Anterior cruciate ligament injuries micro

Presented By:
Dr Nishank Verma
MPT Sports
Jamia Millia Islamia

Anatomy (1)
 Anterior Cruciate Ligament
Originates at postero-medial corner of lateral femoral condyle.
Inserts at anterolateral aspect of tibial spine.
It is intra-capsular and located outside the synovial fluid.
The anterior cruciate ligament (ACL) consists of two major fiber
bundles, namely the anteromedial (AM) and postero-lateral (PL)
bundles.

Anatomy
The AM bundle overlies the PL bundle, and the PL bundle
can only be seen by retraction of the AM bundle with a
probe.
When the knee is extended, the PL bundle is tight and the
AM bundle is moderately lax. As the knee is flexed, the
femoral attachment of the ACL becomes horizontally
oriented, causing the AM bundle to tighten and the PL bundle
to relax.
Functions: The AM bundle is the primary restraint against
anterior tibial translation in flexion, the PL bundle tends to
stabilize the knee near full extension, particularly against
rotatory loads.

Epidemiology of ACL Injuries(2,3)
 There’s an incidence of 36.9 injuries per 1,00,000 person per
year in United States.
 There are an estimated 80,000 to 100,000 anterior cruciate
ligament (ACL) repairs in the U.S each year.
 Most ACL tears occur from non-contact injuries.
 There is 1.4 to 9.5 times increased risk of ACL tear in women.
 The intensity of play is a factor, with a three to five times greater
risk of ACL injuries occurring during games compared with
practices.

Epidemiology in sports (4)
Activity when injured Annual ACL reconstructions incidence
per 100 000 participants
Skiing (alpine and downhill) 417
Australian rules football 273
Rugby (League and Union combined) 255
Soccer (indoor and outdoor combined) 211
Netball 188
Touch football 157
Basketball 109
Motorcycling 65
Skiing has the highest incidence of ACL reconstructions per 100 000
person-years.

Mechanism of injury (3)
 ACL injuries caused by contact require a fixed lower leg (i.e., when
planted) with enough force to cause a tear.
 Contact injuries account for only about 30 percent of ACL injuries.
 The remaining 70 percent of ACL tears are noncontact injuries
occurring primarily during deceleration of the lower extremity, with
the quadriceps maximally contracted and the knee at or near full
extension.
 The rate for non-contact ACL injuries ranges from 70 to 84% of all
ACL tears in both female and male athletes.
 A non-contact ACL injury include: change of direction or cutting
maneuvers combined with deceleration, landing from a
jump in or near full extension, pivoting with knee near full
extension and a planted foot.

 Boden et al. reported a lower extremity alignment
associated with non-contact ACL injury in which the
tibia was externally rotated, the knee was close to full
extension, the foot was planted during deceleration with
valgus collapse at the knee.

ACL injury through a combination of knee valgus and
anterior tibial translation force during a side-cut maneuver in
soccer players

Risk factors (5)
 Environmental factors
Weather
Shoe-surface interaction
Footwear
 Anatomical factors
Joint laxity
Pelvis and trunk
Q-angle
Notch width, ACL size and strength
Foot pronation

Risk factors
 Hormonal factors
Hormones
Effects on laxity
Effects on ACL tensile strength
 Neuromuscular factors
Relative strength and recruitment
Muscular fatigue
 Biomechanical factors
Sagittal plane
Coronal plane
Transverse plane

Environmental risk factors
 Weather:
Scranton et.al found a higher ACL injury rate on natural grass
during dry compared to wet conditions.
Orchard et al. found that high water evaporation in the month before
the match and low rainfall in the year before the match in Australian
Football were significantly associated with a higher incidence of
ACL injuries. This could be explained by an increased friction and
torsional resistance from the shoe-surface interface compared to
wet conditions.
Torg et al. demonstrated that an increase in turf temperature, in
combination with cleat characteristics, affects shoe-surface interface
friction and potentially places the athlete’s knee and ankle at risk of
injury.

 Shoe-surface interaction
Orchard et al. found in Australian Football that games and
practices played on rye grass appeared to have a lower
incidence of ACL tears compared to Bermuda grass.
It was hypothesized that Bermuda grass, with a thicker layer,
would increase shoe-surface traction.
Also, grass cover and root density has been associated with a
greater shoe-surface traction.

 Footwear
Footwear is considered a potential risk factor for ACL tears,
since it modulates foot fixation during the game.
It has been shown that the number, length and cleat
placement was associated with the chance of ACL injuries.
Lambson et.al found a higher risk of ACL tears for the
‘‘edge’’ cleat design. This cleat placement may have provided
significantly higher torsional resistance compared to other
types of cleats.

