SOFT TISSUE INJURY: ACL/PCL

NURUL FARHANA BT HASHIM 2010840364

ANATOMY: ACL & PCL

Functions ACL : Prevent anterior movement of the tibia on the femur. Control normal rolling and gliding movement of the knee. Functions PCL : Primary stabilizer of the knee against posterior movement of the tibia on the femur Maintain rotary stability and as the knees central axis of rotation.
(Magee D. J, 2002)

MECHANISMS OF INJURY
ACL : External rotation with abduction of the flexed knee/hyperextension of knee in internal rotation. (Sports, MVA, falls, work-related injuries) PCL: severe rotational injury, dashboard injury (knee is bent, and an object forcefully strikes the shin backwards) or complete dislocation of the knee.
(Ebnezar J. , 2011)

CLINICAL FEATURES
A "popping" sound at the time of injury Knee swelling within 6 hours of injury due to hemarthrosis Pain, especially when you try to put weight on the injured leg or on certain activity. (walking downhill) The knee feels unstable or may feel like it wants to slip backwards.
(Ebnezar J. , 2011)

DIAGNOSIS
ACL: Physical assessment: Lachman Test, Anterior Drawer Test & Pivot shift test Radiographs: MRI and KT-1000 (higher accuracy than clinical examination in detecting ACL tears when multiple ligaments are torn) PCL: Physical assessment: Posterior Drawer Test Radiographs: X-rays and MRI (clarifying the diagnosis and detecting any other structures of the knee that may be injured)

PHYSICAL ASSESSMENT
TEST PIVOT SHIFT TEST HOW TO PERFORM Patient is supine. Knee is extended, with valgus stress applied on the knee and the tibia is internally rotated The knee is slowly flexed. INFERENCE If the tibias position on the femur reduces as the knee is flexed in the range of 30 to 40 degrees or if there is an anterior subluxation felt during extension the test is positive for a tear of the ACL. A positive result is found if the Tibia moves excessively forward compared to the healthy knee. Used in acute injuries of knee where knee cannot be flexed to 90

LACHMAN S TEST

The patient supine with the knee flexed between 15 and 30 degrees. The practitioner grips the outside of the lower Femur (thigh) with the upper hand and the inside of the upper Tibia with the lower hand. The Femur is stabilised with the upper hand as the lower hand applies an anterior force on the Tibia

TEST

HOW TO PERFORM

INFERENCE A positive result is if the Tibia moves excessively forwards (more than 6 to 8 mm). All test should always be compared with normal knee.

ANTERIOR With the patient supine with the DRAWER TEST injured knee bent to 90 degrees and the foot flat on the table. The practitioner may stabilise the foot by sitting on it. The practitioner will grasp the upper Tibia (shin bone) with both hands. They will then attempt to pull the Tibia forwards, towards them.

POSTERIOR Same as the Anterior Drawer Test but DRAWER TEST tibia is pushed backwards.

Positive test indicates by the movement of the tibia backwards.

DOCTOR MANAGEMENT
ACL: Surgery ACL reconstruction Using tendons from other parts of the body as a substitute for the ACL; patella tendon graft and hamstring muscle tendon graft techniques. Patella tendon graft procedure is the central 1/3 of the patella tendon is removed along with a piece of bone at the attachment sites on the kneecap and tibia. Hamstring graft procedure uses two tendons (semitendinosus or gracilis tendons)are taken from the hamstring muscles and wrapped together forming the new ACL.

PCL: surgery required in complete tears of the ligament with other associated ligament injury. Controversial due to the technical difficulty of the surgery, because of the position of the PCL in the knee. Trying to place a new PCL graft in this position also difficult. In arthroscopic surgery, the surgeon uses several small incisions in the knee joint to reconstruct the ligament.

PHYSIOTHERAPY TREATMENT
Rehabilitation after surgery Patient immobilized in knee POP cast for 6-8 weeks. Goals in initial stages: minimize swelling Decrease pain and inflammation Control stiffness and prevent DVT

Intervention during the initial stages: Icing frequently/cryotheraphy Elevating the affected knee Compression bandage to control edema Active exercise to ankle and toes Knee swinging exercises with the patient sitting at the edge of the bed/chair.
Leg hanging, small rhythmic active knee flexion and extension. Speed of the movement is gradually increased to gain greater mobility

Goals in post-acute stages: to regain full range of motion improves strength, motion and aerobic activity gaining hamstring and quadriceps control Restore strength and dynamic stability increased concentration on balance and mobility.

Intervention during the post-acute stages: Isometric quadriceps exercises

Patients in long sitting position, keeps a soft roll beneath the knee, and press it downwards.

Passive exercise
Feel heel drag: heel is dragged to the buttocks by self assistive method.

work on gait training (walking) Gradual weight-bearing gentle strengthening aerobic work patients on a stationary bicycle strengthening exercise balance and proprioceptive exercises.
Proprioceptive work progresses from static to dynamic techniques including balance exercises on the wobble board and eventually jogging on a mini-tramp.

Goals in functional stages: Return to functional activities.

Intervention during the post-acute stages: some sport-specific activities can be started. light jogging cycling outdoors

REFERENCES
Ebnezar J. (2011)Essentials of Orthopedics for Physiotherapists. New Delhi: Jaypee Brothers Medical Publisher (P) Ltd. Magee D. J. (2002) 4th edition Orthopedic Physical Assessment. Canada. Saunders. Retrieved from: http://orthopedics.about.com/od/aclinjury/tp/acl.htm Retrieved from: http://sportsci.org/encyc/aclinj/aclinj.html#7 Retrieved from: http://orthopedics.about.com/cs/kneeinjuries/a/pcl.ht m Retrieved from: http://orthoinfo.aaos.org/topic.cfm?topic=a00420