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group_5_presentation_3_-_anterior_cruciate_ligament_injury [2016/12/02 01:39]
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 ====== Anterior Cruciate Ligament Injury ====== ====== Anterior Cruciate Ligament Injury ======
  
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 +{{:​acl_bg.gif|}}
  
 +**Figure 1**: The green line represents the placement ​
  
 +of the ACL. (Source: http://​www.leadingmd.com)
  
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-{{:​acl.gif|}} +<br> 
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-**Figure 1**: Green line represents placement of ACL. +</HTML>
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- ​(Source:​ http://​www.leadingmd.com)+
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 The knee joint is made up of the tibia, femur, and patella. It is not a very stable joint and is prone to injury due its complexity and its weight bearing function. (Cimino et al., 2010) Thus, it is stabilized and strengthened by ligaments. Ligaments attach bone to bone, and are very strong but not very flexible. Thus, when stretched, they remain so, and can tear if stretched too far. The knee joint is stabilized by several ligaments, the medial collateral ligament, lateral collateral ligament, posterior cruciate ligament, and anterior cruciate ligament (ACL). (Cimino et al., 2010) The ACL is the primary stabilizer of the knee. It goes diagonally from the top surface of the tibia to the end of the femur. The ACL functions to stop the tibia from anterior translation and internal rotation, and also prevents the over-straightening of the femur on the tibia. (Cimino et al., 2010) The knee joint is made up of the tibia, femur, and patella. It is not a very stable joint and is prone to injury due its complexity and its weight bearing function. (Cimino et al., 2010) Thus, it is stabilized and strengthened by ligaments. Ligaments attach bone to bone, and are very strong but not very flexible. Thus, when stretched, they remain so, and can tear if stretched too far. The knee joint is stabilized by several ligaments, the medial collateral ligament, lateral collateral ligament, posterior cruciate ligament, and anterior cruciate ligament (ACL). (Cimino et al., 2010) The ACL is the primary stabilizer of the knee. It goes diagonally from the top surface of the tibia to the end of the femur. The ACL functions to stop the tibia from anterior translation and internal rotation, and also prevents the over-straightening of the femur on the tibia. (Cimino et al., 2010)
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 +&nbsp; &nbsp; {{:​acl_injury.jpg|}}
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 +&nbsp; &nbsp; &nbsp; **Figure 2**: Shows the movement in leg that results in an ACL tear.
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 +&nbsp; &nbsp; &nbsp; (Source: http://​physioworks.com.au/​)
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-====== ​Incidence ​====== +====== ​Epidemiology ​======
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-{{:​acl_injury.jpg|}}+
  
-**Figure 2**: Shows the movement in leg that results in an ACL tear. 
- 
-(Source: http://​physioworks.com.au/​) 
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 +**Incidence**
 +
 In the U.S., there are about 100,​000-200,​000 ACL ruptures per year and about 100,​000-150,​000 ACL repairs per year. (Mall et al., 2014) These numbers are based on data from several years ago, thus may be higher today due to more younger individuals engaging in high-level sports and more older individuals staying active longer. The current incidence of ACL injuries and repairs is unknown. (Mall et al., 2014) The higher number of ruptures than repairs is due to those who opt for non-surgical treatment. In the U.S., there are about 100,​000-200,​000 ACL ruptures per year and about 100,​000-150,​000 ACL repairs per year. (Mall et al., 2014) These numbers are based on data from several years ago, thus may be higher today due to more younger individuals engaging in high-level sports and more older individuals staying active longer. The current incidence of ACL injuries and repairs is unknown. (Mall et al., 2014) The higher number of ruptures than repairs is due to those who opt for non-surgical treatment.
  
-ACL injuries generally occur beginning in late adolescence. Ages leading up to late adolescence do not typically sustain ACL injuries, but rather sustain growth plate injuries due to the relative weakness of the cartilage at the epiphyseal plate compared with the ACL. (Cimino et al., 2010)  +ACL injuries generally occur beginning in late adolescence. Ages leading up to late adolescence do not typically sustain ACL injuries, but rather sustain growth plate injuries due to the relative weakness of the cartilage at the epiphyseal plate compared with the ACL. (Popkin & Murnaghan, 2012)  
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 +&nbsp; &nbsp; &nbsp; **Figure 3**: Differences in female and male bodies leading to a difference in risk of sustaining an ACL injury.  
 + 
 +&nbsp; &nbsp; &nbsp; (Source: http://​www.braceability.com/​) 
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-====== ​Risk Factors ​======+ 
 +** Risk Factors ​**
  
