ANTERIOR CRUCIATE LIGAMENT (ACL) TEAR

ANTERIOR CRUCIATE LIGAMENT (ACL) TEAR

OVERVIEW

The anterior cruciate ligament (ACL) is located in the center of the knee, which controls the rotation and forward movement of the tibia (shin bone).

ACL rupture is a common sports-related injury but can also occur in road traffic accidents, falls and work-related injuries occurring during changing the direction rapidly and during a jerky action like landing from a jump or stopping suddenly.

It is more commonly seen in female athletes.

An ACL injury is often associated with damage to articular cartilage, meniscus or other ligaments.

GRADES OF INJURY

ACL tear can be classified into three grades:

Grade 1 Grade 2 Grade 3
Pathology Minor tear around the ligament Single Bundle tear but not completely torn -Fibres of the ligament are completely torn

-Ligament completely torn into two parts

Examination -Tenderness +

-Swelling +

-Increased anterior translation around the knee joint

-Tenderness +

-Swelling+

-Joint Instability 

-No end field

-Tenderness++

-Swelling++

Symptoms -Pain +

-No knee-buckling

-Pain ++

-Difficulty in walking

-Pain

-Knee buckling +

MRI Findings -Fluid around the ligament -Fluid around the ligament

-Partial disruption of the ligament fibers

-Complete disruption of fibers

Causes

An ACL tear is usually sudden and is regularly seen in high thrust sports. It often occurs:

  • An athlete plants a foot & suddenly shifts direction
  • When a person lands on one leg
  • When the hyperextended knee is hit directly
  • Repeated stress on the knee
  • A sudden change of movement
  • Due to a fall

 

Risk Factors

  • Gender 

The rate of ACL injuries is three times higher in females than in males

 

  • Athletes ACL tear commonly occurs in high thrust sports like:
  1. Football
  2. Basketball
  3. Volleyball
  4. Tennis

 

  • Previous ACL Injury 

The risk of re-tearing a previously repaired ACL is 15% more than the risk of tearing a normal ACL.

The risk of an ACL tear in the opposite knee is also higher once the injury has occurred in the first.

 

  • Age Factor

Due to the active lifestyle & high participation in sports activities, the age group of 15-45 is a vulnerable group for an ACL tear 

 

When to see a doctor?

  • A loud “popping sound” in the knee joint
  • Severe pain around the knee
  • Knee buckling
  • Rapid Swelling

Diagnosis

  • Medical history and a physical examination.
  • During the examination, the clinician checks all the structures of the injured knee and compares them with the non injured knee.
  • MRI scan of the knee. Commonly there is damage to the meniscus and other ligaments at the same time as the ACL.
  • X-rays are done to rule out bony avulsions a/w the tear.

Treatment

Initial management after an injury to the knee can help in reducing pain & swelling. This can be achieved by the R.I.C.E. model of self-home care of the injury:

    • Rest the muscles and avoid activity causing contraction of the injured region
    • Ice pack application for around 20 minutes can reduce pain and inflammation
    • Compression wrap around the knee
    • Elevation of the limb

 

Surgery is generally recommended if the patient wishes to get back to sports but it is not absolutely necessary to have this ligament reconstructed. Treatment for an ACL tear depends on the patient’s need. Non-surgical treatment is maybe effective for patients who have low functional demands such as the elderly. Nonsurgical options include:

ACL Reconstruction:

In general, this surgery is very successful, and it does stop the knee from repetitively dislocating and makes it feel stable.

The damaged Ligament is removed & is replaced with a segment of the tendon. This replacement tissue is known as Graft.

Sockets or tunnels are drilled into the thighbone and shinbone to accurately position the graft, which is then secured to your bones with screws or other fixation devices. 

 

Rehabilitation

It is divided into 3 phases:

  1. Acute Phase/Conservative Management
  2. Preoperative Phase
  3. Postoperative Phase

 

  • Acute Phase

Goals:

-To reduce swelling

-To maintain muscle power

-To maintain blood circulation

 

Exercises:

Static quads/SLR

Ankle Movements

Knee flexion/extension in sitting

Patellar mobilizations

Knee bending in prone

Weight transfers in standing

  • Preoperative Phase

Goals:

-Educating the patient about the rehabilitation protocol

-Mentally preparing the patient for the procedure

-Quadriceps exercises to reduce swelling

-Knee Swinging for early return of function

-Knee Strengthening

-To improve posterior stability of the knee

 

Exercises:

  • Isometrics exercises
  • Straight leg raises
  • Range of motion
  • Knee extension exercises:

1.Heel Props

2.Prone hang exercise

-Knee bending exercises:

1.Passive knee bending

2.Wall slides

3.Heel slides

 

-Strengthening Exercises: Once 100 degrees of flexion has been achieved you may begin to work on muscular strength.

This can be achieved by: 

-Stationary Bicycle

-Swimming

-Treadmill

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