ACL management and prevention

ACL management and preventions

Frank Gilroy & Andrew Cunningham

Researched by Christopher Gibson

ACL mechanism of injury

Derrick Rose ACL Knee Injury                       Michael Owen ACL Rupture
    NBA Playoffs Game 1                          England vs Sweden 2006 World C2012  

70-80% Non-Contact

Most common injury mechanism:
-Hip adduction
-Hip internal rotation
-Knee abduction
-Tibial rotation
-Anterior tibial translation
-Ankle eversion

20-30% Contact

Ususally lateral blow



Boden BP et al., Mechanisms of anterior cruciate ligament injury.

Deficient success?

Pierre Vaultier

  • Wins Snowboard-Cross gold at Sochi winter Olympics
  • 2months after ACL rupture

Dejuan Blair

  • 6ft 7, 122Kg
  • Centre Washington Wizards (NBA)

All Blacks

  • 1999 Autumn tour
  • 6 ACL deficient knees in 30man Squad

Simple Gilroy analogy

Rehabilitation ladder

Rehabilitation guidelines

Post-op bracing

Return to sport following ACR reconstruction- barriers to return to sport

  • Fear – reinjury/ pain/ added financial burden/ fear of playing sport.
  • Hesitation & Lack of confidence – Not being able to play at same level as before/ knee wouldn’t perform the same as before.

(Burland et al., 2018 & Tjong et al., 2014)

Grindem et al.’s (2016) study identified that:
Within the first 2 years following ACL-R, 30% of individuals who returned to sports involving jumping, pivoting and hard cutting manoeuvres experienced reinjury, whereas this accounted for only 8% of individuals in other sports.
For every month that RTS was delayed until
9 months post ACL-R, the rate of knee reinjury was reduced by 51%.
More symmetrical quadriceps strength prior to RTS significantly reduced the knee reinjury rate.

A study by Ardern et al. (2014) reviewed 69 articles reporting on 7556 participants who underwent ACL reconstruction surgery and concluded that on average:
81% returned to any sport
65% returned to preinjury level of sport
55% returned to competitive level of sport

Consitencey is key in rehabilitation

QASLS – Herrington et al 2013

  • 10 point scoring system with excellent validity against gold standard


A 21-year population-based study by Sanders et al. (2016) stated annual occurrence rate of 68.6 ACL injuries per 100,000 person-years in the USA.

Sanders et al. (2016) also noted peak incidence differences between males and females.
Males 19-25 years old
Females 14-18 years old


Athletes involved in sports that involve cutting and pivoting movements are at a high risk of ACL injuries (Joseph et al., 2013).
Walden et al.’s (2016) study within professional football identified that on average a player at every club would sustain an ACL injury every 2nd season.

Return to play criteria



  • Continue activities where instability occurs
  • Don’t ignore joint signs ie swelling!


  • Increase muscle strength in Core & Hamstrings (Blackburn T.J et al 2013)
  • Encourage patients to accept limitations and protect for future
  • BALANCE, BALANCE, BALANCE! (Proprioception)




  • Underestimate the importance of pre-op preparation: it’s crucial
  • Do not brace isolated ACL – Braces prevent hyperextension; NOT ANTERIOR SHEAR (Wilk et al, 2012)


  • Understand what has been done and liaise with the surgeon.
  • Encourage movement (in particular extension) and weight bearing to prevent adhesions as soon as Strength allows. Tyler et al, (1998)
  • Respect objective markers and time-scales equally!


  • Use realistic timescales for surgical and non-surgical management. Only God can speed it up!
  • Pre-op preparation is as important, if not more important than post-op
    Follow a rehabilitation plan
  • Always work with the surgeon involved -> The Surgeon is the key


To protect the graft, we must appreciate the ACL’s function and failures

Graft selection

Hamstring & BPB graft tissue is both STRONGER & STIFFER than an intact ACL

Fixation strength

So if it is stronger, why are we so protective?

Tissue healing


Note: Revascularisation still occurring up to 24 weeks

  • Revascularization important in ligamentization process
  • Take care not to overload in early stages!


