Anterior Cruciate Ligament

Transcription

1 ACL injury in the female athlete: Train it or sprain it John O Kane MD Associate Professor Family Medicine, Orthopaedics and Sports Medicine U.W. Head Team Physician Anterior Cruciate Ligament Keeps tibia from moving forward (anteriorly translating) under femur Helps restrain against internal and external rotation MRI of normal and torn ACL 1

2 Muscles controlling motion and forces through knee Quadriceps Hamstrings Core stabilizers Hip trunk Quadriceps extend knee and pull tibia forward (load ACL) Hamstrings flex knee and prevent tibial anterior translation (protect ACL) 2

3 Back, abdomen, and hip stabilize core Alpine Ski Lessons Alpine skiing injury statistics: % injury reduction from Tibia and ankle injury rates decreased 90% Knee injuries: from 3 to 20% of total injuries (ACL 10%) significant ligament damage from 17% to 70% Absolute number increased significantly Ettlinger 95 AJSM 3

4 Equipment and surface changes from Boots: leather to plastic Skis: more durable, faster, quicker turning Bindings: releasable & anti-friction devices Surface: more grooming and man-made snow allowing higher speeds Can a training program reduce serious knee injuries? Ski patrol subjects shown video of ACL injuries noting technical factors associated with injury Subjects once aware of high risk positions, work to avoid getting into these positions Ettlinger 95 AJSM Positions associated with ACL injury Phantom foot Skier weight back Uphill arm back Hips below knees Uphill ski unweighted Weight on inside edge of downhill ski Upper body facing downhill ski 4

5 Technical changes to avoid risky scenarios Before fall: arms forward skis within shoulders' width hands over skis avoid jumping land with knees bent While falling: flex knees don't stand until stopped avoid reaching back with uphill hand Results of training program By the third year of the program, the subject group had a 62% reduction in serious knee sprains (p<0.005) compared to a control group of patrollers 70% subjects men Ettlinger 95 AJSM What are skiing s lessons? Knee injury rates are modifiable Technique changes may be part of puzzle A certain level of training may be necessary to positively change technique (subjects all professional skiers) Beware of safer equipment Injury relocation instead of prevention Higher performance may equal more injuries 5

6 Title IX Educational programs receiving federal assistance can not exclude anyone from participation on the basis of sex , 000 female HS athletes 30,000 female college athletes 3 million female HS athletes 205, 000 female college athletes 20 years after Title IX, Female ACL epidemic comes into focus Indoor soccer: girls 43% of players, 80% of ACL tears (Lindenfeld AJSM 94) NCAA soccer: 2.4 x higher (Arendt & Dick AJSM 95) NCAA basketball: 4.1x higher (A & D AJSM 95) Alpine skiing: 3.1 x higher (Stevenson et al IOJ 98) Overall non-contact injuries in soccer, volleyball, basketball: x higher (prevention of non-contact ACL injuries 99) Fast forward 15 years Currently 3-40 ACL tears per hour 50% age In women, peak incidence age Murray 13 About 50% have associated cartilage injury Granan 09 OA in > 50%: 12 years post injury regardless of treatment Lohmander 04 6

7 Possible explanations for female ACL injury rates Hormonal Factors Anatomic Factors Heredity Neuromuscular Factors Biomechanical Factors Hormonal Factors-basic science Increasing estrogen levels decrease collagen synthesis in vitro human tissue (Yu 99) Estrogen treated rabbits with lower ACL tensile strength (Slauterbeck 99) Hormonal Factors-Clinical Research More ACL injuries menstrual days (Wojtys et al 98) Didn t control for OCPs 20 of 21 ACL injuries follicular or luteal (Arendt et al 99) More ACL injuries around ovulation (midcycle) and less luteal phase (between ovulation and menses) (Wojtys et al 02) OC use diminished significance 7

8 Hormonal Factors-Clinical Research OCP users have statistically less laxity on KT-1000 (Martineau CJSM 04) Results most significant for OCP users not currently menstruating Authors?- Might continuous OCPs protect against injury by decreasing laxity Agel, Arendt 06 Survey of NCAA soccer and BB programs 3150 athletes Evaluating ankle sprains and ACL tears Recall of menstrual cycle different than prospective assessment OCP use and day of menstrual cycle not a/w injury Hormonal Factors-Conclusions Uneven distribution of injury through menstrual cycle suggests some hormone involvement but role unclear Oral contraceptives role in injury unclear but they may decrease ligamentous laxity 8

