The Physician and Sportsmedicine
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State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians Matt Salzler, Benedict U. Nwachukwu, Samuel Rosas, Chau Nguyen, Tsun Yee Law, Thomas Eberle & Frank McCormick To cite this article: Matt Salzler, Benedict U. Nwachukwu, Samuel Rosas, Chau Nguyen, Tsun Yee Law, Thomas Eberle & Frank McCormick (2015) State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians, The Physician and Sportsmedicine, 43:2, 169-177 To link to this article: http://dx.doi.org/10.1080/00913847.2015.1016865
Published online: 23 Feb 2015.
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Date: 30 September 2015, At: 04:40
http://informahealthcare.com/psm ISSN: 0091-3847 (print) Phys Sportsmed, 2015; 43(2): 169–177 DOI: 10.1080/00913847.2015.1016865
CLINICAL FEATURE REVIEW
State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians Matt Salzler1, Benedict U. Nwachukwu2, Samuel Rosas3, Chau Nguyen3, Tsun Yee Law3, Thomas Eberle4 and Frank McCormick4
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1
Tufts Medical Center, Department of Orthopedic Surgery, Boston, MA, USA, 2Hospital For Special Surgery, Department of Orthopedic Surgery, New York, NY, USA, 3Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA, and 4Holy Cross Hospital, Department of Orthopedic Surgery, Fort Lauderdale, FL, USA Abstract
Keywords
The purpose of this article is to provide primary care physicians and other members of the medical community with an updated, general review on the subject of anterior cruciate ligament (ACL) tears. We aim to enhance awareness of these injuries and to prepare those practicing in the primary care setting to address these injuries. Because ACL injuries are quite common, it is very likely that a primary care physician will encounter these injuries and need to address them acutely. The current literature is replete with new concepts and controversies regarding ACL injuries, and this article provides a concise review for our target audience in regard to the care of a patient with an ACL injury. This article is composed of an overview with current epidemiologic data, basic anatomy and physiology, clinical presentation, physical examination findings, imaging modalities, and treatment options. After reading this short article, a medical care provider should understand ACL injuries and their appropriate management.
Anterior cruciate ligaments, articular ligament, physical therapy modality, physical therapy techniques
Introduction Anterior cruciate ligament (ACL) tears are among the most common knee injuries. An estimated 200,000 ACL tears occur each year in the United States [1], which amounts to 1 in 3500 people [1,3]. This type of injury occurs commonly during sporting activities such as soccer, football, and other sports involving cutting movements [5,6]. After the initial injury, many patients experience hemarthrosis, crepitus, instability, and pain. As the first medical professional to encounter these patients, a primary care physician must be able to provide a diagnostic impression and deliver proper care prior to referral to a specialist. In this article we provide the readers with the information on the anatomy and physiology of the knee, clinical presentation of ACL injuries, methods of examining the knee, imaging modalities, surgical techniques, treatment options, and current debates on the topic. Our expectation after reading this article is that primary care physicians will have the most recent information and reinforce their knowledge regarding a common knee injury such that patients can benefit from proper and timely care.
Anatomy and function Proper evaluation of ACL tears and associated injury patterns is guided by a general understanding of basic knee anatomy.
History Received 24 October 2014 Accepted 7 January 2015 Published online 23 February 2015
The ACL is one of four main ligaments that stabilize the knee joint and provides nearly 90% of the stability to anterior translation [7,8]. The femoral insertion site of the ACL is located on the lateral intercondylar wall 43% of the distance from the proximal to distal femoral articular margin and, in the anterior to posterior dimension, 2.5 mm plus the radius of the ACL footprint anterior to the posterior articular margin [9]. Previous literature described the position as 1 O’clock on the left knee and 11 O’clock position on the right knee in reference to a clock placed in the intercondylar notch. This two-dimensional reference to a three-dimensional structure led to nonanatomic ACL reconstructions, and recent literature has discarded the clock position for this more precise description of the location of the femoral origin of the ACL. The ACL’s insertion on the tibial plateau is 15 mm anterior to the posterior cruciate ligament (PCL) insertion and two-fifths of the width from the medial to lateral tibial spine [9]. The ACL is composed of two bundles: the anteromedial bundle, which tightens in knee flexion, and the larger posterolateral bundle, which tightens in knee extension [10]. These biomechanical differences allow the ACL to remain taut throughout a wide range of knee motion and enable the ACL to rotate as the knee moves from extension to flexion [7]. An intact ACL stabilizes the femur on the tibia and prevents anterior tibial translation and rotation during agility
Correspondence: Samuel Rosas, MS, Holy Cross Orthopedic Research Institute, 5597 N. Dixie Highway, Fort Lauderdale, FL 33334, USA. E-mail: [email protected] 2015 Informa UK Ltd.
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exercises, jumping, deceleration, and pivoting with sudden changes of direction [3,5,6,11]. Thus, the ACL is an important structure in maintaining full knee function. Recently, the anterolateral ligament (ALL) has gained wide attention. Segond initially described it in the nineteenth century as a “resistant band” that is now recognized as a secondary stabilizer of tibial rotation in addition to the ACL [12]. This ligament is located on the lateral knee; it arises from the lateral femoral epicondyle anterior to the lateral collateral ligament (LCL) and attaches on the lateral tibia. Because of its location, it is in close proximity to the lateral meniscus, genicular vein, and artery [12]. In a study of 206 diagnostic knee magnetic resonance imaging (MRI) confirming ACL tears, 78.8% of the knees demonstrated a concomitant injury to the ALL [13]. This suggests a relationship between the two ligaments, but further biomechanical studies are needed to determine their clinical relationship and role of the ALL, if any, in the treatment of ACL injuries.
Clinical presentation ACL injuries occur commonly in sports such as basketball, soccer, football, and wrestling, and the mechanism of injury is more commonly a noncontact injury than one caused by contact [15]. Typically, ACL tears result from landing with the knee in nearly full extension, or from pivoting while changing direction after a sudden deceleration [5,6]. Certain athletic training programs have been shown to alter athlete’s lower extremity biomechanics in order to reduce the risk of ACL injury [16,17]. A recent systematic review found that these programs provide a risk reduction of 52% in female athletes and 85% in male athletes [18]. In addition to knee pain, swelling, and difficulty in bearing weight following an ACL injury, patients typically report hearing a “pop” or feeling a tearing sensation and their knee “giving way” [19]. Approximately 80% of patients notice a rapid onset of swelling within 3 hours of injury. However, a gradual swelling over 24 hours does not rule out an ACL tear [7,19]. The swelling results from a hemarthrosis, which follows an ACL rupture. In high-impact sports, hemarthrosis may be a result of an intraarticular fracture, which must be considered during the evaluation. Patients with chronic tears often complain of instability with side-to-side movements, which may cause a fall, inability to return to recreational activities, and discomfort when walking or running. Chronic tears may also lead to further development of injuries such as meniscal tears [20], and therefore, patients may complain of meniscal pain, pain with weight bearing, kneeling, and a potential locking sensation in the knee.
