Anterior Cruciate Ligament Injury - Clinical Review

Client:
A 29 y/o male who is a soccer player for the Philippine Team ℅ (L) knee pain and difficulty
in weight- bearing (WB). ~ 5 weeks p injury, while playing soccer, the pt. Believed that the injury
occured when pivoting on his (L) leg while trying to get out of the way of another player. Pt.
reported that there was no pain right p the injury and continued playing until the pt. Experienced
an increase in pain and difficulty in WB. The pt. consulted an MD, no imaging was done therefore
his injury could not be properly diagnosed. The pt. has stopped playing soccer and experienced
a ~ 65% improvement since the initial injury. The area of pain was described deep within the joint
and localized on the posterior aspect of the knee.

Title/Condition:
Anterior Cruciate Ligament Injury (ACL Injury)

Differential Diagnosis:
● Posterior Cruciate Ligament Injury (PCL Injury)
● Articular Cartilage Injury
● Patello-Femoral Pain Syndrome (PFPS)
● Meniscal Tear

Description:
Anterior cruciate ligament (ACL) injury is one of the most common injuries in sports, with
previous studies showing males had a higher absolute ACL injury rate of 57% -69% than
females.(Dai et al., 2012). According to Siel (2016), males were more likely to be injured in
pivoting/contact sports before 35 years old. About 72% of all ACL injuries occur in males due to
the fact that males participate in sports more than females (Woo et al., 2001). The important
ligaments of the knee consists of the ACL, PCL, LCL, and MCL. The ACL connects the medial
border of the lateral femoral condyle to the anterior aspect of the tibia, while the PCL connects
the lateral border of the medial femoral condyle to the posterior aspect of the tibia. Therefore the
main actions of the ACL and PCL are to prevent anterior and posterior translations (English,S., &
Perret, D., 2010). ACL injury consists of an audible popping sound, the early occurrence of
swelling as a result of hemarthrosis, and an inability to continue to participate in the game or
practice after the injury (Spindler & Wright, 2008).
 According to Musahl et al., (2020) the goal for ACL treatment such as performing an early,
anatomic ACL reconstruction to afford restoration of joint stability and knee function will help
prevent negative effects such as arthrofibrosis, subsequent meniscus and articular cartilage
injury, and/or the development of OA. There has been an increased focus on the importance of
performing EBP which refers to exercise therapy, which may include with other modalities that
have scientific evidence of benefit. Exercise therapy consists of resistance training,
neuromuscular exercise, high-level dynamic functional tasks and sport-specific training (Filbay &
Grindem, 2019).
Causes:
● The mechanism of injury of ACL in individuals who partake in physical activities often
involves faulty landing technique, deceleration, pivoting or cutting with excessive anterior
shear forces (Brophy et al., 2010).
● Noncontact ACL injuries during a deceleration maneuver combined with a change of
direction while the foot is in a closed chain position (foot is pronated, tibia is internally
rotated, and the knee is at or near full extension (range of 0–20 degrees of flexion); if the
athlete attempts to change direction this causes excessive torsional force that can
potentially strain or rupture the ACL (Silvers & Mandelbaum, 2011).

