A torn ACL usually occurs as a result of an acute non-contact deceleration injury, forceful hyperextension, or excessive rotational forces about the knee. The ligament may be completely torn, partially torn, or avulsed from its origin or insertion. The ACL is the primary restraint to excessive anterior translation and rotation of the tibia on the femur, therefore complete ACL disruption typically results in dynamic knee instability or inability to respond to quick changes in position. The ACL also contains mechanoreceptors and therefore directly influences the neuromuscular control of the knee. ACL deficiency causes partial deafferentation and alters spinal and supraspinal motor control. The changes in motor control strategy can reveal changes in proprioception, postural control, muscle strength, movement and recruitment patterns.
The ACL starts on the posteromedial aspect of the intercondylar notch on the lateral femoral condyle, inserting broadly onto the articular surface of the tibia, medial to the attachment of the anterior horn of the lateral meniscus. The ACL prevents excessive anterior translation of the tibia on the femur and acts to minimize the tibial rotation and resist valgus/varus forces. ACL receives rich blood supply from middle geniculate artery. The ACL is intra-articular, but extrasynovial. Due to poor intrinsic healing properties of the ACL, it will not heal on its own.
History
● Female: male ratio ranges from 2-8 : 1 ● Incidence of non-contact ACL injuries is greatest in athletes between 15-40 YO ● Noncontact injuries account for up to 70% of injuries, especially in females ● Injuries occur primarily among active people, especially in sports involving cutting, pivoting and decelerating ● In children, falling off of a bike while trying to plant the ipsilateral foot is a common mechanism of ACL avulsion from the tibial eminence ● Audible pop at the time of injury ● Rapid development of hemarthrosis ● Inability to return to play ● Pain ● Feeling of the knee being unstable or buckling with attempted weight-bearing ● History of prior ACL injury
Physical Exam
● Hemarthrosis; if injury is recent ● Chronic ACL tears may or may not have an associated effusion ● Acutely, ROM is impaired; particularly in flexion o May be due to a combination of pain and stiffness from hemarthrosis o May also have an associated bone bruise, meniscal tear or articular cartilage injury ● Tenderness is found at the lateral femoral condyle and lateral tibial plateau ● Lachman test is the most accurate maneuver (most sensitive) for detecting an acute ACL tear o If ACL is intact, firm end point is found o If this does not occur, and there is >2mm of anterior movement compared to the injured knee, the test is positive ● Pivot shift test performs better in chronic tears or under anesthesia o This test is technically difficult, but the best test for dynamic rotatory instability o highest specificity but lacked sensitivity, especially in awake patients ● Anterior drawer is often positive, but is less sensitive and specific o better for diagnosis of chronic injuries than acute but is not sensitive enough for routine use alone
Further Investigations
● Plain radiographs o Often negative o May reveal the lateral capsular sign/Segond fracture (small capsular avulsion off the lateral aspect of the proximal tibia) o Uncommon, but virtually pathognomonic for ACL tear ● MRI o Excellent sensitivity and specificity for ACL tears o Can reveal associated injuries
Intrinsic Risk Factors
● Those with rupture had a significantly greater lateral tibial plateau slope than those without rupture ● Narrow intercondylar notch ● ACL geometry in females ● Foot pronation ● Pelvic tilt ● Generalized joint laxity ● Anterior knee laxity in females ● Menstrual cycle phase o Increased risk of ACL injury in female athletes due to increased ligamentous laxity in the first half of the menstrual cycle during the pre-ovulatory phase. o Oral contraceptive use, in addition to neuromuscular training, may increase dynamic knee stability and lessen the risk of ACL injury secondary to hormonal changes during the menstrual cycle ● Dynamic knee valgus ● Knee flexor/extensor pre-activation in females ● Familial predisposition ● Presence of collagen type I alpha 1 (COL1A1) gene ● Height ● BMI
Extrinsic Risk factors
● A shoe-surface interface that increased ground friction and a position of play that predisposed the athlete to unanticipated sidestepping ● Increased risk of ACL injury in football players who performed on synthetic playing surfaces but, interestingly, no increased risk in soccer players on similar surfaces
Sex Differences