9 Anatomic factors Anatomic factors that increase ACL risk Increased ligamentous laxity Smaller femoral notch Increased posterior tibial slope Anatomic Factors-Ligamentous laxity Females > ligamentous laxity and associated proprioceptive deficits (Rozzi 99) Beighton score >4: > 5x injury risk (Ostenberg and Roos 00) Additional studies correlate laxity by KT-1000, Beighton, or knee hyperextension with increased injury risk 9

10 Anatomic Factors-Notch width Narrow notch has smaller ligament with suggestion of increase injury risk regardless of gender Shelbourne 98 Posterior tibial slope 21.7% increased risk of noncontact ACL injury with each degree increase of the lateral tibial plateau slope among females only. Beynnon 14 Inherited predisposition- familial Case control 171 surgical ACL tears vs matched controls: subjects with ACL tear over 2x as likely to have 1 st degree relative with ACL tear Flynn et al 05 10

11 Inherited predisposition- racial Cohort study WNBA ACL tear rate per 1000 athletic exposures white/european 0.45/1000 A.A./Hispanic/Asian 0.07/1000 White/European 6x ACL injury rate Trojian AJSM 06 Anatomic factors- summary Women are more lax and laxity is associated with injury Smaller ligament more likely to be torn in both genders Post tibial slope risk factor for women Predisposition to tear ACL inherited Unfortunately, anatomy is hard to change 11

12 Neuromuscular gender differences Men through voluntarily muscle contraction, increase knee stiffness more efficiently than women Bryant, Cooke 88 Time from nerve firing to peak muscle contraction (electromechanical delay) is twice as fast in men Komi, Karlsson 78 Neuromuscular gender differences Men have greater muscle cross section Female athletes are more quad dominant and hamstring inhibited Huston 96 Hamstrings activate later and weaker than quads Unopposed quad contraction is sufficient to tear the ACL Role of gender in biomechanics Gender differences occur after maturation Prepubertal boys and girls have no difference in ACL injury rates Rate climbs for girls after age 13 Knee flexion angle with jump stop decreases for girls after 13 (Yu et al AJSM 05) 12

13 Quad/ham ratios through puberty Through puberty % increase in strength Boys: Quads-148%, hams-179% Girls: Quads-44%, hams-27% Quad/ham ratio (p<0.05) Immature boys (1.58) Mature boys (1.48) Immature girls (1.74) Mature girls (2.06) Ahmad et al, AJSM 06 Is PFP predictor for ACL tear? Girls age 13: > 15 Nm knee abduction load landing increases risk patellofemoral pain Girls age 16: >25 Nm increases risk PFP and ACL tear Those with ACL tear lower ham/quad ratio than PFP group Myer 14 Neuromuscular summary Females quad dominant Unopposed quad contraction sufficient to tear ACL at lower flexion angles Quad/ham ratio increases and knee flexion at landing decreases for girls at puberty (around age 13) coincident with rise in ACL injury rates 13

14 Biomechanical Factors-video ACL tears occur with combined loads (rotation + varus/valgus) with rapid deceleration, cutting, pivoting, or landing Women cut and land more upright with increased trunk, hip, and knee extension This position facilitates quad activation and inhibits hamstrings Biomechanical Factors-video During injury Knee flexed < 30 degrees Valgus position of knee Foot externally rotated Center of gravity behind knee Hewett et al AJSM 05 Cohort 205 females soccer, VB, BB Pretest drop jump with force plate and 3-D cameras Over 3 seasons, 9 ACL tears Injured Less flexion 2.5 x greater external knee valgus moment 20% higher vertical ground reaction force 14

15 Neuromuscular and Biomechanical summary Video and biomechanics portrait a high risk scenario for ACL injury High risk scenario Quad dominance relative to hamstring and posterior/lateral hip Low knee flexion angles at landing Increased dynamic valgus What are potential prevention strategies? Prophylactic bracing Deppen 94 4 yr HS FB, 8 teams, prospective No difference in injury rate and severity 15

