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Neuromuscular and Strength Training Programs

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Neuromuscular and Strength Training Programs

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One public health intervention designed to reduce the risk of injury to the ACL is neuromuscular and strength training programs. These programs help athletes and patients train core, quadriceps, and hamstring muscles that will increase balance, stability, and controlled movements. Lack of these things is a major cause of ACL injuries, so if we can implement programs that work on these muscle groups and controlled movements we can help reduce the chance of suffering an ACL injury. One challenge in implementing this is money. Most people do not have the money to pay for these programs but incorporating them into schools may be a way to educate people affordably at a young age. The National Federation of State High School Associations is already working on educating and implementing strength and neuromuscular training for high school athletes.

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There are currently many courses one can take to earn numerous certificates. Through different programs, people can become Sportsmetric certified or even physical trainers. As many athletes are required to exercise regularly, trainers are necessary in order for them to implement proper techniques. This can help reduce the risk of ACL injuries as athletes are less likely to make a move that will hurt themselves or others. Those who become certified can utilize their skills and educate others.

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If companies made more ergonomic and naturally shaped footwear, then everyone would have better stability and structure. Thus reducing the likelihood and risk of ACL tears.

However, implementing better footwear would prove challenging as the social norm for shoes has long been instated. Narrower toe-boxes and tall silhouettes are associated with beauty but can be detrimental to health. Therefore education on how footwear affects your health should be widespread so that the public can make better-more informed decisions thus increasing the amount of people who choose to wear proper footwear.

Another method of influence would be through advertising and subliminal messaging. People are easily influenced and commonly like to chase trends so if companies can sign more celebrities into repping their shoes and if they can also cater to young people, then proper footwear would be the upcoming turn in fashion and health. Brookes Adrenaline GTS shoe boasts exceptional abilities to cushion certain movements as well as GuideRails that restrict hyper tension movements.

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Biomechanical analysis and motion capture technologies assess an individual's movement patterns during physical activities. They are used to identify biomechanical risk factors associated with any ACL injuries. Primarily used for preventing ACL injuries by observing and correcting movement patterns that may contribute to increased injury risk.

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Acoustic pressure waves are used to stimulate blood circulation and promote tissue repair, and cell growth in the targeted areas. This can reverse the anterior cruciate ligament rupture. This is used as a treatment for an ACL injury. It is also meant to accelerate the healing process significantly.

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An MRI can show the extent of the injuries as well as signs of damage to the surrounding tissues in the knee through imaging. Doctors usually depend on this type of technology because of its high accuracy and proficiency. One possible negative aspect of relying on MRIs is that a lot of acute details can easily be missed if not searched for properly which can lead to a worse injury in the future.

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Examiners can gain insights into the impact and loading on joints in the knee. This device can help adjust the training regime performed by the athletes so that the chances of getting an ACL injury are reduced. The finite techniques of certain movements, such as pivoting or jumping, may be improved and refined by using the force plate technology to create a better technique for the motion.

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A new technology improving the ACL injury field is something called a BEAR (Bridge-Enhanced ACL Restoration) Implant. This is a new and upcoming method to treat an ACL tear. Instead of removing the torn ACL tissue and replacing it with an auto or allograft, doctors use a protein structure, the patient's blood, and sutures to help the ACL tissue grow back, connecting the two torn ends. This will reduce recovery time, the risk of surgical failure due to foreign tissue, and reduce the atrophy of certain muscles. One major negative thing about the BEAR Implant is that right now it only is designed for completely torn ACLs. This method of recovery excludes anyone with a sprained or partially torn ACL. If this method could be used to address those groups, it would be much more effective in healing the ACL as a whole. Another negative effect is a risk of re-injury and infection; however, these can be more overlooked because that is to be expected with any ACL procedure.

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BEAR® Implant for Patients | ACL Recovery | Miach Orthopaedics

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The BEAR® Implant is the first medical advancement to enable your body to heal its own torn anterior cruciate ligament (ACL). Find out if you’re eligible.

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New tracking sensors such as the ViPerform AMI can track real-time data of athletes. They detect muscle and motion which can also develop an exercise program designed to decrease the risk of an ACL tear.

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When physically exhausted, it is important to stop exercising and rest. One should stop exercising when exhaustion leads to movements and technique being sloppy. The more and more our muscles become tired, the less force and strength they have, impacting our ability to control our movements such as cutting or landing properly. Getting adequate sleep each night and resting when your body reaches this point of physical exhaustion will help prevent non-contact ACL injuries because our muscles will be stronger, and we will have more control over our movements. This can be challenging because people are constantly pushing themselves to compete, even when tired, especially as athletes. Peer pressure from fans, teammates, or coaches to continue playing presents a challenge, but if it reaches the point of dangerous exhaustion, one should stop and take the time to recover.

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Several research has been performed about fatigue in football (4,9,15,20,25) and particular attention should be paid to its association with injury risk. Does fatigue only influences soft tissue injury or has repercussions in other injury types? In this FootballMedicine article we reply to some of the questions that we believe are frequently brought up to discussion when fatigue is the main topic. We discuss some of the issues around fatigue in football, such as its association with different injury types (and not exclusively soft tissue ones). In this context we also discuss how the adaptation to training and playing loads imposed to players plays a fundamental role in fatigue occurrence in game days, ultimately leading to higher injury risk. Together with this also some of the current ways of monitoring fatigue and how it should affect training and rehabilitation periodization strategies are also mentioned.

What is fatigue?

Fatigue has been defined in numerous ways. In football it can be defined as a state that enables the performance of a given task due to the inability of our body to recruit its muscles and move the different segments in an efficient way. It is a sensation with a detrimental impact at a physiological, functional and perceptual level, which can last several days after exercise (20). One of levels at which fatigue occur after a significant physical stimulus is the peripheral one in which the skeletal muscles will be under the influence of local inflammatory phenomenon and a short term muscle damage (7,14). The other form includes a central level fatigue related to the decreased ability of the Central Nervous System to activate the neural pathway for the muscle contraction to occur (17).

Does fatigue influences injury risk?

Yes. The fact that most of injuries occur in the latter stages of games halves (6) has been associated with decrements in functional markers such as strength (12,21,24) or joint position sense (22), measured at half time and after 90 minutes of real match play or simulation protocols. Additionally to isolated variables quantification such as strength or joint positions sense, authors like Barrett et al. (2016) using a soccer specific simulation protocol have shown a loss of movement efficiency that occurs throughout a football match. In their study there was an increase of the ratio between the accelerometer-derived variable PlayerLoad™ and the total distance covered in the latter stages of each half. This suggests a loss of efficiency in the participant´s locomotive skills throughout the protocol, which theoretically can be associated to the increased injury incidence observed in these periods.

Does fatigue only influences soft tissue injury risk?

No. Although it seems logical that over-exerted muscles will become progressively insufficient and therefore at increased risk of injury, this decreases in the muscles strength and neural firing rate may also be detrimental to the players´ motor control abilities, with consequences to overall motor control. For example, the decrease in joint position sense throughout the game (22) will most likely be detrimental to the reflexive (and often protective) response to joint movements. This will be responsible for an increased likelihood of a traumatic joint injury, such as the anterior cruciate ligament (ACL) rupture.

Video 1. Ibrahimovic´s knee injury sustained close to the end of the game against RSC Anderlecht for UEFA Europa League.

Poor luck or poor preparation?

