ACL Injuries in Women Athletes 2011
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ACL Injuries in Women Athletes 2011

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Female athletes are six times as liable as male athletes to be injured playing sport. One of the most common of those is the ACL or anterior cruciate ligament. Dr. Connie Lebrun, MD, sports......

Female athletes are six times as liable as male athletes to be injured playing sport. One of the most common of those is the ACL or anterior cruciate ligament. Dr. Connie Lebrun, MD, sports medicine physician at the Glen Sather Sports Medicine Clinic at the University of Alberta discusses causes and treatment of the injury.

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  • 1. ACL Injuries in Women
    Management and Prevention
    Dr. Connie Lebrun MDCM, MPE, CCFP,
    Dip. Sport Med, FACSM
    Clinical Director Glen Sather Sports Medicine Clinic
    University of Alberta, Edmonton, Alberta, CANADA
  • 2. Figure 1
    Complex Integrative Morphological and Mechanical Contributions to ACL Injury Risk.
    McLean, Scott; Beaulieu, Melanie
    Exercise & Sport Sciences Reviews. 38(4):192-200, October 2010.
    DOI: 10.1097/JES.0b013e3181f450b4
    Figure 1 . Combined effects of fatigue and decision making on key knee joint biomechanical parameters during a high-impact single leg landing task. As fatigue progressed, statistically significant (P Med Sci Sports Exerc. 2009; 41(8):1661-72. Copyright (C) 2009 Lippincott Williams & Wilkins. Used with permission.]
    ©2010The Amercian College of Sports Medicine. Published by Lippincott Williams & Wilkins, Inc.
    2
  • 3. TABLE.
    Complex Integrative Morphological and Mechanical Contributions to ACL Injury Risk.
    McLean, Scott; Beaulieu, Melanie
    Exercise & Sport Sciences Reviews. 38(4):192-200, October 2010.
    DOI: 10.1097/JES.0b013e3181f450b4
    TABLE. Research studies investigating explicit links between morphological and knee joint biomechanical factors associated with anterior cruciate ligament (ACL) injury risk.
    ©2010The Amercian College of Sports Medicine. Published by Lippincott Williams & Wilkins, Inc.
    3
  • 4. Figure 2
    Complex Integrative Morphological and Mechanical Contributions to ACL Injury Risk.
    McLean, Scott; Beaulieu, Melanie
    Exercise & Sport Sciences Reviews. 38(4):192-200, October 2010.
    DOI: 10.1097/JES.0b013e3181f450b4
    Figure 2 . A custom designed manual loading device was used to apply combined 3D loads to male and female cadaveric knee specimens (A). Using these and resultant ligament strain data, specimen-specific regression models were developed that could predict peak anterior cruciate ligament (ACL) strain magnitudes to within 0.51% +/- 0.01% and 0.52% +/- 0.06% of measured data, and within 0.61% +/- 0.11% and 0.57% +/- 0.05% of validation data (not used in model development) respectively (B). Application of combined valgus (45 Nm), internal rotation (20 Nm) and compressive (300 N) loads at a fixed knee flexion angle (40 deg) and three discrete anterior tibial shear load magnitudes (50 N, 100 N and 150 N) resulted in predicted peak female ACL strains that were significantly greater than male ACL strain values (C). [Adapted from Mizuno K, Andrish JT, van den Bogert AJ, McLean SG. Gender dimorphic ACL strain in response to combined dynamic 3D knee joint loading: implications for ACL injury risk. Knee. 2009; 16(6):432-40. Copyright (C) 2009 Elsevier. Used with permission.]
    ©2010The Amercian College of Sports Medicine. Published by Lippincott Williams & Wilkins, Inc.
    4
  • 5. Figure 3
    Complex Integrative Morphological and Mechanical Contributions to ACL Injury Risk.
    McLean, Scott; Beaulieu, Melanie
    Exercise & Sport Sciences Reviews. 38(4):192-200, October 2010.
