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Renato Semadeni and Kai-Uwe Schmitt

Objective:

In this study a numerical model of a skier was developed to investigate the effect of different rehabilitation strategies after anterior cruciate ligament (ACL) rupture.

Methods:

A computer model using a combined finite-element and multibody approach was established. The model includes a detailed representation of the knee structures, as well as all major leg muscles. Using this model, different strategies after ACL rupture were analyzed.

Results:

The benefit of muscle training to compensate for a loss of the ACL was shown. The results indicate that an increase of 10% of the physiological cross-sectional area has a positive effect without subjecting other knee structures to critical loads. Simulating the use of a hamstring graft indicated increasing knee loads. A patellar-tendon graft resulted in an increase of the stress on the lateral collateral ligament.

Conclusion:

Muscle training of both extensors and flexors is beneficial in medical rehabilitation of ACL-deficient and ACL-reconstructed knees.

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Zakariya Nawasreh, David Logerstedt, Adam Marmon and Lynn Snyder-Mackler

Rupturing the anterior cruciate ligament (ACL) is a common knee injury in sport activities. 1 Repeated episodes of knee instability, joint effusion, quadriceps strength deficits, limb-to-limb movement asymmetry, neuromuscular dysfunction, and abnormal gait pattern are commonplace after ACL rupture

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Emily R. Hunt, Cassandra N. Parise and Timothy A. Butterfield

Clinical Question What are the effects of nonoperative treatment on isokinetic muscle strength, the single-leg hop test, and the iKDC-2000 in patients who have sustained an ACL rupture? Search Strategy In November 2018, we performed a comprehensive computerized search using the following terms (Figure  1

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Marta Stepien-Slodkowska, Krzysztof Ficek, Pawel Zietek, Mariusz Kaczmarczyk, Wioletta Lubkowska, Miroslawa Szark-Eckardt and Pawel Cieszczyk

Context:

The most commonly injured body part for skiing has been found to be the knee. The rupture of the anterior cruciate ligament (ACL) was the most frequent diagnosis. ACL ruptures are determined by several extrinsic and intrinsic risk factors including those that are hormonal, neuromuscular, anatomical, or genetic.

Objectives:

To examine the association of both COL1A1 rs1800012 (+1245G/T) and COL1A1 rs1107946 (–1997G/T) polymorphisms, individually and as haplotypes, with ACL ruptures in recreational Polish skiers.

Design:

Genomic DNA was extracted from buccal cells donated by the subjects, and genotyping was carried out using real-time polymerase chain reaction.

Settings:

University laboratory.

Participants:

138 male recreational skiers with surgically diagnosed primary ruptures and 183 apparently healthy male recreational skiers not differing markedly in age or level of exposure to ACL injury.

Main Outcome Measures:

COL1A1 rs1800012 and COL1A1 rs1107946 polymorphisms.

Results:

There were significant differences in genotype distribution of the COL1A1 rs1800012 polymorphism between the ACL rupture group and the control group. The GG homozygotes were underrepresented in the ACL rupture group compared with the control group. There were no significant differences in genotype distribution or allele frequency of COL1A1 rs1107946 polymorphisms between the ACL rupture group and the control group. The G-G (COL1A1 rs1800012G and COL1A1 rs1107946G) haplotype was the most common. There were no significant differences in haplotype distribution between the ACL-rupture and control groups.

Conclusion:

The study showed that GG homozygotes were underrepresented in the ACL-rupture group compared with the control group, which suggests an association with reduced risk of ACL injury.

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Yukio Urabe, Mitsuo Ochi and Kiyoshi Onari

Objective:

To investigate changes in muscle strength in the lower extremity after ACL reconstruction.

Design:

Prospective case series.

Dependent Variables:

Isokinetic muscle strength measured in 6 movements (hip extension/flexion, hip adduction/abduction, knee extension/flexion) and circumference of the thigh/calf.

Setting:

Clinic and home.

Patients:

44 (24 men, 20 women) between the ages of 16 and 47 years with an ACL rupture. All underwent reconstruction via a semitendinosus autograft.

Main Outcome Measures:

The peak torque for each joint movement was recorded. Repeated-measures ANOVA and power analysis were conducted to detect significant interaction effects.

Results:

The decline of muscle strength after ACL reconstruction remained not only in the knee extensors and flexors but also in the hip adductors.

Conclusion:

Rehabilitation programs that address the behavioral patterns and physiological characteristics of an ACL injury will benefit the athlete’s whole body and lead to a full recovery.

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Michael J. Axe, Katherine Linsay and Lynn Snyder-Mackler

The purpose of this study was to determine whether there was a relationship between knee hyperextension and intra-articular pathology in 100 consecutive patients whose sole ligament injury was an arthroscopically confirmed anterior cruciate ligament (ACL) rupture. Hyperextension of both knees was measured using a supine heel-height measurement of high reliability. There was more articular damage to the total joint, lateral joint, and lateral meniscus in patients who hyperextended than in those who did not. There was more articular damage to the total joint and medial joint in patients who were chronically ACL deficient than in those who were acutely or subacutely ACL deficient. The results demonstrate that individuals with ACL injuries whose knees hyperextend 3 cm or more sustain significantly more joint damage at the time of injury than in those whose knees hyperextend less than 3 cm. This study further defines the role of knee hyperextension in ACL injuries and offers a useful and reliable means of measuring knee hyperextension.