● Small sex-based differences in biomechanics that are unlikely to contribute to the increased injury risk recognized in female athletes o Females were found to land from a jump with: ▪ Increased knee abduction motion, including abduction angle. abduction angular motion, & abduction moment when compared with males ● Some evidence suggesting that unplanned sidestepping can alter knee biomechanics and it may be beneficial to incorporate these tasks into injury prevention programs ● There was weak or null evidence for fatigue and lack of vision affecting knee biomechanics ● Knee biomechanics in females tends to differ from males during tasks related to injury, such as landing from a jump
Associated Injuries
● Meniscal tears o Meniscal symptoms in the face of chronic laxity suggest the need for ACL reconstruction o Meniscectomy without ACL reconstruction only be performed in the presence of a symptomatic, irreparable meniscal lesion and lack of functional instability in an inactive or elderly patient o Intact or repaired menisci were associated with favorable outcomes in ACL-reconstructed knees, while repair of degenerative meniscal tears was not ● Multiligament Tears o greater rate of return to activity with surgery compared with conservative treatment (61% vs 31%) of ACL-MCL injuries ● Other intra-articular Injuries o Bone bruises are often seen on MRI in association with ACL pathology, especially on the lateral femoral condyle and posterior lateral tibial plateau o This pattern of bruising is more suggestive of a multiplanar, valgus-loading ACL injury mechanism (pivot-shift) than hyperextension valgus or varus mechanisms; however, this review did not examine clinical outcomes of bone bruising o Incidence of severe chondral injury in knees with ACL rupture is between 16% and 46%
Non-operative vs Operative
● Non-copers vs Copers o 1/3 of this population does not experience impairment or disability and are referred to as copers o Individuals wishing to return to pivoting sports are best treated with ACL reconstruction regardless of coping ability o Kaplan found objective differences between copers and non-copers that could be identified with screening examinations and specific algorithms. o More research is needed to determine whether copers have better outcomes after non-operative management than non-copers ● Skeletally Immature o Weak evidence for surgical treatment in this population and recommended that the surgeon wait until skeletal maturity for reconstruction if possible o Activity modification and bracing were favored as alternative modalities ● Skeletally Mature o Cochrane review concluded that there was insufficient evidence from previous randomized trials to determine whether operative or non-operative treatment of ACL injuries was more effective in adults o ACL can regain continuity after partial or complete rupture, as seen on MRI after a period of non-operative treatment o Weak association between continuity of the ligament on MRI and clinical stability at follow-up, including functional outcome scores, and complaints o good short- to mid-term prognosis for nonoperatively treated ACL tears, as measured by the Lysholm score and hop-for-distance limb symmetry index. Tegner activity scores revealed that activity levels were reduced by 21% after nonoperative treatment o increased stability at 1 to 10 years after ACL reconstruction compared with nonoperative treatment. However, there was no difference in stability and return to play between operative and nonoperative treatment over the long term ● ACL reconstruction was associated with fewer meniscal injuries and subsequent surgeries than non-operative management o no differences in IKDC scores, Tegner scores, Lysholm scores, and radiographic arthritis between the 2 groups
Graft Choice
● ACL can regain continuity after partial or complete rupture, as seen on MRI after a period of non-operative treatment ● Autografts offer improved outcome scores and greater patient satisfaction compared with allografts, and autografts are preferred in young, active populations ● BPTB autograft is associated with greater improvement in stability compared with HT autograft; however, there is no difference in clinical knee scores and rate of failure ● Anterior knee pain and kneeling pain occur more frequently with BPTB autograft than HT autograft ● Possibly a decrease in quadriceps and hamstring isokinetic muscle strength secondary to patellar tendon and HT harvest, respectively, that may persist for greater than 2 years ● Quad tendon autograft o Quadriceps tendon autografts were associated with good clinical and functional outcomes, decreased anterior knee pain, and greater graft cross-sectional area as compared with BPTB autograft o Quadriceps tendon is a promising graft option; however, the current level of evidence is of poor quality and further studies are required
Postural Control, gait, stance, and proprioception
