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Anterior Cruciate Ligament in the Female Athlete Dr. Rocco Simmerano Athletic Trainers Meeting June 3, 2006.

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Presentation on theme: "Anterior Cruciate Ligament in the Female Athlete Dr. Rocco Simmerano Athletic Trainers Meeting June 3, 2006."— Presentation transcript:

1 Anterior Cruciate Ligament in the Female Athlete Dr. Rocco Simmerano Athletic Trainers Meeting June 3, 2006

2 Overview Epidemiology Relevant Anatomy Mechanisms of Injury Risk Factors Physical Exam Diagnostic Imaging Treatment Options

3 ACL Injury Approximately 80,000 tears/year in the US 50,000 reconstructions/year ($1 billion) years old 70 % sports related Absolute numbers show males > females However, in sports where both men and women compete, women are 2-8 times more likely to tear their ACL

4 Anatomy Musculature Bones Ligaments Tendons Cartilage

5 Musculature Quadriceps Rectus Femoris Vastus Lateralis Vastus Medialis Vastus Intermedius Hamstrings Biceps Femoris Semimembranosis Semtitendinosis Gracilis Gastroc-soleus complex

6 Ligaments Medial (tibial) collateral ligament Lateral (fibular) collateral ligament Function in side to side control

7 Ligaments Anterior cruciate ligament Posterior Cruciate Ligament Function in front to back control of the knee

8 Tendons Patellar tendon Part of the extensor mechanism Continuation of the quadriceps

9 Cartilage Menisci Secondary stabilizers Load transmission

10 Functions of the ACL Prevents anterior movement of the tibia on the femur Checks lateral rotation of the tibia in flexion Checks extension/hyperextension of trhe knee

11 Mechanism of ACL Injury Contact Non-contact Change of direction with foot planted Deceleration Awkward landing Out of control

12 Risk Factors for ACL Injury Environmental Equipment, Landscape, Shoes Anatomic Lower extremity alignment, laxity, notch size Hormonal Biomechanical Muscular strength, neuromuscular control

13 Environmental Risk Factors Bracing No evidence that prophylactic bracing prevents injury Shoe-Surface Interaction Multifactoral, higher friction associated with higher risk of injury

14 Anatomic Risk Factors Alignment Women have higher Q angles, more femoral anteversion, excessive tibial torsion, higher foot pronation FEMALEMALE Q Angle

15 Anatomic Risk Factors Laxity More common in women than men Role in injury still unclear Notch Size 9 of 15 studies support narrow notch width as a contributing factor In general, notch width is more narrow in women

16 Hormonal Risk Factors Estrogen and Progesterone receptors found on the ACL They can influence the mechanical properties of the ACL Higher estrogen levels reduces the tensile strength of rabbit ACL

17 Hormonal Risk Factors Studies attempting to link ACL injury with menstrual cycle are conflicting Survery of 103 ACL injuries in NCAA womens basketball players from showed injury most commonly occurred in the peri-menstrual peroid (just before or just after) Role of oral contraceptives is still unknown

18 Biomechanical Risk Factors Proprioception and neuromuscular control Hamstring and Quad balance Women tend to have less hamstring activation than men Eccentric quad contraction Hip extensor strength Women tend to have weaker hamstrings and glutei which leads to more upright landings after jumps More valgus knee angle in women increases stress on the ACL

19 Physical Exam Swelling Instability Lachman Anterior drawer Pivot shift

20 Magnetic Resonance Imaging

21 Immediate Care RICE Rest, Ice, Compression and Elevation Crutches Knee Immobilizer Quadriceps inhibition Referral to Orthopaedist

22 Treatment Options Age of patient Activity level Associated injuries Meniscus Cartilage Other ligaments Surgery vs. bracing/activity modification

23 Surgery Timingpre-hab Risks of arthrofibrosis Graft choices Bone-patellar tendon-bone autograft Hamstrings autograft Allograft Prepubescent reconstruction?


25 Rehabilitation Phase Ipre-op Regain quad control, optomize ROM Phase II0-2 weeks Wound healing, full extension, 90 deg flexion Phase III3-5 weeks Full ROM Phase IV6 weeks + Strength

26 Injury Prevention Neuromuscular Training Altering pivot/cut activities Landing on bent rather than straight knee Unpublished data showed an 89% decrease in ACl injuries in Division 1 female athletes over 2 years Prophylactic proprioceptive training 10 fold decrease in injuries over 3 years but a poorly matched control group

27 Questions? Thank You!!!

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