Anterior cruciate ligament injury

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Anterior cruciate ligament injury is when the anterior cruciate ligament (ACL) is stretched, partially torn, or completely torn. The most common injury is total tear. Symptoms include pain, the sound of an eruption during injury, knee instability, and joint swelling. Swelling usually appears within a few hours. In about 50% of cases, other structures of the knee such as the surrounding ligaments, cartilage, or meniscus are damaged.

The underlying mechanism often involves rapid change in direction, abrupt stop, landing after the jump, or direct contact to the knee. This is more common in athletes, especially those who participate in alpine skiing, soccer, soccer, or basketball. Diagnosis is usually done by physical examination and is sometimes supported by magnetic resonance imaging (MRI). Physical examination will often show tenderness around the knee joint, decrease the range of knee movement, and increase joint laxity.

Prevention is by neuromuscular training and core reinforcement. Treatment recommendations depend on the desired level of activity. In those with low future activity levels, non-surgical management including bracing and physiotherapy may be sufficient. In those with high activity levels, surgical repair through anterior cruciate ligament reconstruction antroscopy is often recommended. This involves replacement with a tendon taken from another area of ​​the body or from a corpse. After rehabilitation surgery involves slowly extending the range of joint motion, and strengthening the muscles around the knee. Surgery, if recommended, is generally not done until the initial inflammation of the injury has been resolved.

Approximately 200,000 people are affected per year in the United States. In some sports, women have a higher risk of ACL injury, while in others, both sexes are equally affected. Many people with complete tears that do not receive surgery can not play sports, and can develop osteoarthritis.

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Signs and symptoms

When an individual has an ACL injury, they tend to hear "pop" in their knees followed by pain and swelling. They may also experience instability in the knee after they continue walking and other activities, because the ligaments can no longer stabilize the knee joint and keep the tibia from sliding forward.

The reduced range of knee motion and pain along the joint line is also a common sign of acute ACL injury. Pain and swelling can disappear by itself; However, the knee will remain unstable and return to exercise without treatment can cause further damage to the knee.

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Cause

ACL injuries are most likely to occur in the following situations:

• Change directions quickly (also known as "truncation")
• Land from an awkward jump
• Suddenly paused while running
• Direct contact or knee-jerk impact (e.g., during soccer or motor vehicle crashes)

These movements cause the tibia to shift away from the femur quickly, placing strain on the knee joint and potentially causing the ACL to rupture.

Women excellence

Women athletes are two to eight times more likely to tense their ACLs in sports that involve cutting and jumping than men who play the same particular sport. NCAA data has found a relative injury rate per 1,000 athlete exposures as follows:

• Men's basket 0.07, women's basketball 0.23
• Lacrosse man 0.12, lacrosse lady 0.17
• Men's soccer 0.09, soccer women 0.28

The highest level of ACL injuries in women occur in gymnastics, with the rate of injuries per 1,000 athlete exposures 0.33 Of the four sports with the highest rate of ACL injuries, three were women - gymnastics, basketball and football.

The differences between men and women identified as potential causes are active knee joint muscle protection, differences in foot/pelvic alignment, and relative ligament weakness caused by differences in hormonal activity of estrogen and relaxin.

Theories of domination

Some studies suggest that there are four neuromuscular imbalances that affect women for higher incidence of ACL injury. Female athletes are more likely to jump and land with their knees relatively straight and collapse toward each other, while most of their weight falls on one leg and their upper body tilts to one side. Several theories have been described to further explain this imbalance. These include ligament dominance, quadriceps dominance, foot dominance, and the theory of stem dominance.

The theory of ligament dominance shows that when female athletes land after jumping, their muscles do not adequately absorb the impact of the soil. As a result, the knee ligament must absorb force, leading to higher risk of injury. The dominance of quadriceps refers to the female athlete's tendency to preferably use the quadriceps muscles to stabilize the knee joint. Given the quadriceps muscles working to pull the tibia forward, the extraordinary contraction of the quadriceps can put pressure on the ACL, increasing the risk of injury.

Leg dominance illustrates the observation that women tend to put more weight on one leg than others. Finally, the dominance of the stems suggests that males typically exhibit greater control of the stem in performance situations as evidenced by greater activation of the internal oblique muscle. Female athletes are more likely to land with their upper bodies tilted to one side and heavier on one leg than others, thereby placing a greater rotational force on their knees.

Hormonal and anatomical differences

Before puberty, there was no noticeable difference in the frequency of ACL tears between the sexes. Changes in sex hormone levels, in particular elevated estrogen and relaxin levels in women during the menstrual cycle, have been hypothesized as a predisposing cause of ACL rupture. This is because they can increase joint limbs and extended soft tissues around the knee joint.