Risk Factors:
● Age
○ 15 to 25 y/o (Nessler, Denney & Sampley, 2017)
● Sex
○ Female, four to six times greater than male (Kaeding et al., 2015; Nessler, Denney
& Sampley, 2017)
● Body Mass Index (BMI)
○ Pfeifer, Beattie, Sacko & Hand, (2018) reported that individuals who have higher
weight than average have greater risk of injury.
● Onset of Menarche
○ Females who are in post of menarche or in the pre-ovulatory menstrual phase have
increased risk of injury (Pfeifer, Beattie, Sacko & Hand, 2018).
● High level of activity
○ High activity levels are risk factors for ACL injury (Levins et al., 2017).
● Sport participation
○ Increased sport participation sessions per week have higher risk of injury (Pfeifer,
Beattie, Sacko & Hand, 2018).
● Prior ACL Injury
○ Previous ACL injury has higher risk of reinjury on the same knee ( Pfeifer, Beattie,
Sacko & Hand, 2018).
● Playing surface
○ Uneven playing surfaces may play a role in ACL incidence rates,landing or
stepping on an uneven surface (inconsistency in grass or another player) (Silvers
& Mandelbaum, 2011)
○ (Pfeifer, Beattie, Sacko & Hand, 2018),
● Weather conditions
○ Cold weather was associated with a lower risk of ACL injuries compared with hot
weather in open/ outdoor stadiums (Silvers & Mandelbaum, 2011).
● Muscle strength
○ If presence of weakness of hamstrings or a delay in contraction time in comparison
with the quadriceps, the ACL may be at an increased risk for injury and
subsequently lead to tensile failure (Silvers & Mandelbaum, 2011).
● Increased joint laxity
○ Females have higher chance of generalized joint laxity than male that increased
greater risk of ACL injury (Hewett et al., 2016).
● Q-angle
○ Wetters et al., (2016) illustrated that an increase in Q-angle has been correlated
with decreased muscular control and dynamic knee valgus in athletes who have
sports that require jumping.
● Anterior pelvic tilt
○ Based on the article of Hertel et al.(2004), a relationship between pelvic tilt angle
and anterior cruciate ligament injury where limbs that had previously suffered ACL
ruptures were found to have increased navicular drop and anterior pelvic tilt
compared to uninjured limbs.
● Subtalar pronation
○ According to Loudon, Jenkins, and Loudon (1998) subjects with ACL injuries had
greater amounts of subtalar joint pronation than non-injured subjects and
concluded that hyperpronation of the foot and ankle may increase the risk of ACL
injury.
● Increased posterior tibial slope (PTS)
○ Increased in lateral PTS was linked with greater risk of ACL tear (Bojicic et al.,
2017).
● Decreased width of femoral notch
○ It is associated that the decreased width of femoral notch will increase chance of
ACL strain with the position of knee extension and extreme internal rotation of tibia
(Levins et al., 2017).
● Decreased ACL size
○ The reduced size of ACL is a significant risk factor for ACL injury (Bayer et al.,
2020).
● Limb alignment
○ Wetters et al., (2016), reported that limb position at the time of a non-contact injury
have higher consistent findings of risk of injury.
● Multiple neuromuscular factors
 ○ Neuromuscular factors are associated with an athlete ’s risk for future ACL injuries
(Hewett et al., 2016).
● Footwear
○ Athletic footwear also has the potential to increase the risk of non-contact ACL
injury by increasing peak KFM during sporting activities (Sayer et al.,2018).

