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ANTERIOR CRUCIATE LIGAMENT: A RESEARCH UPDATE ON THE CANCER OF THE KNEE
Luke Bahnmaier MS, ATC/L, OTC
Idaho Athletic Trainer’s Association Summer Symposium
July 26, 2014
Objectives
Epidemiology/Prevalence
Factors influencing ACL injury
Screening programs
Injury prevention programs
Return to play
Things to consider….
Factors Influencing ACL Injury
Anatomic
Hormonal
NeuromuscularModifiable
Non-modifiable
Quasi-modifiable
Anatomic/Developmental Factors
Q-Angle
Static pelvis and hip alignment
Body Mass Index
Knee Joint Laxity
Femoral Notch Width/Height
ACL cross-sectional area/volume/length/ultrastructure
Tibiofemoral Joint Geometry/Morphology Medial and Lateral Posterior Tibial Slope (MTS and PTS) MTS:PTS ratio Tibial Plateau Width (TPW), and Depth
Anatomic/Developmental Factors
Geometric Profile More important than we thought?
Tibial geometry influences hip and knee joint biomechanics and forces during drop-jump and SL land-and-cut tasks (Schultz and Schmitz, 2010, McLean et al., 2010)
Retrospective review of ACL injured patients shows increased posterior tibial slopes, and increased MTS: LTS ratio and shapes (Brandon et al., 2006, Todd et al., 2010)
Tibial sub-chondral bone geometry retrospectively predicted ACL injury (Hashemi et al., 2010)
Similar findings when tibial articular cartilage is mapped (Beynnon et al., 2014)
Anatomic Factors
What We Still Don’t Know….
Large-scale, prospective studies to incorporate all LE alignment and
geometric measures to determine most susceptible profiles Interaction of joint laxity,
tibial geometry, and ACL size on knee joint
biomechanics and ACL load
Is there a practical tool that can be used to
elucidate these measures on the field or in the
training room?
HORMONESResearch suggests
females suffer most ACL injuries during the pre-
ovulatory (follicular) phase, compared to
post-ovulatory (luteal) phase
HORMONESRisk of ACL may be
higher in female athletes with elevated serum relaxin concentration
Sex hormone receptors present on the human ACL potential direct influence on structure
Cyclic variations in knee laxity may result in
altered knee biomechanics throughout the menstrual cycle
Neuromuscular/Biomechanical
Extensively researched
Neuromuscular measures + Biomechanical measures = Neuromechanics
Neuromuscular/Biomechanical
What we THINK we know…
Move differently than….
Neuromuscular/Biomechanical
ACL is loaded by combined sagittal and non-sagittal plane loads, compressive and shear forces
• Knee valgus, internal rotation, and anterior shear forces• “Dynamic Valgus” phenomenon…
Females vs. Males
Females land “stiff”, with less knee and hip flexion• Increased VGR forces…rely on passive restraints to absorb energy
More “quad dominant” landing patterns• Thought to increase anterior shear forces during “stiff” landing
Land with increased knee valgus angles
Screening Programs
What’s out there?• Laboratory 3D Motion Capture Programs
• Expensive laboratory equipment• Very accurate….Very expensive• Not practical for on-field utility
• 2D Video Analysis• Less expensive….• Still time intensive• Still not very practical (You already have ImPACT baselines…now you’re
telling me we need to do a 2D video jumping analysis?!?!?!)
• Landing Error Scoring System (LESS)• Recently developed, easy to implement, based off the BESS test• Still requires video analysis, however
Screening Programs
3D Motion Capture Systems
DARI System, University of Missouri
Brett Hayes
“It allows us to see the small changes in joint angles, joint torques and even muscular instabilities that are difficult — if not impossible — to measure with the naked eye,” said Brett Hayes, a physical therapist and physical rehabilitation manager for the Missouri Orthopaedic Institute. “We’re able to determine where that specific athlete may have a muscular imbalance, a joint imbalance or basically just a weakness that we can see is a detriment to performance or, in worst cases, we can see as potentially leading to injury if we don’t address it.”
Screening Programs
Landing Error Scoring System (LESS)• Valid and reliable (Padua et al., 2009)• Intra- and inter-rater reliability good to excellent (Padua et
al., 2009, Onate et al., 2010)• LESS scores higher in subjects s/p ACL-R (Bell et al., 2014)
Injury Prevention Programs
Multiple studies have shown training programs correlate with changes in biomechanical profiles thought to be “high-
risk”
….So why wouldn’t these programs work to prevent, or reduce, ACL injury?
Short answer:…some have shown promising results, though study
design has been questionable
Long answer:…Talk to Dr. Shea and get his opinion
Injury Prevention ProgramsHewett and colleagues, AJSM, 1999
Sportsmetrics program
6 week pre-season program
1,263 basketball, soccer, and volleyball athletes for 1 season
Injury Prevention Programs
Mandelbaum and colleagues, AJSM, 2005
Prevent injury, Enhance Performance (PEP) Program
Injury Prevention Programs
Gilchrist et al., AJSM 2008
Prevent injury, Enhance Performance (PEP) Program
Prospective, RCT of D-1 collegiate female soccer athletes
Intervention athletes 3.3 times less likely to suffer NC-ACL
Only statistical significance was ACL injuries in practice…
Promising trend in a Level I study…how do we interpret?
Injury Prevention Programs
Pfeiffer and colleagues, JBJS 2006
Boise, Idaho Special!
Prospective, non-randomized, two year study
Program similar to Sportsmetrics, but less time-intensive
Injury Prevention ProgramsThings to Consider…
Retention of movement patterns affected by program duration (Padua et al., AJSM 2012)
Current, commercially available training programs may not affect LE biomechanics for youth athletes under the age of 12 (DiStefano et al., AJSM 2011)
Numbers needed to treat to prevent 1 non-contact ACL injury over one season is estimated at 108 individuals (Sugimoto et al., Br J Sports Med. 2012)
Peripheral and central fatigue, with unanticipated landings, are shown to significantly affect LE biomechanics during landing and cutting….so WHY aren’t we incorporating these into our programs? (McLean and Samorezov 2009, Borotikar 2007, McLean 2007)
Return to SportRyan Mizner PT, PhD
University of Montana
Growing body of evidence showing significant asymmetries in landing biomechanics at time of RTS following ACL-R (Paterno et al., 2011, Di Stasi et al., 2013, Delahunt et al., 2012, Webster et al., 2014)
Asymmetries retrospectively predicted re-rupture or contra-lateral ACL tear upon RTS (Paterno et al., 2010)
Asymmetries present even in those who have passed RTS testing (Di Stasi et al., 2013)Do we need to include 3-D motion analysis in our
RTS criteria?
Return to Sport: Re-injury
Incidence rate of ACL injury following ACL-R 15 times greater than that of controls (Paterno et al., 2012)
• Females 4X more likely to suffer ACL graft rupture, 6X more likely to suffer contralateral ACL injury
29.5% of 78 patients who underwent ACL-R (Paterno et al., 2014)
• Risk of second ACL injury 6 times greater in ACL-R group• Twice as likely to suffer contralateral ACL injury
For patients under 20 s/p ACL-R, odds of suffering ipsilateral and contralateral ACL injury increased 6-, and 3-fold, respectively (Webster et al., 2014)
Clinical Take Home Points
Critically evaluate research, don’t swallow the “Blue Kool-Aid”
Consider modifying current prevention programs to include fatigue, with unanticipated movements
Consider assessing jump-landing movement patterns with return to play, access to 3-D motion
analysis?
Understand that geometric profiles of the tibia may be more important in ACL injury risk than we have
historically thought