Anterior cruciate ligament injury, 3 Phases, Anatomy, Treatment?

Anterior cruciate ligament injury overview:

Anterior cruciate ligament injury (ACL). The anterior cruciate ligament is one of the most commonly torn ligaments in the knee joint. Injury to this ligament is the result of rotational movements at the knee joint mostly in sports activities. Females and ergonomic factors are major risk factors to the injury of this ligament. When the ligament is torn there is extreme pain and feelings of instability at the knee joint. A pop may also be felt at the time of injury. Non- operative or surgical treatment may be recommended depending on the grades of torn ACL.

What is an Anterior cruciate ligament injury?

ACL stands for anterior cruciate ligament which is present at the front of the knee and connects the femur ( thigh bone) to the tibia ( shin bone ). It is a strong ligament that provides anterior stability to the knee and easily and most commonly injured in activities that require a sudden change in direction and rotation such as some sports like volleyball, basketball, and soccer. l

Anatomy of ACL:

The Anterior Cruciate ligament is a tough band of dense connective tissue which connects the femur to the tibia. ACL has two components one is an anteromedial bundle and the second is a posterolateral bundle.

 Attachment: 

Proximally it arises from the posteromedial part of the medial aspect of the lateral condyle of the femur in the intercondylar notch. From here it runs medially, anteriorly, and inferiorly to blend with the anterior horn of medial meniscus anterior to the intercondylar eminence at the tibia.

Function: 

It provides anteromedial stability to the knee and resists rotational loads and anterior tibial translation.

What is the Mechanism of an ACL injury?

There are two types of the mechanism of injury;

Contact mechanism of injury:

The most usual contact mechanism is a blow to the outside of the knee which is called valgus force and this type of mechanism not only torn ACL ligament but also a combination of injury occurs which includes medial collateral ligament (MCL) and medial meniscus. So this type of injury is called “terrible triad” or “unholy triad”.

Anterior cruciate ligament injury

Noncontact mechanism of injury:

The noncontact mechanism is when there is no physical contact between players. The 1st most ordinary mechanism is external rotation of the tibia when the foot is in plantar flexion. According to different studies, this mechanism accounts for 78% of all ACL injuries.

And the second most common mechanism is a sudden change in direction in certain sports where the leg is forcefully hyperextended. 

What are the signs and symptoms of an ACL injury?

Sign and symptoms of Anterior cruciate ligament injury  are given below:

• Severe pain inside the knee.
• At the time of injury, a loud pop is felt.
• A lot of swelling and tenderness.
• Giving way” or knee instability sensation when putting weight on joint.
• Difficulty in walking
• Decrease range of motion at the knee joint.

What are the causes/risk factors of an ACL injury?

• The most common risk factor is athletic females. Female athletes are at three times greater risk of ACL injury than males. The reasons behind this are biomechanical, neuromuscular, structural, and hormonal differences between males and females.
•  Abruptly changing direction 
• Contact sports
• Suddenly stop
• Improper landing or jumping
• Direct force to the lateral side of the foot
• Playing on rough surfaces.
• Improper footwear

Can you still walk with a torn ACL?

Walking is possible when there is a mild tear or sprain to the ligament, otherwise, you can walk with a protective device or knee brace when the acute symptoms subside.

What does ligament pain feel like in the knee?

Severe pain is felt at the time of ligament injury and motion becomes impossible.  Pain is usually felt inside the joint at the center of the knee because the ligament is located here.

What are the grades of ACL tears?

On the severity of injury torn ligament is considered into three grades.

• Grade 1:

  In this grade, the ligament is slightly stretched or mild damage to the ligament occurs. Pain and swelling are present but no feeling of instability at the joint. the ligament is treated through conservative management.

• Grade 2:

 Half fibers of the ligament are torn so grade two is also called the partial tear of the ACL ligament. Severe pain, rapid swelling, and tenderness are present. the feeling of instability is also present. treatment is mostly through conservative management. surgery is recommended in some cases when conservative management fails.

• Grade 3:

It is also called a complete ligament tear because the ACL is torn into two pieces. Pain is sometimes present or sometimes absent due to complete rupture of fibers. The knee joint is totally unstable. So mostly reconstruction of ligament is recommended.https://youtu.be/gInKdBMpUtQ

What is the diagnosis of an ACL injury?

