The anterior cruciate ligament (ACL) is one of the key ligaments that help to stabilize the knee joint. It runs diagonally through the centre of the knee joint and attaches to the back of the femur (thigh bone) and to the front of the tibia (shin bone). The function of ACL is to prevent tibia from sliding forward relative to the femur. The ACL also assists with preventing excessive knee extension, knee varus and valgus movements, and tibial rotation. According to Naraghi & White (2016), the ACL is the most commonly reconstructed knee ligament and one of the most commonly injured knee ligaments. An intact ACL will protects the menisci from shearing forces that occur during athletic maneuvers, such as landing from a jump, pivoting, or decelerating from a run (LaBella et al. 2014 ). Common sign and symptoms of ACL tear is usually include a loud “pop” or a “popping” sensation in the knee. A torn ACL is often accompanied by hemarthrosis (bleeding into the joint space) which may be visible as a large tense swelling of the knee (Sports Medicine Australia, 2015). This will cause a person to have severe pain and inability to continue activity, loss of range of motion and feeling of instability or “giving way” with weight bearing.Approximately 70% of ACL tears are as a result of non contact injuries, with 30% caused by a direct impact to the knee. (LaBella et al, 2014). Non contact ACL injuries occur due to the position of the knee, the ground reaction force, and quadriceps loading, and valgus/ varus and rotatory forces on the knee. It usually occur when hips are internally rotated and adducted, tibia are externally rotated, and feet are everted. In contact sports the ACL can be injured when a direct blow is applied to the outside of the knee.The meniscus plays a vital role in protecting the integrity of the knee, with contributions to shock absorption, load transmission, joint nutrition, and stability. meniscal tears are frequently seen in the athletic population either as an isolated finding or in conjunction with ligamentous injuries (Naraghi & White, 2016). Not all meniscal tears are symptomatic or require treatment. It has been shown that meniscal tears may be seen in up to 63% of asymptomatic knees. The mechanism of menisci injury usually due to degenerative or traumatic. Degenerative tears occur as part of progressive wear in the whole joint or as a result of habitual, prolonged squatting. In the older adult, the tear may be due to a natural degeneration of the menisci that occurs with age. The traumatic type of injury is quite common in the athletic setting. Functional instability after anterior cruciate ligament (ACL) injury can be successfully treated with ligament reconstruction. It is important to perform the surgery within 12 months after injury because prolonged time to surgery will increase the risk of medial meniscus injury and decreased repair rate (Chhadia, 2011). Meanwhile the treatment options for meniscal tears fall into three broad categories; non-operative, meniscectomy or meniscal repair (Mordecai et al, 2014). Partial meniscectomy is suitable for symptomatic tears not amenable to repair, and can still preserve meniscal function especially when the peripheral meniscal rim is intact. Meniscal repair shows 80% success at 2 years and is more suitable in younger patients with reducible tears that are peripheral (e.g., nearer the capsular attachment) and horizontal or longitudinal in nature (Mordecai et al, 2014). LITERATURE REVIEWMeniscal injuries commonly occur in conjunction with anterior cruciate ligament (ACL) tears. The association of meniscal tears with ligamentous injuries has been most extensively studied in the setting of ACL tears. Based on a research conducted by Kelly et al. (2012), nearly equivalent incidence of meniscal injury in acute and chronically injured knees. This shows that the medial and lateral meniscus has similar rates of injury associate with ACL deficient injured knee. However, a recent study conducted by Hagino et al. (2015) demonstrated that lateral meniscal tear was commonly associated with acute ACL injury, while medial meniscal tear with chronic ACL injury. Therefore, the lateral meniscus has higher rate of injury in acute ACL injury rather than the medial meniscus.An article by Drogset et al (2006) suggested that early surgical intervention for ACL deficient knee would be beneficial because the knees at an early stage had far less cartilage damage than did knees with late surgery. Besides, a literature review by Snoeker et al. (2013) & Church et al. (2005) has shown a strong evidence for an increased risk