ACL RECONSTRUCTION:

ACCELERATED REHAB
From theory to intervention application

Võ Dương Hương Quỳnh, MD

Phẫu thuật Nội soi khớp cơ bản
MỤC TIÊU BÀI HỌC
1) Mô tả quá trình lành mảnh ghép tái tạo ACL
2) Trình bày nguyên tắc PHCN áp dụng sinh cơ
học lành mảnh ghép tái tạo ACL
3) Nhận biết một số vấn đề xảy ra trong quá
trình lành mảnh ghép ACL sau phẫu thuật tái
tạo
ANATOMY
 Knee joints (2): femur<>tibia (thigh bonne<>Shin
bone), patella<>front of femur
 Ligament around: stabilize the joint: collateral

ligaments and cruciate ligaments within the joint

 ACL: stops the tibia shearing forwards. It
runback and upwards from its insertion on the
tibia to its origin on femur
 The most important groups of muscles
supporting the knee are quadriceps muscle on
the front of the thigh, and hamstrings which lie
back on the thigh. Calf muscle (gastrocnemius)
provides additional support.
GRAFT MATURATION PROCESS
 Begins at implantation
 Progresses over the next 1 to 2 years.
 Autografts are strongest at the time of implantation.
 Process of functional adaptation (ligamentization)
 Gradual biologic transformation.
 Distinct stages of maturation 14,87,89:
1. Necrosis
2. Revascularization
3. Cellular proliferation
4. Collagen formation, remodeling, and
maturation
NECROSIS
 Commences immediately and generally lasts 2 weeks
 Native tendon (graft) cells diminish, and replacement

cells can be present as early as the first week

 Cellular repopulation occurs before revascularization.

 Early full ROM is desirable

 Bone blood supply and synovial fluid

REVASCULARIZATION
 Revascularization occurs within the first 6 to 8 weeks
after implantation
 Via the fat pads, synovium, and endosteum

 From peripheral to central.

 Inflammatory response should be under control  delayed

healing process and potential graft problems

 As the new cells find their way to this frame and add
stability to this weak structure, rehabilitation must be
careful not to disrupt or stretch them
 Bone plugs incorporate into their respective bone tunnels

over a 12­weeks period but are felt to near completion by

approximately the sixth postoperative week (patella tendon)
CELLULAR PROLIFERATION AND COLLAGEN
FORMATION
 Continuing process throughout the maturation
process
 Function of collagen in the ligament is to

withstand tension
 During the rehabilitation program, pain and
edema should dictate the speed at which the
patient may progres
 KT­1000 (Medmetric, San Diego) is helpful as well

 These ACL autografts approximate 30% to 50% of

the normal ACL strength 1 to 2 years
postoperatively (*)
INTERVENTION PRINCIPE/GRAFT MATURATION

Still Strong/ Fixation device

GRAFTS: ADVANTAGES AND DISADVANTAGES
“PROBLEMS POST ACL RECONSTRUCTION”
Pain and effusion
Brace & Weight Bearing
Motion
Muscles training
Open Vs Closed Kinetic Chaine
Exercises
Electrical muscle Stimulation and
Biofeedback
Proprioception
PAIN AND EFFUSION
 Especially early stage
 Cause reflex inhibition of muscle activities

 PRICE principle: protection, rest, ice

(cryotherapy), compression, elevation

 Narcotic and anti inflammatory pain medicament

 Muscles activation: quad sets/ankle pump:

help reduce swelling by improving venous return,
muscle stimulation of quadri
 BRACE & WEIGHT BEARING

SIZE:
Theo số đo chu vi
khớp gối (ngang vị
trí xương bánh chè)
­ Size S với số đo
chu vi khớp gối
từ 30 ­ 34 cm
­ Size M 34 ­ 38 cm
­ Size L 38 ­ 42 cm
­ Size XL 42 ­ 46 cm
­ Size XXL 46 ­
50 cm
BRACE & WEIGHT BEARING
 Before, WB was prohibited earlier Rehab
protocols
 Current trend is immediate WB

 Helps to improve cartilage nutrition, reduce

disuse osteopenia, and fasten quadriceps

recovery
 Weight bearing status­ This applies to all ACL

reconstruction unless otherwise specified.