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Figure 1. Illustration showing the Lachman’s test. The patient is instructed to lay supine on the table. The examiner flexes the patients’ knee to 30 flexion and must verify that the patient’s muscles are not contracted. Then the clinician places his or her hands with two fingers just below the patellar tendon insertion. Then, a gentle force is applied intended to translate the tibia anteriorly. The test is positive when the tibia translates anteriorly > 5 mm or when no firm end point is felt.
flexion, and slightly externally rotated to relax the pull of the quadriceps and iliotibial band (Figure 1) [7]. This positioning minimizes any secondary support given to the injured knee and allows for a better direct evaluation of ACL competency. The test is positive when a no firm end point is felt and/or when the tibia translates anteriorly > 5 mm. Comparison with the contralateral knee is useful as some patients may have genetic laxity. The anterior drawer test has a reported sensitivity from 80% to 99% [23] and may be used in combination with the Lachman’s test to obtain more evidence that points in the direction of an ACL tear. With the patient in the supine position and the affected knee flexed to 90 , the examiner pulls the tibia anteriorly to test for anterior translation (Figure 2). The pivot shift test is the most specific test for a complete ACL tear with a specificity of 98%, but it has a low sensitivity of 24%–48% (Figure 3) [21,22]. The pivot shift test is performed with the patient supine, the hip flexed up to 30 , and with the knee flexed at 20 , and a force is applied to further flex the knee while at the same time additional valgus force is directed toward the midline. A feeling of a shift or a “popping feeling” describes a positive test.
Physical examination findings A focused physical examination test includes the Lachman’s test, the anterior drawer, and the pivot-shift test. Assessment of ACL tear in an acute setting is best performed with the Lachman’s test, with the highest sensitivity of 85% and a specificity of 94%–99%, which combine to capture a large number of tears without including many false negatives [21,22]. The Lachman’s test evaluates the injured knee for ACL laxity by placing the knee in a position of 20 –30
Figure 2. Illustration showing the anterior drawer test. With the patients lying supine, the physician flexes the patients knee to 90 flexion and proceeds to place his or her thumbs medial and lateral to the patellar tendon. Later, a force is applied directed anteriorly looking for tibia translation. Movement > 5 mm is indicative of an anterior cruciate ligament tear, as well as a no firm end point.
DOI: 10.1080/00913847.2015.1016865
State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians
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Figure 3. Illustration showing the pivot shift test. This examination is done in the same position as in Figures 1 and 2. The patient’s knee is flexed up to 80 and a valgus force is applied while also pushing the knee toward the chest. When a pivot or a “step-wise” sensation is felt, the test is said to be positive.
Evaluating for associated injuries An isolated acute ACL rupture occurs in < 10% of the cases [24-26]. Concomitant injuries include meniscus, articular and subchondral bone injuries, as well as collateral ligament tears. ACL tears are mostly associated with meniscal injuries, with a high prevalence of 60%–75% [27,24-26]. O’Donoghue first described the “unhappy triad” in 1950, in which he described an ACL tear, a medial collateral ligament (MCL) tear, and medial meniscal injury [28]. Despite this initial description; when an ACL tear is present with a combined MCL ligament tear, the lateral meniscus is more likely to be injured than the medial meniscus [28]. These findings are currently the accepted concept of the unhappy triad, which occurs commonly after an athlete sustains a blow to the knee. In a recent multicenter study of over 1000 ACL injuries, 36% of the patients had a concomitant medial meniscus tear and 44% had a lateral meniscus tear [29]. At the time of injury, the lateral meniscus is most commonly damaged. However, after the injury, persistent episodes of instability that displace the tibia lead to medial meniscus tears as the medial meniscus is a secondary restraint to anterior translation of the tibia. In addition to meniscal injuries, chondral injuries also often occur at the time of injury when there is an abnormal contact between the articular surfaces. Care must be taken to evaluate for collateral ligament injuries including the MCL and LCL as these injuries often occur in conjunction with ACL tears. To test for MCL and LCL stability, with the patient supine on the table, the examiner holds the femur in place at 0 and then at 30 of knee flexion with one hand while applying a valgus (for MCL) and then a varus force (for LCL) to the knee. A positive test for a collateral ligament tear will be > 5 of opening or asymmetry as compared with the uninjured knee. The PCL should also be examined when an injury to the knee has occurred. The incidence of PCL injuries varies according to the patient population and the inciting event, that is, traumatic injury or non-traumatic. The overall incidence reported by Wind et al. is 3% in the general population, whereas in the traumatic setting the overall incidence is 37%. In high-velocity injuries, the same authors found PCL injuries in 95% of combined ligaments knee injuries. The most
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commonly performed test to clinically evaluate the competency of the PCL is the posterior drawer test, which is performed in the same manner as the anterior drawer test, although with a posteriorly directed force applied to the tibia. A positive test constitutes an ill-defined end point of tibial translation and/or if the tibia translates > 10–15 mm [30]. This test has been reported to have 90% sensitivity and 99% specificity [31]. The quad activation test is also used in the examination of the PCL. It is performed by placing the patient in a supine position and flexing the patients’ knee to 90 . The examiner sits on the patients’ foot and asks the patient to “kick” or apply force directing the foot to the ceiling. This force causes the quadriceps muscle to activate, and if a PCL injury exists, the tibia is translated anteriorly. A systematic review reported sensitivity ranging from 53% to 98% and specificity ranging from 96% to 100%, and recommended that the quadriceps activation test be used for detecting a PCL injury. In addition to evaluating for other ligamentous injuries, meniscal injuries should be examined with the McMurray’s test and by assessing joint line tenderness. McMurray’s test is performed by having the patient lay supine on the table. The clinician flexes the knee to 90 and applies a rotational force to the tibia. The lateral meniscus is examined with external rotation, and the medial meniscus is examined with internal rotation. Pain and/or clicking at 90 indicate a positive McMurray’s test. The sensitivity for this exam ranges from 16% to 86% with a 29%–96% specificity [32]. In a study that evaluated 109 patients with a history of possible meniscal injuries, the diagnostic accuracy of joint line tenderness for meniscal injuries was reported to be 81% for medial meniscal injuries and 90% for lateral meniscus (Figure 4) [33]. This test is performed by applying pressure with a finger at the joint line of the knee, and the patient acknowledges whether they have pain.
Imaging Isolated acute ACL tear injuries typically appear normal on plain X-ray films. However, the presence of a Segond fracture, a small avulsion fracture of the lateral tibial eminence, is highly suggestive of ACL rupture [3].
Figure 4. Illustration showing the palpation for joint line tenderness test. This is done by pressing over the bones of the joint. In order to better define the joint line, the clinician can flex and extend the knee to observe where the joint contact points are located.
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MRI is the most accurate noninvasive diagnostic modality in identifying a torn ACL, with sensitivity of 86%–95.9%, and specificity of 91%–95% [1]. MRI findings include direct and indirect signs of injury, with indirect signs representing findings seen not directly on the ACL fibers. A normal ACL appears as dark signal with a normal trajectory, and the lack of dark signal with disorganized or disrupted fibers implies an ACL injury. Indirect signs are equally as important. A pathognomonic sign for an ACL rupture is the presence of bone bruising which can be seen as a distortion of the normal appearance of the bone on either the femur or tibia. Other indirect signs include anterior tibial translation seen in a sagittal view, which is measured by tracing a vertical line from the posterior femur toward the ground; the posterior aspect of the tibia must not be further than 7 mm anterior to this line. This has a sensitivity of 86% and sensitivity of 99% for ACL tears. When anterior tibial translation occurs, a second indirect sign may appear as the uncovering of the posterior aspect of the lateral meniscus, which is seen when a portion of the lateral meniscus is more posterior than the tibia. Another useful sign is to determine whether the ACL fibers are parallel to Blumensaat’s line, a line is traced on a sagittal view from the posterior aspect of the femur to the most anterior portion of the tibia. Another indirect sign of an ACL tear is viewing of the entirety of the LCL fibers in one coronal MRI slice [35]. Much of the reliance on indirect signs is due to the fact that the ACL does not lie directly in the sagittal or coronal plane, making direct visualization suboptimal. Recently, the use of a sagittal oblique MRI in the plane of the ACL has been described to better evaluate the ACL directly [36,37]. Every lesion occurring at the knee has its own direct and indirect signs; for that reason we suggest discussing the MRI with a radiologist or orthopedic surgeon when in doubt of the findings. Further, with the knowledge that only 10% of ACL tears are isolated ACL injuries, the majority of patients require an MRI not only to confirm the ACL injury but also as an important preoperative test in order manage patients according to the entirety of their pathology.
