Sean Rafferty

I. Mechanism of Injury
A. Forms of Injury
1. Foot is planted → pivoted knee while running (can happen on all surfaces)
2. Force from the side of the knee
a) -Ex. Football tackle
3. Girls- sharp change in direction of the trailing leg (“away leg”)
a) Ex. Changing direction in soccer
4. Unhappy Triad:
a) MCL, ACL, and Medial Meniscus are all torn
(1) Much less common
II. Types of ACL Tests
A. 1. Drawer Sign: (hips flexed at 45°, knees flexed at 90°)- easiest to perform
1. Pull tibia, sit on knee, look for laxity (loose knee ligaments)
B. 2. Lachman Test: More specific & trustworthy
1. Leg straight, hold femur & lift tibia, look for instability in the knee
C. 3. Pivot Shift: (only done under anesthesia)
1. Detect instability in the knee (ACL)
2. “Joint play”- The motions of sliding, rolling, spinning, or compressing
that occur between bony surfaces within a joint when the bones move
through ranges of motion
a) Can be too little, normal, or too much
3. Very unstable → unable to provide support (similar to #1)
III. Meniscus Involvement Congruencey Tests
1. McMurray’s
2. Apley’s
3. Thessaly
IV. ACL Protocols
A. Schools of Thought
1. Conservative- Wait until stitches come out from surgery (10-14 days or
longer)
a) Knee is mobilized with brace
2. Aggressive- Begin working on strengthening immediately following
surgery (begin Quad Sets 2 days following surgery)
B. Goal #1: Quad Set
1. Engage quad muscle fully 5x’’
a) FAULT: Quad muscle will buckle or give-way due to inhibition
from swelling & weakness
C. Goal #2: Full Knee Extension (prior to weight bearing exercises/weight shifting
from calf to hamstring)
 1. At rest for proper femur → tibia alignment
a) Creates tensile stress for Patella
2. Bearing weight (bony stress) properly with full knee extension
a) FAULT: Flexion contracture (bent knee gait)
(1) Creates joint stress
D. Goal #3: Assisted Ambulation (Walking)
1. How to walk with a crutch (walker or cane) with ACL injury
a) If right knee injured, crutch should be on left
b) If left knee injured, crutch should be on right
2. With a cane → perform “step to, step through” motion
a) Injured leg steps to healthy leg ahead
b) Healthy leg then steps forward and process repeats
3. Phases of Gait: Heel strike → foot flat → mid stance → toe off
V. Why do girls have more ACL tears? (4 female: 1 male)
A. Q-Angle- measured angle from the femur to tibia (valgus knee)
1. Angle is greater in women compared to men due to wider hips
a) Normal: < 8° (less than)
b) Abnormal: >11° (greater than)
2. Angle of pull for quadriceps (from femur to tibia) is askew rather than
straight
3. Men have more control due to stronger quadriceps and hamstrings
VI. General Anatomy of the Quadriceps & Hamstrings
A. Quadriceps- one of the largest/strongest muscles in the body
1. Vastus Medialis- different nerve compared to others
a) First to atrophy (lose/lack of bulk)
b) Closest to the inside of the knee
c) 45° angle to quad tendon = larger Q-angle (angulation much
greater)
d) Angled slightly different then other muscles in quadricep
2. Vastus Intermedius- innervated by the same nerve as the Vastus Lateralis
3. Vastus Lateralis- farther outside, near ITB
4. Rectus Femoris- strongest muscle of quadricep
B. Strength Contribution Ratio of Quadriceps to Hamstrings (Normal)
1. 60% : 40% (Quadricep : Hamstring)
VII. Understanding ACL Anatomy
A. Anatomy:
1. ACL attaches to the front of the tibia and back of the femur
B. Function:
1. Prevents tibia from sliding forward on femur
a) During tear tibia slides forward
b) Shift occurs in knee joint in change of direction
 2. After Full Tear:
a) Classified as ACL Deficient Knee (not functioning or gone)
b) 1st Stabilizer: strengthen ligaments in knee
c) 2nd Stabilizer: strengthen hamstrings dynamic
C. Possible Setbacks
a) ACL Deficient Knee results in many issues
(1) Could have Micro tears or possibly be retorn at 8 weeks
due to the patient “feeling strong and good again"
b) ACL is weakest at 8 weeks post-operative
D. Contribution of ACL, Hamstrings, and Quadriceps
1. ACL & Hamstrings in back of leg prevent tibia from moving (rotating)
forward
a) Quadriceps and Hamstrings have to be strong (50:50 contribution)