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 ====== Diagnosis ====== ====== Diagnosis ======
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 +**Figure 4**: Illustrates the steps for the pivot shift test (Source: Fpnotebook,​2016)
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 For the clinical examination of a suspected ACL injury, the pivot-shift test, anterior drawer test and Lachman test are used.  For the clinical examination of a suspected ACL injury, the pivot-shift test, anterior drawer test and Lachman test are used. 
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 The pivot shift is difficult to perform in the office, it is usually more helpful in the operating room with a patient under the influence of anesthesia. The pivot shift maneuver identifies abnormal motion of the knee joint when there is an ACL tear present. The pivot shift is difficult to perform in the office, it is usually more helpful in the operating room with a patient under the influence of anesthesia. The pivot shift maneuver identifies abnormal motion of the knee joint when there is an ACL tear present.
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-**Figure X**: Illustrates the steps for the pivot shift test (Source: Fpnotebook,​2016)+
  
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 The drawer test is used in the primary clinical assessment of suspected rupture of the cruciate ligaments in the knee. During the test, the patient should be supine with the hips flexed to 45 degrees, the knees flexed to 90 degrees and the feet flat on table. The drawer test is used in the primary clinical assessment of suspected rupture of the cruciate ligaments in the knee. During the test, the patient should be supine with the hips flexed to 45 degrees, the knees flexed to 90 degrees and the feet flat on table.
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 The Lachman test is known by most authorities as the most reliable and sensitive test, and usually a better alternative to the anterior drawer test. The ACL can also be detected using a magnetic resonance imaging scan (MRI scan). The Lachman test is known by most authorities as the most reliable and sensitive test, and usually a better alternative to the anterior drawer test. The ACL can also be detected using a magnetic resonance imaging scan (MRI scan).
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 Even though clinical examination if done by a professional can be accurate, the diagnosis is usually confirmed by MRI scan, which has significantly narrowed the need for diagnostic arthroscopy and which has a greater accuracy than clinical examination. It may also show a graphic of other structures which may have been involved in the injury, such as a meniscus, or collateral ligament, or posterolateral corner of the knee joint. Even though clinical examination if done by a professional can be accurate, the diagnosis is usually confirmed by MRI scan, which has significantly narrowed the need for diagnostic arthroscopy and which has a greater accuracy than clinical examination. It may also show a graphic of other structures which may have been involved in the injury, such as a meniscus, or collateral ligament, or posterolateral corner of the knee joint.
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 ====== Treatment ====== ====== Treatment ======
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-{{:​brace.jpg|Figure X: Illustrates a typical knee brace looks like.  +&nbsp; &​nbsp; ​{{:​brace.jpg|Figure X: Illustrates a typical knee brace looks like.  
- ​(Source:​ Better Braces, 2016)}}+&nbsp; &​nbsp; ​(Source: Better Braces, 2016)}}
  
-**Figure ​X**: Illustrates a typical knee brace looks like.+&nbsp; &​nbsp; ​**Figure ​5**: Illustrates a typical knee brace looks like.
  
- (Source:​Better Braces, 2016).+&nbsp; &​nbsp; ​(Source:​Better Braces, 2016).
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-{{:​surgical_treatment_1.jpg|Figure X: Demonstrates the knee and ACL before and after surgery. (Source: A.D.A.M, 2013}}+&nbsp; &​nbsp; ​{{:​surgical_treatment_1.jpg|Figure X: Demonstrates the knee and ACL before and after surgery. (Source: A.D.A.M, 2013}}
  
  
-**Figure ​X**:​Demonstrates the knee and ACL +&nbsp; &​nbsp; ​**Figure ​6**:​Demonstrates the knee and ACL 
  
-before and after surgery.  +&nbsp; &​nbsp; ​before and after surgery.  
-(Source:​A.D.A.M,​ 2013).+&nbsp; &​nbsp; ​(Source:​A.D.A.M,​ 2013).
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 {{:​allograft.jpg|Figure X: Illustrates the different type of allografts that can be used for this surgery. ​ {{:​allograft.jpg|Figure X: Illustrates the different type of allografts that can be used for this surgery. ​
-  (Source: Mayo Foundation for Medical Education and Research, 2016)}}+  (Source: Mayo Foundation for Medical Education and Research, 2016)}} ​&nbsp; &nbsp;
  
