Anterior Cruciate Ligament (ACL) Injury;

Causes, Diagnosis and Treatment .

Om Pal Singh (PT)
Introduction

• The knee joint is a Hinge type synovial joint , which mainly allows for flexion and
extension (and a small degree of medial and lateral rotation). It is formed by
articulations between the patella, femur and tibia.
• Knee is responsible for absorbing shock and providing stability when in motion.
• Knee is stabilises by 
medial collateral ligament, lateral collateral ligament, posterior cruciate ligament, a
nd anterior cruciate ligament
.
Introduction
• Athletes that participate in highly demanding sports such as soccer,
football, basketball, and netball are more likely to sustain an ACL
injury.
• The anterior cruciate ligament (ACL) is one of a pair of cruciate
ligaments. ACL crosses the posterior cruciate ligament to form an
“X”. It is composed of strong, fibrous material and assists in
controlling excessive motion.
Women are at greater risk of ACL injury due to the gender s
pecific changes that occur at the onset of puberty.
Relevant anatomy of ACL:-

• The ACL arises from the anteromedial aspect of the intercondylar

area on the tibial plateau and passes upwards and backwards to
attach to the posteromedial aspect of the lateral femoral condyle.
• ACL which runs diagonally through the knee, from the lateral aspect
of the femur to the medial tibia. The ACL ranges from 25 to 35 mm in
length, approximately 10 mm in breadth, and 4 to 10 mm in width.
• Ligaments consist of fibroblast cells and the extracellular matrix (EC
M
).
• Fibroblasts are immature , Large, Flat, and Branched cells that have
retained the ability to divide. and secrete collagen
fibers and ground substance that constitutes the ECM.
Relevant anatomy of ACL:-

• Collagen fibers are regularly arranged bundles of fibers in a parallel

pattern. This arrangement provides mechanical resistance to pull
force along the axis of fibers.
• Ground substance forms the matrix and has multiple functions such
as storing water, serving as a medium for the exchange of materials
between cells and blood and controls the overall metabolic activity of
the tissue.
ACL is composed of two principal parts: small anteromedial Band(AMB) and a
larger bulky posterolateral Band (PLB)
• The AMB is responsible for the posterior translation of the f
emur at flexion, and the PLB resists hyperextension and pre
vents posterior translation of the femur in extension
.
•  anteromedial bundle is tight in flexion, attaches to roof of
intercondylar notch.
• posterolateral bundle is tight in extension , attaches to wall of
intercondylar notch.
Injury of ACL:-

• A ligament is a tough, flexible and strong band of tissue that holds

bones and cartilage together within your knee and tissue that help
connect your thigh bone (femur) to your shinbone (tibia).
• It prevents the shin bone from sliding out in front of the thigh bone.as
it resists anterior tibial translation and rotational loads.
• The anterior cruciate ligament (ACL) can be torn by hyperextension of the knee
joint, or by the application of a large force to the back of the knee with the joint
partly flexed.
• Younger athletes usually sustain growth plate injuries (avulsion fractures) rather
than ligamentous injuries because of the relative weakness of the cartilage at the
epiphyseal plate compared with the ACL.
Mechanism of injury :-

• ACL injury occurs when an excessive tension force is applied on the ACL. A non‐contact
ACL injury occurs when a person themselves generates great forces or moments at the knee
that apply excessive loading on the ACL.
• 70% of knee injuries are Non-Contact with knee in "Dynamic Valgus Position“
• Anterior shear force at the proximal end of the tibia is a major contributor to ACL loading,
whereas valgus, Varus and internal rotation moments of the knee can increase ACL loading
when an anterior shear force is applied to the proximal end of the tibia.
• According to these ACL loading mechanisms, a small knee
flexion angle, a strong quadriceps muscle contraction or a
great posterior ground reaction force can increase ACL
loading.
Why are Women more at risk of ACL injury?:-

• Women are at greater risk of ACL injury due to the gender specific changes that
occur at the onset of puberty. Due to the genetic bone structure, Females are
predisposed to valgus forces at the knee due to their wider hips.
• It is also know that Female athletes are generally not as strong as their Male
counterparts, who receive a dose of testosterone, ILGF and growth hormone during
puberty that contributes to the increase in strength, and therefore dynamic knee
stability.
• Female athletes had a higher incidence of ACL injuries compared with their male c
ounterparts. the incidence in female athletes is two to eight times higher than in mal
es in soccer, basketball and volleyball..
Risk Factor:-

