ACL rehabilitation

1. MANAGEMENT OF ACL INJURY Presenter :- Dr. CHETHAN. C Moderator :- Dr. DIGANTA BORAH 4/3/2013

2. WHAT TO EXPECT ANATOMY BIOMECHANICS MECHANISIM OF INJURY SIGNS AND SYMPTOMS TREATMENT - CONSERVATIVE - OPERATIVE PREVENTION

3. INTRODUCTION Anterior cruciate ligament (ACL) injuries are common severe traumatic knee injuries Annual incidence 81 per 100,000 persons aged between 10 and 64 years There are an estimated 80,000 to 100,000 anterior cruciate ligament (ACL) repairs in the United States each year. Most ACL tears occur from noncontact injuries. Women experience ACL tears up to nine times more often than men. Past two decades have seen a significant increase in the number of ACL tears in adolescents.

4. ANATOMY

5. ANATOMY ACL originates on the medial wall of the lateral femoral condyle , courses anteriorly and medially across the knee joint and inserts into the tibial articular surface. It consists of two functional bundles, anteromedial (AM) bundle and posterolateral (PL) bundle. Primary role of the ACL is to provide primary anteroposterior stability and secondary rotatory stability

6. Multiple type III collagen–positive fibrils form a collagen fiber that is bundled together and ensheathed by a thin layer of connective tissue named the endotendineum . Bundled fibers + endotendineum subfascicular unit. Subfasciculi are collected in another connective tissue layer called the epitendineum , a much thicker layer than the endotendineum . The ligament is surrounded by the paratenon , which blends in with the epitendineum .

7. ANATOMY Blood supply to the ACL is primarily the middle genicular , inferior medial and lateral genicular arteries. Ligamentous branches form a periligamentous plexus The innervation of the ACL comes from the posterior Nerve supply is from articular nerve, a branch of the tibial nerve Mechanoreceptors have been described on the surface of the ACL , located at the femoral insertion site. They have proprioceptive qualities.

8. Biomechanics The main function of the ACL is restraint of anteroposterior translation of the tibia relative to the femur. It also acts as a secondary restraint to tibial rotation and valgus or varus stress. Older ACLs fail with lower loads than do younger ACLs. With passive range knee extension, the ACL experiences forces of about 100 N, whereas walking produces about 400 N of force. Activities involving acceleration, deceleration, or cutting maneuvers can produce up to 1700 N of force on the ACL. The ACL has a maximal tensile load of 2160 ± 157 N and a stiffness of 242 ± 28 N/mm.

9. It is able to withstand strain of roughly 20% before failing. Important variables that influence ACL strain are the position of the knee and the dynamic interaction of muscle activity. As shown by Beynnon and colleagues, increasing knee extension increases strain on the ACL. Position and length of the bundles vary with changing angles of knee flexion and extension , the ligament has been shown to elongate by up to 3 mm with extension.

10. From 0 to 30 of flexion, the AM bundle shortens from its baseline length. With continued flexion from 30 to70 , the AM bundle lengthens back to its baseline length. Beyond 70 of flexion, the bundle continues to elongate, beyond the baseline length, until it reaches maximal strain at about120 of flexion. The PL bundle is at maximal length and maximal strain when the knee is at full extension. As the knee is flexed, the PL bundle shortens, achieving minimal strain at about 120 .

11. Typically, injury to extra- articular ligaments leads to hematoma, organizes into a fibrinogen mesh, inflammatory response, inflammation wanes, granulation tissue forms and reorganizes into fibrous tissue. Fibrous scar tissue restores function to the ligament. ACL, however, is intraarticular . ACL is encased in only a thin envelope of synovial lining Synovial lining is compromised, bleeding dissipates throughout the joint space and is unable to organize into fibrous tissue. Fibrous scar tissue never occurs, and the ligament remains functionally incompetent.

12. Mechanisms of Injury Common MOI’s Slight knee flexion with/ tibial external rotation /internal rotation at foot strike Excessive valgus , varus , hyperextension or rotation Quads active Skiing Phantom Foot Knee hyperextension in ski boot Valgus rotation Other Sports Sudden d eceleration Abrupt change of direction (fixed foot) Single leg landing

13. Mechanisms of Injury The skier falls back, trying to pull himself up, the boot levers the knee forward in conjunction with a forceful quadriceps contraction Deceleration with change of direction Landing from a jump Sudden stop on extended knee

14. CLASSIFICATION There is no standardized system widely used in the evaluation of ACL injuries. Grade I: A mild injury that causes only microscopic tears in the ACL. Grade II: A moderate injury in which the ACL is partially torn. The knee can be somewhat unstable and can "give away" periodically when you stand or walk. Grade III: A severe injury in which the ACL is completely torn through and the knee feels very unstable.

