ACL Injury Risk Factors and Prevention An Update. Kevin Latz, MD CMH Section of Sports Medicine

Transcription

1 ACL Injury Risk Factors and Prevention An Update Kevin Latz, MD CMH Section of Sports Medicine

2 Case Scenario 14 yo female soccer player Changed directions quickly when ball was taken from her No contact with another player Felt/heard pop Unable to continue playing Immediate onset of pain and swelling

3 ACL Anatomy

4 More ACL Anatomy

5 What We Know about ACL Tears K ACL injuries per year Majority (70%) of ACL injuries are the result of non contact mechanismcut/deceleration Women 3-5 X more likely than males to sustain a knee ligament injury (soccer/bb) Asymetrical risk begins with adolescence Most vulnerable age group Great Cost

6 Cost? Monetary surgery linked to cost savings Loss of a season Loss of peer group Academic performance/motivation Loss of academic opportunities Development of Osteoarthritis Moon group 2013 JBJS

7 What We Definitely Know Surgery entails reconstruction/replacement of ligament rather than repair Surgery is failure

8 What We Think We Know Reason(s) why women are more likely than men to be injured/risk factors Whether injury prevention programs work Identify high risk athletes

9 Risk Factors for ACL Tears Environmental Anatomic Hormonal Neuromuscular Extrinsic vs Intrinsic

10 Risk Factors for Male ACL Tears Extrinsic factors cleat, playing surface, field conditions Intrinsic factors sagital slope of tibia

11 Playing Surface (Friction is Bad) 2004 prospective study comparing Field Turf with natural grass Texas high school football 50% reduction in ACL injuries with artificial surface Increased risk with artificial floor vs wood floor in Norwegian female team handball (increased friction with artificial floor)

12 Role of Footwear Shorter cleat length and fewer cleats associated with reduced risk of knee and ankle injuries Increased shoe-surface traction risk factor for ACL injury

13 Risk Factors for Female ACL Tears Anatomical (notch width/shape (A), acl size, quadriceps angle, slope of tibia) Hormonal (estrogen, androgen) Neuromuscular (deficit in strength/recruitment of hamstrings) Biomechanical (knee valgus/extension/er) Diminished trunk control and core strength Decreased sports experience with Title IX

14 Knee Injury Prevention Programs Balance Strength Flexibility Proprioception Neuromuscular control

15 Difficulties in Evaluating Injury Prevention Programs Multiple training programs Differences in supervision, frequency, length and compliance with programs Lumping of results of different neuromuscular programs Measuring different outcomes

16 Utility of Knee Injury Prevention Programs - Shea Two year prospective study involving 1439 high school female athletes (soccer, basketball, volleyball) 20 minute program w/in practice Focus on jumping mechanics and deceleration No decrease in knee injuries Pfeiffer JBJS 2006

17 Shea (KLIP) Program

18 Utility of Knee Injury Prevention Programs - Mandelbaum 1435 Div. 1 female soccer athletes PEP (Prevent Injury and Enhance Performance) 30 minute warm up program 3 X week Trend toward decrease in knee injuries, contact and non contact ACL tears with program

19 Mandelbaum (PEP) Program

20 Efficacy of Knee Injury Prevention Reviewed literature and found 10 RCT No meta-analysis(pooling) secondary to heterogenicity Two programs resulted in decreased knee injuries No study which used ACL injuries as outcome measure showed reduction in ACL injuries Shea CORR 2012

21 Efficacy of Prevention Progams presently there is insufficient although encouraging evidence supporting the premise that ACL prevention programs improve performance or alter what are thought to be key risk factors for injury Hunt study group AJSM 2006

22 Identification of High Risk Athlete? Box jumping Aerobic conditioning

23 At Risk Athlete

24 At Risk Athlete

25 What We Don t Know - Utility of Knee Braces Number of manufacturers - Breg, Townsend, Bledsoe, Donjoy Role is to decrease anterior tibial translation Also prevents hyperextension Utilized prophylactically and post operatively

26 Evidence of Utility of Functional Bracing Randomized prospective study involving USMA intramural tackle football. Non braced athletes 3 X greater risk of ACL injuries Randomized prospective multicenter study involving reconstructed cadets found brace had no effect on incidence of graft tear Prospective study c/w decreased knee injury rate with brace use in ACL deficient professional skiers

27 Recommendations Identify high risk athletes Protect against fatigue Consider implementing a knee ligament prevention program (high risk athlete) Programs should include stretching, strengthening, aerobic conditioning, plyometrics, balance training and risk awareness If reconstruct, consider changing tibia slope