In addition, the female pelvis widens during puberty through the influence of sex hormones. This wider pelvis requires the femur to lead to the knee. This angle toward the knee is referred to as the angle Q. The average Q angle for men is 14 degrees and the average for women is 17 degrees. Steps can be taken to reduce this Q angle, such as using orthotics. A relatively wide female hip and widening Q angle can cause a possible increase in ACL tears in women.

ACL, muscle stiffness, and strength

During puberty, sex hormones also affect the form of soft tissue that changes throughout the body. The tissue remodeling results in smaller female ACLs and will fail (ie tear) at lower loading forces, and differences in ligament and muscle stiffness between men and women. Women's knees are less rigid than men during muscle activation. Styles applied to less rigid knees tend to produce ACL tears.

In addition, the quadriceps femoral muscle is the antagonist to the ACL. According to a study conducted on female athletes at the University of Michigan, 31% of female athletes recruited the first femoral quadriceps muscle compared with 17% in men. Due to the increased contraction of the quadriceps femoral muscles during physical activity, an increase in strains is placed into the ACL due to "anterior tibial translation".

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Pathophysiology

The knee joint is formed by three bones: the femur (thighbone), the tibia (shinbone), and the patella (kneecap). These bones are held together by the ligaments, which are the strong tissue of the tissues that keep the joints stable when a person walks, runs, jumps, etc. There are two types of ligaments in the knee: collateral ligament and cruciate ligament.

Collateral ligaments include the medial collateral ligament (along the inside of the knee) and the lateral collateral ligament or fibula (along the outside of the knee). These two ligaments serve to limit the knee sideways movement.

The cruciate ligament forms an "X" inside the knee joint with the anterior cruciate ligament running from the front of the tibia to the back of the femur, and the posterior cruciate ligament running from behind the tibia to the front of the femur. An anterior cruciate ligament prevents the tibia from sliding out in front of the femur and providing stability of the rotation.

There are also two C-shaped structures made of cartilage called the medial meniscus and lateral meniscus that sit on the tibia in the knee joint and serve as a cushion for the bone.

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Diagnosis

Manual test

Most ACL injuries can be diagnosed by examining the knee and comparing it with another, uninjured knee. When a doctor suspects an ACL injury to someone who reports knee-jerk sounds followed by swelling, pain, and knee joint instability, they can perform several tests to evaluate damage to the knee. These tests include pivot-shift tests, anterior drawer tests, and Lachman tests. The pivot-shift test involves flexing the knee while holding the ankle and slightly turning the tibia inside. In an anterior drawer test, the examiner flexs the knee to 90 degrees, sits at the person's feet, and gently pulls the tibia toward him. The Lachman test is done by placing one hand on the thigh of the person and the other on the tibia and pulling the tibia forward. These tests are intended to test whether the ACL is intact and therefore able to limit the forward movement of the tibia. The Lachman test is recognized by most authorities as the most reliable and sensitive of the three.

Medical description

Although clinical examination in experienced hands can be accurate, the diagnosis is usually confirmed by magnetic resonance imaging, which provides soft-tissue images such as ligaments and cartilage around the knee. It also allows visualization of other structures that may be inadvertently involved, such as the menisci or collateral ligaments. X-rays may be performed in addition to evaluating whether one of the bones in the knee joint is broken during an injury.

MRIs may be the most commonly used techniques for diagnosing ACL states, but are not always the most reliable techniques because ACL can be obscured by blood that fills the joints after injury.

Other forms of evaluation that can be used in cases of physical examination and MRI can not be concluded are laksymetry testing (ie arthrometry and stress imaging), which involves applying power to the leg and measuring the resulting knee displacement.

Classification

Injury to the ligaments is called a sprain. The American Academy of Orthopedic Surgeons define ACL injuries in terms of severity and classify them as Grade 1, 2, or 3 sprains. Grade 1 sprains occur when the ligaments are stretched slightly but the stability of the knee joint is not affected. Grade 2 sprains occur when the ligaments are stretched to the point of being loose; this is also referred to as a partial tear. Grade 3 sprains occur when the ligaments are completely torn into two parts, and the knee joint is no longer stable. This is the most common type of ACL injury.

About half of ACL injuries occur along with injuries to other structures in the knee, including other ligaments, meniscus, or cartilage in the bone surface. The specific pattern of injuries called "happy triads" (also known as "terrible triads", or "triad O'Donoghue") involves injuries to ACL, MCL, and medial meniscus, and occurs when lateral forces are applied to the knee while the foot remains on the ground.

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Prevention

Interest in reducing non-contact ACL injuries has been intense. The International Olympic Committee, following a comprehensive review of prevention strategies, has stated that an injury prevention program has a measurable effect on reducing injuries. These programs are particularly important in female athletes who bear a higher incidence of ACL injury than male athletes, as well as in children and adolescents at high risk for a second ACL tear.

