PROJECT REPORT ON
ACL
INJURIES
BY :
PIYUSH
INTRODUCTION
The anterior cruciate
ligament (ACL) is one of
the most important of four
strong ligaments
connecting the bones of
the knee joint. It is often
injured.
Ligaments are strong,
dense structures made of
connective tissue that
stabilize a joint. They
connect bone to bone
across the joint.
A tear to the anterior cruciate ligament (ACL)
results from overstretching of this ligament
within the knee.
It's usually due to a sudden stop and twisting
motion of the knee, or a force or "blow" to the front
of the knee.
The extent of the tear can be a partial or a
complete tear.
Individuals experiencing a tear to the ACL may or
may not feel a pop at the time of the injury.
It is often injured together with other structures
inside the knee joint.
After the initial injury, the knee may swell and
become painful.
Instability or a sensation the knee is "giving out"
may be a major complaint following this injury.
ANATOMY
The knee is a hinge joint made up of
three bones held firmly together by
ligaments that stabilize the joint. The
bones that meet at the knee are the
upper leg bone (the femur), the lower leg
bone (the tibia), and the knee cap (the
patella). A smooth protective layer
called cartilage, which allows the bones
to glide smoothly upon each other, lines
the bones inside the joint
The important parts of the knee include
Bones and joints
Ligaments and tendons
Muscles
Nerves
Blood vessels
Bones and Joints
The knee is the meeting place of two
important bones in the leg, the femur (the
thighbone) and the tibia (the shinbone).
The patella (or kneecap, as it is commonly
called) is made of bone and sits in front of
the knee.
The knee joint is a synovial joint. Synovial
joints are enclosed by a ligament capsule
and contain a fluid, called synovial fluid,
which lubricates the joint.
Ligaments
MCL (Medial collateral ligament)
LCL (Lateral collateral ligament)
ACL (Anterior cruciate ligament)
PCL (Posterior cruciate ligament)
Menisci (Medial & lateral)
MCL : It joins femoral condyle to tibial
shaft medially
LCL: It joins femoral condyle to fibular
head laterally
The MCL and LCL prevent the knee from
moving too far in the side-to-side
direction.
ACL : It begins with anterior part of
intercondylar area of tibia, runs upwards
& backwards, & laterally & is attached to
the post part of medial surface of lateral
condyle of femur.
PCL : It begins from the post part of
intercondylar area of tibia, runs upwards,
forwards & medially & is attached to the
anterior part of the lateral surface of
medial condyle of femur.
The ACL keeps the tibia from sliding too
far forward in relation to the femur. The
PCL keeps the tibia from sliding too far
backward in relation to the femur.
Working together, the two cruciate
ligaments control the back-and-forth
motion of the knee. The ligaments, all
taken together, are the most important
structures controlling stability of the
knee.
MENISCI
Medial meniscus
Lateral meniscus
The two menisci of the knee are
important for two reasons:
They work like a gasket to spread the force
from the weight of the body over a larger
area
They help the ligaments with stability of
the knee.
Muscles
Muscles control the movement of the knee
joint. Rehabilitation of these muscles is
most important following an ACL injury or
reconstruction.
The major muscles of the knee joint
involved with bending and straightening
the knee are:
Quadriceps
Hamstrings
Quadriceps
The quadriceps muscle is made up of the four large
muscles at the front of the thigh (these muscles are
the rectus femoris, the vastus lateralis, the vastus
intermedius, and the vastus medialis).
Hamstrings
The hamstring muscles are the muscles at the
back of the upper leg. They flex (bend backward)
the lower leg. Individually, the muscles of the
hamstrings are the biceps femoris, semitendinosus,
and semimembranosus.
Maximum movements and muscles
Extension 5-10° Flexion 120-150°
Quadriceps (with (In order of importance)
some assistance from Semimembranosus
the Tensor fasciae latae) Semitendinosus
Biceps femoris
Gracilis
Sartorius
Popliteus
Gastrocnemius
Internal rotation* 10° External rotation* 30-40°
(In order of importance) Biceps femoris
Semimembranosus
Semitendinosus
Gracilis Sartorius
Popliteus
CLASSIFICATION OF ACL INJURIES
An anterior cruciate ligament (ACL) injury often
is called a 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
Grade II sprain
The fibres of the ligament are partially torn.
There is a little tenderness and moderate swelling.
The joint may feel unstable or give out during
activity
Grade III sprain
The fibres of the ligament are completely torn
(ruptured); the ligament itself has torn completely
into two parts.
There is tenderness (but not a lot of 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.
Etiology
Movements of the knee that place a great strain
on the ACL can cause damage to the ligament.