● At a mean 29-month follow-up, patients with ACLR demonstrated impaired lower limb postural control in both static and dynamic testing ● Differences were most notable with backward perturbation and unstable testing platforms ● Injury to the ACL is related to impaired postural control in both legs, which should be taken into account during rehabilitation ● Proprioception may improve but biomechanical differences in gait may remain for at least 5 years or perhaps permanently after surgery
Arthritis
● Several studies have examined long-term (>8-10 years) radiographic follow-up after ACL reconstruction and reported the prevalence of moderate to severe arthritis at 10 years after ACL reconstruction to be 27.9% and 23%, respectively ● Meniscus injury and meniscectomy are 2 common risk factors of arthritis after ACL reconstruction ● ACL - reconstructed knees and non-operatively treated knees demonstrated a risk of 4.71 times and 2.41 times, respectively, for development of moderate to severe arthritis compared with controls
Partial ACL tears
● Despite good outcomes of partial ACL tears in the medium-term when patients limited sports activity, a positive pivot shift test emerged in 26% of cases, suggesting progression of laxity over time. ● Indications for the reconstruction or augmentation of partial ACL tears are therefore similar to complete ACL tears and include: o Patients with a soft stop on Lachman test o Functional instability o Wish to return to pivot sports
Treatment Options
● Primary prevention 1. Training programs targeting proprioception, neuromuscular control and proper sport-specific technique 2. Results of a systematic review suggest that ACL injury prevention training programs have a substantial beneficial effect in reducing risk of ACL injury, particularly in male athletes 3. Odds ratios favoring participants younger than 18 years versus those older than 18 years, demonstrating a greater prophylactic effect in participants younger than 18 years. 4. Effects of Injury-Prevention Training Programs on Injury Reduction and Performance Enhancement ▪ Although good evidence indicates that multicomponent preventive training programs are effective in reducing ACL injury rates in females, research in males is limited. ▪ Recent meta-analyses of multicomponent preventive training programs suggest that including specific exercises (i.e. strength, proximal control, or core stabilization) may be more effective in reducing ACL injuries, whereas other exercises may be less effective (i.e. balance, static stretching). However, specific exercises for reducing ACL injuries have not been directly compared. Similarly, the role of exercise progression over the course of an injury-prevention program has not been examined. ▪ A growing body of research is addressing the effects of exercise-based injury-prevention programs on biomechanics and neuromuscular control. However, these studies have not consistently investigated programs shown to be effective in reducing the risk of ACL or knee injuries. ▪ The body of research evaluating prospective risk factors for ACL injury remains limited. Thus, it is not yet possible to identify those individuals who should be targeted for ACL injury-prevention interventions ● Secondary prevention 1. Multiple small studies have shown that training programs that develop proper footwork, landing technique, correct body alignment, improved proprioception, strength, fitness and neuromuscular recruitment patterns can decrease the risk of significant knee injury 2. These measures can be used as secondary prevention to minimize the risk of ipsilateral recurrence or contralateral injury 3. A brace is worn initially when an athlete is returning to play after ACL reconstruction, but there is no evidence that it decreases the risk of ACL injury ● Treatment 1. The main goals of treatment for an isolated ACL tear are to alleviate symptoms, restore function, minimize complications 2. Initial treatment consists of protected weight-bearing, rest, ice, compression, elevation and bracing 3. NSAIDs or analgesics may help control pain and swelling, but do not alter the course of the injury ● Physical therapy goals 1. Gentle (pain-free) active ROM exercises can be instituted within the first few days after injury 2. Initial therapy goals include relieving pain and swelling, and re-establishing full ROM 3. Subsequent goals include regaining strength, proprioception and dynamic stability 4. No sound evidence has shown superiority of any one particular rehabilitation program 5. If the patient is not improving as expected or decides on operative management, in most cases nothing is lost with an initial trial of physical therapy 6. However, if the patient experiences recurrent tibiofemoral subluxation episodes, this can lead to meniscal tears and articular cartilage damage. ● Sedentary individuals 1. Low physical demands 2. Are poor surgical candidates 3. Are not interested in pursuing high-level treatment 4. Best treated with home physical therapy exercises, knee bracing and activity modification to minimize risk of instability episodes ● Moderate intensity demands 