ANTERIOR CRUCIATE LIGAMENT INJURY

PREPARED BY: FATEN RAFIQAH BT RAHIMAN 2010202696

INTRODUCTION

The anterior cruciate ligament (ACL) is one of the most important of four strong ligaments connecting the bones of the knee joint. It is often injured. Ligaments are strong, dense structures made of connective tissue that stabilize a joint. They connect bone to bone across the joint. The knee joint provides mobility and stability for legs during walking and running activities. However, these functions can be compromised if the knee is injured. With the increased popularity of and participation in sports and fitness activities, the number of knee injuries has increased.

The severity of these injuries varies from mild strains (injury to a muscle or its tendon, which connects muscle to bone) or sprains (injury to a ligament, which connects two bones) to complete tears of the ligaments and other soft tissue structures of the knee. Without the ACL, the knee would often buckle and probably fall to the ground Of all major knee injuries, about sixty percent involve the ACL. Studies show that women have a higher incidence of ACL injury than men

ANATOMY

The knee joint comprises the cartilagecovered surfaces of three bones ,the femur ,the patella ,and the tibia Four main ligaments help stabilize the knee, the medial and lateral ,collateral ligaments resist side-to-side motion, and the anterior and posterior cruciate ligaments resist forward and backward motion

Knee Anatomy

The anterior cruciate ligament (ACL) lies inside the knee joint It consists of strong fibers (or collagen) that function like the strands of a rope or cable. This ligament provides most of the support that prevents the tibia from slipping forward against the femur

WHAT IS ACL INJURY

An ACL injury is a sprain, in which the ligament is torn or stretched beyond its normal range. In almost all cases, when the ACL is torn, it's almost always due to at least one of the following patterns of injury:

Pattern of injury

A sudden stop, twist, pivot or change in direction at the knee joint :These knee movements are a routine part of football, basketball, soccer, rugby, gymnastics and skiing. For this reason, athletes who participate in these sports have an especially high risk of ACL tears. Extreme hyperextension of the knee : Sometimes, during athletic jumps and landings, the knee straightens out more than it should and extends beyond its normal range of motion, causing an ACL tear. This type of ACL injury often occurs because of a missed dismount in gymnastics or an awkward landing in basketball.

Direct contact : The ACL may be injured during contact sports, usually during direct impact to the outside of the knee or lower leg. Examples are a sideways football tackle, a misdirected soccer kick that strikes the knee or a sliding tackle in soccer.

ACL injuries are classified by the following grading system: Grade I : A mild injury that causes only microscopic tears in the ACL. Although these tiny tears may stretch the ligament out of shape, they do not affect the overall ability of the knee joint to support the weight. Grade II : A moderate injury in which the ACL is partially torn. The knee can be somewhat unstable and can "give way" periodically when stand or walk. Grade III : A severe injury in which the ACL is completely torn through and the knee feels very unstable.

Function of ACL

To provide stability to the knee and minimize stress across the knee joint: It restrains excessive forward movement of the lower leg bone (the tibia) in relation to the thigh bone (the femur). It limits rotational movements of the knee.

Signs

Most people who have torn the ACL heard a "pop" in their knee as the ligament tore. Falls to the ground. Feels instability in knee. Usually,the knee swells within the first hour after injury and is quite painful. The injured person cannot continue his or her activity.

Symptoms

Feeling a "pop" inside the knee when the ACL tears Significant knee swelling and deformity within a few hours after injury Severe knee pain that prevent from continuing to participate in the sport (most common in partial tears of the ACL) No knee pain, especially if the ACL has been completely torn and there is no tension across the injured ligament A black and blue discoloration around the knee, due to bleeding from inside the knee joint

Mechanism of injury

When it functions normally, the ACL can handle large forces with little or no problem. If, however, the knee receives forces of a high magnitude (occur during a slip and fall, sudden change in direction, landing off balance while jumping, or hyperextension of the knee) and the muscles cannot help absorb the stress, the ACL may take all the load, and it may tear (fig. A) When the ligament tears, it generally ruptures like a rope, and the knee momentarily slides out of place (fig.B)