Surgical versus conservative treatment The management of ACL injuries includes both conservative and surgical interventions. The ideal goal of either treatment plan is to provide the knee with the stability needed to meet the demands of the patient and to decrease the risk of associated future knee pathology such as meniscal tears and osteoarthritis. The determination of the optimal treatment remains controversial [1,3,8,38,39]. While surgical repair is widely accepted in the treatment of ACL rupture in young persons and athletes, conservative treatment may have good outcomes in the general population [40]. In September 2014, the American Academy of Orthopaedic Surgeons developed evidence-based treatment guidelines regarding ACL tears [41]. They found that “[m]oderate evidence supports surgical reconstruction in active young adult [20,26,28,30-33,39,42-51] patients with an ACL tear” and “limited evidence [sic] supports non-surgical management for less active patients with less laxity”. Rather than using a strict age or activity level cutoff for determination of treatment, orthopedic surgeons
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often make recommendations based upon the physiological age of the patient [52]. Even when surgery is recommended, patients are often instructed to undergo preoperative physical therapy in order to improve quadriceps and hamstring strength as these have been shown to enhance recuperation after surgery by decreasing scar tissue and contractures. This has been shown in a randomized controlled trial to produce better outcomes after surgery [53]. At an urgent care center in a primary care office, the physician should initiate treatment with nonsteroidal antiinflammatory drugs, ice, and rest and may consider bracing in order to decrease edema and assist in stabilization [42,43].
Conservative management There are certain patients or “copers” who may do well with conservative management, despite an ACL rupture. In a series of 292 patients, Daniels et al. found that 56 (19%) of the patients were clinically stable [54] based on anterior translation measurements. They later developed a treatment algorithm for patients based on their risk, which accounted for their amount of anterior instability and their activity level. Despite the degree of risk, he found that early as opposed to delayed reconstruction led to a lower risk of late meniscus tears [55]. The later meniscal tears in the low risk or more stable patients may be due to rotationally unstable knees, which suggest that we still cannot accurately predict which patients are going to be “copers”. Apart from this, a randomized controlled trial of ACL tears found no difference in outcome between early ACL reconstruction and structured rehabilitation with the option for a delayed reconstruction [56]. Patients who elect non-operative treatment are managed with consistent and structured physiotherapy, which includes quadriceps and hamstring strengthening and stretching. Diligence in these routine-strengthening exercises is required to achieve a better functional outcome. Additionally, some studies have shown the support in the use of knee bracing in chronic ACL-deficient knees, and in knees post-ACL reconstruction [57]. However, the role of functional knee bracing in an acute ACL tear injury remains unclear [42]. There is controversy over the effect of bracing on quadriceps muscle strengthening or on preventing post-traumatic osteoarthritis [42,43,57].
Surgical management Reconstructive surgery of an ACL rupture involves the reconstruction of the torn ligament using a substitute graft of a tendon or ligament and passing it through drilled tunnels in the tibia and femur to approximate the normal anatomy [1]. ACL reconstruction is typically performed arthroscopically. Tendon allografts are chosen in ~ 40% of primary ACL reconstructions performed in the United States, with the remaining 60% utilizing autografts, which are tendons from the patient’s hamstring (semitendinosus and gracilis), patellar tendon, or quadriceps tendon [1,38,39,58]. Graft selection depends on different factors such as patients’ age, previous level of activity, desired activity level after surgery, and
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DOI: 10.1080/00913847.2015.1016865
State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians
lifestyle. Each graft has different biomechanical properties, different associated recoveries, and different potential complications; therefore, graft choice is an important part of the surgical procedure. Surgery may be performed arthroscopically or, less commonly, in conjunction with open surgery depending on the concomitant injuries sustained. There are many different techniques utilized in ACL reconstruction, but the guiding principle is that a new tendinous graft replaces the ruptured ACL in an attempt to mimic the native anatomy. Here we describe a typical ACL reconstruction surgery. The surgery begins by identifying the landmarks of the knee, which include the patella, patellar tendon, tibial tubercle, and tibial plateau. Afterward, a diagnostic arthroscopy is performed to diagnose and address any other possible injuries present. Typically, this is done by examining the entire joint in a systematic fashion, starting with the medial compartment then lateral compartment and finally the patella-femoral joint; although this order varies among surgeons. The menisci are probed to rule out any tears, and the ACL and PCL are probed to check their integrity. The cartilage is inspected to detect any signs of osteoarthritis and/ or possible focal chondral defects. After the diagnostic arthroscopy is completed, the remainder of the ACL is excised and the ACL origin and insertion are prepared for graft implantation. Next, the tibial and femoral tunnels are created; the method by which the tunnels are drilled is a current source of controversy. Regardless of technique, the tunnels must be placed carefully in order to restore the anatomy as closely as possible to the patients’ own. After the graft is passed, it is fixed in the bone tunnels with the surgeon’s choice of fixation devices, which include suspensory buttons, interference screws within the tunnels, and screws outside of the tunnels. Finally, an arthroscopic inspection of the joint is performed followed by a physical examination to evaluate the graft and address any possible problems, which could include under- or over-tensioning the graft, prior to closure. Closure is done in layers and a cryotherapy device is applied to the knee in order to minimize swelling. The first postoperative visit is usually within the first week to evaluate the status of the patient and the incisions, and for suture removal.
Surgical complications Unfortunately, every surgical procedure is associated with complications. Complications may be subdivided into surgical and nonsurgical complications and may vary depending upon the type of procedure, patient demographics, surgeon experience, and type of anesthesia. Surgical complications may include the following: pain at the surgical site, surgical site infection, stiffness, deep vein thrombosis, neural, vascular, or ligamentous injuries, and others. A recent report which examined 92,565 patients who underwent arthroscopic knee surgery reported an overall complication rate of 4.7% and a complication rate of 9.0% in ACL reconstructions [59]. Overall, there were more surgical (3.68%) than medical or anesthetic complications, and the most common complication was infection (0.84%). A re-tear of the ACL graft is a primary concern of patients and is more common in younger athletes [60]. A recent systematic review
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found a re-tear rate of 5.8%; however, the rate of tearing the contralateral ACL is twice as high (11.8%) [61]. Although it is not a direct complication, the current literature suggests that ACL-deficient knees will develop osteoarthritis. Hui et al. [62] found that 51% of patients with isolated ACL tears had radiographic signs of osteoarthritis at 15 years of follow up. Current debate exists on whether ACL reconstructive surgery decreases the development or at least delays the development of osteoarthritis. A recent Cochrane review notes the need for well-developed randomized control trials to improve our understanding of the potential effects of ACL reconstruction on the development of osteoarthritis.