for medial meniscal tears was found when time between ACL injury and reconstruction surgery was greater than 12 months. Thus, the ACL reconstruction surgery should be carried out within 12 months of injury to minimize the risk of meniscal tears.Therefore, my case study for this musculoskeletal posting will be discussed about an individual who having ACL reconstruction with meniscus repair due to ACL and meniscus tear. CASE PRESENTATIONSUBJECTIVE ASSESSMENTMrs L is a 32 years old Malay female who was diagnosed with left anterior cruciate ligament (ACL) tear and medial meniscus tear. She was managed operatively and conservatively. The operative done by doctor is arthroscopic ACL reconstruction with medial meniscus repair. The conservative management including medications and refer for physiotherapy. On 13 November 2017, full assessment followed by treatments was carried out to Mrs L in the physiotherapy gym at Physiotherapy Department at International Islamic University Malaysia Medical Center (IIUMMC). The chief complaints was pain at the incision site and posterior of knee especially during bending the knee.. Figure 1 below shows the body chart for anterior and posterior view (red dots indicate the area of pain). For present history, it has been day 6 post athroscopic ACL resonstruction and medial meniscus repair. Operation had ben done on 7th November 2017. Currently, patient was undergo physiotherapy treatment and this is the second visit. Previously patient had history of been kicked by opponent during netball games and cause injury at lateral side of knee in 2015. At that time, pt just seek for traditional treatment. The injury at left knee become worst when she had alleged fall with twisted knee when playing zumba in March 2017. This incident had brought her to IIUMMC for further investigation.Patient has no any medical illness. She took painkiller only when needed. For family history, there are no history of ACL and meniscus tear in her family. For social history, Mrs L was already married and having 3 children. She work as admistrative assistant at Pejabat Tanah Pahang. They stayed at single storey house, no stairs and equipped with sitting toilet. Mrs. L is an active person. She practicing an active lifestyle by involving in zumba, netball and hiking. Mrs. L had done MRI Left knee on 20th April 2017. The findings show there are posterior horn of medial meniscus tear and ACL tear with associated posterolateral corner injury. There is also lateral tilt and translation of patella with tear of the lateral prepatellar fat and suspicious injury of medial patella retinaculum.For pain assessment, the area of pain is at the anterior and posterior of left knee joint. The nature of pain is throbbing pain which has VAS of 4/10. The aggravating factors are bending the knee and when patient want to stand from sitting position. The VAS for aggravating factors increased to 8/10. The ease factor is by applying ice pack at the effected area. The VAS is reduced to 2/10. The severity is high while the irritability is medium. The pain is non specific . It is on and off pain which only on when aggravated. Besides, the functional activities also effected as the patient unable to fully bend the knee. So she has to pray by sitting on the chair. OBJECTIVE ASSESSMENTGenerally, Mrs. L is a moderate size Malay female came to department accompanied by her husband. She walk using crutches with no weight bearing. Patient wear knee braces on her left knee. Patient has normal posture. No muscle wasting seen for bilateral upper and lower limb. Surgical site secured with bandage. Redness and swelling were noted over left knee.On palpation, mild tenderness noted with moderate palpation on left knee. There is increased in warmth also on left knee. For the range of motion (ROM), the left knee flexion is limited with end range pain. Generally patient can perform active full range of motion (AFROM) for both upper limbs and lower limbs. Her muscle power was graded using modified medical research council scale. For both upper limbs was scored 5/5. For lower limbs generally scored 5/5 except for knee flexion and extension with scored 3/5. Patient has an intact sensation. The other tests unable to perform because patient’s left knee is secured with bandage. So the test will be performed on next visit.For outcome measure, Lower Extremities Functional Scales was done to Mrs. L during the assessment. According to Dingemans et al. (2017), the lower extremity functional scale (LEFS) is a well-known and validated instrument for measurement of lower extremity function. For LEFS, patient