Commonly football coaches refer to "luck" as the main reason for having injuries, especially when their squads present high incidence of traumatic injuries to joints and not soft tissues. However, is this exclusively associated with luck? Insufficiencies in training methods have been associated often with soft tissue injury, but is there an association between fatigue (this one resulting from deficits in training) and traumatic injuries such as the ACL one?

At Football Medicine® we definitively believe so. As we referred previously in this text most of injuries are sustained during the latter stages of game halves, and this includes traumatic joint injuries were ACL is included. There are several reasons why players could be excessively fatigued during a game: 1) insufficient training stimulus (undertraining) leading to the player inability to cope with the game´s physical demands; 2) excessive training stimulus and insufficient recovery from training leading up to the game (overtraining), resulting in the player to start the game not fully recovered from the previous trainings; 3) sudden increases in fixture congestion with abrupt peaks in physical load leading to insufficient recovery between matches; and 4) a particular load increase in a game like (e.g.) the event of extra-time .

What determines the players´ level of fatigue?

Fatigue is a fundamental part of the training process. Reaching the state of fatigue means that the metabolic or/and mechanical stress placed on the player´s body is significant, working as a trigger to generate fundamental adaptations to reach a right level of physical performance. However, in order to maintain a proper level of fitness, working under some level of fatigue during training is necessary. Simultaneously, also during the game as the player reaches a certain level of tolerance to the game physical effort, there will be a tendency of pushing himself to further beyond, ending up working with some level of fatigue also during the game.

Although this process is well known, if the player´s fitness status of the player is the correct one, especially during the game day, the likelihood of the player to be exposed to extreme levels of fatigue will decrease, and therefore not only it will not impair his performance levels as also the will not increase his injury risk.

For this matter the training process is fundamental. First through a progressive exposition from the pre-season to the competitive period to a level of load that creates a positive adaptation in the player musculoskeletal system to the game demands (and obviously to the manager tactical demands). Unsurprisingly, extensive research using several approaches has establish a relation between training loads and injury occurrence in football and other team sports, regardless of its nature (2,3,5,10,11,13).

Second, using a periodization training model throughout the week, that depending on the number of days between games should guarantee a proper recovery from the previous game and preparation to the following one. The latter issue was previously discussed in this Football Medicine® article in which models of periodization are suggested.
TRAINING PERIODIZATION AND INJURY PREVENTION - MODEL A TRAINING PERIODIZATION AND INJURY PREVENTION - MODEL B
How long should we expect players to recover from fatigue and return to regular levels?

Understanding how long the players´ body takes to return to baseline levels both in physiological and functional parameters in football has being of important matter of interest and research (4,7, 14,25). For example, just recently, a study from Thomas et al. (2017) using a soccer simulation protocol has shown that functional variables like maximum voluntary contractions and quadriceps potentiated twitch force were not at baseline levels until 72 hours post -protocol. Voluntary muscle activation was also not at regular levels at 48 hours post-exercise. In a metabolic rather than functional perspective, a study performed with professional French league players by Djaoui et al. (2016) showed that physiological markers like creatine kinase and heart rate at rest were only significantly higher during 24 hours post-match, whereas post effort recovery heart rate remained significantly different at 48 hours. Although is generally accepted that 48 hours is the standard time to recover from fatigue, different studies regarding functional and physiological markers not only show asynchronies between these to return to baseline levels , as also call the attention to factors such as the players age which may play a significant role on the recovery time.

This type of information is useful to establish training methods, and deciding when and how to apply physical stimulus to the players, understanding that pushing them too soon after a match may be detrimental and not beneficial to their fitness status, and negatively affect performance on the following match.

How can the players´ fatigue be monitored?

Several forms of monitoring can be performed in professional football to monitor the player´s fatigue status, with some of it being briefly addressed in this opinion article.

Neuromuscular fatigue is generally accessed through the use of countermovement and squat jumps where variables such as duration time, time to peak force/power or flight time:contraction time ratio have been shown valid for assessing neuromuscular fatigue status (27).

Biochemical markers to assess muscle damage include measurements of blood creatine kinase or myoglobin (1). Increases in creatine kinase in football were associated with the muscle damage provoked by sprinting and high intensity running that occurs in football (26). However some questioning around the factors leading to the increased levels of creatine kinase following a soccer match still remains (25). Other assessment methods include salivary cortisol and testosterone levels to determine immunity breakdowns following matches and stress hormone responses to soccer play (18, 26).

Also, in a review by Thorpe et al. (2017) several forms of monitoring are detailed, including the ones referent to the autonomic nervous system function such as submaximal heart rate, heart rate variability and heart rate recovery. This methods, although constitute promising approaches to monitor recovery and performance in athletes are still being a focus of research in order to understand its meaningfulness, especially in team sports.

Readiness questionnaires are also another common form of monitoring the players physical and psychological status for training and competing. Although valuable, this form of monitoring depends on the honesty of the athletes. In our experience at FootballMedicine, suspicions from the players that this may affect selection or personal discredit to this monitoring strategy may affect this honesty, creating a bias in this form of evaluation. However, apart from this fact, this form of assessment has shown better sensitivity than objective measures to variations in training load, both acute and chronic (23).

Several examples given by England Premier League and Championship clubs include monitoring strategies, together with other training methodology and injury prevention aspects.

Figure 1. Methods used for fatigue indicators monitoring, creatine kinase levels (left), vertical jump assessment (right).

What about injured players and re-conditioning/re-loading strategies? Should the medical staff consider all this also during rehabilitation in football?

Yes. Several forms of physical stimulus are part of a rehabilitation plan, such as strength training in a gymnasium and outfield re-conditioning involving (or that should inolve) football drills. Therefore, guidelines during rehabilitation regarding exercise are quite similar to a regular training regime, yet with some adjustments or increased need of recover between stimuli considering there is an on-going healing process together with a detraining period. The detraining period associated with the injury, which varies in duration depending on the injury type, will probably be responsible for extra recovery needs from physical stimulus once the player is introduced to significant load during rehabilitation. Overloading the athlete after this detraining together with a continuous loading of a recently injured area without recovery periods in between will only not impair his improvement as also could have detrimental effects in his rehabilitation.

For example, starting and outfield re-conditioning program will be affected by the players injured area and remaining body mechanical properties regarding load absorption and locomotion strategies. The latter are affected by variables like (e.g.) tissue stiffness (29), which in turn will be significantly affected by immobilization or detraining periods (16). These physical/biomechanical properties will directly affect the athlete´s body energy demands to propel his body forward and to overcome external forces acting on his body, and therefore determine his cardiovascular/metabolic response to support the metabolic requirements of the involved musculoskeletal structures (28). This is a good reason to establish a progression of loads, if possible based on the player´s individualized profile using portable monitoring devices such as GPS. Together with this it is also valuable to define periodization strategies considering a balance between physical stimulus and recovery, allowing a higher effectiveness to the load responsiveness and adaptation by the player.

"If you fail to prepare, you're prepared to fail."

Mark Spitz

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Ferraz R, van den Tillaar R, Marques MC. (2012). The effect of fatigue on kicking velocity in soccer players. J Hum Kinet, 35, pp. 97-107.

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Greig, M., & Siegler, J.C. (2009). Soccer-specific fatigue and eccentric hamstrings muscle strength. J Athl Train, 44(2), pp. 180-184.