State-of-the-art physical therapy Physical therapy is a major component of the recovery process of an ACL tear and is essential for obtaining excellent results. We also advise patients to undergo a strict rehabilitation program prior to reconstruction as this has been shown by a randomized control trial to help accelerate the recovery phase [63]. Because of muscle memory, it is easier to regain muscle strength than to build it de novo. A basic program with squats, straight leg raises, knee flexion, and core exercises is recommended. One new development postoperative rehabilitation protocols is the consent of an accelerated protocol, which progresses more rapidly through the phases of recovery. A recent large trial that compared an accelerated versus a nonaccelerated rehabilitation protocol determined that at the 2-year follow-up point, there was no statistically significant difference between the groups regarding knee laxity, proprioception, function, and patient satisfaction [13]. We recommend that each patient undergoes a physical therapy program that matches their specific goals. Other rehabilitation therapies include water training or decreased gravity treadmills. The latter uses a modified electronic prosthesis that reduces body weight and allows for earlier activity levels with decreased force across the reconstructed ACL. This warrants further investigation, but it appears to be a safe and effective technology [64]. Following surgery, the initial goal is to regain range of motion (ROM); once completed, rehabilitation shifts toward recovering neuromuscular function. Week 1: Focuses on mobility following surgery. We strongly advise not to force ROM. Initiation of physical therapy .
Manual therapy: Stimulation to quadriceps/hamstrings/gastrocnemius; patellofemoral and tibiofemoral non-thrust manipulation.
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Therapeutic exercises: Non-weight bearing: straight leg raises, quadriceps and gluteal sets, seated or prone heel slides; Full weight-bearing (FWB) in brace: weight shifts forward/side, heel raises, standing abduction/flexion;
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Home Exercise Program: ROM therapeutic exercises performed 6 times/day for swelling/pain. . . .
Begin increasing weight bearing and wean from crutches as able to demonstrate good mechanics. Brace is to be used until 1–2 weeks postoperation depending on ability to control the leg with ambulation. Goals: ROM goal should be at least 0 –75 ; Independent straight leg raise; and Full extension with active vastus medialis and oblique (VMO) recruitment.
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Manual therapy:
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Kinesiology taping (if needed). Therapeutic exercises:
Manual therapy:
Weeks 8–12: will reduce number of visits to 1 time/week.
Stimulation to quadriceps, hamstrings, gastrocnemius, scar tissue; Patellofemoral and tibiofemoral non-thrust manipulation; Progress ROM, can use end range. Leg holds, if edema is minimal.
Continued with supervised care 1 time/ week; Begin jogging when hip and knee strength allow normal mechanics and no pain; Add complex lateral movements (carioca); Add plyometrics; and Add sport-specific training.
Therapeutic exercises:
Begin increasing weight-bearing and wean from crutches as able to demonstrate good mechanics. Brace is to be used until 1–2 weeks postoperation depending on ability to control the leg with ambulation. Goals:
Weeks 4–5: Manual therapy: Continue with stimulation and non-thrust manipulation for ROM as necessary; Kinesiology taping of the quadriceps/hamstring, as necessary. .
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Weeks 2–3:
ROM goal should be at least 0 –110 ;independent straight leg raise; andfull extension with active VMO recruitment.
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Weeks 6–7: MD follow up at 6 weeks.
Continue restive progressions for lower extremity and core; Progress balance with single leg exercises; Add Lateral training; andcontinue to monitor exercises for signs of diminished eccentric, varus, and valgus.
Bike riding when patient has > 100 flexion/can perform full revolutions;FWB (in brace): progress with light resistive therapeutic exercises in weight-bearing through available range up to 90 flexion: leg press, mini squats, assisted lunges, all planes of hip motions, hamstring curls, balance/ proprioception, and core stability;ROM therapeutic exercises performed 6 times/day for swelling/pain (if necessary);Pool exercises when incision closed;Avoid varus/valgus knee motion with therapeutic exercises; .
Add Stairmaster, VersaClimber, Elliptical Trainer, if available.
Therapeutic exercises:
Continue to progress weight-bearing exercises, progressing ROM past 90 . Add single leg loading with leg press;Advance core stabilization program and balance/proprioception;
Current debates As old debates on the optimal graft choice and fixation methods continue, a new and major debate in ACL reconstructions is determining the optimal method of drilling the femoral tunnel. This debate arises from discussions on the benefits of a single-bundle (one tendon) versus double-bundle (two tendons) ACL reconstruction. Double-bundle reconstructions have shown improved laxity measurements, but no difference in patient reported outcomes when compared with singlebundle reconstructions [65]. Despite not changing patient reported outcomes, awareness of the double-bundle technique refocused orthopedic surgeons on the importance of recreating the anatomy of the native ACL even in single-bundle ACL reconstructions. This has coincided with a multicenter study on failed ACL reconstructions that found femoral tunnel malposition in 47.5% of the failures [66]. Because of this, new techniques or alterations of prior techniques for drilling the femoral tunnel have been developed including drilling from an anteromedial portal, through the tibial tunnel, or, less commonly, from outside the femur. The older transtibial technique has been updated to allow for a more accurate placement of the femoral tunnel, but it may come at the expense of the tibial tunnel [67]. The newer anteromedial portal technique had some initial complications including short tunnels, breaking the posterior femoral cortex, and peroneal nerve, and biceps tendon injuries – all of which have been addressed with drilling with more knee flexion. A recent systematic review of the two techniques found that anteromedial portal drilling more consistently places both tunnels anatomically and has better translational and rotational control, but, to date, no difference in outcome has been found between the two techniques [68]. An additional meta-analysis of 49 studies also found that anteromedial portal drilling had improved
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DOI: 10.1080/00913847.2015.1016865
State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians
biomechanics, and it found a small but statistically significant increase in the Lysholm outcome score [69]. Another continued debate in ACL surgery is whether ACL reconstruction can decrease the rate or slow the progression of the development of osteoarthritis. ACL-deficient knees have been shown to have higher rates of meniscal tears, and meniscal injuries have been associated with osteoarthritis. Despite this, one recent trial of patients with ACL injuries randomized to early reconstruction or the option of delayed reconstruction found no difference in the amount of radiographic arthritis at 5 years of follow up [70]. A separate meta-analysis with an average of 14 years of follow up found that ACL reconstruction was associated with less need for further knee surgeries and greater improvement in activity using the Tegner Activity Scale, but it also found no difference in radiographic arthritis [71]. The above questions as well as questions regarding the optimal graft choice, graft preparation, postoperative rehabilitation protocol, and others require a combination of prospective randomized studies as well as multicenter studies and national registries. The first national registry for ACL reconstructions has been established in Denmark. The United States has recently developed the Multicenter Orthopaedic Outcomes Network and the Multicenter ACL Revision Study to begin to address these questions with a higher level of evidence. Hopefully, within the next decade, we will be able to answer these and other questions with a higher level of confidence and evidence.
Summary Physicians in the primary care setting encounter a vast amount of musculoskeletal complaints and injuries. This article presents up-to-date information in order to develop a comprehensive understanding of ACL injuries, which occur commonly in young patients. ACL tears often present in a primary setting. The most sensitive and specific test for diagnosis of an ACL tear is the Lachman’s test, which should be performed in combination with the anterior drawer test. A high percentage of ACL tears have concomitant injuries which must not be overlooked as they can alter management. MRI is of great value for proper diagnosis of an ACL tear and for further evaluation of additional injuries. Early physical therapy is recommended. Treatment options, including operative and non-operative management, take into account patients’ age, activity level, and concomitant injuries. Because of the need for timely diagnosis and treatment of an ACL tear, primary care physicians should consider early referral to an orthopedic surgeon or a sports medicine specialist. Further, future research is needed to focus on the assessment of short- and long-term effects of surgical and conservative treatments of ACL injuries.
