Arthroscopic-assisted reconstruction of the anterior cruciate ligament

Arthroscopic-assisted Reconstruction of the Anterior Cruciate Ligament RUPTURE OF THE ANTERIOR CRUCIATE LIGAMENT can lead to degenerative arthritis of the knee. Persons who participate in sports that require jumping and pivoting are at a high risk for injury leading to repeated episodes of instability, and surgical reconstruction is usually undertaken. Although no procedure can exactly replicate the kinematic and anatomic properties of the anterior cruciate ligament, intra-articular reconstruction with a strong and isometric graft offers the best hone, of restoring anatomic and functional stability and preventing future degenerative changes.

Traditional intra-articular reconstruction is associated with substantial morbidity from the surgical dissection necessary to expose the torn anterior cruciate ligament and then implant the substitute. In most cases, this has meant severe pain, swelling, and difficulty initiating range-of-motion exercises in the immediate postoperative period, resulting in a hospital stay of three to five days.

Arthroscopic techniques have recently been used to reconstruct the anterior cruciate ligament by adding a small extracapsular incision along with routine arthroscopic portals. This procedure is often done on an outpatient basis, and usually only an overnight hospital stay is required. With diminished pain, range of motion can be regained early. The cosmetic advantage of arthroscopic-assisted reconstruction of the anterior cruciate ligament is obvious.

The arthroscopic procedure begins with the use of a motorized shaver and burr to remove remnants of the torn ligament and to enlarge the intercondylar notch of the femur to prevent impingement of the graft as the knee extends. A special aiming guide allows a tunnel to be drilled into the joint at the selected tibial attachment site. Work is carried out through this tunnel while viewing arthroscopically, and the femoral attachment site is selected. A strain gauge is used to measure any shortening or elongation between the selected points. If substantial strain is found, the femoral attachment site can be altered. Once an acceptable site is located, the bony tunnel for the anterior cruciate ligament graft is drilled from within the joint, using the tibial tunnel as a working portal. The selected graft (usually autogenous tissue) is then passed through the tibial tunnel, across the joint, and positioned in the closed femoral tunnnel. After the graft is securely fixed, immediate range of motion is allowed.

Regardless of the method of reconstruction, all biologic grafts used to reconstruct the anterior cruciate ligament undergo revascularization that requires protection of the graft from excessive activity for several months. Despite the improved cosmetic and perioperative advantages of arthroscopic reconstruction, the long-term outcome is similar to the results achieved by open methods.

Acute care for ankle sprain

The history: In ankle injury, the history can be an opportunity to prepare the patient for the painful phases of the exam. In addition to applying ice, elevating the leg, and trying to gain the patient’s confidence, consider giving an agalgesic. The mechanism of the injury can help in diagnosis, while degrees of pain and swelling are less specific indicators. In children with open epiphyses keep a high index of suspicion for fracture of the growth plate.

In assessing the severity of an ankle injury, the history taking offers not only useful information but also an opportunity to gain the patient’s confidence, which can help when you come to the painful phases of the examination. Keeping the ankle elevated with ice packs applied during the history also helps, as does examining the uninjured ankle first when you do begin the exam. For some patients in severe pain, giving an analgesic before beginning the physical examination may be important in making the exam tolerable. You could try meperidine HCl (Demerol) or acetaminophen with codeine (Anacin-3 w/Codeine, Empracet w/Codeine, Tylenol w/Codeine, etc.).

Knowing the mechanism of injury can be helpful in diagnosis. An injury sustained while playing basketball, volleyball, gymnastics, or another sport that involves jumping is likely to be a typical lateral inversion sprain, while fracture is more likely if the injury occurred in a high-energy activity such as motorcycling. A patient’s report that the injury was accompanied by a crack or snap may indicate fracture or tendon injury.

In children with open epiphyses, fracture to the growth plate is always a possibility. While more severe epiphyseal fractures are relatively easy to recognize and can be picked up on X-ray, a Salter-Harris type I fracture is not obvious and may not show any displacement on X-ray. If a child has ankle pain, the mechanism of injury seems severe enough to have caused ligamentous damage, and there is local swelling, assume fracture. As a rule, the ligaments are stronger than the epiphyses in children: Sprains around the epiphyses are rare, and in fact Salter-Harris type I fractures may be more common.

The patient who sustains an ankle injury while running may have more than just a sprain. Runners are prone to stress fractures. Ask the runner if he or she has recently changed to a new type of running shoe, started running on a different surface, or increased mileage.

A history of repeated sprains suggests the possibility of chronic ankle instability. The patient with such instability could benefit from referral to an orthopedist for evaluation. Orthotic treatment frequently obviates surgery.