Examination:
Subjective:
1. Past Medical History: Does the patient have any history of ACL injury or any injury on
the knee? Was there any surgery performed on the knee?
- Nearly 1 in 4 young athletic patients who sustain an ACL injury and return to high-risk
sports will go on to sustain another ACL injury at some point of their career. Compared to
uninjured adolescents, a young athlete who returns to sports after ACLR may be at a 30
to 40 times greater risk of ACL injury (Wiggins et al., 2016).
2. Nature of Symptoms: What are the symptoms that bother the patient? Was the onset of
pain or other symptoms slow or sudden?
- More than five years after ACL rupture, knee pain, symptoms, recreational limitations, and
impaired QOL are common (Filbay & Grindem, 2019). Persons with an undiscovered ACL
injury will experience some degree of pain, discomfort, and disability that will be
aggravated by playing soccer (Bjordal et al., 1997)
3. Aggravating/Alleviating Factors: What are the exact movements or activities that cause
symptoms? Does the symptoms stay the same with cessation of activity or does it
decrease?
- More than half of those with ACL rupture who regularly participated in high-level activities
such as jumping, pivoting and cutting sports before injury have significant knee instability,
even during daily activities (“non-copers”). There are some individuals, though, who are
able to return to these high level activities without episodes of giving way (“copers”)
(Chieleswski et al., 2001).
4. Mechanism of Injury: Was there any inciting trauma or repetitive activity to the knee prior
to the injury?
- ACL injuries that occur without physical contact between athletes are referred to as non-
contact ACL injuries and most commonly occurs through non-contact mechanism of injury
in sports in which sudden deceleration, landing, and pivoting maneuvers are repeatedly
performed. Mechanically, ACL injury occurs when an excessive tension force is applied
 on the ACL. A non-contact ACL injury occurs when a person themselves generates great
forces or moments at the knee that apply excessive loading on the ACL (Yu & Garrette,
2007). Non-contact mechanisms account for 60-70% of ACL injuries (Sherman & Naclerio,
2017).
5. Dominant extremity: Is the patient right-footed or left-footed?
- Right-footed kickers have a higher propensity of tearing their left ACL since the plant foot
is the left leg. When the players are preparing to strike a ball with their right foot, they load
their left leg with a significant amount of torque and stress to ensure maximal force
distribution to the ball with their contralateral foot (Erickson et al., 2013).
6. Medications: Has the patient taken analgesics, steroids, or any other medications?
- Medication for ACL injuries consists of analgesics. Preoperative drugs may include
cyclooxygenase-2 (COX-2) inhibitors and opiod analgesic agents. Postoperatively, the
patient may obtain pain relief through nonsteroidal anti-inflammatory drugs (NSAIDs) and
opioid analgesics (Gammons et al., 2016). The combination of COX-2 inhibitor and
dexamethasone results in better pain relief 24 hours after surgery in patients undergoing
outpatient ACL surgery, compared to COX-2 inhibitor alone or dexamethasone alone
(Dahl & Waage, 2011).
7. Tests conducted: Has the pt. undergone any clinical examination or imaging techniques
after the injury? Was there any other structures affected by the injury?
- Clinical examination of knee injuries, specifically ACL tears, is indicated immediately
following injury. The clinical exam will include observation, palpation, clinical diagnostic
tests, and a neurological exam. Positive clinical diagnostic tests should prompt the
examiner to refer the patient for further diagnostic testing (Brady & Weiss, 2018). MRI has
shown a high prevalence of clinically occult bony lesions in the affected knee patients with
an acute ACL tear. An “MRI triad” has been described, consisting of ACL disruption, bone
bruise to the terminal sulcus of the lateral femoral condyle, and areas of abnormal signal
to the posterolateral corner of the tibial plateau (Maffulli et al., 2003).
8. Alternative Treatment: Has the pt. been wearing knee bracing after the injury?
- Bracing has been proposed as a means of reducing ACL injury, since the ligament may
be subject to much lower peak strain in a functional brace, as has been suggested with
the use of a motion-capture system in evaluations of an athlete at high risk for ACL injury
(Musahl & Karlsson, 2019).
Objective:
1. Gait abnormality: Observe the patient’s knee joint angles and moments compared with
the uninjured limb during walking, stair climbing, and running.
- When compared with the uninjured contralateral side, less flexion and less internal rotation
was found for the injured knee during walking. During stair descent, peak flexion was
decreased for injured knee compared with uninjured knee. Overall, reduced flexion and
adduction moments indicate altered joint loading (Kaur et al., 2016).
2. Muscle strength: Assess for the knee muscles strength with comparison of both sides.
- Typical sequelae of ACL injury and surgical treatment include persistent quadriceps
femoris strength deficits, which may remain at the time of return of activity despite targeted
rehabilitation (Birchmeier et al., 2019). The deficit of isometric quadriceps muscle strength
on the injured side compared with that of the uninjured side was explained by the
voluntary-activation deficit and a true muscle weakness. On the other hand, the diminished
muscle strength of the uninjured side was explained sufficiently by the voluntary-activation
deficit alone (Urbach et al., 1999).
3. Joint mobility: Passively examine the patient’s mobility. Note any movement that
produces or increases existing pain or symptoms.
- Typical impairments after injury include varying degrees of muscle strength deficits,
altered movement patterns, decreased knee joint proprioception, and increased passive
knee laxity. Collectively, these impairments contribute to the varying degrees of functional
knee instability that patients with ACL rupture experience.(Filbay & Grindem, 2019).
4. Proprioception: Assess for the knee’s ability to provide afferent information on the
position and movements of the joint.
- ACL injuries can be detrimental to proprioception of the knee and this may lead to
abnormal movement patterns which are a mechanism for further injuries and long-term
secondary problems. The two most common proprioception measurement techniques are
joint kinesthesia and joint position sense (Herrington & Tyson, 2014).
5. Ocular Inspection: Observe the patient’s expression or attitude towards the treatment. Is
the patient apprehensive, in discomfort, or restless? Is the patient willing to move?
- Lack of knee confidence and fear of movement due to injury are common and are related
to poorer patient-reported function and performance-based function. Positive
psychological readiness to return-to-sport is associated with better patient-reported and
performance-based function (Hart et al., 2017).
Diagnostic Tests:
Rule In:
● Lachman
The patient is in supine position. The clinician positions the patient’s knee at 15-30˚ of
flexion while holding the tibial plateau with one hand and the proximal aspect of the knee
with the other hand. The clinician applies a swift anterior perpendicular force to the tibia.
The test is considered positive when the clinician observes an anterior glide of the tibia
and/or palpates an absent end-feel significantly different from the unaffected side (Décary
et al., 2018).

