ACL Anatomy

Importance of ACL Injury

Season ending injury
6-9 mo recovery time

Costly

ACL INJURIES IN SPORT

Annemarie Alf, PT, DPT,CSCS
Performance Physical Therapist

Stats for ACL Injuries

Female athletes competing in sports that
include jumping and cutting demonstrate a
4-10x higher incidence of knee injury than
do male athletes in the same sports.

Mechanisms of ACL Injuries

Contact vs Non- Contact

Injuries

Two thirds of all ACL injuries are non-contact

injuries and the three major ways that these
injuries occur:
1. Planting and Cutting
2. Straight knee landing
3. One step stop landing with a hyperextended
knee
* correlated with knee torsion, deceleration, rapid
change in direction

Risk factors that may

CONTRIBUTE TO ACL tears
EXTRINSIC FACTORS
Meteorological conditions (Orchard et al)
Type of surface (Myers MC, Barnhill BS)
Type of footwear (Lambon et al)
INTRINSIC FACTORS
Q angle (Shambaugh et al)
Knee valgus (Ford et al; Hewett et al)
Over 22.5 Nm indicates high risk (Hewett et al)
Foot pronation (Allan and Glascoe; Woodford-Rogers et al)
Excessive hip adduction due to weak hip stabilizers (C. Powers)
Body mass index (Brown et al; Knapik et al)

Contributing factors that can be

changed or trained (Arendt et al and Griffin et al)
Joint proprioception
Neuromuscular recruitment and muscle
imbalances (quad-hamstring ratio)
Muscle strength (both eccentric and
concentric) and flexibility
Joint posture and alignment
Resistance to fatigue

Risk Factors

Risk Factors Continued

Notch Size/ACL Size (Souryal and Freeman and Shelbourne and Kerr)
Hormones (Shultz et al; Wojtys et al; Slauterbeck et al)
Altered muscle activation patterns (Hutson and Wojtys; Malinzak et al)
Quadriceps dominant contraction
Inadequate muscle stiffness (Kibler and Livingston; Granata et al)
Abnormal loading of the knee due to unsuccessful
dynamic postural adjustments (Chris Powers; Griffin et al.)

Hamstring/Quadriceps imbalance
Poor hamstring strength
Hamstrings protect ACL
Quads stretch/stress ACL

Slow activation of hamstring

muscles with pivot / landing
Hewett AJSM 1999, Crosier AJSM 2002, Huston
1996 AJSM, Orchard AJSM 1997, Baratta AJSM 1988

RESEARCH RESULTS

(Huston et al. 24 )

Female athletes and controls demonstrated more anterior tibial laxity than
their male counterparts and significantly less muscle strength and
endurance
Compared with the male athletes the female athletes took significantly
longer to generate maximum hamstring muscle torque during isokinetic
testing
Female athletes relied more on their quadriceps muscles in response to
anterior tibial translation; the three other test groups relied more on their
hamstring muscles for initial knee stabilization
So what does this mean?

Prevention Plan: Jump Training

Program
PLAYERS TRAINED 6 WEEKS IN JUMPING AND LANDING TECHNIQUES,
JUMPING FOR INCREASED VERTICAL HEIGHT, AND INCREASED
STRENGTH
TRAINING SESSIONS APPROX. 2 HOURS PER DAY, 3 DAYS PER WEEK, ON
ALTERNATING DAYS
3 PHASES
4 BASIC TECHNIQUES DRILLED:
1) CORRECT POSTURE (SPINE ERECT, SHOULDERS BACK) AND CORECT
BODY ALIGNMENT (CHEST OVER KNEES) THROUGHOUT THE JUMPS
2) JUMPING STRAIGHT UP WITH NO EXCESSIVE SIDE-SIDE OR
FORWARD-BACKWARD MOVEMENTS
3) SOFT LANDINGS INCLUDING TOE-HEEL ROCKING AND BENT KNEES
4) INSTANT RECOIL PREPARATION FOR THE NEXT JUMP
(Hewitt el al, 1996)

The Prevention Plan: Plyometric Training

The Prevention Plan: Plyometric Training

Phase 2: FOCUS ON FUNDAMENTALS

Phase 1: FOCUS ON TECHNIQUE

Exercise

CONCENTRATED ON THE USE OF PROPER TECHNIQUE TO BUILD A BASE OF

STRENGTH, POWER AND ABILITY
Exercise
Repetitions or time

Repetitions or time

The Prevention Plan: Plyometric Training

Phase 3: PERFORMANCE
FOCUSED ON ACHIEVING MAXIMAL VERTICAL JUMP HT.
Exercise
Repetitions or Time

TECHNIQUE

WEEK 1

WEEK 2

Fundamentals

Week 3

Week 4

Performance

Week 5

Week 6

WALL JUMPS

20 sec

25 sec

Wall Jumps

30 sec

30 sec

Wall Jumps

30 sec

30 sec

TUCK JUMPS

20 sec

25 sec

Tuck Jumps

30 sec

30 sec

10 reps

5 reps

10 reps

5 reps

8 reps

Mattress Jumps

30 sec/ 30 sec

30s/30s (side-side/ back-front)

SQUAT JUMPS

10 sec

Jump, Jump, Jump, Vert.