able to score 16/80 which equivalent to 20 percent. Thus, she has lower score which indicates greater disability of lower limbs. ANALYSISFor physiotherapist impression, firstly is throbbing pain over left knee due to sore of the surgical incision. Secondly, reduced range of motion of left knee flexion due to pain. Thirdly, weakness of quadriceps and hamstring due to lack of activity.Short Term GoalLong Term Goal1. To reduce pain within 1/72. To reduce swelling within 3/71. To optimize functional activities such as praying without pain and limitation3. To improve range of motion within 1/52.4. To improve strength of knee flexor and extensor within 2/52.2. To return back to sport specific activities with no pain. PLAN OF TREATMENTS & INTERVENTIONSFor Mrs. L, a list of treatments was planned to be carried out based on rehabilitation protocol for ACL reconstruction with meniscus repair by Northon Orthopaedic Specialists. Those treatments were ice therapy, isometric strengthening exercise such as static quad exercise, inner range quadriceps, and straight leg raises. Other treatment are gait training, home exercise program, and patient education. Some treatments and its techniques were done to her including:1. Icepackpt in half lying, apply icepack on left knee for 20 minutes. 2. Static quadriceps exercisept in half lying, ask pt to pushing down into the bed with the back of the knee, hold for 10 sec. Do for 10 times for 3 sets.3. Inner range quadricepspt in half lying with a towel rolled under knee, ask pt to gently press the knee straight down into the towel as pt raise the foot. Hold for 10 sec. Do for 10 times for 3 sets.4. patient educationeducate pt the importance of maintaining exs level, educate pt to be consistent to do exs as prescribed, educate pt the correct way of performing the exs 5. Home Exercise Programme (HEP)Teach and ask pt to do strengthening exs (SQE and IRQ exs )at home. Hold 10 sec. Do 10 reps for 3 session per day. Encourage pt to apply icepack at the surgical site after exs for 10-15 minutes.EVALUATION & REVIEWDuring the evaluation after the treatment session ended, patient claimed that he feel better and able to complete all the exercises given. There is no increase in ROM and muscle power but the pain is reduced from VAS: 4/10 to 3/10. Thus, in the next session, review will be done for range of motion, muscle power and muscle girth measurement. Progression of treatments will focus on strengthening, partial weight bearing, and ROM exercise.Next Follow-up: 21 November 2017 No new active complaints from patient. Patient came to physio gym with partial weight bearing and there is no bandage around the knee. The swelling still occur, but only mild swelling. There is also no warmness over left knee. For range of motion, there is increase ROM for left knee from previously. There is also improvement in muscle power of left knee flexor and extensor from 3/5 to 4/5. The patellar mobility for left knee is reduced compared to the right knee. It indicates the stiffness of patella tendon of left knee. For outcome measure, Mrs. L score 20/80 for LEFS equal to 25 percent which indicates a slight improvement in lower limb function. The interventions that had been given to patient included:1. Icepack: patient in long sitting. Apply icepack on left knee for 10 minutes2. static cycling: patient sit on ergometer. Ask patient to cycling for 20 minutes3. gait retraining with partial weight bearing: teach patient to walk using crutches with partial weight bearing4. step ups exercise:patient in standing position while holding the stairs bar. Ask pt to step up by leading with the operated leg and then step down. Make sure patient just put partial weight bearing on operated leg. Repeat exs for 100 times5. Ultrasound: patient in long sitting. Apply ultrsound of 1MHz, 0.8 W/cm2 on anterior knee joint and distal thigh for 5 minutes.6. home exercise programme: Teach and ask pt to do strengthening exs at home 3 times per day. Educate and encourage patient to continue ROM exercise by sliding heel on bed at home minimal 2 times daily At the end of treatments, range of motion of left knee flexion improved from 65 degree to 70 degree of flexion.The number of repetitions and sets given to patient is 10 repetitions for 3 sets. The American College of Sports Medicine (ACSM) recommends that a strength training program should be performed a minimum of two non-consecutive days each week, with one set of 8 to 12 repetitions for healthy adults or 10 to 15 repetitions for older and frail individuals. DISCUSSIONThe discussion will focus on several treatments have been given