ACL INJURY

&
ACL PROTOCOL
MELBOURNE
GUIDELINE
 ANATOMY

Knee is held together by several important ligaments.

One of the most important ligament to the knee stability is the Anterior
Cruciate Ligament (ACL).

Origin:
Medial wall of the lateral femoral condyle
Insertion:
Middle of the intercondylar area.

Function
• Prevent hyperextension of knee
• Prevents excessive tibial medial and lateral rotation, as well
as varus and valgus stresses. 
 The ACL has a tensile strength of 494.6 lbs.

•Two bundles of ACL

•  Anteromedial bundle
•  Insertion is in the anterior part of
the tibial ACL
• Primary restraint against anterior
tibial translation

•2) Posterolateral bundle

• Insertion at the posterior part of tibia
• Stabilize the knee near full
extension. (twisting and pivots)
Biomechanics:

Passive knee extension produces forces along ACL only during last 10 degrees of knee extension

Hyper-extension:
- Posterolateral bundle of the ACL is tight in extension
- 5 degrees of hyperextension, ACL forces range between 50 and 240 newtons;
- Hyperextension of the knee: Forces ACL> PCL

Flexion:
- Anteromedial bundle of the ACL is tight in flexion

Taut
The bulk of the fibers of the anterior cruciate ligament (ACL) is taut in
maximal extension, while that of the posterior cruciate ligament (PCL) is taut
in the intermediate positions and in maximal flexion
 ACL INJURY
An anterior cruciate ligament injury is the over-stretching or tearing of the
anterior cruciate ligament (ACL) in the knee. A tear may be partial or complete

ACL injury is caused

 Excessive force of twisting of the knee joint and
 The hyperextension of the lower leg that make the tibia forward
away from thigh bone.
 The injury also caused by repetitive strain.

In the sport activities that can put stress on the knee is :

• Suddenly changing the position
• Suddenly stop.
• Incorrect landing when jumped
• Pivoting with the foot firmly planted
• Direct blow to the knee, such as a football tackle
 CLINICAL FEATURES
“Pop” sound
produce in the
Unstable knee. Pain
knee during the
time of injury

Loss of range of Inability to bear

Swelling
motion weight

ACL CLASSIFICATION

Mild damaged. ACL is mildly stretched but still

GRADE 1 provides adequate stability to the knee joint.

GRADE 2 Grade 2 injuries involve partial tearing of the ACL

GRADE 3 Complete tears

RICE ACL repair Brace

Rehabilitation
Diagnosis

• MRI
• Ultrasound

Other tests
Anterior Drawer Test:

• Pt. supine on a plinth with their hips flexed to 45 degrees, knees flexed
to 90 degrees, and feet flat on the plinth. The examiner sits on the toes
of the tested extremity to help stabilize it. The examiner grasps the
proximal lower leg, just below the tibial plateau or tibiofemoral joint
line, and attempts to translate the lower leg anteriorly.
• Pain and ant. Translation

Lachman Test:

• Lie the patient supine on the bed. Place the patient's knee in
about 20-30 degrees flexion. The examiner should place one
hand behind the tibia and the other on the patient's thigh.
Therapist pull the tibia anteriorly.
• Pain and ant. translation
 ACL
PROTOCOL
(Melbourne
Guideline)
Pre-op Phase :Injury Recovery & Readiness
for Surgery

Goals:
 Eliminates swelling
 Regain full range of motion
 Regain 90% strengthening the quads and hamstring
compared with the other side
Outcome Test Description Goal
Measure
Passive Bony landmarks: greater trochanter, the lateral femoral 0°
Knee Extension condyle, and the lateral malleolus.

Passive Bony landmarks: greater trochanter, the lateral femoral 125+

Knee Flexion condyle, and the lateral malleolus.

Swelling/ Stroke Test/ Sweep test (Sturgill et al, 2009) Zero

Effusion Zero: No wave produced on downstroke – 1+
Trace: Small wave on medial side with downstroke
1+: Large bulge on medial side with downstroke
2+: Effusion spontaneously returns to medial side after
upstroke
3+: So much fluid that it is not possible to move the effusion
out of the medial aspect of the knee
 Strength Hand held dynamometer testing (Mentiplay et al, 2015) 90%
Quads: Participant seated and hip and knees flexed at compared
90°. Dynamometer placed on the anterior aspect of the with
shank, proximal to the ankle joint. other
Hamstrings: Participant seated and hips and knees flexed side
at 90 deg. Dynamometer placed on the posterior aspect
of the shank, proximal to the ankle joint.

