Anterior Cruciate Ligament Injury Research Articles

An integrative approach in the management of ACL injury through Ayurveda and Physiotherapy- A Case report

The knee joint is a synovial hinge joint pivotal to human locomotion and stability. Comprising intricate articulations between the femur, tibia and patella. It facilitates complex movements, from flexion and extension to rotation. Knee ligaments are commonly injured due to indirect forces, such as twisting or bending of the knee, or rotational movements of the joint. Among these ligaments, the anterior cruciate ligament (ACL) is particularly important as it primarily prevents excessive forward movement of the tibia relative to the femur. Additionally, it contributes to the stability of the knee joint in both frontal and transverse planes. Injury to the ACL, whether through trauma or overuse, can compromise knee stability and function, often requiring surgical intervention and rehabilitation to restore optimal joint function. In the conventional treatment regimen, options like exercises, braces, lifestyle changes, and surgeries, including graft fixation, are utilized. Surgical procedures may result in complications such as post-operative stiffness and pain. These complications can impact mobility and overall quality of life, Ayurvedic treatment modalities like Snehana (oleation), Swedana (sudation), Basti Karma (medicated enema), Upanaha (local application) etc. have demonstrated notable improvements in both traumatic and degenerative conditions, with a particular emphasis on delaying the onset of osteoarthritis. The present study concludes that the integrative approach of Ayurveda and Physiotherapy helps to manage ACL injury.

Association Between Compliance with Quadriceps Strengthening Exercises and Recovery Rate in Patients after Arthroscopic ACL Reconstruction

Background: Anterior Cruciate Ligament injuries are a common occurrence, especially sports activities. Arthroscopic ACL reconstruction has become a standard surgical intervention aiming to restore knee stability and function. However, successful recovery post-surgery relies on effectiveness of rehabilitation protocols, particularly quadriceps strengthening exercises. objective :To evaluate patient compliance with prescribed quadriceps strengthening exercises after ACL reconstruction surgery. Method: Cross sectional study design was utilized .45 was sample size. convenience sampling technique was used. Individuals aged 30 to 50 who have undergone within six months post-ACL reconstruction were included .Self developed questionnaire utilized .Those who have had ACL reconstruction on the opposite knee within the last year were excluded. The study was conducted in A.O Hospital Nazimabad, CMT 2 Talwar Karachi Study ran from May 2023 to October 2023.SPSS Version 25 was utilized for statistical analysis. Results: Correlation analysis is conducted to check the relationship between the Compliance with Quadriceps Strengthening Exercises and the participant’s demographic variables such as Gender, Education, Occupation, weight and BMI. Gender and compliance with quadriceps exercises have a -1.56-correlation coefficient. The level of education and compliance with quadriceps exercises had a 3.15 correlation coefficient. The occupation and compliance with quadriceps exercises had a -2.05-correlation coefficient. Weight and compliance with quadriceps strengthening activities have a 2.79 correlation coefficient. Conclusion: Correlation and regression analyses revealed complex relationships between demographics and compliance, emphasizing its pivotal role in predicting recovery impact. Understanding these interactions is vital for tailored rehabilitation after ACL surgery.

Concomitant Popliteomeniscal Fascicles Tears Are Found in 21% of Professional Soccer Players With Acute Anterior Cruciate Ligament Injuries

PurposeTo investigate the incidence of popliteomeniscal fascicles (PMF) tears in anterior cruciate ligament (ACL) rupture in professional soccer players, to describe arthroscopic and MRI findings and treatment of these lesions with clinical outcomes, and to evaluate the incidence of subsequent lateral meniscus tears and ACL reinjury. MethodsACL reconstructions on soccer players were retrospectively analyzed, and among them, a cohort of patients with PMFs tears was reviewed. The cohort was assessed with magnetic resonance imaging (MRI) examination, arthrometric testing, Lysholm score and IKDC score. The occurrence of subsequent lateral meniscus tears and ACL reinjury were evaluated. ResultsA total of 208 ACL reconstructions were identified. From these, 43 males and 3 females with a mean age of 24 ± 4.2 years were included. Median time from injury to surgery was 5 days. Pre-operative MRI showed a tear of posterior PMFs in 24 out of 47 knees (51.1%). The mean pre-op arthrometric measured laxity was 4.3 ± 1.65 mm, and post-op 0.1 ± 1.1 mm. Pre-op Lysholm score and IKDC score were respectively 50.4 ± 25.4 and 39.6 ± 5, post-op was 98 ± 2.4 and 73.6 ± 1.2. Mean time to return to play, at the same pr-op level for all patients, was 184 ± 41.7 days. One patient underwent ACL revision due to a reinjury 9 months after surgery, while no lateral meniscus tears occurred in the follow-up period. ConclusionsPopliteomeniscal fascicles tears are found in approximately 20% of professional soccer players with acute ACL injuries. After ACL reconstruction and PFT repair, outcomes including return to play are good, ACL retear is low, and recurrent lateral meniscus tears were not observed. Level of EvidenceLevel IV, Therapeutic case series.

