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Ligament Tear
Synonyms
ICD-9 Codes
717.83
Chronic disruption of anterior
cruciate ligament
844.2
Acute anterior cruciate ligament
tear
ACL tear
Anterior cruciate insufficiency
Cruciate ligament tear
Internal derangement of knee
Torn cruciate
Definition
Femur
Anterior
cruciate
ligament
Tear
Tibia
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knee shows a
complete anterior
cruciate ligament tear.
Clinical Symptoms
Patients with ACL tears usually report sudden pain and giving
way of the knee from a twisting or hyperextension-type injury.
One third of patients report an audible pop as the ligament tears.
A patient who sustains an ACL tear during athletic activity
usually is unable to continue participating because of pain
and/or instability. The pain increases because an effusion caused
by bleeding into the joint (hemarthrosis) develops rapidly.
As the swelling resolves, the patient temporarily may have no
trouble moving the knee; however, if the tear is left untreated,
recurrent instability develops, particularly with attempts to return
to agility sports involving pivoting, running, or jumping.
Chronic knee instability from an untreated ACL tear can lead to
further meniscal and articular cartilage damage, with resulting
degenerative arthritis.
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Figure 2 Lachman test. A, The knee is flexed approximately 30. The examiner gently pulls the tibia forward
with the medial hand while stabilizing the distal femur with the lateral hand. In a relaxed patient,
increased anterior translation of the tibia (in comparison to the uninjured knee) with a soft end point
constitutes a positive test. B, Diagram showing movement of the tibia relative to the femur.
Tests
The most sensitive test for ACL insufficiency is the Lachman
test, in which the knee is flexed to 30 and the tibia is gently
pulled forward while the femur is stabilized (Figure 2). It is
critical that the patients leg, especially the hamstrings, be
relaxed. Otherwise, an accurate examination cannot be
performed. Because of the subcutaneous location of the medial
tibia, it is easier to grasp the tibia on the medial side (right hand
for right knee, left hand for left knee) while stabilizing the
femur from the lateral side with the opposite hand. If the thigh
is large, the examiner may find it difficult to support the thigh in
one hand. In this situation, the examiner may place his or her
knee under the patients thigh. The examiner uses one hand to
stabilize the patients thigh in this position. The examiners other
hand gently elevates the tibia from the supported femur.
Increased motion of the tibia with no solid end point indicates a
tear of the ACL. The anterior drawer test, performed with the
knee flexed to 90, is negative in 50% of acute ACL tears and
thus is less helpful.
Diagnostic Tests
AP, lateral, and tunnel views of the knee should be ordered for
every patient with a suspected ACL tear. Usually these
radiographs are positive only for an effusion and possibly an
avulsion fracture of the lateral capsular margin of the tibia
(lateral capsular sign or Segond fracture); however, radiographs
are helpful in ruling out other pathology.
MRI is sensitive for detecting ACL tears. It also is extremely
useful for evaluating a knee with an acute effusion.
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Physical Examination
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Differential Diagnosis
Treatment
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Rehabilitation Prescription
The goal of initial treatment of a torn ACL is to control the
inflammation and pain with rest, ice, compression, and elevation
(RICE) of the leg. In addition, maintaining the range of motion
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Exercise Type
Number of
Repetitions/Sets
Muscle Group
Number of Days
per Week
Number of
Weeks
Hamstring curls
(standing)
Hamstrings
20 repetitions/3 sets
4 to 5
3 to 4
Straight-leg raises
Quadriceps
20 repetitions/3 sets
4 to 5
3 to 4
Hip abduction
Gluteus medius
20 repetitions/3 sets
4 to 5
3 to 4
Hip adduction
Adductor group
20 repetitions/3 sets
4 to 5
3 to 4
Gluteus maximus
20 repetitions/3 sets
4 to 5
3 to 4
Wall slides
Quadriceps, hamstrings
20 repetitions/3 sets
4 to 5
3 to 4
Hamstring Curls
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Straight-Leg Raises
Hip Abduction
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Hip Adduction
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Wall Slides
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