The degrees of pain and swelling are relatively unspecific gauges of the severity of an injury. Hairline fractures may not produce any swelling, for instance, although they usually do produce some pain. The degree of swelling also depends in part on whether the patient applied ice packs before coming in–and on a variety of factors such as whether the patient waited to come in because he did not want to “bother the doctor.’

EXPRESS STOP

Physical examination: Examining the injured ankle allows you to assess stability and identify areas of suspicion for X-ray. Examine both lower extremities from hips to toes. Identify areas of pain. The pain of fracture is often well localized. Carry out the anterior drawer test if it can be done without intolerable pain. Test the uninjured ankle first for comparison. A negative test does not rule out instability if the patient resists the force applied by the examiner.

The major objectives of the physical examination in ankle injury are to assess the stability of the ankle and to identify areas of suspicion for radiologic examination. Since the patient’s injuries may not be limited to the ankle, assess the alignment of both lower extremities from hips to toes. If possible, observe how the patient stands and walks.

While the patient is supine, compare the appearance, positions, and attitudes of the extremities. The presence of ecchymoses and swelling suggests high-energy trauma involving torn, bleeding ligaments or, perhaps, fracture or injury of the tibia or fibula. A noticeable inversion of the injured foot as compared with the other one is indicative of severe sprain or fracture.

Have the patient point to where pain is localized. Identify areas that are painful on palpation. Pain during isometric muscle contractions suggests a muscle or tendon injury. Fractures and dislocations generally produce pain well localized to the area of the injury.

Fractures of the malleoli are serious injuries that require immediate orthopedic referral, as do all displaced and compound fractures. Swelling with a palpable deficiency of tissue over the lateral malleolus and inversion of the foot suggests that the lateral ligament has been avulsed from the malleolus.

If you find that the injury does not require immediate orthopedic attention (see “Ankle injury: Indications for consultation’), you might consider splinting the ankle and sending the patient home for 48-72 hours with instructions to apply ice packs, keep the ankle elevated, and return for examination when the swelling has gone down and the pain has abated.

The anterior drawer test is useful for assessing the stability of the anterior talofibular ligament if it can be carried out without causing intolerable pain. With the patient supine, place the palm of one hand on the distal tibia and the other on the heel. Pull slowly and steadily forward on the heel with about 20 lb of force while stabilizing the tibia (see Figure 1). Do the test on the uninjured ankle first to obtain a basis for comparison. Some individuals have normally lax ligaments.

If the visible or palpable laxity is more than 3 mm (1/8 in) greater in the injured ankle than in the uninjured one, the patient probably has a grade II or III sprain of the anterior talofibular ligament (see “The three grades of ankle sprain,’ page 54). You might also feel a subtle grinding or a vibration, which is another indication of instability.

Failure to elicit a visible or palpable clinical sign with the anterior drawer test does not rule out injury if the patient resists the examiner. X-rays taken during a repetition of the test and during the inversion test (see “X-ray examination’) may still demonstrate instability.

EXPRESS STOP

X-ray examination: Ankle injures involving pain and swelling practically demand X-ray studies. If AP, lateral, oblique, and mortise views of both ankles rule out fracture, consider stress testing–under local anesthesia, if necessary. In the anterior drawer test, look for anterior displacement of the talus. In the inversion test, measure the tilt of the talus on the tibia. In both cases use the unaffected leg as the normal reference.

Most authorities agree that X-rays are practically mandatory in any situation involving pain and swelling in the ankle region. While stress X-rays are important in evaluating sprains, it is important to obtain AP, lateral, oblique, and mortise views of both ankles first to rule out fractures (see Figure 3, page 57). Two types of stress X-rays are usually included in the ankle evaluation: the anterior drawer test and the inversion test. You might want to consider performing the radiographic stress testing yourself under some circumstances –if, for instance, the patient seems likely to be more relaxed and cooperative with his or her own physician.

If pain or the patient’s anxiety about manipulation of the injured ankle seems likely to interfere with the exam, a local anesthetic such as 0.5% lidocaine HCl (Xylocaine) might be necessary. If so, give it once the physical examination is complete and the preliminary X-rays are obtained. Under sterile technique, inject the lidocaine along the deltoid ligament and into the intra-articular talofibular joint.

To perform the stress testing, the examiner, protected by a lead apron and gloves, sits on a stool at the feet of the recumbent patient. The anterior drawer test is performed as during the physical exam, but with the patient positioned on his side with the lateral aspect of the lower foot on the X-ray plate, the other leg crossed over (see “Physical examination’ for testing technique). A positive X-ray will show a greater anterior displacement of the talus on the affected side, indicative of damage to the anterior talofibular ligament. This gap may not be obvious except by comparison with the same view of the uninjured ankle.