Dr.s Management

Non-Operative Non-operative management was recommended to the patients who had low athletic demands or sedentary occupations ( Segawa , Omori and Koga, 2001). Generally, the doctor will prescribe NSAIDs (non steroidal anti inflammatory drug) which is consisting of fentanyl, meperidine and morphine sulfate for pain management ( Barker ,Leonard ,Hansen et. al, 2009 ) Moreover, they also encourage the using of brace up to 4 to 6 week, and then followed by referring the patient to the physiotherapy for further management ( Ebnezar ,2006).

Operative (Arthroscopic reconstruction) Generally ACL reconstruction should not be performed in the acute phase due to increased risk of arthrofibrosis. The operation should be delayed for 2 to 3 weeks ( Ng , 2002). The patient with partial ACL tears went on to complete ACL deficiency when treated conservatively. However, if the knee condition is getting worst after post injury the surgery is highly recommended to protect the meniscus. Currently, studies have shown a high risk of meniscal injury in the ACL deficient knee in active patients ( Drakos and Warren , 2009). The Functional outcome after a period of rehabilitation proving a more sensitive indicator of the need for surgery in the ACL deficient patient (Herrington , 2004).

Physiotherapy Management

Divided into four phases. In the first one to two weeks the aims of therapy are to decrease pain and swelling, and increase the range of motion of the knee. A post-operative brace is ranged from 30 to 90 and is used until there is adequate quadriceps control. Physiotherapy including CPM is used immediately post operatively. In this early phase there is an emphasis on static contraction of the hamstrings and co-contractions of the hamstrings and the quadriceps. Crutch -walking with partial weight bearing is allowed and the usual modalities are used to reduce pain and swelling.

During the second phase, from two to six weeks, the emphasis is on increasing the range of motion, increasing weight bearing and gaining hamstring and quadriceps control. The patient is usually out of the brace by the third to fourth week. During this phase gait re-education and static proprioception exercises commence. This may include balancing on the affected leg, biofeedback techniques and pool work to maintain conditioning and range of motion.

During the third stage, from six to twelve weeks, emphasis is placed on improved muscular control, proprioception and general muscular strengthening. Proprioceptive work progresses from static to dynamic techniques including balance exercises on the wobble board and eventually jogging on a minitramp. The patient should have a full range of motion during this stage and gentle resistance work should be added. By the end of this period the patient should be able to cycle normally, swim with a straight leg kick and be able to jog freely on the mini-tramp.

The fourth phase of rehabilitation from twelve weeks to six months involves the gradual re-introduction of sports specific exercises aimed at improving agility and reaction times and increasing total leg strength. An elite athlete who has had a technically well performed early reconstruction of the anterior cruciate ligament followed by an adequate and successful rehabilitation program, should be able to return to the field of his chosen sport between six and nine months.

Case Study

Subjective Assessment

Name: Miss A Age: 16 years old Gender: Female Race: Malay D.O.A: 26/4/2012 Dr. dx. : L ACL & medial meniscus tear Dr. mx. : 1. conservative 2. refer to physiotherapist

Problem: 1. c/o pain at L kn. after walks for 2 hours. 2. Pt. feel jt. Instability during walking. 3. c/o difficulty to perform prayer and squatting.

Current hx. : 2nd fall on (July 2011) during playing netball but she didnt go to hospital. After that, the pain get worsen and she went to hospital on (Dec 2011). Then, she undergone MRI (29/3/12). The result is 2/52 after that (12/4/12). Result: L ACL & medial meniscus tear. Now, she come for rehabilitation.

Past hx. : 1st fall on (7/4/2011) during playing netball and she went to the hospital on the same day. Then, doctor ask her to come again after 2/52. After that, she went to clinic and undergone x-ray (8/4/11). Result: no #. She didnt go to hospital again. Pain resolve by using oilment and rest. She also wear kn. guard.