Using inertial measurement units to estimate ground reaction force and knee angular velocity during decelerations

Despite undergoing anterior cruciate ligament (ACL) reconstruction, athletes continue to present altered ground reaction force (GRF) and knee angular velocities (AV) for 6-24 months as they return to highly demanding tasks such as rapid decelerations (Schmitt et al., 2015, Med Sci Sports Ex, 47, 1426). In-field identification of GRF and knee AV during such deceleration tasks is challenging due to the laboratory restrictions of force platforms and 3D motion capture. Therefore, the use of inertial measurement units (IMU) has been suggested as an appropriate alternative to estimate such variables in the field (Pratt & Sigward, 2018. Sensors, 3460). The study aimed to establish whether IMU-derived measures can be used to estimate GRF and knee AV that are indicative of ACL injury risk during decelerations. Following ethical approval from the Cardiff Metropolitan Ethics Committee, ten male team-sport athletes performed five maximal decelerations at three approach speeds (100, 85, and 70% relative to maximal attainable speed), for a total of fifteen trials per athlete. GRF and kinematics were measured using four Kistler force platforms and Theia3D markerless motion capture. Pearson’s correlation coefficient was used to determine the relationship between IMeasureU Blue Trident IMUs mounted at the thigh or shank and vertical GRF, horizontal GRF, and knee AV during the first step of deceleration. A measure was considered field-viable if a very large significant correlation (r ≥ 0.7; P ≤ 0.05) was observed. At approach speeds of 85 and 70%, shank AV had a very large significant correlation (r = 0.79, 0.76; P = 0.001, 0.01, respectively) to vertical GRF, a moderate to large significant correlation to horizontal GRF (r = 0.46, 0.51; P = 0.04, 0.02, respectively), and a moderate significant correlation to knee AV (r =0.46, 0.40; P = 0.004, 0.02, respectively). At 100% approach speeds, shank AV had no significant correlation to GRF (r <0.3; P>0.05) and a moderate correlation to knee AV (r = 0.40; P = 0.02). This study was the first to find a strong association between shank AV and vertical GRF for whole-body decelerations at 85 and 70% approach speeds. This supports the use of IMUs in sport-specific settings (e.g., football pitches) to better quantify vertical GRF deficits during decelerations. This can further enhance in-field monitoring of GRF deficits and better assess athletes' readiness to return to sport following ACL reconstruction. However, alternative methods are required to accurately estimate horizontal GRFs and knee AV in the field.

Identifying unstable ramp lesions using ultrasonography.

Patients with suspected ramp lesions on magnetic resonance imaging (MRI) or ultrasonography (US) healed and showed no instability based on intraoperative arthroscopic findings. The purpose of this study was to assess the use of US in evaluating ramp lesions preoperatively and intraoperatively. Eighty-two knees that underwent anterior cruciate ligament (ACL) reconstruction between January 2022 and June 2023 were included to assess the ramp lesion complication rate and instability using arthroscopic findings. The detection rate of ramp lesions using US at the initial visit and preoperatively was also investigated. The test-retest reliability was assessed using the intraclass correlation coefficient and analyzed using two-way random effects and absolute agreement. The patients were divided into two groups based on the presence or absence of ramp lesions, and these data were compared using Student's t-test. Statistical significance was set at p < 0.05. On ultrasound examination, 90.0% of the cases had a ramp lesion at the initial examination, of which 22.2% were poorly delineated on the day of surgery. In the cases where the ramp lesion was unstable at the time of surgery, it could be delineated using US. In the cases where the ramp lesion was stable, it was difficult to delineate the lesion using US. Unstable ramp lesions complicating ACL injuries could be detected using US.

Nonanatomic femoral tunnel placement increases the risk of subsequent meniscal surgery after ACLR: Part II-Patients without recurrent ACL injury.