Jump

Step, Jump up, Down,

Vertical

5 reps

BROAD JUMPS STICK

LAND

Squat Jumps

20 sec

20 sec

5 reps/leg

5 reps/leg

Bounding for Distance

1 run

2 runs

Single legged Jumps

Distance

Double Leg Cone Jumps

30 sec/ 30 sec 30 s/ 30s (side-side/ front-back)

Squat Jumps

25 sec

25 sec

Scissor Jump

30 sec

30 sec

Jumps into Bounding

3 runs

4 runs

et al, 1996
Hop,Hewett
Hop, Stick

5 reps/ leg

5 reps/ leg

Single-legged hop, hop stick

5 reps/leg

5 reps/ leg

15 sec

DOUBLE LEG CONE JUMPS 30s/ 30s

30s/30s (side-side/ back-front)

180 JUMPS

25 sec

20 sec

BOUNDING IN PLACE

20 sec

25 sec

Hewett et al, 1996

POST SURGICAL ACL REHAB

IN ELITE ATHLETES
4 PHASES OF ACL REHABILITATION

ACUTE (0-4 WEEKS)

SUBACUTE (5-11 WEEKS)
SETTLED (12-19 WEEKS)
RETURN TO SPORT (20-24)

Example Case Study

Introduction/Subjective/Clinical Impression:
18-year old female athlete, who sustained an injury while playing soccer 1 week ago. She was evaluated
by a physical therapist 1 day status post R ACL allograft and meniscal repair. Patient also presents with
Grade II MCL sprain. Surgeon has indicated NWB status for first two weeks postoperative, the second
two weeks PWB, and then WBAT from five weeks on. Prior to surgery, patient was PWB. There is
swelling at the right knee and surrounding areas causing discomfort and limitation of range of motion.
Patient is currently ambulating on crutches with no WB on RLE. Prognosis for recovery is excellent.
Patient is a National Team soccer athlete, has excellent cardiovascular health, no other medical issues
and is eager to return to sports as soon as possible. Patient reports severe right knee pain of 8/10 and
stiffness after surgery one day ago.

Impairments/Objective Measures:
-Edema and joint effusion of the R knee, with atrophy to R quads and calf muscles:
-Decreased A/PROM: -10/-15 degrees R knee extension and 90/100 degrees R knee flexion
with swelling end-feel. Left knee A/PROM extension 5/5 degrees and flexion 140/140 degrees
with normal end-feel.
-Hypomobile tibiofemoral and patellofemoral joints of R knee in all directions with swelling endfeel. L=WNL
-Abnormal gait pattern: decreased weight bearing on R LE.
-Incomplete MMT /MLT exam due to pain and swelling at the right knee.

ACUTE 0-4 weeks

LTG: In four weeks the patient will achieve the following goals to
increase range of motion, decrease swelling, stabilize muscle
atrophy, and decrease pain in the right knee in order to return to
sport in six months.
Decrease edema/effusion at R knee joint line
Increase A/PROM of right knee flexion to 100/105 degrees and right
knee extension to -5/-5 degrees.
Increase R patellar accessory mobility by 1 grade in all directions
and decrease swelling end-feel.
Normalize gait: teach patient modified 3-point gait pattern with PWB
on R LE; normal stride length with proper heel strike to toe off with
no VC for 500 feet.
Complete MMT exam when tolerated by patient.

ACUTE 0-4 weeks

STG: In two weeks the patient will achieve the following to achieve LTGs
listed above.
Decrease edema/effusion of R knee joint
Increase A/PROM of R knee flexion to 80/90 degrees and R knee
extension -5/-2.5 degrees.
Increase right patellar accessory mobility by grade in all directions and
decrease swelling end-feel.
Normalize gait: heel strike to toe off SL RLE on treadmill for 5 minutes at
1.0 mph, no incline.
Complete MMT exam when tolerated by patient.