1. Low to moderate physical activity with relatively low demands for dynamic knee stability 2. Depending on severity of the injury and the specific lifestyle demands, formal physical therapy and customized ACL bracing may work best for this group 3. Modification may also be necessary if they continue to have instability episodes despite this approach ● Intense dynamic demands 1. High activity levels and intense physical demands requiring dynamic knee stability 2. Includes high level athletes in sports that require frequent cutting, pivoting, jumping and deceleration and people who perform heavy manual labor or who work in a setting where knee instability could prove dangerous 3. These patients are best served by surgical reconstruction of the ACL 4. There is evidence to suggest that nonsurgical management may be an appropriate choice for some patients with moderate to high activity levels and that rehab should be considered as a primary treatment in these patients 5. When comparing rehab + early ACL reconstruction with rehab + optional delayed ACL reconstruction, there was no difference in outcomes in young active adults with an acute ACL tear 6. ACL reconstruction can be performed as soon as the swelling has resolved and good ROM is restored 7. Physical therapy can begin within the first few days post-op ● PRP 1. Insufficient evidence to determine the effectiveness of PRP on ACL reconstructions ● Knee Bracing Post-operatively 1. No evidence that braces contribute to pain control, graft stability, ROM, or protection from additional injury 2. Literature shows no added benefit from bracing in the postoperative period ● Continuous Passive Motion 1. Moderate evidence was found for increasing ROM after ACL reconstruction, suggesting no added benefit of CPM compared with standard treatment ● Cryotherapy 1. Cryotherapy was statistically significantly associated with reduced pain but was not significantly associated with ROM or postoperative drainage output 2. Cryotherapy is safe and effective during this short-term postoperative period. However, there were no other significant results. ● (P)Rehabilitation 1. Modifiable factors that may predict the outcome of treatment: ▪ A preoperative extension deficit is a major risk factor for an extension deficit after ACLR ▪ A preoperative deficit in quad strength of >20% has a significant negative consequence for the self-reported outcome 2 years post-ACLR ▪ Pre-habilitation ensures better self-reported knee function up to 2 years post-ACLR ▪ Information about walking with crutches, early post-op exercises and rehab process may improve a patient’s self-efficacy o Use of physical therapy ▪ Lack of high-quality studies and contradictory results; therefore, unclear whether there is a benefit of supervised rehab compared to home-based rehab or no rehab at all ▪ A minimally supervised rehab program may result in successful rehab in specific groups that are highly motivated and live far from a physical therapist ▪ When comparing a 19-week to a 32-week rehab program, there are no differences in terms of laxity, ROM, self-reported knee function, single-leg hop test for distance or isokinetic concentric quad and hamstring strength o OKC vs. CKC Quad exercises ▪ CKC and OKC training can be used for regaining quad strength ▪ After ACLR, OKC exercises can be performed from week 4 post-op in a restricted ROM of 90-45° o Strength and neuromuscular training ▪ Neuromuscular training: training enhancing unconscious motor responses by stimulating afferent signals and central mechanisms responsible for dynamic joint control ▪ These exercises are designed to induce compensatory changes in muscle activation patterns and facilitate dynamic joint stability ▪ Starting eccentric quad training (in CKC) from 3 weeks after ACLR is safe and contributes to a bigger improvement in quad strength than concentric training ▪ Neuromuscular training should be added to strength training to optimize self-reported outcome measurements ▪ Isometric quad exercises are safe from the first post-op week ▪ Immediate weight-bearing does not affect knee laxity and results in decreased incidence of anterior knee pain o Electrostimulation and electromyographic feedback ▪ Electrostimulation, in combination with conventional rehab, might be more effective for improving muscle strength for up to 2 months after ACLR than conventional rehab alone. However, its effect on long-term functional performance and self-reported knee function is inconclusive. ▪ Electromyographic feedback might improve short-term postsurgical pain after ACLR
Return to Play
