ANTERIOR CRUCIATE

LIGAMENT
2
1
MEDICAL BACKGROUND
ANATOMY

3
ANATOMY OF
THE ACL
4
Anatomy of the ACL

▰ Attached distally to the tibia on

the lateral and anterior aspect of
the medial intercondylar tibial
spine
▰ Extends superiorly, laterally and
posteriorly to attach to the
postero-medial aspect of the
lateral femoral condyle
5
Anatomy of the ACL

▰ The major blood supply of the anterior

cruciate ligament arises from the middle
genicular artery

6
Anatomy of the ACL

▰ The ACL consists of two separate bundles

▰ Anteromedial bundle (AMB)
▰ Posterolateral bundle (PLB)

7
FUNCTIONS
OF THE ACL
8
Functions of the ACL

▰ Primary restraint against anterior translation

of the tibia on the femur (Open Kinematic
Chain)
▰ Responsible for resisting hyperextension of
the knee

9
Functions of the ACL

▰ The two separate bundles become taut

depending on the knee angle
▰ AMB – becomes taut with knee close to
full flexion; PLB loosens
▰ PLB – becomes taut with the knee close
to full extension; AMB loosens

10
Functions of the ACL

11
Functions of the ACL

▰ Provides rotary stability of the knee during

medial/lateral rotation, varus/valgus
angulations, and combinations thereof
▰ Greater rotary stability provided by the
PLB than by the AMB
▰ Medial rotation of the tibia on the femur
increase the strain on the AMB with peak
strain occurring between 10-15 degrees
12
Functions of the ACL

▰ Provides rotary stability of the knee during

medial/lateral rotation, varus/valgus
angulations, and combinations thereof
▰ With valgus loading = lengths of both
bundles increase as knee flexion
increases

13
LOADING PATTERNS
OF THE ACL

14
Loading Patterns of the ACL

▰ MOI occurs commonly when the knee is

slightly flexed and the tibia is rotated in either
direction in weight-bearing
▰ In flexion and medial rotation = ACL is
tensed as it winds around the PCL
▰ In flexion and lateral rotation = ACL is
tensed as it is stretched over the lateral
femoral condyle
15
MUSCLES
SURROUNDING THE
KNEE JOINT
16
Muscles surrounding the knee joint

▰ The function of the muscles is either to

induce or minimize strain in the ACL

17
Muscles surrounding the knee joint

▰ An isolated quadriceps muscle contraction is

capable of generating an anterior shear force
on the tibia with the tibiofemoral joint near
full extension

18
Muscles surrounding the knee joint

▰ Fleming and colleagues stated the

gastrocnemius muscles has the potential to
translate the tibia anteriorly and strain the
ACL
▰ The tibia is pushed forward when the muscle
is in active contraction or passive stretch

19
Muscles surrounding the knee joint

▰ The hamstring muscles are capable of

inducing a posterior shear force on the tibia
throughout the range of knee flexion
▰ Have the potential to relieve the ACL of
some stress of checking anterior shear of
the tibia on the femur

20
Muscles surrounding the knee joint

▰ The soleus muscle also have the ability to

posteriorly translate the tibia and assist the
ACL in restraining anterior tibial translation

21
Muscles surrounding the knee joint

▰ Co-contraction of multiple muscles across

the knee can influence the strain on the ACL
▰ Co-contraction will reduce the anterior shear
force on the tibia, but it increases joint
compressive loads

22
Muscles surrounding the knee joint

▰ Activation of the hamstrings and quadriceps

muscles may allow the hamstrings to counter
the anterior translation imposed by the
quadriceps to reduce strain on the ACL

23
Muscles surrounding the knee joint

▰ Activation of both the gastrocnemius and the

quadriceps muscles may result in greater
strain on the ACL

24
PATHOPHYSIOLOGY
OF THE ACL

25
Pathophysiology of the ACL

▰ The ACL functions as a primary restraint to

anterior translation of the tibia on the femur
and as a secondary restraint to valgus
rotation and varus rotation in the extended
knee

26
Pathophysiology of the ACL

▰ According to Thomas M. DeBernardino, MD

▰ There is a significant increase in the
meniscal pathology when ACL
reconstruction is delayed
▰ Increases incidence of Osteoarthritis

27
Pathophysiology of the ACL

▰ Causes of ACL injury (according to

Muhammad Ariff B Mahdzub, MBBS)
▰ Changing direction rapidly
▰ Stopping suddenly
▰ Slowing down while running
▰ Landing from a jump incorrectly
▰ Direct contact or collision, such as a
football tackle
▰ Twisted leg
28
Pathophysiology of the ACL

▰ Grading of ligamentous lesions (Hertling and Kesslet)

▰ Grade I: Mild sprain with no gross loss of integrity
of the ligament fibers. On examination there is no
joint-play hypermobility
▰ Grade II: Moderate tear, with partial loss of
integrity of the ligament, manifested as mild joint-
play instability
▰ Grade III: Severe tear or complete rupture of the
ligament, manifested as mild joint-play
hypermobility
29
2
ETIOLOGY