The purpose of this study was to identify risk factors for subsequent meniscal surgery following anterior cruciate ligament (ACL) reconstruction (ACLR) in patients without recurrent ACL injury. Patients aged ≥14 years who underwent primary ACLR with minimum 1-year follow-up and without recurrent ACL injury were retrospectively reviewed. Patient demographics and surgical data at the time of ACLR were collected. Postoperative radiographs were used to measure femoral and tibial tunnel position, and posterior tibial slope. Univariate and multivariate analyses were performed to identify risk factors for subsequent meniscal surgery. Of 629 ACLRs that fulfilled the inclusion criteria, subsequent meniscal surgery was performed in 65 [10.3%] patients. Multivariate analysis revealed that medial meniscal repair at the time of ACLR, younger age, anterior femoral tunnel position and distal femoral tunnel position were significantly associated with subsequent meniscal surgery (p < 0.001, p = 0.016, p = 0.015, p = 0.035, respectively). The frequency of femoral tunnel placement >10% outside of the literature-established anatomic position was significantly higher in those who underwent subsequent meniscal surgery compared to those who did not (38.3% vs. 20.3%, p = 0.006). Posterior tibial slope and ACL graft type were not significantly associated with subsequent meniscal surgery. Medial meniscal repair at the time of ACLR, younger age and nonanatomic femoral tunnel placement were risk factors for subsequent meniscal surgery in patients without recurrent ACL injury. Femoral tunnel placement <10% outside of the native anatomic position is important to reduce the risk of subsequent meniscal surgery. Level IV.

Application of Machine Learning Methods to Investigate Joint Load in Agility on the Football Field: Creating the Model, Part I.

Laboratory studies have limitations in screening for anterior cruciate ligament (ACL) injury risk due to their lack of ecological validity. Machine learning (ML) methods coupled with wearable sensors are state-of-art approaches for joint load estimation outside the laboratory in athletic tasks. The aim of this study was to investigate ML approaches in predicting knee joint loading during sport-specific agility tasks. We explored the possibility of predicting high and low knee abduction moments (KAMs) from kinematic data collected in a laboratory setting through wearable sensors and of predicting the actual KAM from kinematics. Xsens MVN Analyze and Vicon motion analysis, together with Bertec force plates, were used. Talented female football (soccer) players (n = 32, age 14.8 ± 1.0 y, height 167.9 ± 5.1 cm, mass 57.5 ± 8.0 kg) performed unanticipated sidestep cutting movements (number of trials analyzed = 1105). According to the findings of this technical note, classification models that aim to identify the players exhibiting high or low KAM are preferable to the ones that aim to predict the actual peak KAM magnitude. The possibility of classifying high versus low KAMs during agility with good approximation (AUC 0.81-0.85) represents a step towards testing in an ecologically valid environment.

Establishment of a Posttraumatic Osteoarthritis Model in Mice Induced by Noninvasive Anterior Cruciate Ligament Tear

Background: Animal models that use open surgical transection of the anterior cruciate ligament (ACL) do not accurately simulate the clinical condition regarding the pivot-shift mechanism and the associated inflammatory response that occurs before reconstruction. Purpose/Hypothesis: The purpose was to characterize a reproducible manual, nonsurgical method to mimic an isolated ACL tear in a clinically relevant model and to evaluate the development of progressive posttraumatic osteoarthritis due to ACL injury. It was hypothesized that the ACL could be reproducibly torn with minimal damage to other ligaments and that there would be progressive development of degenerative joint disease after ACL injury. Study Design: Controlled laboratory study. Methods: A total of 37 mice (strain C57BL/6) were used to compare the manual procedure with sham surgery (sham group; n = 10) and with the established surgical ACL transection (ACLT) procedure (surgical group; n = 27). In the sham group, a closed manual procedure was performed on the right knee and sham surgery on the left knee. In the surgical group, the closed manual procedure was performed on the right knee and surgical ACLT on the left knee. Dissection using India ink, histological assessment with safranin O and hematoxylin-eosin staining, radiological evaluation through radiographs and microfocus computed tomography scans, and gait analyses were performed to assess cartilage/ligament status. Osteoarthritis Research Society International (OARSI) and synovitis scores, anterior tibial translation, range of motion, bone microstructure, osteophyte volume, and pain were assessed at 2, 4, and 8 weeks postoperatively. Results: The manual procedure successfully resulted in an ACL rupture and associated meniscal injury. The posterior cruciate, lateral collateral, and medial collateral ligaments were intact in all dissected knees. Two weeks after ACL tear, the surgical group showed a significantly higher synovitis score, whereas 8 weeks after ACL tear, the manual group showed a significantly higher volume of osteophytes. No significant differences were found between the groups in terms of OARSI score, anterior tibial translation, range of motion, bone microstructure computed tomography values, and stride distance/irregularity. Conclusion: This procedure can be used to create an ACL tear model without causing grossly evident injuries to other ligaments and avoiding the risk of cartilage damage from surgical instruments. Clinical Relevance: This procedure offers a more clinically relevant ACL tear model and facilitates simple, inexpensive, and reproducible development of posttraumatic osteoarthritis.