  • Allison, G. 2000, “Knee bracing increases thigh muscle atrophy but improves knee function after ACL reconstruction”, Australian Journal of Physiotherapy, Vol. 46, no. 3, pp. 238.
  • Brandsson, S., Faxen, E., Kartus, J., Eriksson, B. & Karlsson, J. 2001, “Is a knee brace advantageous after anterior cruciate ligament surgery?”, Scandinavian Journal of Medicine & Science in Sports, Vol. 11, no. 2, pp. 110-114.
  • Duthon, V., Barea, C., Abrassart, S., Fasel, J., Fritschy, D. & Ménétrey, J. 2006, “Anatomy of the anterior cruciate ligament”, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 14, no. 3, pp. 204-213.
  • Fakuda, T.Y, Fingerhut, D., Coimbra Moreira, V., Ferreira Camarini, P.M., Foloco Scodeller, N., Duarte, A., 2013 “Open kinetic chain exercises in a restricted range of motion after anterior cruciate ligament reconstruction: A randomized controlled clinical trial”, American Journal of Sports Medicine Vol. 41, no. 4, pp. 788.
  • Grodski, M. & Marks, R. 2008, “Exercises following anterior cruciate ligament reconstructive surgery: Biomechanical considerations and efficacy of current approaches” Research in Sports Medicine Vol. 16, no. 3, pp.75-96.
  • Harvey, A., Thomas, N.P. & Amis, A.A. 2005, “Fixation of the graft in reconstruction of the anterior cruciate ligament”, The Journal of Bone and Joint Surgery.British Volume, Vol. 87, no. 5, pp. 593-603.
  • Honl, M., Carrero, V., Hille, E., Schneider, E. & Morlock, M.M. 2002, “Bone-patellar tendon-bone grafts for anterior cruciate ligament reconstruction: An in vitro comparison of mechanical behavior under failure tensile loading and cyclic submaximal tensile loading”, The American Journal of Sports Medicine, Vol. 30, no. 4, pp. 549-557.
  • Joint Letter, 1999, “Bracing after ACL surgery provides no long-term benefit in randomized trial”, Joint Letter, Vol. 5, no. 5, pp. 59-59.
  • Kartus, J., Stener, S., Köhler, K., Sernert, N., Eriksson, B.I. & Karlsson, J. 1997, “Is bracing after anterior cruciate ligament reconstruction necessary? A 2-year follow-up of 78 consecutive patients rehabilitated with or without a brace”, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 5, no. 3, pp. 157-161.
  • Kousa, P., Jarvinen, T.L., Vihavainen, M., Kannus, P. & Jarvinen, M. 2003, “The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction. part I: Femoral site”,Joint Letter, 1999, “Bracing after ACL surgery provides no long-term benefit in randomized trial”, Joint Letter, Vol. 5, no. 5, pp. 59-59.
  • Kousa, P., Järvinen, T.L.N., Vihavainen, M., Kannus, P. & Järvinen, M. 2003, “The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction: Part II: Tibial site”, The American Journal of Sports Medicine, Vol. 31, no. 2, pp. 182-188.
  • McDevitt, E.R., Taylor, D.C., Miller, M.D., Gerber, J.P., Ziemke, G., Hinkin, D., et al. 2004, “Functional bracing after anterior cruciate ligament reconstruction: A prospective, randomized, multicenter study”, The American Journal of Sports Medicine, Vol. 32, no. 8, pp. 1887-1892.
  • Nikolaou, P.K., Seaber, A.V., Glisson, R.R., Ribbeck, B.M. & Bassett, F.H.,3rd 1986, “Anterior cruciate ligament allograft transplantation. long-term function, histology, revascularization, and operative technique”, The American Journal of Sports Medicine, Vol. 14, no. 5, pp. 348-360.
  • Noyes FR, Matthews DS, Mooar PA, Grood ES. 1983  ”The Symptomatic anterior cruciate-deficient knee”. Journal of Bone Joint Surgery; vol65, pp163-73.
  • Prohaska, D.J., Giffin, J.R. & Harner, C.D. 2001, Comparison of graft choices for ACL surgery  [online]. Available at: [Accessed 15/Nov 2014].
  • Reinhardt, K.R., Hetsroni, I. & Marx, R.G. 2010, “Graft selection for anterior cruciate ligament reconstruction: A level I systematic review comparing failure rates and functional outcomes”, Orthopedic Clinics of North America, Vol. 41, no. 2, pp. 249-262.
  • Thomee, R., Kaplan, Y., Kvist, J., Myklebust, G., Risbery, M.A., Theisen, D., 2011, “Muscle Strength and hop performance criteria prior to return to sports after ACL reconstruction”, Knee Surgery Traumatology, Arthroscopy: Official Journal of the ESSKA, Vol.19, no. 11, pp. 1798-1805.
  • Tripp, D.A, Ebel-Lam, A., Birchard, J., Stanish, W. & Brewer, B.W. 2007, “Fear of reinjury, negative affect, and catastrophizing predicting return to sport in recreational athletes with anterior cruciate ligament injuries at 1 year post surgery”, Rehabilitation Psychology, Vol.52, no.1, pp.74-85
  • Woo, S.L., Wu, C., Dede, O., Vercillo, F. & Noorani, S. 2006, “Journal of orthopaedic surgery and research”, Journal of Orthopaedic Surgery and Research, Vol. 1, , pp. 2. 

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