 Day 1­7 = 50% body weight (2 crutches)
 Day 8­14 = 50­75% body weight (1 crutch)
 End of week 2 = full weight bearing
WEIGHT BEARING
2 Crutches 1 crutch
MOTION
 Common causes: arthrofibrosis, inapproriate
graft placement or tensioning  anterior knee
pain, abnormal gait, musscle atrophy,
degenerative changes of the joint
 Usually, the loss of extension is more commonly
seen and more poorly tolerated than the loss off
flexion
 The goal is to achieve full extension right after
surgery and regain 10o of flexion per day
 By 7­10 days post­op, the knee should achieve

90o of flexion
MOTION
 Early passive and active ROM using CPM
 Prevention is the key to achieve ROM: control

pain and swelling, early reactivation of Quadri,

patella mobilization, early return to WB
 Functional bracing, easy way of ensure full knee
extension
 Knee immobilizer should be worn while sleeping

for the first 2 weeks, and while you walk until

you regain muscle control of the leg
MUSCLE TRAINING ISSUES
 To prevent muscle atrophy and weakness
 Muscle activation and strengthening, voluntary

exercises, electrical muscle stimulation, and

biofeedback.
 Electrical stimulation can help to initiate muscle
activation, when reflex inhibition can not be
overcome in patients who are suffering pain and
swelling
 Quadriceps muscle strength is correlated with
good outcomes after ACL reconstruction
 Strenghthening of the Quads is the focus of many

rehab programs
OPEN VS CLOSED KINETIC CHAINE
EXERCISES
 CKC safer than OKC
 CKC apply less anteriorly directed forces on the tibia, increase
biofemoral compressive force, increase co­contraction of hamstring and
quad, mimic functional activities more closely than OKC, and reduce
the incidence of patellofemoral complication
 CKC exercises are defined as those in which the foot is still in contact
with a solid surface GRF is transmitted to all of the joints in lower
limbs and muscles apsnning all of the joints of lower extremities are
used
 Squat/leg press

 OKC: one segments of the limp is stabilized while the other moves
freely, and only musscle spanning the knee are required to perform the
excercises
 Leg extension machine

 Many activities can not be clearly classified as OKC or CKC

 Daily activities like walking , stair climbing and jumbing are

combination of OKC and CKC movements.
OPEN VS CLOSED KINETIC CHAINE
EXERCISES
 CKC><OKC: BTPT ok but not hamstring
 Heijne 163 began OKC knee extension exercises at 4 weeks and 12 weeks

for both hamstring tendon and patellar tendon grafts. Quadriceps muscle
torque was not significantly different for any group. But the early
addition of OKC exercises for patients receiving hamstring tendon
autografts resulted in significant increased laxity over time
 Potential increased strain to the graft with OKC exercises in low levels of

flexion (<30°), isometric quadriceps exercises should be done at 0°, 90°,

and 60°.
 superior patellar glide with each quad set, and an inferior patellar glide

when they relax.

 If a hamstring graft is used, the patient should wait until after the

fourth week (90­40)

 if a hamstring autograft was used, when strengthening the hamstrings.

If, for example, the patient receives a concomitant meniscal repair,

weightbearing and/or hamstring strengthening exercises may be delayed
for 4 to 6 weeks.
ELECTRICAL MUSCLE
STIMULATION AND BIOFEEDBACK
 Electrical muscle stimulation is used as an adjuct
to voluntary exercises in an effort to recover
muscles strength after ACL reconstruction
 The effectiveness of this method is controversial
in literature
PROPRIOCEPTION
 Defined as the culmination of all neural inputs
originate from joints, tendon, muscles, and
associated deep tissue proprioceptors.
 Mechanoreceptors are specialized nerves located in

skin, joints, tendon, ligament, and skeletal muscle

 After ACL reconstruction, patients continue to have

defiits in proprioception and neuromuscular joint

control for at least months and as long as 1 year
after surgery
 It is important to incorporate beginning,

intermediate, and advanced proprioception training

exercises throughout the postop rehabilitation
protocol
ACCELERATED
PROTOCOL
Phase 1: 0 to 4 Weeks
Maximum Protection
Phase 2: 4 to 10 Weeks
Moderate Protection
Phase3 : Weeks 11–24
Minimum Protection
Phase 4: Return­to­Activity
≥ 6 Months
PREOPERATIVE MANAGEMENT
Goals  Increase ROM, especially