Reconstruction of the Anterior Cruciate Ligament Using the Over-The-Top Technique Combined with a Lateral Plasty: A Case Report of 3 Patients

The over-the-top technique with lateral plasty is a technique that allows anterior cruciate ligament reconstruction and lateral plasty using a graft consisting of semitendinosus and gracilis that remain attached at the tibial level. This technique uses only the tibial tunnel without the femoral tunnel. We report on a series of 3 patients operated on for anterior knee instability following an anterior cruciate ligament injury in the orthopaedic department of the Delafontaine Hospital in Saint Denis, France, and discuss the results with a review of the literature.

Effect of open vs. closed kinetic chain exercises in ACL rehabilitation on knee joint pain, laxity, extensor muscles strength, and function: a systematic review with meta-analysis.

PROSPERO [CRD42023475230].

Investigation of the anatomic risk factors in acute anterior cruciate ligament ruptures to develop ramp lesions of the medial meniscus by quantitative MRI

ObjectiveTo investigate the anatomic risk factors of knee in patients with acute non-contact anterior cruciate ligament (aACL) ruptures to develop ramp lesions.MethodsA total of 202 subjects were retrospectively divided into three groups: (1) aACL ruptures combined with ramp lesions group (n = 76); (2) isolated ACL ruptures group (n = 56) and (3) normal controls group (n = 70). Quantitative morphological parameters on MRI were measured including: diameter of medial femoral condyle (MFC), anterior-posterior length and depth of medial tibial plateau (MTP AP length and depth), lateral posterior tibial slope (LPTS) and medial posterior tibial slope (MTPS), asymmetry of LPTS and MPTS (LMPTS), lateral meniscal slope (LMS), and medial meniscal slope (MMS).ResultsThe MTP AP length, MTP AP length/MFC diameter ratio, MTP depth, LPTS and the asymmetry of LMPTS showed significant differences among the three groups (p < 0.001). The risk factors associated with the ramp lesions including a longer MTP AP length (OR 1.17, 95% CI 1.00–1.44, p = 0.044), increased MTP depth (OR 1.91, 95% CI 1.22–3.00, p = 0.005) and lager ratio (OR 1.11, 95% CI 1.01–1.22, p = 0.036). The highest AUC was the MTP AP length/MFC diameter ratio (0.74; 95% CI, 0.66–0.82). The combination model increased higher accuracy (0.80; 95% CI, 0.72–0.88).ConclusionSeveral bony anatomic characteristics of the knee, especially the morphology of medial tibia plateau, are additional risk factors for aACL ruptures to develop ramp lesions.Critical relevance statementPredictive anatomic risk factors of the knee for patients with acute non-contact anterior cruciate ligament (aACL) ruptures to develop ramp lesions, especially the morphology of medial tibia plateau, are detectable by MRI.Key PointsRamp lesion development can complicate aACL ruptures and requires specific treatment.Longer AP length and increased MTP depth are risk factors for concurrent ramp lesions.Identification of ramp lesions allows for the most appropriate treatment.Graphical

3-Dimensional Biomechanics of Noncontact Anterior Cruciate Ligament Injuries in Male Professional Soccer Players

