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ACL

ACL Injury

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The anterior cruciate ligament (ACL) receives the most injuries then the other ligaments. Injuries of the ACL range from mild such as small tears to severe when the ligament is completely torn.

Epidemiology

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Mountcastle et. al performed a study on gender difference in ACL tears in relationship wih physical activities. The researchers performed an epidemiology study on young athletic populations. Preceding studies have signified that women that participate in the same physical activities as men are more at risk for ACL injuries. The authors hypothesize that the frequency rate for males and females in the athletic and college aged population is the same. The procedures for the study was college graduation classes from 1994-2003 at a major institutions. The players who received a whole tear were examined for apparatus of injury and the type of sport they played when the injury occurred. The authors calculated the accident rate, opinion of danger, gender incidents, class year, and the accident rate differentiating men and women. There was 353 ACL injuries in 10 classes during the span of the study. The researchers calculated a 4 year accident proportion of 3.24 per 100 students for men, and 3.51 for women. Overall, the ACL injury rate not including male only sports was substantial greater in women with an incidence ration of 1.51 (pg 5). Women are more likely to get injured at gymnastics course with an incidence ration of 5.67, with an indoor obstacle course test is 3.72, and 2.42 incidence ratio on basketball. The authors concluded that there is slim gender difference in gender ACL tear. On the other hand, there were significant gender differences ACL injury rates when particular specific sports and physical activites were compared. Also, when male only sports were detached from the whole rate evaluation.

An iconic finding is that women are three times more probable to have an ACL injury than men. The reason is because of the variation of hormone levels. Also, ligament strength of the ACL handles more force in man than in women. Most importantly, there is substantial difference neuromuscular coordination and control in landing, women have less hip and knee flexion. Athletic trainers and team physicians advise female athletes to adapt an ACL conditioning program.

Causes

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Torn ACL’s are most of the time related to high impact sports or when the knee is forced to make sharp changes in movement and during abrupt stops from high speed. These types of injuries are prevalent in soccer, high jump, basketball, and football. The reason most ACL injuries occurred in football is because there is a lot of twisting, turning, and pivoting. The foot is planted all the time which makes the knee vulnerable for injury at any time. The reason is because the foot plants, but the knee still has momentum and can twist. When an external force is going to hit the knee a fast reaction time may not be there to avoid it, especially high heel shoes. ACL tears can also happen among older individuals from a slip and fall and they are seen mostly in people over forty due to wear and tear of the ligaments.

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ACL injury

Injury Types

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Causes on ACL injuries have been ongoing. The center on research has been ground thickness, types of grass, and the types of cleats. There are many ways the ACL can be torn the most prevalent is when the knee is bent too much toward the back and when it goes too far to the side. Tears in the anterior cruciate ligament usually take place when the knee receives direct impact while the leg is in a stable position.

Diagnosis

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An ACL tear can be determined by the an individual if a popping sound is heard after impact, swelling after a couple of hours, severe pain when bending the knee, and when the knee buckles or locks during movement

  • Lachman’s test
   *The knee is flexed at 30 degrees
   *Doctor pull on the tibia to identify frontward motion of the lower leg in comparison to the upper leg. 
   *A knee that has an ACL tear will have a lot of forward motion at the conclusion of the movement
  • Pivot shift test
    *Person lies on one side of the body
    *Knee is extended and internally rotated
    *Doctor applies stress to lateral side of the knee, while the knee is being flexed 
    *A positive test indicates a crash felt at 30 degrees flexion.
  • MRI test
    *Painless procedure
    *The image will indicate the degree of tear
    *Also will indicate if surgery is needed

Symptoms

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A torn ACL is less likely to control the movements of the knee. When tears to the ACL is not repaired it can sometimes cause damage to the cartilage inside the knee because with the torn ACL the tibia and femur bone are more likely to rub against each other. Common symptoms include the following.

  • Swelling occurs around the knee joint.
  • There is a lot of pain around the knee especially with bending or strengthening
  • A loud pop may be heard from the tibia and femur rubbing against each other.
  • Decrease of range of motion
  • The knee can’t bend around 90 degrees or fully extend
  • Loss of strength in the quadriceps
  • The knee totally gives up or tightens, because there is no communication with the muscles to carry on the knee steady.

Treatment

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Immediately after the tear of the ACL, the person should rest it, ice it every fifteen to twenty minutes, produce compression on the knee, and then elevate above the heart; this process helps decrease the swelling and reduce the pain. The form of treatment is determined based on the severity of the tear on the ligament. Small tears in the ACL may just require several months of rehab in order to strengthen the surrounding muscles, the hamstring and the quadriceps, so that these muscles can compensate for the torn ligament.

