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TC(995).(05).Orthopedics Case No 73. Anterior Cruciate Ligament বা ACL tear

Anterior Cruciate Ligament বা ACL tear — বাংলা নোট

ACL tear হলো হাঁটুর ভিতরের প্রধান ligament Anterior Cruciate Ligament আংশিক বা সম্পূর্ণ ছিঁড়ে যাওয়া। ACL tibia-কে femur-এর সামনে বেশি সরে যাওয়া এবং pivot/rotation instability থেকে রক্ষা করে। তাই ACL ছিঁড়লে হাঁটু “give way” করে, especially খেলাধুলা, দৌড়, jump landing বা sudden direction change করার সময়। AAOS ও NICE অনুযায়ী ACL injury সাধারণত sudden deceleration, pivoting, cutting, jump landing বা twisting mechanism-এর পরে হয়।

1. Definition — সংজ্ঞা

ACL tear = হাঁটুর anterior cruciate ligament-এর partial অথবা complete rupture, যার ফলে হাঁটুর anterior translation ও rotational stability নষ্ট হয়।

Type:

  1. Grade I sprain: ligament stretch, tear নেই/খুব minor।
  2. Grade II partial tear: ligament আংশিক ছিঁড়ে গেছে, laxity থাকে।
  3. Grade III complete tear: ligament সম্পূর্ণ ছিঁড়ে যায়; most clinically significant।

2. Causes / Etiology — কারণগুলো

A. Non-contact injury — সবচেয়ে common

  1. Sudden stop / deceleration
    দৌড়ানোর সময় হঠাৎ থামলে tibia সামনের দিকে shear force পায়, ACL tear হতে পারে।
  2. Pivoting / sudden direction change
    ফুট মাটিতে fixed কিন্তু body ঘুরে গেলে knee valgus + rotation হয়।
  3. Jump থেকে ভুলভাবে landing
    knee inward collapse বা valgus landing করলে ACL strain বেড়ে যায়।
  4. Hyperextension injury
    হাঁটু অতিরিক্ত সোজা হয়ে পিছনের দিকে lock হলে ACL overstretch/tear হতে পারে।

B. Contact injury

  1. Football tackle / direct blow
    হাঁটুর side বা front-এ strong impact হলে ACL tear হতে পারে।
  2. Road traffic accident / fall
    twisting + impact mechanism একসাথে থাকলে ACL, MCL, meniscus একসাথে injury হতে পারে।

C. Risk factors

  1. Football, basketball, handball, kabaddi, volleyball, cricket fielding
    cutting, pivoting, jumping বেশি থাকে।
  2. Female athletes
    wider pelvis, neuromuscular control pattern, landing mechanics, hormonal laxity—এসব কারণে risk বেশি হতে পারে।
  3. Poor hamstring–quadriceps balance
    hamstring weak হলে anterior tibial translation control কমে যায়।
  4. Previous ACL injury বা inadequate rehab
    আগের injury থাকলে reinjury risk বেশি।

3. Pathophysiology — কীভাবে সমস্যা হয়

ACL tear হলে tibia femur-এর তুলনায় সামনে বেশি সরে যেতে পারে এবং knee rotational control কমে যায়। ফলে রোগী হাঁটুতে instability অনুভব করে। ACL tear-এর সাথে অনেক সময় meniscus tear, cartilage injury, bone bruise, MCL injury থাকে। Evidence-based review অনুযায়ী ACL rupture diagnosis-এ history, clinical examination এবং imaging মিলিয়ে সিদ্ধান্ত নেওয়া উচিত, কারণ concomitant meniscus/cartilage/ligament injury common।

4. Symptoms — লক্ষণগুলো

  1. “Pop” sound বা pop অনুভব করা
    injury হওয়ার মুহূর্তে অনেক রোগী হাঁটুর ভিতরে “pop” শুনে/অনুভব করে।
  2. Immediate pain
    injury-এর সাথে সাথে হাঁটুতে তীব্র ব্যথা হয়।
  3. Rapid swelling / haemarthrosis
    কয়েক ঘণ্টার মধ্যে হাঁটু ফুলে যায়; ACL tear-এ joint bleeding হতে পারে।
  4. Knee giving way / instability
    হাঁটু ভেঙে যাচ্ছে বা সরে যাচ্ছে মনে হয়, বিশেষ করে turning/pivoting করলে।
  5. Walking difficulty / weight bearing pain
    রোগী অনেক সময় খেলা চালিয়ে যেতে পারে না, হাঁটতে কষ্ট হয়।
  6. Loss of range of motion
    হাঁটু পুরো ভাঁজ/সোজা করতে সমস্যা হয়।
  7. Joint line tenderness / locking থাকলে
    meniscus tear co-exist করতে পারে।