Lachman's test is generally regarded as the best test for assessing ACL integrity with a
sensitivity of 87% and a specificity of 93% (Coffey & Bordoni, 2020).

● Anterior drawer test

The patient is in supine position. The clinician positions the patient’s knee at 90˚ of flexion
while stabilizing the limb by sitting on the foot of the patient. Using both hands, the clinician
holds the tibial plateau and applies a slow anterior perpendicular force to the tibia. The
test is considered positive when the clinician observes an anterior glide of the tibia
significantly different from the unaffected side (Décary et al., 2018).

The anterior drawer test has a sensitivity of 48% and a specificity of 93% (Coffey &
Bordoni, 2020).

● Pivot shift
The patient is in supine position. The clinician fully extends and internally rotates the
patient’s knee. The clinician’s distal hand is placed at the patient’s ankle to maintain
internal rotation while his other hand palpates the lateral tibial plateau while inducing a
slight valgus stress on the knee. The clinician then slowly flexes the knee. The test is
considered positive if, during the first 30˚ of flexion, the clinician observes or palpates a
subluxation and/or gliding of the tibial plateau significantly different from the unaffected
side (Décary et al., 2018).

The pivot shift test has a sensitivity of 61% and a specificity of 97% and has the highest
positive predictive value of the 3 tests.Results have suggested that the pivot shift test has
 a lower sensitivity than the Lachman test because it is generally a harder test to perform
in the acute setting due to patient guarding (Coffey & Bordoni, 2020).

● Lever sign
The Lever Sign test involves placing a fulcrum under the supine patient's calf and applying
a downward force to the quadriceps. Depending on whether the ACL is intact or not, the
patient's heel will either rise off of the examination table or remain down (Lelli et al., 2016).

Lever Sign test is both sensitive and specific in diagnosing ACL tears. sensitivity and
specificity were 0.77 and 0.90. This test may be used in addition to other tests to rule in
and rule out the presence of an ACL rupture (Lelli et al., 2016).