Background: The understanding of noncontact anterior cruciate ligament (ACL) injury causation in soccer has improved over the past decades. Bidimensional video analyses have significantly augmented our awareness, representing to date the only practical method to describe injury biomechanics. However, the extent of the problem continues to raise serious concerns. Purpose: To advance our understanding of the causal pathways leading to ACL injury with a large-scale reconstruction of 3-dimensional (3D) whole-body joint kinematics of injuries that occurred to male elite soccer players, as well as to compare the joint angle time course among situational patterns. Study Design: Descriptive laboratory study. Methods: A total of 33 consecutive noncontact and indirect contact ACL injuries that occurred in 6 national and 2 international professional leagues (seasons 2020-2021 to 2022-2023 until December 2022) were analyzed: (1) multiview noncoaxial television images were inspected; (2) multiple camera views were taken from 400 ms before the initial ground contact to 200 ms after the injury frame; (3) a size-matched pitch was modeled and used to calibrate cameras; (4) a 3D skeletal model was adjusted to fit the player's pose in each frame/view; and (5) poses were interpolated, and Euler joint angles were extracted. Results: The authors reconstructed the 3D lower limb joint kinematic curves preceding and during ACL injuries in 33 cases; notably, a sudden external (up to 5°) and then internal knee rotation was observed after the initial contact and before the injury frame. The overall kinematics at injury were knee moderately flexed (45.9°± 21.7°), abducted (4.3°± 5.1°), and externally rotated (3.0°± 6.4°); trunk shallowly flexed (17.4°± 12.5°) and rotated and tilted toward the injured side; and hip flexed (32.0°± 18.7°), abducted (31.1°± 12.0°), and slightly internally rotated (6.6°± 12.2°). Variable behaviors were observed at the ankle level. Conclusion: Via reconstruction of the sequence of whole-body joint motion leading to injury, we confirmed the accepted gross biomechanics (dynamic valgus trend). This study significantly enriches the current knowledge on multiplanar kinematic features (transverse and coronal plane rotations). Furthermore, it was shown that ACL injuries in male professional soccer players manifest through distinct biomechanical footprints related to the concurrent game situation. Clinical Relevance: Interventions aimed at reducing ACL injuries in soccer should consider that environmental features (ie, situational patterns) affect injury mechanics.

Anterior cruciate ligament injury and age affect knee cartilage T2 but not thickness

ObjectiveTo investigate the effect of unilateral anterior cruciate ligament (ACL) injury on cartilage thickness and composition, specifically laminar transverse relaxation time (T2) by magnetic resonance imaging (MRI), in younger and older participants and to compare within-person side differences in these parameters between ACL-injured and healthy controls. DesignQuantitative double-echo steady-state (qDESS) 3 Tesla MRI-sequences were acquired in both knees of 85 participants in four groups: 20–30 years: healthy, HEA20–30, n=24; ACL-injured, ACL20–30, n=23; 40–60 years: healthy, HEA40–60, n=24; ACL-injured, ACL40–60, n=14 (ACL injury 2–10 years prior to study inclusion). Weight-bearing femorotibial cartilages were manually segmented; cartilage T2 and thickness were computed using custom software. Mean and side difference in subregional cartilage thickness, superficial and deep cartilage T2 were compared within and between groups using non-parametric statistics. ResultsCartilage thickness did not differ within or between groups. Only the side difference in medial femorotibial cartilage thickness was greater in ACL20–30 than in HEA20–30. Deep zone T2 was longer in the ACL-injured than in the contralateral uninjured knees and than in healthy controls, especially in the lateral compartment. Most ACL-injured participants had side differences in femorotibial deep zone T2 above the threshold derived from controls. ConclusionIn the ACL-injured knee, early compositional differences in femorotibial cartilage (T2) appear to occur in the deep zone and precede cartilage thickness loss. These results suggest that monitoring laminar T2 after ACL injury may be useful in the diagnosing and monitoring early articular cartilage changes.

Management of Meniscus Pathology with Concomitant Anterior Cruciate Ligament Injury.

The purpose of this review is to summarize current clinical knowledge on the prevalence and types of meniscus pathology seen with concomitant anterior cruciate ligament (ACL) injury, as well as surgical techniques, clinical outcomes, and rehabilitation following operative management of these pathologies. Meniscus pathology with concomitant ACL injury is relatively common, with reports of meniscus pathology identified in 21-64% of operative ACL injuries. These concomitant injuries have been associated with increased age and body mass index. Lateral meniscus pathology is more common in acute ACL injury, while medial meniscus pathology is more typical in chronic ACL deficiency. Meniscus tear patterns associated with concomitant ACL injury include meniscus root tears, lateral meniscus oblique radial tears of the posterior horn (14%), and ramp lesions of the medial meniscus (8-24%). These meniscal pathologies with concomitant ACL injury are associated with increased rotational laxity and meniscal extrusion. There is a paucity of comparative studies to determine the optimal meniscus repair technique, as well as rehabilitation protocol, depending on specific tear pattern, location, and ACL reconstruction technique. There has been a substantial increase in recent publications demonstrating the importance of meniscus repair at the time of ACL repair or reconstruction to restore knee biomechanics and reduce the risk of progressive osteoarthritic degeneration. Through these studies, there has been a growing understanding of the meniscus tear patterns commonly identified or nearly missed during ACL reconstruction. Surgical management of meniscal pathology with concomitant ACL injury implements the same principles as utilized in the setting of isolated meniscus repair alone: anatomic reduction, biologic preparation and augmentation, and circumferential compression. Advances in repair techniques have demonstrated promising clinical outcomes, and the ability to restore and preserve the meniscus in pathologies previously deemed irreparable. Further research to determine the optimal surgical technique for specific tear patterns, as well as rehabilitation protocols for meniscus pathology with concomitant ACL injury, is warranted.