• Decrease swelling and extension, increase

inflammation quadriceps/hamstrings
strength, and achieve a
• Increase ROM
normal gait pattern
• Increase quadriceps 
Rehabilitation brace locked
strength
in extension and use two
• Evaluate the entire crutches for the 1st week
LE  Braces improve extension,

and decrease pain and graft

strain following ACL
reconstruction
WHY REHAB PREOP
 Higher risk for complications exists if surgery is
performed (1) before obtaining a homeostatic
environment, (2) if range of motion (ROM) is limited
(especially extension), and (3) when quadriceps and
hamstring contraction is inadequate (i.e., unable to
perform a straight leg raise [SLR])
 With postponing reconstruction in an active population,

the risk is higher for meniscal and chondral surface

damage.
 Sterett and associates used the minimal criteria of

active ROM of 0° to 120°, active quadriceps control, and

the ability to perform an SLR without a lag, minimal to
no swelling present before operating as determinants of
successful outcome.
PHASE 1: 0 TO 4 WEEKS POST­OP
MAXIMUM PROTECTION
Goals:
• Protect the healing graft
• Decrease swelling and inflammation
• Attain full extension
• Increase quadriceps strength
Achieve the following by the end of wk 4:
• ROM 0°­125°
• Transfers (supine­sit) without assisting involved leg (SLR
independent)
• Good quality thigh and calf muscle contraction
• Full weight bearing
• Walk without crutches or cane (household and limited
community distances)
• Self­manage edema/pain
PHASE 1: 0 TO 4 WEEKS POST­OP
MAXIMUM PROTECTION
Patient presentation Key examination

• Postoperative • Pain scale

hemarthrosis, pain • Joint effusion—girth
• Postoperative pain • Ligament stability—
• Decreased ROM
joint arthrometer (days
• Diminished voluntary
7–14)
quadriceps activation
• ROM
• Ambulation with
crutches • Patellar mobility
• Protective bracing (may • Muscle control
or may not be worn) • Functional status
 PHASE 1: 0 TO 4 WEEKS POST­OP
INTERVENTION
Early: days 1–14 Late: weeks 2–4
• Continue as above
• PRICE: protective bracing, ice, compression, •Progress to full
elevation weightbearing; begin mini
• Gait training: crutches, partial weight bearing closed chain squats;
to WBAT (weight bearing pain free) heel/toe raises
• PROM—supine knee extension, prone heel • SLRs in four planes cont’d
hangs, supine wall slides
•Low­load PRE: hamstrings
• AROM–heel slides, SLR (brace locked at 0°);
hip (flexion, extension, abduction, adduction); •Initiate open­chain knee
standing hamstring curls extension (range 90–40)
• Patellar mobilization (grades I and II) •Trunk/pelvis stabilization
• Muscle setting, isometrics: quadriceps, •Aerobic conditioning:
hamstrings, adductors at multiple angles (may stationary cycle
augment with E­stim_NMSE)
• Assisted SLRs—supine
• Ankle pumps
EXERCISE PRECAUTIONS AFTER
ACL RECONSTRUCTION
 Resistance Training — General Precautions
• Progress exercises more gradually for reconstruction with hamstring tendon
graft than bone­patellar tendon­bone graft.
• Progress knee flexor strengthening exercises cautiously if a hamstring tendon
graft was harvested and knee extensor strengthening if a patellar tendon graft
was harvested.
 Closed­Chain Training
• When squatting in an upright position be sure that the knees do not move
anterior to the toes as the hips descend because this increases shear forces on
the tibia and could potentially place excess stress on the autograft.
• Avoid closed­chain strengthening of the quadriceps between 60 to 90 of knee
flexion.(*)
Open­Chain Training

• During PRE to strengthen hip musculature, initially place the resistance

above the knee until knee control is established.
• Avoid resisted, open­chain knee extension between 45 to 15.*
• Avoid applying resistance to the distal tibia during quadriceps
strengthening.*
 EXERCISES

Knee extension Static quad

Heel Slide

Prone Knee bend

EXERCISES
Straight Leg raise Patellar Mobilization
 PHASE 1: 0 TO 4 WEEKS POST­OP
GUIDELINES FOR USING AND DISCHARGING
BRACE/CRUTCHES

Guidelines for Using and Discharging Brace and Crutches

Brace Locked in full extension for the first week
Unlocked for exercises in physical therapy
Discharged when the patient has full extension,
no lag with an SLR, and at least 100° of flexion