Special Question

General Health : pt. is in good condition PMHx./surgery: NiL Medication: Painkiller Dr. Ix. : pt. claimed she had undergone MRI (29/3/12). Result: L ACL & medial meniscus tear. Occupation/ recreation: - a student - very active in sports such as netball, basketball, softball, hockey etc. Type of house: double-storey house, sit toilet, her room at 2nd floor Pacemaker/ hearing aid : No Smoking/ alcohol : No

Body Chart
Painscale : P1-VAS 3/10 on walking and initiate sit to stand P2-VAS 2/10 while walking VAS 1/10 in rest position Area: Refer to body chart Nature of pain: Throbbing pain Aggravating factors: Vigorous activity (sports) VAS 5/10 Easing factors: Rest 24 hours: No specific pain pattern Irritability: Medium

P1

P2

Objective Assessment

General observation : A thin Malay girl walk into department independently. Coorperative and obey command. Gait is normal. Local observation : - posture :normal - no swelling at L kn. - no redness at L kn. Palpation: - no warmth at L kn. - no muscles tenderness at L kn. - deep palpation: pain at post. L kn.

ROM Joint Movement Right Active Right Passive Left Active Left Passive

Hip

Flex.
Ext. Abd. Add. Int.rot. AFROM with no pain

Ext.rot.
Kn. Flex. Ext. Ankle Dorsiflex. Plantarflex. Subtalar Inversion Eversion Intervention : ROM of L kn. ext. (lag 3) & kn. flex. d/t muscles tightness. AFROM with no pain AFROM with no pain 0 - 75 0 3 FROM with ERP

MMT
Joint Hip Mov.(muscles) Flex. (iliapsoas) Ext. (glut.max.) Abd. (TFL) 5/5 5/5 Right Left

Add. (add.magnus)
Kn. Ank. Flex. (hamstring) Ext. (quadricep) Dorsiflex. (tibialis ant.) Plantarflex. (gastrocnemius) 5/5 2/5

5/5

Interpretation: muscle power of L kn. flex. & ext. d/t lack of use.

Muscle bulk
MUscles VMO (5cm) Quadriceps (10cm) Hamstring (15cm) Gastrocnemius (10cm) Right 34cm 37.5cm 42.5cm 33.5cm Left 33cm 37cm 42cm 32.5cm

Interpretation : muscle bulk of L leg d/t reduce muscle activity.

Limb length

True limb length :

Right 57cm Left 58cm Difference 1cm

Apparent limb length :

Right Left Difference

65cm

65cm

Interpretation: True limb length and apparent limb length of R & L leg is normal.

Patella mobility: R
superior

lateral

medial

Interpretation: no tightness/ stiffness (normal)

posterior

Patella mobility : L
superior

lateral

medial

inferior

Interpretation: no tightness/stiffness (normal)

Q-angle :
Right 12 Left 15

(normal female: 18)

Interpretation: Indicate patello femoral pathology.

Proprioception : Open eyes : R L 22secs 20secs Close eyes : R L 12 secs 10secs Interpretation: Reduce proprioception of L kn. d/t ligamentous injury.

Special test

Anterior drawer test: +ve (L kn.) Posterior drawer test: -ve Lachmans test : +ve (L kn.) Valgus test: -ve Varus test: -ve McMurrey test: -ve

Interpretation: Pt. complain pain during do Ant. drawer test & Lachmans test indicate ACL tear.

Analysis:
1.

2.

3.

4.

5.

Pain on L kn. d/t ligamentous injury. ROM of L kn. flex. & ext. d/t muscles tightness. muscles power of L kn. flex. & ext. d/t lack of use. muscles bulk of L leg d/t reduce muscles activity. proprioception of L kn. d/t ligamentous injury.

Short term goal

1. 2.

3.
4. 5.

To relief pain within 1/52. To ROM within 3/52. To muscles power within 3/52. To build muscles bulk within 3/52. To proprioception within 2/52. To restore optimal functional activities within 5/52. To restore normal strength, endurance & flexibility within 6/52.