Hulin, B.T., Gabbett, T.J., Lawson, D.W., & Caputi, P. (2015). The acute:chronic workload ratio predicts injury: high chronic workload may decrease injury risk in elite rugby league players. Br J Sports Med, 0, pp. 1-7.

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Fatigue, Football Vital Sign - Football Medicine insights about how fatigue affects your players´ management - Football Medicine

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Several research has been performed about fatigue in football (4,9,15,20,25) and particular attention should be paid to its association with injury risk. Does fatigue only influences soft tissue injury or...

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Strengthening exercises, more specifically core, quadriceps, and hamstring can prevent getting an ACL injury. By strengthening the muscles around the knee, it provides support and additional stability. Core strengthening improves an individual’s stability, reducing risks of any movements that might cause an ACL injury. Actions such as pivoting, jumping, and sprinting rely on core strength to retain stability during the movement, which is where an ACL injury may occur.

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Consistently seeing a physical therapist can play a crucial role in preventing ACL injuries through a variety of approaches that are meant for the prevention of injury. This can also prevent all sorts of other injuries while doing maintenance for the body.

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The regulation or improvement of rules will help to hold dirty players accountable for their hits or tackles. Calling penalties on dirty plays may save someone's life or career. A lot of ACL tears are caused by direct and possibly premeditated blows to the knee. The challenging part about this is the players themselves because they're so used to playing the game a certain way, and all of a sudden there are all these new rules to abide by, and it may be difficult for them to follow.

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Alex Smith Suffers Horrific Leg  Injury HD

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ACL tears normally happen when someone has a sudden movement or weird turn, but we can improve our body's capability to handle those movements. Having good agility can greatly help you move your body and change direction/speed. Agility training can greatly improve dynamic and sport-specific movements.

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One special population affected by ACL injuries is women. Not only are females more likely to injure their ACLs, but they are also less likely to have successful surgeries and make a full recovery/return to normal activity. This is because rehabilitation protocols and surgical operations on the ACL are not specialized for women. A woman's muscles, movements, and body vary from a man's. An example is a woman's hips/Q angle is usually wider than a man's, making the angle and force load on the knee and muscles greater. Surgical and rehabilitation methods should reflect this, but as of now, this is not widely the case, leading to women being more directly impacted by an injury to the ACL.

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Older people can be at a higher risk for ACL tearing. Although they are less likely to perform high-intensity activities such as exercise, their physical bodies are less equipped to handle stress. So, trips, falls, accidents, or hits can greatly increase in risk factor as people age which is why the older population can be more susceptible to ACL tearing.

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Minorities (Black and Hispanic Populations)

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Minorities (Black and Hispanic Populations)

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One special population that is affected by an ACL injury is minorities, specifically those of Hispanic or Black race. This population struggles with getting the proper treatment for their ACL injury. They are less likely to undergo an ACL reconstruction and attend comparatively fewer physical therapy sessions than Caucasians. Those of Black and Hispanic race struggle with those things because of language barriers, access to health care, and racial bias. Treatment for ACL injuries is expensive and can be a financial burden, so pairing the financial burden with these other factors greatly affects minorities in getting the proper care and treatment for an injured ACL.

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Abstract

Purpose of Review

Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury.

Recent Findings

Females are at increased risk for ACL injury compared to males. Intrinsic differences such as increased quadriceps angle and increased posterior tibial slope may be contributing factors. Despite lower rates of injury, males undergo ACL reconstruction (ACLR) more frequently. There is conflicting evidence regarding gender differences in graft failure and ACL revision rates, but males demonstrate higher return to sport (RTS) rates. Females report worse functional outcome scores and have worse biomechanical metrics following ACLR. Direct evidence of racial and ethnic disparities is limited, but present. White athletes have greater risk of ACL injury compared to Black athletes. Non-White and Spanish-speaking patients are less likely to undergo ACLR after ACL tear. Black and Hispanic youth have greater surgical delay to ACLR, increased risk for loss to clinical follow-up, and less physical therapy sessions, thereby leading to greater deficits in knee extensor strength during rehabilitation. Hispanic and Black patients also have greater risk for hospital admission after ACLR, though this disparity is improving.

Summary

Females have higher rates of ACL injury with inconclusive evidence on anatomic predisposition and ACL failure rate differences between genders. Recent literature has suggested inferior RTS and functional outcomes following ACLR in females. Though there is limited and mixed data on incidence and outcome differences between races and ethnic groups, recent studies suggest there may be disparities in those who undergo ACLR and time to treatment.

Keywords: ACL disparities, ACL gender differences

Introduction

Differences in race, ethnicity, gender, and socioeconomic status within the diverse population of the USA have led to the permeation of disparities across many different specialties in medicine and surgery [ 1- 3]. Within orthopedic surgery in particular, disparities in utilization, selection, treatment, and outcomes have been shown in multiple subspecialties [ 4- 9]. Here, we review the existing evidence in the literature pertaining to disparities in anterior cruciate ligament (ACL) injury, management, and outcomes. ACL injury is the most common isolated ligamentous injury that occurs in athletes, with over 100,000 ACL reconstructions performed per year and over three billion dollars in estimated costs annually in the USA alone [ 10- 13]. The profound clinical and economic impact of ACL injuries highlights the importance of understanding and addressing disparities that exist to ensure adequate patient care.

Gender Disparity in ACL Injury, Treatment, and Outcomes

Compared to male counterparts within the same sport, it has been well established that female athletes are two to eight times more likely to sustain an ACL injury [ 14- 16]. With the increase in participation in youth athletics as well as expansion of women's collegiate and professional programs over the last few decades [ 17], it has become increasingly important to better understand potential mechanisms underlying the gender difference in injury rates.

Intrinsic Risk Factors and Predisposition to Injury

Anatomic variation in the femoral intercondylar notch (ICN) has been studied as a possible intrinsic risk factor contributing to the discrepancy in ACL injury between male and female athletes. Notch width index (NWI) is a measure that attempts to standardize notch width relative to overall distal femoral width and is commonly used to define the size of the ICN. Compared to males, females have smaller NWI and smaller standardized ACL cross-sectional area [ 18, 19]. While ICN stenosis has been shown to be associated with an increased risk of noncontact ACL injury [ 20], there is conflicting data surrounding the significance of NWI differences between males and females in the context of ACL injury [ 21- 23]. A study of 108 ACL injury radiographs compared to controls showed a higher proportion of A-shaped notches (notch narrows from base to midsection and apex) in females relative to males; however, notch shape and sex did not correlate with injury status [ 24]. Similarly, there have been conflicting findings regarding the association of notch size and ACL size [ 22, 25]. In summary, there appears to be a difference in ICN size and ACL size between genders without conclusive correlation to injury (Table ​(Table1 1 ).

Table 1

Quadriceps angle

Up to 5.8° greater in females compared to males leading to a more laterally directed pull of the quadriceps, which may place the ACL at higher risk for injury [18, 26]

Intercondylar notch

Although female patients have smaller notch width indices than males, there is conflicting data surrounding the significance of differences in notch width in the context of ACL injuries [ 18- 23].

ACL size

When standardized for body weight and height, females have a smaller ACL size and cross-sectional area than males; however, there is no conclusive correlation to ACL injury [ 19, 22, 25].

Tibial slope

There is currently mixed data surrounding the significance of posterior tibial slope on differences in ACL injury rates between males and females [ 27- 30].