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Mina Samukawa, David Magee and Masaki Katayose

Context:

The effects of tibial rotation after ACL injury have not yet been well determined.

Objective:

To show whether clinical outcomes such as the amount of tibial rotation can affect functional outcomes in normal and ACL deficient knees.

Design:

Case control study.

Setting:

Research laboratory.

Participants:

Twenty normal subjects (Control) and 20 subjects with ACL deficient knees (ACL).

Main Outcome Measures:

Tibial rotation at 30 and 90 degrees of knee flexion was measured using an inclinometer. One-legged hop, crossover hop, figure-of-eight running and 10-m running tests were used and determined the effect(s) of tibial rotation on the outcome of the functional tests.

Results:

There were significant between-group differences in internal and external rotation. The relationship between external tibial rotation and the figure-of-eight index was significantly negatively correlated.

Conclusions:

The amount of tibial rotation is greater in ACL ruptured knees than in uninjured knees, and these greater amounts of tibial rotation affected the figure-of-eight running index.

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Peter Schaff, Lars Nordsletten and Arne Kristian Aune

The purpose of this study was to examine motion and muscle activity in downhill skiing in order to estimate muscular involvement during the landing phase and its potential effect on ACL injury. Specially developed 8-channel portable electromyo-graphy registration was conducted during three jumps on the Russi jump of the 1994 Olympic downhill slope, and six control jumps were carried out in the laboratory. The results reveal that the skier adapts to the expected loading of the knee, possibly by using a learned motor control pattern. It is still not clear, however, how important muscular adaptation to expected forces is. The complex functional EMG pattern that skiers use while landing indicates that ACL rupture caused during a backward fall in downhill skiing might be due to a combination of the boot-top-induced anterior shear, the force generated in the ACL by forceful knee hyperflexion supported by the high bending moment generated by a stiff spoiler, and the possible absence of a significant protecting hamstrings force during maximum loading.

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Mason D. Smith and David R. Bell

Context:

Anterior cruciate ligament (ACL) reconstruction is the standard of care for individuals with ACL rupture. Balance deficits have been observed in patients with ACL reconstruction (ACLR) using advanced posturography, which is the current gold standard. It is unclear if postural-control deficits exist when assessed by the Balance Error Scoring System (BESS), which is a clinical assessment of balance.

Objective:

The purpose of this study is to determine if postural-control deficits are present in individuals with ACLR as measured by the BESS.

Participants:

Thirty participants were included in this study. Fifteen had a history of unilateral ACLR and were compared with 15 matched controls.

Interventions:

The BESS consists of 3 stances (double-limb, single-limb, and tandem) on 2 surfaces (firm and foam). Participants begin in each stance with hands on their hips and eyes closed while trying to stand as still as possible for 20 s.

Main Outcome Measures:

Each participant performed 3 trials of each stance (18 total), and errors were assessed during each trial and summed to create a total score.

Results:

We observed a significant group × stance interaction (P = .004) and a significant main effect for stance (P < .001). Post hoc analysis revealed that the ACLR group had worse balance on the single-leg foam stance than did controls. Finally, the reconstructed group had more errors when total BESS score was examined (P = .02).

Conclusions:

Balance deficits exist in individuals with ACLR as measured by the BESS. Total BESS score was different between groups. The only condition that differed between groups was the single-leg stance on the unstable foam surface.

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Tania Suarez, Luca Laudani, Arrigo Giombini, Vincenzo Maria Saraceni, Pier Paolo Mariani, Fabio Pigozzi and Andrea Macaluso

Context:

Tearing of the anterior cruciate ligament (ACL) may disrupt the ability to recognize the knee position in space during limb-repositioning tasks, which is referred to as joint-position sense (JPS). Impairments in JPS have been shown to be lower during active than passive repositioning tasks, thus suggesting that coactivation patterns of the muscles surrounding the knee might compensate for the disrupted JPS and ensure accurate limb repositioning in ACL-deficient individuals.

Objective:

To investigate muscle coactivation patterns during JPS repositioning tasks in ACL-deficient and healthy individuals.

Design:

Prospective observational study.

Setting:

Functional assessment laboratory.

Participants:

8 men age 25 ± 8 y with isolated ACL rupture and 10 men age 30 ± 4 y with no history of knee injury.

Intervention:

JPS was evaluated by means of an electrogoniometer in a sitting position during either passive or active joint-positioning and -repositioning tasks with a 40° target knee angle.

Main Outcome Measures:

Root mean square (RMS) of the surface electromyogram from the vastus lateralis and biceps femoris muscles was measured during active joint positioning and repositioning.

Results:

Healthy participants showed a significant decrease in vastus lateralis RMS (−19%) and an increase in biceps femoris RMS (+26%) during joint repositioning compared with positioning. In contrast, ACL-deficient patients showed no modulation in muscle coactivation between joint positioning and repositioning, although they exhibited significantly lower RMS of the vastus lateralis (injured limb, −28%; uninjured limb, −21%) and higher RMS of the biceps femoris (injured limb, +19%; uninjured limb, +30%) than the healthy participants during joint positioning.

Conclusions:

The lack of modulation in muscle coactivation patterns between joint positioning and repositioning in ACL-deficient patients might be attributed to disrupted neural control after the injury-related loss of proprioceptive information. These results should be taken into account in the design of rehabilitation protocols with emphasis on muscle coactivation and JPS.