There are different options to diagnose ACL tears and check the severity of torn ligaments. These diagnostic options include:

Clinical history:

Whenever you have torn ligament and visit a healthcare practitioner he takes a thorough history from you and asks many questions about your condition such as;

• Where do you exactly feel the pain?
• What is the quality of your pain?
• Do you feel any pop at the time of injury?
• What was the position of your leg when you got injured

After completing medical history your doctor or physical therapist moves to physical examination of your knee.

Physical examination:

Your health care work inspects your knee to check the sign and symptoms of ACL tear such as swelling and tenderness then compare your affected knee with the sound knee to examine the changes. And then perform the movement at your leg in different directions to check the range of motion and functions of the knee joint. He or she may also perform different diagnostic tests to assess knee stability or severity of the tear. These physical examination  tests are given below;

1. Lachman’s test

It is the most common test to check the stability of the anterior cruciate ligament. The patient is lying supine on the treatment table with the affected knee flexed at 20 to 30 degrees of flexion. The therapist holds the patient's thigh with one hand and the other hand placed on the tibia and pulls the tibia forward. Restriction to anterior movement occurs when the ACL ligament is stable. When there is an ACL injury, the leg moves freely out of its normal range and there is no hard endpoint and this is a positive sign.

2. Anterior drawer test

While examining this test patient is positioned supine lying with 45 degrees flexion at the hip joint and 90 degrees flexion at the knee joint. Examiner is sitting at the front of the patient's leg while putting the lightweight of his or her leg on the patient's foot, grasping the tibia with both hands, and placing the thumb on the tibial joint line. The therapist pulls the patient's leg forward. Free movement of the tibia without any restriction and no hard end feel are the positive signs of ACL ligament tear.

Medical Imaging:

Medical imaging includes x-ray, MRI, and Ultrasound.

X-rays:

X-rays are performed to rule out a bone fracture but not to check ACL tear because soft tissues like ligaments, tendons, and capsules are not shown on x-ray.

Magnetic resonance imaging(MRI):

MRI is the best diagnostic test for torn ACL. To create an image of soft and hard tissues in your body MRI uses radio waves and magnetic fields. MRI shows the severity of ACL damage and injury to other structures of the knee like ligament, tendons or muscles, etc. So it is the best option to see the extent of the damage.

Ultrasound:

It uses sound waves of high frequency to create a picture of the knee. As the ACL location is deep inside the knee so the picture of an ACL tear is not clear on ultrasound and that's why it's not the best option for ACL injury. But other structures like ligaments and tendons are easily seen so it is used to rule out injuries of secondary structures of the knee like ligament, tendon, and capsule.

What is the treatment for Anterior cruciate ligament injury?

ACL tear is managed in 3 ways;

1. Nonoperative management 
2. Reconstruction surgery
3. Postoperative management

Treatment of Anterior cruciate ligament injury before surgery:

Acute injury, partial ligament tear, and sometimes complete rupture of the ligament are treated conservatively by the use of R.I.C.E and exercises. When the acute stage subsides then exercises should be performed to regain normal range of motion, increase strength, endurance, and neuromuscular control at the knee joint. Nonoperative treatment depends on the patient's activity level before the injury and returns to activity after injury. As people who have to participate in sports require more neuromuscular control and dynamic stability. So nonoperative management is divided into 4 phases of rehabilitation.

Rehabilitation of Anterior cruciate ligament injury:

There are four different phases of rehabilitation to reduce the signs and symptoms of an ACL tear and Anterior cruciate ligament injuries such as pain, inflammation, and joint effusion by performing exercises for several weeks.

Maximum protection phase: weeks 1-3

The first immediate treatment after an injury is R.I.C.E can be applied by self or by your health care professional at the clinic:

• Rest. rest is necessary to promote healing so avoid activities such as walking and running immediately after injury.
• Ice . apply icing by using ice packs or ice sprays for 20 sec after every two hours throughout the day. It helps to reduce swelling by constricting the capillaries and also decreases pain so give a soothing effect.
• Compression.  It is applied through compression garments or a tight elastic bandage around the injured knee. It helps to reduce swelling.
• Elevation. Elevate the leg by placing two or more cushions under the affected knee to reduce inflammation.

