1. Rehabilitation of anterior cruciate ligament Dr. Ali Abd El-Monsif Thabet

2. Introduction Anterior Cruciate ligament (ACL) : Attachments : Attachments : ♦The ACL is attached to the anterior part of the intercondylar area of the tibia (tibial spine) where it extends superiorly and posteriorly to attach to the posteromedial aspect of the lateral femoral condyle ♦The ACL is attached to the anterior part of the intercondylar area of the tibia (tibial spine) where it extends superiorly and posteriorly to attach to the posteromedial aspect of the lateral femoral condyle The ACL may also be considered to consist of two separate bands that wrap around each other. Each of these bands is thought to have a different role in controlling tibiofemoral motion. The ACL may also be considered to consist of two separate bands that wrap around each other. Each of these bands is thought to have a different role in controlling tibiofemoral motion.

4. The ACL is supplied by genicular arteries, which are branches of the popliteal artery. A vascular plexus in the synovial membrane serves as a secondary source of tissue nutrition. The ACL is supplied by genicular arteries, which are branches of the popliteal artery. A vascular plexus in the synovial membrane serves as a secondary source of tissue nutrition. The ACL is innervated by branches of the tibial nerve. The ACL is innervated by branches of the tibial nerve. Mechanoreceptors that resemble Golgi tendon organs are present throughout the ligamentous substance and create a reflex network influences the dynamic stabilization of the knee as muscle firing is initiated whenever the ACL is subjected to excessive load forces. Mechanoreceptors that resemble Golgi tendon organs are present throughout the ligamentous substance and create a reflex network influences the dynamic stabilization of the knee as muscle firing is initiated whenever the ACL is subjected to excessive load forces.

5. Biomechanics Biomechanics Kinetic Kinetic The ACL can withstand tensile forces of up to 1730 N before rupturing, the average tensile load on the ACL is 454 N during normal activities of daily living. The ACL can withstand tensile forces of up to 1730 N before rupturing, the average tensile load on the ACL is 454 N during normal activities of daily living.

6. Kinematics The kinematics of the knee are modulated by the restraining effects of the cruciate and collateral ligaments. The kinematics of the knee are modulated by the restraining effects of the cruciate and collateral ligaments. Together, the cruciate ligaments provide the primary static restraint for antero-posterior stability of the tibiofemoral joint Together, the cruciate ligaments provide the primary static restraint for antero-posterior stability of the tibiofemoral joint

8. Pathomechanics The ACL is perhaps the most commonly injured ligament in the knee. The ACL is perhaps the most commonly injured ligament in the knee. Tears of the ACL occur in the midsubstance of the ligament about 75 percent of the time, with 20 percent of the tears at the femur and 5 percent at the tibia. Tears of the ACL occur in the midsubstance of the ligament about 75 percent of the time, with 20 percent of the tears at the femur and 5 percent at the tibia.

9. Mechanism of Injuries The most common mechanism of ACL injury involves The most common mechanism of ACL injury involves

10. Mechanism of Injuries External rotation of the femur on fixed tibia External rotation of the femur on fixed tibia

12. “Unhappy triad” O'Donohue The “unhappy triad” O'Donohue refers a sprain injury that involves three structures of the knee. These are the medial collateral ligament, anterior cruciate ligament, and the medial meniscus. Occur with contact Occur with contact

13. The severity of the injury indicated by the degree of laxity or instability. A grade 1 sprain A grade 1 sprain A grade 2 sprain A grade 2 sprain A grade 3 sprain A grade 3 sprain

14. Differential diagnosis The Lachman and Pivot shift tests are the most reliable noninvasive indicators of ACL damage The Lachman and Pivot shift tests are the most reliable noninvasive indicators of ACL damage

15. Anterior drawer test

16. Thank you