Crutch Bilateral crutches following surgery for first 4 wk

After 4 wk, wean to one crutch and then
discharge as long as the patient has a normal
gait pattern without pain
PHASE 2: 4 TO 10 WEEKS
MODERATE PROTECTION
Goals
• Increase LE strength
• Increase neuromuscular control
• Normalize gait
• Prepare for running
Achieve the following by the end of wk 10:
• Full pain­free ROM
• 4/5 Muscular strength (MMT)
• Dynamic control of knee
• Improved kinesthetic awareness
• Normalize gait pattern and ADL function
• Adherence to home program
PHASE 2: 4 TO 10 WEEKS
MODERATE PROTECTION
Presentation
• Pain controlled
• Joint effusion controlled
• Full or near full ROM
• Fair plus to good muscle
strength (3/5 to 4/5)
• Muscular control of joint
• Independent ambulation
Key examination
procedures
• Pain scale
• Effusion—girth
• Ligament stability—
joint arthrometer
• ROM
• Patellar mobility
• Muscle strength
• Functional status
PHASE 2: 4 TO 10 WEEKS
INTERVENTION
Early: weeks 5–7 Late: weeks 7–10

• Multiple­angle isometrics
• Continue as above; advance
•Advance closed chain strengthening (include PNF
strengthening and PRE­step patterns), endurance and
up/down flexibility
• LE stretching program • Advance proprioceptive
• Endurance training (e.g., training to high speed stepping
drills, unstable surface challenge
bike, pool)
drills, and balance exercises
• Proprioceptive training:
• Initiate a walk/jog program at
single­leg stance, tilt board, the end of this phase
BAPS board
• Initiate plyometric drills:
• Stabilization exercises, bounding, jumping
elastic bands, band walking • LE stretching program (IJ)
PHASE 2: 4 TO 10 WEEKS
ATTENTION
 full passive ROM and normalized pain­free
independent gait and lasts until the patient
begins to run
 both concentric and eccentric, and isolate specific
muscles as well as combine the entire kinetic
chain
 protect the healing graft by keeping exercises in

the protected ranges. Approximately 6 to 8 weeks

after surgery, the mechanical strength of the
healing graft is at its weakest (therapeutic ex)
 Balance exercises can begin as soon as the

patient is comfortable with weight bearing

EXERCISES

Wall slide Wall squat (mini squat_0­30o)

 EXERCISES
Squat combined elastic band Squat+? Spider Killer

NHẬN XÉT GÌ?

https://mikereinold.com/tag/onlinekneeseminar­com/page/4/
 EXERCISES ­ PROPRIOCEPTIVE TRAINING

Proprioceptive training Single les stance on towel (end of

Single les stance stage)
QUADRICEPS STRENGTHENING COMBINED
WITH FUNCTIONAL BRACE

Step up and down. Patients progress from 2­inch to 6­inch high

steps. Care is taken to prevent increased stress on the graft and
patella (knee is kept in line with the foot and not allowed to migrate
anterior to the toes during the exercise).
PHASE3 : WEEKS 11–24
MINIMUM PROTECTION
GOAL Achieve the following by the
• No instability end of wk 24:
• No swelling •Come within 10% of full
range flexion
• No pain
•Isokinetic test within 25% of
• Good to normal muscle
uninvolved knee
strength (4/5 to 5/5)
•Run 1 mile without pain
• Unrestricted ADL
function (patient dependent)
• Possible use of •Initiate sport­ of activity
functional brace specific training, modifying
appropriately
PHASE3 : WEEKS 11–24
MINIMUM PROTECTION
Patient presentation Examination

• No instability • Ligament
• No swelling stability—joint
• No pain arthrometer
• Good to normal muscle • Muscle strength
strength (4/5 to 5/5 on • Functional status
MMT)
• Unrestricted ADL
function
• Possible use of
functional brace
PHASE 3 : WEEKS 11–24 (3­6M)
INTERVENTION
• Continue LE stretching program
• Advance PRE/initiate isokinetic training (if desired)
• Advanced closed­chain exercise, plyometric drills
(bouncing, jumping rope, box jumps: double­ /single­leg)
• Advanced proprioceptive training
• Progressive agility drills (figure­8, skillspecific
patterns)
• Simulated work or sport­specific endurance training
• Progress running program: fullspeed jogging, sprints,
running and cutting
BÀI TẬP CO BẬT PLYOMETRIC
ADVANCED BALANCE
RETURN­TO­ACTIVITY
PHASE: ≥ 6 MONTHS
GOAL
• Increase strength
• Increase power
• Increase endurance
• Regain ability to function at highest desired level
• Transition to maintenance program
• Reduce risk of reinjury
PHASE: ≥ 6 MONTHS
RETURN­TO­ACTIVITY
Patient presentation Examination