Conservative Treatment

The types of conservative treatments include short term and long term. During the short term the athlete must use crutches and a detachable splint. Also, the person must use a ice pack to decrease the pain and swelling. Attending current physical therapy sessions is recommended to recover muscular strength and full range of motion. An ACL brace is recommended for the patient because it protects the knee when tripping and falling. The brace also helps resting the knee, and also copes with extending the leg. The person may not return to physical activity until full range of motion and power are recuperated. The long term phase includes the continuance of a knee brace. The quadriceps and hamstrings must be strengthen through weight training. If the athlete returned to sport there has to be a reduction in excessive pivoting. The ACL patient has to be going to physical therapy sessions and using ice packs. The physician may prescribed anti-inflammatory medications.

Surgery

If the tare is severe, surgery may be necessary because the ACL can not heal independently because there is a lack of blood supply going to this ligament. Surgery is usually required among athletes because the ACL is needed in order to perform sharp movements safely and with stability. The surgery of the ACL is usually done several weak after the injury in order to allow the swelling and inflammation to go down. During surgery the ACL is not repaired instead, it is reconstructed using other ligaments in the body. There are three different types of ACL surgery.

  • The first type is the patella tendon-bone auto graft is when the surgeon takes a piece of the patella tendon and uses it to reconstruct the new ACL tendon.
  • The second type is hamstring tendon auto graft this is when the surgeon uses two tendons from the back of the knee and doubles them to become the new ACL tendon.
  • The third type is when tissue is taken from a cadaver to for the new ACL.

Patella tendon-bone auto graft and hamstring auto graft are the most common and preferred because it produce the best results.

Rehab

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After the surgery, rehabilitation is required in order to strengthen the surrounding muscles and stabilize the joint. After one week of surgery on the ACL, a rehabilitation routine is developed with the physical therapist. It is recommended that the patient engage in ten weeks or twenty sessions of physical therapy for complete recovery.

  • A couple of weeks after the surgery the physical therapist are focused on decreasing pain and swelling by improving the range of motion and strengthening muscle activity.
  • The third or fourth week after surgery the physical therapy is focused on promoting joint protection and more exercises are performed during these weeks. Bending and straightening of the knee in the pool along with walking is incorporated into the rehabilitation routine. The stair master in a sitting positions helps strengthen the surrounding muscles of the knee joint. Mini wall squats at a 45 degree angle are important along with Balance activities.
  • During the sixth week, walking or moving from one place to another is the most important. The development of motion among the patient is accomplished through getting the knee to bend from zero to 130 degrees along with single leg mini squats, step ups and downs with a four to eight inch block, and exercises to strengthen the gastrocnemius.
  • The eighth week moderate exercises are performed because the main focus is gaining full range of motion of the knee and this is done by increasing the resistance of previous exercises.
  • The final week of rehabilitation the patient engage in light activities the main focus is on strengthening of the quadriceps and hamstring and mobility

After these ten weeks of rehabilitation, the patient should be able to perform the same activities prior to the injury with the same ease.

Prevention

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ACL injury prevention should be taken sincerely. The best way to prevent an ACL injury is to implement and add warm up drills like jumping and balancing. These drills will induce increase neuromuscular control and conditioning. In turn, muscular reactions will improve thus decreasing the risk of an ACL injury. A warm up program of at least 15 minutes 2-3 times per week is essential in order to prevent an ACL injury. Identifying the causes of the ACL and how painful they are the best way to avoid or escaped a painful experience it is to stretch the ligament before a physical activity. The leg muscles like the quadriceps and hamstrings have to be made stronger.

  • Backward running to warm up the hip extensors and hamstrings
  • One of the fundamental ways to avoid an ACL injury is to not wear shoes that have cleats in contact sports.
  • When a person has already suffered an ACL injury, but wants to return to competitive sports, the best way to prevent another injury is to strengthen the quadriceps and hamstrings.
  • Another way is to change mechanics like pivoting, cutting excessively because it puts extra stress on the knee.
  • Overall, sports like football, soccer, basketball, and other contact sports the risk is always high.
  • The best way is to wear a knee brace.

Stretching

Stretching the quadriceps and hamstrings before an event will also prevent ACL injury because it promotes flexibility, decrease firmness, and increase performance. The muscle stretching has to be done in reps.

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Quaricep Stretching
  • Calf Stretch 1-2 minute of stretching the lower leg muscles. Ankle circles is will stretch the gastrocnemius.
  • Quadriceps- 2-3 minutes of seated butterfly 3 reps of 20 seconds
  • Hamstrings-1 minute of wall sits 2 reps of 30 seconds
  • Inner thigh stretch- 1 minute of knee to chest
  • Hip flexors-2 reps of at least 20 seconds of lunges

References

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