For the inversion test, the patient lies supine. Grasping the talus and calcaneus, the examiner applies an inverting force–one that tends to turn the sole of the foot inward (see Figure 2, page 51). In examining the film, look for a talar tilt in the mortise–that is, a tilt of the talus with respect to the tibia (see Figure 4, page 57). Since the normal tilt varies substantially, consider the tilt of the uninjured ankle the normal for the patient. If the injured ankle tilts at least 6 degrees more than the uninjured one, the calcaneofibular and anterior talofibular ligaments are both torn. (Usually, the calcaneofibular ligament will not tear until the anterior talofibular ligament does.)

EXPRESS STOP

Treatment: Immobilization of the injured ankle is the basic tactic of initial therapy. Grade I sprains can often be managed with elevation and ice, and few sprains need casting. Avoid casting severely swollen limbs. Athletes or others desiring quick return to mobility can be treated with taping and rehabilitative therapy. Splinting is recommended for most patients. Inflatable ankle braces have become popular alternatives to taping and casting.

While early mobilization is important to rapid recovery from ankle sprains, immobilization of the joint is basic to initial treatment of almost all such injuries. Grade I sprains can usually be managed with nothing more than elevation and application of ice packs for 3-4 days. Compression, by means of an elastic bandage (Ace Bandage) applied over padding, may also help. Persistence of pain, swelling, or both is an indication for reevaluation.

In most more severe sprains, immediate orthopedic referral is unnecessary. Injuries ranging in severity from grade II and grade III sprains to nondisplaced fractures can generally be managed with secondary referral. The decision whether to obtain a consultation before treating is often complicated by the difficulty of distinguishing between grade II and grade III sprains. Stress testing can provide useful information for making this decision. If the inversion test is negative, the injury is likely to be a grade I or grade II sprain that can be treated successfully without surgery. A positive talar tilt on stress testing suggests a grade III sprain.

When immediate referral is indicated, a simple device such as a brace, pillow splint, air splint, or cardboard box splint can be used to prevent additional tissue damage while the patient is being transported. Once the foot is immobilized, check to make sure it is in a neutral position to avoid strangulation of circulatory supply distally.

Splinting is usually the best way to immobilize the joint. As few as 6% of sprains require casting. If examination and initial plain X-rays suggest a grade II or grade III sprain or a nondisplaced fracture, consider delaying casting and applying a well-padded posterior splint instead. Circular casts are not recommended when the limb is severely swollen and likely to swell more. Send the patient home with instructions to keep the affected limb elevated above heart level and to apply ice packs. After two or three days, the swelling should have subsided, and he or she can then return for casting, if necessary.

Many different kinds of ready-made splints are available. Be sure to pad the splint well before wrapping with woven gauze (Kerlix), stretch gauze, or elastic bandage (see Figure 5, page 58, for a more elaborate technique).

The choice of treatment for ankle sprains depends to a large extent on the patient’s life-style. If athletics are important to the patient with a grade I or grade II sprain, or if a bulky dressing would be particularly inconvenient, consider nonrigid dressings such as taping to allow early return to motion. With such treatment, however, the patient must have the time and willingness to undertake the necessary physical therapy. The taping technique used for athletes protects the ankle from additional eversion or inversion stress while allowing some plantar flexion and dorsiflexion. It also permits some walking and partial weight bearing. Early motion and weight bearing can provide a number of benefits, including decreasing muscle atrophy, promoting proper organization of collagen fibers during ligament healing, maintaining proprioception, and promoting lymphatic drainage.

The patient whose sprain is severe enough to require casting will need to spend 2-3 weeks in a short leg-walking cast, using crutches to help maintain balance. Be sure to trim the lateral superior aspect of the cast so that the peroneal nerve is not covered, and make sure the foot is in a neutral position. Immobilization in an equinus position may delay return to full ambulation.

Instruct the patient to report any tingling or loss of sensation in the toes and any swelling or pain. Chronic instability could result from premature return to full weight bearing and mobility, so if examination shows that the ankle is still unstable after 2-3 weeks of immobilization, continue the immobilization, recasting if necessary.

As alternatives to strapping and casting, various types of ankle braces are available. One that has become quite popular in recent years features an inflatable brace that surrounds the joint (Air-Stirrup Ankle Brace). Braces provide more support than taping, while allowing some dorsiflexion and plantar flexion. The simplicity of removal and reapplication facilitates an early return to motion. The patient can be weaned gradually from the device as the stability of the ankle joint returns. A brace can be used similarly after removal of a plaster cast.

