Sports Medicine—Are We Any Closer to Preventing Anterior Cruciate Ligament Injuries?

Neetu Rishiraj, Jack E Taunton, Robert Lloyd-Smith, William Regan, Navin Prasad
US Musculoskeletal Review, 2011;6(1):61-4
pdf icon download pdf ejournal view ejournal

Abstract

Anterior cruciate ligament (non-contact and contact) injuries continue to disrupt professional and personal careers. Treatment costs (short- and long-term) continue to increase at an alarming rate. Researchers continue to investigate various possible intrinsic and extrinsic ACL injury causing factors; however, ACL injury rates have not decreased. Recently, several new intriguing ACL injury/prevention mechanisms have been presented and perhaps this will allow researchers to investigate different mechanisms in preventing knee ligament injuries. The goal for this article is to present a brief review of the past and present concepts being considered as possible mechanism(s) for preventing ACL injuries and the potential role of functional knee braces in ‘protecting’ the ACL from injury.
Keywords
Anterior cruciate ligament (ACL), injury, non-contact, prevention
Disclosure The authors have no conflicts of interest to declare.
Received: March 08, 2011 Accepted May 31, 2011
Correspondence: Neetu Rishiraj, ATC, PhD, ACTIN Health & Rehabilitation Inc., 5767 Oak Street, Vancouver, BC, Canada, V6M 2V7. E: nrishiraj@actinhealth.com

Data from the US in the mid-2000s reported approximately 300,000 new anterior cruciate ligament (ACL) injuries, which occurred annually at a cost of almost US$3 billion for surgical reconstruction and lengthy rehabilitation.1,2 Several authors have stated that the risk for being diagnosed with osteoarthritis (OA) increases 100 times in athletes who have sustained a knee injury,3,4 while a recent publication listed a 51% higher risk for radiologic signs of OA five to 15 years post injury.5 The value mentioned above did not include the costs for initial evaluation and treatment of those injured individuals requiring non-surgical care, or the cost of future healthcare and future employment status (estimated to be $US3.4 billion in 1997)6 for those who develop post-traumatic OA.7,8 Knee injury prevention should be of greater concern when statistics on return to sport post injury (with both conservative management and/or with ACL reconstruction) illustrate decreased level of participation, earlier forced retirement, and/or continued knee joint discomfort.9 Following reconstruction, not all individuals return to their pre-injury level of competition, and those that do can expect a 33% reduction in performance level compared with pre-injury levels.10 Even if an athlete returns to sport post-injury and rehabilitation (conservative and/or post-surgery), the risk for a contralateral ACL injury occurring is greater than the risk for sustaining an initial ACL injury.11 The probability of experiencing a contralateral ACL injury is directly related to returning to a high activity level and no conclusive evidence was found for factors such as female gender, family history of ACL injuries, and a narrow intercondylar notch.11 Swärd et al.11 suggested that the risk factors acquired post ACL injury, such as altered biomechanics and altered neuromuscular function, affecting both the injured and the contralateral leg, further increase the risk for a contralateral ACL injury. The above results are supported by Webster and Gribble12 who reported that athletes continued to demonstrate dynamic postural-control deficits as evidenced by their difficulty in controlling ground reaction forces, even 2.5 years post ACL reconstruction. In this article, we address the current ACL injury prevention research efforts and the potential role of knee bracing in preventing knee ligament injury.

Methods
The following online databases were accessed to search relevant articles: EBM reviews, PubMed, SportsDiscus, Ovid, MEDLINE, and Proquest 5000. The search reference terms, ‘knee injuries’, ‘ACL’, ‘MCL’, ‘non-contact’, ‘contact’, ‘prevention’, ‘bracing’, ‘knee bracing’, ‘functional knee bracing’, ‘prophylactic knee bracing’ were used. Abstracts were retrieved, reviewed, and were included for review that were deemed relevant. More than 2,000 articles on ACL injuries have been published over the past two decades,13 from which 701 articles were reviewed. For this article, our criteria for inclusion were comprehensive, and thus we included non-randomised prospective and retrospective studies.

