*** Regretfully, I procrastinated this assignment and was unable to complete the full rough draft by the

deadline listed in the Assignments section of the Blackboard. The progress I have made thus far is shown
below, and follows the general flow outlined in Bloggy 3.2. The references are currently incomplete, and I
intend to normalize the format of these as I continue to construct this paper. As you will undoubtedly
notice, two full sections are currently empty. It is my intention to fill those in as well. Any guidance you,
my Revision Club partners, can provide, will be immensely appreciated. I am sorry to have given you an
incomplete product, but I hope useful criticisms can be made on it in its current form.***

Introduction

The anterior cruciate ligament (ACL) is a band of dense, connective tissue that stretches from the femur
to the tibia. Its main purpose is to resist the anterior translation/medial rotation of the tibia in relation
to the femur. In other words, its function is to stabilize the knee joint and to prevent excessive rotation
or forward movement of the lower leg. [1] Figure 1 (below) shows a diagram of the ACLs location relative
to the rest of the knee anatomy.

Commented [AG1]: I think it might be more aesthetically

pleasing in your final copy to wrap text around pictures so
each section is more contained

Figure 1: ACL and surrounding anatomical features of the knee. [2]

The ACL is one of the most frequently injured structures, especially amongst individuals competing in
high impact sporting activities. [3] These injuries typically result from sudden stops, jumps, or directional
changes, and have a high incidence rate in sports that require those types of movements basketball,
soccer, and skiing, for example. [4] Figure 2 (below) shows the common mechanism of ACL injury as well
as an example of how this injury can occur.
Figure 2: Common mechanism of ACL injury. [5]

Because of its location and surrounding anatomy, the ACL cannot heal on its own. Limited blood flow
makes self-regeneration nearly impossible. Thus, reconstructive surgery is typically required. When
combined with thorough rehabilitative therapy, ACL functionality can return much closer to that of the
unaffected limb than ever before. Commented [AG2]: Something I remember from working
in my PT clinic was how patients frequently became
There are three important aspects of treating ACL injuries: pre-reconstruction care (prehabilitation), stronger and more stable in the affected leg, which in turn
ACLR, and post-reconstruction care (rehabilitation). Prehabilitation consists of strengthening of leg caused slight injury to the healthy leg. Maybe include the
significance of making both legs healthier?
muscles and management of swelling to ease the transition from post-ACLR into rehabilitation. ACLR is
Commented [AG3]: You havent yet used this
typically done by grafting a donor tendon (or a tendon from elsewhere in the patients body) through a
abbreviation so maybe include what it stands for?
procedure called a bone-patellar tendon-bone (BPTB) graft. [6] Rehabilitation is typically supervised by a
physical therapist and is comprised of activities and exercises that: 1) increase range of motion (ROM),
2) increase knee stability, and 3) return strength and functionality as close to non-injured knee as
possible.

Despite the attention that has been paid to ACL reconstruction and (p)rehabilitation over the years,
much is still unknown about the proper timing and protocols for ACL reconstruction (ACLR) and
rehabilitation, respectively. To understand where current knowledge is on the subject, attention must
be paid to the original research that formed the basis of contemporary understanding. Therefore, to
comprehend the perspectives of current experts, the research of those before them must be
appreciated. Commented [AG4]: Very good way of introducing
significance of previous work and seguing into your next
Early ACL Procedures and Protocols section.

In the 1960s through the 1970s, not much was known about how to properly treat anterior cruciate
ligament (ACL) injuries. Originally, very little was done after an ACL injury had been sustained. Athletes
would continue to compete in their respective sport, often exacerbating their ACL injury. They would
also further damage their knee by tearing the meniscus supporting connective tissue that would be
overworked in the absence of a functioning ACL. [7] Diagnostic screens were also poorly constructed and
suffered greatly from a lack of the technology medical professionals have today. In the 60s, a four-
question questionnaire that evaluated the presence/absence of a pop, the ability of the patient to
continue the activity post-injury, swelling status, and maximum swelling time, was the main measure Commented [AG5]: You go into more detail on this
taken to establish the diagnosis of torn ACL. [8] Between limited diagnostic criteria and minimal post- questionnaire in a little bit so maybe to reduce repetition
remove it here?
injury care, ACL injuries in the mid-20th century typically resulted in poor patient outcomes and
increased prevalence of injury-related complications later in life.

In the 1970s, experts began giving ACL injuries the attention they deserved as they rose in prevalence.
Research showed that isolated that is, without comorbidity ACL injuries were far more common Commented [AG6]: Potential keyword?
than previously thought. A study done on patients at the West Point Academy between the ages of 18- Commented [AG7]: Maybe mention the main author of
22 illustrated the early diagnostic methods and treatment protocols used to treat ACL injuries. Figure 3 the study?
(below) shows some statistics on the patients included in this study.