    DOI: 10.1097/JES.0b013e3181f450b4
    Figure 3 . Associations between key knee joint anatomical indices and peak stance phase knee joint biomechanical variables during a single-leg landing task. Specifically, peak anterior knee joint reaction force was significantly positively correlated with lateral posterior tibial slope (LTS) (A). Peak knee joint internal rotation angle was significantly positively correlated with the ratio between medial and lateral posterior tibial slopes (MTS:LTS) (B). Peak knee abduction angle was significantly positively correlated with both MTS:LTS and the ratio between the tibial plateau width and the intercondylar distance (TPW:ICD) (C). [Adapted from McLean SG, Lucey SM, Rohrer S, Brandon C. Knee joint anatomy predicts extreme in vivo knee joint mechanics during single leg landings. Clin Biomech. 2010;In press. Copyright (C) 2010 Elsevier. Used with permission.]
    ©2010The Amercian College of Sports Medicine. Published by Lippincott Williams & Wilkins, Inc.
    5
  • 6. Figure 4
    Complex Integrative Morphological and Mechanical Contributions to ACL Injury Risk.
    McLean, Scott; Beaulieu, Melanie
    Exercise & Sport Sciences Reviews. 38(4):192-200, October 2010.
    DOI: 10.1097/JES.0b013e3181f450b4
    Figure 4 . Conceptual model depicting integrative morphological and biomechanical contributions to knee joint and anterior cruciate ligament (ACL) loading during high-impact landing maneuvers. Explicit combinations of postural alignment and knee joint anatomical and laxity factors are posited to implicate within the ACL injury risk via the generation of large knee joint and resultant ACL load states. For the associated figure, ABd = abduction; IR = internal rotation; Ant Shear = anterior tibial shear; Fx = force in the x-axis direction; Fy = force in the y-axis direction; Fz = force in the z-axis direction; Mx = moment about the x-axis; My = moment about the y-axis; Mz = moment about the z-axis.
    ©2010The Amercian College of Sports Medicine. Published by Lippincott Williams & Wilkins, Inc.
    6
  • 7. Figure 5
    Complex Integrative Morphological and Mechanical Contributions to ACL Injury Risk.
    McLean, Scott; Beaulieu, Melanie
    Exercise & Sport Sciences Reviews. 38(4):192-200, October 2010.
    DOI: 10.1097/JES.0b013e3181f450b4
    Figure 5 . Surrogate (integrative forward dynamic and finite element) modeling techniques proposed to successfully investigate anterior cruciate ligament (ACL) causality based on integrative neuromechanical and morphological factors. Systematic and/or random perturbations can be applied at each level of the modeling pipeline, based on quantified variations in each measure, to determine ACL injury risk arising through individual-specific neuromechanical and morphological vulnerabilities.
    ©2010The Amercian College of Sports Medicine. Published by Lippincott Williams & Wilkins, Inc.
    7
  • 8.
  • 9.
  • 10. UWO Mustangs
  • 11. Are Women More at Risk?
  • 12. Anatomy of ACL
    Origin from lateral femoral condyle
    Insertion to tibial plateau medial to anterior horn of lateral meniscus
  • 13. ACL Injury
    “Commonest cause of the ex-athlete”
    1 in 10 female athletes (N.C.A.A.)
    2-6 times higher incidence than males in same sport
  • 14. NATIONAL COLLEGIATEATHLETIC ASSOCIATION
    INJURY SURVEILLANCE SYSTEM (ISS)
  • 15. SportYear ISSBegan
    Soccer (/) 1984/83
    Softball 1984
    Ice Hockey () 1984
    Field Hockey () 1984
    Basketball (/) 1986/86
    Spring Football 1986
    SportYear ISSBegan
    Football 1982
    Volleyball () 1982
    Gymnastics (/) 1983/84
    Wrestling 1983
    Baseball 1983
    Lacrosse (/) 1984/83
    Based on exposure rates
  • 16.
  • 17. SOCCERACL Injury Rate, 1989-98
    0.32
    2.8 X
    0.13
  • 18.