Recently, much emphasis has been placed on the geometry of the knee, specifically the quadriceps angle (Q angle) and posterior tibial slope (PTS). The Q angle has been shown to be up to 5.8° greater in females compared to that in males leading to a more laterally directed pull of the quadriceps, which may place the ACL at higher risk for injury [ 18, 26]. It is widely accepted that an increase in PTS places the tibia more anterior relative to the femur during quadriceps contraction, which may result in increased strain on the ACL. This has been supported by multiple studies that have demonstrated increased risk of ACL injuries in those with higher PTS.

Hohmann et al. found that PTS of the medial plateau was higher in ACL-injured females than males [ 27]. Similarly, Terauchi et al. found that medial plateau PTS was significantly greater in the ACL-deficient females compared to controls, whereas no significant difference was seen between the injured and control male groups [ 28]. In contrast, multiple studies have noted no significant difference in PTS measurements between men and women with ACL injury [ 29, 30]. Given the mixed results when comparing gender, it may be that the risk for ACL injury in relation to PTS is associated with a particular threshold measure rather than sex.

Estrogen, progesterone, and androgen receptors have been localized to fibroblasts and endothelial cells within the ACL, thereby suggesting a hormonal influence on susceptibility to ACL injury [ 31, 32]. A meta-analysis found that anterior knee laxity was greater in the ovulatory phase than in the luteal phase and lowest in the follicular phase [ 33]. Interestingly, ACL injury is more likely to occur in the early and late follicular phases [ 34, 35]. There is a lack of large-scale studies that compare hormone levels, markers of laxity, and injury between genders. Thus, the current data is insufficient to make any conclusive statement regarding the influence of hormonal and menstrual cycles on the rate of ACL injury in females.

Biomechanical and kinematic factors have also been extensively studied as possible explanations to gender differences in ACL injury. Females have a higher quadriceps-to-hamstring mass ratio and a higher ratio of quadriceps-to-hamstring recruitment [ 36]. Furthermore, females have been noted to land in a more erect posture with an external rotation position [ 19]. These factors have been theorized to increase the stress on the ACL. Females have also been shown to have higher recruitment of lateral thigh musculature and to consequently have up to a 2.5 times greater knee abduction moment [ 37]. While this has not been directly linked to ACL injury, these abduction moment differences arise after pubertal growth spurts around the time which the disproportionate increase in female injury rates occurs [ 38].

Ultimately, many physiologic, biomechanical, and kinematic differences have been established that may explain differences in ACL injury rates between males and females, which as it stands appears to be a multifactorial phenomenon.

Treatment

Over the past few decades, there has been a significant increase in the rates of ACLR among both men and women in the USA and internationally [ 39- 41]. A 2017 study showed that females aged 13-17 had the highest rate of ACLR, more than any other sex-age strata [ 42]. Despite higher rates of primary injury in female athletes, males have been reported to undergo ACLR more frequently [ 43, 44]. However, there has been an increase in the proportion of females undergoing ACLR compared to males in both ambulatory and inpatient settings [ 45]. Additionally, graft choice has previously been thought to be influenced by gender, with females more likely to receive an allograft as opposed to autograft revision ACLR [ 46]. However, Svantesson et al. subsequently reported no gender difference with graft choice in primary ACLR [ 47].

Outcomes

Currently, there exists conflicting evidence regarding differences in graft failure between genders. While females have been shown to have greater laxity on post-operative physical exam [ 48], a multitude of studies have shown no significant difference in graft rupture/failure rates [ 49- 54]. On the contrary, other studies have identified male sex as a risk factor for ipsilateral revision and graft failure following primary ACLR [ 55, 56]. Risk for contralateral ACLR also has conflicting evidence, with some studies identifying female sex as a risk factor [ 57- 59], and others showing no significant difference between male and female patients [ 60, 61].

Another primary outcome of interest specifically in athletes that undergo ACLR is the overall time to return to sport (RTS). Young, male athletes have significantly higher RTS rates compared to female athletes at 12 months post primary ACLR (differences summarized in Table ​Table2) 2 ) [ 62, 63*]. One potential explanation is that male patients have been shown to have greater psychological readiness to RTS throughout the entire rehabilitation process compared to females [ 64, 65, 66*] and self-reported psychological readiness has been identified as the most significant factor in predicting subsequent return to comparable athletic performance [ 67]. This implies a potential role for psychological treatment as part of the post-ACLR rehabilitation programs and a need to further understand RTS protocols for athletes.

Table 2

Study

Study variables

Methods

Findings

Hamrin Senorski [ 62]

RTS rates

Males and females; evaluated at 12 months after surgery for RTS via Tegner Activity Scale

Patients of male sex found to have favorable odds ratio for RTS after ACLR compared to females (OR, 2.58; 95% CI, 1.43-4.65; P = .0016)

Webster [ 63*]

RTS rates

Males and females; evaluated at 12 months after surgery for return to sport

Male athletes who were in the ≤ 25-year and 26- to 35-year age brackets had significantly higher return rates than female athletes (52% vs 39% and 37% vs 18%, respectively; P < .001), whereas no sex-based differences in RTS were seen after 36 years of age.

Kostyun [ 64]

Readiness to RTS

Males and females; assessed with ACL-RSI scores at pre-op, 3 months after surgery, and at RTS clearance

Female athletes reported lower readiness to RTS at all three time points of the study ( P < 0.010).

Webster [ 66*]

Readiness to RTS

Males and females; participants evaluated after clearance for RTS, psychological readiness assessed with ACL-RSI scores

Male patients who participated frequently in sports before ACL injury had higher psychological readiness than females ( β = 5.8; 95% CI, 2-10).

Webster [ 67]

Return to pre-injury performance, RTS

Males and females; patients followed out to a mean of 3 years to determine if they returned to pre-injury level of performance

Males and females had similar rates of return to pre-injury performance, as well as return to competition at 12 months after surgery.

In the current literature, male patients have superior functional outcomes following primary ACLR. Data from the Swedish knee ligament registry shows favorable outcomes for males for the Knee Injury and Osteoarthritis Outcome (KOOS) score and EuroQol EQ-5D health status measure [ 68]. Similar findings have been documented with self-reported knee questionnaires [ 69, 70]. Furthermore, male patients who return to work and drive sooner have greater odds of participating in moderate-to-vigorous physical activity after ACLR [ 71, 72].

In addition to RTS and functional outcomes, post-operative biomechanical testing also favors males. In both animal and human studies, females have decreased knee extensor muscle strength compared to males at 1 year after surgery, and slower rates of quadriceps torque development in the affected limb [ 73, 74*, 75- 77]. Female athletes with ACLR also display worse Landing Error Scoring System (LESS) scores and are more likely than males to commit errors related to medial knee displacement during landing movement patterns [ 78]. The overall discrepancy in outcomes between genders, specifically for primary ACLR, highlights the importance of personalized rehabilitation protocols and further level I studies to elucidate the important modifiable risk factors both pre- and post-operatively.

Disparities in Race and Ethnicity

Predisposition to Injury

Anatomic variation in femoral ICN has been studied within patients of different races and ethnicities as a possible risk factor for ACL injury. Compared with African American males, Caucasian males consistently have narrower ICN width; however, there is conflicting evidence surrounding females of various races, with some studies showing significant differences between African American and White females, and others showing no difference [ 79, 80]. Additionally, no significant anatomic discrepancy has been identified in Q angle or PTS between White and African patients [ 81, 82]. Injury trends within the Women's National Basketball Association (WNBA) help illustrate potential disparities by race, with White athletes having more than 6 times the ACL tear rate of other ethnic groups combined [ 83]. Data of Han Chinese patients with ACL injuries shows a higher proportion of patients with a small tibial footprint size compared to Western populations with ACL injuries, suggesting differences in tibial footprint size could play a role between races [ 84, 85]. There is a paucity of studies and limited data on racial and ethnic predisposition to ACL injury despite well-described anatomic differences.