The Effect of Greater Area Deprivation and Medicaid Insurance Status on Timing of Care and Rate of Reinjury After Anterior Cruciate Ligament Reconstruction.

Lower socioeconomic status and public insurance lead to a longer delay to surgery and a higher likelihood of concomitant pathology before undergoing anterior cruciate ligament reconstruction (ACLR). However, few studies have examined the influence of community deprivation on ACLR timing and outcomes. The primary aim of this study was to define the effect of the area deprivation index (ADI) and insurance classification on access to orthopaedic care after an ACL rupture, and the secondary aim was to determine whether these variables were associated with a second ACL injury after primary ACLR. It was hypothesized that patients with a greater national ADI percentile and Medicaid insurance would experience longer delays to care and an increased risk of reinjury after ACLR. Cohort study; Level of evidence, 3. A retrospective study was performed to evaluate patients undergoing primary ACLR between 2016 and 2019. The national ADI percentile was obtained utilizing the Neighborhood Atlas website. The relationship between national ADI percentile and care characteristics (eg, time to specialized care) was investigated using the Spearman rho correlation coefficient (r). The association between patient and care characteristics and second ACL injury after the index procedure (ie, graft rerupture or contralateral ACL rupture) was investigated using binary logistic regression. A total of 197 patients met the inclusion criteria. Longer times from injury to surgery (r = 0.238; P < .001) and from specialized care to surgery (r = 0.217; P = .002) were associated with a greater national ADI percentile. The second injury group reported significantly greater national ADI (P = .026) and included a greater percentage of patients with Medicaid insurance (31.3%) compared with the no second injury group. Patients experienced 5.1% greater odds of a second ACL injury for each additional month between evaluation and surgery. Greater national ADI percentile and Medicaid insurance status were associated with adverse ACLR timing and outcomes. Patients with a greater national ADI percentile took significantly longer to obtain surgery after ACL injury. Those who sustained a second ACL injury after ACLR had an overall higher mean national ADI percentile and included a greater proportion of patients with Medicaid compared with those who did not sustain a second ACL injury. Future studies should critically investigate the underlying factors of these associations to reach equity in orthopaedic care.

Strength of the Uninvolved Limb Following Return to Activity After ACL Injury: Implications for Symmetry as a Marker of Sufficient Strength.

Muscular strength deficits are common after ACL injury. While the Limb Symmetry Index (LSI), using the uninvolved limb as a reference, is widely used, negative strength adaptations may affect both limbs post-injury. It is uncertain how the strength of the uninvolved limb in those with an ACL injury compares to uninjured individuals, making it unclear whether it is appropriate as a benchmark for determining sufficient strength. To compare the strength of key lower extremity muscles of the uninvolved limb in those with history of ACL injury (ACL-I) to the dominant limb in individuals with no history of ACL injury (control). Cross-sectional study. Methods: A total of 5,727 military cadets were examined, with 82 females and 126 males in the ACL-I group and 2,146 females and 3,373 males in the control group. Maximum isometric strength was assessed for six muscle groups measured with a hand-held dynamometer. Separate two-way ANOVAs with limb and sex were performed for each muscle group. Significant main effects for limb were observed with the uninvolved limb in the ACL-I group displaying greater strength compared to the dominant limb in the control group for the quadriceps, hamstrings, and gluteus medius, but effect sizes were small (Cohen's d <0.25). Significant main effects for sex were observed with greater male muscular strength in all six muscle groups with small to large effect sizes (Cohen's d 0.49-1.46). No limb-by-sex interactions were observed. There was no evidence of reduced strength in the uninvolved limb in those with a history of ACL injury compared to the dominant limb in those with no prior ACL injury. This finding suggests that, after clearance to return to activities, the uninvolved limb can be used as a standard for comparison of sufficient strength, including when using the LSI. Level of Evidence: Level 3.

Lack of Consensus on the Management of Medial Collateral Ligament Tears in the Setting of Concomitant Anterior Cruciate Ligament Injury: A Critical Analysis.

