Essay Instructions: This is a research paper on the ACL. I have a start on the paper, but it will need revised and reformated. I would like to add 7 pages to the current paper. Below is the guidelines for the paper. I will also like 7 additional references for the paper. It paper should be in apa format.
1-2 page introducing the topic (1-2)
2-4 pages frequency, severity, and cause of injury (3-6)
7-8 pages caring and preventing injury (10-14)
2 pages summarizing, providing thesis, and best applications (12-15)
Introduction
Anatomy and Biomechanics
The anterior cruciate ligament (ACL) is an important structure in the knee. It originates on the lateral femoral condyle and inserts into the tibial plateau medial to the anterior horn of the lateral meniscus (Evans, Chew, & Stanish, 2006). The femoral attachment is on the lateral wall of the inter-condylar notch posteriorly. The tibial attachment is on the anterior part of the tibial plateau near the tibial spines. The ACL has an anteromedial band that is tighter in flexion and a posterolateral band that is tighter in extension (Bonci, 1999). During anterior tibial loading, the ACL plays an important role in limiting anterior tibial translation (Sakane, Livesay, Fox, Rudy, Runco, & Woo, 1999). The primary function of the ACL is to provide knee stability, primarily against anterior translation of the tibia on the femur, proprioception at the knee, and knee hyperextension.
Common Mechanisms of Injury
An anterior cruciate ligament (ACL) injury can vary in three grades: partial sprains (grade one or two) to a complete tear (grade three). If other structures in the knee are damaged as well, the injury is described as being “combined” rather than “isolated” when only the ACL is damaged. Complete ligament ruptures, especially those involving the ACL, are often associated with other ligamentous injuries, leading to the clinical complaint of knee instability (Smith, Rosenlund, Aune, MacLean, & Hillis, 2004). Combined tears usually occur with damage to one or many of the following knee anatomical structures: the menisci, the articular cartilage, the collateral ligaments, and/or the joint capsule (Bonci, 1999).
Athletes are more likely to injure the ACL and other structures in games versus practice, and contact injuries are more frequent than noncontact injuries (Dick, Ferrara, Agel, Courson, Marshall, Hanley, & Reifsteck, 2007). The most common mechanism of injury is a plant and cut or “flexion-valgus-external rotation movement” (Evans, Chew, & Stanish, 2006). In other words, the foot plants with slight knee flexion, then on attempting to turn outward the tibia externally rotates while the femur internally rotates and with slight valgus can cause enough force to tear an ACL, and probably other knee anatomical structures. For a complete and/or partial tear, the patient will immediately be unable to bear any weight on the injured leg and could have possibly heard a pop or snap. Other common mechanisms of injury for an ACL injury include direct trauma, sudden stops, and jumping. Each sports mechanism of injury will differ with the required movements of the knee.
Predisposing Factors
There are many different predisposing factors that can target a patient for an anterior cruciate ligament (ACL). Intrinsic factors are internal elements that include age, gender, previous injury, and body composition, etc., whereas extrinsic factors are external elements such as shoe traction, playing field, and environment. Some athletes may come to preseason poorly conditioned, thus, the stress of the high-intensity, high-load preseason training may result in an excess of injuries (Hootman, Dick, & Agel, 2007). Also, preseason practices often include multiple practices a day limiting recovery time. Preseason practices also may have less skilled or “walk-on” persons trying out for the sport; and such individuals may be more susceptible to injury (Hootman, Dick, & Agel, 2007). Unfortunately for females, they have a four-to-six increased risk for ACL injury compared to males in the same sport/playing level due to the hormonal levels (i.e. release of hormones during menstrual cycle), biomechanical differences (i.e. increased Q angle), and lack of neuromuscular development after puberty (Bonci, 1999).
Preventative Techniques
Testing for Injuries
There are many different types of tests that test the stability of the anterior cruciate ligament (ACL). Common tests performed by orthopedists in determining an ACL injury are the Lachman test, anterior drawer, pivot shift test, and Slocum drawer. The Lachman test provides the best overall positive and negative likelihood ratios, whereas the pivot shift test solely has a high positive likelihood ratio, and the anterior drawer test is mediocre in both categories (Ostrowski, 2006). If absolute displacement found during the anterior drawer test is larger than that in the Lachman test, this may indicate a combined ACL+MCL injury (Smith, Rosenlund, Aune, MacLean, & Hillis, 2004).