5. Clinically Diagnosis — clinical diagnosis কীভাবে করবেন

A. History

  1. Injury mechanism: pivot, twist, sudden stop, landing, tackle।
  2. Pop sound ছিল কি না।
  3. swelling কত দ্রুত হয়েছে—২–৬ ঘণ্টার মধ্যে swelling হলে haemarthrosis suspect।
  4. giving way/instability আছে কি না।
  5. locking/catching থাকলে meniscus injury ভাববেন।
  6. previous knee injury/surgery।

B. Physical examination

Important tests:

  1. Lachman test — most useful acute test
    Knee 20–30° flexion করে tibia anteriorly pull করা হয়। Increased anterior translation + soft endpoint = ACL tear suggestive। Medscape notes Lachman is highly sensitive in acute ACL rupture।
  2. Anterior drawer test
    Knee 90° flexion করে tibia সামনে টানা হয়। Acute pain/swelling থাকলে false negative হতে পারে।
  3. Pivot shift test
    ACL deficiency-এর rotational instability ধরতে useful; positive হলে ACL tear খুব strongly suggestive, তবে acute pain/swelling থাকলে করা কঠিন।
  4. Lever sign / Lelli test
    Bedside supportive test; ACL rupture suspect করতে সাহায্য করে।
  5. Associated injury check
    Valgus stress = MCL, varus stress = LCL, posterior drawer = PCL, McMurray/Thessaly = meniscus।

Red flag / urgent ortho referral

  • Locked knee
  • Neurovascular deficit
  • Gross instability / multi-ligament injury
  • Suspected fracture/dislocation
  • Large tense haemarthrosis
  • Athlete needing return-to-sport planning

6. Investigation — specific investigations

  1. X-ray knee: AP + lateral ± skyline/tunnel view
    ACL দেখা যায় না, কিন্তু fracture, tibial spine avulsion, Segond fracture, osteochondral injury exclude করতে লাগে।
  2. MRI knee — investigation of choice
    ACL tear confirm করে এবং meniscus, cartilage, bone bruise, collateral ligament injury দেখায়। Research review notes MRI is a primary imaging study for ACL injury and associated injuries।
  3. Arthroscopy
    Diagnostic হিসেবে এখন routine নয়; therapeutic arthroscopy/reconstruction-এর সময় direct visualization হয়।
  4. KT-1000 / arthrometer
    Objective anterior tibial translation measure করতে পারে, mostly sports medicine setting-এ।
  5. Pre-op tests, যদি surgery লাগে
    CBC, RBS, renal function, coagulation profile, ECG/chest assessment as indicated, anaesthesia fitness।

7. Differential Diagnosis — ACL tear-এর মতো দেখাতে পারে

  1. Meniscal tear
  2. MCL/LCL sprain
  3. PCL injury
  4. Patellar dislocation
  5. Tibial plateau fracture
  6. Osteochondral fracture
  7. Quadriceps/patellar tendon rupture
  8. Acute haemarthrosis from intra-articular fracture

8. Complications — রোগ না ধরলে/ঠিকমতো treat না করলে

  1. Recurrent instability
    হাঁটু বারবার “give way” করলে daily activity ও sports performance কমে যায়।
  2. Meniscal tear
    unstable knee বারবার pivot করলে meniscus ছিঁড়ে যেতে পারে।
  3. Cartilage damage
    repeated abnormal movement cartilage ক্ষতি করে।
  4. Early osteoarthritis
    ACL tear ± meniscal/cartilage injury দীর্ঘমেয়াদে knee OA risk বাড়ায়।
  5. Muscle wasting
    pain ও disuse-এর কারণে quadriceps wasting হয়।
  6. Loss of sports/career limitation
    athlete হলে return-to-sport delay বা failure হতে পারে।
  7. Post-operative complications
    ACL reconstruction করলে infection, DVT, graft failure, stiffness/arthrofibrosis, persistent pain হতে পারে।

9. Treatment / Management — guideline-based

BMJ Best Practice অনুযায়ী initial treatment সাধারণত protection, rest, ice, compression, elevation and analgesia; এরপর patient-এর activity goal, instability, associated injury অনুযায়ী bracing, physiotherapy, activity modification বা ACL reconstruction লাগে।