Table: INITIAL MANAGEMENT OF ANKLE SPRAIN

Photo: Anatomy of the ankle

Photo: FIGURE 1: The anterior drawer test evaluates the stability of the anterior talofibular ligament. To perform the test, stabilize the leg with one hand while pulling forward on the heel with the other. When anterior movement of the talus with respect to the mortise is 3 mm (1/8 in) greater in the injured ankle than in the uninjured one, a grade II or III sprain is probable.

Photo: FIGURE 2: The inversion test can detect gross lateral instability of the ankle caused by tears in the anterior talofibular and calcaneofibular ligaments. The test is performed with the patient supine and the ankle over the X-ray plate. Stabilizing the tibia with one hand, the examiner applies an inverting force to the talus and calcaneus. A tilt of the talus with respect to the tibia that is at least 6 degrees greater on the injured side than on the uninjured side indicates that both ligaments are torn

Photo: FIGURE 3: A nonstress X-ray view can reveal severe ankle sprain as well as rule out fracture. Here a lateral view of the left ankle shows anterior subluxation of the talus from the tibia. Note the opening of the posterior ankle joint.

Photo: FIGURE 4: A tibiotalar tilt (TTT) produced in the inversion test can be measured on the film. While the results are often significant only when the injured and uninjured ankles are compared, extreme tilts such as this one are strongly suggestive of injury.

Photo: FIGURE 5: An effective ankle splint can be made by applying layers of cotton sheeting around the ankle and lower leg, adding a layer of stretch gauze over the cotton (a), applying a layer of plaster or other splinting material over the gauze to make a posterior splint (b), and covering the splint with stretch gauze or an elastic bandage.

Sports Injuries of the Shoulder – Conservative Management

In the preface of this new textbook, editor and primary author Thomas Souza states, whereas the 1980s was the decade of the knee, the 1990s is the decade of the shoulder.” Recently published textbooks (ie, The Shoulder, by Andrews and Wilk) and journal articles, along with increasing numbers of continuing education courses on the shoulder, would seem to lend credence to this statement. Souza, a chiropractor, enlists a cross-section of clinical specialists (orthopedic surgery, physical therapy, athletic train-radiology, and chiropractic) to provide a clinical guide to those practitioners treating shoulder dysfunction. The text aims to synthesize current information regarding conservative (nonsurgical) management of sports-related injuries. Souza achieves this goal by producing a fairly comprehensive, well-written text that has applications for all health care professions.

The 20 chapters (14 written by the author) are divided into five sections: functional anatomy and biomechanics; history and physical examination; radiographic and special imaging specific disorders and treatment, rehabilitation, and preventions. The first 2 chapters on anatomy and general biomechanics are well written and illustrated. The chapter on the shoulder in throwing sports adequately, if not exhaustively, covers the mechanics of throwing. Other sports such as tennis an golf are also included in this chapter. The topics of swimming and weight training are given separate chapters that detail proper technique and the most frequent pitfalls in training. Another great resource regarding the shoulder and reviews of various recovery aides like braces, slings, and immobilizers can be found at http://sprainedshoulder.org 

Special mention should be made of the chapter on positional examination, as it provides an efficient model and rationale for the physical examination. Also included in the section on history and physical examination is a chapter on isokinetic testing and exercise. in addition to providing testing protocols, treatment principles, and an extensive reference list, the authors give normative muscle performance data for a variety of athletic populations.

Of the chapters containing information on diagnostic imaging, the magnetic resonance imaging (MRI) chapter may be most beneficial to physical therapists. Along with a brief anatomy overview, the authors list specific benefits and potential pitfalls of (MRI) in a clear, concise fashion. A very cursory chapter on arthroscopic surgery is included.

A majority of the text is dedicated to specific disorders and their treatment. Separate chapters cover glenohumeral instability; impingement; frozen shoulder; sternoclavicular, acromioclavicular, and scapular disorders; and other extrinsic causes of shoulder pain. Uses of electrical modalities are very limited, whereas specific treatments of myofascial trigger points, cross-friction massage, and acupuncture/acupressure are given in greater detail. The chapter on mobilization and adjustive procedures will be of interest to manual therapists.

In summary, some members of the physical therapy community may disregard this text because it is primarily written by a chiropractor. Others will find it a refreshing example of a diverse array of clinical specialties finding a common ground, in this case the shoulder. Regardless, this is a worthy text for the orthopedic physical therapist treating shoulder dysfunction.