Hyperextension of the knee, caused by
accidents associated with:
Skiing
Volleyball
Basketball
Soccer
Football
Pivoting injuries of the knee are seen in
sports such as:
Football
Tennis
Basketball
Soccer
Non-Athletic-Related Injuries
Motor vehicle accidents in which the knee
is forced under the dashboard may also
cause rupture of the ACL.
Repeated trauma and wear and tear can
be a knee problem at any age causing
small tears in the ligament, which over time
become complete tears
CLINICAL FEATURES
Feeling or hearing a "pop" in the knee at the time of
injury
Sudden instability in the knee (the knee feels
wobbly, buckles or gives out) after a jump or change
in direction or after a direct blow to the side of the
knee
Pain on the outside and back of the knee
Knee swelling within the first few hours of the injury.
This may be a sign of bleeding inside the joint
(hemarthrosis). Swelling that occurs suddenly is
usually a sign of a serious knee injury.
Limited knee movement because of swelling and/or
pain
DIAGNOSIS
The diagnosis of an ACL tear is based on
Physical examination,
Radiographic Evaluation
MRI (Magnetic Resonance Imaging)
KT 1000
Physical Examination
Thorough history addressing how the
injury occurred and ascertaining when the
pain may have first appeared. Questions
regarding any earlier knee injuries are
important as often ligaments and cartilage
structures may have been previously
strained. Any previous episodes of knee
instability or the knee giving way is
important information.
SPECIAL TESTS
Laschman’s test
Anterior drawer test
Pivot shift
Lachman's Test:
Anterior Drawer Test
Pivot Shift Test
Radiographic
Evaluation
MRI
KT 1000
MANAGEMENT
Immediately After the injury
R.I.C.E. treatment is recommended.
Rest
Ice
Compression
Elevation
Conservative treatment
Bracing
Rehabilitation Brace
Functional Brace
SURGICAL PROCEDURES
There are several available operative
procedures:
Patellar tendon graft procedure (BPTB)
Hamstring graft procedure
Allograft procedure
Patellar tendon graft procedure
This type of ACL replacement uses the middle third
of the person's own patella tendon and is referred to
as a bone-patella-tendon-bone (BPTB) graft.
Hamstring graft procedure
Surgeon uses the patient's own hamstring
tendon, either
the semitendinosus or gracilis tendons from the
same leg.
Allograft procedure
Another option is the use of tissue from a
cadaver (a deceased person) called an allograft.
Physiotherapy protocol following ACL
reconstruction (BPTB GRAFT)
Day 0 to Day 10
Static quadriceps exercises i.e. tightening
of thigh muscles in order to achieve
complete straightening of the knee joint
Ankle toe pump exercise
Non weight bearing ambulation with the
help of either a walker or elbow crutches
The knee is in a knee brace hence knee
bending & range of motion exercises are
not possible & should not be attempted
DAY 11 TO DAY 20
Once all the stitches are removed Range of Motion
exercises are to be started. The knee brace is removed
and weight bearing with the help of a stick is allowed.
The exercises are continued as above but with
additions, namely:
Sitting at the edge of the bed with the knee bent as far
as possible- flexing and extending the knee to increase
the range of motion. We should try and increase the
range of motion freely without force to at least 90deg by
the end of one week.
Standing with the support of a stick in the opposite hand
and doing alternate leg standing i.e. marching in one
place.
Gait training with a single stick for support. The stick is
to be used for two weeks.
DAY 21 onwards
Increase the range of motion to 100- 110
deg during the fourth week.
Quadriceps strengthening exercises namely
knee tightening, and straight leg raising with
the knee in complete extension to start
against gentle manual resistance.
Closed chain exercises for quadriceps and
hamstring strengthening.
Half squats to increase the range of motion.
Wobble board balancing for quads- hams
balancing.
Abductor- adductor strengthening in standing
with therabands.
As the strength improves the patient can be
weaned off the stick while walking (usually at
about 3 weeks from surgery).
The range of motion has to be increased to
normal i.e. 135 deg by the end of six weeks
from the date of surgery.
Gait training and muscle strengthening exercises to continue
with increasing intensity till normal range of motion is achieved
and the muscle strength return to 5/5, Ideally the patient comes
back for a review with the surgeon/physiotherapist at 10 days
post op, then 21 days post-op, then at 6 weeks post op, then at
10 weeks post op, then at 12 weeks post op and finally at 16
weeks post op. By this time the full range of motion and muscle
strength should be achieved. Only after getting a clearance
from the surgeon should the patient resume any kind of sports
activities.
Cryotherapy (ice packs) for the operated knee is very helpful in
the initial 3-4 weeks for reduction of pain and swelling.
The knee may continue to feel sore, swollen and stiff for a few
months from surgery. This is normal and nothing to worry
about.
Car driving maybe resumed after 8 weeks from the date of
surgery