  
-**Figure ​4**:  Illustrates the different type of +**Figure ​7**:  Illustrates the different type of &nbsp; &nbsp;
  
-allografts that can be used for this surgery. ​+allografts that can be used for this surgery. ​&nbsp; &nbsp;
  
-(Source: Mayo Foundation for Medical ​+(Source: Mayo Foundation for Medical ​&nbsp; &nbsp;
  
-Education and Research, 2016).+Education and Research, 2016). ​&nbsp; &​nbsp;​ 
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-{{:​autograft.jpg|Figure X: Illustrates the retrieval and extraction of an autograft. (Source: Mayo Foundation for Medical Education and Research, 2016}}+&nbsp; &​nbsp; ​{{:​autograft.jpg|Figure X: Illustrates the retrieval and extraction of an autograft. (Source: Mayo Foundation for Medical Education and Research, 2016}}
  
  
-**Figure ​X**:​Illustrates the retrieval and +&nbsp; &​nbsp; ​**Figure ​8**:​Illustrates the retrieval and 
  
-extraction of an autograft.+&nbsp; &​nbsp; ​extraction of an autograft.
  
-(Source:​Mayo Foundation for +&nbsp; &​nbsp; ​(Source:​Mayo Foundation for 
  
-Medical Education and Research, 2016).+&nbsp; &​nbsp; ​Medical Education and Research, 2016).
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-{{:​post_surgery.jpg|Figure X: Illustrates the surgical repair of the ACL and knee.  +{{:​post_surgery.jpg|Figure X: Illustrates the surgical repair of the ACLand ​knee.  
- ​(Source:​ Tower Orthopaedics,​ 2016)}}+ ​(Source:​ Tower Orthopaedics,​ 2016)}} ​&nbsp; &nbsp;
  
-**Figure ​X**: Illustrates the surgical repair of the ACL      +**Figure ​9**: Illustrates the surgical repair of the ACL &nbsp; &nbsp;
  
-and knee. +and knee.
  
- ​(Source:​Tower Orthopaedics,​ 2016).+ ​(Source:​Tower Orthopaedics,​ 2016). ​&nbsp; &nbsp;
  
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   * Excessive Bleeding and blood clotting   * Excessive Bleeding and blood clotting
   * Persistent Knee Pain   * Persistent Knee Pain
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 ====== Rehabilitation ====== ​ ====== Rehabilitation ====== ​
  
-ACL Rehabilitation +<style justify>
 When rehabilitating an ACL injury, it is important to ensure that therapy begins immediately after surgery. The PRICE method is most commonly used to help reduce swelling and discomfort. Physical therapy revolves around strengthening the muscles surrounding the knee. The ACL itself is simply a ligament and so it is difficult to target it directly with rehabilitation,​ instead by strengthening the surrounding muscles such as the quadriceps, hamstrings, and gastrocnemius,​ we hope to help stabilize the knee and alleviate unnecessary strain on the knee and its ligaments. There are numerous exercises which can be done to strengthen these muscles and are easily found and well known, so instead of discussing different exercises we will look at open vs kinetic chain exercises and which will be better in rehabilitating the newly grafted ACL. When rehabilitating an ACL injury, it is important to ensure that therapy begins immediately after surgery. The PRICE method is most commonly used to help reduce swelling and discomfort. Physical therapy revolves around strengthening the muscles surrounding the knee. The ACL itself is simply a ligament and so it is difficult to target it directly with rehabilitation,​ instead by strengthening the surrounding muscles such as the quadriceps, hamstrings, and gastrocnemius,​ we hope to help stabilize the knee and alleviate unnecessary strain on the knee and its ligaments. There are numerous exercises which can be done to strengthen these muscles and are easily found and well known, so instead of discussing different exercises we will look at open vs kinetic chain exercises and which will be better in rehabilitating the newly grafted ACL.
  