A. Acute phase — first 48–72 hours

  1. Protection + Rest
    running/jumping বন্ধ।
  2. Ice
    15–20 মিনিট করে দিনে 3–5 বার।
  3. Compression bandage
    swelling কমাতে।
  4. Elevation
    leg heart level-এর উপরে রাখা।
  5. Crutches / knee brace
    painful weight bearing হলে।
  6. Early physiotherapy
    swelling কমানো, full extension regain, quadriceps activation।

B. Conservative treatment — কখন করা যায়

Conservative rehab করা যায় যদি:

  • partial tear বা low-demand patient
  • instability কম
  • sports pivoting demand কম
  • surgery contraindicated
  • patient structured rehab করতে পারবে

BMJ randomized trial-এ young active adults-এর মধ্যে structured rehabilitation with optional delayed reconstruction strategy পাঁচ বছরে early reconstruction strategy-এর চেয়ে worse ছিল না; তাই selected patient-এ initial rehab reasonable।

C. Surgical treatment — কখন ACL reconstruction ভাববেন

  1. Complete ACL tear + recurrent instability
  2. Young active athlete / pivoting sports
  3. Associated repairable meniscus injury
  4. Multi-ligament injury
  5. Patient high-demand occupation
  6. Conservative rehab fail

AAOS 2022 guideline ACL injury management নিয়ে skeletally mature ও immature patient—দুই group-এর জন্য recommendations দিয়েছে।

10. Pharmacological Management — Bangladesh practice list

Important: ACL tear-এ medicine ligament heal করে না। Medicine দেওয়া হয় pain, swelling, inflammation, gastric protection, post-op infection prevention, selected DVT prophylaxis-এর জন্য। নিচের doses adult typical; renal disease, liver disease, pregnancy, peptic ulcer, anticoagulant use, asthma, hypertension, heart disease থাকলে dose/choice change হবে।

1) Paracetamol

  1. Generic name: Paracetamol
  2. Therapeutic category: Non-opioid analgesic / antipyretic
  3. Pharmacological class: Para-aminophenol derivative; central analgesic
  4. Why used: mild–moderate pain control; NSAID contraindicated হলে safer option।
  5. Adult dose: 500–1000 mg PO every 6–8 hours PRN; সাধারণত max 3 g/day safer, physician-supervised max 4 g/day।
  6. Duration: 3–5 days PRN; persistent pain হলে reassess।
  7. Bangladesh available brand examples: Napa 500 mg, Ace 500 mg, Reset 500 mg। MedEx-এ Napa 500 mg Beximco, Ace 500 mg Square, Reset 500 mg Incepta হিসেবে listed।
  8. Side effects: nausea, rash; overdose হলে severe hepatotoxicity।
  9. Interaction: alcohol, liver enzyme inducer, multiple paracetamol-containing cold/pain medicines একসাথে না। MedlinePlus warns too much acetaminophen can cause serious liver damage।

2) Ibuprofen

  1. Generic name: Ibuprofen
  2. Therapeutic category: NSAID analgesic / anti-inflammatory
  3. Pharmacological class: Non-selective COX inhibitor
  4. Why used: acute pain + swelling/inflammation কমাতে।
  5. Adult dose: 400 mg PO after food 2–3 times daily।
  6. Duration: 3–5 days; lowest effective dose।
  7. Bangladesh available brand examples: Flamex 400 mg, Profen 400 mg, Reumafen 400 mg, Inflam 400 mg। MedEx brand listে এগুলো ibuprofen 400 mg হিসেবে আছে।
  8. Side effects: gastritis, dyspepsia, GI bleed, renal impairment, BP rise, bronchospasm in NSAID-sensitive asthma।
  9. Interaction: anticoagulant/warfarin, steroid, other NSAID, SSRI/SNRI, ACEi/ARB + diuretic, alcohol। NHS notes NSAIDs with anticoagulants, steroids, antidepressants and BP medicines can cause problems।