Declaration of interest The author reports no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians Matt Salzler, Benedict U. Nwachukwu, Samuel Rosas, Chau Nguyen, Tsun Yee Law, Thomas Eberle & Frank McCormick To cite this article: Matt Salzler, Benedict U. Nwachukwu, Samuel Rosas, Chau Nguyen, Tsun Yee Law, Thomas Eberle & Frank McCormick (2015) State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians, The Physician and Sportsmedicine, 43:2, 169-177 To link to this article: http://dx.doi.org/10.1080/00913847.2015.1016865
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Date: 30 September 2015, At: 04:40
http://informahealthcare.com/psm ISSN: 0091-3847 (print) Phys Sportsmed, 2015; 43(2): 169–177 DOI: 10.1080/00913847.2015.1016865
CLINICAL FEATURE REVIEW
State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians Matt Salzler1, Benedict U. Nwachukwu2, Samuel Rosas3, Chau Nguyen3, Tsun Yee Law3, Thomas Eberle4 and Frank McCormick4
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1
Tufts Medical Center, Department of Orthopedic Surgery, Boston, MA, USA, 2Hospital For Special Surgery, Department of Orthopedic Surgery, New York, NY, USA, 3Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA, and 4Holy Cross Hospital, Department of Orthopedic Surgery, Fort Lauderdale, FL, USA Abstract
Keywords
The purpose of this article is to provide primary care physicians and other members of the medical community with an updated, general review on the subject of anterior cruciate ligament (ACL) tears. We aim to enhance awareness of these injuries and to prepare those practicing in the primary care setting to address these injuries. Because ACL injuries are quite common, it is very likely that a primary care physician will encounter these injuries and need to address them acutely. The current literature is replete with new concepts and controversies regarding ACL injuries, and this article provides a concise review for our target audience in regard to the care of a patient with an ACL injury. This article is composed of an overview with current epidemiologic data, basic anatomy and physiology, clinical presentation, physical examination findings, imaging modalities, and treatment options. After reading this short article, a medical care provider should understand ACL injuries and their appropriate management.
Anterior cruciate ligaments, articular ligament, physical therapy modality, physical therapy techniques
Introduction Anterior cruciate ligament (ACL) tears are among the most common knee injuries. An estimated 200,000 ACL tears occur each year in the United States [1], which amounts to 1 in 3500 people [1,3]. This type of injury occurs commonly during sporting activities such as soccer, football, and other sports involving cutting movements [5,6]. After the initial injury, many patients experience hemarthrosis, crepitus, instability, and pain. As the first medical professional to encounter these patients, a primary care physician must be able to provide a diagnostic impression and deliver proper care prior to referral to a specialist. In this article we provide the readers with the information on the anatomy and physiology of the knee, clinical presentation of ACL injuries, methods of examining the knee, imaging modalities, surgical techniques, treatment options, and current debates on the topic. Our expectation after reading this article is that primary care physicians will have the most recent information and reinforce their knowledge regarding a common knee injury such that patients can benefit from proper and timely care.
Anatomy and function Proper evaluation of ACL tears and associated injury patterns is guided by a general understanding of basic knee anatomy.
History Received 24 October 2014 Accepted 7 January 2015 Published online 23 February 2015
The ACL is one of four main ligaments that stabilize the knee joint and provides nearly 90% of the stability to anterior translation [7,8]. The femoral insertion site of the ACL is located on the lateral intercondylar wall 43% of the distance from the proximal to distal femoral articular margin and, in the anterior to posterior dimension, 2.5 mm plus the radius of the ACL footprint anterior to the posterior articular margin [9]. Previous literature described the position as 1 O’clock on the left knee and 11 O’clock position on the right knee in reference to a clock placed in the intercondylar notch. This two-dimensional reference to a three-dimensional structure led to nonanatomic ACL reconstructions, and recent literature has discarded the clock position for this more precise description of the location of the femoral origin of the ACL. The ACL’s insertion on the tibial plateau is 15 mm anterior to the posterior cruciate ligament (PCL) insertion and two-fifths of the width from the medial to lateral tibial spine [9]. The ACL is composed of two bundles: the anteromedial bundle, which tightens in knee flexion, and the larger posterolateral bundle, which tightens in knee extension [10]. These biomechanical differences allow the ACL to remain taut throughout a wide range of knee motion and enable the ACL to rotate as the knee moves from extension to flexion [7]. An intact ACL stabilizes the femur on the tibia and prevents anterior tibial translation and rotation during agility
Correspondence: Samuel Rosas, MS, Holy Cross Orthopedic Research Institute, 5597 N. Dixie Highway, Fort Lauderdale, FL 33334, USA. E-mail: [email protected] 2015 Informa UK Ltd.
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exercises, jumping, deceleration, and pivoting with sudden changes of direction [3,5,6,11]. Thus, the ACL is an important structure in maintaining full knee function. Recently, the anterolateral ligament (ALL) has gained wide attention. Segond initially described it in the nineteenth century as a “resistant band” that is now recognized as a secondary stabilizer of tibial rotation in addition to the ACL [12]. This ligament is located on the lateral knee; it arises from the lateral femoral epicondyle anterior to the lateral collateral ligament (LCL) and attaches on the lateral tibia. Because of its location, it is in close proximity to the lateral meniscus, genicular vein, and artery [12]. In a study of 206 diagnostic knee magnetic resonance imaging (MRI) confirming ACL tears, 78.8% of the knees demonstrated a concomitant injury to the ALL [13]. This suggests a relationship between the two ligaments, but further biomechanical studies are needed to determine their clinical relationship and role of the ALL, if any, in the treatment of ACL injuries.
Clinical presentation ACL injuries occur commonly in sports such as basketball, soccer, football, and wrestling, and the mechanism of injury is more commonly a noncontact injury than one caused by contact [15]. Typically, ACL tears result from landing with the knee in nearly full extension, or from pivoting while changing direction after a sudden deceleration [5,6]. Certain athletic training programs have been shown to alter athlete’s lower extremity biomechanics in order to reduce the risk of ACL injury [16,17]. A recent systematic review found that these programs provide a risk reduction of 52% in female athletes and 85% in male athletes [18]. In addition to knee pain, swelling, and difficulty in bearing weight following an ACL injury, patients typically report hearing a “pop” or feeling a tearing sensation and their knee “giving way” [19]. Approximately 80% of patients notice a rapid onset of swelling within 3 hours of injury. However, a gradual swelling over 24 hours does not rule out an ACL tear [7,19]. The swelling results from a hemarthrosis, which follows an ACL rupture. In high-impact sports, hemarthrosis may be a result of an intraarticular fracture, which must be considered during the evaluation. Patients with chronic tears often complain of instability with side-to-side movements, which may cause a fall, inability to return to recreational activities, and discomfort when walking or running. Chronic tears may also lead to further development of injuries such as meniscal tears [20], and therefore, patients may complain of meniscal pain, pain with weight bearing, kneeling, and a potential locking sensation in the knee.