  • 19. BASKETBALLACL Injury Rate, 1989-98
    0.29
    3.5X
    0.09
  • 20.
  • 21. Mechanism of ACL Injury
    Non-contact mechanism (80%)
    Rapid but awkward stop
    The position of “no return”
    ACL tears in 70 ms
  • 22. Risk Factors:
    Gender Differences?
  • 26. Anterior Cruciate Ligament Injury in the Female Athlete
    Intrinsic factors:
    Alignment
    Hyperextension
    Physiological rotatory laxity
    ACL size
    Notch size and shape
    Hormonal influences
    Inherited skills and coordination
  • 27. Anterior Cruciate Ligament Injury in the Female Athlete
    Extrinsic factors:
    Strength
    Conditioning
    Shoes
    Motivation
  • 28. Anterior Cruciate Ligament Injury in the Female Athlete
    Combined (partially controllable):
    Proprioception (position sense/balance)
    Neuromuscular activation patterns
    Sport-specific skills (acquired)
  • 29. Gender Differences?
  • 30. Non-Contact Anterior Cruciate Ligament Injuries: Risk Factors and Prevention Strategies
    A Consensus Conference held at Hunt Valley, Maryland on June 10, 1999
    Sponsored by AAOS, AOSSM, NCAA, and NATA
    Organized by Letha Y. Griffin, M.D., Ph.D.
    Elizabeth A. Arendt, M.D.
  • 31. Hunt Valley Consensus ConferenceJune 1999
    Reviewed research to date:
    Anatomic risk factors
    Hormonal risk factors
    Biomechanical/neuromuscular risk factors
    Reviewed videos on non-contact ACL injuries
    Reviewed existing neuromuscular programs
  • 32. Hunt Valley Consensus ConferenceJune 1999
    • GOALS:
    • 33. to increase awareness of “at risk” population
    • 34. to stimulate increased research efforts
  • Hunt Valley Consensus Conference: June 1999 HORMONAL RISK FACTORS
    No consensus that sex specific hormones play a role in increased ACL injuries in females
    No evidence to recommend modification of sports or hormonal modification for females
    Remains a “fertile” area for future research
  • 35. Existence of Hormone Receptors in Ligaments
    Model: human ACL, 5  & 5
    cell culture
    Relaxin receptor sites :
    • Found in female ACL
    • 36. NOT found in male ACL
    Degroo et al.,Trans Ortho Res Soc, 2001
  • 37. Effects of Hormones - Cellular Mechanisms
    Model:
    Sheep ACL fibroblasts
    Cyclic estrus function
    Estrogen receptors present in sheep ACL fibroblasts
    No effect of physiologic levels of estrogen on cell proliferation or collagen synthesis
    Seneviratne et al.
    Trans. Ortho. Res. Soc, 2000
  • 38. Effects of Hormones-Mechanical Properties of Ligaments
    Model:
    • mouse knee joint
    • 39. mechanically quantified drawer test
    ligament stiffness
    Estrogen + Relaxin
    Levine et al.,Ortho Trans, 1999
  • 40. Effects of Hormones-Mechanical Properties of Ligaments
    Model: sheep
    • 38 animals (38 ACL/10MCL)
    • 41. 6 months
    • 42. ligament failure test
    No effect of estrogen level on
    mechanical properties of ACL or MCL
    Strickland et al.,Trans of Ortho Res Soc, 2000
  • 43. Effects of Hormones-Mechanical Properties of Ligaments
    Model: primate
    • 26 animals (26 ACL/26 PT)
    • 44. 2 years
    • 45. ligament failure test
    No correlation between ACL or Patellar tendon material properties and estrogen levels.
    Arendt et al.,ISAKOS, 2001
  • 46. Effects of Hormones-Mechanical Properties of Ligaments
    Estrogen and progesterone receptor sites have been reported in human ACL cells.
    Relaxin receptor sites have been reported in female ACL cells.