to Mrs L throughout my posting period at IIUMMC.The first treatment is icepack. In addition to medication, exercises, postsurgical compression wraps and elevation, cryotherapy help to reduce postsurgical pain (Grinsven, 2010). According to Dambros et al. (2012), they said that cryotherapy in the immediate postoperative period in association with an exercise protocol was effective in reducing pain and improve range of motion of the knee in adults submitted to ACL reconstruction surgery, with application time of 20 minutes and carried out twice a day. In my opinion, cold therapy are effective in minimizing postoperative pain and reducing the swelling because cold treatment reduces the blood flow to the injured area thus reducing the risk of pain and swelling.Besides that, isometric strengthening such as static quad exercise and inner range quad also help to regain the muscle control around the operated knee. Grinsven (2010) claimed that :”Without endangering the ACL graft, muscle control can be regained and should be initiated in phase 1 by isometric, closed chain (safe range 0°– 60° ) and open chain (safe range 90°- 40°) exercises without additional weight. In addition, static cycling is one of the treatment that had been given to the patient in order to improve patellar mobility besides improving the knee joint stability. Rissels et al. (2013) said that cycling has an additional impact on balance, over and above what is gained through other physical activity. Thus, cycling may further reduce falls risk even among adults who are already physically active.Gait retraining with partial weight bearing are one of the important treatment that I gave to my patient. Partial weight bearing should be given in early postoperative week. According to Carter (2009) based on the rehabilitation protocol of ACL rereconstruction and meniscus repair, weight bearing should be limited on the operative knee by using crutches for first week post operative. Toe-touch weight bearing only is allowed during this first week. After the first week, full weight bearing is allowed only while wearing the hinged brace locked in full extension (0 degrees). Crutches may be discarded when the knee is comfortable enough to walk with no limp gait. Besides, early weight bearing is also beneficial to reduce the pain and thus reducing the graft laxity (Menski et al., 2012).The next treatment is step ups exercise. Step ups exercise is a closed chain exercise which may help to reduce pain as it put less tension on the knee joint. Adams et al. (2012) claimed that in early post operative phase of ACL reconstruction, treatments incorporate weight-bearing (closed-chain) activities such as wall slides and stepups in pain-free ranges (typically 0°-60°), have been shown to be safe and effective, to possibly place less stress on the healing graft, and to cause less patellofemoral pain. Daniel (2016) also said that:”close knee chain rehabilitation within the first 6 weeks post-surgery might allow for better patellar tracking with minimal stress on the ACL and can help maintain good joint congruency”Besides, I also give therapeutic ultrasound treatment for the patient. Ultrasound is believed to improve range of motion. Morishita et al., (2014) conducted a study and proved that ultrasound affected the sensitivity of sensory receptors such as muscle spindle and high threshold mechanoreceptors in skeletal muscle and this led to the increased ROM. In addition, patient education also had been given to patient. It is important to educate the patient in the rehabilitation process as it may promotes early recovery of the knee function. Menski et al. (2012) claimed that “Education about postsurgical exercises, reasons for limited motion and crutch use and cryotherapy all will help stimulate early functional recover of knee function and help the patient create a realistic image about the rehabilitation process in general”.Furthermore, home exercise programme is vital in order to achieve maximal performance of the exercise. According to Keun (2017), prevention of ACL injuries and rehabilitative exercise training can help to achieve optimal exercise performance while avoiding the risk of sports-related injury.To conclude, further research in this field should focus on selecting the most appropriate treatments method which shown promising results. Rehabilitation following ACL reconstruction should be based on clinical science and the best available evidence. Therefore, research on the effectiveness of various treatment in the rehabilitation of ACL reconstruction and meniscus repair is recommended for the future.