ANTERIOR CRUCIATE LIGAMENT TEAR (BLOWN OUT KNEE) Reported by: Jose Laureano Exequiel G.

Aspacio BSN3-4 RLE Group 2

INTRODUCTION An injury to the anterior cruciate ligament can be a debilitating musculoskeletal injury to the knee, seen most often in athletes. Non-contact tears and ruptures are the most common causes of ACL injury. The anterior cruciate ligament (ACL) is an important ligament for proper movement. ACL injury more commonly causes knee instability than does injury to other knee ligaments. SIGNS AND SYMPTOMS CAUSES ACL injuries occur when an athlete rapidly decelerates, followed by a sharp or sudden change in direction (cutting). ACL failure has been linked to heavy or stiff-legged landing; as well as twisting or turning the knee while landing, especially when the knee is in the valgus (knock-knee) position. The majority of ACL injuries occur in athletes landing flat on their heels. The latter directs the forces directly up the tibia into the knee, while the straight-knee position places the lateral femoral condyle on the back-slanted portion of the tibia. The resultant forward slide of the tibia relative to the femur is restrained primarily by the now-vulnerable ACL. DIAGNOSTIC EXAMINATIONS An ACL tear can be determined by the individual if a popping sound is heard after impact, swelling after a couple of hours, severe pain when bending the knee, and when the knee buckles or locks during movement. This can be further tested and diagnosed with MRI (Magnetic Resonance Imaging). Anterior Drawer Test. The test is performed as follows: the patient is positioned lying supine. 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. Lachman Test. The test is performed as follows: the knee is flexed at 30 degrees. Examiner pulls on the tibia to assess the amount of anterior motion of the tibia in comparison to the femur An ACL-deficient knee will demonstrate increased forward translation of the tibia at the conclusion of the movement. Sudden Popping Sound Swelling Instability of the knee (wobble feeling) Pain (moderate to severe)

Pivot Shift test. The test is performed as follows: 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 crash felt at 30 degrees flexion indicate a positive test.

PATHOPHYSIOLOGY

The ACL originates from the posteromedial aspect of the intercondylar notch on the lateral femoral condyle. It inserts broadly onto the articular surface of the tibia, medial to the attachment of the anterior horn of the lateral meniscus. The ACL prevents excessive anterior translation of the tibia on the femur and also acts to minimise tibial rotation and resist valgus and varus forces. The ACL receives a rich blood supply, primarily from the middle geniculate artery, so when the ACL is ruptured, a haemarthrosis usually develops rapidly. However, despite its intra-articular location, the ACL is actually extrasynovial. Due to the poor intrinsic healing properties of the ACL, a torn ACL will not heal on its own. Over time, the damaged fibres may scar down to the posterior cruciate ligament or to the intercondylar notch. This may result in confusing findings on physical examination but rarely if ever results in functional stability. PREVENTION Research has shown that the incidence of non-contact ACL injury can be reduced anywhere from 20% to 80% by engaging in regular neuromuscular training that is designed to enhance proprioception, balance, proper movement patterns and muscle strength. TREATMENT Conservative Management Immediately after the tear of the ACL, the person should: rest it ice it every 15 to 20 minutes produce compression on the knee and then elevate above the heart; Surgery Surgery is usually required among athletes because the ACL is needed in order to perform sharp movements safely and with stability. The surgery of the ACL is usually done several weeks after the injury in order to allow the swelling and inflammation to go down. During surgery the ACL is not repaired instead, it is reconstructed using other ligaments in the body. 1. Patella Tendon Bone Auto graft

The central 1/3 of the patella tendon is removed along with a piece of bone at the attachment sites on the kneecap and tibia. The advantages of using this method is that the patella tendon and ACL are relatively the same length and it uses a bone to bone attachment which most surgeons agree is much stronger than other healing methods. Disadvantages of this method are common anterior knee pain due to the removal of bone from the kneecap. 2. Hamstring Auto graft Two tendons are taken from the hamstring muscles and wrapped together forming the new ACL. Advantages of this method are less pain associated with post surgery healing than that of the patella tendon-bone graft due to the fact no bone was removed and the incision is small. Disadvantages of this method is that it takes longer to heal since there is no bone to bone healing and the tendon to bone takes awhile to become rigid. After the surgery, rehabilitation is required in order to strengthen the surrounding muscles and stabilize the joint.

In general, a rehabilitation period of six months to a year is required to regain pre-surgery strength and use. This is very dependent on the rehabilitation assignment provided by the surgeon as well as the person who is receiving the surgery. External bracing is recommended for athletes in contact and collision sports for a period of time after reconstruction. After surgery, no sports are allowed for 6 to 7 months. Whether the ACL deficient knee is reconstructed or not, the patient is susceptible to early onset of chronic degenerative joint disease. REHABILITATION Phase 1: This step is called the early rehabilitation phase. This is basically the things that were covered in short term, things to reduce pain and swelling while gaining movement. Phase 2: This phase covers weeks 3 and 4. At this point the pain should be subsiding and the patient will be ready to try more things that their knee isnt willing to perform. That is why there is a lot of emphasis put on joint protection during this step. The patient will be able to start doing exercises such as mini wall sits and riding stationary bikes. The aim of this is to be able to bend the knee 100 degrees. Phase 3: This phase is known as the controlled ambulation phase and it covers weeks 4 to 6. At this point the patient will be doing the same exercises from phase 2 plus some more challenging ones. The patient will try to get their knee to bend 130 degrees during this stage. The aim during this period is to focus heavily on improving balance. Phase 4: This is the moderate protection phase and it covers weeks 6 to 8. In this period the patient will try to obtain full range of motion as well as increase resistance for the workouts. Phase 5: This is the light activity phase and it covers weeks 8 to 10. This period will place particular emphasis on strengthening exercises, with increased concentration on balance and mobility. Phase 6: This is the return to activity phase and it lasts from week 10 until the target activity level is reached. At this point the patient will be able to start jogging and performing moderately intense agility drills. Somewhere between month 3 and month 6 the surgeon will probably request that the patient perform physical tests so s/he can monitor the activity level. When the doctor feels comfortable with the progress of the patient, s/he will clear that person to resume a fully active lifestyle.