    The effect of relaxin, or relaxin plus estrogen may merit further investigation.
  • 47. Hormone Levels and ACL Injuries
    Estrogen
    Progesterone
  • 48. Hormone Levels and ACL Injuries
    Population : 17 Norwegian females (8 on BCP)
    team handball players
    menstrual phase at time of N-C ACL injury menstrual history questionnaire
    Myklebust et al., Scand Med Science and Sport, 1998
  • 49. Hormone Levels and ACL Injuries
    • Fewer injuries occurred during mid-cycle.
    • 50. Trend toward in luteal phase
    Myklebust, et al, Scand Med Science and Sport, 1998
  • 51. Hormone Levels and ACL Injuries
    • Population : 61 female recreational skiers
    • 52. Date of injury, cycle length, use of oral contraceptives
    • 53. Date of next menstrual cycle used to calculate phase of cycle in which injury occurred
    No correlation between cycle phase & NC-ACL injury
    Boynton et al.,
    AOSSM, 2000
  • 54. Hormone Levels and ACL Injuries
    Population : 83 College female varsity athletes.
    (25 on birth control pills)
    Menstrual phase at time of N-C ACL
    No data on onset of next menses
    No significant difference in NC-ACL injury & day of menstrual cycle.
    Trend toward in follicular stage
    Arendt et al.,Journal of Gender Specific Medicine, 2002
  • 55. Hormone Levels and ACL Injuries
    Centered moving average
    Smooth out time dependency of the number of injuries
    Arendt et al., Journal of Gender Specific Medicine, 2002
  • 56. Hormone Levels and ACL Injuries
    Non-linear regression model
    • There is a significant difference in the time dependency of the number of injuries
    • 57. Cannot detect exact location ofhigh risk time interval
    Arendt et al., Journal of Gender Specific Medicine, 2002
  • 58. Hormone Levels and ACL Injuries
    Population : 65 females (8 on OCP)
    • Sports related NC-ACL injury
    • 59. Menstrual phase at time of injury
    • 60. Urine specimens within 24 h
    • 61. First day of next cycle
    • 62. Urine analysis for total estrogen, progesterone, and lutinizing hormone metabolites
    Wojtys et al,
    AOSSM, 2001
  • 63. LH Levels
    Progesterone
    Estrogen
    Hormone Levels and ACL Injuries
    Poor correlation between urine metabolites and athlete recollection of cycle
    Higher number of ACL injuries during mid-cycle
    No data on how metaboliteswere used to define stages of cycle
    X = ACL injury
    LH Concentration levels
    Progesterone levels (ng/ml)
    Estrogen levels (pg/ml)
    X
    X X X
    X X X X
    X X X X X X X
    X X X X X X X X X X X
    X X X X X X X X X X X X X X X X X
    X X X X X X X X X X X X X X X X X X X X X X
    Wojtys et.al.,
    AOSSM, 2001
  • 64. Hormone Levels and ACL Injuries
    Population : 35 females
    (25 College / 12 H.S.)
    • Sports related NC-ACL injury
    • 65. Saliva sample within 48 hours of injury
    26/37 (70%) injured ACL in follicular phase
    .
    Slaughterbeck et al.,NATA, 2001
  • 66. Hormones and Tissue Laxity
    Population: 26 high school female athletes
    Normal menstrual cycle
    Prospective single blinded 8 week study
    KT-1000 measurements taken prior to practice
    Repeated measurement of KT-1000 over 8 weeks
    Menstrual cycles charted
    No difference in KT-1000 with phase of the menstrual cycle
    Karageanes et al.,Clin J Sports Med, 2000
  • 67. Hormone Research
    Criticisms:
    One or two measurements not enough to capture female physiology
    Normative standards not well defined
    Small #’s unlikely to capture hormonal variability
    Most studies have large S.D. bars
  • 68. Conclusion
    Menstrual cycle phase & musculoskeletal injury
    Inconclusive data
    Neuromuscular mechanism (?)