Long term goal

1.

2.

Plan of treatment
1.

2.
3. 4. 5. 6. 7.

Pain management. Mobilizing exercise. Stretching exercise. Strengthening exercise. Balance exercise. Patient education. HEP.

Intervention
1. Pain management sup.ly., h/p over B/L kn., 15 mins. 2. Mobilizing exercise Cycling, 15mins. 3. Stretching exercise Long. sitt., bd. fwd., hold 30secs., 5x, 3sets. St., kn. flex., hold 30secs., 5x, 3 sets. 4. Strengthening exercise squatting, hold 10 secs, 15x, 3sets. Lunges, hold 10 secs, 15x, 3 sets. 5. Balance exercise (using wobble board) Ask pt. to balancing body on the wobble board for 30secs. 6. Pt. education Explain to pt. about the problem. Explain the purpose of the exs. Explain the complication of not doing the exs. 7. HEP Advise pt to do all exs taught 3x per day.

Evaluation
1. 2.

3.

Pt. can tolerate with the tx given. Pt. claimed that pain is slightly reduce(VAS 2/10). Pt.s ROM & muscles power remain the same. To re-assess pain scale, ROM & muscles power. To review with all the exercises.

Review
1.

2.

Progression note (15/5/2012)

Subjective assessment: Pt claimed that pain is slightly reduced (VAS 1/10). Objective assessment: Local observation : - posture : UL (normal) - no swelling at L kn. - no redness at L kn. Palpation: - no warmth at L kn. - no muscles tenderness at L kn. - deep palpation: pain at post. L kn.

ROM
Joint Kn. Movement Flex. Ext. Right Active Right Passive Left Active 0-110 0-2 Left Passive
FROM with ERP AFROM with no pain

Interpretation : slightly ROM of L kn. flex. & ext.

MMT
Joint Kn. Movement Flex. (hamstring) Right 5/5 Left 3/5

Ext. (quadriceps)

Interpretation : slightly muscles power of L. kn.

Proprioception : Open eyes : R L 25secs 22secs Close eyes : R L 18 secs 15secs Interpretation: slightly proprioception of L kn.

Analysis:
1.

2.

3.

4.

5.

Pain on L kn. d/t ligamentous injury. ROM of L kn. flex. & ext. d/t muscles tightness. muscles power of L kn. flex. & ext. d/t lack of use. muscles bulk of L leg d/t reduce muscles activity. proprioception of L kn. d/t ligamentous injury.

Short term goal

1. 2.

3.
4. 5.

To relief pain within 1/52. To ROM within 3/52. To muscles power within 3/52. To build muscles bulk within 3/52. To proprioception within 2/52. To restore optimal functional activities within 5/52. To restore normal strength, endurance & flexibility within 6/52.

Long term goal

1.

2.

Plan of treatment
1.

2.
3. 4. 5. 6. 7.

Pain management. Mobilizing exercise. Stretching exercise. Strengthening exercise. Balance exercise. Patient education. HEP.

Intervention
1. Pain management sup.ly., h/p over B/L kn., 15 mins. 2. Mobilizing exercise Cycling, 15mins. 3. Stretching exercise Long. sitt., bd. fwd., hold 30secs., 5x, 3sets. St., kn. flex., hold 30secs., 5x, 3 sets. 4. Strengthening exercise squatting, hold 10 secs, 15x, 3sets. Lunges, hold 10 secs, 15x, 3 sets. 5. Balance exercise (using wobble board) Ask pt. to balancing body on the wobble board for 30secs. 6. Pt. education Explain to pt. about the problem. Explain the purpose of the exs. Explain the complication of not doing the exs. 7. HEP Advise pt to do all exs taught 3x per day.

Evaluation
1. 2. 3.

Pt. can tolerate with the tx. given. Pt. claimed that pain is slightly reduce(VAS 0/10)-rest. Pt.s ROM & muscles power slightly improve from previous visit.

