Anterior Cruciate Ligament (ACL) Injury - Treatment and Prognosis PDF

Anterior Cruciate Ligament David Logerstedt, PT, MPT, PhD Associate Professor Objectives Compare the epidemiology of injury to anterior cruciate ligament (ACL) Describe the mechanism of injury, symptoms & signs of ACL injuries. Describe the special tests/tissue loading utilized...

Anterior Cruciate Ligament David Logerstedt, PT, MPT, PhD Associate Professor Objectives Compare the epidemiology of injury to anterior cruciate ligament (ACL) Describe the mechanism of injury, symptoms & signs of ACL injuries. Describe the special tests/tissue loading utilized to determine the presence of injury to the ACL. Design a plan of care to address the typical impairments, activity limitations, and participation restrictions caused by ACL injuries. Design a plan of care to address the typical impairments, activity limitations, and participation restrictions ACL injury post-operatively Knee Ligaments Ligaments – critical for stability Primary stabilizer of the knee Guide movement Knee kinematics is altered when 1 or more are injured Functional deficits Sprain – varying degrees Macrotrauma vs. microtrauma Structure/tissue capacity Ligament Strength PCL ACL MCL LCL 2000-2500 1200-2200 799 392-750 Newtons 3000 2000 1000 0 Anterior Cruciate Ligament Prevalent injury: 100,000- Attachments 250,000 per year in USA Lateral femoral condyle: ~ 100,000 annually in US posteromedial surface (Hughes 2006) Anterior to medial 34/100,000 inhabitants in Norway intercondylar tubercle (Granan 2008) Three bands Incidence peaks during 3rd Anteromedial: taut in flexion & decade of life extension Posterolateral: taut in extension only Intermediate ACL-structure/tissue capacity ACL loading was higher Primary restraint to: knee flexion angle less than 30 o in Anterior translation combination with higher hip flexion and lower ankle plantar flexion angles Medial rotation from initial contact to peak knee flexion during landing (Carlson, Sheehan, & Boden , 2016) cutting/pivoting maneuver (Walden et al., 2015) Secondary restraint to: application of a quadriceps force when combined with knee internal rotation Valgus rotation valgus load combined with knee internal rotation Varus rotation excessive valgus knee loads applied during weightbearing, decelerating activities (Shim okochi & Shult z, 2008; Walden et al., 2015) ACL loading Logerstedt 2022 ACL Injury-Mechanism of Injury Non-contact Deceleration + twist Valgus collapse landing excessive IR OR combination of IR and hyperextension blow to the knee while athlete is performing cutting maneuver (“unhappy triad”) Noncontact more common than contact injuries https://www.youtube.com/watch?v=LoFimQmMrbM Concomitant Injuries Other ligaments Complete MCL lesions: ~80% incidence of concomitant ligament damage, and 95% of the time, it is ACL Fetto 1976, Halinen 2006 Meniscus High incidence of meniscal tears occur with injury to the ACL, ranging from 22% to 86%. O’Conner 2005 Articular Cartilage Nearly 50% of ACL injuries also result in damage to the articular cartilage Magnusson 2010 Risk factors Predisposing factors for the risk of sustaining a non-contact ACL injury dry weather prior ACL reconstruction shoe-surface interaction familial predisposition artificial turf compared to natural grass female sex increased body mass index pre-ovulatory phase of the menstrual narrow femoral notch size cycle in females increased anterior-posterior laxity combined loading pattern lesser concavity depth of the medial tibial plateau strong quadriceps activation during higher posterior slope of the lateral tibial eccentric contractions plateau Symptoms/signs Acute hemoarthrosis (blood in joint) – within 2-12 hours Audible “pop” with effusion – estimated 70% likelihood ACL Inability to continue activity Joint swelling Thigh weakness NM deficits MRI https://youtu.be/gNTpeCdNf8M Special Tests/Instability Lachman Test Most sensitive test for 1-plane anterior instability/acute Sensitivity Specificity **primarily tests posterolateral band Lachman 85% 94% Anterior 48% 87% Anterior Drawer Test drawer **primarily tests anteromedial band Pivot shift 82-88% 87-96% Pivot Shift Test (Anterolateral Rotatory Instability) more specific than Lachman ACL Practice Pattern Individualized HealthCare Best outcomes for every patient dependent in part by individualizing their treatment Patient goals – Some patients want to delay surgery Athlete competing for scholarship Seasonal worker Response to injury – What are the patient’s symptoms? Healthcare system and physician philosophy – Other countries Waiting lists for surgery Different practice patterns Current Practice Patterns