Case Study Athlete

Subacute Phase 5-11 weeks

Clinical Impression/Subjective: Patient is now partial weight bearing with crutches but can be full
weight bearing standing in place, as per doctor protocol. Patient reports a decrease in pain to a 4/10 on
the visual analog scale. Her AROM and PROM have increased in both extension and flexion of right
knee with a abnormal muscular endfeel. Her right tibiofemoral and patellofemoral joints are still
hypomobile in all directions due to pain, swelling, and muscle guarding. Some MMTs are performed and
patient shows decreased strength and muscle atrophy in right knee musculature. MMT of quad and
gastroc not performed due to nature of ACL graft. Patient prognosis is excellent due to her motivation to
return to soccer, her young age and athleticism, and the positive progression of her healing.
Impairments/Objective Measures:
Edema and joint effusion of the R knee, with atrophy to R quads and calf muscles
Decreased A/PROM of right knee: flexion 120/125 and extension -5/-5 with abnormal muscle end-feel.
L=WNL
Hypomobile tibiofemoral and patellofemoral joints of R knee in all directions with abnormal capsule endfeel. L=WNL
Decreased strength and muscle atrophy of the following muscles:
Hip Adductors/ Hip Flexors/ Hamstrings / Glut Max/ Glut Med
Incomplete MMT of quad, gatroc, and soleus muscles due to unsafe application of force across knee.
Abnormal gait pattern with decreased knee extension, stride length, and decreased weight bearing of
right LE.

Rationale Summary for Acute:

The main goals for the acute phase are to protect the repair of the
right knee, reduce inflammation, prevent further atrophy of knee
muscles, reduce pain, increase range of motion of the joint, and
maintain the conditioning of all of the other muscles. Once these
goals have been accomplished, we can begin to strengthen the
muscles surrounding the knee and have the patient weight bear to
facilitate functional activities.

ACUTE HEP

Subacute Phase 5-11 weeks

LTG: By week 12, the patient will achieve the following goals to increase
range of motion, decrease swelling, reduce atrophy, and increase strength
in the right knee in order to return to soccer in six months.
Reduce edema of right knee to R=L.
Increase A/PROM of right knee to 135/140 degrees of flexion and 0/0
degrees of extension and reduce abnormal muscle end-feel. L=R
Increase joint accessory mobility of right knee in all directions by 1 grade
and decrease abnormal capsule end-feel so the L=R
Increase strength/reduce atrophy of all of the muscles listed above by 1
grade.
Complete MMT of right quad, gastroc, and soleus and treat accordingly.
Normalize Gait: Pt. will be able to walk with a symmetrical gait pattern and
equal WB with no assistive device for 30 minutes at 3.5 mph on treadmill;
15 minutes with 10% incline.

Home Exercise Program

Ice/ Cold Pack for 10-15 min every hour
Compression bandage and elevate leg whenever possible
throughout the day and night but should be removed for icing and
ROM exercises.
Therapeutic Exercise:
Quad Sets 3X20 2/day
Glut Sets 3X20 2/day
Heel Slides c Towel 3X20 2/day
Prone Knee Hangs 6x30 hold 2/day
Ankle Pumps sets of 10 each leg every hour.

Subacute Phase 5-11 weeks

STG: By week 8, the patient will achieve the following short term goals to
achieve the above LTG.
Reduce edema of right knee
Increase A/PROM of right knee to 115/120 degrees of flexion and 3/3
degrees of extension and reduce abnormal muscle end-feel.
Increase joint accessory mobility of right knee by grade in all directions
and decrease abnormal muscle end-feel.
Increase strength/reduce atrophy of all muscles listed previously by
grade.
Complete MMT of right quad, gastroc, and soleus and treat accordingly.
Normalize Gait: Pt. will be able to walk with a symmetrical gait pattern and
equal WB with no assistive devices for 15 minutes at 3.5 mph on treadmill;
no incline

 Rationale Summary:

The overall goals of the subacute phase are to advance healing,

increase strength, increase ROM, normalize gait, increase WB, and
to protect the integrity of the graft because at 3-4 months the graft is
at its weakest point.

Settled Phase
12-19 weeks

LTG: In 19 weeks, pt will be able to achieve the following to

increase strength, power, endurance and agility in order to be able
to play collegiate soccer within 6 months.
Increase strength of R quads and calf muscle to 5/5. L=R
Decrease atrophy of R knee musculature to L=R.
Increase functional ability: Pt will run 20 minutes on treadmill at 6.0
mph and 10 minutes at 8.0 mph with no incline. Pt will be able to
perform a vertical jump of at least 20 inches and run a T-drill under
12 seconds.

SETTLED PHASE
12-19 weeks post-op

CASE STUDY CONTD.

SETTLED 12-19 WEEKS POST-OP

Subacute Phase 5-11 weeks

Clinical Impression: At 12 weeks, the patient presents with

decreased strength of her right hamstrings, glut medius, quad, and
calf muscles with mild atrophy noted. She has decreased muscle
length of the rectus femoris and quadriceps muscles but has a
normalized gait pattern and is walking free of an assistive device.
She has no signs of inflammation or swelling, and her right knee
A/PROM is equal to her left knee A/PROM, ranging from 0-140
degrees, with a normal muscle end-feel. Her joint accessory
mobility is still hypomobile in all direction, with an abnormal capsular
end-feel. She occasionally experiences 2/10 pain with activity. In
order to return to national team soccer, patient must increase
functional mobility to run, make rapid postural adjustments, and
jump free from injury. At 18 weeks patient referred to knee bracing
rep to have custom ACL brace fitting.

