ACL Injuries

The Anterior Cruciate Ligament (ACL) plays an important role in providing stability in the knee. In particular, it restrains the lower leg (Tibia) from translating forward in relation to the thigh (Femur). Injury to this ligament is one of the most common sports injuries with estimates between 75,000 - 250,000 new reports in the US each year ¹.

The highest incidence of ACL reconstructions are found in Skiing, followed by Australian Rules Football (AFL), Rugby, Netball and Soccer ². In soccer, ACL injuries account for 1.3% of injuries in males and 3.7% for females ³.

WHY IS THE INCIDENCE IN FEMALES HIGHER?

The reason for the increased incidence of ACL injuries in female sports people isn't clear, however studies suggest potential factors such as anatomy, hormones, strength and conditioning. The physical structure of the ligament in females has been found to be geometrically smaller than in men. Additionally it has been shown to have lower linear stiffness which is characterised by minor elongation and lower energy absorption under load when compared with males. Evidence has indicated that hormonal factors may play a role, with a significantly higher incidence of injury in the pre-ovulatory phase of the menstrual cycle ^{2, 18, 21} .

What Are Common Mechanisms Of ACL Injury?

Anterior cruciate injuries often occur while decelerating while landing from a jump or from running while the knee is slightly flexed. At the time of injury, a combined motion of knee valgus and knee internal-external rotation are common ⁷ .

Here we can see the left foot is fixed, while the knee moves in to a valgus while the leg is internally rotated.

Types Of ACL Repairs

Debate exists about the appropriateness of surgical repair for ACL injuries and is typically determined by the patients knee function or by their expectations to return to sport.  

Autograft

The harvesting of the patients own tissue from various donor sites.  Tissue commonly harvested includes the Semitendinosis tendon, Gracillis Tendon, Patellar Tendon or Quadricep tendon.

Synthetics - LARS Graft

A synthetic ligament which may be threaded through the stumps of the injured ligament to aid with support and healing of the tissue.  Debate exists about the longevity of these artificial grafts.

Allograft

Donated tissue from a cadaver.  The harvested tissue may be the Patellar tendon, hamstring tendon or even the Achilles tendon.

Typical ACL Rehab Programs

Post-Surgery⁷

Week 1

• Regular icing and elevation to reduce swelling
• The goal of full extension and 70⁰ of knee flexion by the end of the first week
• The use of knee brace and crutchs are essential
• Strengthening exercises fo the calf, hamstring and quadriceps (vastus medialis)

Week 3-4

• Aim to increase the stance phase of the operated leg during gait
• Weaning off crutches

Week 5

• Commencement of close chain exercises for the hamstrings and quadriceps (bike, leg press, step)
• Proprioception and coordination exercise may be started if strength is good

Week 10

• Forward, backward and lateral dynamic movements can be included

Month 3

• The patient can move on to functional exercises such as running and jumping
• Exercises increase in complexity, challenging speed, performance, balance and strength

Month 4-5

• Final goal is to maximise endurance and strength of the knee stabilisers
• Acceleration, deceleration, and cutting manoeuvers are done to improve arthrokinetic reflexes
• Sports specific exercise

ACL Injury Prevention Programs

As previously mentioned, altered neuromuscular control is suggested as a risk factor for non-contact ACL injuries. There have been several programs developed which aim to improve neuromuscular and proprioceptive abilities, such as the following:

• The PEP Program
• The Vermont ACL Program
• The Cincinnati Sportsmetrics Training Program
• The Henning Program

The Preventitive injury and Enhancement Program (PEP) is a specific training session that replaces a traditional warm-up. Its main forcus is to educate players on strategies to avoid injury vulnerable positions, while increasing flexibility, strength, and proprioception. In a recent study of Luke et al., young female soccer players who underwent the PEP Program had 88% less ACL injuries in the first year and 74% in the following year¹.

The PEP Program

Section 1 - Warm-Up

The purpose of the warm-up is to prepare yourself for activity which inturn reduces your risk of injury. This section consits of running in a line, running from side to side, and backward running.