Anatomical risk factors
 Joint laxity (6,7)
Soderman et al. investigated the risk of leg injuries among
female soccer players presenting with general joint laxity
and knee hyperextension.
Uhorchak specifically reported a 2.8 times greater risk of
non-contact ACL injury in the United States Military
Academy cadets with generalized joint laxity compared to
normal joint laxity subjects in a prospective 4-year
evaluation.

 Pelvis and trunk
Anterior pelvic tilt places the hip into an internally rotated,
anteverted, and flexed position, which lengthens and
weakens the hamstrings and changes moment arms of the
gluteal muscles.
Genu recurvatum, excessive navicular drop, and excessive
subtalar pronation are more commonly found in ACL-
injured subjects compared to non-ACL-injured subjects,
all factors that have also been related to ACL preloading.

 Torsional anatomic abnormalities are also related to
altered lower extremity biomechanics.
 The toe-in gait demonstrates the femoral torsion position and is
often associated with increased external tibial torsion which has
been related to the functional valgus collapse at the knee joint.

 Q-angle
The Q-angle is the angle formed by a line
directed from the anterior-superior iliac spine to central
patella and a second line directed from the central patella to
tibial tubercle.
A high Q-angle may alter the lower limb biomechanics and
place the knee at a higher risk to static and dynamic valgus
stresses.

 Notch width, ACL size and strength
Chandrashekar et al. found that ACLs in women were smaller
in length, cross-sectional area, volume, and mass when
compared with that of men.
The authors also demonstrated a lower fibril concentration
and lower percent area occupied by collagen fibrils in
females compared to males.
Women may have lower tensile linear stiffness with less
elongation at failure, and lower energy absorption and load at
failure than men.

 The smaller the inter-condylar notch the smaller the
cross-sectional area of the ACL.
 An impingement of the ACL at the anterior and
posterior roof of the notch may occur during tibial
external rotation and abduction.

 Foot pronation
Foot pronation and navicular drop have been considered a
risk factor for ACL injuries.
Subtalar joint pronation creates a compensatory increase in
the internal tibial rotation, at the knee during extension
(Beckett et al.)

Hormonal risk factors
 Hormones
Human ACL cells had both estrogen and progesterone
receptor sites.
Hormonal risk factors are believed to play an important
role for non-contact ACL injuries among female athletes.
Studies show an effect of pre-ovulatory phase, of the
menstrual cycle for increased ACL injuries.

 Effects on laxity
There is an increased knee laxity during the ovulatory or
post-ovulatory phases of the cycle.
Hicks-Little et al.found that the ovulation and luteal phases
of the menstrual cycle significantly increased anterior
displacement about the knee.

 Effects on ACL tensile strength
Estrogen and progesterone have been found to affect the
collagen metabolism in both animal models and humans.
Essentially, estrogen decreased fibroblast
proliferation and type I pro-collagen synthesis whereas
progesterone levels attenuated estrogen inhibitory effect on
collagen metabolism of female ACLs, both in a dose- and
time-dependent manner.

Neuromuscular risk factors
 Relative strength and recruitment
Women may have an imbalance between muscular
strength, flexibility, and coordination within their lower
extremities. Deficits in relative hamstring strength may
contribute to increased risk of ACL injury in soccer
players.
Chappell et al. found that female soccer, basketball,
and volleyball players prepared for landing with
increased quadriceps activation and decreased hamstring
activation, which may result in increased ACL loading
during the landing of the stop-jump task and the risk for
non-contact ACL injury.

Neuromuscular risk factors
 Muscular fatigue
Since muscles contribute to joint stability, muscular fatigue might
be a risk factor for ligament injuries.
Fatigued muscles are able to absorb less energy before reaching
the degree of stretch that causes injuries .
Under fatigued conditions, it was shown that males and females
decrease knee flexion angle and increase proximal tibial anterior
shear force and knee varus moments when performing stop-jump
tasks
Fatigue increased initial and peak knee abduction and internal
rotation motions and peak knee internal rotation, adduction, and
abduction moments, with the latter being more pronounced in
females.

Biomechanical risk factors
 Biomechanics of playing actions are necessary to
understand the pathomechanics of ACL injuries and to
offer effective prevention programs.
 It was postulated that hip low forward flexion, hip
adduction, hip internal rotation, knee valgus, knee
extension, and knee external rotation may place the
ACL to a high risk of rupture. It was called the
‘‘position of no return’’

 Sagittal plane
Sagittal plane biomechanics have yielded many studies on
trunk, hip, knee, and ankle flexion angles when performing
sport tasks. The more joints are flexed during landing, the
more the energy is absorbed and the less the impact is
transferred to the knee.
Blackburn and Padua demonstrated that increased trunk
flexion during landing also increased hip and knee flexion
angles. A less erected posture during landing has been
associated with a reduced ACL injury risk.