30
Etiology

▰ According to Magee, ACL injury can occur

both contact and non contact mechanism
▰ Most common non-contact – rotational
mechanism in which the tibia is externally
rotated on the planted foot
▰ 78% of all ACL injuries
▰ Second most common non-contact –
forceful hyperextension of the knee
31
Etiology

▰ According to Magee, ACL injury can occur

both contact and non contact mechanism
▰ Most common MOI (contact mechanism)
– a blow to the lateral side of the knee
resulting in a valgus force to the knee
▰ Can also affect the MCL and medial
meniscus

32
3
EPIDEMIOLOGY

33
Etiology

▰ Females are at a higher risk of ACL injury

when sports participation numbers are
considered
▰ According to Kisner, a woman is three
times more likely to tear the ACL than a
man

34
Etiology

▰ Risk factors identified by clinicians and

scientists
▰ Biomechanical risk factors
▰ Neuromuscular risk factors
▰ Structural risk factors
▰ Hormonal differences

35
Etiology

▰ Biomechanical risk factors

▰ Effect of the total chain (trunk, hip, knee,
and ankle) on ACL injuries
▰ Improper dynamic movement,
deceleration, and change of direction
▰ Decreased hip flexion angles and
knee flexion during cutting activities
in the female athlete
36
Etiology

▰ Neuromuscular risk factors

▰ Have an influence on biomechanical
factors in that neuromuscular control
influences joint position and movement

37
Etiology

▰ Neuromuscular risk factors

▰ Valgus collapse at the knee and
decreased use of the hip extensors has
been reported to be more common in
women than in men
▰ Weaker hip and knee strength in women
compared to males

38
Etiology

▰ Structural risk factors

▰ Femoral notch size
▰ Height is smaller and angle is larger in the
male compared to the female
▰ May affect ACL size
▰ ACL size
▰ female > male
▰ The ACL in female has a lower modulus of
elasticity, and a lower failure strength thus the
joint is laxer than in the male
39
Etiology

▰ Hormonal differences
▰ Sex- hormones have a time-dependency
effect that influences ACL tissue
characteristics, such as increasing risk of
injury during the preovulatory phase of
the menstrual cycle in females

40
4
SIGNS AND SYMPTOMS

41
Signs and Symptoms

▰ Common Structural and Functional Impairments,

Activity Limitations, and Participation Restrictions
(Functional Limitations/Disabilities)
▰ Following trauma, the joint does not swell for
several hours. If blood vessels are torn, swelling
is usually immediate

42
Signs and Symptoms

▰ If tested when the joint is not swollen, the patient feels

pain when the injured ligament is stressed
▰ If there is a complete tear, instability is detected when
the torn ligament is tested
▰ When effused, motion is restricted, the joint assumes
a position of minimum stress (usually flexed 25
degrees), and the quadriceps muscles are inhibited
(shut down)

43
Signs and Symptoms

▰ When acute, the knee cannot bear weight, and the

person cannot ambulate without an assistive device
▰ With a complete tear, there is instability, and the knee
may give way during weight-bearing, which would
prevent the individual from returning to specific work
or sport and recreation activities that require dynamic
knee stability

44
5
DIFFERENTIAL
DIAGNOSIS

45
Differential Diagnosis

▰ Medial Collateral Ligament

▰ The MCL courses from the medial femoral
condyle to the proximal medial tibia
▰ Provides restraint against valgus force

46
Differential Diagnosis

▰ Medial Collateral Ligament

▰ MOI of the MCL tear = sustained valgus force with
the foot planted
▰ Signs and Symptoms
▰ Tenderness along the course of the MCL
▰ Localized pain to the medial side of the knee
▰ (+) Valgus Test

47
Differential Diagnosis

▰ Medial Meniscal Tear

▰ MOI in acute meniscal tear = foot is planted and
the femur is internally rotated; valgus force is
applied to the flexed knee
▰ According to Ricklin, medial meniscus lesion is
attached more firmly than the relatively mobile
lateral meniscus  greater incidence of medial
meniscus injury

48
Differential Diagnosis

▰ Medial Meniscal Tear

▰ Signs and symptoms are similar to the ACL
▰ Pain on weight-bearing
▰ Twisting movements
▰ Joint effusion
▰ Locking of the knee

49
Differential Diagnosis

▰ Medial Meniscal Tear

▰ According to Braddom, the hallmarks of the
physical examination include medial or lateral
joint line tenderness, effusion, and positive
McMurray’s Test

50
6
DIAGNOSTIC
PROCEDURES

51
Diagnostic Procedures

▰ Arthroscopy
▰ A surgical procedure; most invasive technique to
assess the anterior cruciate ligament
▰ Performed using an arthrocope that is inserted
into the joint through a small incision so that the
ACL can be directly seen on a computer screen

52
Diagnostic Procedures

▰ Radiography
▰ TELOS – used to run radiography assessment on
patients suffering from ACL injuries by analyzing
the position of the tibia compared to the femur
while applying a single force on the tibia