3) Naproxen

  1. Generic name: Naproxen / Naproxen sodium
  2. Therapeutic category: NSAID analgesic / anti-inflammatory
  3. Pharmacological class: Non-selective COX inhibitor
  4. Why used: longer acting pain + swelling control।
  5. Adult dose: 250–500 mg PO twice daily after food।
  6. Duration: 3–7 days; high GI/renal/CV risk থাকলে avoid।
  7. Bangladesh available brand examples: Naproxen 500 mg Tablet, Naprosyn Plus 500 mg + 20 mg combination। MedEx lists Naproxen 500 mg tablet and Naprosyn Plus as NSAID class।
  8. Side effects: gastric pain, ulcer/bleeding, renal dysfunction, fluid retention।
  9. Interaction: anticoagulant, antiplatelet, steroid, SSRI, ACEi/ARB/diuretic, other NSAID।

4) Diclofenac sodium

  1. Generic name: Diclofenac sodium
  2. Therapeutic category: NSAID
  3. Pharmacological class: Non-selective COX inhibitor
  4. Why used: moderate pain and inflammatory swelling control; topical gel local painে useful।
  5. Adult dose:
    • Tablet: 50 mg PO 2–3 times daily after food, or SR 100 mg once daily।
    • Gel 1%: local application 2–4 times daily, intact skin only।
  6. Duration: oral 3–5 days; topical 7–14 days PRN।
  7. Bangladesh available brand examples: Diclofen 50 mg tablet, Diclofen 1% gel, Diclofast SR 100 mg, Diclonil 50 mg/SR 100 mg—MedEx brand listে listed।
  8. Side effects: gastritis, GI bleed, renal impairment, edema, BP rise, CV risk।
  9. Interaction: anticoagulant/antiplatelet, steroid, SSRI, ACEi/ARB + diuretic, methotrexate/lithium toxicity risk।

5) Aceclofenac

  1. Generic name: Aceclofenac
  2. Therapeutic category: NSAID
  3. Pharmacological class: Phenylacetic acid derivative NSAID; COX inhibitor
  4. Why used: soft tissue injury/trauma-associated pain and inflammation।
  5. Adult dose: 100 mg PO twice daily after food।
  6. Duration: 3–5 days; avoid long course without review।
  7. Bangladesh available brand examples: Flexi 100 mg, Movex 100 mg, Avenac 100 mg, Ceclofen 100 mg, Nofenac 100 mg। MedEx lists multiple aceclofenac 100 mg brands including Flexi, Movex, Avenac, Ceclofen, Nofenac।
  8. Side effects: dyspepsia, abdominal pain, GI bleeding, renal impairment, edema।
  9. Interaction: same NSAID interactions—warfarin/DOAC, steroid, SSRI, ACEi/ARB/diuretic, other NSAID।

6) Etoricoxib

  1. Generic name: Etoricoxib
  2. Therapeutic category: NSAID / coxib
  3. Pharmacological class: Selective COX-2 inhibitor
  4. Why used: moderate inflammatory pain; gastric intolerance risk থাকলে sometimes preferred, but CV risk assess করতে হবে।
  5. Adult dose: 60–90 mg PO once daily after food। Severe acute painে 90–120 mg short course physician decision।
  6. Duration: 3–5 days; shortest possible।
  7. Bangladesh available brand examples: Setorib 60 mg/90 mg/120 mg, SB-Eto 60 mg/120 mg। MedEx brand listে etoricoxib brands হিসেবে listed।
  8. Side effects: BP rise, edema, dyspepsia, renal impairment, cardiovascular risk।
  9. Interaction: warfarin/anticoagulant, ACEi/ARB/diuretic, lithium, methotrexate; uncontrolled hypertension/heart diseaseে avoid/very cautious। NICE BNF dose information includes etoricoxib indications and dosing by condition।

7) Tramadol — severe pain only

  1. Generic name: Tramadol hydrochloride
  2. Therapeutic category: Opioid analgesic
  3. Pharmacological class: Centrally acting opioid agonist + monoamine reuptake inhibitor
  4. Why used: severe acute pain বা post-operative pain, যখন paracetamol/NSAID যথেষ্ট না।
  5. Adult dose: 50 mg PO every 6–8 hours PRN; max 400 mg/day। MedEx lists usual 50–100 mg every 4–6 hours, max 400 mg/day।
  6. Duration: 1–3 days only; dependence/sedation risk।
  7. Bangladesh available brand examples: Trado 50 mg, Tranal 50 mg, Tamadol 50 mg, Tramamax 50 mg; injection forms 100 mg/2 ml exist.
  8. Side effects: nausea, vomiting, dizziness, constipation, drowsiness, respiratory depression, seizure risk, dependence।
  9. Interaction: alcohol, benzodiazepines, sedatives, other opioids, SSRI/SNRI/TCA/MAOI—serotonin syndrome/seizure/respiratory depression risk। MedlinePlus warns tramadol with certain medicines can cause serious breathing problems, sedation or coma।