Single Hop Test Single leg hop test (Reid et al, 2007) 90%
Subjects stand on one leg and hop as far forward as compared
possible and land on the same leg. The distance is with
recorded from toe at take-off to heel at landing with a other
tape measure which is fixed to the ground. Two valid side
hops are performed, with the average (mean) of the
2 being used for calculation.

A limb symmetry index is calculated by dividing the mean

distance (cm) of the involved limb by the mean distance
of the non involved limb then multiplying by 100.
MANAGEMENT

 Regular icing of the knee

 Range of motion exercise
 Low impact aerobic exercise such as cycling, elliptical,
swimming.
 Strengthening exercise (Calf raises, Quad sets & straight
leg raise)
Phase 1: Recovery from
Surgery
Goals:
 Get the knee straight (full extension)
 Settle the swelling down to ‘mild’
 Get the quadriceps firing again
MANAGEMENT

 Regular icing of the knee ( RICE )

 Gentle range of motion exercises to improve knee
extension (straightening) and flexion (bending).
 Strengthening exercise(Quad sets, IRQ, straight leg raise,
Hip abduction)
Outcome Test Description Goal
Measure
Passive Bony landmarks: greater trochanter, the lateral femoral 0°
Knee Extension condyle, and the lateral malleolus.
Passive Bony landmarks: greater trochanter, the lateral femoral 125+
Knee Flexion condyle, and the lateral malleolus.

Swelling/ Stroke Test (Sturgill et al, 2009) Zero

Effusion Zero: No wave produced on downstroke – 1+
Trace: Small wave on medial side with downstroke
1+: Large bulge on medial side with downstroke
2+: Effusion spontaneously returns to medial side after
upstroke
3+: So much fluid that it is not possible to move the effusion
out of the medial aspect of the knee

Strength Quadriceps lag test *variation (Stillman, 2004) With the patient 0 to 5 lag
sitting on the edge of a treatment bed, the therapist takes the
relaxed knee into full passive extension. The patient is then
required to maintain full active extension of the knee when the
therapist removes support (within 1 week to 2)
Phase 2 : Strength and neuromuscular
control
Goals:
 Regain most of your single leg balance
 Regain most of your muscle strength
 Single leg squat with good technique and
alignment
Management/ exercise :
 Strengthening exercises
Lunges, step-ups, squats, bridging, calf raises, hip abduction strengthening, core
exercises.
 Balance exercise
 Gait re-education
 Non-impact aerobic exercise
(cycling, swimming, and walking)
Outcome Measure Test Description Goal

Passive Bony landmarks: greater trochanter, the lateral femoral Equal to

Knee Extension condyle, and the lateral malleolus. other side

Passive Bony landmarks: greater trochanter, the lateral femoral 125+

Knee Flexion condyle, and the lateral malleolus.

Swelling/ Stroke Test (Sturgill et al, 2009) Zero

Effusion Zero: No wave produced on downstroke
Trace: Small wave on medial side with downstroke
1+: Large bulge on medial side with downstroke
2+: Effusion spontaneously returns to medial side after
upstroke
3+: So much fluid that it is not possible to move the effusion
out of the medial aspect of the knee

Single Leg > 85%

Bridges compared
with other
side
Hurdle
requirement
= >20
Repeat this action as many times as possible repetitions
touching the assessors hand each time. The test concludes
when the subject is unable to bridge to the original height
(assessors hand) 20cm
Functional Alignment Test Single leg squat test (Crossley et al, 2011) Subjects stand on one leg on a 20cm Good
box with arms crossed. 5 x single leg squats are performed in a slow controlled
manner (at a rate of 2 seconds per squat). The task is rated as “good”, “fair” or
“poor”. For a subject to be rated “good”;
• Maintain balance
• Perform the movement smoothly
• Squat must be to at least 60 degrees
• No trunk movement (lateral deviation, rotation, lateral flexion, forward flexion)
• No pelvic movement (shunt or lateral deviation, rotation, or tilt)
• No hip adduction or internal rotation
• No knee valgus
• Centre of knee remains over center of foot

