Anterior Cruciate Ligament Sprain

Grade III ACL Sprain: Most Likely Clinical Presentation

1) 14-29 y/o 2) Overall higher activity level 3) Significant pain 4) Effusion 5) Edema that significantly limits ROM 6) May be unable to bear weight resulting in dependence on an assistive device 7) Ligamentous testing reveals visible laxity and may exacerbate pain level

Grade III ACL Sprain: Likely Additional Findings

1) 2/3 of ACL tears have an accompanying meniscal tear 2) Collateral ligaments may also be involved, though not as commonly as the menisci

Grade III ACL Sprain: Assistive and Adaptive Devices

1) Analysis of components and safety of a device 2) Potential use of crutches

Special Tests to Identify ACL Tear

1) Anterior Drawer Test 2) Lachman Test 3) Lateral Pivot Shift Test

Grade III ACL Sprain: Most Appropriate Tests/Measures

1) Anthropometric characteristics 2) Arousal, attention and cognition 3) Assistive and adaptive devices 4) Gait, locomotion and balance 5) Integumentary integrity 6) Joint integrity and mobility 7) Muscle performance 8) Orthotic, protective, and supportive devices 9) Pain 10) ROM 11) Self-care and home management 12) Sensory integrity

Grade III ACL Sprain: Integumentary Integrity

1) Assess sensation 2) Skin assessment

Grade III ACL Sprain: Causative Factors

1) Body movement and positioning 2) Muscle strength 3) Joint laxity 4) Q angle 5) Narrow intercondylar notch

ACL Sprain: Treatment

1) Initially RICE, NSAIDs, and analgesics prn 2) Conservative tx includes LE strengthening exercises emphasizing quads and hamstring 3) Surgery often warranted for a complete ACL tear 4) Surgery most often consists of intra-articular reconstruction using the patellar tendon, iliotibial band or hamstrings tendon 5) A derotation brace may be beneficial for a pt with an ACL deficient knee, but has limited benefit for a pt following surgery

Grade III ACL Sprain: Anthropometric Characteristics

1) Knee effusion 2) LE circumferential measurements

Grade III PCL Sprain: Distinguishing Characteristics

1) Less common than ACL sprain 2) Most common MOI is a "dashboard" injury or forced knee hyperflexion as foot is plantar flexed 3) Typically produce effusion, posterior tenderness and a positive posterior drawer test 4) Knee extension often limited d/t effusion and stretching of posterior capsule and gastrocnemius 5) Rehab program typically emphasizes strengthening of quads 6) May not exhibit any functional performance limitations, surgical intervention is therefore far less common than with an ACL sprain 7) Knee joint arthrokinematics altered and patient is more susceptible to degenerative changes

ACL Sprain: SxS

1) Loud pop 2) Feeling the knee "giving way" or "buckling" followed by dizziness, sweating, and swelling

Grade III ACL Sprain: Lab or Imaging Studies to Confirm Dx

1) MRI preferred to identify injury of soft tissue structures 2) X-rays may be used to rule out a fracture

Grade III ACL Sprain: What history should be documented?

1) Mechanism of injury 2) Current symptoms 3) PMH 4) Medications 5) Living environment 6) Social history and habits 7) Social support system

Grade III ACL Sprain: Arousal, Attention, and Cognition

1) Mental status 2) Learning ability 3) Memory 4) Motivation

ACL Sprain: Etiology

1) Non-contact twisting injury associate with hyperextension, varus or valgus stress to the knee 2) Often involves injury to other knee structures such as the medial capsule, MCL, and menisci

Grade III ACL Sprain: Likely PT Outcome

1) Patients may be able to participate in light to moderate athletic activities without formal surgical reconstruction 2) Return to previous functional level 4-6 months post-op

Grade III ACL Sprain: Recommended Home Care Regimen

1) ROM 2) Strengthening 3) Palliative care 4) Functional activities

ACL

1) Runs from anterior intercondylar area of the tibia to the medial aspect of the lateral femoral condyle in the intercondylar notch 2) Prevents anterior displacement of the tibia on the femur and posterior displacement of the femur on a fixed tibia 3) Broad cord that has long collagen strands 4) Permits up to 500 lbs of pressure prior to rupture 5) Poor blood supply and does not have the ability to heal a complete tear

Grade III ACL Sprain: Joint Integumentary and Mobility

1) Special tests for ligaments and menisci 2) Palpation of structures 3) Joint play 4) Soft tissue restrictions 5) Joint pain

Grade III ACL Sprain: Muscle Performance

1) Strength and AROM assessment 2) Resisted isometrics 3) Muscle contraction characteristics 4) Muscle endurance

Grade III ACL Sprain: What additional info should be obtained to confirm the dx?

1) Subjective reports such as hearing a loud pop or feeling as though the knee buckled 2) Special tests, which should be performed bilaterally

Grade III ACL Sprain: Orthotic, Protective, and Supportive Devices

1) Use of bracing, taping or wrapping 2) Foot orthotic assessment

Grade III ACL Sprain: ROM

AROM and PROM

How is the extent of an ACL Sprain classified?

According to the extent of ligament damage

How is the direction of ACL laxity classified?

Anterolateral or Anteromedial

Grade III ACL Sprain: Self-care and Home Management

Assess functional capacity

Grade III ACL Sprain

Completely torn ligament

Are males or females more likely to sustain a Grade III ACL Sprain?

Females

How does the ACL most commonly sustain an injury?

Hyperflexion, rapid deceleration, hyperextension or landing in an unbalanced position

At what point in the ligament does an ACL tear usually occur?

In the mid-substance rather than near the attachments

What is the Unhappy Triad?

Injury to the ACL, MCL and medial meniscus

Grade I ACL Sprain

Involves microscopic tears of the ligament

Grade III ACL Sprain: Pain

Pain perception assessment scale

What is the most commonly utilized graft for ACL reconstruction?

Patellar tendon

Grade III ACL Sprain: Long Term Outcomes

Patients that elect not to have reconstructive surgery will likely be at increased risk for instability and subsequent deterioration of joint surfaces

Grade III ACL Sprain: Sensory Integrity

Proprioception and Kinesthesia

Grade III ACL Sprain: Gait, Locomotion, and Balance

Safety during gait with an AD

Grade III ACL Sprain: Most Likely Contributing Factor

Sports requiring high levels of agility

Grade III ACL Sprain: Why are closed-chain exercises preferred to open-chain?

They minimize anterior translation of the tibia

What is necessary in tx for patients s/p ACL rupture who elect not to have surgery?

To begin an aggressive strengthening program once the acute phase of injury has subsided

What should be a requirement for patients s/p ACL rupture to be able to return to unrestricted sports?

To complete a functional progression