Friday, May 7, 2010

Can we prevent ACL tears?

St. Luke’s Health Watch


By DR. TONY BUONCRISTIANI

With all the winter sporting activities, knee ligament injuries are unfortunately common. Even with our bleak snow year, I still performed numerous ACL reconstructions this winter on beginner and expert skiers alike.

One can sprain or tear a ligament. The most common ligament injury is a sprain of the medial collateral, or "inside," ligament. This is usually successfully treated with bracing. By contrast, an anterior cruciate ligament tear is often treated surgically with reconstruction in active people. An ACL injury is commonly a result of a non-contact twisting or pivoting. Meniscal cartilage is torn in association with ACL injuries 40-70 percent of the time.

The ACL functions as one of the primary stabilizers of the knee, providing back-to-front (translational) and cutting/pivoting or side-to-side (rotational) stability. The ACL has different components to perform these functions. In contrast, the meniscus (medial and lateral) act predominantly as the cushion or shock absorber of the knee, and its damage may result in the development of arthritis.

More than 250,000 ACL injuries occur in the United States each year. Unfortunately, we sports orthopedists are seeing a younger population of ACL injuries, attributed to our children's participation in a higher level of competition at younger ages. Bracing has been found to be ineffective in preventing subsequent subluxation or "tweaking" episodes.

ACL surgery continues to improve with cutting-edge technology, such as performing a more "anatomic" reconstruction, which more closely mimics the normal kinematics or movements of the knee. It is hoped that this will provide more stability, increase function and decrease arthritis compared to previous ACL reconstructions. In addition, due to increased technology and more aggressive rehabilitation, athletes can often return to competition earlier, before the graft has fully matured or incorporated. Unfortunately, this has led to many young athletes' sustaining a re-tear and needing a revision ACL reconstruction surgery. Several recent Olympians at Whistler had undergone revision ACL reconstructions.

To date, there is no standardized intervention program established to prevent non-contact ACL injuries. However, multi-component programs (i.e. balance and strengthening, stretching, body awareness, targeted core and trunk control, lower extremity, and plyometrics, which are rapid explosive jumping exercises) appear to be successful training tools in reducing non-contact ACL injuries by decreasing landing forces and increasing effective muscle activation. This program, which focuses on neuromuscular control, appears to significantly reduce the risk of ACL injuries in female athletes, who have a higher rate of non-contact ACL tears. Female skiers have four times the ACL injury rate of male skiers.

To answer the lead question, ACL tears cannot be fully prevented. However, preseason injury-prevention programs combined with an in-season maintenance program should be advocated to significantly decrease or prevent injury. Unfortunately, compliance may in fact be the limiting factor to the overall success of ACL injury interventions. As a sports orthopedist, my goal is to have such programs implemented at the various sports levels and activities in the Wood River Valley.

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Dr. Tony Buoncristiani is a Sports Medicine and Shoulder Fellowship-trained, board-certified orthopedic surgeon.




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