15. ACL Injury & Open Growth Plates Classification Non - traumatic Congenital ACL absence Post - traumatic - Tibial eminence avulsion (common in age<12) - Mid-substance tear ( common in age>12 ) - Femoral avulsion (rare, repair )

16. Tibial Eminence Avulsions Classification Type I: minimal / no displacement Type II: anterior hinging (1/2 to 1/3 eminence) Type III: avulsed fragment displaced Type IV: avulsed and fragmented

17. EVALUATION A thorough patient history is the initial step to diagnose and treat ACL injuries. Mechanism of injury, initial symptoms, previous injuries, time since injury, and any late sequelae, including reinjuries . Sensations such as popping or tearing at the time of injury. Inability to bear weight on the injured leg and instability or the sensation of the knee “giving out.” Unable to participate after sustaining an acute injury. Post-traumatic swelling of the knee joint which is manifestation of hemarthrosis , seen within 12 hours after injury.

18. Physical Examination and Testing Examinations performed immediately after an injury are more accurate than after the injury response has been initiated. If the examination is delayed and the initial symptoms have manifested, decreasing the accuracy of the examination. Repeat the examination in a few days. Malalignment can be indicative of a fracture or a sign of knee dislocation Depending on the time frame of the examination, an effusion may be detectable.

19. Palpation Swelling To detect injury to surrounding knee structures. Medial and lateral joint line tenderness may in concomitant meniscal or chondral injury. Functional testing. Active and passive range of motion ,check for loss of motion. Factors that may cause loss of motion - pain in the knee - a large effusion, an incompetent extensor mechanism, or a mechanical block.

20. Stability testing (anterior stability, posterior, varus , valgus , and rotational stability). Anterior stability testing Lachman and anterior drawer’s test. Lachman test is performed while the knee is flexed at 20 to 30 . In this position, a manual anterior force is applied to the proximal tibia while the distal femur is stabilized with the opposite hand. Assess the degree of anterior translation of the tibia relative to the femur and in the firmness of the end point at which translation is halted.

21. Compare between the injured and the contralateral normal knee. The degree of translation is categorized in grades of laxity. Grade I laxity describes 1 to 5 mm of increased anterior translation. Grade II laxity is 6 to 10 mm. grade III is more than 10 mm. Arthrometers employed to provide objective instrumented laxity measures of ACL laxity. The KT-1000 (MED metric,San Diego, CA) is the mostly commonly cited device. Anterior drawer test - knee is placed in 90 of flexion, and the foot is held in place throughout the examination.

22. Pivot shift test The test begins with the knee in full extension, and the patient is asked to relax the musculature of the limb being tested. A valgus stress is placed on the tibia, while an axial load and internal rotation are simultaneously applied. The knee is then slowly flexed with these applied forces. During this motion, the lateral side of the plateau subluxates to a greater extent than the medial side. With further flexion, the lateral tibia reduces, producing the pivot shift. This test is graded on the degree of subluxation and reduction of the lateral compartment of the knee, with grade 0 having no detectable shift, grade I having the tibia in a smooth glide during reduction, grade II having an abrupt reduction, and grade III having the tibia momentarily lock in the subluxated position before reduction.

23. IMAGING Plain radiographic imaging plays a primary role in the exclusion of associated injuries in the evaluation of the ACL. Lateral capsular avulsions ( Segond’s fractures ) and tibial eminence avulsion fractures seen in younger patients or those with osteopenia . MRI is a highly useful tool for confirming the diagnosis of ACL disease. It is highly specific and sensitive and is able to provide information on the other intra- articular structures in the knee as well as evaluate both bundles of the native ACL

24. GENDER ISSUSES Female athletes have a 4 to 6 fold greater incidence The reasons for this gender disparity in ACL injuries are likely multifactorial. - anatomic - hormonal - neuromuscular - biomechanical differences Increased activation of the quadriceps relative to the hamstrings (Q/H ratio) as well as decreased ratio of firing of medial to lateral quadriceps and hamstrings.

