ACL INJURY AND REHABILITATION
Dr. Anushree Rai
Assistant Professor
Background:
• Anterior cruciate ligament (ACL) is a broad, intraarticular, extra synovial
ligament with attachments running from the postero-medial surface of the lateral
femoral condyle to the anterior intercondylar surface of the tibia
Incidence:
common
• ~400,000 ACL reconstructions / year
• account for half of all knee injuries
Demographics:
• more common among female athlete
• females sustain ACL injuries at a younger age than males
• females get more ACL injuries on the supporting leg (males get more ACL injuries on the
kicking leg)
Risk factors:
• female participation in soccer, male participation in basketball
• valgus moment at knee and adduction moment at hip upon landing
Mechanism of injury:
Pathophysiology
• non-contact pivoting injury
1.tibia translates anteriorly while knee is in slight flexion and valgus
2.blow to the lateral aspect of the knee
3.common activities are soccer, basketball, skiing, and football
4.pre-ponderance for females due to landing biomechanics and
neuromuscular activation patterns (quadriceps dominant) play the biggest role
Associated conditions:
• meniscal tears
• lateral meniscal tears in 54% of acute ACL tears, medial in chronic cases
• PCL, LCL injuries
• chronic ACL deficient knees associated with:;
1. chondral injuries
2. complex, unrepairable meniscal tears and bucket handle medial meniscus tears
Anatomy:
• two bundles measuring combined 32mm length x 7-12mm width
1. anteromedial bundle:
• more isometric
• tightest in flexion
• primarily responsible for restraining anterior tibial translation (anterior drawer
test)
2. Posterolateral bundle:
• greater length changes
• tightest in extension
• primarily responsible for rotational stability (pivot shift test)
• Function:
• provides 85% of the stability to prevent anterior translation of the tibia relative to
the femur
• acts as a secondary restraint to tibial rotation and varus/valgus rotation
• PRESENTATION
1. History
• felt a "pop"
• pain deep in the knee
• immediate swelling (70%) / hemarthrosis
2. Symptoms
• generalized knee pain
• feelings of instability preventing return to sport
• difficulty weightbearing
3. Physical exam
1. Inspection
• effusion
• quadricep avoidance gait (does not actively extend knee)
2. coronal or sagittal plane deformity
• varus deformity increases risk for ACL re-rupture
3. motion
• lack of full extension secondary to meniscal injury or arthrofibrosis
• evaluate for meniscal or concomitant ligamentous injuries (McMurray, varus/valgus stress)
4. Provocative tests:
• Lachman's test
• most sensitive exam test
• grading
• A= firm endpoint, B= no endpoint
• Grade 1: 3-5 mm translation
• Grade 2 A/B: 5-10mm translation
• Grade 3 A/B: > 10mm translation
Pivot shift
• knee brought from extension (anteriorly subluxated) to flexion (reduced) with
valgus and internal rotation of tibia
• reduces at 20-30° of flexion due to IT band tension
• patient must be completely relaxed (easier to elicit under anesthesia)
IMAGING:
Radiographs
recommended views:
• AP, lateral, sunrise/merchant/skyline
view
Findings:
• often normal
• Segond fracture (avulsion fracture of
the proximal lateral tibia) is
pathognomonic for an ACL tear
• represents bony avulsion by
the anterolateral ligament (ALL)
deep sulcus (terminalis) sign
• depression on the lateral femoral condyle at
the terminal sulcus, a junction between the
weight bearing tibial articular surface and the
patellar articular surface of the femoral
condyle
MRI
• indications
• to confirm clinical diagnosis of ACL rupture and evaluate for concomitant
pathology
CT scan
1. indications
• revision setting to evaluate for bone loss
2. sensitivity and specificity
• most sensitive and specific test for bone loss associated with osteolysis and tunnel
widening
Treatment:
• Treatment individualized to patient based on activity level, age,
demands, and concomitant pathology
Nonoperative:
1. physical therapy, lifestyle modifications
indications
• low demand patients with decreased laxity
• recreational athlete not participating in cutting/pivoting activities
Operative
1. ACL reconstruction
Indications:
• must have full motion of knee restored following injury (unless meniscal tear causing
mechanical block)
• younger, more active patients (reduces the incidence of meniscal or chondral injury)
• children (activity limitation is not realistic)
• older active patients (age >40 is not a contraindication if high demand athlete)
• partial/single bundle tears with clinical and functional instability
• prior ACL reconstruction failure
2. ACL repair
Indications:
• avulsion rupture patterns
Surgical vs. Non-operative ACL
Rehabilitation
• Non-operative treatment has typically been chosen by older, less active
individuals and consists of early therapy, bracing, and activity modification.
Pre- Operative Rehab:
• Outcome: Prehab has the benefit of helping patients feel mentally prepared for
the surgery itself ; improved knee and muscle strength in the prehab group.
Physical therapy, lifestyle
modifications
1. Technique
• early symptomatic treatment followed by 3 months of supervised physical therapy
• physical therapy focusing on range of motion and progressing to quad, hamstring,
hip abductor and core strengthening
• re-evaluation at conclusion to assess progress
• functional braces demonstrate no added functional stability
1. Early post-operative
immediate
• aggressive cryotherapy (ice)
• immediate weight bearing (shown to reduce patellofemoral pain)
• emphasize early full passive extension (especially if associated with MCL injury
or patella dislocation)
1. early rehab:
• focus rehab on exercises that do not place excess stress on graft
Appropriate rehab focuses:
• eccentric strengthening at 3 weeks has been shown to result in increased quadriceps volume
and strength
• isometric hamstring contractions at any angle
• isometric quadriceps, or simultaneous quadriceps and hamstrings contraction
• active knee motion between 35 degrees and 90 degrees of flexion
• core and gluteal strengthening incorporated throughout therapy
• emphasize closed chain (foot planted) exercises
i.e. squats or leg-press
Avoid:
• isokinetic quadricep strengthening (15-30°) during early rehab
• open chain quadriceps strengthening
i.e. leg extensions mimic anterior drawer and Lachman maneuvers