» There is no clear agreement on the optimal timing or superior type of fixation for medial collateral ligament (MCL) tears in the setting of anterior cruciate ligament (ACL) injury.» Anatomic healing of medial knee structures is critical to maintain native knee kinematics, supported by biomechanical studies that demonstrate increased graft laxity and residual valgus rotational instability after ACL reconstruction (ACLR) alone in the setting of concomitant ACL/MCL injury.» Historically, most surgeons have favored treating acute combined ACL/MCL tears conservatively with MCL rehabilitation, followed by stress radiographs at 6 weeks after injury to assess for persistent valgus laxity before performing delayed ACLR to allow for full knee range of motion, and reduce the risk of postoperative stiffness and arthrofibrosis.» However, with the advancement of early mobilization and aggressive physical therapy protocols, acute surgical management of MCL tears in the setting of ACL injury can have benefits of avoiding residual laxity and further intra-articular damage, as well as earlier return to sport.» Residual valgus laxity from incomplete MCL healing at the time of ACLR should be addressed surgically, as this can lead to an increased risk of ACLR graft failure.» The treatment of combined ACL/MCL injuries requires an individualized approach, including athlete-specific factors such as level and position of play, timing of injury related to in-season play, contact vs. noncontact sport, and anticipated longevity, as well as consideration of the tear pattern, acuity of injury, tissue quality, and surgeon familiarity with the available techniques.

Influence of the Menstrual Cycle and Training on the Performance of a Perturbed Single-Leg Squatting Task in Female Collegiate Athletes.

Anterior cruciate ligament (ACL) injuries often occur when an athlete experiences an unexpected disruption, or perturbation, during sports. ACL injury rates may also be influenced by the menstrual cycle. To determine whether training adaptations to knee control and muscle activity during a perturbed single-leg squatting (SLS) task depend on menstrual cycle phase in female athletes. Controlled laboratory study. A total of 21 healthy female collegiate athletes (current or former [<3 years]) who competed in 9 different sports performed an SLS task in which they attempted to match their knee position (user signal) to a target signal. The protocol consisted of a 9-condition pretest, 5 sets of 3 training trials, and a 9-condition posttest. One perturbation was delivered in each condition by altering the resistance of the device. Sagittal knee control (absolute error between the target signal and user signal) was assessed using a potentiometer. Muscle activity during perturbed squat cycles was normalized to maximal activation and to corresponding muscle activity during unperturbed squat cycles (%unperturbed) within the same test condition. Athletes performed the protocol during a distinct menstrual cycle phase (early follicular [EF], late follicular [LF], midluteal [ML]). Two-way mixed analysis of variance was used to determine the effects of the menstrual cycle and training on knee control and muscle activity during task performance. Venous blood was collected for hormonal analysis, and a series of health questionnaires and anthropometric measures were also assessed to determine differences among the menstrual cycle groups. After training, athletes demonstrated better knee control during the perturbed squat cycles (lower absolute error, P < .001) and greater soleus feedback responses to the perturbation (%unperturbed, P = .035). Better knee control was demonstrated in the ML phase versus the EF phase during unperturbed and perturbed squat cycles (P < .039 for both). Quadriceps activation was greater in the ML phase compared with the EF and LF phases, both immediately before and after the perturbation (P < .001 for all). Athletes learned to improve knee control during the perturbed performance regardless of menstrual cycle phase. The best knee control and greatest quadriceps activation during the perturbed squatting task was found in the ML phase. These findings may correspond to a lower incidence of ACL injury in the luteal phase and alterations in exercise performance across the menstrual cycle.

Physiotherapy management of functional activity disorders of knee dekstra et cause post-op anterior cruciate ligament reconstruction

Introduction: anterior cruciate ligament injury is one of the common knee injuries among athletes, which can cause functional activity impairment of the knee, such as pain, edema, range of motion limitation, contracture, and anxiety. Anterior cruciate ligament reconstruction is a surgical procedure that aims to restore the stability and function of the knee. Patients who undergo Anterior cruciate ligament reconstruction require appropriate physiotherapy management to accelerate the healing and recovery process. Aim: this study aims to determine the physiotherapy management of functional activity disorders of the knee joints and the causes of postoperative anterior cruciate ligament reconstruction. Methods: this study used a case study method with a research subject of a 24-year-old male who suffered an anterior cruciate ligament injury on the right knee and underwent Anterior cruciate ligament reconstruction. Data were collected using instruments such as the VAS pain scale, goniometer to measure a range of motion, MMT to measure muscle strength, and international knee documentation committee questionnaire to measure functional activity. Results: showed a decrease in pain, an increase in range of motion, an increase in muscle strength, and an increase in functional activity on the right knee caused post-op Anterior cruciate ligament reconstruction after receiving physiotherapy intervention for 9 sessions. Conclusion: physiotherapy management given in the form of electrical muscle stimulation, prone hang, passive range of motion exercise, patella mobilization, isotonic &amp; isometric strengthening, and walking exercise, as well as education, can help overcome functional activity impairment on the right knee et cause post-op anterior cruciate ligament reconstruction.