ACL rupture Non-operative management ACL reconstruction Non-op vs Reconstruction Not all experience knee instability or activity limitations (Daniel 1995, Lephart 1992, Snyder-Mackler 1997) No differences in self-reported function (Frobell 2010) Surgery does not prevent early onset of OA (Lohmander 2007) Low prevalence (0-13%) isolated ACL Moderate (21-48%) combined injuries ICF Classification: Ligament Sprain/Tear Impairment-based categories of Knee instability (b7150 Stability of a single joint) Movement coordination impairments (b7601 Control of complex voluntary movements) Clinical findings to place patient in these categories: Passive knee instability, joint pain, effusion, movement coordination impairments Logerstedt DS, et al. JOSPT 2010, 2017 ACL Deficient athletes Recurrent giving way episodes – Increased risk for secondary injury, extending the original knee injury Meniscus tearing Articular cartilage damage – Not amenable with current surgical techniques Decline in functional activity status Key: Prospectively identifying individuals with best potential to compensate for absence of ligamentous support through enhanced dynamic knee stability Differential Response To ACL Injury Copers: asymptomatic return to pre-injury activities for at least one year – Neuromuscular adaptations result in dynamic knee stability even in absence of ligamentous stability Non-copers: symptomatic knee instability after ACL injury – Inadequate compensations in response to ligament rupture Potential copers: good knee stability early after ACL injury – Intermediate to copers and non-copers  Copers Potential Noncopers Potential Copers (PC) (NC) Noncopers (PNC) Exceptional Strength Reduced Co-contraction strength similar to kinematics strategy More potential and kinetics Transition in coordinated noncopers support movement Resemble moment to hip strategies potential Transition in noncopers support kinematically moment to Resemble ankle uninjured subjects kinetically Who is safe to test? Management Algorithm No concomitant injuries Multiple ligament laxity Repairable meniscus tear Full thickness articular cartilage injury No physical impairments Trace or less effusion Full knee ROM ≥70% Quadriceps strength Able to hop on injured leg without pain Will treat impairments prior to screening How do you classify? Functional Testing ○ Battery of tests Impairment-based Performance-based Self-reported outcomes Screening examination (Potential coper vs Potential Noncoper) Classification criteria Classification status Giving ways < 1 episode Potential coper: Meets all criteria 6-meter timed hop > 80% LSI KOS-ADLS > 80% Potential Non-coper: Fail at least one GRS > 60% criteria Prognosis Fluidity of Coper status Thoma AJSM 2019 10-session NMST program over an approximately 5 week duration progressive strengthening, plyometric, and neuromuscular exercises Success meeting or exceeding sex- and age-matched norms (15th percentile) on the International Knee Documentation Committee Subjective Knee Form (IKDC) no ACL graft rupture ≤1 episode of giving way within the last year Failure falling below IKDC age -matched norms sustaining a second ACL injury multiple episodes of giving way in the last year Outcomes after Non-op/Pre-op NM training Grindem 2014 significantly older (30.2 ± 8.8) than the surgically treated group (24.0 ± 7.2) less likely to participate in level-I sports prior to injury more likely to participate in level-II sports prior to injury (p = 0.038) Quadriceps, Hamstrings Index > 90% after training Current Practice Patterns Quadriceps strengthening – Progressive resisted exercise (Fitzgerald 2000, Perry 2005, Logerstedt 2010) – Neuromuscular electrical stimulation (NMES) (Bax 2005, Wright 2008, Kim 2010) Perturbation/Neuromuscular training – Improves knee function (Ihara 1986, Beard 1994, Fitzgerald 2000, Eitzen 2010) – Variable response to rehab (Fitzgerald 2000, Eitzen 2010) Quadriceps strength training Augments with perturbation training ○MVIC QI > 90% - home program ○MVIC QI < 90% - clinic quadriceps program ○MVIC QI < 80% - clinic program and NMES Perturbation training Rollerboard/platform Rollerboard Rockerboard Cross bracing protocol Idea to brace a knee with acute ACL rupture in 90 degrees flexion. ○ Ruptured remnants of the ACL are in closest proximity at ≥90 degrees of knee flexion ○ Hypothesised that reducing the gap between the torn ends of the ACL and holding the knee in this position could encourage the formation of a bridge of connective tissue between the torn ends of the ACL and subsequent ACL healing (Filbay BJSM 2023) 1/3 of ruptured ACLs may display evidence of healing on MRI when patients are managed with