• Most ACL injuries occur when an anterior force is applied to the tibia.
• Injuries to the anterior cruciate ligament (ACL) are immediately disabling and are
associated with long-term consequences, such as posttraumatic osteoarthritis..
• There are a number of factors that increase your risk of an ACL injury, including:-.
Risk factor:-
• 1- Being female: — The rate of ACL injuries is higher in female athletes than in males
possibly due to differences in anatomy, muscle strength and hormonal influences.
• 2- Participating in certain sports:- commonly occur in sports such as basketball,
soccer, football, volleyball, downhill skiing, lacrosse, and tennis. These sports require
frequent and sudden deceleration, such as cutting, pivoting, or landing on one leg.
• 3- Previously torn ACL
• 4- Age:- ACL tears are most common between the ages of 15 and 45, mostly due to the
more active lifestyle and higher participation in sports.
• 5- Using faulty movement patterns
Biomechanics of Knee Joint in Stair Climbing:-
• Level walking involves up to 30° flexion at the knee joint but during stair climbing, the knee flexion
angle varies from 60° to 135°, depending on the height of each stair and Quadriceps contract
eccentrically during knee flexion.
Biomechanics of Knee Joint in Stair Climbing:-

• The canter of rotation (CoR) of the knee joint varies with respect to the angle of flexion.
For the first 30° of flexion, femoral condyle undergoes minimal anterior translation.
Between 30° and 135°, the femoral condyle undergoes larger anterior translation.
• 1-Hamstring muscles are attached behind the knee and therefore apply a posterior
shear force on the tibia and this force depends upon the magnitude and direction of
the individual forces. The highest shear forces at ACL occur during hyperextension
(−5° of flexion) of the knee joint.
• 2-Hamstring muscles are attached behind the knee . The shear force due to the
patellar tendon (high quadriceps force) has the largest share in determining the
total shear force and occurs during the contralateral toe off (CTO).
Symptoms of ACL Injury:-

• A "popping" sound at the time of injury.

• Pain, especially when you try to put weight on the injured leg
• Knee swelling within 6 hours of injury.
• Difficulty in continuing with your sport.
• Reduced range of motion.
• Joint tenderness.
• Initial inability to weight bear, which improves in a short period.
• Knee felt to "gives way" especially during pivoting movement.
What causes ACL injuries?:-

• 1-Changing direction rapidly

• 2-Stopping suddenly while speedily running
• 3-Faulty landing
• 4-Participating in high demand game with relatively poor condition
• 5-Slowing down or stopping suddenly
• 6-Jumping and landing
• 7-Contact and collisions
 Grades
• Grades 1 Sprains:-
• 1- The ACL ligament is pulled,
No tear.
• 2- No joint instability.
• 3- The ligament is mildly
damaged in a Grade 1 Sprain. It
has been slightly stretched, but is
still able to help keep the knee
joint stable.
Grades
• Grades 2 Sprains:-
• 1-Less than 50% fibres of the ACL are torn: Partial tear.
• 2-Minimal joint instability.
• 3-A Grade 2 Sprain stretches the ligament to the point where it becomes loose. This
is often referred to as a partial tear of the ligament.
Grades
• Grades 3 Sprains:-
• 1- 50-100% fibres of ACL are torn: Complete tear
• 2-Joint is unstable. Giving away sensation may be present
• 3-This type of sprain is most commonly referred to as a complete tear of the ligament.
The ligament has been split into two pieces, and the knee joint is unstable.
• 4-As grade 3 tears involve complete disruption of the integrity of the ligament, people
often feel a sudden sharp pain initially. It occurs most commonly with a popping sound.
Diagnostic Procedure:-

• The diagnosis of an ACL tear can typically be made by an

experienced sports medicine specialist or A Physiotherapist
based on the players history of the injury.
 1-Physical Examination :-

• This type of assessment is probably the

first evaluation you will undergo if you
suspect an ACL tear.
• While diagnostic anatomical assessment
are essential, they often rely on subjective
factors such as the experience of the
physician, muscle relaxation, and
underlying knee variability.
1-Physical Examination :-
• Physical diagnosis is particularly difficult in older patients and in patients with
severe injury and soft-tissue swelling and guarding.
• The Lachman test is the most accurate test for detecting ACL injury, followed by
the anterior drawer test and the pivot shift test.
• 2-Arthrometer / Laximeters
• 3- Radiography
• 4-MRI
• 5- Arthroscopy
 Note:-
The Lachman's Test is the most accurate test for detecting an ACL tear.

