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ACL knee injury is common in sports that involve sudden changes of direction,
such as football, and soccer. Most are non-contact injuries that occur during
sudden twisting motion (for example, when the feet are planted one way and the
knees are turned another way) or when landing from a jump.
The knee is similar to a hinge joint, located where the end of the thigh bone
(femur) meets the top of the shin bone (tibia). Four main ligaments connect these
two bones:
Medial collateral ligament (MCL) - runs along the inner part (side) of the
knee and prevents the knee from bending inward.
Lateral collateral ligament (LCL) - runs along the outer part (side) of the
knee and prevents the knee from bending outward.
Anterior cruciate ligament (ACL) - lies in the middle of the knee. It
prevents the tibia from sliding out in front of the femur, and provides
rotational stability to the knee.
Posterior cruciate ligament (PCL) - works with the ACL. It prevents the
tibia from sliding backwards under the femur.
The ACL and PCL cross each other inside the knee, forming an "X." This is why
they are called the "cruciate" (cross-like) ligaments. The role of the Anterior
Cruciate Ligament is to prevent forward movement of the Tibia from underneath
the femur. The Posterior Cruciate Ligament prevents movement of the Tibia in a
backwards direction.
ACL knee injury often occur with other injuries. The classic example is when the
ACL is torn at the same time as both the MCL and medial meniscus (one of the
shock-absorbing cartilages in the knee). This type of injury often occurs in football
players and skiers.
Women are more likely to have an ACL tear than men. The cause for this is not
completely understood, but it may be due to differences in anatomy and muscle
function.
Adults usually tear their ACL in the middle of the ligament or pull the ligament off
the femur bone. These injuries do not heal by themselves. Children are more
likely to pull off their ACL with a piece of bone still attached. These injuries may
heal on their own, or they may require an operation to fix the bone.
Some people are able to live and function normally with a torn ACL. However,
most people complain that their knee is unstable and may "give out" with physical
activity. Unrepaired ACL tears may also lead to early arthritis in the affected knee.
Causes for ACL Knee Injury
Coming to a quick stop, combined with a direction change while running, pivoting,
landing from a jump, or overextending the knee joint (called hyperextended
knee), also can cause injury to the ACL.
ACL tears may be due to contact or non-contact injuries. A blow to the side of the
knee, which can occur during a football tackle, may result in an ACL tear.
Basketball, football, soccer, and skiing are common causes of ACL tears.
The pivot-shift test, anterior drawer test and the Lachman test are
used during the clinical examination of suspected ACL injury. The ACL can
also be visualized using a magnetic resonance imaging scan.
Pivot Shift Test- Person lies on one side of the body. Knee is extended
and internally rotated. Doctor applies stress to lateral side of the knee,
while the knee is being flexed. A positive test indicates a crash felt at 30
degrees flexion.
Anterior drawer test- The patient is positioned lying supine with the hip
flexed to 45° and the knee to 90°. The examiner positions themselves by
sitting on the examination table in front of the involved knee and grasping
the tibia just below the joint line of the knee. The thumbs are placed along
the joint line on either side of the patellar tendon. The index fingers are
used to palpate the hamstring tendons to ensure that they are relaxed. The
tibia is then drawn forward anteriorly. An increased amount of anterior tibial
translation compared with the opposite limb or lack of a firm end-point
indicates either a sprain of the anteromedial bundle of the ACL or a
complete tear of the ACL. This test should be performed along with other
ACL-specific tests to help obtain a proper diagnosis.
Ankle pumps.
Heel slides- knee flexion upto tolerance and knee extension to 0˚.
SLR– 3 way SLR(flexion, abduction, adduction).
Initially
Quadriceps setting.
Hamstring setting( 3 times more than quads setting).
Elecrical muscle stimulation to quadriceps during voluntary muscle
stimulation.
Progress to-
Mini squat.
Lunges.
Static cycling.
Step up and down.
BIOMECHANICAL COSIDERATION
CKC Eg. mini squat, lunges can be safely used during rehabilitation of ACL
bcoz-
CKC generate low anterior shear force on the tibia whereas open chain
extension places significant strain on ACL. CKC provide significant
compression across the knee. CKC activates co-contraction of the quads &
hams. OKC provide focused muscle strengthening (rectus femoris). With
fatigue any stabilising effect of these isolated muscle is lost and can put
the ACL at greater risk. CKC doesn’t provide focused muscle strengthening
(vastis) and provide a safer environment for the ACL in the setting of
fatigue.
Therapeutic exercises for acl knee injury- • Heel slides / wall slides. •
Quadriceps sets, hamstrings sets [electrical stimulation as needed]. •
Patellar mobilisation. • Non-weight bearing gastrocsoleus, hamstring
streches. • Sitting assisted flexion hangs. • Prone leg hangs for extension.
• Straight leg raises(SLR) all planes with braces in full extension untill
quadriceps strength is sufficient to prevent extention lag.
Functional training-
Goals- • Restore normal gait. • Restore full ROM. • Protect graft fixation. •
Improve strength, endurence and proprioception to prepare for functional
activities.
PHASE 4 : Month 4
Therapeutic exercises acl knee injury- • Continue and progress flexibility and
strengthing programs.
Functional training-