● An extensive test battery should be used for determining return to play ● Not clear which cut-off point of the leg-symmetry index should be used for strength and hop tests o >90% could be used o In cutting/pivoting sports, >100% is recommended ● Men are 1.4 times more likely to return to their preinjury sport level than women ● BPTB was 1.2 times more likely to return to preinjury sport level than HS ● Rate of return to preinjury play level for non-professional pivoting athletes after ACLR is 65% ● Psychological factors of self-efficacy, locus of control and fear of reinjury have influence on the rehab process and RTP after ACLR ● Risk of reinjuries o The risk of a contralateral ACL rupture (>10%) is higher than the risk of graft re-rupture (~5%) up to 10 years after ACLR or first-time ACL rupture o Altered neuromuscular function and biomechanics (greater hip IR, dynamic knee valgus or less knee flexion during landing) after ACLR could be a risk factor for second ACL injury (graft re-rupture or contralateral rupture)
Post-operative Rehabilitation
● Maintain communication between surgeon and physical therapist ● Goal-based progression: patient can start with the next phase only when specific goals of the previous phase are achieved and confirmed with objective tests ● Should start rehab immediately after ACLR and continue for 9-12 months
● Phase 1: o Goal is to have minimal synovitis/effusion, extension 0°, voluntary quadriceps control, active dynamic gait pattern. o Mobility ▪ Passive mobilization of the patella (both medial-lateral and inferior-superior translations) when there is a mobility deficit. Aim at a good patella mobility (left=right) in four to six weeks. ▪ Active and/or passive knee extension exercises, when there is an extension deficit. If the extension deficit is more than 10°, use heel props. Aim at an extension of 0° in 2-4 weeks. ▪ Heel-slides to improve knee flexion. Aim at 120-130° of flexion in four to six weeks. ▪ In case of increasing knee temperature, effusion or pain as a reaction to mobilizations, evaluate treatment and re-adjust it by enhancing rest periods, using cryotherapy and/or NSAID’s (after consultation of a doctor). Cryotherapy only influences pain, not effusion. o Strength training ▪ Reactivation of the quadriceps: active knee extensions when seated with the legs straightened. Use manual facilitation techniques or electrostimulation when voluntary contraction of the quadriceps is not possible. ▪ Progress from isometric quadriceps exercise (ASLR), to concentric and eccentric exercises provided that the knee does not react with increasing temperature, effusion and/or pain. ▪ Closed kinetic chain quadriceps training (ROM 0-60°), for instance with the leg press, squat or step-up. ▪ BPTB-graft: ● Open kinetic chain quadriceps exercises (for instance leg extension) can be performed with resistance from week 4 in ROM 90-45°. ▪ HS-graft: ● Open kinetic chain quadriceps exercises can be performed without resistance from week 4 in ROM 90-45°. ▪ For both BPTB-graft and HS-graft: ● Increase ROM with 10° every week from week 5: week 5 ROM 90-30°, week 6 ROM 90-20°, week 7 ROM 90-10° to full-ROM in week 8. ● Concentric and eccentric strength training of the gluteal muscles, hamstrings and calf muscles. o Neuromuscular training ▪ Neuromuscular training on two legs, for instance on a wobble-board (only forward-backward movements). Gradually increase difficulty by ● Adding perturbation ● Without the patient being able to see what the physical therapist is doing ● Training on one leg ● Training on an increasingly difficult board ● Training with eyes closed ● Adding tasks (for example: catch and throw a ball or answer a difficult arithmetical problem. ● Encourage a correct quality of performance (e.g. trunk lateroflexion, hip- and knee flexion, dynamic knee valgus and knee-over-toe) during strength training and walking. Use implicit learning techniques instead of explicit learning techniques. o Walking and bicycling ▪ Load the operated leg, if necessary, with crutches. Keep using crutches as long as there is a deviation in the gait pattern. Practice gait in different speeds and on various surfaces. ▪ Start cycling on a hometrainer when knee flexion reaches 100°. Use cycling as a warm-up and mobilization exercise.
o Criteria to start phase 2: ▪ Closed wound ▪ No knee pain with phase 1 exercises (VAS) ▪ Minimal synovitis or effusion ▪ Normal mobility (left=right) of the patellofemoral joint ▪ Knee extension of at least 0° and a 120-130° flexion ▪ Voluntary control of the quadriceps ▪ Active dynamic gait pattern without crutches ▪ Correct qualitative performance of phase 1 exercises. o Abnormal progress if: ▪ The wound doesn’t close or if there is an infection: refer the patient to the surgeon. ▪ There is still a considerable amount of mobility loss in the patella after 6 to 8 weeks. Consult the surgeon because of the risk on infrapatellar contracture syndrome. ▪ The (loaded) extension is less than 0° after 6 to 8 weeks or decreases. Consult the surgeon because of the risk on arthrofibrosis or cyclops lesion. ▪ There is still no voluntary quadriceps control after 6 to 8 weeks. ▪ There is still no dynamic gait pattern.