  • 69. Consensus Statements: 1999 Anatomic Risk Factors
    No consensus on role of the intracondylar notch
    No consensus on role of ligament size
  • 70. Consensus Statements: 1999Anatomic Risk Factors
    No consensus on role of anatomic alignment
  • 71. Anatomic Risk Factor ACL Size
    Size of ACL: less force is required to rupture a smaller ligament
  • 72. Anatomic Risk FactorsACL Size
    Cadaver knees ( N =16 )
    Direct measurement technique
    Smaller ACL (cross-section) in females compared to males
    Muneta et al.,AJSM, 1997
  • 73. Anatomic Risk Factor ACL Size
    Measured ACL width on MRI
    Males ACL (6.1mm) > females ACL (5.2mm)
    Did not control for height and weight
    Staubli etal.,Arthroscopy, 1999
  • 74. Anatomic Risk Factor ACL Size
    Measured ACL (cross-section) on CT scan
    Male ACL (47.1mm) > female ACL (35.1mm)
    Controlled for height and weight
    Jackowski et al.,(Thesis, London, Ont.) 2001
  • 75. Anatomic Risk Factors ACL Size
    Measured ACL cross-section on MRI
    Case control study:matched for gender, age, and activity
    20 F ACL deficient knees: contralateral knee compared to 20 controls
    ACL deficient group had smaller x-sect (31mm) than controls (42.9mm)
    Willits et al.,AOSSM, 1999
  • 76. THE FAMILIAL PREDISPOSITION TOWARDS TEARING THE ACL: A CASE-CONTROL STUDY
    K. Flynn BSc
    C. Pedersen MSc
    A. Kirkley, MD
    C. Lebrun, MD
    Peter J. Fowler, MD
    The University of Western Ontario, London
  • 77. Anatomic Risk FactorsACL Size
    Based on data to date it appears that the increased rate of ACL tears seen in patients with narrower notches may simply be a manifestation of a smaller ACL.
    Is the smaller ACL appropriate for the size / strength of the individual ????
    If no -- is it due to gender, hormones, training??
  • 78. Anatomic Risk Factor Tibial Slope
    Tibial Slope: in the “quads active” mechanism of ACL injury, the tibia is planted & the quadriceps contracts resulting in sufficient force to cause excessive posterior translation of the femur in relation to the tibia, resulting in tearing of the ACL.
    The greater the tibial slope the easier it is for the femur to “slide” down the slope thus tearing the ACL
  • 79. Anatomic Risk Factor Tibial Slope
    There is a 6 mm increase in anterior tibial translation for every 10 degree increase in anterior tibial slope
    DeJour and Bonnin,JBJS, 1994
  • 80. Tibial Slope ACL Deficient Knees
  • 81. Anatomic Risk Factor Tibial Slope
    Tibial slope measured on CT scan
    No difference in males (8.3 degrees) vs. female (8.1 degrees) varsity athletes
    Jackowski et al.,(Thesis, London, Ont.) 2001
  • 82. Anatomic Risk Factor Tibial Slope
    XR measurement
    case control study: 50 ACL deficient knees to age matched PF knees
    no significant difference in ACL deficient knees (9.7 degrees) to controls (9.9 degrees)
    Meister et al.,Amer J Knee Surg, 1997
  • 83. Anatomic Risk Factor Tibial Slope
    Absolute measurement not contributory (?)
    Slope plus muscle contractioncombined effect (?)
  • 84. Prevention Strategies for Anatomic Risk Factors
    Anatomic risk factors are difficult to alter
    Little agreement regarding which anatomic factors may be significant, hence no prevention strategies recommended at this time.
  • 85. Hunt Valley Consensus ConferenceVideos of ACL Injuries
    54 videos of ACL injuries were collected in preparation for consensus conference
    22/54 in basketball: 15 women, 5 men, 2 ?