Treatment

Race and ethnicity have been shown to influence treatment following ACL injury. White patients are more likely than non-White patients to undergo ACLR after ACL injury diagnosis [ 86]. Language similarly influences rates of ACLR, as patients that speak English as a primary language are most likely to undergo surgical reconstruction, followed by multilanguage households, while exclusively Spanish-speaking patients are significantly less likely to undergo reconstruction [ 86]. Among pediatric and adolescent populations, Black and Hispanic patients experience greater surgical delays after ACL rupture [ 87**]. In the Kaiser Permanente ACL registry data, when controlling for insurance status, Asian, Hispanic, and Black patients were less likely to undergo elective ACL revision compared to White patients, despite having comparable access to care through Kaiser [ 88**]. Race distribution was significantly different across graft types used in the Kaiser data, with a lower proportion of White patients in the bone-tendon-bone (BTB) autograft group compared to the hamstring autograft or allograft groups [ 89]. Black high school and collegiate athletes are more likely to receive a BTB versus hamstring autograft [ 90]. In the post-operative period, Black and other non-White races have significantly increased risk of loss to clinical follow-up [ 91]. Additionally, young Black and Hispanic athletes also have less physical therapy sessions during the rehabilitation process, highlighting further racial disparity in ACL treatment [ 87**].

Outcomes

There is limited and mixed evidence on the influence of race and ethnicity on post-operative complications following ACLR. Some studies have shown that White patients have a significantly higher risk than Hispanic, Asian, and Black patients for ipsilateral revision and contralateral ACLR [ 92- 94] while others have found no difference in ipsilateral revision rates between races [ 87**, 95]. Hispanic ethnicity [ 96] and Black race [ 97] have been identified as risk factors for post-operative readmission following ACLR. However, between 2007 and 2015, readmission rates of Black and Hispanic patients have been decreasing relative to that of White patients [ 98*].

There is limited and thus inconclusive data for disparities in RTS and biomechanical testing. A study of 915 pediatric primary ACLRs showed no difference in RTS clearance by race, though Black and Hispanic patients were significantly less likely to be cleared to RTS overall [ 87**]. Another study did not find a significant difference between White and non-White patients in RTS rates at 2-year follow-up [ 99]. Isokinetic dynamometer testing has shown that Black and Hispanic pediatric and adolescent patients experience significantly greater quadriceps deficits at 6 and 9 months following ACLR, likely due in part to a discrepancy in physical therapy follow-up [ 87**]. Overall, while the studies are limited, racial and ethnic disparities exist in treatment and outcome and this is likely multifactorial, but implies the presence of biases that require further investigation.

Where Do We Go from Here?

Gender differences are evident and call for gender-specific studies in order to better understand injury and pathophysiology and close the gap in outcomes between males and females. Given the much higher incidence of ACL injury in females, there is a demand for more studies focusing on injury prevention such as neuromuscular and proprioceptive training. Special attention is needed for young female athletes as the number of sports programs continues to increase. There is a paucity of literature on high-performance female athletes compared to available data for male athletes [ 100]. Limited understanding of differences in anatomy, physiology, and biomechanics along with applying male-dominant research to all is likely contributing to the inferior outcomes reported among females.

Health care providers across all specialties including orthopedic surgery show implicit biases related to race and gender, similar to those of the general public [ 101, 102]. Druckman et al. analyzed how sports medical staff responded to student-athlete case vignettes and showed that staff viewed Black athletes as having higher initial pain tolerance after ACL tear compared to their White peers [ 103]. While such biases have not been directly shown to effect outcomes, it is likely a contributory factor that has to be addressed at the individual level. Providers must make an effort to take into consideration not only race and gender, but also important social determinants of health, access to care, and patient expectations all of which can have a large impact on patient outcomes.

Lastly, it has been well documented that patient satisfaction and health outcomes are favorable when there is racial, ethnic, and linguistic concordance between the physician and patient [ 104- 106]). Within orthopedic surgery residency programs, between 2006 and 2015, female representation increased from 10.9 to 14.4%, but this rate of increase was significantly lower than those of many other surgical specialties. Additionally, there was no significant improvement in racial/ethnic diversity among orthopedic residency programs over the same time period [ 107*]. A recent study similarly showed that Latino, African American, and Native American groups were significantly underrepresented in orthopedic residencies [ 108]. A more representative workforce from surgeon to physical therapists to athletic trainers may have a positive impact on disparities and treatment outcomes.

Conclusion

There is broad evidence of disparities surrounding the incidence, treatment, and outcomes following ACL injury. Disproportionate rates of injury, anatomic differences, variable biomechanics, access to care, and implicit biases among other factors must be considered. While there is evidence of improvement in certain areas, we still have work to do to close the gap and optimize care for all.

Compliance with Ethical Standards

Conflict of Interest

Sai K. Devana, Carlos Solorzano, Benedict Nwachukwu, and Kristofer J. Jones declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

All authors have no financial relationships to disclose

Footnotes

This article is part of the Topical Collection on Gender and Racial Disparities
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Sai K. Devana, Email: moc.liamg@anavedks.

Carlos Solorzano, Email: ude.alcu.tendem@onazrolosc.

Benedict Nwachukwu, Email: moc.liamg@uwkuhcawn.u.neb.

Kristofer J. Jones, Email: ude.alcu.tendem@senojjk.

References

Papers of particular interest, published recently, have been highlighted as: * Of importance ** Of major importance

17. Stracciolini A, Amar-Dolan L, Howell DR, Alex T, Berkner P, Sandstrom NJ, et al. Female sport participation effect on long-term health-related quality of life. Clin J Sport Med [Internet]. 2018; Publish Ah. Available from: https://journals.lww.com/00042752-900000000-99150 [ PubMed]

35. Griffin LY, Albohm MJ, Arendt EA, Bahr R, Beynnon BD, DeMaio M, Dick RW, Engebretsen L, Garrett WE, Hannafin JA, Hewett TE, Huston LJ, Ireland ML, Johnson RJ, Lephart S, Mandelbaum BR, Mann BJ, Marks PH, Marshall SW, et al. Understanding and preventing noncontact anterior cruciate ligament injuries. Am J Sports Med [Internet]. 2006;34:1512-32. 10.1177/0363546506286866. [ PubMed]

52. Samitier G, Marcano AI, Alentorn-Geli E, Cugat R, Farmer KW, Moser MW. Failure of anterior cruciate ligament reconstruction. Arch bone Jt Surg [Internet]. 2015;3:220-240. [[ PMC free article] [ PubMed] Google Scholar]

66.*. Webster KE, Nagelli CV, Hewett TE, Feller JA. Factors associated with psychological readiness to return to sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med [Internet]. 2018;46:1545-50. 10.1177/0363546518773757. Emphasizes current disparity in psychological readiness between male and female athletes to RTS after ACLR

87.**. Bram JT, Talathi NS, Patel NM, DeFrancesco CJ, Striano BM, Ganley TJ. How do race and insurance status affect the care of pediatric anterior cruciate ligament injuries? Clin J Sport Med [Internet]. 2018;Publish Ah. Available from: https://journals.lww.com/00042752-900000000-99090; First study to investigate differences in isokinetic strength testing after pediatric ACLR by race and insurance status