Review
1. 2. 3.

To re-assess pain scale, ROM & muscles power. To review with all the exercises. To do exercises to improve agility and total leg strength.

Evidence based

Author, Date, and country L. Herrington 17 August 2004 United Kingdom Title The rehabilitation of two patients with functionally unstable ACL deficient knees Sample 52 year old male skier and 45 year old male footballer Methods 1.)There is 2 patient : a.)Patient 1 (52-year-old male with mis substance ACL tear after fell while skiing ) -He was then referred to physiotherapy for his treatment starting 6 weeks after the original injury. b.) Patient 2 (45 year old male with full mid substance ACL tear after fell while playing football) -He was then referred to physiotherapy his treatment starting seven and a half weeks after the original injury. Outcome measures 1.)A functional rating score (Lysholm score) 2.)Lachmans and Anterior drawer test 3.)Isokinetic strength test(hamstring and quad) 4.)Cybex Norm isokinetic dynamometer 5.)Limb symmetry index(LSI) Findings After 16 weeks post injury, both patient able to regain their functional activity and return sport that they played previously without any problem

Author, Date, and country A.G. Angoules , A.F. Mavrogenis , R. Dimitriou , K. Karzis , E. Drakoulakis , J. Michos and P.J. Papagelopoulos 21 January 2010 Athens, Greece Title Knee proprioception following ACL reconstruction; a prospective trial comparing hamstrings with bonepatellar tendonbone autograft Sample 40 patients (34 men and six women; mean age 31 years) Methods -The patients were sequentially allocated into two surgical groups depending on their order of presentation. -Group A included 20 patients (16 men and four women) in whom a four strand ipsilateral hamstring (semitendinosus/gracillis) autograft has been used -Group B included 20 patients (18 men and two women) in whom ipsilateral bonepatellar tendonbone autograft has been used -The contralateral healthy knee was used as internal control -All intra-operative factors such as graft fixation techniques were standardized; all procedures were arthroscopic assisted and performed by the same surgeons. - All patients were rehabilitated by the same postoperative rehabilitation protocol of the operated knee, and were assessed in a similar fashion. -Evaluation of proprioception was done in both knees of all patients, preoperatively and at the ACL-operated knee at 3, 6 and 12 months postoperatively

Outcome measures 1.)Joint position sense(JPS) -The knees were positioned in extension (0), and were passively flexed by the JPS to 15, 45 and 75; the patients were asked to recognise the joint position and to actively flex the knee to that particular position. 2.) Time threshold to detection of passive motion (TTDPM) -The TTDPM of flexion and extension movements was measured at starting angles of 15 (near-terminal range of motion) and 45 (midrange of motion) 3.) Magnetic resonance imaging -Used to diagnosis unilateral ACL rupture Findings -No statistical difference was found between the ACL operated and the contralateral knees in JPS 15, 45 and 75 at 6 and 12 months, in both study groups. -No statistical difference was found between the ACL operated and the contralateral knees in TTDPM 15 at 6 and 12 months, nor regarding TTDPM 45 at 3, 6 and 12 months, in group A. -No statistical difference was found in JPS and TTDPM between the two grafts, at any time period. -Knee proprioception returned to normal with ACL reconstruction at 6 months postoperatively, without any statistically significant difference between the autografts used

Open kinetic chain exercise (OCKE) and Close kinetic chain exercise (CKCE) Initially, close kinetic chain exercises (CKCE) is not recommended after ACL reconstruction because of the potential increase in strain on the graft. The patient may start open kinetic chain exercises (OKCE) such as leg extension from 90 to 30, as we do not want to stress the ACL graft with the terminal 30( Drakos and Warren , 2009). The study from (FANELLI , 2003 ) noted a different suggestion and he saying patient should progress closed kinetic chain strength training After ACL repair. However, OKCE is proven better than CKCE after ACL postoperative period due to less less strain on the graft.