16 Changes to surface Overall, higher friction increases injury risk Shoe/surface interface (Taylor 2012) Factors increasing friction Dry surface Warm surface Turf > grass or hard wood Surface risk factors American football higher risk on turf Hershman 2012 College soccer lower risk on field turf Meyers 2013 Turf may be safer at lower levels and riskier at highest levels Injury reduction training programs Henning program Caraffa program Cincinnati Sportsmetrics training program Hewett AJSM 99 PEP program Mandelbaum AJSM 05 FIFA

17 Henning program Change plant and cut to accelerated rounded turn Land hip and knee flexed, trunk balanced Decelerate 3 small steps with knees bent Instructional video-practice drills 2 Div.1 BB teams: 89% decrease ACL tears comparing 2 years before program to 2 years after. (Renstrom 08) Caraffa program Balance training program using progressively more difficult balancing boards, 20 mins QD pre-season then 3x wk. Non-randomized trial with 300 semi-pro and amateur soccer players suggests sevenfold increased ACL injury rate in those not doing program Cincinnati Sportsmetrics training program- Hewett et al AJSM 99 3 x wk for 6 wks: stretching, plyometrics, leg closed chain strengthening. Plyos become progressively more difficult and proper jumping technique emphasized 1263 H.S. BB, Soccer, VB athletes, 1 season: outcome serious ligament injury Trained girls and boy controls-no difference Untrained girls significantly more injuries 17

18 PEP- prevent injury, enhance performance Warm-up, stretching, strengthening (core emphasis), plyometrics (emphasize technique, sports specific agility training 15 minutes 3x/week PEP- U14-U18 Non-randomized First year: 84% reduction ACL tears compared to control Second year: 74% reduction PEP- NCAA D1 Randomized 2002 season, 35 control and 26 intervention teams ACL injury rate significantly lower for practices but not games Rate lower in 2cd half of season Program may take 6-8 wks to work 6 recurrences in controls and none in intervention group 18

19 FIFA-11+ Soligard et al 08 Combination of F-MARC 11 and PEP N=1892 Running, balance, plyometrics, core stability FIFA 11+ Recommended twice weekly to start at age 14 Knee injuries decreased 50%, sig. decrease in all injuries, overuse, and severe In MALES, 72% reduction lower ext injury Grooms 13 Factors that contribute to successful injury reduction program Alter loading of tibio-femoral joint Proper landing and cutting technique Landing softly on forefoot Engaging knee and hip flexion Land on 2 feet if possible Try to avoid excessive valgus Focus on knee over toe while cutting Renstrom 08 19

20 Factors that contribute to successful injury reduction program Multifaceted programs- neuromuscular and educational interventions Stretching, proprioception, strength Plyometrics, agility, core control Feedback on proper technique, body awareness Stojanovic 12 Alentorn-Geli 08 Gagnier 13 What about compliance? 4556 players (Hagglund 13) High compliance quartile 88% reduction Low quartile: NS injury reduction Significant deterioration compliance though season What about compliance? N=8118 (Wingfield 13) Overall 64% reduction in ACL tear Other severe knee injury NS Compliant (at least 1 session/wk) 83% reduction in ACL tear 82% reduction severe knee injury 47% reduction in any acute knee injury 20

21 Do you need to believe? Coaches 63% believed inadequate warm-up injury RF None believed it could prevent knee injury Players 76% believed inadequate warm-up injury RF 5% believed it could prevent knee injury Beliefs did not affect adherence to program Years of experience negatively associated with adherence. McKay 14 At what age do you start? FIFA 11+ states age 14 Peak incidence starts at age 15 Landing knee valgus increases significantly between 5 th and 9 th grade (Sasaki 13) 6 month injury prevention program though puberty significantly decreases valgus alignment (Otsuki 14) Summary Hormonal influence unclear Braces don t work and shoes should be a little slippery Anatomic risk factors include laxity, ligament size, and tibial slope Neuromuscular and biomechanical factors likely major contributors Valgus, quad dominance, inadequate knee flexion 21