 Decker et.al. suggested that a decreased hip musculature
activity may produce a higher ground reaction force,
because muscles would be used to absorb energy from a
certain task.
 It is also postulated that a decreased hip and knee flexion
angles at landing places the ACL at a greater risk of injury,
because a greater peak landing force is transmitted to the knee.

 Coronal plane
Coronal plane knee biomechanics are also related to
ACL injury.
Women have greater valgus moments than men during the
landing phase. This can lead to increased risk of ACL tear.
Landry et al. found an increased ankle eversion angle in elite
female soccer players compared with male players for
unanticipated run and cross-cut maneuvers.
Excessive ankle eversion may increase internal tibial
rotation, knee valgus stress, anterior tibial translation, and
loading on the ACL during extension.

 Transverse plane
Hip biomechanical findings mainly refer to a greater hip
internal rotation, maximum angular displacement and a
lower gluteal EMG activity at landing in female soccer,
basketball, and volleyball players compared to males.
When performing unanticipated side-cut maneuvers, female
soccer players exhibited more hip external rotation
compared with the male athletes.

Signs and symptoms
 Triad:
An acute blow or twisting or cutting injury
An immediate effusion
Inability to continue to play
 Popping
 Giving way- sudden weakness in the leg that causes the
leg to go into mild hyperextension.

Diagnosis (11)
 The most accurate diagnosis is achieved by integrating
patient history, physical examination findings, imaging
studies, and routine orthopedic follow-up.
 Patient History
ACL injuries typically occur in patients who
participate in activities that require running, jumping,
or cutting.
Injury may be characterized as a “pop” or buckling
of the knee with eventual swelling from a traumatic
hemarthrosis.

Diagnosis
 Physical Examination
The knee is first inspected for any bruising or contusion that may
indicate a more serious injury.
The knee is checked for an effusion.
Range of motion is assessed. Limited motion may indicate
concomitant meniscal pathology.
Locking of the knee or a block to extension may be the result of
interposition of a partial ACL tear.
The knee is then examined for any tenderness or swelling along the
joint line.

Diagnosis
 The ligamentous examination is performed, and its findings
compared with those of the contralateral extremity.
 Special tests:
Anterior drawer test
Lachman test
Anterior drawer test Lachman test

Diagnosis
 Imaging studies
Radiographs have limited value in the diagnosis of acute
ACL injury.
Findings are indirect and limited to bone abnormalities.
Avulsion fracture of ACL at the tibial insertion or femoral
origin can be found on radiographs.

Diagnosis
 Segond fracture: Avulsion fracture of lateral tibial condyle
of the knee

Diagnosis (contd.)
 MRI: The oblique sagittal plane is the most helpful in diagnosis.
Normal ACL Torn ACL

Diagnosis
 In chronic case the fibres can be completely absorbed.

Diagnosis
 Partial tears are characterized by
increased signal intensity and fiber
laxity with increased concavity (or
bowing) of the ACL.
 If >50% of the ACL fibres are torn
= high grade tear,
 If 10% -50% of fibres torn =
medium grade tear
 If <10% of fibres torn = low grade
tear (13)

Diagnosis (contd.)
 The deep lateral femoral
notch sign, although
uncommon, is quite
specific for ACL tear and
is due to impaction
injury of the lateral
femoral condyle onto the
tibia.
Patellar buckling sign and lateral femoral
notch sign

Diagnosis (contd.)
 Anterior tibial translation
 If there is ≥ 5 mm anterior
translocation of the tibia relative to
the femur, this would be indicative
of ACL tear, while an anterior
tibial translation > 7 mm is fully
diagnostic of ACL tear.

Surgical approach
 The surgical approach to ACL tears is the
reconstruction of the ACL with the use of a graft (a
piece of tendon) passed through tunnels drilled into the
tibia and femur at insertion points of the ligament to
approximate normal anatomy, with the goal of
eliminating ACL instability.
 Either patellar tendon or hamstring tendon may be used.

ACL Reconstruction with patellar tendon

Non-operative ACL Rehabilitation (15)
 Resistive exercises:
Leg extensions, leg curls, and leg press .
Perform 2 sets of 10 repetitions at 50% of the 1-
repetition maximum
2 sets of 8 repetitions at 75% of the 1-repetition
maximum
2 sets of 5 repetitions using maximum effort.
The leg extension exercise is performed through a
joint excursion from 90 to 45 degrees of flexion to
minimize anterior tibial shearing during the exercise.

Non-operative ACL Rehabilitation (cont.)
 Cardiovascular training techniques:
Selected based on each subject's sports activities.
A graded running program is used for subjects involved in running
sports.
The running program:
begin with treadmill running level surface running
hill running sprinting figure-
eight running.