Options for Repair
Following a rupture of the anterior cruciate ligament, there are different methods available to re-establish the stability of the knee joint (Gorschewsky, Klakow, Pütz, Mahn, & Neumann, 2007). In the instance of a partial ACL injury, the individual may opt for conservative treatment that focuses on muscle strengthening, proprioceptive training, and protective bracing (Evans, Chew, & Stanish, 2006). The modern orthopedic surgeon has a variety of techniques and materials that may be applied to specific clinical situations. Many different graft sources and types of fixation exist (Mahirogullari, Oguz, & Ozkan, 2006). The two most common grafts used in ACL reconstruction are the bone-patellar tendon-bone (BPTB) and semitendinosus-gracilis autografts (Denti, Lo Vetere, Bandi, & Volpi, 2006). Different forms of the grafts are categorized as autograft (individual’s own tissue), allograft (tissue from donor), or synthetic (man made). Today, both the BTPB and semitendinosus-gracilis grafts are used about equally often; deciding which graft is right for the ACL reconstruction depends on the time since injury, amount of laxity, relevant medical history, and postoperative occupation (Denti, Lo Vetere, Bandi, & Volpi, 2006). The BPTB graft is used for many reasons that include: 1. show better stability and a lower failure rate with patellar tendon grafts; 2. has a twenty precent greater chance to return to preinjury activity levels; and 3. patients with BPTB grafts were more likely to have normal Lachman, normal pivot-shift, and less loss of flexion (Maletis, Cameron, Tengan, & Burchette, 2007). A common complaint with the bone-patellar tendon-bone graft is anterior knee pain and quadriceps muscle weakness due to the removal of a portion of the patellar tendon. The hamstring graft is beneficial for individuals who have mild to moderate knee laxity, anterior knee dysfunction, and who want to avoid a recurrence of postoperative pain in the hamstring area. An observation distinguished by individuals with the hamstring graft was the higher incidence of anterior knee laxity (Mahirogullari, Oguz, & Ozkan, 2006). Anatomic reconstructions of ACL with double bundle gracilis and semitendonosus tendons graft, reproducing AM and PL bundles, have been introduced to offer a better biomechanical outcome, especially during rotatory loads (Monaco, Labianca, Conteduca, De Carli, & Ferretti, 2007).
Rehabilitation
Prior to surgery, starting a preoperative rehabilitation program can greatly increase the individual’s healing time. Exercises would include swelling reduction, hyperextension exercises, and gait training (Arnold, & Shelbourne 2000). In the first weeks of rehabilitation, after anterior cruciate ligament (ACL) surgery, pain control, reduction of swelling, regaining range of motion, and strengthening the quadriceps muscle group are the major goals. Allowing the individual to regain range of motion immediately postoperatively will eliminate the need for any other surgeries to regain range of motion. Once pain has subsided, additional exercises can be implemented to work on regaining complete range of motion, teaching proper gait, and muscle strengthening of all affected muscle groups. It is important not to progress too quickly because stress on the new graft can cause irritation and improper healing. Closed kinetic chained exercises are initiated first because they are considered “safe,” and stress is focused on many joints and can help control any possible irritation of the new graft (Fitzgerald, 1997). The progression of exercises should begin with range of motion and strengthening of muscles and eventually end with the individual able to complete sport specific drills without pain or swelling.
Return to Play
After a rehabilitation program, which targeted range of motion and muscle strengthening, certain sport specific drills can be done to determine if the individual is ready to return to normal physical activity. With an accelerated rehabilitation program, positive motivation, and near absence of functional limitations, an individual can return to sport sooner and be more satisfied. An individual competing with functional problems increases the risk of secondary injury, accelerated deterioration of knee function, and progressive osteoarthritis (Smith, Rosenlund, Aune, MacLean, & Hillis, 2004). Functional knee braces have also become popular for protection of the graft during rehabilitation after anterior cruciate ligament reconstruction and provide support when the individual returns to play. The brace is designed to minimize internal and external rotation and anterior and posterior translation of the tibia. It is important for each physical therapist to individually assess each patient and be able to recognize when the individual is best suited to return to play.
Conclusion
References
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