● Phase 2: o Goal: performing sport specific tasks and physically demanding work without restrictions. o Mobility ▪ Maintain full patellofemoral and tibiofemoral range of motion. o Strength training ▪ Increase closed kinetic chain quadriceps exercises in range of motion, to full ROM in week 8 and add one-legged exercises (for instance lunges or single-leg squats). ▪ Increase open kinetic chain quadriceps exercises in range of motion, to full ROM in week 8. ▪ Note that patients with HS-grafts are allowed to perform open kinetic chain exercises with resistance only from week 12. ▪ Intensify strength training of the gluteal muscles, hamstrings and calf muscles. ▪ Decrease repetitions and increase resistance for all strength exercises. o Neuromuscular training ▪ Increase difficulty of neuromuscular and perturbation training: ● By altering from static to dynamic training ● By altering from forward-backward movements to sideward movements ● By changing predictability, speed, direction and amplitude of the disturbance, for example on a moving platform, with two-legged jumps, including rotations. ● Keep paying attention to a correct quality of performance during strength training, walking and jogging. o Walking and bicycling ▪ Start bicycling outdoors at the start of phase 2. ▪ Add cyclic training to the program, for example cross-trainer or rowing machine. ▪ Start jogging in week 10 to 12, but only if it is performed symmetrically and the knee does not react with increasing temperature, effusion or pain. ▪ Increase cardiovascular training (mainly aerobic). o Sport specific training ▪ Start agility training under supervision of a physical therapist. ▪ Pay attention to a correct quality of performance.
o Criteria to start phase 3: ▪ Correct qualitative performance of phase 2 exercises ▪ Limb Symmetry Index (LSI) >80% for quadriceps and hamstring strength ▪ LSI >80% for a hop test battery, with preference towards the hop test battery of Gustavsson ▪ Complete the IKDC Subjective knee evaluation form and/or KOOS. ▪ Complete a psychological questionnaire (TSK-11, ACL-RSI, K-SES)
● Phase 3: o Goal: return to sport or physically demanding work. o Mobility ▪ Maintain full patellofemoral and tibiofemoral range of motion. o Strength training ▪ Intensify (sport) specific strength training. o Neuromuscular training ▪ Increase difficulty of neuromuscular and perturbation training: ● With single-legged jumps ● With emphasis on sport-specific movement ● Keep paying attention to a correct quality of performance during strength training, walking, jogging, and sport specific exercises. o Walking and bicycling ▪ Enhance bicycling or jogging in intensity and duration. ▪ Built sport specific load concerning energy expenditure (anaerobic lactic, anaerobic alactic, aerobic) and surface (for example soccer field, road, forest or sports hall) o Sport specific training ▪ Increase and intensify agility training. ▪ Restart training at the patient’s own sports club. o Criteria for return to play: ▪ No knee pain at sport specific activities. ▪ No giving way or fear of giving way during sport specific activities. ▪ Active dynamic gait pattern, symmetrical jogging pattern, and correct quality of performance with all sport specific activities. ▪ Limb symmetry index (LSI) >90% for quadriceps and hamstring strength (to exclude quadriceps dominance and leg dominance). ▪ For return to recreational sports and noncontact or non-pivoting sports ● Limb Symmetry Index should be at least 90% and single-leg hop should be 90% on at least 1 maximal or 1 endurance test. Preference towards the hop test battery of Gustavsson, with the single-leg hop-and-hold test added. ▪ For return to competitive, contact, and pivoting sports ● Limb Symmetry Index of 100% and a single- leg hop of 90% (compared with the contralateral limb) on 2 maximal and 1 endurance series ● Drop jump test with observation or video-analysis of the quality of movement, at least measuring trunk lateroflexion, dynamic knee valgus (to exclude ligament dominance) and the knee flexion angle when landing. ● Complete the IKDC Subjective knee evaluation form and/or KOOS. ● Complete a psychological questionnaire (TSK-11, ACL-RSI, K-SES). ▪ The 2 most common reasons for not returning to sport are fear of re-injury and functional problems of the reconstructed knee
References
1. BMJ Best Practice 2. Van Melick et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med. 2016 Dec;50(24):1506-1515 3. Padua et al. National Athletic Trainers’ Association Position Statement: Prevention of Anterior Cruciate Ligament Injury. Journal of Athletic Training 2018;53(1):000–000 4. Anderson et al. A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament. The Orthopaedic Journal of Sports Medicine. 2016. 4(3), 2325967116634074
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Dr. Mike Hadbavny
Victoria Sports Chiropractor FRCCSS(C)
If you are interested in learning more about how chiropractic care can be effective for your particular condition or health goals, contact Dr. Mike Hadbavny at 250-881-7881 today to make an appointment and discover the many benefits of seeing a chiropractor in Victoria BC. Contact us today.