors
 Estrogen can  ligament
looseness
 Estrogen levels  in girls
 Estrogen ’d at specific
times in menstrual cycle
Contd…
 Knee anatomy
 Smaller intercondylar
notch
 ACL may get stretched
across bone and torn
 Athletes with bilateral
ACL injuries have
smaller ICN
 Lower extremity alignment
 Women more knock-
kneed
 May allow quad to exert
more stress on ACL
This diagram shows one of the possible theories on why
females tear their ACL more often. Look at the “reverse U
shape” compared to the “A shape notch”.
 How can you recognize an ACL tear in an
athlete?

 An athlete with an ACL tear will experience:

 Swelling
 Loss of range of motion
 Effusion-hemarthrosis, immediate
 Pain or tenderness along the joint line
 Discomfort and unstable walking
- The athlete will report that the knee was forced
beyond its normal range
- The athlete may report having felt a pop, tear,
or snapping sound
 Special Tests

 Anterior drawer

 Lachman test

 Pivot shift test

 Valgus stress test

at full extension!
LIGAMENT INJURIES:DIAGNOSIS

 Serial Exams
 Plain radiography
 Arthrocentesis ?
 MRI??
Treatment for ACL tears

There are both surgical and non-surgical options for treating an ACL
tears.
Surgical
* When doctors do ACL reconstructive surgery, they usually
replace the ligament by a substitute graft made of tendon.
This is because ACL tears that used suture to sew it back
together showed to fail over time. Some of the grafts that
doctors may use are Patellar, Hamstring, Quadriceps, Auto
graft (taken from a cadaver).
* In repair surgery, the doctors sews together the torn ligament.
This type of surgery has been shown to fail, therefore more
often the doctors will do reconstructive surgery.
 Arthroscopic Surgery
 There are many benefits to this surgery and it is
becoming more popular.
This surgery:
- Uses smaller incisions
- Has fewer risks than open surgery
- Rehabilitation is usually quicker
- Doctors can see and work on the knee structures
*The primary goal of ACL surgery is to restore
normal stability in the knee and the level of
function the person had before the knee injury,
limit loss of function in the knee, and prevent
injury or degeneration to other knee structures.
The picture above shows an arthroscopic view of an ACL after using a hamstring auto
graft.
Rehabilitation
 Physical therapy is a crucial part
of ACL surgery. Most of the
success of the surgery is
dependent upon the athlete’s
determination to build strength
within the knee. This should begin
immediately after surgery.
 The first 10-14 days after the
surgery, the focus is on the ability
to fully straighten the knee and
restore quadriceps control. The
knee should be iced regularly to
reduce swelling.
 Physical therapy will work on the
same exercises as post surgery,
but an athlete may have to modify
their activity style. For example,
limit sports involving cutting,
pivoting and landing.
Sample Rehabilitation Program
 WEEK 0-2:
 Weight bearing as tolerated(25%-50%)
 Quadriceps and Hamstring isometrics
 Electrical muscle stimulation
 Ankle ROM and strengthening
 Heel slides
 Patellar mobilization
 WEEK 4:
 Full weight bearing with protective brace Straight leg raises
 Quadriceps and Hamstring isometrics
 Straight leg raises
 Electrical muscle stimulation
 Pool exercises (hip and ankle)
 Stationary bike
 Trunk/ pelviis stabilization
 WEEK 6:
 Full weight bearing without brace
 Quadriceps and Hamstring isometrics
 Straight leg raises with weight
 Hamstring curls
Hamstring Curl
 Hip progressive resistance exercises
 Proprioceptive training
 Cycling for ROM
 Contd…
 WEEK 8:
 Full weight bearing without brace  6 MONTHS:
 ROM should be 0 and 110 degrees  Flexibility exercises
 Cycling  Begin terminal knee extension
 Hamstring curls   Running drills
 Jump rope  Drills specific to sport or occupation
 Swimming
 3 MONTHS:
 ROM 0 and 125 degrees
 Treadmill walking
 Cycling
 Quarter squats
 Plyometric drills ( bouncing, box jumps
etc)
 4 - 6 MONTHS:
 Full ROM
 Agility drills
 Isotonic knee extensions
 Isokinetics when 10% of body weight
can be done isotonically
 Step-ups
Bracing
 “There is little evidence to
support the use of a post-
operative brace following
isolated reconstruction of the
ACL.”
 “Although the exact
mechanism for any beneficial
effect of functional bracing
remains unknown, ACL
deficient athletes commonly
report improved confidence
with use of a functional knee
brace.”
 “The use of functional bracing
should perhaps be reserved
for return to sport following
revision surgery or in athletes
who have suffered a multiple
ligament injury.”
Rehabilitation
 Slight variations depending on age, history, activity level, graft
source and associated injuries.
 Five phases
 Phase I- Immediate post-op (0-2 weeks)
 Phase II- Early Rehabilitation Activities (2-6 weeks)
 Phase III- Advanced Rehabilitation Activities (6-10 weeks)
 Phase IV- Advanced Functional Activities (10 weeks- 6
months)
 Phase V- Return to Sport (6-12 months)
 Returning to competition
 The patient may return to sports when there is no more pain or
swelling, when full knee range of motion has been achieved, and
when muscle strength, endurance and full use of the leg have been
fully restored.
 If patient has met criteria of full ROM, good stability, and 90% or
better strength compared to uninvolved extremity they are
considered to be eligible to return to play.
 They should also have a positive psychological mind set.
 The final decision should be made by the physical therapist who
has been through the entire rehabilitation process.
Prevention

 Similar to preventing all other injuries, proper warm up and stretching

is vital.
 The newest prevention techniques for ACL tears has been in specific
jumping and landing training techniques. Programs that are designed
to enhance the dynamic function of the leg are ones that have proven
to work the best.
 Many preventive programs have these same common denominators:
 *Improving balance on single legs specifically
 *focusing on avoiding the knock-kneed position when landing,
stopping and cutting
 *strengthening the core muscles around the pelvis including the
hamstring and back of thigh
 *plyometrics
 *teaching proper landing techniques
 *using verbal cues such as “light as a feather” or “recoil like a
spring” when teaching landing help athletes focus on the
technique
Prevention Strategies

 Shoe wear / field surface

 Bracing
 Exercise Programs
 Change muscle strength + activation

 Change landing / Pivoting patterns

Prevention: shoe wear
 Shoes with lower ACL injury risk:
 Cleats flat, all the same size on forefoot

 Screw in cleats with 0.5in ht/diameter cleats

 Pivot disk: 10-cm circular edge on sole of forefoot

 Flat shoes on turf

 Want balance of too much / too little traction

THANK YOU