Our topic. What we are going to discuss. ACL injury. ACL Injury. Societal costs of injury 5/16/2014. Anterior Cruciate Ligament Injuries

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1 Our topic Anterior Cruciate Ligament Injuries Judith R. Peterson, MD Clinical Associate Professor Sanford School of Med USD Yankton Medical Clinic What we are going to discuss ACL anatomy ACL risk factors for injury Long term issues of ACL injury Strategies for prevention of ACL injury Common sports injury Mechanisms of injury Direct Injury Indirect Injury Male athletes Female athletes ACL injury ACL Injury Common sports injury Higher rates of non contact ACL in female versus male athletes Year round female participants 5% injury rate Females and males with differing risks (Prodromos CC, Han Y, Rogowski J, et al. Arthroscopy. 2007; 23(12): ) Societal costs of injury Lifetime cost estimate for ACL surgical repair Greater than $38,000 dollars Some controversies regarding this data (Mather RC, Koenig L, Kocher MS, et al. J Bone Joint Surg Am. 2013;95: ) 1

2 ACL injury immediate expenses and issues Physician evaluation Radiography Rehabilitation Potential surgical intervention Immediate morbidity and loss of function Injury Rates Football 6.29/10,000 AE Girl s soccer 4.53/1000 AE Girls gymnastics 4.23/10,000 AE Girls versus Boys Injury Rates High School Girls at higher risk For all comparable sports RR=2.38 Men s spring football Women s gymnastics Equal injury rates College athletics (Swenson DM, Collins CL, Best TM, et al. Epidemiology of knee injuries.. Med Sci Sports Exerc. 2013; 45(3): ) (Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries J of Athletic Training. 2007;42(2): ) High Rates of Injury in College Three of the four sports with highest injury rates Women s gymnastics Women s soccer Women s basketball ACL injury Long term issues females Of young adults with ACL injuries 13.9 % knee OA by age 65 with ACL injury compared to 6% OA without ACL injury Female soccer players with ACL injury 82% with radiographic knee arthritic changes 12 years Similar findings in males 2

3 ACL crisis findings in male athletes ACL anatomy Radiographic abnormalities in 78% of evaluated knees Surgical versus conservative treatment did not affect outcome 80% of respondents with decreased activity at 14 yrs post 69% report the knee injury as the cause (Von Porat A, Roos EM, Roos H. Ann Rheum Dis 2004; 63: ) Prevents anterior tibial translation ACL Two discrete bundles Inserts tibial intercondylar eminence Variable tension depending on knee flexion angle and rotational stress Particular risk 0 40 deg knee flexion (Besier TF, Lloyd DG, Cochrane JL, et al. Med Sci Sports Exerc. 2001;33: ) ACL blood supply Injury risk factors Middle genicular artery Derives from popliteal artery Contributions inferomedial genicular Contributions inferolateral genicular Injury and blood supply damage (Flandry F and Hommel G. Sports Med Arthrosc Rev. 2011; 19(2): ) External Internal Injury risk Tackling or being tackled ACL reconstruction 3 rd most common procedure NFL prospects Most common medical fail for NFL (Shah VM et al. Return to play after ACL reconstruction in NFL athletes. Am J Sports Med. 2010; 38(11): ) Injury Risk Factors External Foot ball cleat design Shoe surface coefficient of friction 3

4 Intrinsic risk factors Genetics 23.4% of those with ACL tear have 1 st degree relative with tear Variants in metalloproteinase genes associated with ACL injury risk (Posthumus M, Scand J Med Sci Sports 2012; 22: ) Risk factors Anatomic Femoral intercondylar notch width index Femoral intercondylar notch morphology Posterior tibial slope (Shelburne KB,et al. J Orthopaedic Research 2011;29: ) Notch width Posterior tibial Slope (ajs.sagepub.com) ACL structure and risk Female ACL 8.3% lower tensile load to failure Female ACL less elastic Female ACL is shorter Smaller ACL maximal area when standardized for body weight (Anderson AF, Dome DC, Gautam S, et al.. American J Sports Med. 2001; 29(1): ) Gender specific neuromuscular activation Landing with increased knee extension Increased vertical ground forces Increased knee valgus moments (Kobayashi Het al. J Sports Sci Med. 2010; 9(4): ) 4