For skating sports:
training begin with sliding-board skating simulation
straight ice skating quick stops
and starts cutting changing directions

 Agility training techniques:
Side sliding
Cariocas
Forward and backward quick start-and-stop shuttle runs
Multi-directional quick start-and-stop running
Figure-eight running

 Sport-specific skills: initiated when subjects tolerate
full-effort agility training without pain or swelling.
 Sport-specific tasks, such as ball catching, passing, and
kicking.
 Sport-specific skills are also practiced in the context of
playing situations.
 For example, basketball players begin practicing
dribbling skills, jump shots.
 Hockey players would perform stick handling, passing,
and shooting drills during their workouts.

 Perturbation training program:
 Techniques are:
Anteroposterior and Medio-lateral rotary perturbations on a
tilt board,
Multidirectional perturbations while the subjects are
standing with one lower extremity on a roller board and the
contralateral lower extremity on a stationary platform.
Multi-directional perturbations while the subjects were
standing in single-limb support on a roller board.

Tilt board Roller board
Roller board/ stationary
platform

Postoperative anterior cruciate ligament
reconstruction protocol (16)
 Phase I: PO Weeks 1–4
 Goals:
Protect graft fixation
Minimize effects of immobilization
Control inflammation
Full extension ROM
 Brace/WB status
Brace Week 0–1
Week 1–2 Unlocked for ambulation when full extension
with no lag

reconstruction protocol (contd.)
 Week 2–4
DC brace when full extension with no lag
WB as tolerated
Bilateral axillary crutches
 Therapeutic exercises
Heel slides as tolerated
Wall slides
Quadriceps sets
Patellar mobilizations
Gastrocnemius and hamstring stretches
SLR – with brace if extensor lag

 Quadriceps isometrics
 Toe raises bilaterally
 Terminal knee extension
 Balance – bilateral weight shifts
 Stationary bike (high seat, low tension)
 Criteria for Advancement II
 Good quad set
 Approximately 120° flexion
 Full knee extension

 Phase II: PO Weeks 4–6
 Goals:
Restore normal gait
Maintain full extension
Progress flexion ROM
Protect graft fixation
 WB status: No assistive device when gait with no pain.
 Toe raises unilaterally
 Leg press – bilaterally
 Balance – bilateral weight shifts – unilateral
 Hamstring isometrics
 Hamstring and gastrocnemius & soleus stretch

 Criteria for Advancement III
Excellent quadriceps set
SLR without extensor lag
Full knee extension
No signs of inflammation

 Phase III: PO 6 Weeks–3 Months
 Goals:
 Full ROM
 Improve strength
 Improve endurance
 Improve proprioception
 Prepare for functional activities
 Avoid overstressing graft
 WB status: functional brace may be recommended for use
during sports for first 1-2 years after surgery

 Therapeutic exercise:
 Flexibility as appropriate
 Isolated knee extension 90°–45° progress to eccentrics
 Advanced CKC – Single leg squats; leg press – unilaterally (0°–45°)
 Step-ups (begin 2′′ progressing to 8′′)
 Criteria for Advancement to IV
 Full pain-free ROM
 85% quadriceps and hamstring strength
 Good static proprioception and balance

 Phase IV: PO 3 months–6 months
 Goals:
 Progress strength
 Progress power
 Progress proprioception
 Prepare for return to controlled individual functional
activities/sports
 WB status: functional brace may be recommended for
use during sports for first 1-2 years after surgery

 Begin in-line jogging
 Initiate bilateral plyometric exercises
 Progress proprioception
 Walk/jog progressions
 Criteria for Advancement to V
 Full pain-free ROM – flexion and extension
 No patellofemoral irritation
 90% quadriceps and hamstring strength

 Phase V: 6 months +
 Goals:
Progress strength
Progress power
Progress proprioception
Prepare for full return to athletics including individual/team
sports.
Safe return to athletics including individual team sports
 WB status: functional brace may be recommended for use
during sports for first 1-2 years after surgery.

Continue to progress flexibility and strength
Progress plyometrics-unilateral
Walk/jog progression
Forward/ backward running progression from ½, ¼, full
speed
Cutting, cross-over drills, carioca
Initiate sports specific drills
Gradual return to sports participation
Maintenance of strength and endurance.

References
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of Arthroscopic and Related Surgery, Nov.2006: 22(11); 1143-1145
2. Imino F.C,volk B.S, Md,don Setter D. Anterior Cruciate Ligament Injury: Diagnosis,
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model? Scand J Med Sci Sports 2011
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References
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Neuromuscular and lower limb biomechanical differences exist between male and
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References
12. Ng WHA, Griffith JF, Hung EHY, Paunipagar B, Kan Yip Law BKY, Yung
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Musculoskelet Med (2012) 5:59–71

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