ACL

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 Table of contents
01 02
Definition Epidemiology

03 04
Anatomy Mechanism of injury
 Table of contents

Risk factors ASSESSMENT

Plan of treatment Prognosis

Definition 01
● Anterior cruciate ligament (ACL) rupture is a common and devastating

injury that can result in knee instability.

● ACL's insertion pattern on the femur and tibia, with a flat, 'ribbon-like' form
 02 Epidemiology
• The text discusses the incidence ratios of ACL injuries between male and female athletes in

various sports, including basketball, soccer, lacrosse, and Alpine skiing

• It highlights the higher risk of ACL injuries for female participants in soccer and basketball,

compared to their male counterparts

• It also mentions the impact of training and injury-reduction programs on reducing the risk of ACL

tears in soccer but not in basketball

• The text also notes that recreational Alpine skiers have a higher rate of ACL tears compared to

elite skiers, and volleyball may be a low-risk sport for ACL injuries

• The study also found that year-round female football and basketball players have an ACL injury

risk of around 5%
 03 ANATOMY
The anterior cruciate ligament
(ACL) is a dense connective
tissue that connects the femur to
the tibia
It arises from the medial aspect of
the lateral femoral condyle and
blends with the anterior horn of
the medial meniscus
The ligament turns slightly
outward as it crosses the joint
The ACL has an avascular zone in
the fibrocartilage
04 Mechanism of injury

• Suddenly slowing down and changing

direction (cutting)
• Pivoting with your foot firmly planted
• Landing awkwardly from a jump
• Stopping suddenly
• Receiving a direct blow to the knee or
having a collision, such as a football tackle
 Risk factors

ACL tears are common,

especially among athletes
who play sports requiring
sudden stops, twisting, or
changing directions, such
as soccer, football,
basketball, gymnastics, and
lacrosse.
 Risk factors
• Being female — possibly due to differences in anatomy, muscle
strength and hormonal influences
• Participating in certain sports, such as soccer, football, basketball,
gymnastics and downhill skiing
• Poor conditioning
• Using faulty movement patterns, such as moving the knees inward
during a squat
• Wearing footwear that doesn't fit properly
• Using poorly maintained sports equipment, such as ski bindings that
aren't adjusted properly
• Playing on artificial turf
 Grades

1
2
The injury stretched your
ACL enough to damage it,
but it’s still in one piece and
holding your knee bones
together. The injury stretched your
ACL so much that it was
partially torn and loosened.
3
A complete tear — your
ACL is in two pieces.
 Assessment
1 2 3

Pain assessment Trophic assessment Articular assessment

4 5 6

Muscular assessment Functional assessment Specific tests

 Pain Assessment 1
• The pain assessment shows that patients treated with BTB had more pain than those treated with
HS
• Furthermore, teenagers reported more pain, catastrophizing, and anxiety than adults, with
helplessness and rumination playing a major role in the variations in catastrophizing
Keeping the swelling to minimum.
Upun rubture heat start radiating

Trophic assessment 2
 Articular Assessment
● The focus should be on strengthening and proprioception while keeping the injured
knee in a calm state to improve range of motion and reduce swelling
● RICE and electrotherapy can be used in the weeks before surgery to achieve full range
of motion and decrease joint effusion
 Muscular Assessment
1. Weak ness in the quadriceps
2. The text discusses the impact of various muscles on the stress placed on the anterior cruciate
ligament (ACL) in the knee
3. It states that certain muscles such as the hamstrings, soleus, and gluteus medius are effective at
lessening the stress on the ACL, while the quadriceps and gastrocnemius increase the ACL stress
4. The hamstrings are effective at reducing posterior shear stress on the tibia, unloading the ACL,
but their effectiveness decreases at lower knee flexion angles, which are common during ACL
damage
5. The soleus and gastrocnemius also play roles in generating shear stresses, with the soleus
potentially acting as a significant agonist of the ACL during low knee flexion angles
6. The text also mentions the role of the gluteus medius in resisting knee valgus loading, which is an
important indicator of ACL strain
7. The text suggests that therapies aimed at reducing the risk of ACL damage should target the
function of these muscles
 Functional assessment
1. A study compared 19 people with ACL reconstruction and 17 healthy controls
2. No significant differences were found in age, height, body mass, and Tegner scores,
indicating all post-ACL individuals had returned to normal activity levels
 Specific tests
1. The Lachman test, AD sign, and pivot shift test in outpatient settings have sensitivities
and specificities ranging from 75% to 100%
2. Under anesthesia, the Lachman test and AD sign have a sensitivity of 92
3. 9% and 100% specificity
4. The pivot shift test is highly specific for diagnosing ACL laxity in a non-acute setting
5. The McMurray test has lower sensitivity and specificity for diagnosing medial and
lateral meniscus injuries, especially in the presence of ACL injury
6. The pivot shift test under anesthesia is the most sensitive and specific test for
diagnosing ACL laxity in a non-acute setting, while the McMurray test is not sensitive
for diagnosing meniscal injury with ACL injury present
 Plan of
treatment
 Plan of treatment