ACL-injured soccer players see high knee injury rate after rehab

Swedish professional soccer players who experienced an anterior cruciate ligament injury and returned to play after treatment had a significantly greater risk of injury to either knee compared to players without ACL injuries, researchers from Linkoping University in Sweden have reported. The results were statistically significant whether the risk of knee injury was calculated for the ACL-injured knee or the ACL-injured player.

“The first few months after return to soccer is of major concern, since many injuries, especially synovitis, occurred during this period,” said Markus Walden, MD, the study’s lead author, an orthopedic resident at Central Hospital in Kristianstad, Sweden. “Surgeons should think twice before performing a revisional ACL reconstruction after a rerupture or primary ACL reconstruction in a knee with known osteoarthritis with the aim of bringing the athlete back to a highly knee-demanding sport.”

The subjects were 310 out of 312 first team squad players on the 14 Swedish professional soccer teams who gave consent to participate in the study. Prior to the season, 24 players had a history of 28 ACL injuries. All of the injuries, except the bilateral injuries of one player, were surgically treated.

During the 2001 season, 50% of the ACL-injured players suffered at least one knee injury, significantly more than the 21% of the other players, the researchers reported in the February issue of the British Journal of Sports Medicine. This was despite the fact that the ACL-injured group played significantly fewer days due to injury. The total number of injuries per hour played and the number of lower limb injuries unrelated to the knee did not differ significantly between the groups.

The ACL-injured group experienced one overuse injury and three traumatic injuries to the contralateral healthy knee, with the remaining 20 knee injuries occurring to the ACL-injured knee. The risk of both overuse knee injury and traumatic knee injury was significantly higher in the ACL-injured group than in the other players. Among the injuries the ACL-injured group sustained during the 2001 season were one ACL tear to a non-ACL-injured knee and 10 cases of synovitis of which nine were to ACL-injured knees and four recurrent injuries to three players. Of the 10 athletes who had undergone ACL reconstruction during the previous season, five suffered nine overuse injuries and another a secondary meniscus tear, all to their reconstructed knees.

“The picture sometimes put forward by the media is that a torn cruciate means surgery followed by six months of rehabilitation, and then the problem is solved,” Walden said. “However, in our clinical experience we have noticed that some of the players have knee symptoms in spite of optimal surgery and physiotherapy.”

The researchers suggested that the time to return to contact sports after ACL reconstruction, traditionally six months, may be too short and that significant thigh muscle strength deficits and reduced performance on the one-leg jump test are still often present then. Other possible reasons the researchers hypothesized for the high rate of overuse injuries in ACL-reconstructed knees include that the transition from rehabilitation to training and competitive games could result in overloading of remodeled or not-yet-healed tissues, that previously injured athletes may engage in a relatively high intensity of play to prove their performance ability to their coaches, and that the rehabilitated knee may experience altered kinematics and lower proprioception.

Sprained shoulder

Sometimes you wake up to find that you’ve got a pain in your shoulder. This can be because you’ve slept in a bad position – causing you to have a shoulder sprain. It can really interfere with your everyday duties. Even simple things like carrying your bag over your shoulders can cause a lot of discomfort. It’s not a major thing to worry about but you do need to attend to it.

A shoulder sprain occurs when the ligaments in our shoulders are stretched beyond their capacity or have suffered a small tear. These ligaments hold the shoulder bones in place. To be specific, it’s when the glenohumeral joint has been injured. This is the point where the shoulder blades, the bone and the humerus meet. A shoulder sprain occurs when there is a heavy blow to the shoulder causing a dislocated shoulder or a light trauma to the juncture.

A sprained shoulder can be caused by a strong twist of the shoulder, a heavy blow to the shoulder, using your arms to break a fall without bending them.

You will need to attend to the shoulder sprain before it gets worse. It you don’t attend to it, it will make the injury worse and really get in the way with your daily life. If it doesn’t heal, you will not be able to participate in any sporting activities, cause problems with your balance, can cause loose joints and connective tissue disorders and decrease the strength in your muscles and ligaments.

You will be able to tell if it is a shoulder sprain if you find it hard to move your shoulder, lift your arms above your head, feel pain in your shoulder, have inflammation in your shoulder area or have any swelling there.

You can get an x-ray, MRI or an arthrogram to check if it really is a shoulder sprain.
To treat it, rest your shoulder as much as possible, 3 to 4 times a day, apply an ice pack for 15-20 minutes. Do this for a few days.

When you have received a shoulder sprain, gentle exercises to strengthen and stretch the muscles can be beneficial. Mild forms of exercise and supervised stretching can bring back strength to the shoulder.