5 Knee Joint Morphology The Q angle Smaller knee joint articular surface Medial tibia 32.9% less surface area 33.4% less lateral tibial surface area (Faber SC. Et al Skeletal Radiol 2001; 30(3): ) Femoral to tibial angle Greater in females than males Increased Q Leads to increased ACL load Through increased lateral pull of quadriceps (Tillman MD, Bauer JA, Cauraugh JH et al. J Sports Med Phys Fitness. 2005; 45(3): ) Fatigue Peripheral fatigue Central fatigue Unilateral fatigue > increased hip internal rotation and decreased control PREVENTION Critical Even more critical once we consider risk of additional ACL injury (McLean SG and Samorezov JE. Med Sci Sports Exerc. 2009; 41(8); ) PEP Program PEP field layout Warm up, stretching, strengthening, plyometrics, agility, etc minutes On field No specialized equipment The Santa Monica Sports Medicine Research Foundation. The PEP Program: Prevent Injury and Enhance Performance. pdf 5

6 PEP 37,476 athletic exposures PEP trained (1041 trained) 68,580 for untrained (1905 controls) 2 ACL tears in protocol group 32 tears in control athletes 88% reduction in tears PEP year two 844 trained 1913 controls 30,384 AE in trained 68,868 AE in untrained 4 ACL tears in protocol 35 ACL tears in control 74% reduction ACL injury in participants compared to controls (Mandelbaum BR, Silvers HJ, et al. Am J Sports Med. 2005; 33(7): ) Cincinnati Sports Medicine Researchand Education Foundation Protocol Pre season conditioning 6 week program 3 days/week minutes AT and PT demonstrate proper stretching Cincinnati Results 23,138 AE untrained females 17,222 AE in trained females 21,390 AE control males 5 non contact ACL injuries untrained females 0 non contact ACL injuries trained females (Hewett TE et al. Am J Sports Med 1999; 27(6): ) Cincinnati Results continued Knee injury incidence per 1000 AE 0.12 trained females Knee injury incidence 0.43 in untrained female athletes Waldén protocol 6 exercises performed twice weekly 15 minute duration Progressive neuromuscular challenges 2479 protocol group 2085 control group 7 in trained group had ACL injury 14 in control group had ACL injury AE not calculated in this study (Waldén M, Atroshi I, Magnusson H, et al. Prevention of acute knee injuries in adolescent female soccer players: cluster randomized controlled trial. BMJ. 2012; 344: e3042) 6

7 Do the programs really help? Meta analysis done by Dr. Sadoghi Athletes in prevention programs do better 62% reduction in ACL injuries (Sadoghi) Do these programs assist the male athlete? Prevention program risk reduction for which athlete 85% risk reduction in males 52% in females Through adherence to a risk reduction neuromuscular re education program. (Sadoghi P et al. J Bone Joint Surg Am. 2012; 94: ) Compliance and Outcomes Improved compliance with programs Did improve outcomes Which is the ideal program? What about our younger athletes Programs have been adapted ACL program improved vertical jump height and balance No injuries from program (DiStefano LJ et al. J Strength Cond Res. 2010; 24(2): ) 7

8 Program integration Study Utah girls soccer Ages 11 collegiate Only 19.8% of respondents had ACL prevention program (Joy EA et al. Journal of Strength and Conditioning Research 2013; 27(8): ) Some thoughts on how to decrease injuries (Radiopaedia.org) Action plan for Pediatricians The athlete The PPE Offering programs Talking with athletes About prevention programs Talking with parents Talking with coaches About prevention programs About prevention programs 8

9 What we reviewed today ACL anatomy ACL risk factors for injury Long term issues of ACL injury Strategies for prevention of ACL injury Thank you very much 9