98.*. Li LT, Bokshan SL, McGlone PJ, Owens BD. Decline in racial disparities for United States hospital admissions after anterior cruciate ligament reconstruction from 2007 to 2015. Orthop J Sport Med [Internet]. 2020;8:232596712096447. 10.1177/2325967120964473. Outlines recent improvement of disparity in hospitalizations by race after ACLR [ PMC free article] [ PubMed]

105. Walker KO, Moreno G, Grumbach K. The association among specialty, race, ethnicity, and practice location among California physicians in diverse specialties. J Natl Med Assoc [Internet]. 2012;104:46-52. [[ PMC free article] [ PubMed] Google Scholar]

106. Poma PA. Race/ethnicity concordance between patients and physicians. J Natl Med Assoc [Internet]. 2017;109:6-8. [[ PubMed] Google Scholar]

108. McDonald TC, Drake LC, Replogle WH, Graves ML, Brooks JT. Barriers to increasing diversity in orthopaedics. JBJS Open Access [Internet]. 2020;5:e0007-7. 10.2106/JBJS.OA.20.00007.

Articles from Current Reviews in Musculoskeletal Medicine are provided here courtesy of Humana Press

# data[].attributes.attachment_link.title
Disparities in ACL Reconstruction: the Influence of Gender and Race on Incidence, Treatment, and Outcomes

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Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury.Females ...

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Increasing sleep can radically improve healing outcomes and repair of the affected structures. Unfortunately, increasing the amount of sleep can prove to be more difficult than originally thought. Due to the time commitment, supporting steps it can take to promote a healthy sleep cycle and relaxation, and overall life circumstances, improving sleep could be rated at a 6-star difficulty. A therapist can help relieve many stresses and anxiety which can prevent healthy sleep.

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While recovering from an ACL injury, one may have to increase their physical activity in order to regain strength and mobility. This physical exercise may include jogging, light weight lifting, etc. They may be at a difficulty level of 8 because of the pain one may endure doing these exercises and having to incorporate this into one's schedule when it is not something they normally do. This can also be seen as a restriction. Time may be limited for most people, especially when they already have a fairly busy schedule. Another restriction may be money because gym memberships, athleisure wear, and trainers all cost money.

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When someone suffers from an ACL tear, they have to change how they spend their time. In regards to recovery when they're not in a PT session, a physical therapist may recommend an at-home treatment alongside rehabilitation through PT. The term R.I.C.E. pertains to the resting, icing, compressing, and elevating of the knee to help it heal. Resting is necessary to keep off the knee while also keeping it compressed with a wrap or brace. It's also necessary when icing the knee, for it to be propped up on a pillow for more elevation. On a scale of 1-10, the patient might be at an 4 or 5 in regards to the difficulty in making this lifestyle change because it can be very time-consuming and a tedious process to recover. There are a multitude of reasons for why a patient might find R.I.C.E. difficult to do. Some patients may find it difficult to invest enough time into R.I.C.E. treatment because they do not see immediate results. Another problem that arises is the commitment to performing the treatment everyday, at least several times a day.

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Dietary changes can vastly improve recovery from an ACL injury. This includes getting a balanced diet with a higher content of protein and omega-3 fatty acids. Including protein in your diet helps with muscle development and growth. During recovery, the ACL must be strengthened along with the muscles around it because they all work together to maintain stability and increase motion. Getting foods with omega-3 fatty acids will also help reduce swelling around the ACL, helping increase recovery time and lessen pain. On a scale of 1-10 difficulty, getting increased amounts of protein and omega 3 in your diet would be an 8. Getting a well-rounded diet that is higher in protein is not cheap. It also requires more time and commitment to plan and cook these meals. One way to work around cost is to find foods both high in protein and omega 3s, such as fish and certain seeds. Another cheaper alternative to get omega 3 is through supplements rather than food.

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One physical rehabilitation treatment necessary for an ACL injury is gait training. This may be necessary because with an ACL injury comes limited mobility in the knee. Limited mobility in the knee can cause issues developing a normal gait pattern when walking, running, or going upstairs. Gait training can involve squats, heel raises, and knee extensions that will help strengthen the muscles needed for a normal gait pattern. It can also involve stretches such as knee slides or prone knee flexion that will increase mobility in the knee. Walking exercises involve walking on a treadmill or in different patterns with hurdles to develop walking mechanics, control, and mobility. A physical therapist can provide gait training for an ACL.

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Balance also has to be regained after an ACL injury which isn’t just about rebuilding the quad muscles but also developing the supporting structures and neural pathways. Exercise and electrical stimulation can be utilized to redevelop balance. A PT would most likely deliver this treatment because they utilize both sides of the body in comparison to each other instead of just focusing on the injured knee.

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Neuromuscular training reignites the connection between the brain and the leg for more finite movements, regaining stability by activating the parts of the leg that had gone dormant during the ACL recovery. Neuromuscular training also benefits the individual by improving reaction time and activaton of specific muscle groups. A PT would be more equipped to deliver this treatment as they look at the body as a whole rather than focusing on just the knee.

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If intubation is necessary for an ACL reconstructive surgery, an initial assessment must be done first to see if the patient is medically cleared to have an intubation. An intubation during surgery is when a tube is placed down the mouth to keep an airway open from the mouth to the trachea. This is important in some ACL surgeries to make sure the patient is still able to breathe while sedated. An SLP can perform this assessment and determine the safety of the patient if intubation is performed. For example, someone with previous trauma or a major obstruction preventing the placement of the tube in the airway will not be cleared. An intubation can not be performed unless the patient is medically cleared beforehand, making the SLP's role in some ACL surgeries crucial.

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If you were to have suffered from an ACL Injury, how would you be most psychologically affected?

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The education awareness campaigns target athletes, coaches, parents, and healthcare professionals to create an understanding of the importance of proper training techniques, stretches that target specific ares of the knee, and warm-up exercises that can help reduce the risk of ACL injuries. Communities can work towards creating a culture of proactive injury management after gaining more insight into the occurrences of ACL injuries. South Shore Hospital is one of the campaigns that aims to prevent ACL injuries that occur during sports events.

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Those with an ACL injury, especially those a part of teams or groups, can tend to feel alone and isolated. This can be due to many reasons, such as feeling that we are not good enough anymore, embarrassed, letting the team down, or not belonging due to a loss in athletic identity. These feelings can lead us to be socially awkward, anxious around others, and distant from those around us. Social skills training will help those with these feelings by improving communication skills, building empathy and understanding, boosting self-confidence, and improving their social problem-solving. While we do not think of an ACL injury causing these things, it can take a toll on one's social life, making social skills training very beneficial.

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Often times with an ACL injury, issues with regulating and controlling emotions follow. Patients can become depressed from a lack of movement or have a lack of confidence in their abilities. An ACL injury can also come with added stress and pressure to return to normal activity quickly or from not being where one wants to be in the recovery process. By recognizing the changes in emotion, we can regulate the changes and practice exercises to help with that. These exercises can consist of breathing exercises, meditation, and self-awareness.

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Medications such as antidepressants or just normal mood stabilizers can be used to treat psychological disorders. They accomplish this by modifying brain activity and chemicals.