References:
  1. Renstrom P, Ljungqvist A, Arendt E, et al., Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement, Br J Sports Med, 2008;42:394–412.
  2. Griffin LY, Albohm MJ, Arendt EA, et al., Understanding and preventing noncontact anterior cruciate ligament injuries, Am J Sports Med, 2006;34:1512–32.
  3. Feller J, Anterior cruciate ligament rupture: is osteoarthritis inevitable?, Br J Sports Med, 2004;38:383–4.
  4. Von Porat A, Roos EM, Roos H, High prevalence for osteoarthritis 14 years after an anterior cruciate ligament tear in male soccer players: a study of radiographic and patient relevant outcomes, Br J Sports Med, 2004;63:269–73.
  5. Neuman P, Englund M, Kostogiannis I, et al., Prevalence of tibiofemoral osteoarthritis 15 years after nonoperative treatment of anterior cruciate ligament injury: a prospective cohort study, Am J Sports Med, 2008;36:1717–25.
  6. National Centre for Chronic Disease Prevention and Health Promotion, Arthritis, National Statistics; Epidemiology Briefs- Osteoarthritis. Available at: www.cdcgov/arthritis/data_statistics /epi_briefs/osteoarthritishtm (accessed October 30, 2007).
  7. Hewett TE, Myer GD, Ford KR, Anterior cruciate ligament injuries; Part I, mechanisms and risk factors, Am J Sports Med, 2006;34:299–311.
  8. Mehrotra C, Remington PL, Naimi TS, et al., Trends in total knee replacement surgeries and implications for public health, 1990–2000, Public Health Rep, 2005;120:278–82.
  9. Jones HP, Appleyard RC, Mahajan S, Murrell GA, Meniscal and chondral loss in the anterior cruciate ligament injured knee, Sports Med, 2003;33:1075–89.
  10. Carey JL, Huffman GR, Parekh SG, Sennett BJ, Outcomes of anterior cruciate ligament injuries to running backs and wide receivers in the National Football League, Am J Sports Med, 2006;34:1911–7.
  11. Swärd P, Kostogiannis I, Roos H, Risk factors for a contralateral anterior cruciate ligament injury, Knee Surg Sports Traumatol Arthrosc, 2010;18:277–91.
  12. Webster KA, Gribble PA, Time to stabilization of anterior cruciate ligament–reconstructed versus healthy knees in National Collegiate Athletic Association Division I female athletes, J Athl Train, 2010;45:580–5.
  13. Miller RH, Knee injuries. In: Canale ST (ed.), Campbell's Operative Orthopaedics. 10th ed., Mosby: Philadelphia, 2003;2155–338.
  14. Rishiraj N, Taunton JE, Clement DB, et al., Role of functional knee bracing in a dynamic setting, NZ J Sports Med, 2000;28:54–61. 15. Markolf KL, Graff-Redford A, Amstutz HC, In vivo knee stability: A quantitative assessment using an instrumented clinical testing apparatus, J Bone Joint Surg Am, 1978;60A:664–74.
  15. Pope MH, Johnson DW, Brown DW, Tighe C, The role of the muscular in injuries to the medial collateral ligaments, J Bone Joint Surg Am, 1979;61:398–492.
  16. Krosshaug T, Nakamae A, Boden BP, et al., Mechanisms of anterior cruciate ligament injury in basketball: video analysis of 39 cases, Am J Sports Med, 2007;35:359–67.
  17. Lephart SM, Abt JP, Ferris CM, Neuromuscular contributions of anterior cruciate ligament injuries in females, Curr Opin Rheumatol, 2002;14:168–73.
  18. Hashemi J, Breighner R, Chandrashekar N, et al., Hip extension, knee flexion paradox: A new mechanism for non-contact ACL injury, J Biomechanics, 2011 Feb 24;44(4):577–85.
  19. Shultz SJ, Schmitz RJ, Nguyen A-D, et al., ACL research retreat V: An update on ACL injury risk and prevention, March 25–27, 2010, Greensboro, NC, J Athl Train, 2010;45:499–508.
  20. McLean SG, Beaulieu ML, Complex integrative morphological and mechanical contributions to ACL injury risk, Exerc Sport Sci Rev, 2010;38:192–200.
  21. Stijak L, Herzog RF, Schai P, Is there an influence of the tibial slope of the lateral condyle on the ACL lesion? A case-control study, Knee Surg Sports Traumatol Arthrosc, 2008;16:112–7.
  22. Hashemi J, Chandrashekar N, Mansouri H, Shallow medial tibial plateau and steep medial and lateral tibial slopes: new risk factors for anterior cruciate ligament injuries, Am J Sports Med, 2010;38:54–62.
  23. Branch TP, Hunter RF, Functional analysis of anterior cruciate braces, Clin Sports Med, 1990;9:771–97.
  24. Bisson LJ, Gurske-DePerio J, Axial and sagittal knee geometry as a risk factor for noncontact anterior cruciate ligament tear: a casecontrol study, Arthroscopy, 2010;26:901–6.
  25. Dick R, Hertel J, Agel J, et al., Descriptive epidemiology of collegiate men’s basketball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003–2004, J Athl Train, 2007;42:194–201.
  26. Agel J, Olson DE, Dick R, et al., Descriptive epidemiology of collegiate women’s basketball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003– 2004, J Athl Train, 2007;42:202–10.
  27. Dick R, Romani WA, Agel J, et al., Descriptive epidemiology of collegiate men's lacrosse injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003– 2004, J Athl Train, 2007;42:255–61.
