CPD Task 3 (1 Hour)
Acromial clavicular ligament (ACL) Knee injury:
The ACL provides approximately 85% of total restraining force of anterior translation. It also prevents excessive tibial medial and lateral rotation, as well as varus and valgus stresses. (Physiopedia, 2021).
Anatomy:
- The ACL is a band-like structure of dense connective tissues.
- The ACL is attached to a fossa on the posterior aspect of the medial surface of the lateral femoral condyle.
Etiology (Rolf,2007):
- Most cases are a non-contact injury.
- Athlete suffers hyperextension or valgus rotation sprain.
- Mostly a non-contact injury, where player loses balance and twists the knee.
- Ligament can rupture partially or completely.
- Often associated with other injuries in the cartilage, menisci, capsule or other ligaments.
Signs and Symptoms (Rolf,2007):
- Pain and immediate hemarthrosis caused by bleeding of a ruptured ligament.
- Common in contact sports such as football and rugby
- Often a ‘pop’ sound from the knee and inability to continue.
- Positive Anterior draw test
- Positive Pivot shift test
- Positive Lachman’s test
Differential diagnosis (Rolf,2007):
- Posterior cruciate ligament rupture
- X-Ray to rule out fractures.
- MRI can verify complete tear of ACL and associated injuries.
- Refer to orthopedic surgeon for further investigation.
Treatment:
- ACL reconstruction will allow return to professional sports in about 6-9 months.
- High risk of re-injury in first 5 years and risk of developing osteoarthritis is significant compared to non-injured knee (Rolf,2007)
- Norwegian studies showed that the prevention of ACL injuries was possible with the use of neuromuscular training programmes. According to Felson prevention of joint injuries would give an additional 14–25% reduction in the prevalence of osteoarthritis (Takeda et al., 2011).
- Proprioceptive and neuromuscular interventions after ankle and knee joint injuries can be effective for the prevention of recurrent injuries and the improvement of joint functionality (Zech, Hubsher, Banzer, Hansel, Pfeifer,2009).
- Neuromuscular exercises in an 8-week study to for patients with mild to moderate osteoarthritis (Clausen et al., 2017).
- strength gain: squat, lunge, step-up, and kettlebell swing.
- Functional performance: weight transfer, cloth under foot, mini trampoline, cable, and elastics band.
- Postural stability: pelvic lift, side-lying jumping jacks and some levels containing jumps (mini trampoline)
Phases of rehabilitation (Recovery usually takes around 9 months), as Almajidy and Naji, (2020):
- Prehabilitation before surgery.
- Acute Recovery (Phase 1)
- Ice and elevation
- Immediate weight bearing to help facilitate strength.
- Most will leave hospital on crutches to achieve normal gait pattern and prevent fatigue.
- Gentle hamstring stretches.
- Patella mobilisations to maintain patella mobility.
- Active ROM exercises as swelling permits
- Active hamstring strengthening beginning with static weight bearing co-contractions and progress to active free hamstring contractions by day
- Active quad strengthening starting with static co contractions.
- Resisted hamstring strengthening avoided for at least 6-8 weeks.
- Muscular Control and Coordination (Phase 2)
- Exercise bike as tolerated.
- Full ROM passive and active
- Progress motor control- squats, lunges, stepping, resistance bands
- Week 6 hamstring progressions (eccentric and machines introduced)
- Balance exercises
- Glute, hip, ITB, gastric, soleus and core strength
- Emphasis on glute max strength as deficits are strong predictor for Reinjury.
- Proprioception and Agility (Phase 3)
- Running may happen once good muscular strength established (usually around 3 months)
- Proprioception work should include hopping and jumping emphasising good landing techniques.
- Agility work- shuttle runs, bounding runs, sideway running, skipping etc.
- Good form in change of direction
- Sports Specific Skills (Phase 4)
- Perfect jumping, landing and change of direction techniques.
- Regain confidence in sport specific drills.
- Return to Play (Phase 5)
- FIFA 11+
- Achieve >90% on Patient Reported Outcome Score (e.g., IKDC
Subjective Score)
- >90% quads strength & >90% hop symmetry
- Completed on field sports specific rehabilitation & return to team training.
- Athlete has confidence and is comfortable to return to sports.
- Athlete understands the importance of continued injury prevention program while active in team ball sports.
References
Almajidy, A. K., Naji, S. H., & Almajidy, R. K. (2020). A prospective case study: Comparing two surgical techniques—the closing and reverse wedge osteotomy for treating clinodactyly. Iraqi National journal of Medicine, 2(1).
Clausen, B., Holsgaard-Larsen, A., & Roos, E. M. (2017). An 8-week neuromuscular exercise program for patients with mild to moderate knee osteoarthritis: a case series drawn from a registered clinical trial. Journal of athletic training, 52(6), 592-605.
Hamido, F., Habiba, A. A., Marwan, Y., Soliman, A. S., Elkhadrawe, T. A., Morsi, M. G.,… & Nagi, A. (2021). Anterolateral ligament reconstruction improves the clinical and functional outcomes of anterior cruciate ligament reconstruction in athletes. Knee Surgery, Sports Traumatology, Arthroscopy, 29(4), 1173-1180.
Rolf, C. (2007). The sports injuries handbook: diagnosis and management. A&C Black.
Takeda, H., Nakagawa, T., Nakamura, K., & Engebretsen, L. (2011). Prevention and management of knee osteoarthritis and knee cartilage injury in sports. British journal of sports medicine, 45(4), 304-309.
Zech, A., Hubscher, M., Vogt, L., Banzer, W., Hansel, F., & Pfeifer, K. (2009).
Neuromuscular training for rehabilitation of sports injuries: a systematic review. Med Sci Sports Exerc, 41(10), 1831-1841.