01 02

surgical PT plan
Surgery to treat knee injury is often an
outpatient surgery, which means you can
return home the same day. Your surgeon will
conduct a knee arthroscopy, a minimally
invasive procedure for repairing the damage
inside your knee. Ask your surgeon what to
expect.(31)
 Phases
01
02
03
ACUTE STAGE 04
Pre-surgical Stage

Post-surgical Stage
Return to sport
 Acute phase
1. After an ACL injury, regardless of whether surgery will take place or not,
physiotherapy management focuses on regaining range of movement, strength,
proprioception and stability. In the acute stage PEACE AND LOVE should be used in
order to reduce swelling and pain, to attempt full range of motion and to decrease joint
effusion. Appropriate anti-inflammatory medications are used to help control pain and
swelling
 Pre surgery phase
1. ACL surgery should be delayed until the acute inflammatory phase has passed to reduce the risk
of developing a stiff knee after surgery
2. The surgery should only be performed if there is persistent instability of the knee with complaints
of giving way, as it is difficult to diagnose in an acute situation
3. Physiotherapy is important in preparing the knee for surgery, with a focus on strength and
proprioception
4. RICE and electrotherapy can be used to improve range of motion and decrease joint effusion
5. The pre-surgical stage can last a few days or several weeks, during which the physiotherapist must
maintain the compliance of the patient by setting measurable weekly objectives for improvement
6. Different exercise plans can be provided for the gym and home, focusing on reinforcing muscular
strength and proprioception while avoiding sub-maximal loads to prevent knee swelling or re-
injury due to lack of proprioception
 Post surgery

1. ACL rehabilitation has evolved over the last decade, with various tissues and grafts
being used for ACL reconstruction
2. The most commonly used are autografts and sometimes allografts
3. The process of "ligamentization" of the grafts requires precautions in terms of loading
and physical requests
4. The remodeling of the new ACL is a process that continues for 9 years or more, and
seems to be a process of adaptation rather than full restoration
5. Physiotherapic approach during After Surgery Stage remains similar for different
grafts, with focus on pain, swelling, muscular contracture, and gait patterns as
indicators for a good outcome
 Three important factors in the After Surgery Stage are early terminal knee extension equal to the
contralateral side, early weight bearing, and closed and open kinetic chain strengthening exercises
Early knee extension establishes the foundation for rehabilitation, and the incidence of knee flexion
contracture has significantly decreased with accelerated knee extension immediately after surgery
A good physiotherapic program is dependent on achieving goals week by week, according to the ACL
Rehabilitation Guidelines
 Return to sport

1. After surgery, athletes may experience strength and power deficiencies, increasing the
risk of future injuries and hindering their performance
2. Researchers suggest the surgically repaired limb should perform at least 90% as well
as the undamaged leg before returning to sports
3. Three hopping tests can help ensure a safe return to sport after ACL reconstruction by
measuring side-to-side differences
 Prognosis
Rehabilitation after ACL reconstruction has
evolved to a progression-based program,
considering forces on the healing ACL
graft
Early focus is on knee extension,
decreasing swelling, and building
quadriceps strength
Therapeutic exercises progress in difficulty
and position, with neuromuscular training
incorporated
Objective criteria, not just time frames,
guide the progression
Returning to sports requires meeting
criteria after six months, with controlled
athletic activity volume in the post-
rehabilitation period
 Thank You
Any questions?