• No instability • Full clinical

• Muscle function 70% of examination
noninvolved extremity • Ligament stability
• No symptoms of instability,• Muscle strength
pain or swelling during the
• Functional testing
previous phase
• Possible use of functional
brace or sleeve during
highdemand work or sports
PHASE: ≥ 6 MONTHS
INTERVENTION
• Continue to progress PRE and flexibility
exercises
• Advance agility drills
• Advance running drills
• Implement drills specific to sport or occupation
• Determine the need for protective bracing prior
to return to sport or work
CHƯƠNG TRÌNH PHCN BV CR
CT PHCN BV CR
TROUBLESHOOTING
ARTHROFIBROSIS

 One of the most devastating complications after

ACL reconstruction
 Knee synovium and fat pad inflamed 

thickened joint capsuleobliterate the medial

and lateral gutters and suprapatellar pouch
 patellar tendon shorten patella baja: cause
articular damage.
TROUBLESHOOTING
ARTHROFIBROSIS

 Paulos and colleagues have defined three stages in the

arthrofibrotic knee:
1. Early stage, stage 1 (2 to 6 weeks), decreased
extension, quadriceps lag, diminished patellar mobility,
joint swelling, and failure to progress in rehabilitation.
2. Active stage, stage 2 (6 to 30 weeks), marked decrease
in ROM, decreased patellar mobility, quadriceps
atrophy, skin changes, and osteopenia. These patients
walk with a significant limp.
3. Residual stage, stage 3 (beyond 8 months), marked
decrease in ROM, patellar rigidity, quadriceps atrophy,
patella baja, osteopenia, and possibly arthrosis
TROUBLESHOOTING
ARTHROFIBROSIS
 Anti inflammatory agents
 Aggressive physical therapy, and patellar

mobilization are the initial treatments for all

stages of arthrofibrosis.
 Arthroscopic débridement, open débridement,
and dynamic splinting are usually required in
the later stages
 Cyclops lesion???
TROUBLESHOOTING
ANTERIOR KNEE PAIN

 Commonly occurs after ACL reconstruction (Bach

and colleagues reported an 18% incidence, Kartus and
associates reported a 33.6% incidence)
 More frequently after BPTB autograft
reconstructions than with hamstring autograft
 Emphasis should be placed on quadriceps
strengthening in protected ranges of 0° to 45° for
CKC and 90° to 45° for OKC, and avoidance of
pain.
TROUBLESHOOTING
B. ANTERIOR KNEE PAIN
 If the patient has limited joint motion before
surgery, especially in extension, then a
continuous passive motion device should be used
immediately after surgery
 During the first postoperative phase, ROM
complications, if present, usually occur in
extension.
 If mobilization and home exercises are not
effective, then the patient should try adding
weight to the ankle during the prone hanging
exercises
 TAKE HOME MESSAGE
 Rehabilitation following ACL reconstruction must
prepare the patient to return to his or her prior level
of function. This long process begins immediately
following injury with accurate diagnosis and
determination.
 Following surgery, protecting the healing graft,

immediately decreasing swelling, increasing ROM,

and strengthening in protected ranges is warranted.
 Global kinetic chain strengthening and

neuromuscular training, as well as injury

prevention tactics, should be incorporated to best
prepare the patient to safely return to the prior
level of function.
MENISCAL REPAIR
 ACL + Meniscus +MLL
 Limited research is available regarding physical
therapy protocols after meniscus repair and long­
term outcomes.
 Clinic protocols vary with the degree of
weight bearing, duration of immobilization,
control of range of motion (ROM), and time
frame for a return to sports or work.
FACTORS INFLUENCING THE
PROGRESSION
OF REHABILITATION AFTER MENISCUS
REPAIR
 Location and size of the tear (i.e., the zone[s]
affected and their vascularity)
 Type of tear (tear pattern and complexity)