Researchers have found that female athletes often land with relatively straight knees and collapse inwardly against one another, with most of their weight on one leg and their upper body tilting to one side; These four factors place excessive pressure on the ligaments in the knee and thus increase the likelihood of torn ACLs. There is evidence that engaging in neuromuscular training (NMT) to counteract these factors and emphasizing proper landing techniques may reduce the risk of ACL injury, especially in young female athletes.

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Treatment

Non-surgical treatment for ACL rupture (also referred to as "conservative management") is recommended for individuals who are not very active or engaged in sports that cut and rotate movements, and often include physical therapy and knee support.

In athletes or individuals with additional knee injuries such as damage to cartilage, menisci or other ligaments, surgery is usually recommended.

Nonsurgical

A torn ACL will not heal without surgery (ie a torn piece will not come back together to form a functional ligament). However, if the knee remains stable enough to allow walking and the individual does not plan to participate in high-level activity, the doctor will recommend physical therapy and bracing rather than surgery.

Immediately after the ACL tear, the RICE model should begin: rest, icing for 15-20 minutes every 2 hours, compression, and elevation. This process helps reduce swelling and reduce pain. A brace can be used to protect knee shape instability, and crutches can be used to prevent weight when the knee is being healed. When the swelling decreases, physical therapy will begin to return the function to the knee and strengthen the surrounding muscles (hamstring and quadriceps) so that the muscles can compensate for the torn ligaments and stabilize the knee.

Surgery

ACL reconstruction surgery involves replacing a torn ACL with a "graft", which is a tendon taken from another source. The graft can be taken from the patellar tendon, hamstring tendon, the quadriceps tendon of the patient ("autograft") or cadaver ("allograft"). The transplant serves as a scaffolding on which new ligamentous tissue will grow.

Surgery is performed with an arthroscope or small camera inserted inside the knee, with additional small incisions made around the knee to enter the surgical instruments. This method is less invasive and proven to result in less pain from surgery, less time at the hospital, and faster recovery time than open surgery (where long incisions are made on the front of the knee and joints are exposed and exposed).

ACL reconstruction timing has been controversial, with some studies showing worse outcomes when surgery is done immediately after injury, and others show no difference in outcome when surgery is performed immediately than when surgery is delayed. The American Orthopedic Surgeons Academy has stated that there is moderate evidence to support guidelines that ACL reconstruction must occur within five months after injury to improve patient function and protect the knee from further injury; However, additional research needs to be done to determine the best time for surgery and to better understand the effects of time on clinical outcomes.

Rehabilitation

The purpose of rehabilitation after an ACL injury is to regain strength and knee motion. If an individual with an ACL injury undergoes surgery, the first rehabilitation process will focus on slowly increasing the range of motion of the joints, then strengthening the surrounding muscles to protect the new ligaments and stabilize the knee. Finally, special functional training for activities required for a particular sport begins. It may take six months or more before an athlete can return to the sport after surgery, as it is important to regain balance and control the knee to prevent a second injury.

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Prognosis

The prognosis of an ACL injury is generally good, with many people regaining the function of an injured leg in a few months. ACL injuries were once a career-end injury to competitive athletes; However, in recent years, ACL reconstruction surgery followed by physical therapy has allowed many athletes to return to pre-injury performance levels.

Long-term complications of ACL injuries include knee arthritis and/or tearing of the ligaments. Factors that increase the risk of arthritis include initial injury severity, injury to other structures in the knee, and post-treatment activity level. Not repairing tears to ACLs can sometimes cause damage to cartilage inside the knee because with torn ACLs, tibia bones and femur bones are more likely to rub against each other.

Unfortunately, young female athletes have a significant risk of tearing up repaired ACLs, or tearing ACLs in other knees after recovery. This risk has been recorded as nearly 1 out of every 4 young athletes. Therefore, athletes should be screened for any neuromuscular deficits (ie greater weakness in one leg than the other, or the wrong landing form) before returning to the sport.

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Epidemiology

There are approximately 200,000 ACL tears annually in the United States, with more than 100,000 ACL reconstructions per year. More than 95% of the ACL reconstruction is done in an outpatient setting. The most common procedures performed during ACL reconstruction are partial menisectomy and chondroplasty.

Young athlete

High school athletes have a higher risk of ACL tears than non-athletes. This risk increases with certain types of sports. Among middle school girls, sports with the highest risk of ACL is soccer, followed by basketball and lacrosse. The highest risk sport for boys is basketball, followed by lacrosse and soccer.

Young children and athletes may benefit from early surgical reconstruction after an ACL injury. Young athletes who have their initial reconstructive ACL tear surgery are more likely to return to their previous athletic ability level when compared with those who underwent delayed surgery or nonoperative treatment. They also tend to experience instability in their knees if they undergo early surgery.

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References

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External links

Source of the article : Wikipedia