Section 2 - Strengthening

This section is focused on increasing leg strength and therefore creating a more stable knee. Exercises consist of walking lunges, russian hamstring, and single toe raises.

Section 3 - Plyometrics

This section helps to build power, strength, and speed. Exercises include lateral hops over a cone, forward/backward hops over a cone, single leg hops over a cone, vertical jumps with headers, and scissor jumps.

Section 4 - Agility

Working to increase dynamic stability of the hip, knee and ankle complex. Exercises include a forward run with 3 step deceleration, lateral diagonal runs, and bounding runs.

Your usual training program is done here

Section 5 - Stretching

By preforming stretches, you can maintain your range of motion, reducess post-exercise stiffness/soreness, reduce joint stiffness, and improve your overall mobility. Stretches include calf stretching, quadricep stretching, figure four hamstring stretching, inner thigh stretching, and hip flexor stretching.

An example of setting up your field for the PEP program is shown below.


If you would like to read more about the PEP program, by following this link.
Read More...

References

¹ Tandoğan, R. N., Mann, G., & Verdonk, R. (2011). Sports injuries: prevention, diagnosis, treatment and rehabilitation. M. N. Doral (Ed.). Springer Science & Business Media.

² Janssen, K. W., Orchard, J. W., Driscoll, T. R., & Van Mechelen, W. (2012). High incidence and costs for anterior cruciate ligament reconstructions performed in Australia from 2003–2004 to 2007–2008: time for an anterior cruciate ligament register by Scandinavian model?. Scandinavian journal of medicine & science in sports, 22(4), 495-501.

³ Alentorn-Geli, E., Myer, G. D., Silvers, H. J., Samitier, G., Romero, D., Lázaro-Haro, C., & Cugat, R. (2009). Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee surgery, sports traumatology, arthroscopy, 17(7), 705-729.

⁴ Arendt, E.A.: Musculoskeletal injuries of the knee: are females at greater risk? Minn. Med. 90, 38–40 (2007)

⁵ Slauterbeck, J.R., Fuzie, S.F., Smith, M.P., et al.: The menstrual cycle, sex hormones, and anterior cruciate ligament injury. J. Athl. Train. 37, 275–278 (2002)

⁶ Wojtys, E.M., Huston, L., Boynton, M.D., et al.: The effect of men- strual cycle on anterior cruciate ligament in women as determined by hormone levels. Am. J. Sports Med. 30, 182–188 (2002)

⁷ Physiopedia - ACL Rehabilitation, accessed 22/5/2015

Getting Your Wriggle On

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Children (0-5 years) - Australian Physical Activity & Sedentary Behaviour Guidelines

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Children (5-12 years) - Australian Physical Activity & Sedentary Behaviour Guidelines

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Young People (13-17 years) - Australian Physical & Sedentary Behaviour Guidelines

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Adults (18-64 years) - Australian Physical & Sedentary Behaviour Guidelines

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Older Adults (65+ years) - Australian Physical & Sedentary Behaviour Guidelines

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Physiotherapy In Stroke

Stroke Facts and Figures

1. Stroke is Australia’s second biggest killer after coronary heart disease and a leading cause of disability.
2. 1 in 6 people will have a stroke in their lifetime. These people are someone’s sister, brother, wife, husband, daughter, son, partner, mother, father… friend. Behind the numbers are real lives.
3. In 2012 about 50,000 Australians suffered new and recurrent strokes – that is 1000 strokes every week or one stroke every 10 minutes.
4. In 2012 there were nearly 130,000 or 30% of stroke survivors under the age of 65 in the community. [In 2012 there were over 420,000 people living with the effects of stroke and 30% of these people were of working age.]
5. In 2012 there were over 420,000 people living with the effects of stroke. This is predicted to increase to 709,000 in 2032.
6. Stroke kills more women than breast cancer and more men than prostate cancer.
7. 65% of those living with stroke also suffer a disability that impedes their ability to carry out daily living activities unassisted.
8. In 2012, the total financial costs of stroke in Australia were estimated to be $5 billion.
9. The estimate of $49.3 billion in burden of disease costs for stroke is comparable to the $41 billion burden of disease costs that Deloitte Access Economics estimated for anxiety and depression in 2010.
10. The FAST test is an easy way to recognise and remember the signs of stroke. Using the FAST test involves asking these simple questions:

Face	Check their face. Has their mouth drooped?
Arm	Can they lift both arms?
Speech	Is their speech slurred? Do they understand you?
Time	Time is critical. If you see any of these signs, call 000 straight away

What is a Stroke?