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CBT is a sort of talk therapy that aims to reduce symptoms of depression, anxiety, anger, and any other mental health conditions there may be post-injury. The long-term goal of this therapy is to hopefully improve or brighten the outlook that the patient may have on their future and motivate them to put in the work that will help to bring them back to those previous behaviors and mentality. Any sort of healthcare professional who has been trained in CBT has the capability of delivering this treatment. This may include psychiatrists, psychologists, or mental health nurses.

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When an ACL injury first occurs, pain and swelling may develop between 1-7 days after the injury. This may continue for much longer if the injury is not treated properly. For example, if one is to return to normal day-to-day activities, their knee may start swelling again and further injuries may occur.

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ACL injuries often result in long-term instability of the affected knee joint, making it susceptible to future injuries and impairing an individual's ability to engage in activities that require agility and stability.

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If patients with an ACL injury go the route of surgery, it does lead to an increased risk of a second or repeated surgery. Patients after the surgery are likely to experience issues in the same knee. After having your knee opened up and worked on, it can cause stress on the joints and tissue within the knee. The ACL itself can also be more susceptible to tearing after a procedure. If the surgeon uses a cadaver graft to replace the ACL, there is a risk that the surgery fails or is less likely to be successful. The cadaver graft is not our body's tissue, so it may be weaker and have trouble fusing with our body's tissue. Using a cadaver graft versus one's tissue is still debated today among surgeons. However, more and more studies show the risk of using a cadaver graft. Therefore, due to having the knee worked on internally and even the specifics of the surgery, people are more at risk for further procedures after one.

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If you've torn your ACL and you are debating surgery, deciding on the type of graft to use to reconstruct the ligament can be a source of significant anxiety and confusion. You may encounter conflicting information on the chance of suffering a re-rupture based on the graft source, as well as the potential downsides of a particular graft. In this article, we will discuss the options, and I will outline the factors that I discuss with my patients to help them choose the best graft for their lifestyle and activity level.

Autograft vs. Allograft

ACL grafts are broadly characterized in to autografts and allografts. Autograft tissue is obtained from another part of the patient's own body, while allografts are obtained from a tissue donor. Autograft tissue generally is harvested from around the injured knee. In rare cases, autograft tissue may be taken from the patient's non-injured knee.

The advantages of autograft tissue are the following:

Autograft tissue has a lower re-rupture rate in younger, high-activity patients

Your body will not reject autograft tissue

No risk of disease transmission

Faster incorporation/return to full activities

Lower cost

The disadvantages of autograft tissue include:

Greater post-operative pain

Potential for knee pain or weakness

Potential for a second scar over the area where the tissue is harvested

The advantages of allograft include:

Less post-operative pain

Smaller scars

Easier rehabilitation

No graft harvest site issues

The disadvantages of allograft include:

A higher re-rupture rate, particularly in young, active patients

A small risk of disease transmission or graft rejection

Higher cost

Generally speaking, I prefer autograft tissue over allograft tissue in most patients. It is more reliable, and ultimately, give me the confidence to allow the patient to return to their sport sooner.

There are three common sources for autograft ACL:

1. Patella Tendon

2. Hamstring Tendon

3. Quadriceps Tendon

In the young, high-level, or profession athlete, I will almost exclusively use patellar tendon autograft. This is the "gold standard" for ACL reconstruction with the longest track record of success. Overall, it has the lowest re-rupture rate and lowest likelihood of stretching out over time. The downside of this graft is that it is harvested from the front of the knee and can be associated with post-operative pain in certain patients. This is usually due to poor rehab, and consequently, can be avoided in most cases with appropriate physical therapy and strenghtening of the muscles around the knee.

For patients who would like to avoid the possibility of anterior (front) knee pain, or already have a history of anterior knee pain, I would advise the use of a hamstring tendon graft or quadriceps tendon graft. Both of these are excellent alternatives to the patella tendon graft.

Hamstrings also have a long track record but do have a small increased risk of stretching out over time, particularly in young females. Quadriceps tendon graft is a relatively new option but the short-term results are promising. It is a large, strong graft, and is well suited for young patients, and it is also very useful in cases of revision (redo) ACL surgery where a hamstring or patellar tendon graft may have already been harvested.

I reserve allograft for patients who are low-demand or those who simply do not want to use their own tissue.

The common sources for allograft tissue include:

1. Achilles' Tendon

2. Patella Tendon

3. Hamstring Tendon

Each of these have very similar biomechanic and biologic properties. If you choose to use allograft, speak to your doctor about the graft that she or he prefers, and the type of sterilization or processing that is utilized. In general, grafts that are harvested in a sterile fashion and minimally processed have the best biomechanical properties. Consequently, they may have lower re-rupture rates, but this is not definitively supported by the literature.

To summarize, ACL surgery is not a "one size fits all" procedure. The surgeon should work with the patient to determine which approach is best for them, and will yield the lowest risk of re-injury, and the greatest likelihood of return to sport.

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Choosing an ACL Graft - what is your best option? - Dr. Frank Petrigliano

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If you've torn your ACL and you are debating surgery, deciding on the type of graft to use to reconstruct the ligament can be a source of significant anxiety and confusion.

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Knee stiffness severely restricts patients from returning to their original exercise level. This postoperative stiffness manifests as an insufficient range of motion, which can be caused by poor graft position, cyclops lesions, and arthrofibrosis. Arthrofibrosis is caused when excessive scar tissue forms around a joint, limiting range of motion and causing pain and disability along with contributing factors in the form of infections and bleeding leading to that difficulty in restrengthening that ligament and the structures surrounding it.

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When the ACL is torn, it can cause instability in the knee, leading to abnormal wear and tear on the cartilage. Over time, osteoarthritis can develop, causing pain and reducing joint function.

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The ACL prevents the tibia from shifting too far forward over the femur and knee. Physical examinations can be done to see if this function has been lost. Observing these examinations can help us determine if more medical imaging and treatment are necessary. Therefore, physical examinations are a good starting step in the diagnosis process.

One physical examination is the Lachman test. To perform the Lachman test, one should bend the patient's knee about 30 degrees and slightly rotate the knee to the outside. Then, grab above the knee on the femur while pulling from behind the tibia. This tests the knee's anterior translation. Extreme anterior translation will be shown by the tibia not having a stopping point when pulling it forward. When performing the Lachman test, you should always compare it to the healthy knee. Looking at the healthy knee allows you to set a standard of what is "normal" anterior translation for the patient.

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Lachman Test | Anterior Cruciate Ligament (ACL) Rupture Knee

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With an ACL tear, it's difficult to bare weight on the injured limb but not completely. There are three other major ligaments that help to support the knee but by severing the ACL, it becomes a struggle to twist your body while maintaining stability. The combination of the remaining healthy ligaments and a ruptured ACL results in the limping that you may see.

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RICE stands for rest, ice, compression, and elevation. All four of these things will lessen the swelling throughout the knee. Swelling in the knee can cause pain as well as lessen the accuracy of medical imaging. Therefore it is important to do these four these when experiencing swelling in the knee after an ACL injury.

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A loss of coordination is often associated with an ACL injury, as damage to this crucial knee ligament can disrupt the stability of the joint. When the ACL is compromised, individuals may experience difficulty in controlling leg movements and maintaining balance, leading to a noticeable loss of coordination, particularly in activities that involve pivoting or rapid changes in direction.

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Though not likely, patients may also go the nonsurgical route and decide to wear a brace to protect from instability while also going through physical therapy to strengthen the surrounding ligaments to provide greater stability.