  28. Dick R, Lincoln AE, Agel J, et al., Descriptive epidemiology of collegiate women's lacrosse injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003– 2004, J Athl Train, 2007;42:262–9.
  29. Dick R, Putukian M, Agel J, et al., Descriptive epidemiology of collegiate women’s soccer injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2002– 2003, J Athl Train, 2007;42:278–85.
  30. Agel J, Evans TA, Dick R, et al., Descriptive epidemiology of collegiate men's soccer injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2002– 2003, J Athl Train, 2007;42:270–7.
  31. Dick R, Ferrara MS, Agel J, et al., Descriptive epidemiology of collegiate men's football injuries: National Collegiate Athletic Association Injury Surveillance System, 1988–1989 through 2003– 2004, J Athl Train, 2007;42:221–33.
  32. Agel J, Dompier TP, Dick R, Marshall SW, Descriptive epidemiology of collegiate men’s ice hockey injuries: national collegiate athletic association injury surveillance system, 1988–1989 through 2003–2004, J Athl Train, 2007;42:241–8.
  33. Agel J, Dick R, Nelson B, et al., Descriptive epidemiology of collegiate women's ice hockey injuries: National Collegiate Athletic Association Injury Surveillance System, 2000–2001 through 2003–2004, J Athl Train, 2007;42:249–54.
  34. Decoster LC, Vailas JC, Functional anterior cruciate ligament bracing: a survey of current brace prescriptions patterns, Orthopedics, 2003;26:701–6.
  35. DeVita P, Lassiter TJ, Hortobagyi T, Torry M, Functional knee bracing effects during walking in patients with anterior cruciate ligament reconstruction, Am J Sports Med, 1998;26:778–84.
  36. Risberg MA, Holm I, Steen H, et al., The effect of knee bracing after anterior cruciate ligament reconstruction, Am J Sports Med, 1999;27:76–83.
  37. Liu SH, Lundsdorn T, Guide S, Vangsness CTJ, Comparison of functional knee braces for control of anterior tibial displacement, Clin Orthop Relat Res, 1994;303:203–10.
  38. AAOS, Position Paper: The use of knee braces, Rosemont, IL, 2004.
  39. Fleming BC, Renstrom PA, Beynnon BD, et al., The influence of functional knee bracing on anterior cruciate ligament strain biomechanics in weight bearing and nonweightbearing knees, Am J Sports Med, 2000;28:815–24.
  40. Beynnon BD, Fleming BC, Churchill DL, Brown D, The effect of anterior cruciate ligament deficiency and functional knee bracing on translation of the tibia relative to the femur during nonweightbearing and weight bearing, Am J Sports Med, 2003;31:99–105.
  41. Granberry WM, Noble PC, Woods GW, Evaluation of an electrogoniometric instrument for measurement of laxity of the knee, J Bone Joint Surg Am, 1990;72:1316–22.
  42. DeVita P, Hunter PB, Skelly WA, Effects of a functional knee brace on the biomechanics of running, Med Sci Sports Exerc, 1992;24:797–804.
  43. Rishiraj N, Taunton JE, Lloyd-Smith R, et al., Drop & hop jump GRFs and joint kinematics of braced non-injured subjects: Preliminary study, Minerva Orthop E Trauma, 2009;60:193–204.
  44. Paluska SA, McKeag DB, Knee braces: Current evidence and clinical recommendations for their use, Am Fam Physician, 2000;61:411–8 and 23–4.
  45. Albright JP, Powell JW, Smith W, et al., Medial collateral ligament knee sprains in college football. Effectiveness of preventive braces,Am J Sports Med, 1994;22:12–8.
  46. Albright JP, Powell JW, Smith W, et al., Medial collateral ligament knee sprains in college football. Brace wear preference and injury risk, Am J Sports Med, 1994;22:2–11.
  47. Rishiraj N, Taunton JE, Niven B, et al., Performance of healthy braced subjects during aerobic and anaerobic capacity tasks, J Athl Train, 2011; in press.
  48. Rishiraj N, Taunton JE, Lloyd-Smith R, et al., Effect of functional knee brace use on acceleration, agility, leg power and speed performance in healthy athletes, Br J Sports Med, 2011; in press.
  49. Rishiraj N, Taunton JE, Lloyd-Smith R, et al., Does the use of a functional knee brace by non-injured subjects hinder agility, power, and speed performance levels?, (Initial study), Minerva Ortho E Trauma, 2011;62:9–17.
  50. Rishiraj N, Taunton JE, Lloyd-Smith R, et al., Is adaptation to functional knee brace use in non-injured subjects during aerobic activity possible? A possible first step in preventing knee ligament injuries (Pilot Study), Minerva Ortho E Trauma, 2008;59:313–20.
  51. Rishiraj N, Taunton JE, Lloyd-Smith R, et al., Functional knee brace use by non-injured subjects while performing an anaerobic capacity task (Preliminary study), J Sports Med Phys Fitness, 2010;50:422–7.
  52. Bahr R, Krosshaug T, Understanding the injury mechanisms: a key component to prevent injuries in sports, Br J Sports Med, 2005;39:324–9.
close

This content is copyright protected

However, if you would like to share the information on this webpage, you may use the headline and link below:

Sports Medicine—Are We Any Closer to Preventing Anterior Cruciate Ligament Injuries?

Read more: Sports Medicine—Are We Any Closer to Preventing Anterior Cruciate Ligament Injuries?