ACL management and preventions
Frank Gilroy & Andrew Cunningham
Researched by Christopher Gibson
ACL mechanism of injury
Derrick Rose ACL Knee Injury Michael Owen ACL Rupture
NBA Playoffs Game 1 England vs Sweden 2006 World C2012
Most common injury mechanism:
-Hip internal rotation
-Anterior tibial translation
Ususally lateral blow
Boden BP et al., Mechanisms of anterior cruciate ligament injury.
- Wins Snowboard-Cross gold at Sochi winter Olympics
- 2months after ACL rupture
- 6ft 7, 122Kg
- Centre Washington Wizards (NBA)
- 1999 Autumn tour
- 6 ACL deficient knees in 30man Squad
Simple Gilroy analogy
Return to sport following ACR reconstruction- barriers to return to sport
- Fear – reinjury/ pain/ added financial burden/ fear of playing sport.
- Hesitation & Lack of confidence – Not being able to play at same level as before/ knee wouldn’t perform the same as before.
(Burland et al., 2018 & Tjong et al., 2014)
Grindem et al.’s (2016) study identified that:
Within the first 2 years following ACL-R, 30% of individuals who returned to sports involving jumping, pivoting and hard cutting manoeuvres experienced reinjury, whereas this accounted for only 8% of individuals in other sports.
For every month that RTS was delayed until
9 months post ACL-R, the rate of knee reinjury was reduced by 51%.
More symmetrical quadriceps strength prior to RTS significantly reduced the knee reinjury rate.
A study by Ardern et al. (2014) reviewed 69 articles reporting on 7556 participants who underwent ACL reconstruction surgery and concluded that on average:
81% returned to any sport
65% returned to preinjury level of sport
55% returned to competitive level of sport
Consitencey is key in rehabilitation
QASLS – Herrington et al 2013
- 10 point scoring system with excellent validity against gold standard
A 21-year population-based study by Sanders et al. (2016) stated annual occurrence rate of 68.6 ACL injuries per 100,000 person-years in the USA.
Sanders et al. (2016) also noted peak incidence differences between males and females.
Males 19-25 years old
Females 14-18 years old
ACL INJURIES IN SPORT
Athletes involved in sports that involve cutting and pivoting movements are at a high risk of ACL injuries (Joseph et al., 2013).
Walden et al.’s (2016) study within professional football identified that on average a player at every club would sustain an ACL injury every 2nd season.
Return to play criteria
- Continue activities where instability occurs
- Don’t ignore joint signs ie swelling!
- Increase muscle strength in Core & Hamstrings (Blackburn T.J et al 2013)
- Encourage patients to accept limitations and protect for future
- BALANCE, BALANCE, BALANCE! (Proprioception)
- Underestimate the importance of pre-op preparation: it’s crucial
- Do not brace isolated ACL – Braces prevent hyperextension; NOT ANTERIOR SHEAR (Wilk et al, 2012)
- Understand what has been done and liaise with the surgeon.
- Encourage movement (in particular extension) and weight bearing to prevent adhesions as soon as Strength allows. Tyler et al, (1998)
- Respect objective markers and time-scales equally!
- Use realistic timescales for surgical and non-surgical management. Only God can speed it up!
- Pre-op preparation is as important, if not more important than post-op
Follow a rehabilitation plan
- Always work with the surgeon involved -> The Surgeon is the key
To protect the graft, we must appreciate the ACL’s function and failures
Hamstring & BPB graft tissue is both STRONGER & STIFFER than an intact ACL
So if it is stronger, why are we so protective?
Note: Revascularisation still occurring up to 24 weeks
- Revascularization important in ligamentization process
- Take care not to overload in early stages!
- Allison, G. 2000, “Knee bracing increases thigh muscle atrophy but improves knee function after ACL reconstruction”, Australian Journal of Physiotherapy, Vol. 46, no. 3, pp. 238.
- Brandsson, S., Faxen, E., Kartus, J., Eriksson, B. & Karlsson, J. 2001, “Is a knee brace advantageous after anterior cruciate ligament surgery?”, Scandinavian Journal of Medicine & Science in Sports, Vol. 11, no. 2, pp. 110-114.
- Duthon, V., Barea, C., Abrassart, S., Fasel, J., Fritschy, D. & Ménétrey, J. 2006, “Anatomy of the anterior cruciate ligament”, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 14, no. 3, pp. 204-213.
- Fakuda, T.Y, Fingerhut, D., Coimbra Moreira, V., Ferreira Camarini, P.M., Foloco Scodeller, N., Duarte, A., 2013 “Open kinetic chain exercises in a restricted range of motion after anterior cruciate ligament reconstruction: A randomized controlled clinical trial”, American Journal of Sports Medicine Vol. 41, no. 4, pp. 788.
- Grodski, M. & Marks, R. 2008, “Exercises following anterior cruciate ligament reconstructive surgery: Biomechanical considerations and efficacy of current approaches” Research in Sports Medicine Vol. 16, no. 3, pp.75-96.
- Harvey, A., Thomas, N.P. & Amis, A.A. 2005, “Fixation of the graft in reconstruction of the anterior cruciate ligament”, The Journal of Bone and Joint Surgery.British Volume, Vol. 87, no. 5, pp. 593-603.
- Honl, M., Carrero, V., Hille, E., Schneider, E. & Morlock, M.M. 2002, “Bone-patellar tendon-bone grafts for anterior cruciate ligament reconstruction: An in vitro comparison of mechanical behavior under failure tensile loading and cyclic submaximal tensile loading”, The American Journal of Sports Medicine, Vol. 30, no. 4, pp. 549-557.
- Joint Letter, 1999, “Bracing after ACL surgery provides no long-term benefit in randomized trial”, Joint Letter, Vol. 5, no. 5, pp. 59-59.
- Kartus, J., Stener, S., Köhler, K., Sernert, N., Eriksson, B.I. & Karlsson, J. 1997, “Is bracing after anterior cruciate ligament reconstruction necessary? A 2-year follow-up of 78 consecutive patients rehabilitated with or without a brace”, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 5, no. 3, pp. 157-161.
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- Kousa, P., Järvinen, T.L.N., Vihavainen, M., Kannus, P. & Järvinen, M. 2003, “The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction: Part II: Tibial site”, The American Journal of Sports Medicine, Vol. 31, no. 2, pp. 182-188.
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- Prohaska, D.J., Giffin, J.R. & Harner, C.D. 2001, Comparison of graft choices for ACL surgery [online]. Available at: http://www.drprohaska.com/patienthandouts/ACL%20Graft%20Comparison.pdf [Accessed 15/Nov 2014].
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