A Stroke is defined as an acute neurological deficit lasting more than 24hrs and is caused by a cerebrovascular aetiology.  The translation?  Neurological symptoms that last for more than 24hrs that can be attributed to changes in the blood supply to the brain.  Strokes can be subdivided into either;

• Ischaemic
  • a reduction of the blood supply to the brain caused by a blockage or narrowing of the arteries that supply the brain.
  • approximately 85% of strokes are ischaemic
• Haemorrhagic
  • the rupture of a blood vessel in the brain which increases the pressures inside the skull and can therefore limit the delivery of oxygen rich blood to brain tissue
  • approximately 15% of strokes are haemorrhagic

Just like your muscles, brain tissue relies on a constant blood supply to deliver enough oxygen.  In fact, did you know that the brain uses more than 20% of the bodies blood and oxygen?  With such a large oxygen demand, any prolonged interruption can lead to cell damage and eventually cell death.

The brain is divided into several areas that control different functions. These include how you move your body, receive sensory messages (such as touch, sight or smell), use language and think. Because different arteries supply different areas of the brain, where the brain is damaged will determine which functions are affected.

Every stroke is different. Each person affected by stroke will have different problems and different needs. The way in which you might be affected depends on where in the brain the stroke happens and how big the stroke is. A stroke on the right side of the brain generally causes problems on the left side of the body. A stroke on the left side of the brain causes problems on the right side of the body. Some strokes happen at the base of the brain and can cause problems with eating, breathing and moving.

 So is it all doom & gloom?

Good news, there are always continuing advances in the management of stroke.  The use of clot busting drugs and advances in surgical procedures can have a large impact on the severity of symptoms following stroke.  Other advances in neuroscience include the discovery that the brain has the ability to change.  It has the ability to develop new connections between neurons.  This potential for change in the brain and nervous system is termed 'Neuroplasticity'.  It's this neuroplasticity that physiotherapy aims to capitalise on.  Through repeated practice of tasks and the promotion of functional movements, those who have suffered a stroke can make remarkable improvements in their functional capacity.  Rehabilitation that may include gait retraining, task specific training that focuses on reach and grasp, postural alignment, muscular strength & endurance exercises, and spasticity management are all areas that a physiotherapist plays a role.

Physiotherapists working in the neurological field have advanced skills in analysing deficits and clinically reasoning strategies to maximise their patients rehabilitation and ultimately improve their quality of life.  Common conditions physiotherapists encounter in neuro include Stroke, Cerebral Palsy, Multiple Sclerosis, Guillain-Barrè Syndrome, Traumatic Brain & Spinal Cord Injuries and Parkinson's Disease.

So why the article on Stroke?

My name is Luke and I'm currently in my final year of the Master of Physiotherapy program at Flinders University.  Exposure to all areas of physiotherapy, which includes neurological physio, are part of the course.  Before covering the material last semester, I had a poor understanding of neurological conditions and the impact they can have.  I believe that sharing information about common conditions helps to increase everyone's health literacy and helps dispel myths.  Over the next two months I have the exciting opportunity to be working at the Royal Adelaide Hospital in their acute neurological wards.  It's sure to be a challenging time but I'm looking forward to building on my knowledge in the neurological physiotherapy area.

Australian Sroke Foundation (2014) Retrieved from
https://strokefoundation.com.au/health-professionals/tools-and-resources/facts-and-figures-about-stroke/

AIHW 2013. Stroke and its management in Australia: an update. Cardiovascular disease series 37. Cat. no. CVD 61. Canberra: AIHW.