rehabilitation only, and that ACL healing may be associated with favourable outcomes 14% re-injured their ACL at a range of 5 to 18 months post bracing2. ○ These injuries occurred during high-speed skiing/cycling accidents or were rugby or Australian football (AFL) contact injuries Protocol Applying a knee brace, ideally within the first 10 days post injury Immobilizing the knee at 90 degrees flexion for the first 4 weeks, 24 hours per day Brace is then adjusted at weekly increments to allow a progressive increase in range of motion: ○ Week 1-4: brace locked at 90 degrees flexion ○ Week 5: 60 to 90 degrees flexion ○ Week 6: 45 to 90 degrees flexion ○ Week 7: 30 degrees to full flexion ○ Week 8: 20 degrees to full flexion ○ Week 9: 10 degrees to full flexion ○ Week 10-11: unrestricted knee flexion/extension in brace ○ Week 12: brace is removed ambulates non weight bearing for the initial 6-8 weeks but weight bearing is encouraged during rehabilitation exercises and ambulation as soon as the brace range of motion allows  ACL reconstruction Indications for surgery Knee “gives way” – recurrent instability High-level athletes ACL reconstruction Acceptable graft material Adequate notchplasty Tunnel(s) placement (moving target) Appropriate tensioning Adequate fixation!! Double bundle ACLR (Image: Freddie Fu, Orthopedics Today 2008)  Acceptable Graft Material (2200 N) Autograft patellar tendon (central 1/3) hamstrings (quadrupled semi-T or semi-T + gracilis) Quadriceps tendon fresh frozen allograft Graft Strength/stiffness ACL 2000 N BPTB more like ACL Maximum load to failure Hamstrings more elastic 630.8N for the Quadrupled semitendinosus graft, advantages and 473.5N for the Quadrupled disadvantages hamstring tendon graft 413.3N for the Patellar tendons 416.4N for the Quadrupled gracilis graft Bottom Line BPTB graft or quadrupled hamstring graft fixed with standard fixations should withstand the rigors of a progressive rehab program including early, full weight- bearing and emphasis on regaining full knee extension Allografts Longer to remodel Fresh frozen Cellular DNA – 4 weeks Graft Biology graft is strongest the day it is implanted weakens over the 1st 12 weeks Bridge-Enhanced Anterior Cruciate Ligament Repair use of a resorbable protein-based implant in combination with autologous blood to bridge the gap between two torn edges of a midsubstance ACL tear Outcomes ○ Mean IKDC values at final follow-up: 88.9 to 91.7 in the BEAR cohort 84.6 to 84.8 for ACLR ○ KOOS similar between BEAR vs ACLR ○ ACL repair may be associated with greater graft re-rupture rates in comparison with ACLR with failure rates reaching up to 14% in BEAR Rehabilitation-operative Pre-operative: Neuromuscular training, aggressive quadriceps strengthening (Fitzgerald 2000, Hartigan 2010) Surgical intervention: BPTB or Hamstring autograft or soft tissue allograft Post-operative: ACLR rehabilitation guidelines (criteria-based) (Manal 1996, Adams 2011)  Logerstedt 2022 Logerstedt 2017 Days 1-7 Inflammation control Full active knee extension Patellar mobility Quadriceps strengthening Gait training http://www.mikereinold.com/2013/03/reha bilitation-following-acl-reconstruction- surgery.html ROM impairments Associated with poor knee functional outcomes (Benum, 1982; K. Donald Shelbourne, Urch, et al., 2012) Persistent knee extension motion deficit can cause: Shelbourne, 2012; Shelbourne,1996 anterior knee pain quadriceps weakness increased risk of knee osteoarthritis ROM deficits pre-operative motion loss (Mauro, 2008; Shelbourne & Johnson, 1994) length of time between the injury and surgery Kwok, 2013 surgical techniques (including improper surgical techniques) (Harner, 1992; Millett, 2001) prolonged post-operative immobilization (Cosgarea, 1995) Strength Impairments Quadriceps muscle strength deficits, ranging from 15% to 40%, and atrophy of the involved limb can persist for 5 years after ACL reconstruction. (Ch mielewski, 2004; de J ong, 2007; Feller & Webster, 2003; Hartigan, 2009) negative impact on knee joint functional performance (d e Jon g, 2007 ; Hartigan, 2009; Keays, 20 03; Schmitt, 2 012) Strength deficits associated with increased risk of second ACL injury (Hurley, 1992; Schmitt, 2012) development of knee osteoarthritis (Tourville, 2013) WB exercises at low knee flexion ROM (0° to 60°) should be implemented early after ACL reconstruction because WB exercises are safe and place less shear force on the new graft when compared to NWB exercises. (Glass, 2010) Resisted NWB quadriceps exercises Initial: nonresisted active extension, immediate post-op as tolerated Early in rehabilitation, low loads to the point of muscle failure are appropriate