Figure 3: Information regarding ACL injury patients in West Point study. [8]

As mentioned earlier, the diagnostic measures during this time period were limited and very subjective.
The four following questions were combined with patient history to form the basis of the isolated ACL
injury diagnosis the physicians in this study concluded:

1) Did you hear a pop or feel a pop?

2) Were you able to continue participation?
3) Did the knee become grossly swollen?
4) When did it become maximally swollen?

Given appropriate answers to these questions, and relevant past medical history, doctors diagnosed
these patients with torn ACLs. [8] These questions and criteria formed the basis of early ACL injury
diagnosis.

At the time, the repair strategy was equally antiquated. A small suture was run through the ACL that Commented [AG8]: I like this phrasing!
connected it to its origin. This strategy was determined to be unsatisfactory for long-term healing, and
often was passed over as an ACLR option for more effective options such as a synthetic substitution or a
tendon transfer. The procedure utilized in this study caused high rates of further injuries, the most Commented [AG9]: Which study is this referring to? Or
do you mean the procedure in the old treatment method?
common of which were medial meniscus tears which, as mentioned in the introduction, resulted from
increased stress on the meniscus due to lack of a functioning ACL.

Figure 4: Further injuries sustained by patients in the West Point study [8]

Along with the diagnostic criteria, the assessment of recovery at this time was also highly subjective and
difficult to accurately measure. It stood that knowledge of the behavior of the ACL would be paramount
when creating effective prehabilitation, ACLR, and rehabilitation protocols.

A study done in 1984 provided concrete evidence that physicians and physical therapists could use to Commented [AG10]: Again, I would include a name here
base their rehabilitation strategies on. Strain behavior on the ACL given different movements and to make referring back to it more clear.
positions was observed on cadavers. At this time, the typical procedure was to perform the
reconstruction without any prehabilitation and then immobilize the knee for >6 weeks post-
reconstruction. It was understood that any movement could impede the healing of the ACL and result in
deformations that could prevent a return to full functionality. [9]

The figure below is an example of the data that resulted from this study. In it, the different methods of
knee flexion were tested and the strain was quantified given specific degree measurements.

Figure 5: Simulated eccentric and isometric quadriceps tests. [9]

Many such graphs were included in this study, and they all assessed different movement mechanisms
and positions and their effects on ACL strain.
The main conclusion of this study was that strain on the ACL significantly differed depending on the
passive/active nature of knee flexion. This formed as an effective base for physicians and physical
therapists to build their treatment protocols on. Knowing which positions caused the most stress
allowed them to develop a tentative timetable of treatment that prioritized low-stress activities and
movements early on in the rehabilitation protocol, and slowly progressed to the higher stress activities
as the ACL healed.

These major findings from the 1960s-1980s provided medical professionals with a great deal of
knowledge pertaining to ACL injuries and treatment. This information served to progress the general
understanding of these injuries amongst members of this discourse community. As time passed, Commented [AG11]: Good connection!
continuing discoveries revolutionized treatment protocols and improved patient outcomes.

Contemporary ACL Procedures and Protocols

As knowledge of ACL injuries improved, so too did the treatment methods. Despite the impact that the
earlier studies (mentioned above) had on the field, further discoveries would prove these contributions
obsolete and create a new norm of treatment for ACL injuries

The first of the three major aspects of ACL injury treatment to be reassessed was the rehabilitation
portion. As mentioned earlier, medical professionals once believed that at least 6 weeks of immobility
were necessary in order to allow the ACL to heal properly. A study published in the mid 1990s asserted
that a more accelerated rehabilitation schedule not only failed to negative impact patient outcomes, but
actually improved the reported outcomes. [10]

This new accelerated rehabilitation protocol followed the general schedule laid out below:

1st day post-ACLR: full weight-bearing and knee extension

2nd week post-ACLR: 100 ROM and, if achieved, guided exercises and strengthening

4th week post-ACLR: unlimited activities of daily living (ADLs)

8th week post-ACLR: return to light sports if strength scores >70% of uninvolved limb* Commented [AG12]: Would it be useful to explain how
strength is scored? Like comparing reps on the leg press
*Where strength scores were measures used to assess the functionality of the affected limb. between injured and healthy leg.

This study marked the beginning of a trend in which rehabilitation activities moved closer and closer
post-ACLR. It began after it was discovered that patients who were noncompliant with their
rehabilitation protocol (that is, they progressed through their rehabilitation at their own pace and did
not wait the prescribed times for certain activities,) seemed to show better outcomes. It appeared that
the negative effects outlined in the cadaver ACL strain study were not as legitimate as previously
thought. [10]

The following figure shows a detailed post-ACLR rehabilitation schedule posited by an article published Commented [AG13]: Published where?
in 2012. It lists timeframes post-ACLR as well as activities that should be accomplished within the given
periods.
Figure 6: A detailed schedule of rehabilitation activities.