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Figure 1. Illustration showing the Lachman’s test. The patient is instructed to lay supine on the table. The examiner flexes the patients’ knee to 30 flexion and must verify that the patient’s muscles are not contracted. Then the clinician places his or her hands with two fingers just below the patellar tendon insertion. Then, a gentle force is applied intended to translate the tibia anteriorly. The test is positive when the tibia translates anteriorly > 5 mm or when no firm end point is felt.
flexion, and slightly externally rotated to relax the pull of the quadriceps and iliotibial band (Figure 1) [7]. This positioning minimizes any secondary support given to the injured knee and allows for a better direct evaluation of ACL competency. The test is positive when a no firm end point is felt and/or when the tibia translates anteriorly > 5 mm. Comparison with the contralateral knee is useful as some patients may have genetic laxity. The anterior drawer test has a reported sensitivity from 80% to 99% [23] and may be used in combination with the Lachman’s test to obtain more evidence that points in the direction of an ACL tear. With the patient in the supine position and the affected knee flexed to 90 , the examiner pulls the tibia anteriorly to test for anterior translation (Figure 2). The pivot shift test is the most specific test for a complete ACL tear with a specificity of 98%, but it has a low sensitivity of 24%–48% (Figure 3) [21,22]. The pivot shift test is performed with the patient supine, the hip flexed up to 30 , and with the knee flexed at 20 , and a force is applied to further flex the knee while at the same time additional valgus force is directed toward the midline. A feeling of a shift or a “popping feeling” describes a positive test.
Physical examination findings A focused physical examination test includes the Lachman’s test, the anterior drawer, and the pivot-shift test. Assessment of ACL tear in an acute setting is best performed with the Lachman’s test, with the highest sensitivity of 85% and a specificity of 94%–99%, which combine to capture a large number of tears without including many false negatives [21,22]. The Lachman’s test evaluates the injured knee for ACL laxity by placing the knee in a position of 20 –30
Figure 2. Illustration showing the anterior drawer test. With the patients lying supine, the physician flexes the patients knee to 90 flexion and proceeds to place his or her thumbs medial and lateral to the patellar tendon. Later, a force is applied directed anteriorly looking for tibia translation. Movement > 5 mm is indicative of an anterior cruciate ligament tear, as well as a no firm end point.
DOI: 10.1080/00913847.2015.1016865
State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians
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Figure 3. Illustration showing the pivot shift test. This examination is done in the same position as in Figures 1 and 2. The patient’s knee is flexed up to 80 and a valgus force is applied while also pushing the knee toward the chest. When a pivot or a “step-wise” sensation is felt, the test is said to be positive.
Evaluating for associated injuries An isolated acute ACL rupture occurs in < 10% of the cases [24-26]. Concomitant injuries include meniscus, articular and subchondral bone injuries, as well as collateral ligament tears. ACL tears are mostly associated with meniscal injuries, with a high prevalence of 60%–75% [27,24-26]. O’Donoghue first described the “unhappy triad” in 1950, in which he described an ACL tear, a medial collateral ligament (MCL) tear, and medial meniscal injury [28]. Despite this initial description; when an ACL tear is present with a combined MCL ligament tear, the lateral meniscus is more likely to be injured than the medial meniscus [28]. These findings are currently the accepted concept of the unhappy triad, which occurs commonly after an athlete sustains a blow to the knee. In a recent multicenter study of over 1000 ACL injuries, 36% of the patients had a concomitant medial meniscus tear and 44% had a lateral meniscus tear [29]. At the time of injury, the lateral meniscus is most commonly damaged. However, after the injury, persistent episodes of instability that displace the tibia lead to medial meniscus tears as the medial meniscus is a secondary restraint to anterior translation of the tibia. In addition to meniscal injuries, chondral injuries also often occur at the time of injury when there is an abnormal contact between the articular surfaces. Care must be taken to evaluate for collateral ligament injuries including the MCL and LCL as these injuries often occur in conjunction with ACL tears. To test for MCL and LCL stability, with the patient supine on the table, the examiner holds the femur in place at 0 and then at 30 of knee flexion with one hand while applying a valgus (for MCL) and then a varus force (for LCL) to the knee. A positive test for a collateral ligament tear will be > 5 of opening or asymmetry as compared with the uninjured knee. The PCL should also be examined when an injury to the knee has occurred. The incidence of PCL injuries varies according to the patient population and the inciting event, that is, traumatic injury or non-traumatic. The overall incidence reported by Wind et al. is 3% in the general population, whereas in the traumatic setting the overall incidence is 37%. In high-velocity injuries, the same authors found PCL injuries in 95% of combined ligaments knee injuries. The most
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commonly performed test to clinically evaluate the competency of the PCL is the posterior drawer test, which is performed in the same manner as the anterior drawer test, although with a posteriorly directed force applied to the tibia. A positive test constitutes an ill-defined end point of tibial translation and/or if the tibia translates > 10–15 mm [30]. This test has been reported to have 90% sensitivity and 99% specificity [31]. The quad activation test is also used in the examination of the PCL. It is performed by placing the patient in a supine position and flexing the patients’ knee to 90 . The examiner sits on the patients’ foot and asks the patient to “kick” or apply force directing the foot to the ceiling. This force causes the quadriceps muscle to activate, and if a PCL injury exists, the tibia is translated anteriorly. A systematic review reported sensitivity ranging from 53% to 98% and specificity ranging from 96% to 100%, and recommended that the quadriceps activation test be used for detecting a PCL injury. In addition to evaluating for other ligamentous injuries, meniscal injuries should be examined with the McMurray’s test and by assessing joint line tenderness. McMurray’s test is performed by having the patient lay supine on the table. The clinician flexes the knee to 90 and applies a rotational force to the tibia. The lateral meniscus is examined with external rotation, and the medial meniscus is examined with internal rotation. Pain and/or clicking at 90 indicate a positive McMurray’s test. The sensitivity for this exam ranges from 16% to 86% with a 29%–96% specificity [32]. In a study that evaluated 109 patients with a history of possible meniscal injuries, the diagnostic accuracy of joint line tenderness for meniscal injuries was reported to be 81% for medial meniscal injuries and 90% for lateral meniscus (Figure 4) [33]. This test is performed by applying pressure with a finger at the joint line of the knee, and the patient acknowledges whether they have pain.
Imaging Isolated acute ACL tear injuries typically appear normal on plain X-ray films. However, the presence of a Segond fracture, a small avulsion fracture of the lateral tibial eminence, is highly suggestive of ACL rupture [3].
Figure 4. Illustration showing the palpation for joint line tenderness test. This is done by pressing over the bones of the joint. In order to better define the joint line, the clinician can flex and extend the knee to observe where the joint contact points are located.
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MRI is the most accurate noninvasive diagnostic modality in identifying a torn ACL, with sensitivity of 86%–95.9%, and specificity of 91%–95% [1]. MRI findings include direct and indirect signs of injury, with indirect signs representing findings seen not directly on the ACL fibers. A normal ACL appears as dark signal with a normal trajectory, and the lack of dark signal with disorganized or disrupted fibers implies an ACL injury. Indirect signs are equally as important. A pathognomonic sign for an ACL rupture is the presence of bone bruising which can be seen as a distortion of the normal appearance of the bone on either the femur or tibia. Other indirect signs include anterior tibial translation seen in a sagittal view, which is measured by tracing a vertical line from the posterior femur toward the ground; the posterior aspect of the tibia must not be further than 7 mm anterior to this line. This has a sensitivity of 86% and sensitivity of 99% for ACL tears. When anterior tibial translation occurs, a second indirect sign may appear as the uncovering of the posterior aspect of the lateral meniscus, which is seen when a portion of the lateral meniscus is more posterior than the tibia. Another useful sign is to determine whether the ACL fibers are parallel to Blumensaat’s line, a line is traced on a sagittal view from the posterior aspect of the femur to the most anterior portion of the tibia. Another indirect sign of an ACL tear is viewing of the entirety of the LCL fibers in one coronal MRI slice [35]. Much of the reliance on indirect signs is due to the fact that the ACL does not lie directly in the sagittal or coronal plane, making direct visualization suboptimal. Recently, the use of a sagittal oblique MRI in the plane of the ACL has been described to better evaluate the ACL directly [36,37]. Every lesion occurring at the knee has its own direct and indirect signs; for that reason we suggest discussing the MRI with a radiologist or orthopedic surgeon when in doubt of the findings. Further, with the knowledge that only 10% of ACL tears are isolated ACL injuries, the majority of patients require an MRI not only to confirm the ACL injury but also as an important preoperative test in order manage patients according to the entirety of their pathology.