Comparison of surgical or non-surgical management for non-acute anterior cruciate ligament injury: the ACL SNNAP RCT.

Anterior cruciate ligament injury of the knee is common and leads to decreased activity and risk of secondary osteoarthritis of the knee. Management of patients with a non-acute anterior cruciate ligament injury can be non-surgical (rehabilitation) or surgical (reconstruction). However, insufficient evidence exists to guide treatment. To determine in patients with non-acute anterior cruciate ligament injury and symptoms of instability whether a strategy of surgical management (reconstruction) without prior rehabilitation was more clinically and cost-effective than non-surgical management (rehabilitation). A pragmatic, multicentre, superiority, randomised controlled trial with two-arm parallel groups and 1:1 allocation. Due to the nature of the interventions, no blinding could be carried out. Twenty-nine NHS orthopaedic units in the United Kingdom. Participants with a symptomatic (instability) non-acute anterior cruciate ligament-injured knee. Patients in the surgical management arm underwent surgical anterior cruciate ligament reconstruction as soon as possible and without any further rehabilitation. Patients in the rehabilitation arm attended physiotherapy sessions and only were listed for reconstructive surgery on continued instability following rehabilitation. Surgery following initial rehabilitation was an expected outcome for many patients and within protocol. The primary outcome was the Knee Injury and Osteoarthritis Outcome Score 4 at 18 months post randomisation. Secondary outcomes included return to sport/activity, intervention-related complications, patient satisfaction, expectations of activity, generic health quality of life, knee-specific quality of life and resource usage. Three hundred and sixteen participants were recruited between February 2017 and April 2020 with 156 randomised to surgical management and 160 to rehabilitation. Forty-one per cent (n = 65) of those allocated to rehabilitation underwent subsequent reconstruction within 18 months with 38% (n = 61) completing rehabilitation and not undergoing surgery. Seventy-two per cent (n = 113) of those allocated to surgery underwent reconstruction within 18 months. Follow-up at the primary outcome time point was 78% (n = 248; surgical, n = 128; rehabilitation, n = 120). Both groups improved over time. Adjusted mean Knee Injury and Osteoarthritis Outcome Score 4 scores at 18 months had increased to 73.0 in the surgical arm and to 64.6 in the rehabilitation arm. The adjusted mean difference was 7.9 (95% confidence interval 2.5 to 13.2; p = 0.005) in favour of surgical management. The per-protocol analyses supported the intention-to-treat results, with all treatment effects favouring surgical management at a level reaching statistical significance. There was a significant difference in Tegner Activity Score at 18 months. Sixty-eight per cent (n = 65) of surgery patients did not reach their expected activity level compared to 73% (n = 63) in the rehabilitation arm. There were no differences between groups in surgical complications (n = 1 surgery, n = 2 rehab) or clinical events (n = 11 surgery, n = 12 rehab). Of surgery patients, 82.9% were satisfied compared to 68.1% of rehabilitation patients. Health economic analysis found that surgical management led to improved health-related quality of life compared to non-surgical management (0.052 quality-adjusted life-years, p = 0.177), but with higher NHS healthcare costs (£1107, p < 0.001). The incremental cost-effectiveness ratio for the surgical management programme versus rehabilitation was £19,346 per quality-adjusted life-year gained. Using £20,000-30,000 per quality-adjusted life-year thresholds, surgical management is cost-effective in the UK setting with a probability of being the most cost-effective option at 51% and 72%, respectively. Not all surgical patients underwent reconstruction, but this did not affect trial interpretation. The adherence to physiotherapy was patchy, but the trial was designed as pragmatic. Surgical management (reconstruction) for non-acute anterior cruciate ligament-injured patients was superior to non-surgical management (rehabilitation). Although physiotherapy can still provide benefit, later-presenting non-acute anterior cruciate ligament-injured patients benefit more from surgical reconstruction without delaying for a prior period of rehabilitation. Confirmatory studies and those to explore the influence of fidelity and compliance will be useful. This trial is registered as Current Controlled Trials ISRCTN10110685; ClinicalTrials.gov Identifier: NCT02980367. This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/140/63) and is published in full in Health Technology Assessment; Vol. 28, No. 27. See the NIHR Funding and Awards website for further award information.