    Mechanism of injury: jump stop, jump landing, sudden deceleration
  • 86. ACL Injured on Landing
    Knee slightly flexed
    Knee in valgus, external rotation
  • 87. ACL Injured on Landing
    Knee slightly flexed
    Knee in valgus, external rotation
  • 88. Videos of ACL InjuriesConclusions
    Most common positions at injury were landing from a jump, jump stop, sudden deceleration
    Injured leg was usually not extended, but less than 30º flexion
  • 89. Research Needs: Non-Contact ACL Injuries
    What is the mechanism of injury in non-contact injuries to the ACL?
    Video data conflicts with in vitro data concerning ACL failure mechanisms
  • 90. Injury Mechanisms – Body Positions
  • 91. Knee Biomechanics (in vitro)
    External loads of valgus and external rotation do not load the ACL between 100 and 300 flexion
    Quadriceps activation can load the ACL between 100 and 300 flexion; this is increased if no hamstrings activation
  • 92. Consensus Statements: 1999Biomechanical Risk Factors
    At this time, neuromuscular factors appear to be the most important reason for the differing ACL injury rates between males and females
    Strong quadriceps activation during eccentric contraction a major factor in injury to ACL
  • 93. Neuromuscular Prevention Programs
    Henning - Griffis Program
    Caraffa Program
    Wedderkopp’s Program
    Cincinnati Program
    Frappier Program (Fargo, N.D.)
    Santa Monica Program (PEP)
    Norwegian Awareness Program
  • 94. Norwegian Awareness Program
    Three types of excercises with progression:
    Floor
    Airex balancemat
    Balance board
    5 weeks 2-4 x per week
    Then 1 x week through the season (Oct-April)
  • 95. Results After 9900 Season: All 3 Divisions
  • 96. Conclusion:
    Only 29% of the teams carried out the program according to the plan
    Elite teams had the best compliance
    Exercise quality improved when led by physical therapists
    Compliance may be improved by:
    More information
    Changes in type of excercises
    Improved info to the coach
    Sign a contract with the team
  • 97. New and More Sports RelatedTraining Programs
    Handball related excercises
    Fakes
    Two-leg landing
    Less static excercises
    Increased skill-level
    Increased number of two-persons drills
    Increased knowledge and motivation for players
  • 98. Floor Exercises – Progression
    Run wtake off
    Jump and two-leg landing
    Jump-in fake
    Turn around jump
    Jump in with two leg landing
  • 99. Air Mat Progression
    Receive ball on one leg
    Jump shot with two leg landing
    One leg landing
    Two and one leg ”fight”
    Jump in with turnround
  • 100. Baps Board Progression:
    Two leg passes
    Knee flex two leg and one leg
    Passes one leg
    One leg ball dribling wclosed eyes
    Two leg and one leg ”fight”
  • 101. All Divisions
    1999-00: 5 of 23
    2000-01: 7 of 17
  • 102. Elite Division
    1999-00: 4 of 6
    2000-01: 3 of 5
  • 103. Conclusion:
    An awareness program reduced ACL injuries in Norwegian team handball by 40% overall and 50% at elite level
  • 104. Conclusions
    Prevention of ACL injuries is possible:
    Neuromuscular training
    Focus on knee position
    Change the plant and cut and landing technique
    Possibilities for better results with more control of the training
  • 105. Research Needs: Non-Contact ACL Injuries
    What are strategies for preventing non-contact ACL injuries?
    What do all these programs have in common?
  • 106. Research Needs: Non-Contact ACL Injuries
    Proprioception training
    Identifying at risk motions and positions.
    Train avoidance techniques when possible
    Training programs that enhance body control, in particular rotational control of the limb
    Pelvifemoral muscles (hip extension, hip abduction, abdominals)
  • 107. Research Needs: Non-Contact ACL Injuries
    What specific neuromuscular factor accounts for the difference in ACL injury incidence between males and females? - most studied risk factor to date is GENDER
  • 108. Take “3” to Save the KNEE
    Accentuate Balanced Body Motion
    Control Limb Rotation
    Land with Bent Knee and Hip