8) Pantoprazole / Esomeprazole / Omeprazole — gastric protection

  1. Generic name: Pantoprazole / Esomeprazole / Omeprazole
  2. Therapeutic category: Anti-ulcerant
  3. Pharmacological class: Proton Pump Inhibitor বা PPI
  4. Why used: NSAID-induced gastritis/ulcer risk কমাতে, especially dyspepsia, previous ulcer, steroid/anticoagulant use, older age।
  5. Adult dose:
    • Pantoprazole 20–40 mg once daily before breakfast
    • Esomeprazole 20–40 mg once daily before breakfast
    • Omeprazole 20 mg once daily before breakfast
  6. Duration: NSAID যতদিন, সাধারণত 3–7 days; high-risk patientে longer physician decision।
  7. Bangladesh available brand examples:
    • Pantoprazole: Pantid 20/40 mg, Pantobex 20/40 mg, Pantonix 20/40 mg, Protocid 20/40 mg।
    • Esomeprazole: Exor 40 mg, EZ-20 20 mg, Progut MUPS 20/40 mg।
    • Omeprazole: Losectil MUPS 20/40 mg, O-20 20 mg, Nuprazol 20 mg।
  8. Side effects: headache, diarrhea/constipation, nausea; long-term useে B12/Mg deficiency, fracture/C. difficile risk।
  9. Interaction: clopidogrel-এর সাথে omeprazole/esomeprazole caution; warfarin/phenytoin monitoring; long-term unnecessary use avoid।

9) Cefazolin — surgery prophylaxis only

  1. Generic name: Cefazolin sodium
  2. Therapeutic category: Antibiotic
  3. Pharmacological class: 1st-generation cephalosporin
  4. Why used: ACL reconstruction surgery-এর perioperative infection prophylaxis; routine ACL tear outpatient pain-এর জন্য antibiotic লাগে না।
  5. Adult dose: 1–2 g IV within 30–60 min before incision; long surgery হলে repeat dose; usually ≤24 hours post-op protocol। MedEx lists perioperative prophylactic cefazolin 1 g IM/IV 30 min–1 hour before surgery and 24-hour postoperative dosing option।
  6. Bangladesh available brand examples: Cefazol 500 mg/1 g, Cefalin 1 g, Zolibac 1 g।
  7. Side effects: allergy, rash, diarrhea, injection site pain, rare anaphylaxis।
  8. Interaction: anticoagulant effect monitoring, nephrotoxic drugs with renal caution; beta-lactam allergy history check।

10) Enoxaparin — selected post-op/high-risk prophylaxis

  1. Generic name: Enoxaparin sodium
  2. Therapeutic category: Anticoagulant
  3. Pharmacological class: Low molecular weight heparin বা LMWH
  4. Why used: ACL reconstruction/immobilization-এর পরে selected high-risk patient-এ DVT prophylaxis; routine সব ACL patient-এ নয়।
  5. Adult dose: common prophylaxis 40 mg SC once daily; renal impairment/bleeding risk অনুযায়ী adjust।
  6. Duration: usually 7–14 days or surgeon protocol/risk-based।
  7. Bangladesh available brand: MedEx lists enoxaparin for prophylaxis of venous thromboembolic disease associated with orthopedic/general surgery।
  8. Side effects: bleeding, bruising, thrombocytopenia, injection site hematoma।
  9. Interaction: aspirin, clopidogrel, warfarin/DOAC, NSAIDs, SSRI/SNRI—bleeding risk বাড়ে।

11. Bangladesh doctors commonly prescribe — practical list

ACL tear patient এ Bangladesh practice-এ সাধারণত symptomatic prescription pattern এমন হতে পারে:

  1. Paracetamol 500 mg — pain control, safest first-line analgesic।
  2. NSAID: Aceclofenac 100 mg / Etoricoxib 90 mg / Diclofenac 50 mg / Ibuprofen 400 mg / Naproxen 500 mg — pain + inflammation/swelling কমাতে short course।
  3. PPI: Pantoprazole 20/40 mg বা Esomeprazole 20/40 mg — NSAID দিলে gastric protection, especially gastritis/ulcer risk থাকলে।
  4. Tramadol 50 mg — severe pain বা post-op pain; short duration only।
  5. Topical diclofenac gel 1% — local pain, oral NSAID avoid করতে চাইলে adjunct।
  6. Cefazolin IV — ACL reconstruction surgery হলে perioperative prophylaxis only।
  7. Enoxaparin SC — surgery/immobilization + high DVT risk থাকলে selected cases।