Surgical versus conservative treatment The management of ACL injuries includes both conservative and surgical interventions. The ideal goal of either treatment plan is to provide the knee with the stability needed to meet the demands of the patient and to decrease the risk of associated future knee pathology such as meniscal tears and osteoarthritis. The determination of the optimal treatment remains controversial [1,3,8,38,39]. While surgical repair is widely accepted in the treatment of ACL rupture in young persons and athletes, conservative treatment may have good outcomes in the general population [40]. In September 2014, the American Academy of Orthopaedic Surgeons developed evidence-based treatment guidelines regarding ACL tears [41]. They found that “[m]oderate evidence supports surgical reconstruction in active young adult [20,26,28,30-33,39,42-51] patients with an ACL tear” and “limited evidence [sic] supports non-surgical management for less active patients with less laxity”. Rather than using a strict age or activity level cutoff for determination of treatment, orthopedic surgeons
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often make recommendations based upon the physiological age of the patient [52]. Even when surgery is recommended, patients are often instructed to undergo preoperative physical therapy in order to improve quadriceps and hamstring strength as these have been shown to enhance recuperation after surgery by decreasing scar tissue and contractures. This has been shown in a randomized controlled trial to produce better outcomes after surgery [53]. At an urgent care center in a primary care office, the physician should initiate treatment with nonsteroidal antiinflammatory drugs, ice, and rest and may consider bracing in order to decrease edema and assist in stabilization [42,43].
Conservative management There are certain patients or “copers” who may do well with conservative management, despite an ACL rupture. In a series of 292 patients, Daniels et al. found that 56 (19%) of the patients were clinically stable [54] based on anterior translation measurements. They later developed a treatment algorithm for patients based on their risk, which accounted for their amount of anterior instability and their activity level. Despite the degree of risk, he found that early as opposed to delayed reconstruction led to a lower risk of late meniscus tears [55]. The later meniscal tears in the low risk or more stable patients may be due to rotationally unstable knees, which suggest that we still cannot accurately predict which patients are going to be “copers”. Apart from this, a randomized controlled trial of ACL tears found no difference in outcome between early ACL reconstruction and structured rehabilitation with the option for a delayed reconstruction [56]. Patients who elect non-operative treatment are managed with consistent and structured physiotherapy, which includes quadriceps and hamstring strengthening and stretching. Diligence in these routine-strengthening exercises is required to achieve a better functional outcome. Additionally, some studies have shown the support in the use of knee bracing in chronic ACL-deficient knees, and in knees post-ACL reconstruction [57]. However, the role of functional knee bracing in an acute ACL tear injury remains unclear [42]. There is controversy over the effect of bracing on quadriceps muscle strengthening or on preventing post-traumatic osteoarthritis [42,43,57].
Surgical management Reconstructive surgery of an ACL rupture involves the reconstruction of the torn ligament using a substitute graft of a tendon or ligament and passing it through drilled tunnels in the tibia and femur to approximate the normal anatomy [1]. ACL reconstruction is typically performed arthroscopically. Tendon allografts are chosen in ~ 40% of primary ACL reconstructions performed in the United States, with the remaining 60% utilizing autografts, which are tendons from the patient’s hamstring (semitendinosus and gracilis), patellar tendon, or quadriceps tendon [1,38,39,58]. Graft selection depends on different factors such as patients’ age, previous level of activity, desired activity level after surgery, and
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lifestyle. Each graft has different biomechanical properties, different associated recoveries, and different potential complications; therefore, graft choice is an important part of the surgical procedure. Surgery may be performed arthroscopically or, less commonly, in conjunction with open surgery depending on the concomitant injuries sustained. There are many different techniques utilized in ACL reconstruction, but the guiding principle is that a new tendinous graft replaces the ruptured ACL in an attempt to mimic the native anatomy. Here we describe a typical ACL reconstruction surgery. The surgery begins by identifying the landmarks of the knee, which include the patella, patellar tendon, tibial tubercle, and tibial plateau. Afterward, a diagnostic arthroscopy is performed to diagnose and address any other possible injuries present. Typically, this is done by examining the entire joint in a systematic fashion, starting with the medial compartment then lateral compartment and finally the patella-femoral joint; although this order varies among surgeons. The menisci are probed to rule out any tears, and the ACL and PCL are probed to check their integrity. The cartilage is inspected to detect any signs of osteoarthritis and/ or possible focal chondral defects. After the diagnostic arthroscopy is completed, the remainder of the ACL is excised and the ACL origin and insertion are prepared for graft implantation. Next, the tibial and femoral tunnels are created; the method by which the tunnels are drilled is a current source of controversy. Regardless of technique, the tunnels must be placed carefully in order to restore the anatomy as closely as possible to the patients’ own. After the graft is passed, it is fixed in the bone tunnels with the surgeon’s choice of fixation devices, which include suspensory buttons, interference screws within the tunnels, and screws outside of the tunnels. Finally, an arthroscopic inspection of the joint is performed followed by a physical examination to evaluate the graft and address any possible problems, which could include under- or over-tensioning the graft, prior to closure. Closure is done in layers and a cryotherapy device is applied to the knee in order to minimize swelling. The first postoperative visit is usually within the first week to evaluate the status of the patient and the incisions, and for suture removal.
Surgical complications Unfortunately, every surgical procedure is associated with complications. Complications may be subdivided into surgical and nonsurgical complications and may vary depending upon the type of procedure, patient demographics, surgeon experience, and type of anesthesia. Surgical complications may include the following: pain at the surgical site, surgical site infection, stiffness, deep vein thrombosis, neural, vascular, or ligamentous injuries, and others. A recent report which examined 92,565 patients who underwent arthroscopic knee surgery reported an overall complication rate of 4.7% and a complication rate of 9.0% in ACL reconstructions [59]. Overall, there were more surgical (3.68%) than medical or anesthetic complications, and the most common complication was infection (0.84%). A re-tear of the ACL graft is a primary concern of patients and is more common in younger athletes [60]. A recent systematic review
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found a re-tear rate of 5.8%; however, the rate of tearing the contralateral ACL is twice as high (11.8%) [61]. Although it is not a direct complication, the current literature suggests that ACL-deficient knees will develop osteoarthritis. Hui et al. [62] found that 51% of patients with isolated ACL tears had radiographic signs of osteoarthritis at 15 years of follow up. Current debate exists on whether ACL reconstructive surgery decreases the development or at least delays the development of osteoarthritis. A recent Cochrane review notes the need for well-developed randomized control trials to improve our understanding of the potential effects of ACL reconstruction on the development of osteoarthritis.