25. ELDERLY ACL reconstruction for those patients who wish to remain active, Remain involved with high-risk activities “physiologically” young

26. Associated Injuries Knee O’Donoghue coined the phrase “the unhappy triad” in referring to the association of ACL injury with MCL and medial meniscal tears. Lately lateral meniscal tears are more commonly seen in association with combined ACL and MCL injuries.

27. Treatment for ACL injuries Immediately after injury P. R.I.C.E Non surgical treatment Exercise (after swelling decreases and weight-bearing progresses) Braces Surgical treatment

28. BRACES R ange of motion control. FUNCTIONAL BRACE h ave rigid metal supports down the sides of the brace to reduce knee instability following injury.

29. Non surgical Treatment Isolated ACL tears With partial tears and NO instability symptoms With complete tears and NO symptoms of knee instability during low-demand sports who are willing to give up high-demand sports Who do light manual work or live sedentary lifestyles Whose growth plates are still open (children)

30. Non surgical Precautions Modification of active lifestyle to avoid high demand activities Muscle strengthening exercises for life May require knee brace Despite above precautions ,secondary damage to knee cartilage & meniscus leading to premature arthritis

31. Operative Management Knee Early surgical treatment of ACL injury involved attempts at primary repair. Augmentation procedures intra- articular and extra- articular Autogenous reconstruction Thus, both primary repair and augmentation procedures fell from favor.

32. Prosthetic ligament reconstruction devices became popular in the 1980s. Carbon fiber, polylactic acid (PLA)–coated carbon fiber, and polytetrafluoroethylene (PTFE) were all introduced during this period. The most popular device, the Kennedy ligament augmentation device (LAD) introduced in 1980, was a flat 6-mm diamond-braided polypropylene device. A gradual transition has occurred from open reconstructive procedures, to an arthroscopic two-incision technique, to an arthroscopic one-incision technique Timing of Surgery There has been ample debate surrounding the ideal timing of ACL reconstruction surgery.

33. Graft Selection The optimal graft material for ACL reconstruction remains an area of active debate. The ideal graft should have structural properties similar to the native ACL that are present at implantation and persist throughout the “ ligamentization ” process , secure fixation, good biologic incorporation, and minimal donor site morbidity. Autograft ACL graft options include bone–patellar tendon–bone (BPTB), quadriceps tendon, and quadrupled semitendinosus and gracilis hamstring (HS) tendon. Allograft options include quadriceps, Achilles, tibialis anterior or posterior, BPTB, and HS. BPTB is the graft of choice (ease of harvest, comparable structural properties to native ACL, rigid fixation, bone-to-bone healing, and favorable track record, considered the gold standard against which other grafts are compared).

34. Graft Healing Biologic graft healing encompasses both the graft attachment site healing as well as the healing process of ligamentization or graft revascularization and incorporation. Attachment site healing in grafts containing bone, particularly autografts , closely resembles fracture healing with graft bone–to–host bone healing occurring within 6 weeks. Purely soft tissue grafts typically take 8 to 12 weeks to heal into host bone. The process of graft revascularization and incorporation proceeds through well-defined phases starting with an - inflammatory phase

35. Host revascularization, lasts from about day 20 to 3 to 6 months after surgery. Final phase collagen maturation. Allografts proceed at a slower rate, leading to a potentially increased rupture rate.

36. Donor Site Complications and Graft Harvest Although donor site complications are infrequently reported overall, most of the complications arise from autograft BPTB grafts. Patellar fractures, patellar tendon ruptures, localized numbness, and tendonitis, patellar tendon rupture rarerly . Closure of the patellar tendon after harvest may cause shortening of the tendon. Anterior knee pain after BPTB harvest has been reported to occur in up to 50% of cases,

37. Graft Tension Appropriate graft tensioning remains a difficult quantifiable task. Adequate tension is necessary to restore adequate anteroposterior stability at the time of ACL reconstruction, whereas too much tension may lead to graft stretching, fixation failure, and capture of the knee. Multiple variables that affect graft tensioning, knee flexion angle and rotational position of the knee during tensioning and the specific graft type used.