 Type of surgical fixation device used

 Alignment of the knee joint (normal, varus,

valgus)
 Concomitant injuries (ligament, chondral defect)
with or without reconstruction or repair
MENISCUS ZONES

Blood
supply

Lack of
blood
supply
IMMOBILIZATION, PROTECTIVE BRACING,
AND WEIGHT BEARING
 Maintained in full extension in the postoperative
immobilizer
 Thigh­high compression stockings to control swelling may be

worn.
 To protect the repaired meniscus during the first few

postoperative weeks, the range­limiting long­leg brace is

worn continuously (day and night) and locked in full
extension
 unlocked periodically during the day to initiate early ROM

exercises and for bathing

 Depending on the site of the lesion and repair, flexion motion

is kept between 0° to no more than 90° for 2 weeks or longer

 After a central zone repair, the patient typically wears the

brace for about 6 weeks or until adequate quadriceps control

has been reestablished.
WEIGHT BEARING
 Following a peripheral zone repair, partial
weight bearing (ranging from 25% to 50%) during
ambulation with crutches and with the brace
locked in full extension is allowed during the
immediate postoperative period (first 2 weeks)
 If quadriceps control is sufficient, full weight
bearing may be permitted by 4 weeks after a
peripheral repair111 and by 6 to 8 weeks after a
central repair or transplantation
EXERCISE PRECAUTIONS AFTER
MENISCUS REPAIR*
General Precautions
■ Progress exercises and weight bearing more
gradually after central zone meniscus repairs or
meniscus transplantations than after peripheral
zone repairs.
■ If the patient experiences a clicking sensation in
the knee during exercise or weight­bearing
activities, report it immediately to the surgeon.
EXERCISE PRECAUTIONS AFTER
MENISCUS REPAIR*
Early and Intermediate Rehabilitation
■ Increase knee flexion gradually, especially after a central
zone repair.
■ If a stationary bicycle is used for cardiopulmonary
conditioning, set the seat height as high as possible
to limit the range of knee flexion.
■ During weight­bearing exercises, such as lunges and squats,
do not perform knee flexion beyond 45° for 4 weeks or
beyond 60° to 70° for 8 weeks. Flexion beyond 60° to 70°
places posterior translation forces on a repaired meniscus,
increasing the risk of displacement during early healing.
■ Postpone use of a leg press machine until about 8 weeks.
Limit motion from 0° to 60°.
■ Avoid twisting motions during weight­bearing activities.
■ Postpone hamstring curls until about 8 weeks.
MENISCUS MOVEMENT WITH KNEE FLEXION

Active knee flexion pulls the medial & lateral

meniscus posterior. This activity increased
stress on the repaired and healing tissues
 PASSIVE KNEE FLEXION
BASED ON ASSESSMENT OF PAIN
(0, 30O, 60O, 70O, 90O)

0­
60o:4ws
90o: 4­
6ws

0­90o
4­6ws
EXERCISE PRECAUTIONS AFTER
MENISCUS REPAIR*
Advanced Rehabilitation
■ Do not perform exercises that involve deep
squatting, deep lunges, twisting, or pivoting for
at least 4 to 6 months. (The greater the flexion
angle, the greater the stress on the meniscus.)
■ Do not begin jogging or running program until 5
to 6 months.
Return to Activity
■ Refrain from recreational and sports activities
that involve repetitive, high joint compressions
and shear forces.
■ Avoid prolonged squatting in full flexion.
REHAB PROGRAM

Protect Improve Functional

healing ROM & Activities &
tissue Muscle Sport
Strength
REFERENCES
1. Rehab for the postSurgical orthopedic patient 3 rd
2. Therapeutic exercises 7th
SCH
SCH
 Phase 1: Roulement
pur pendant 15°
 Phase 2: roulement
associé à un
patinement
 Phase 3: patinement
pur à partir de 120°
ainsi: dans la flexion,
le condyle glisse et
recule dans
l’extension, le condyle
glisse et avance
Le condyle latéral recule plus que le
condyle médial
LCA RESTRAINT
Le LCA
 freine le recul du condyle externe lors de la flexion et

lui impose un roulement patinant

 son action est couplée à celle du LLI sur le condyle

interne, la partie antérieure du fx superficiel du LLI

restant tendu en flexion