Optimal management of ACL injury in 2007 - Part 1

[physiobob]

by Mr Andy Williams, FRCS (Orth)

Abstract
Anterior cruciate ligament (ACL) injury is relatively common. The incidence is increasing, partly due to the growing competitive nature of sport and participation of individuals in sport, and particularly involvement among women who have a significantly higher instance of ACL rupture compared to males. Despite the increase in profile of this injury the diagnosis is often missed on first presentation and even correctly diagnosed, management is not necessarily as good as one would expect.

Article Credit:

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[vickyr]

Thanks for this. Any chance of seeing part 2?

[sharileedahl]

Let see if I can get the ball rolling with some discussion about this article...
First, with an interest in prevention, I have read some articles about high school girls and ACL tears and the effect of proprioceptive training....looks like it is beneficial. What I really wanted to ask others about is their thoughts on some of the points in this article. Maybe my assessment and problem-solving is stuck in a rut with ACL injuries but...
1. I have only seen a hand full of ACL tears in the last couple years (due to place of work) however in the past, I do not recall commonly seeing lateral meniscus tears &/or "posterolateral corner" injuries with ACL ruptures. Is this a common finding with any of you reading this as noted in the article (p.7). If so, what are your typical findings (i.e. subjective / objective)?
Thanks.....

[WrightDPT]

Any thoughts on the use of open versus closed kinetic chain exercises following ACL repair. Closed chain exercises certainly have the added benefit of being more functional, utilizing proprioceptive principles, and strenghtening mutliple muscle groups. In my experience, it is common place to limit open chain knee extension from 30* to 90* for several months. It is my understanding that these limitations serve to decrease sheer stress on the graft. Any thoughts on this. I have always been curious as to how much stress is actually occuring with an unresisted open chain knee extension. In comparison to sheer stresses with typical walking activities I would think stress a long arc quad would be relatively minimal. This exercise would certainly be beneficial for increasing quad strength and VMO activity. Especially considering the post surgical inhibition of quad and VMO.

[sharileedahl]

Regarding open vs closed chain exercise....I have always gone with the same thoughts as you (WrightDPT) but I'm having a vague memory of reading an article recently regarding the minimal stress to the graft with open-chain exercise which would support the more recent support of quicker ACL rehab protocols.
I'll do a search for those papers and get back to you......

[sharileedahl]

Originally Posted by sharileedahl

Regarding open vs closed chain exercise....I have always gone with the same thoughts as you (WrightDPT) but I'm having a vague memory of reading an article recently regarding the minimal stress to the graft with open-chain exercise which would support the more recent support of quicker ACL rehab protocols.
I'll do a search for those papers and get back to you......

OK....looked through the journals that I have read at home and done a search of abstracts that I may have reviewed recently and can't find anything about shear stresses with open-chain knee extension.
So... either I'm not looking in the right spot or I made an assumption....
The most recent article re. ACL rehab that I have read goes through a progression for return-to-sport (RTS). Based on functional criteria, the athlete can be progressed much more quickly than with the traditional ACL rehab protocol with successful, early RTS as early as 2-3 months. My assumption may have been that because RTS (in some sports) could include running backward, pivoting, kicking.... then open-chain knee extension must not produce a significant enough amount of shear stress to the ACL to contraindicate the activity. (Again, this is my assumption only.)
There is a contact email address for one of the authors. I am going to send off an email to him to see what their group's thought is on this. I'll get back to you re. what I hear.

The article is....
Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Rehabilitation after Anterior Cruciate Ligament Reconstruction: Criteria-Based Progression Through the Return-to-Sport Phase. J Orthop Sports Phys Ther, 2006; 36(6): 385-402.

[jesspt]

Shari,

Here's an editorial by Kevin Wilk, PT, a US physical therapist who has contributed a lot to the releevant ACL rehab literature. He comments specifically on how fast should we be rehabbing these patients.

[sharileedahl]

Thanks for that "jesspt". It will be interesting to see long-term results of these accelerated program....I'm sure the research is coming.....

One of the points in the attached editorial made me wonder if the amount / timing of revascularization matters. The point that revascularization may not happen for many months. Yet I don't think the failure rates are that high with a traditional rehab protocol.....So - can the graft have enough strength even without being fully revascularized??????

[mira_16]

Hi sharileedahl,

I saw you request in another thread for someone to pay attention to you!

I browsed over the article and read your question. I want to read the article more closely but from what I understood they don't necessarily say it's common for the postero-lateral compartment to get injured. In my experience the medial compartment (MCL, Medial meniscus) are injured as well (ie unhappy triad injuries). Perhaps I'm wrong though. I need to brush up on my anatomy of specific attachments to remember what is under stress when the ACL is torn.
Anyways, to sum it up, I think postero-lateral injuries can occur, however I don't think they are common with ACL injuries (perhaps more so with PCL injuries). I would think medial injuries would be more common due to their attachments and areas of stress.

Correct me if i'm wrong.......?

[sharileedahl]

"Not surprisingly with the major injury that ACL rupture represents, other structures within the knee joint can be damaged. The classic 'unhappy Triad of O'Donaghue' (a combination of medial meniscal and medial collateral ligament tears with an ACL rupture) is actually very rarely associated with a fresh ACL rupture. It was described years ago when it was normal for ACL ruptures to present at a late stage after the original injury. In late presentations medial meniscal tears tend to appear. It is far more common for the lateral meniscus to be torn than the medial in an acute ACL rupture due to the lateral subluxation of the joint that typically occurs."

Thanks mira. Above is the quote that I was referring to. Reading it again, I don't think that I caught what the author was saying. The "unhappy triad" was noted to be uncommon but was found more often when ACL tears were seen well after the fact. Although you're correct that the author isn't saying that lateral meniscus tears are more common with acute ACL tears (that is the part I misunderstood), the author does say that lateral meniscal tears are more common than medial with acute tears. That is the part that surprised me. Thinking back I can't remember seeing many folks (maybe one) with lateral meniscal injuries along with an ACL tear. That being said I haven't seen a lot of "unhappy triad" injuries either. However I can think of a few with MCL involvement (but not med. meniscus).

[rocket]

The posterolateral corner gets damaged as the knee (fem-tib) joint generally dislocates when the ACL ruptures. The femur externally rotates on the tibia and falls off the back of the tibia plateau as the tibia translates anteriorly. As it falls off it grinds away on the structures of the P/Lcorner. You then get the classic bone bruising on the anterior aspect of the lateral femoral condyle and posteriorlateral tibia on MRI following an ACL rupture. I've found a small MRI picture via google but probly easier to look at one of your patient's MRI.

I remember the ACL rupture mechanism as being the opposite to the screw home mechanism of the knee when it is fully extended as the ACL helps guide that.

I find that most of my patient with "fresh" ACL ruptures have tenderness over their posterolateral joint line. It is easily missed though if you don't look for it because it is not a routine area of palpation.