from 90-0o (Noehren 2021) As the patient progresses, resistance must increase to at least 60% to 70% of the 1- repetition maximum. Hop performance After ACL reconstruction –Low after surgery(Perry 2005; de Jong 2007; Hopper 2008) –Improved to > 90 % at 1 year(Moksnes 2008; Hopper 2008 ) Logerstedt 2012 Neuromuscular training Increases neuromuscular awareness and improves dynamic stability of the knee joint (Cooper, 2005; Fitzgerald, 2000; Fitzgerald, 2000; Fu, 2013; Gerber, 2009; Gerber, 2007; Risberg, 2007) Similar to higher patient-reported and performance based outcomes (Hartigan, 2010; Arundale, 2017) Mitigate abnormal gait pattern prior to the reconstruction surgery (Di Stasi, 2012) Pre-operative perturbation training was effective to restore normal limb-to-limb biomechanical symmetry at 6 months after surgery (Hartigan, 2009) Our guidelines Running 3-5 months Level II sports 6-9 months position specific Level I sports 6-12 months Prognosis Functional recovery Pattern of functional recovery prior to, after ACL reconstruction (Keays 2001; Hopper 2008; Risberg 2009) High limb symmetry important in function, return to sport – Contribute to more “normal” gait pattern(Lewek 2002) – Reduce abnormal limb to limb joint loading(Shelbourne 2006; Myer 2008) – Reduce risk of further injury or reinjury(Hewett 2005; Paterno 2010) 22-28% poor knee function at one year (Hartigan 2010, Logerstedt 2012) Return to sports 69 studies looking at 7556 participants at a mean followup of 40 months (Ardern 2011) 81% had returned to some kind of sports participation 65% had returned to their pre-injury level of participation 55% had returned to competitive sport ~90% achieved normal knee function when assessed postoperatively (laxity and strength), 85% with outcome surveys Fear of re-injury was #1 reason for reduction or cessation of activity The longer the follow ups, the less % returned to sport Return to play - Level I 4 months to never median = 9 months Getting longer Patient-Report of Function 6 months common time for clearance for return-to-activities (RTA) (Barber-Westin 2011) Low patient self-report at 6 months and 1 year after surgery 2012,KSSTA, Hartigan 2010) (Logerstedt Low self-report scores in those who have NOT returned to pre-injury activities (IKDC 2000) (Lentz 2012) ACLR patients that have RTA have lower self-report scores (IKDC 2000) (Schmitt 2012) Increased of fear re-injury 1 year after surgery (Lentz 2012) 61 Return to sports decision making Creighton et al, CJSM 2010  Clearance for RTA is commonly time based (Barber-Westin 2011) Outcomes after surgery Decreased quadriceps strength (Schmitt 2012) Decreased functional performance (Logerstedt 2012, KSSTA, AJSM, Hartigan 2010) Low patient-reported measures (Hartigan 2010, Logerstedt 2012, KSSTA, Schmitt 2012) Return to sport criteria Function related to RTS Athletes with knee function below normal ranges are more likely to have not passed RTS criteria than those with knee function within normal ranges and potentially have greater risk for lower patient satisfaction, suboptimal athletic performance and re-injury. Passing screening exam and running progression beginning to practice, not direct return to preinjury level and intensity What are successful outcomes? (Lynch BJSM 2013) Incidence of 2nd injury: 3-49% Ipsilateral re-tear: History of ACLR: 15x greater Men (3x more likely) injury risk compared to healthy Hamstrings autograft Younger age Graft angle Allografts: Cutting/pivoting sports: 3.9 fold 5x more likely to require revision compared to autografts Contralateral tear: Women (6x more likely) BPTB autograft Older age Cutting/pivoting sports: 5 fold Sex and age Women: Younger athletes 16 fold greater risk of injury compared to healthy < 18 years: 17% retear 6 fold increase for ipsilateral tear 4 x greater risk compared to men 3 fold increase for contralateral with ACLR tear 18-25 years: 7% >25 years: 4%  Secondary prevention Prevention Exercises: Nordic Hamstring Curls Standing Squat Drop Jumps Triple Single-leg Hop Tuck Jumps Tim Hewett & OSTR 69 Perturbation Training or other NM Rockerboard Rollerboard with Rollerboard A/P, M/L, Diagonal Platform Involved limb Right and Left only  Quadriceps Agility Drills Strengthening What should we be counseling patients? Just because you have ACLR, doesn’t mean you will return to sports at all, and most likely not at the same level of performance Your risk of reinjury is high in the near term, higher if you are younger, higher (ipsilateral) if you are male and (contralateral) if you are female Regardless of surgery, your risk of OA is high in the long term If you need revision surgery risk of OA is higher Summary