38. GRAFT FIXATION Mechanical fixation to host bone can be categorized as either - direct fixation (interference screws, staples, spiked washers), which compresses the graft against the host bone, - indirect fixation (cross-pin, screw and post, Endo Button), which suspends the graft within a bony tunnel. For BPTB grafts, the most commonly performed and reported fixation is direct fixation using interference screws on both the tibial and femoral sides

39. POST OPERATIVE REHABILITATION: Early range of motion Immediate weight-bearing Early return to sport, in the shortest time possible withoutcompromising the integrity of the surgically reconstructed knee. Rehabilitation protocol for ACL reconstruction has changed dramatically during the past several years. Instead of conservative rehabilitation with limitation of range of motion, delayed weight-bearing (8 to 10 weeks), and delayed return to sports (9 to 12 months) Current ACL reconstruction rehabilitation protocols emphasize immediate ROM, immediate weight-bearing, and earlier return to sports(4 to 6 months)

40. Open and Closed Kinetic Chain Exercise Closed kinematic chain (CKC) exercises are safer than the open kinematic chain(OKC) exercises CKC exercises apply less anteriorly directed forces on the tibia, increase tibiofemoral compressive forces, increase co-contraction of the hamstrings, mimic functional activities more closely than OKC exercises, and reduce the incidence of patellofemoral complications, especially at low knee flexion angles. CKC exercises are defined as those in which the foot is in contact with a solid surface GRF is transmitted to all of the joints in the lower extremity, and muscles spanning all of the joints of the lower extremity are used Squat and leg press.

41. OKC exercises are defined as those in which the foot is not in contact with a solid surface. One segment of the limb is stabilized while the other segment moves freely, and only the muscles spanning the knee are required to perform the exercise. Leg extension machine. Many activities cannot be clearly classified as CKC or OKC. Daily activities like walking, stair climbing, and jumping are combinations of OKC and CKC movements

42. REHABILITATION CONSIDERATIONS Pain and Effusion cause reflex inhibition of muscle activity PRICE principle, protection, including rest, ice, compression, and elevation. Narcotic and anti-inflammatory pain medications Muscle activities like quad sets and ankle pumps can help to reduce swelling by improving venous return muscle stimulation of the quadriceps

43. Cryotherapy Ice packs, ice baths, and continuous flow cooling devices. Lowers joint temperature. Motion Loss of motion is one of the most common complications. common causes include arthrofibrosis , inappropriate graft placement or tensioning. Leads to anterior knee pain, abnormal gait, muscle atrophy, and early degenerative changes of the joint. Usually, the loss of extension is more commonly seen and more poorly tolerated than the loss of flexion.

44. The goal is to achieve full extension right after the surgery and regain 10 degrees of flexion per day. By 7 to 10 days post op the knee should achieve 90 of flexion. Bracing in slight hyperextension, an easy way to ensure full knee extension. Early passive and active range of motion using continuous passive motion machine. Prevention is the key to achieving range of motion. - control of pain and swelling, - early reactivation of quadriceps - patellar mobilization, - early return to weight-bearing

45. Weight-Bearing Weight-bearing was prohibited earlier rehabilitation protocols Current trend is immediate weight-bearing Helps to improve cartilage nutrition, reduce disuse osteopenia , and hasten quadriceps recovery. Muscle Training Issues To prevent muscle atrophy and weakness. Muscle activation and strengthening, voluntary exercises, electrical muscle stimulation, and biofeedback. Electrical stimulation can help to initiate muscle activation , when reflex inhibition can not be overcome in patients who are suffering severe pain and swelling.

46. Quadriceps muscle strength is correlated with good outcomes after ACL reconstruction. Strengthening of the quadriceps is the focus of many rehabilitation programs. Appropriate H- Q ratio. Electrical Muscle Stimulation and Biofeedback Electrical muscle stimulation is used as an adjunct to voluntary exercises in an effort to recover muscle strength after ACL reconstruction. The effectiveness of this method is controversial in the literature.

47. Proprioception Proprioception is defined as the culmination of all neural inputs originating from joints, tendons, muscles, and associated deep tissue proprioceptors. Mechanoreceptors are specialized nerves located in skin, joints, tendon, ligament, and skeletal muscle. After ACL reconstruction, patients continue to have deficits in proprioception and neuromuscular joint control for at least months and as long as 1 year after surgery. It is important to incorporate beginning, intermediate, and advanced proprioceptive training exercises throughout the postoperative rehabilitation protocol.