Exercises for Anterior cruciate ligament injury :

As it is the maximum protection phase exercises should be performed with great care. some exercise which a therapist teach you in phase 1 are given below:

• Passive range of motion
• Active assistive ROM
• Grade I and Grade II patellar mobilization
• Isometric exercise for quads and adductors

Moderate protection phase: weeks 3-6

The goals of the moderate protection phase are to regain full range of motion and muscular strength with a normal gait and daily functional activities.

Exercises Anterior cruciate ligament injury:

Following exercises should be performed during the moderate protection phase.

• Multiple angle isometric exercise
• Strengthening exercises (close chain)
• Stretching exercises such as straight leg raising
• Balance and stabilization exercises
• At the end of this phase starts training specific to the activity.

Minimum protection phase: weeks 5-8

In this phase, advanced exercises are performed to regain more strength, endurance, and neuromuscular control. You can perform the following exercises in this phase:

• Flexibility exercises 
• Advance strength training ( closed chain exercises)
• Advance endurance training
• Running, jogging, and specific drills like cutting and changing direction.
• Running in the figure 8 manner.
• Short duration highest speed workout.

Return to activity phase:

In this phase, the main goal is to protect joints while returning to specific sport activity and other goals are to improve muscle performance and cardiopulmonary fitness. So exercises performed in this phase include:

• Advance strength training as partial squats, step up step down, leg press, and raising hell in plantar flexion and dorsiflexion.
• Apply drills related to sports and occupation.
• More advanced balance training to develop neuromuscular control
• Aerobic programs like biking, running, jogging, swimming, and using a ski machine.
• To protect joints while playing using a protective knee brace.

Surgery for Anterior cruciate ligament injury:

Surgery is recommended when there is a complete ACL tear and elite athletes have to participate in highly challenging sports activities.

ACL reconstruction surgery is now typically a one-hour outpatient procedure performed successfully in different ways. The entire surgery is completed through a few tiny insertions. One is used to insert a camera to get a view inside the joint and the other two or more insertions are on either side of the knee cap to give the surgeon access to the knee joint and for inserting graft.  First of all, surgeons clear the damaged ACL and prepare the area for a new graft. The new graft is a piece of tendon another part of your knee like a hamstring tendon. After successful reconstruction, you have to follow rehabilitation again to gain full strength of ligament and muscles around the knee joint.

Treatment of Anterior cruciate ligament injury after surgery:

Postoperative management is done in three phases of rehabilitation such as:

Maximum protection phase: Day 1 to week 4

The goals of this phase are to the protection of joint, improve healing, prevent reflex inhibition of muscles, decrease swelling and joint effusion, gain active control on a range of motion,weight-bearing as possible, and home-based exercise program :

Treatment :

• R.I.C.E(rest,icing,compression and elevation)
• Weight-bearing as tolerated through proper gait training with the use of knee brace and crutches.
• Mobilization of the patella in all directions(grades I/II)
• Multiple angle isometric exercises for quadriceps, hamstrings, and adductors
• Straight leg raising in supine with assistance.
• Ankle pumps

At the end of this stage progress to full weight-bearing, starts kinetic closed chain exercise like squats, heel raises and toe raises. Strengthening exercises for hamstrings, quadriceps especially vastus medialis, and calf muscles should be performed. Aerobic exercises can also be performed.

Moderate protection phase: weeks 4 -10

The goals of this phase are full pain-free ROM, normal gait pattern, dynamic control at the knee, improve proprioception and normalize ADL.

Treatment:

• Continue multiple angle isometrics (quadriceps, hamstrings)
• Continue closed chain exercises and PRE.
• Stretching  exercises for lower limb
• Balance board training to improve proprioception.
• Endurance and stabilization exercises

At the end of this phase begins advanced strength, endurance and flexibility, and balance drills. Starts a walk/jog program at the end of this phase.

Minimum protection phase: 3-5  month 

The goals of this phase are maximum strength and endurance, regain cardiopulmonary fitness, regain the ability to function at the highest desired level, safe return to sports, and return to a maintenance program.

Treatment of Anterior cruciate ligament injury:

• Continue stretching exercises.
• Continue advance closed chain exercises
• Sports specific training
• Plyometric drills such as bouncing and jumping
• Advance balance training to improve proprioception
• Figure 8 and cutting drills.
• Full speed running, jogging, and sprints.

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