ANTERIOR CRUCIATE LIGAMENT

BY
Dr. VAIBHAV DAVE
ASSISTANT PROFESSOR
FACULTY OF ALLIED HEALTH SCIENCE
DEPARTMENT OF PHYSIOTHERAPY
MADHAV UNIVERSITY
 INTRODUCTION

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 that is
held together by the MCL, LCL, ACL and PCL.
 W INTRODUCTION

The ACL runs diagonal through the knee, crossing the PCL while both both of these connect the femur
to the tibia. (See diagram)

To the right is a completely torn ACL.

 INTRODUCTION

When the ACL is injured, the tibia can slide forward on the femur causing the knee to “give way”. (shown
below)
 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 OF INJURY

• Children can tear their ACL when they stumble or fall.

• It is much harder to fix a child’s tear because of the need to avoid the growth plate.

In the picture above, you can see the athletes left knee turned
inward where she is in the process of tearing her ACL. This
typically happens when landing, cutting or changing direction
quickly.
 SIGNS AND SYMPTOMS

• Swelling
• Loss of range of motion
• Pain or tenderness along the joint line
• Discomfort and unstable walking
• The patient will report that the knee was forced beyond its normal range
• The patient may report having felt a pop, tear, or snapping sound
 ACL EXAM

 Lachman – best
 Pivot Shift – diagnostic
 Anterior drawer – chronic tear
 Associated injuries
 ACL MRI

 95% accurate
 Low signal intensity
 Saggital view
 Acute injury high signal intensity on T2 image
 DIAGNOSIS

• What should you do if you suspect an ACL tear?

• The first thing you should do is apply ice and compression. The athlete should see a doctor immediately
where they can determine if it is actually an ACL tear.
• If you need to move the athlete and they are unstable, have them use crutches.
• A coach should ask the athlete to describe what happened. A lot of athletes who experience an ACL tear will
hear a pop, tear,or snap.
 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.
 ACL RE-CONSTRUCTION SURGERY

Harvest of Ligament Replacement from donor site Grafting of Replacement

(Patellar Tendon) Into Holes Drilled into
Hamstring Tendons are Becoming More Preferable the Femur & Tibia
 ARTHOSCOPIC 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 you 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.
 NON-SURGICAL REHABILITATION

• The picture above shows two young girls focusing on balancing and strengthening the
muscles in their legs.
• If a child or young teen tears their ACL, doctors may suggest only physical therapy.
• 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.
• A knee brace does not prevent knee injuries but can help to stabilize the knee.
 REHABILITATION

• Physical therapy is a crucial part of ACL surgery. Most of the success of the surgery is
dependent upon the athletes 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.
Activities such as the ones below are done by the physical therapist in rehabilitation.
 REHABILITATION

• The entire rehabilitation process takes about 4-6 months to make sure that the athlete is
completely ready to return 100% to athletics. The use of a functional brace is not required after a
successful surgery and rehabilitation, but many athletes feel a greater sense of security using one.
(Shown below)
 REHABILITATION PROGRAM
 WEEKS 0-2:
• Non weight bearing
• Quadriceps and Hamstring isometrics
• Electrical muscle stimulation
• Ankle ROM and strengthening
• Heel slides
• Patellar mobilization
 WEEK 4:
• Non weight bearing
• Quadriceps and Hamstring isometrics
Straight leg raises
• Straight leg raises
• Electrical muscle stimulation
• Stationary bike
• Stairmaster
 WEEK 6:
• Non weight bearing
• Quadriceps and Hamstring isometrics
• Straight leg raises with weight (see diagram)
• Hamstring curls (see diagram) Hamstring Curl
• Hip progressive resistance exercises
• Pool ROM
• Cycling for ROM
 REHABILITATION PROGRAM
WEEK 8:
Begin weight bearing
ROM should be 0 and 110 degrees
Cycling
Hamstring curls
Jump rope
Swimming
3 MONTHS:
ROM 0 and 125 degrees
Treadmill walking
Cycling
Quarter squats
Sport specific skills
4 - 6 MONTHS:
ROM 0 and l40 degrees
Treadmill walking
Isotonic knee extensions
Isokinetics when 10% of body weight can be done isotonically (90-240 degrees/second)
Step-ups
6 MONTHS:
Test isokinetically
Begin terminal knee extension
Running (straight ahead)
 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

 There has been much research into the prevention of ACL tears.
 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
THANK YOU