53
Diagnostic Procedures

▰ Physical Examination
▰ First evaluation too used by physiotherapist who
often suspect ACL injury
▰ Relies on subjective factors
▰ Physical diagnosis is particularly difficult in large
patients with an acute injury and soft tissue
swelling and guarding
▰ Difficulty in assess partial ACL tears

54
Diagnostic Procedures

▰ Physical Examination
▰ Lachman’s Test
▰ Anterior Drawer Test

55
Diagnostic Procedures

▰ MRI Scans
▰ Common technique for objectively diagnosing an
ACL tear
▰ Since the patient is diagnosed in a single position,
the MRI findings are not helpful in ruling in or
ruling out knee instability
▰ Impossible to see the tibia’s behavior
compared to the femur

56
Diagnostic Procedures

▰ MRI Scans
▰ Swelling present in the knee makes it difficult to
diagnose the state of the ACL

57
Diagnostic Procedures

▰ Arthrometers/Laximeters
▰ Less invasive and most reliable technique to
assess the ACL
▰ GNRB – tests the ACL
▰ It applies a translation force or a torque on the
tibia to calculate the resulting displacement or
rotation while maintaining the femur bone locked
in position
▰ Tests are done on both healthy and pathological
knee to compare both differentials
58
Diagnostic Procedures

▰ Arthrometers/Laximeters
▰ Assessments are performed automatically
applying different forces or torques in a controlled
manner

59
Diagnostic Procedures

60
7
TREATMENT PROTOCOL

61
Treatment Protocol

▰ ACL Reconstruction (according to Kisner)

▰ Recommended for surgical reconstruction to
restore knee stability
▰ Lower reinjury of the knee after ACL construction
compared to nonoperative management
▰ Patients < 25 years old who have sustained
an acute primary ACL injury should
participate in conservative course of
treatment

62
Treatment Protocol

▰ ACL Reconstruction (according to Kisner)

▰ Nonsurgical management of isolated ACL tears is likely
to be successful or may be indicated in patient:
▰ With partial tears and no instability
▰ With complete tears and no symptoms of knee
instability during low-demand sports who are
willing to give up high-demand sports
▰ Who do light manual work or sedentary lifestyles
▰ Whose growth plates are still open

63
Treatment Protocol

▰ Indications for Surgery

▰ Disabling instability of the knee due to ACL
deficiency
▰ Frequent episodes of the knee giving way
(buckling) during routine ADL
▰ Positive special tests for ACL
▰ High risk of reinjury

64
Treatment Protocol

▰ Relative contraindications
▰ Relative inactive individual with little to no exposure to
work, sport, and recreational activities that place high
demands on the knee
▰ Ability to make lifestyle modifications to eliminate high-
risk activities
▰ Ability to cope with infrequent episodes of instability
▰ Advanced arthritis of the knee
▰ Poor likelihood of complying with postoperative
restrictions and adhering to a rehabilitation program

65
Treatment Protocol

66
Treatment Protocol

67
Treatment Protocol

68
Treatment Protocol

69
Treatment Protocol

▰ These rehabilitation guidelines were developed collaboratively

by UW Health Sports Rehabilitation and the UW Health Sports
Medicine physician group

70
Treatment Protocol

71
Treatment Protocol

72
Treatment Protocol

73
Treatment Protocol

74
Treatment Protocol

75
Treatment Protocol

76
Treatment Protocol

77
Treatment Protocol

78
Treatment Protocol

79
Treatment Protocol

80
 References

▰ ACL injury: Does it require surgery?. (n.d.). Retrieved from https://orthoinfo.aaos.org/en/treatment/acl-injury-does-it-require-surgery/

▰ Anterior cruciate ligament: Pathology and management. (n.d.). Retrieved from https://www.youtube.com/watch?v=eRpErRI7a1A://
▰ Bhagia, S. (2018). Meniscal injury: Background, pathophysiology, epidemiology. Retrieved from https://emedicine.medscape.com/article/308054-overview#a5
▰ Braddom, R. (2010). Physical medicine and rehabilitation (4th ed.). Elsevier Saunders.
▰ Hertling, D. (2014). Management of common musculoskeletal disorders: Physical therapy principles and methods.
▰ Kisner, C., & Colby, L. (2012). Therapeutic exercise: Foundations and techniques(6th ed.). PA: F.A. Davis Company.
▰ Magee, D. (2014). Orthopedic physical assessment (6th ed.). Elsevier Saunders.
▰ Maguire, J. (2018). Anterior cruciate ligament pathology: Background, anatomy, pathophysiology. Retrieved from
https://emedicine.medscape.com/article/1252414-overview#a8
▰ Mahdzub, M. (n.d.). Pathophysiology anterior cruciate ligament injury. Retrieved from https://www.slideshare.net/ariffmahdzub/pathophysiology-anterior-
cruciate-ligament-injury
▰ New knee arthrometer: GNRB-ACL assessment (Automated anterior drawer test). (n.d.). Retrieved from https://www.youtube.com/watch?v=7LrRGGZCVk8
▰ Top 5 ACL tear diagnostic tests. (n.d.). Retrieved from https://www.genourob.com/diagnostic-ligaments_news_top-5-acl-diagnostic-tests.phtml

81