• Treatment Option:-
• 1- Surgical :-
• 2- Non-Surgical:-
• Athletes who attempt no operative management and continue to play sports with a
chronic ACL tear frequently develop persistent knee instability which presents as a
shifting sensation.
• your physical therapist will work with you to restore your muscle strength, agility,
and balance, so you can return to your regular activities.
• Your physical therapist may teach you ways to modify your physical activity in
order to put less stress on your knee. If you decide to have surgery your physical
therapist can help you before and after the procedure.
• By undertaking a Rehabilitation program, it is possible to function normally
without having surgery to reconstruct a torn ACL.
Physical therapy before surgery:-
• In nonsurgical treatment, progressive physical therapy and rehabilitation can restore the knee to a
condition close to its pre-injury state and educate the patient on how to prevent instability.
• Nonsurgical management of isolated ACL tears is likely to be successful or may be indicated in patients:-
• -With partial tears and no instability symptoms
• -With complete tears and no symptoms of knee instability during low-demand sports who are willing to
give up high-demand sports
• -Who do light manual work or live sedentary lifestyles
• -Whose growth plates are still open
• Before any treatment, encourage strengthening of the quadriceps and hamstrings, as well as range of
motion (ROM) exercises. Performance of ROM helps reduce the amount of effusion and helps the
patient regain motion and strength. It may include treatments such as gentle electrical stimulation
applied to the quadriceps muscle.
Physical therapy before surgery:-

• The rehab program consisted of single- and multiple-joint exercises; open and closed kinetic
chain exercises; and concentric, eccentric, and isometric exercises with 3 to 4 sets and 6 to 8
repetitions per exercise. Plyometric exercises were gradually progressed.
• A trial of conservative management may be considered if the patient has few giving-way
episodes, near normal range of motion on knee extension, minimal or no meniscal damage on
magnetic resonance imaging, strong quadriceps femoris.
Treatment After Surgery:-

• Icing and compression:-Immediately following surgery, your physical

therapist will control your swelling with a cold application, such as an
ice sleeve, that fits around your knee and compresses it.
Treatment After Surgery:-

• Bracing :- Some people with a damaged ACL can

get by with wearing a brace on their knee when
they run or play sports.
• It provides extra support .Some surgeons will
give you a brace to limit your knee movement
(range of motion) following surgery.
• Your physical therapist will fit you with the
brace and teach you how to use it safely. Some
athletes will be fitted for braces as they recover
and begin to return to their sports activities.
Treatment After Surgery:-

• Bearing weight:-you will use crutches to

walk. The amount of weight you are allowed
to put on your leg and how long you use the
crutches will depend on the type of
reconstructive surgery you have received.
• Your physical therapist will design a
treatment program to meet your needs and
gently guide you toward full weight bearing.
Treatment After Surgery:-

• Movement exercises:- Movement exercises help with increasing blood flow, which
also helps reduce swelling. your physical therapist will help you begin to regain
motion in the knee area, and teach you gentle exercises you can do at home. The
focus will be on regaining full movement of your knee.
• Electrical stimulation:- Your physical therapist may use electrical stimulation to
help restore your thigh muscle strength, and help you achieve those last few degrees
of knee motion.
Treatment After Surgery:-

• Strengthening exercises:- your physical therapist will help you increase your ability
to put weight on your knee, using a combination of weight-bearing and non-weight-
bearing exercises. The exercises will focus on your thigh muscles (quadriceps and
hamstrings) and might be limited to a specific range of motion to protect the new
ACL.
• Balance exercises :-Your physical therapist will guide you through exercises on
different surfaces to help restore your balance and coordination. Initially, by the
exercises you will learn how to shift weight on to the surgery leg.
Treatment After Surgery:-

• To prevent ACL injuries:- athletes should participate in neuromuscular and

proprioceptive strengthening and conditioning programs. These should include
plyometric exercises and coaching regarding proper positioning while landing.