Settled Phase
12-19 weeks

STG: In 15 weeks, pt will be able to achieve the following goals in

order to reach LTG.
Increase strength of R hamstrings and gluteus medius to 5/5. L=R
Decrease atrophy of R knee musculature by of impairment
measurements listed above.
Increase functional ability: Pt will run 15 minutes on treadmill at 6.0
mph with no incline and perform a box jump to 8.

Impairments:
Decreased strength of R hamstrings and gluteus medius, both a
4+/5. R quads/calf muscles 4/5. L=WNL
Atrophy of R knee musculature:
Decreased length of R rectus femoris at 75 degrees of knee flexion,
and R hamstrings at 75 degrees. L rectus femoris 90 degrees of
knee flexion and L hamstrings 90 degrees hip flexion.
Hypomobile tibiofemoral and patellofemoral joints of R knee in all
directions with abnormal capsule end-feel. L=WNL
Decreased R SL balance with eyes closed to 20 seconds.
Decreased functional ability: decreased power, endurance, agility,
speed

SETTLED PHASE

Rationale Summary:
In the settled phase of healing, fibroblasts remodel previously laid
down collagen fibers making the connective tissue more functionally
efficient. The collagen becomes stronger, thicker, and realigned to
orient the fibers along the lines of mechanical stress. Rehabilitation
should be sports specific, utilizing the SAID principle to
progressively overload the tissues in ways specific to the
movements needed to play high level soccer. Rehab should also
focus on recruiting both fast twitch muscle fibers to enhance speed,
power, and agility and slow twitch muscle fibers to increase
endurance and dynamic stability. Finally, the patient should be
taught proper techniques in both plyometric and change of direction
drills to recruit muscle fibers in the proper sequence to avoid further
injury and enhance overall sports performance.

RETURN TO SPORT
20-24 weeks post-op

Clinical Impression: Patient has normal and equal strength of

lower extremities with no atrophy noted. She now has normal joint
accessory mobility with a normal capsular end-feel. Despite
normalized strength, ROM, and joint accessory mobility, patient still
lacks some functional ability to play soccer at a national team level.
Physical therapy is needed to improve power, endurance, agility,
speed, and rapid adjustments to postural changes to successfully
play her sport. Patient reports decreased confidence with basic
soccer skills and fear of re-injury.

RETURN TO SPORT
20-24 weeks

Mobility Needs

Impairments:
Decreased functional ability: decreased power, endurance, agility,
speed
LTG: By week 24, pt will be able to run a 40 yard sprint under 5.4
seconds, perform vertical jump of 22 inches, score a level 10 on the
Beep Test, and perform 5/10/5 in under 4 seconds.
STG: By week 22, pt will be able to run a 40 yard sprint under 5.8
seconds, perform vertical jump of 20 inches, score a level 8 on the
Beep Test, and perform the 5/10/5 in 5 seconds.

Functional
Movement
Assessment
Corrective
Needs

Sports Medicine
Assessment

Strength &
Power Needs

Movement
Assessment

Movement
Needs

ESD Needs

History
Injury
Sport
other

SFMA

PHYSICAL
CAPACITY
Strength
Movement
Mobility
Energy Systems

Special Test

Physical: Movement Analysis

Physical :Strength
Physical /Sport: Biomechanical
Nutrition
Mental : Brain
Mental: Mindset
SPORT: TIMING, CAPABILITIES

Physician Dx

REHAB
PLANNING

REHABILITATION
Systemic
Tissue
Neurological
Movement

HEALTH
MENTAL

SPORT SKILL

REGENERATION
MENTAL
FUNCTION

VSP Domains

Physician
Dx

Mind
Brain

Systemic
Tissue
Neurological
Psychological

SPORT SKILL

Mental

Energy
Systems

HEALTH
Mobility

Force
Production

+ Physical
+ Sport
+ Mental
+ Regen

Movement /
Motor Control

8 Categories
REHAB
PLANNING

Neurological

Joint
Function
Neurological

Tissue /
Structural

REHAB PROGRAM
Special
Test

Health /
Systemic

Functional
Movement
Assessment

Athlete Domains
Imaging or
Medical
Tests

High Performance Model

Sports Medicine Assessments

NUTRITION

Sports Medicine Assessments

Cardiovascular
Endocrine
Autonomic
Immune

Technical
Tactical
REHAB

REGENERATION
PHYSICAL CAPACITY