● MRI
MRI was highly sensitive for MM (96%) with specificity of 52%. MRI showed lower
sensitivity (70%) and higher specificity (85.5%) for LM. The specificity of MRI for ACL
rupture was 92%, with sensitivity only 75%.A combination of lever signs, pivot shifts (PSs)
and Lachman tests showed the best sensitivity and specificity in detecting ACL deficiency,
and was superior to MRI (Krakowski et al., 2019)

Rule Out:
● Mcmurray
A test is considered positive when a click can be heard and/or felt on joint line palpation
when the knee is bent beyond 90° flexion and the tibia is rotated on the femur into full
internal rotation then full external rotation (to test the lateral and medial meniscus
respectively) (Blyth et al., 2015).
● Apleys
Apley’s Test is carried out with the patient prone and the knee flexed to 90°. The tibia is
then compressed onto the knee joint while being externally rotated. If this manoeuvre
produces pain, this constitutes a positive test (Blyth et al., 2015).

● Thessaly
The examiner supports the patient by holding the patient’s outstretched hands while
he/she stands flatfooted on the floor. The patient then rotates his or her knee and body,
 internally and externally, three times, keeping the knee in slight flexion (20°). Patients with
a suspected meniscal tear will experience medial or lateral joint line pain if the test is
positive (Goossens et al., 2015).
● Valgus Stress test
The patient toward the edge of the examination table allows the examiner to have the
thigh rest on the bed, which can relax the lower extremity. Stress testing begins by
applying a valgus force at 0 and 30 degrees while assessing the amount of ligament
opening by keeping the examiner’s thumb at the joint line (Craft & Kurzweil, 2015).
● Clarke Test
Patient is positioned in supine or long sitting with the involved knee extended. The
examiner places the web space of his hand just superior to the patella while applying
pressure. The patient is instructed to gently and gradually contract the quadriceps muscle.
A positive sign on this test is pain in the patellofemoral joint (Alshaharani et al., 2018).
● Posterior Drawer test
It is performed with the patient supine on the examination table with the hip flexed 45° and
the knee flexed to about 90°. The examiner places their thumbs on the joint line and
examines the relationship of the femoral condyles and the tibial plateau. If the tibia lies
posterior to the condyle at baseline, there is a high likelihood that the PCL is torn (Badri
et al., 2018).

Functional Testing:
● Functional Performance Testing (FPT)
○ Functional performance test measures utilized with ACL-D and ACL-R athletes
include hop tests, leap and jump tests, and linear sprint, agility, and stair climbing
tests. A hop FPT involves take-off and landing on the same leg. A leap FPT
involves take-off and landing on opposite legs. A jump FPT involves take-off and
landing on both legs. A running or stair climbing FPT involves the rapid cyclical
alternation between legs. Consequently, hop tests are the preferred type of FPT
due to utilization of the uninjured limb as a control for within-subject between-limb
comparisons, and as a reference against which discharge from rehabilitation and
return-to-competition may be determined (Clark, 2001)

Desired Outcomes:
● Decreased pain to the posterior aspect of the (L) knee
 ● Increased flexibility/ROM towards knee flexion and extension
● Maintain mm strength of the quadriceps (VMO), hamstrings and triceps surae
● Increased stability of the knee jt
● Improved ability to FWB on (L) LE
● Improved ability to participate in training and playing soccer
● Improved self-awareness of present condition and decrease the risk of re-injury