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 When specifically looking at an ACL injury and which type of exercise would be best it is important to note the various forces acting on the knee. In an open kinetic chain exercise, such as the leg extension we have the quadriceps being activated to move the foot forward. This is an excellent exercise for quad development however the open kinetic aspect allows for an increased shearing force on the ACL as the motion being performed is one where the tibia is moving anteriorly and the femur is moving posteriorly. So, despite being an excellent exercise for strengthening the quadriceps, the leg extension would not be one of the best options for rehabilitation. Instead something like a squat which is a closed kinetic chain exercise is a much better option. This is because of the activation of the posterior chain including the hamstrings, and soleus. They help produce a posterior shearing force which counteracts the anterior force generated by the quadriceps and so there is a lower shearing force on the ACL which means it is under less stress during the squat than the leg extension. By doing something like the squat it is more beneficial for rehabilitation as progressive overload will be achievable in a shorter timeframe. Therefore it can be concluded that closed kinetic chain exercises can provide better results for rehabilitating an ACL injury. ​ When specifically looking at an ACL injury and which type of exercise would be best it is important to note the various forces acting on the knee. In an open kinetic chain exercise, such as the leg extension we have the quadriceps being activated to move the foot forward. This is an excellent exercise for quad development however the open kinetic aspect allows for an increased shearing force on the ACL as the motion being performed is one where the tibia is moving anteriorly and the femur is moving posteriorly. So, despite being an excellent exercise for strengthening the quadriceps, the leg extension would not be one of the best options for rehabilitation. Instead something like a squat which is a closed kinetic chain exercise is a much better option. This is because of the activation of the posterior chain including the hamstrings, and soleus. They help produce a posterior shearing force which counteracts the anterior force generated by the quadriceps and so there is a lower shearing force on the ACL which means it is under less stress during the squat than the leg extension. By doing something like the squat it is more beneficial for rehabilitation as progressive overload will be achievable in a shorter timeframe. Therefore it can be concluded that closed kinetic chain exercises can provide better results for rehabilitating an ACL injury. ​
  
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 +====== References ======
 +American Academy of Orthopaedic Surgeons. (2016). Anterior Cruciate Ligament (ACL) Injuries. OrthoInfo - AAOS. Retrieved from http://​orthoinfo.aaos.org/​topic.cfm?​topic=A00549 ​
  
-<​HTML>​ +Clayton, R. A. E., and Court-Brown,​ C. M. (2008). The epidemiology of musculoskeletal tendinous and ligamentous injuries. International Journal of the Care of the Injured. 39,  1338-1344.
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 +Cimino, F., Volk, B. S., and Setter, D. (2010). Anterior cruciate ligament injury: Diagnosis, management, and prevention. American Family Physician, 82(8), 917-918.
  
-====== References ======+Gianotti, S. M., Marshall, S. W., Hume, P. A., and Bunt, L. (2009). Incidence of anterior cruciate ligament injury and other knee ligament injuries: A national population-based study. Journal of Science and Medicine in Sport, 12, 622-627. 
 + 
 +Krans, B. (2016, February 22). ACL Reconstruction. Health Line. Retrieved from http://​www.healthline.com/​health/​acl-reconstruction  
 + 
 +Mall, N. A., Chalmers, P. N., Moric, M., Tanaka, M. J., Cole, B. J., Bach, B. R., and Paletta, G. A. (2014). Incidence and trends of anterior cruciate ligament reconstruction in the united states. The American Journal of Sports Medicine, 42(10), 2363-2370.
  
 Mayo Clinic. (2016). Clinical updates. Retrieved from http://​www.mayoclinic.org/​medical-professionals/​clinical-updates/​orthopedic-surgery/​anterior-cruciate-ligament-reconstruction-graft-selection Mayo Clinic. (2016). Clinical updates. Retrieved from http://​www.mayoclinic.org/​medical-professionals/​clinical-updates/​orthopedic-surgery/​anterior-cruciate-ligament-reconstruction-graft-selection
  
 +Popkin, C, A., and Murnaghan, M, L. (2012). Knee injuries in the growing athlete. Journal of Clinical Orthopaedics and Trauma, 26(1), 12-19.
 +
 +UCSF. (2016). ACL Tear. UCSF Medical Center. Retrieved from https://​www.ucsfhealth.org/​conditions/​acl_tear/​
  
 +Zazulak, B. T., Hewett, T. E., Reeves, P. N., Goldberg, B., and Cholewicki, J. (2007). Deficits in neuromuscular control of the trunk predict knee injury risk. The American Journal of Sports Medicine, 35(7), 1123.
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