State-of-the-art physical therapy Physical therapy is a major component of the recovery process of an ACL tear and is essential for obtaining excellent results. We also advise patients to undergo a strict rehabilitation program prior to reconstruction as this has been shown by a randomized control trial to help accelerate the recovery phase [63]. Because of muscle memory, it is easier to regain muscle strength than to build it de novo. A basic program with squats, straight leg raises, knee flexion, and core exercises is recommended. One new development postoperative rehabilitation protocols is the consent of an accelerated protocol, which progresses more rapidly through the phases of recovery. A recent large trial that compared an accelerated versus a nonaccelerated rehabilitation protocol determined that at the 2-year follow-up point, there was no statistically significant difference between the groups regarding knee laxity, proprioception, function, and patient satisfaction [13]. We recommend that each patient undergoes a physical therapy program that matches their specific goals. Other rehabilitation therapies include water training or decreased gravity treadmills. The latter uses a modified electronic prosthesis that reduces body weight and allows for earlier activity levels with decreased force across the reconstructed ACL. This warrants further investigation, but it appears to be a safe and effective technology [64]. Following surgery, the initial goal is to regain range of motion (ROM); once completed, rehabilitation shifts toward recovering neuromuscular function. Week 1: Focuses on mobility following surgery. We strongly advise not to force ROM. Initiation of physical therapy .
Manual therapy: Stimulation to quadriceps/hamstrings/gastrocnemius; patellofemoral and tibiofemoral non-thrust manipulation.
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Therapeutic exercises: Non-weight bearing: straight leg raises, quadriceps and gluteal sets, seated or prone heel slides; Full weight-bearing (FWB) in brace: weight shifts forward/side, heel raises, standing abduction/flexion;
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Home Exercise Program: ROM therapeutic exercises performed 6 times/day for swelling/pain. . . .
Begin increasing weight bearing and wean from crutches as able to demonstrate good mechanics. Brace is to be used until 1–2 weeks postoperation depending on ability to control the leg with ambulation. Goals: ROM goal should be at least 0 –75 ; Independent straight leg raise; and Full extension with active vastus medialis and oblique (VMO) recruitment.
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.
.
. .
Manual therapy:
.
Kinesiology taping (if needed). Therapeutic exercises:
Manual therapy:
Weeks 8–12: will reduce number of visits to 1 time/week.
Stimulation to quadriceps, hamstrings, gastrocnemius, scar tissue; Patellofemoral and tibiofemoral non-thrust manipulation; Progress ROM, can use end range. Leg holds, if edema is minimal.
Continued with supervised care 1 time/ week; Begin jogging when hip and knee strength allow normal mechanics and no pain; Add complex lateral movements (carioca); Add plyometrics; and Add sport-specific training.
Therapeutic exercises:
Begin increasing weight-bearing and wean from crutches as able to demonstrate good mechanics. Brace is to be used until 1–2 weeks postoperation depending on ability to control the leg with ambulation. Goals:
Weeks 4–5: Manual therapy: Continue with stimulation and non-thrust manipulation for ROM as necessary; Kinesiology taping of the quadriceps/hamstring, as necessary. .
.
Weeks 2–3:
ROM goal should be at least 0 –110 ;independent straight leg raise; andfull extension with active VMO recruitment.
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Weeks 6–7: MD follow up at 6 weeks.
Continue restive progressions for lower extremity and core; Progress balance with single leg exercises; Add Lateral training; andcontinue to monitor exercises for signs of diminished eccentric, varus, and valgus.
Bike riding when patient has > 100 flexion/can perform full revolutions;FWB (in brace): progress with light resistive therapeutic exercises in weight-bearing through available range up to 90 flexion: leg press, mini squats, assisted lunges, all planes of hip motions, hamstring curls, balance/ proprioception, and core stability;ROM therapeutic exercises performed 6 times/day for swelling/pain (if necessary);Pool exercises when incision closed;Avoid varus/valgus knee motion with therapeutic exercises; .
Add Stairmaster, VersaClimber, Elliptical Trainer, if available.
Therapeutic exercises:
Continue to progress weight-bearing exercises, progressing ROM past 90 . Add single leg loading with leg press;Advance core stabilization program and balance/proprioception;
Current debates As old debates on the optimal graft choice and fixation methods continue, a new and major debate in ACL reconstructions is determining the optimal method of drilling the femoral tunnel. This debate arises from discussions on the benefits of a single-bundle (one tendon) versus double-bundle (two tendons) ACL reconstruction. Double-bundle reconstructions have shown improved laxity measurements, but no difference in patient reported outcomes when compared with singlebundle reconstructions [65]. Despite not changing patient reported outcomes, awareness of the double-bundle technique refocused orthopedic surgeons on the importance of recreating the anatomy of the native ACL even in single-bundle ACL reconstructions. This has coincided with a multicenter study on failed ACL reconstructions that found femoral tunnel malposition in 47.5% of the failures [66]. Because of this, new techniques or alterations of prior techniques for drilling the femoral tunnel have been developed including drilling from an anteromedial portal, through the tibial tunnel, or, less commonly, from outside the femur. The older transtibial technique has been updated to allow for a more accurate placement of the femoral tunnel, but it may come at the expense of the tibial tunnel [67]. The newer anteromedial portal technique had some initial complications including short tunnels, breaking the posterior femoral cortex, and peroneal nerve, and biceps tendon injuries – all of which have been addressed with drilling with more knee flexion. A recent systematic review of the two techniques found that anteromedial portal drilling more consistently places both tunnels anatomically and has better translational and rotational control, but, to date, no difference in outcome has been found between the two techniques [68]. An additional meta-analysis of 49 studies also found that anteromedial portal drilling had improved
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State-of-the-art anterior cruciate ligament tears: A primer for primary care physicians
biomechanics, and it found a small but statistically significant increase in the Lysholm outcome score [69]. Another continued debate in ACL surgery is whether ACL reconstruction can decrease the rate or slow the progression of the development of osteoarthritis. ACL-deficient knees have been shown to have higher rates of meniscal tears, and meniscal injuries have been associated with osteoarthritis. Despite this, one recent trial of patients with ACL injuries randomized to early reconstruction or the option of delayed reconstruction found no difference in the amount of radiographic arthritis at 5 years of follow up [70]. A separate meta-analysis with an average of 14 years of follow up found that ACL reconstruction was associated with less need for further knee surgeries and greater improvement in activity using the Tegner Activity Scale, but it also found no difference in radiographic arthritis [71]. The above questions as well as questions regarding the optimal graft choice, graft preparation, postoperative rehabilitation protocol, and others require a combination of prospective randomized studies as well as multicenter studies and national registries. The first national registry for ACL reconstructions has been established in Denmark. The United States has recently developed the Multicenter Orthopaedic Outcomes Network and the Multicenter ACL Revision Study to begin to address these questions with a higher level of evidence. Hopefully, within the next decade, we will be able to answer these and other questions with a higher level of confidence and evidence.
Summary Physicians in the primary care setting encounter a vast amount of musculoskeletal complaints and injuries. This article presents up-to-date information in order to develop a comprehensive understanding of ACL injuries, which occur commonly in young patients. ACL tears often present in a primary setting. The most sensitive and specific test for diagnosis of an ACL tear is the Lachman’s test, which should be performed in combination with the anterior drawer test. A high percentage of ACL tears have concomitant injuries which must not be overlooked as they can alter management. MRI is of great value for proper diagnosis of an ACL tear and for further evaluation of additional injuries. Early physical therapy is recommended. Treatment options, including operative and non-operative management, take into account patients’ age, activity level, and concomitant injuries. Because of the need for timely diagnosis and treatment of an ACL tear, primary care physicians should consider early referral to an orthopedic surgeon or a sports medicine specialist. Further, future research is needed to focus on the assessment of short- and long-term effects of surgical and conservative treatments of ACL injuries.
Declaration of interest The author reports no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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![[Reconstruction of partial anterior cruciate ligament tears].](/assets/img/hold.png)