22 Summary Research suggests injury reduction programs with proper components including technique modification reduce risk around 50%. Better compliance improves effectiveness. Start at puberty Sell program to kid and coach as performance enhancing 1. Ettlinger CF, Johnson RJ, Shealy JE. A method to help reduce the risk of serious knee sprains incurred in alpine skiing. Am J Sports Med. Sep-Oct 1995;23(5): Lindenfeld TN, Schmitt M, Hendy, Mangine R, Noyes FR. Incidence of Injury on Indoor Soccer. AJSM. 1994;22(3): Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med. Nov-Dec 1995;23(6): Stevenson H, Webster J, Johnson R, Beynnon B. Gender differences in knee injury epidemiology among competitive alpine ski racers. The Iowa orthopaedic journal. 1998;18: Griffin LY, Agel J, Albohm MJ, et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. The Journal of the American Academy of Orthopaedic Surgeons. May-Jun 2000;8(3): Murray M, Vavken P, Fleming B, eds. The ACL Handbook. Knee Biology, Mechanics, and Treatment. New York: Springer; Granan LP, Forssblad M, Lind M, Engebretsen L. The Scandinavian ACL registries : baseline epidemiology. Acta orthopaedica. Oct 2009;80(5): Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis Rheum. Oct 2004;50(10): Renstrom P, Ljungqvist A, Arendt E, et al. Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement. Br J Sports Med. Jun 2008;42(6): Yu WD, Liu SH, Hatch JD, Panossian V, Finerman GA. Effect of estrogen on cellular metabolism of the human anterior cruciate ligament. Clinical orthopaedics and related research. Sep 1999(366): Slauterbeck J, Clevenger C, Lundberg W, Burchfield DM. Estrogen level alters the failure load of the rabbit anterior cruciate ligament. Journal of orthopaedic research : official publication of the Orthopaedic Research Society. May 1999;17(3): Wojtys EM, Huston LJ, Lindenfeld TN, Hewett TE, Greenfield ML. Association between the menstrual cycle and anterior cruciate ligament injuries in female athletes. Am J Sports Med. Sep-Oct 1998;26(5): Arendt E, Agel J, Dick R. Anterior Cruciate Ligament Patterns Among Collegiate Men and Women. Journal of Athletic Training. 1999;34(2): Wojtys EM, Huston LJ, Boynton MD, Spindler KP, Lindenfeld TN. The effect of the menstrual cycle on anterior cruciate ligament injuries in women as determined by hormone levels. Am J Sports Med. Mar-Apr 2002;30(2): Martineau PA, Al-Jassir F, Lenczner E, Burman ML. Effect of the oral contraceptive pill on ligamentous laxity. Clin J Sport Med. Sep 2004;14(5): Agel J, Bershadsky B, Arendt EA. Hormonal therapy: ACL and ankle injury. Medicine and science in sports and exercise. Jan 2006;38(1): Rozzi SL, Lephart SM, Gear WS, Fu FH. Knee joint laxity and neuromuscular characteristics of male and female soccer and basketball players. Am J Sports Med. May-Jun 1999;27(3):