48. STAGE 1 Begin immediately post op upto 6 weeks Goals Protect graft fixation Control inflammation Achieve full extension and flexion Education Therapeutic excercises Heel slides, quadriceps sets Non weight bearing gastro soleus and hamstring streches Straight leg raises with knee in full extension Isometric quadriceps at 60 and 90

49. STAGE 2 6 to 8 weeks Goals Restore normal gait Maintain full extension and progress with flexion range Graft protection Therapeutic excercises Wall slides 0 to 45 Stationary bike Closed chain terminal extension with resistance tubing Toe raises Balance excercises Hamstring curls Aquatic therapy Weight bearing streches

50. S tage 3 8 weeks to 6 months Goals Achieve full ROM Improve strength, endurance and proprioception Therapeutic exercises Continued flexibility excercises Stairmaster Advanced closed chain(one leg squat, leg press 0 to 50 Proprioceptive excercises (slide boards, Ball excercises with balance activities Progress aquatic therapy- pool runing , swimming

51. S tage 4 6 months to 9 months Goals Achieve progress strength, power, endurance, proprioception To prepare to return to functional activities Therapeutic excercises Continue flexibility and strengething excercises Initiate plyometric program Functional progression walking, jogging, forward and backward running at half and three fourth speed; cutting and cross over Sports specific drills

52. S tage 5 9 months post op Goals Safe return to athletics Maintenance of strength, endurance, proprioception education regarding possible limitations Therapeutic exercises Gradual return to sports Maintenance program

53. PREVENTION Components Of Program Warm up Stretching Agility drills Practice Strength exercises Cool Down Warm up and stretching are to be done at the beginning of practice followed by the agility drills Then, the athlete would be ready for a normal practice session At the conclusion of practice, a brief strengthening session followed by the cool down

54. Warm Up Warm up is designed to get ready for practice activity and to help prevent injury. Set up two markers about 10-20 yards away from each other and have the players perform the following 3 warm up activities about 2 minutes each: Forward jogging- Hip, knee and ankle should be in alignment , the knees are not falling in toward each other , the feet are not moving out to the sides. Side shuffling- maintain hip and knee in bent position and don’t travel standing straight up. Backward jogging-maintain hip, knee, and ankle alignment and not allowing knees to fall inward. They should also stay on their toes and not jog flat footed.

55. Stretching Correct Instructions: Stand on your right leg, bend forward and put your hands on the ground in a V-form. Keep your right leg straight and your right foot flat on the ground. Bend your left leg and place your left ankle across your right calf. Hold this position for 30 seconds. Switch legs and repeat on your left side. Incorrect Things to look for: bending the stance leg, leaning forward in the pushup position, arching the back, or raising up on your toes. Calf Stretch Correct Quadriceps Stretch Instructions : Stand tall with your weight evenly distributed. Bend your left knee, reach behind with your left hand and grab the front of your left ankle. Bring your heel up to your buttock and keep your left knee pointed towards the ground. Keep your left leg close to your right leg. Hold for 30 seconds and repeat on your right side . Incorrect Things to look for : bending at the waist, or letting your knee “wing” out to the side.

56. Hamstring Stretch Instructions: Sit on the ground with your left leg extended out in front. Bend your right knee and place the sole of your shoe on your left inner thigh. Keep your back straight and try to bring your chest to your left knee. Reach towards your left toes and pull them towards your head. Hold for 30 seconds and repeat with the right leg. Things to look for: rounding your back or bouncing. Instructions: Sit on the ground, and spread your legs evenly apart. Keeping your back straight, reach overhead with both hands. Then, slowly reach towards your right foot with both hands. Hold the stretch for 30 seconds and then repeat the stretch on the left side . Things to look for: rounding your back, leaning forward too fast or bouncing Inner Thigh Stretch Hip Flexor Stretch Instructions: Lunge forward leading with your left leg and kneel on your right knee. Rest your left arm on your left thigh, and lean forward with your hips. Keep your balance, reach back for your right ankle and pull your heel to your buttocks. Hold the stretch for 30 seconds and repeat the stretch leading with your right leg forward . Things to look for: maintaining your balance and keeping your hips square with your shoulders.

