ACL-R Flashcards
What are ACL-R outcomes in relation to surgical management?
Poor, only 50% of athletes regain pre-injury level and re-injury risk is high after return.
What is the reinjury risk following ACL-R?
Roughly 6x greater than those who didn’t suffer ACL injury.
What is the function of the ACL?
Prevents anterior translation of the tibia and rotational loads.
What can cause ACL injury?
What is likely mechanism of injury?
~70% Non-Contact (Pivoting, valgus force + IR)
~ 30% Traumatic (Direct blow e.g. tackle or RTC)
What relationship exists between gender and ACL injury?
Women are 3x more likely to injure their ACL.
This is due to their wider pelvis, increased Q-angle, more laxity of ligaments and a smaller intercondylar notch.
What are the grades of ACL Injury?
Grade 1 - no tear, tender and swollen, nil instability or laxity.
Grade 2 - partially torn, some loss of function, some instability, increased translation but firm end range, painful Lachman’s / Anterior Drawer.
Grade 3 - Complete rupture, tender and swollen, increased translation with no end range stop, minimal knee control, positive pivot shift test.
What grade of ACL tear does this sound like:
“tender and swollen, nil instability or laxity, negative Lachman’s / Anterior Drawer.”
Grade 1
What associated injuries often occur alongside an ACL injury?
“Unhappy triad”: Meniscal / MCL
Bone Contusion / Microfracture (Traumatic)
Chondral Injury (Traumatic)
Tibial Plateau Fracture
PLC Injury
Baker’s Cyst
What is the Clinical Presentation of an ACL Injury?
MOI: Cutting / Pivoting maneouvre or single leg standing, landing, jumping.
Audible ‘pop’ during time of injury
Feeling of instability (later masked by swelling).
Episodes of giving way during twisting.
Extremely painful, swollen with restricted movement (especially extension).
TOP medial joint line may indicate associated cartilage injury.
What grade ACL tear does this sound like?
“some loss of function, some instability, increased translation but firm end range, painful Lachman’s / Anterior Drawer.”
Grade 2
Injuries to the ACL rarely occur in isolation, often the “unhappy triad” is affected. What structures make up the “unhappy triad”?
ACL, MCL & (Medial) Meniscus
Lateral Meniscus lesions are present but at a much lower rate than medial meniscus.
What grade ACL tear does this sound like?
“tender and swollen, increased translation with no end range stop, minimal knee control, positive pivot shift test.”
Grade 3
50% of all ACL injuries are found to have associated meniscal injuries, what other structure joins these two to create the “unhappy triad”?
Medial Collateral Ligament
When is it likely that a bone contusion or microfracture has occurred alongside an ACL injury?
When there is a full rupture of the ACL as these are often traumatic and have “bruised the bone”.
How is an ACL injury diagnosed?
- Radiographs
- MRI
- Ultrasonography
- Instrumented Laxity Testing
What special tests may suggest injury to the ACL?
Lachman’s
Anterior Drawer
Pivot Shift
What is the course of management for an ACL tear?
Conservative or Surgical.
Evidence is mixed and recent reviews have found similar results for conservative and surgical approaches.
When is it likely that a chondral injury has occurred alongside an ACL injury?
When the ACL has a traumatic method of injury.
What does ACL Injury Prevention entail?
- Stretching of major surrounding muscles
- Strengthening (Squats, SL Squats, Lunges & Nordics)
- Plyos (SL hopping, Ice Skaters, Jumps)
- Running and direction change
Who should take part in ACL injury preventative measures?
Ideally everyone, however, at risk populations:
- Females.
- Under 18s.
- Soccer & Handball Players.
When is Surgical treatment preferred for an ACL tear?
Younger than 25 & Highly active
Marked anterior tibial subluxation
Additional intra-articular damage
What has been found about the duration of time before returning to sport and the risk of re-injury?
An early return to sport (<9.5 months) has been found as a significant predictor of re-injury.
What proportion of athletes undergo a second revision after their primary ACL operation?
About 25% require secondary revision.
What are the 4 stages of the return to sport protocol?
1 - Dynamic stabilisation and core strengthening
2 - Functional strengthening
3 - Power development
4 - Sports performance symmetry
What role does timing play in re-injury of the ACL?
Return to sport ideally around 9.5 months minimum. It has been found that each month (up to 9 months) return to sport was delayed led to a ~50% reduction in injury re-occurrence.
What is the consequence of ACL surgery on future health of the knee?
Increased likelihood of developing OA, this becomes devastating if there is a second operation required.
What are some very important strength measures to test when discussing return to sport with a patient?
Quadriceps Strength Symmetry
Hamstrings/Quadriceps Strength Ratio
The aim is to achieve minimum 85% strength symmetry before returning to sport.
What is the Return to Sport Criteria?
<10% deficit quads & hams strength
<15% deficit LL symmetry on SL hop
<3mm AP displacement Lachman’s test
Full ROM, painless activities without effusion
What is Mucoid Degeneration of the ACL?
A rare pathological condition in which mucin infiltrates and disorientates fibres of the ACL.
What should be the Goals and Activities for the Initial Phase of ACL Rehab (0-2 weeks)?
Goals:
Pain management, healing ligament, restore ROM, early muscle activation.
Activities:
RICE, Bracing, ROM exercises, Isometric exercises, Non-WB!
What should be the Goals and Activities for the Early Phase of ACL Rehab (2-6 weeks)?
Goals:
Restore ROM, begin strengthening, proprioception and balance
Activities:
ROM & Strengthening, Balance and Proprioception. Hydrotherapy can be used.
What should be the Goals and Activities for the Advanced Phase of ACL Rehab (3 months+)?
Goals:
Achieve near baseline function
Activities:
Plyometrics, functional exercises, Advanced S&C
What should be the Goals and Activities for the Intermediate Phase of ACL Rehab (6-12 weeks)?
Goals:
Neuromuscular control, strength and endurance. (Full ROM)
Activities:
Strengthening, NMT, Cardiovascular