12. Prevention — কীভাবে ACL injury কমাবেন

  1. Neuromuscular training program
    balance, landing, cutting, agility, hamstring–glute strengthening। Systematic review অনুযায়ী well-controlled neuromuscular training female athletes-এ ACL injury risk roughly 50% কমাতে পারে।
  2. Proper landing technique
    jump landing করার সময় knee inward collapse না করে hip-knee-ankle alignment রাখতে হবে।
  3. Hamstring + glute strengthening
    hamstring tibia anterior translation কমাতে সাহায্য করে।
  4. Core stability training
    trunk control ভালো হলে valgus collapse কমে।
  5. Warm-up: FIFA 11+ type program
    football/field sports-এ structured warm-up useful; FIFA 11+ neuromuscular control, strength, balance, agility improve করার জন্য designed।
  6. Fatigue management
    tired অবস্থায় landing mechanics খারাপ হয়; training load monitor করতে হবে।
  7. Correct footwear + playing surface
    excessive grip বা uneven ground ACL injury risk বাড়াতে পারে।
  8. Previous injury হলে full rehab ছাড়া sports return নয়
    pain-free, full ROM, strength symmetry, hop test, cutting/pivot control confirm করতে হবে।

Overview / Summary

ACL tear হলো হাঁটুর major stabilizing ligament ছিঁড়ে যাওয়া। Typical history: twisting/pivot injury, pop sound, rapid swelling, instability। Diagnosis clinical exam—especially Lachman/pivot shift—এবং MRI দ্বারা confirm করা হয়। Treatment হলো acute RICE/POLICE, analgesia, physiotherapy, activity modification, এবং selected patient-এ ACL reconstruction। Medicine ligament heal করে না; pain/swelling ও perioperative issues manage করে।

Actionable Plan / Steps

  1. Acute injury হলে sports বন্ধ + ice + compression + elevation + brace/crutch।
  2. X-ray দিয়ে fracture/avulsion exclude করুন।
  3. Lachman/pivot shift positive বা instability থাকলে MRI knee।
  4. Meniscus locking, recurrent giving way, athlete/high-demand patient হলে orthopaedic sports surgeon referral।
  5. Pain control: paracetamol first; NSAID short course only if no contraindication।
  6. Early physiotherapy: swelling control, full extension, quadriceps activation।
  7. Return-to-sport only after criteria-based rehab; usually ACL reconstruction-এর পরে অনেক ক্ষেত্রে 9–12 months লাগে।

Reference List

Textbook

  1. Campbell’s Operative Orthopaedics, 14th ed. Knee ligament injuries / ACL reconstruction chapters.
  2. DeLee, Drez & Miller’s Orthopaedic Sports Medicine, latest ed. ACL injury and rehabilitation chapters.
  3. Brukner & Khan’s Clinical Sports Medicine, 5th ed. Acute knee injuries / ACL injury chapter.

Guidelines / Clinical resources

  1. AAOS Clinical Practice Guideline: Management of Anterior Cruciate Ligament Injuries, published 2022.
  2. BMJ Best Practice: Anterior cruciate ligament injury, updated 2025.
  3. NICE CKS: Knee pain—assessment; traumatic causes and examination sections.
  4. Aspetar Clinical Practice Guideline on Rehabilitation after ACL Reconstruction, BJSM 2023.

Peer-reviewed journals with DOI

  1. Frobell RB et al. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ. 2013;346:f232. DOI: 10.1136/bmj.f232.
  2. Petushek EJ et al. Evidence-Based Best-Practice Guidelines for Preventing ACL Injuries in Young Female Athletes. Am J Sports Med. 2019;47(7):1744–1753. DOI: 10.1177/0363546518782460.
  3. Brophy RH et al. Management of Anterior Cruciate Ligament Injuries: Evidence-based Clinical Practice Guideline. JAAOS. 2023. DOI listed by journal sources as 10.5435/JAAOS-D-23-00088.

Md.Rafiqul Islam Lipu,Date:-13-06-2026 Saturday,Time:-03-25-12 Pm

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