Calf Raises Single leg calf raises (Hebert et al, 2017) > 85%
Subjects stand on one foot on the edge of the step and compared
perform a calf raise through full range of motion. Calf raises with other
are performed at 1 repetition every 2 seconds. The test side
concludes when subjects are unable to move through full Hurdle
range or slow below the cadence outlined above. requirement
= >20
repetitions

Side Bridge > 85%

Endurance compared
Test with other
side
Hurdle
requirement
The test 30 seconds
(time) ends when the
hips return to the mat.
 Single Leg Single Leg Rise Test (Culvenor et al., 2016 & Thorstensson et > 85%
Squat al., 2004) compared
Subjects sit on a chair (or a plinth) with test leg bent to 90deg, with other
and 10cm from edge of chair. side
With hands folded across the chest, the subject aims to stand Hurdle
up from the sitting position, and sit down as many times as requirement
possible. >10
repetitions
each leg

Balance (Unipedal A
stance test (Springer et (eyes open)
Time ends when;
al, 2007) 43 seconds
• Arms are used (uncrossed)
B
• Use of the raised foot (touches
(eyes closed)
down or other leg) 9 seconds
• Movement of the stance foot (Normative
• 45 secs has elapsed (maximum data for
time) 18-39 year
• Eyes opened on eyes closed trials olds)
Phase 3 Running, Agility and Landings

Goals:
 Attain excellent hopping performance (technique,
distances, & endurance)
 Progress successfully through an agility program
 Regain full strength and balance
Exercise
Return to running, agility, jumping and
hopping, as well as the continuation of a gym
based strength and neuromuscular program.

 Agility drills such as slalom running, shuttle

runs, and ladder drills.
Exercise
 Jumping and hopping exercises usually start
with drills such as scissor jumps and single
hops and progress to box jumps.
Outcome Measure Test Description Goal

Single leg hop test (Noyes et Subjects stand on one leg and hop as far forward as possible >95% compared
al, 1991) and land on the same leg. The average (mean) distance of 2 with other side)
valid hops is recorded with a tape measure which is fixed to
the ground. Measure from toe at take-off to heel at landing.
Triple Hop >95% compared
with other side)

Triple Cross This test is performed on a course consisting of a 15cm >95% compared
Over Hop marking strip on the floor which is 6m long. Subjects are with other side)
Test required to hop three consecutive times on one foot going in
a medial to lateral to medial direction, crossing the strip on
each hop.

Side Hop Subjects stands on test leg with hands behind the back and >95% compared
Test jumps from side to side between two parallel strips of tape, with other side)
placed 40 cm apart on the floor.
Subject jumps as many times as possible during 30sec. The
number of successful jumps performed, without touching the
tape is recorded.
Single Leg Single Leg Rise Test (Culvenor et al., 2016 & Thorstensson et > 95%
Squat al., 2004) compared
Subjects sit on a chair (or a plinth) with test leg bent to 90deg, with other
and 10cm from edge of chair. side
With hands folded across the chest, the subject aims to stand Hurdle
up from the sitting position, and sit down as many times as requirement
possible. >22
repetitions
each leg

Balance Star Excursion Balance Test (Gribble et al, 2012) >95% compared
(Dynamic) with other side)
The star excursion balance test (SEBT) is performed in the
anterior, posterolateral, and posteromedial directions.
A composite score for all 3 directions is obtained for each leg.
A limb symmetry index is then calculated by dividing the
mean distance (in cms) of the involved limb by the mean
distance of the noninvolved limb then multiplying by 100.
Phase 4: Return to Sport

Criteria :
 Successful completion of the Melbourne Return to
Sport Score (>95)
 The athlete is comfortable, confident, and eager to return to
sport, as measured by the ACL-RSI and IKDC
 An ACL injury prevention program is discussed,
Implemented. Performed at least 15 mins prior to each training
session and game.
Phase 5: Prevention of Re-Injury

Components:
• Plyometric, balance, and strengthening exercises
• Must be performed for at least
10mins before every training session and game

Injury preventation programs that

include exercises to help reduce ACL injuries are:
• Sportsmetrics Program
• The 11+ Warm Up
• The PEP Program
• The KNEE Program - Netball Australia
• The FootyFirst Program - AFL
FIFA 11+
FIFA 11+
FIFA 11+
FIFA 11+
FIFA 11+