57. Agility Drills Instructions: While standing on one leg with ball on the ground in front of you, slowly reach down with one hand and touch the ball, then perform using other hand. Repeat 10 times on each side. Things to look for: Do not allow balance knee to fall in towards mid line of body- keep knee in a slightly bent position   Instruction: Stand on one leg and balance while performing soccer kicks with the other or dribbling basketball while balancing. Perform 1-2 minutes each leg. Things to look for: Do not allow balance knee to fall in towards mid line of body- keep knee in a slightly bent position Single Leg Touches Single Leg Sport Specific

58.   Instruction: Stand on one leg and balance while performing soccer kicks with the other or dribbling basketball while balancing. Perform 1-2 minutes each leg.   Things to look for: Do not allow balance knee to fall in towards mid line of body- keep knee in a slightly bent position Single Leg Sport Specific

59.   Instruction: Stand on ground with feet approximately shoulder width-perform a quick squat and then explode into a jump- hold the landing for a 2 count Perform 20 times. Things to look for : When landing make sure to land softly on balls of feet keeping knees slightly bent and pointing straight forward- No landing on heels with knees straight!! Squat Jump With Hold Correct Landing Incorrect landing

60.   Instruction: Stand on ground with feet approximately shoulder width apart- jump into air while bringing knees up toward chest and hitting knees with hands- Be sure to land softly on balls of feet with knees slightly bent- try to bring thighs parallel to ground. Perform 10 times. Things to look for : Off balance landings- should land on balls of feet with knees slightly bent and pointing forward Single Tuck Jump

61.   Instruction: Stand with feet slightly apart- Push off ground with plant leg while moving in a sideways direction landing on opposite foot- hold 2 seconds- repeat with other leg Perform 10 times each leg. Things to look for: Explosion at take off with plant leg making sure knee does not fall in to midline of body and on landing make sure knee stays in a forward direction with a slight bend Lateral Jumps

62. Strength Exercises Front Plank Side Plank   Instruction: Position yourself in a “push-up” start position, with your elbows on the floor in line with shoulders. Tighten your stomach, lift your hips off floor till your legs and upper body are in line with shoulders over elbows. Things to look for: Make sure to keep legs and torso straight. Make sure back is not arched or curved downward. Hold 20 seconds, Repeat 2 times. Instruction: Lie on either side, legs outstretched, lower elbow on floor in line with shoulder. Tighten your stomach muscles, lift your hips off floor until your legs and upper body are in line. Things to look for: Make sure shoulder is positioned over elbow on the floor. Keep legs and torso straight and place upper arm against side. Hold 20 seconds, repeat 2 times each side.

63. Assisted Russian Hamstring Curl   Instruction: Start on knees with arms crossed resting on chest and your partner holding your feet. Keeping your body straight, slowly lower self towards floor and return to upright position. Repeat 20 times. Things to look for: Be sure to tighten your stomach while moving forward and back. Make sure not to arch back when returning to start position.

64. Correct Incorrect Single Leg Calf Raise Things to look for: Be sure to move up and not forward (as shown above in picture 2). Instruction: Stand on one foot and slowly raise up on to toe and then back down. Repeat 10 times each side.

65. Correct Incorrect Instruction: Take large step forward and slowly lower self towards ground keeping your knee directly over your toes. Repeat 10 times each side. Things to look for: Make sure to keep your knee over your toes when performing lunge. Make sure to keep your torso straight when lowering self. Forward Lunge

66. P aediatric ACL INJURY The increased number of pediatric ACL injuries reflects the increased participation seen in youth sports. Most injuries are mid substance ACL tears or tibial avulsion fractures. Femoral avulsion fractures of the ACL attachment are rare. Physical examination should focus on ligamentous instability, patellar instability, and referred pain from the hip. Comparison to the contralateral extremity is critical to rule out ligamentous laxity or congenital absence of the ACL.

67. Type I fractures can be managed with cast immobilization in 20 flexion. Type II fractures can be managed with cast immobilization of ananatomic reduction can be maintained. Type III fractures are generally treated operatively. Treatment of pediatric midsubstance ACL tears is controversial. Nonoperative treatment, however, has led to recurrent instability, pain, and new meniscal and chondral injuries in a high percentage of patients.

68. Operative treatment of pediatric ACL tears, is also controversial. Options include extra- articular reconstructions, intra- articular reconstructions, and combined intra- articular and extra- articular reconstructions. No specific technique has demonstrated superiority. Recently, the most popular techniques have included transphyseal tibial tunnels with an over-the-top femoral placement and transphyseal tibial and femoral tunnels with soft tissue grafts in patients nearing skeletal maturity

69. References Gray's Anatomy - 40th Ed Acland's DVD Atlas of Human Anatomy Campbell_s_Operative_Orthopaedic DeLee and Drezs Orthopaedic Sports Medicine Pub med online articles David IP Orthopedic Rehabilitation, Assessment, and Enablement. Therapeutic excercises 3 rd edn, John v Basmajian DeLisa’s - Physical Medicine Rehabilitation 5 th edn

70. Thank you