Another important aspect of treatment the timing of the three major components listed earlier was
also critically analyzed during this time period. A meta-analysis of existing information on the subject
was prepared which congregated many different contemporary studies. One such study gathered that
any time fewer than 7 days post-injury or greater than 21 days post-injury showed increased risk of
arthrofibrosis excessive scar tissue buildup that prevented full healing. However, with ACLRs between
8-21 days post-injury, patients showed decreased arthrofibrosis relative to the other listed timeframes.
[12]

It was also discovered that any reconstruction time less than a month post-injury showed decreased
knee ROM early in rehab, but showed no difference after a year of treatment relative to those
reconstructions that occurred greater than a month post-injury.

Further information provided in this analysis indicated that there was a strong correlation between
reconstruction prior to 4 weeks post-injury and arthrofibrosis prevalence. There was also a markedly
strong correlation between preoperative irritation of the knee and arthrofibrosis. These correlations
were so strong that each individually resulted in similar patient outcomes. That is, patients with early
ACLRs showed the same arthrofibrosis levels as patients with late ACLRs and high pre-operative knee
irritation. [12]

Another study highlighted and confirmed the link between meniscal tears and ACLR timing. Patients who
waited greater than a year post-injury for an ACLR showed increased incidence of medial meniscus
tears, supporting the study done in the 1960s which came to the same conclusion.
Links between ACLR timing and age were also drawn, but the general idea behind this analysis was that
there was no general consensus on what constituted an early versus a delayed ACLR. Every study Commented [AG14]: Im a little confused on why age is
mentioned provided their own individual definition of each term (sometimes not even providing a mentioned here do you want to explore the relationship
between patient age and ACLR?
definition for one of them at all) which made comparing studies difficult. It was emphasized that
determining a standard timing vernacular would allow for a less subjective evaluation of the timing of
ACLRs.

Given the volume of information introduced over the past few decades, ACL injury treatment has never
been better. Advancements in prehabilitation, reconstruction, and rehabilitation have proven crucial to
improving patient outcomes. However, many experts agree that further advancements are necessary to
improve upon the general lack of success that these protocols have allowed for.

Future ACL Procedures and Protocols

Despite the wealth of existing knowledge on ACL injuries and treatment, much is still unknown.

Conclusion

Acknowledgements

Dear Eric,

I think you have a great paper in the works! I understand that you didnt get as far as you wanted before
submitting the rough draft so if you intended to already do some of my comments please disregard
them.

One overall suggestion I have is to include a name or journal with each study you mention. I got a little
confused about which one was being referred to. Also Im not quite sure the best manner to resolve this
but I felt like as mentioned earlier in multiple phrases broke the flow. Im not sure if its redundant to
say you referred to it before. I would possibly ask Professor Akbari if such phrases are necessary in a
review article.

Overall I found your paper enjoyable to read and learned a lot! Im interested in knowing what the
future of ACLR might look like. Dont forget to go through the abstract/conclusion checklist we were
given or include your list of keywords! Good luck with your final draft.

Regards,

Abigael

References
1: Matsumoto, H., Suda, Y., Otani, T., Niki, Y., Seedhom, B. B., Fujikawa, K. Roles of the anterior cruciate
ligament and the medial collateral ligament in preventing valgus instability. J Orthop Sci. 2001; 6(1), 28-
32.

2: http://www.theskichannel.com/news/featured/20130217/acls-dont-just-grow-on-knees-what-
tearing-an-acl-is-really-like-part-one/attachment/acl-diagram/

3: Van Den Bogert, A. J., McLean, S. G. ACL injuries: do we know the mechanisms? J Orthop Sports Phys
Ther. 2007; 37(2), A8-9.

4: "Overview - Mayo Clinic". Mayo Clinic. N.p., 2017. Web.

5: http://baptisthealth.adam.com/graphics/images/en/18003.jpg

6: Anterior cruciate ligament recons. Using BPTB autograft to avoid harvest-site

7: Anterior Cruciate Ligament (ACL) Injuries Then And Now. Hospital for Special Surgery. N.p., 2017.
Web.

8: Feagin JA, Curl WW. Isolated Tear of the Anterior Cruciate Ligament: 5-Year Follow-Up Study. The
American Journal of Sports Medicine. 1976; 4(3): 95-100.

9: Biomechanics of ACL rehab and reconstruction

10: Accelerated rehab after ACL reconstruction

11: Current concepts for ACL recon: a criterion-based

12: ACL Reconstruction: Its All About Timing