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Pain is a common symptom of ACL tears.  The ACL contains nerve endings that detects position and movement. When the ACL is torn, these nerve endings can be damaged or stretched, leading to pain signals being sent to the brain. Unfortunately, it can also irritate surrounding tissues and nerves, causing pain and resulting in inflammation.

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During an ACL injury, the body will naturally want to protect the damaged area. Inflammation occurs at the damaged area by restricting excessive movement in the damaged area. Inflammation also increases blood flow, which allows the damaged area to recover quicker. Inflammation also clears the debris and gets rid of the dead cells.

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Patients may undergo ACL reconstruction surgery which involves replacing the damaged ligament with a surgical tissue graft either from the patient's own body (tissue from the main patellar tendon or the hamstring) or donated from someone else.

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The primary way to diagnose an ACL injury is via a Magnetic Resonance Imagery. MRI is the primary imaging modality for evaluating ACL injuries. It provides detailed images of soft tissues, including ligaments, tendons, and muscles. An MRI can accurately show the location and severity of an ACL tear, as well as any associated damage to nearby structures.

The secondary way to diagnose an ACL injury is via an X-ray scan. While MRIs can show an ACL injury, X-ray examinations are able to rule out other fractures or injuries. Thus, if the X-ray examination rules out all the other conditions, it is reasonable to access the injury as an ACL injury.

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Fibroblasts contribute to the formation of connective tissue. During an ACL injury, these cells may be damaged and result in difficulty pivoting and turning. This can also result in a weakened ACL in the future

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Landing after a jump can cause an ACL injury. This is especially apparent if the landing was one-legged or if there is weakness in the hip muscles because of the external overload of body weight caused by jumping. If the knees come together while landing, one's knee may have excess stress and therefore can cause the shin bone to rotate slightly. This rotation of the shift can cause the ACL to tear or sprain on impact.

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How ligaments are involved in ACL tears?

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How ligaments are involved in ACL tears?

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Ligaments allow certain movement between bone. They are made from collagen fibers, strong and flexible bundles of tissue resistant to damage. The way they attach to bone will dictate the permitted movement of the ligament.

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When an ACL injury occurs, the anterior cruciate ligament stretches or is being twisted to the point of tearing. The detachment of this ligament leads to an instability caused by a decrease in postural control and the loading ability on the limb. The ACL helps to bind the bones of the leg to each other and when that bind is severed, it's hard to put one's body weight or pressure on that injury.

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The femur and tibia are joined together by the ACL. The ACL prevents the tibia from shifting too far forward in front of the femur. When the tibia is shifted forward due to a contact force it can cause a stretching of the ACL, now causing instability. When the tibia is pushed so far forward it starts to shear and strectch those fibers in the ACL. This pushes the strength of the ACL to it's pathophysiological limit.

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Sudden, forceful changes in direction during sports activities can place excessive stress on the ACL, leading to tears and potential knee injuries. The ACL is particularly vulnerable when the knee abruptly pivots or twists, increasing the risk of tear.

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Chondrocyte Cells are the cells responsible for the cartilage formation. These cells assist in endochondral ossification, which is the process of bone formation that cartilage scaffolds. When the chondroctye cells are damaged, the formation of the bones are cartilage surrounding the ACL can be permanently damaged by recovering into an improper and malunion location.

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Teenagers happen to be the highest-risk age group. Although athletes of all ages are at risks, most athletes are teenagers. Furthermore, ligaments in younger people have not had as much time to develop as ligaments in matured people. In addition, most young athletes train unsafely; commonly developing muscle imbalances and utilizing improper form which increases risk for ACL tears. However, with proper training, anyone can strengthen their knees and reduce the chance for ACL tears.

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An ACL injury happens when the anterior cruciate ligament, which holds the femur and tibia together, tears. Any motion that shifts the tibia forward past typical limits will tear the ligament.

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Females may have weaker hamstrings and preferential utilize the quadriceps muscle group while decelerating. Generally speaking, females tend to have weaker fiber type composition and contractile speed when compared to a male's muscular system.

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The Anterior Cruciate Ligament is one of the most common knee injuries seen, especially in the sports world. It is important to reserach and educate ourselves on the ACL because it is a truly devastating injury and one we sadly see far too often. The ACL helps keep the tibia from shifting forward. An ACL tear can completly derail ones career and make life very difficult. The recovery is a long and grueling proccess. We hope to educate oursleves on the causes, preventitive measures, treatment, and many other things in regards to the ACL.

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ACL injuries can be caused by receiving a direct blow to the knee or having a collision. Many patients complain about hearing and feeling a “pop” in their knee and feeling that their knee “gives out” from under them at the time of the injury.

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Athletes tend to experience ACL injuries the most, especially during competitions. Any physical activity that involves the ACL may result in an injury, such as the simple action of walking that people perform daily. For athletes, ACL injuries become more common as they utilize the muscle more during practices and competitions. Due to decelerating quickly, planting their foot at the wrong angle, pivoting swiftly, or any other utilization of the ACL, athletes experience ACL injuries more often than others.

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One public health intervention designed to reduce the prevalence or risk of injury to the ACL is using natural grass instead of turf. Research has shown that more knee injuries occur on artificial turf when compared to natural grass. It is hard to find an exact linkage to why but data does show that more ACL injuries occur on artificial turf. NFL executives are already pushing for every team to go towards natural grass. One challenge for making this intervention more widespread is the difference in climates across states. Some states have weather that makes growing natural grass very difficult and expensive so in the long run, they believe that artificial grass will be more cost-effective.

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Artificial turf has become an increasingly popular option for sports fields. However, artificial turf comes with its own set of harms.

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One of the most common causes for an ACL injury is through non-contact inidents. That can be from a sudden cut, plant or awkaward fall. This is often seen a lot in sports where athletes moving at high speed make a sudden plant or cut, resulting in a pop and tear of the ACL. Often times athletes ankles are firmly planted into the ground and when making a sudden cut or shift the knee and upper leg shift while ankles are planted. This results in the sudden pop and tear of the ACL. Also non contact injuries can stem from the knee/tibia being rotated inward which stretches and puts more force on the ACL. This all culminates in an ACL tear. Non contact injuries for the ACL can also occur when landing akwardly after jumping or similar incidents.

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Kyler Murray Carted Off With BAD Knee Injury - Doctor Explains

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The majority of causes for an ACL tear amongst athletes are surprisingly non-contact injuries such as sudden twists and changes in direction while running, jumping, or any other form of athletic movement. For example from the volleyball aspect, the sudden change in direction to go for a ball or landing after a hit are both large causes of ACL tears.

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Attention/focus and memory training will help those struggling to retain information, be more physically aware, and focus on multiple things. When dealing with an ACL injury, the person will become so focused on the controlled movements to keep the ACL protected, causing them to lose the ability to process the changing environment around them. This causes a decreased speed in reaction and processing time. A physical therapist can help make a patient more confident in their movements as well as make their movements become habits or muscle memory. Physical therapy can be a way to increase your body's reaction speed and memory with movements involving the leg and knee in the case of an ACL. This will allow the person suffering from an ACL injury to retain more information from their environment and react to stimuli faster because they focus less on protecting the ACL.

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Physical therapy is a treatment for ACL injuries, whether or not surgery is required. With physical therapy, restoring range of motion, strengthen the muscles around the knee, and improving stability and function are the goals.