Joint proprioception The studies prove that loss of joint proprioception will be one of the major complications that will be arising after ACL/PCL repair. However, during the 6 weeks through the 3-month period of time proprioception training should be include in the rehabilitation program with balance platforms (M.C. Drakos and R.F. Warren : 2009) . In addition, (Chmielewski , Wilk , and Mackler , 2001) also suggest the same idea where the rehabilitation should start to emphasize evaluating and treating proprioception. The studies result show that proprioception training of all muscles around the knee joint is very important after ACL/PCL reconstruction (Kuster et al .1995).

Quadriceps control In phase 2, the ROM should be established during this time, and the patients must be able to regain quadriceps control. Strengthening at this point involves leg press ( Drakos and Warren , 2009 ). Rehabilitation should focused on quadriceps strengthening after ACL/PCL Reconstruction ( Chmielewski et al . 2001). Quadriceps muscle strengthening should start earlier after postoperative period ( Li and Ng , 2004).

Conclusion

Patients treated with surgical reconstruction of the ACL have long-term success rates of 82-95%. Recurrent instability and graft failure is seen in approximately 8% of patients. Knee scores of those treated nonoperatively have fair/poor results up to 50% of the time. As many as 40% of patients treated nonoperatively had no episodes of giving way. The knee scores in this group may be too sensitive, not accurately representing the clinical situation. Patients with ACL ruptures, even after successful reconstruction, are at risk for osteoarthrosis.

References

Ajit M. Chaudhari and Thomas P. Andriacchi. (2004). The mechanical consequences of dynamic frontal plane limb alignment for non-contact ACL injury. Journal of Biomechanics 39 .330338. A.G. Angoules , A.F. Mavrogenis , R. Dimitriou , K. Karzis , E. Drakoulakis , J. Michos and P.J. Papagelopoulos . (2010). Knee proprioception following ACL reconstruction; a prospective trial comparing hamstrings with bonepatellar tendonbone autograft. Articel in press. 1-7. Adam L. Bryant , Robert U. Newton and Julie Steele (2009). Successful feed-forward strategies following ACL injury and reconstruction . Journal of Electromyography and Kinesiology 19. 988997 GREGORY C. FANELLI. (2003). Surgical treatment of ACL-PCL medial side- lateral side injuries of the knee. Operative Techniques in Sports Medicine, Vol 11 .No 4. 2003: pp 263-274. Gabriel Y.F. Ng (2002). LIGAMENT INJURY AND REPAIR: CURRENT CONCEPTS. Hong Kong Physiotherapy Journal. Volume 20 . 2002 John Ebnezar.(2006).Essential of orthophedic for physiotherapist (3rd edition) . New Delhi :Jaypee brothers ,Medical publisher Pte.Ldt

L. Herrington. (2004). The rehabilitation of two patients with functionally unstable ACL deficient knees. Physical Therapy in Sport 5 . 175178 Maria G Papandreou , Evdokia V Billis , Emmanouel M Antonogiannakis and Nikos A Papaioannou .(2009). Effect of cross exercise on quadriceps acceleration reaction time and subjective scores (Lysholm questionnaire) following anterior cruciate ligament reconstruction. Journal of Orthopaedic Surgery and Research , 4:2, 1-9. Maureen McEvoy and Triston Shaw .(2004).Australian survey of inpatient management folloing anterior cruciate ligament reconstruction. Hong Kong Physiotherapy Journal .Volume 22. Stephanie J. Bowerman, Darla R. Smith, Mary Carlson and George A. King. (2006). A comparison of factors influencing ACL injury in male and female athletes and nonathletes. Physical Therapy in Sport 7. 144152. Tortora & Derrickson. (2009). Principle of Anatomy and Physiology (12th ed). USA: John Wiley and Sons (Asia) Pte.Ltd. Terese L. Chmielewski a , Kevin E. Wilk b and Lynn Snyder-Mackler. (2002). Changes in weight-bearing following injury or surgical reconstruction of the ACL: relationship to quadriceps strength and function. Gait and Posture 16 . 8795