23 18. Ostenberg A, Roos H. Injury risk factors in female European football. A prospective study of 123 players during one season. Scandinavian journal of medicine & science in sports. Oct 2000;10(5): Shelbourne KD, Davis TJ, Klootwyk TE. The relationship between intercondylar notch width of the femur and the incidence of anterior cruciate ligament tears. A prospective study. Am J Sports Med. May-Jun 1998;26(3): Beynnon BD, Hall JS, Sturnick DR, et al. Increased slope of the lateral tibial plateau subchondral bone is associated with greater risk of noncontact ACL injury in females but not in males: a prospective cohort study with a nested, matched casecontrol analysis. Am J Sports Med. May 2014;42(5): Flynn RK, Pedersen CL, Birmingham TB, Kirkley A, Jackowski D, Fowler PJ. The familial predisposition toward tearing the anterior cruciate ligament: a case control study. Am J Sports Med. Jan 2005;33(1): Trojian TH, Collins S. The anterior cruciate ligament tear rate varies by race in professional Women's basketball. Am J Sports Med. Jun 2006;34(6): Bryant JT, Cooke TDV. Standardized biomechanical measurement for varusvalgus stiffness and rotation in normal knees. Journal of Orthopaedic Research. 1988;6 (6): Komi PV, Karlsson J. Skeletal muscle fibre types, enzyme activities and physical performance in young males and females. Acta physiologica Scandinavica. Jun 1978;103(2): Huston LJ, Wojtys EM. Neuromuscular performance characteristics in elite female athletes. Am J Sports Med. Jul-Aug 1996;24(4): Yu B, McClure SB, Onate JA, Guskiewicz KM, Kirkendall DT, Garrett WE. Age and gender effects on lower extremity kinematics of youth soccer players in a stop-jump task. Am J Sports Med. Sep 2005;33(9): Ahmad CS, Clark AM, Heilmann N, Schoeb JS, Gardner TR, Levine WN. Effect of gender and maturity on quadriceps-to-hamstring strength ratio and anterior cruciate ligament laxity. Am J Sports Med. Mar 2006;34(3): Myer GD, Ford KR, Di Stasi SL, Barber Foss KD, Micheli LJ, Hewett TE. High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: Is PFP itself a predictor for subsequent ACL injury? Br J Sports Med. Mar Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. Apr 2005;33(4): Deppen RJ, Landfried MJ. Efficacy of prophylactic knee bracing in high school football players. The Journal of orthopaedic and sports physical therapy. Nov 1994;20 (5): Taylor SA, Fabricant PD, Khair MM, Haleem AM, Drakos MC. A review of synthetic playing surfaces, the shoe-surface interface, and lower extremity injuries in athletes. The Physician and sportsmedicine. Nov 2012;40(4): Hershman EB, Anderson R, Bergfeld JA, et al. An analysis of specific lower extremity injury rates on grass and FieldTurf playing surfaces in National Football League Games: seasons. Am J Sports Med. Oct 2012;40(10): Meyers MC. Incidence, mechanisms, and severity of match-related collegiate women's soccer injuries on FieldTurf and natural grass surfaces: a 5-year prospective study. Am J Sports Med. Oct 2013;41(10): Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. Nov-Dec 1999;27(6): Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. Jul 2005;33(7): Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A. Prevention of anterior cruciate ligament injuries in soccer. A prospective controlled study of proprioceptive training. Knee Surg Sports Traumatol Arthrosc. 1996;4(1): Soligard T, Myklebust G, Steffen K, et al. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ. 2008;337:a Grooms DR, Palmer T, Onate JA, Myer GD, Grindstaff T. Soccer-specific warmup and lower extremity injury rates in collegiate male soccer players. J Athl Train. Nov- Dec 2013;48(6):

24 39. Stojanovic MD, Ostojic SM. Preventing ACL injuries in team-sport athletes: a systematic review of training interventions. Res Sports Med. Jul 2012;20(3-4): Alentorn-Geli E, Myer GD, Silvers HJ, et al. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 2: a review of prevention programs aimed to modify risk factors and to reduce injury rates. Knee Surg Sports Traumatol Arthrosc. Aug 2009;17(8): Gagnier JJ, Morgenstern H, Chess L. Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: a systematic review and meta-analysis. Am J Sports Med. Aug 2013;41(8): Hagglund M, Atroshi I, Wagner P, Walden M. Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT. Br J Sports Med. Oct 2013;47(15): Wingfield K. Neuromuscular training to prevent knee injuries in adolescent female soccer players. Clin J Sport Med. Sep 2013;23(5): McKay CD, Steffen K, Romiti M, Finch CF, Emery CA. The effect of coach and player injury knowledge, attitudes and beliefs on adherence to the FIFA 11+ programme in female youth soccer. Br J Sports Med. Sep 2014;48(17): Sasaki S, Tsuda E, Yamamoto Y, et al. Change with increasing age in control of the lower limbs during jump-landing in adolescents: a 5-year prospective study. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association. Sep 2013;18(5): Otsuki R, Kuramochi R, Fukubayashi T. Effect of injury prevention training on knee mechanics in female adolescents during puberty. International journal of sports physical therapy. Apr 2014;9(2):