Outcome Measures:
● Visual Analogue Scale for pain - reduced pain
● Goniometry - increased ROM of the (L) knee jt also the quadriceps, hamstrings and triceps
surae muscles
● Manual Muscle Tests - improved muscle strength of (L) quadriceps (VMO), hamstrings
and triceps surae
● Knee injury & Osteoarthritis Outcome Score - improved scores
○ A 42-item self-reported questionnaire of subscales that include pain (9 items),
other symptoms (7 items), function in daily living (17 items), function in sport and
recreation (5 items), and knee-related quality of life (QOL) (4 items), which are
scored individually from 0 (extreme knee problems) to 100 (no knee problems).
○ The MCID for KOOS pain is 16.7 and KOOS sports/recreation is 25. (Ogura, et
al., 2018)
○ An AUC (area under the curve) value of 0.7 to 0.8 was regarded as acceptable
and an AUC value of 0.8 to 0.9 was regarded as excellent. The MCID range of
KOOS are as follows: KOOS symptom scale, 2.5 to 6.3; KOOS activities of daily
living (ADL) score, 3.7 to 9.2; KOOS QOL, 3.7 to 9.3. (Ogura, et al., 2018)
● Tegner Lysholm knee scoring scale - improved scores
○ An 8-item scale with a possible score range: 0–100, where 100 = no symptoms or
disability. Scores are categorized as excellent (95–100), good (84–94), fair (65–
83), and poor (≤64).
○ Individual items are scored differently, using individual scoring scales. The revised
scale modified the original scoring slightly: 1) limp (0, 3, 5), 2) support (0, 2, 5), 3)
locking (0, 2, 6, 10, 15), 4) instability (0, 5, 10, 15, 20, 25), 5) pain (0, 5, 10, 15, 20,
25), 6) swelling (0, 2, 6, 10), 7) stair climbing (0, 2, 6, 10), and 8) squatting (0, 2,
4, 5).
 ○ The MCID is 8.9 and 10.1 for knee injuries, while the standard error of the measure
is reported to range from 3.2 to 3.6 for knee injuries and from 9.7 to 12.5 for mixed
knee pathologies. (Collins, et al., 2011)
Assessment/Plan:
Overall Contraindications/Precautions:
- In the early phases of treatment:
- Avoid activities that perform terminal knee extension and leg balancing
exercises.
- Avoid excessive weight bearing exercises and walking without an AD.
- When planning to progress to another phase of rehabilitation:
- Make sure there is no active inflammation, reactive swelling or jt pain.

Prognosis:
The prognosis of the patient is based on pt’s condition, history of injury and results of the
examination. According to Muaidi et. Al (2007, conservatively managed ACL- deficient knees
have a good short- to mid-term prognosis in terms of self-reported knee function assessed using
the Lysholm knee scoring scale and functional performance assessed using the one limb hop for
distance test.

Other considerations:
- ADLs modification (asc./desc. stairs, prolonged sitting and standing, etc.)
- Patients with ACL injury might only function with some level of activity
modification or will not be able to function at all due to instability. (Paterno,
2017)
- Patellar Mobilization - for ROM restoration and improving knee stability
- These potential areas of limited mobility should be treated with immediate
patellar mobilization in all directions. Emphasis should be placed on
superior-inferior directed patellar mobilization to increase mobility for the
extensor mechanism to function without restrictions of mobility. (Manske,
Prohaska, & Lucas , 2012)
- Initiate Knee Extension Exercises (Quadriceps Activation) - to avoid knee flexion
contractures and quadriceps weakness.
- Quadriceps strength and endurance are of vital importance for normal knee
joint function, so restoring normal quadriceps function after knee joint
 injuries is an essential component of rehabilitation. (Hart, Pietrosimone,
Hertel, & Ingersoll, 2010)
- Lower Body Strengthening c OKC exercises - avoid terminal extension in the early
phases of rehabilitation.
- With an increased demand placed on the ACL by greater shear forces, the
injured or reconstructed ACL graft undergoes a substantial amount of strain
due to the anterior translation of the tibia on the femur, which may result in
increased damage to the ligament. (Glass, Waddell & Hoogenboom, 2010)
- Soccer Training Participation - may only be considered when the pt. achieved all
the rehabilitation goals and got cleared by the PT.
- Consideration of the frequency and intensity of training sessions and
games is vital in soccer patients post injury. A carefully planned
rehabilitation program that addresses all aspects of the game is vital to
return the player to maximum function, while minimizing risk of reinjury.
(Bizzini, Hancock, & Impellizzeri, 2012)
- 65% of patients returned to their preinjury level after a mean follow-up of
40 months after unilateral ACLR, but only 55% returned to competitive
sports, despite having good physical function (Ardern et al., 2014)
- Elite soccer players who had a previous ACL injury/reconstruction have a
significantly higher risk of new knee injury (either reinjury or contralateral
injury). (Bizzini, Hancock, & Impellizzeri, 2012)

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