Chapter 2: ACL Injury, Surgery, and Rehabilitation: A Science-Based and Evidence-Informed Approach 2 CC Hours
By: Jacob J. Capin, PT, DPT, PhD, MS; Zakariya H. Nawasreh, BS, MSc, PhD; and David S. Logerstedt, PT, PhD, MPT, MA, SCS Learning objectives
Describe the diagnostic strategies, management plans, and classification of patients with ACL injury; Formulate a rehabilitation program using clinical strategies and evidence-based interventions after ACL injury and ACL reconstruction Explain the functional and clinical outcomes after ACL injury and reconstruction. Given the modifications and advancements in ACL surgical pro- cedures and the proliferation of research on interventions and outcomes, many clinicians find it difficult to keep apprised of the latest evidence and integrate this new information into their clini- cal practice. Decisions regarding which patients are appropriate for non-operative management of an ACL-deficient knee, how to safely progress patients through a criterion- based guideline, and when to provide recommendations for a safe return back to sports after ACL injury or reconstruction are challenging. Physical therapists and physical therapist assistants will be able to use the knowledge and skills outlined in this course with their patients af- ter ACL injury or surgery to maximize patients’ responses to exer- cise at their current functional level while minimizing risk of injury to the healing tissue(s). adversely impact health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and aware- ness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Addi- tionally, implementing policies and procedures prioritizing equi- table treatment for all patients can play a pivotal role in reduc- ing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treat- ment regardless of their background or characteristics.
After completing this course, the learner will be able to: Identify and describe the anatomy of the anterior cruciate ligament (ACL) and key surrounding structures including how they contribute to knee arthrokinematics; Discuss the typical mechanism of injury, clinical course, and risk factors associated with ACL injury; Apply a comprehensive clinical examination to develop a specific diagnosis for patients with a suspected ACL injury; Course overview Injury to the anterior cruciate ligament (ACL) can be devastating. Approximately 250,000 ACL injuries occur annually in the United States and ACL injury rates are rising, particularly among young in- dividuals involved in jumping, cutting, and pivoting sports (Frank & Jackson, 1997; Griffin et al., 2000; Majewski, Susanne, & Klaus, 2006). ACL injuries typically result in substantial short-term physi- cal impairments and long-term joint morbidity including a high risk for subsequent injury and early, post-traumatic osteoarthritis. The purpose of this intermediate-level course is to provide physi- cal therapists and physical therapist assistants with an overview of the etiology and risk factors of isolated ACL injury; to discuss per- tinent clinical examination, classification, and prognosis after ACL injury and reconstruction; and to review interventions relevant to successful outcomes after injury or surgery. Implicit bias in healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gen- der identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can mani- fest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assump- tions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can
INCIDENCE
Noyes, Torvik, Hyde, & DeLucas, 1974). Approximately 30% of all ACL injuries involve physical contact while the majority are non- contact in nature (Hewett, Stroupe, Nance, & Noyes, 1996). The incidence of noncontact ACL injuries is greater in sports that re- quire multidirectional activities, such as rapid deceleration, pivot- ing, cutting, and landing from jumps (Griffin et al., 2006). Sports activities account for 88% of injuries to the ACL, although ACL injuries from motor vehicle accidents and work injuries have also been reported (Magnussen et al., 2010). In the United States, most ACL injuries occur in young athletes (Wojtys & Brower, 2010) and people of various ages who participate in basketball, soc- cer, football (Magnussen et al., 2010) and downhill skiing (Pujol, Blanchi, & Chambat, 2007). In comparable sports, girls are 3.4 times more likely to sustain an ACL injury than boys (Joseph et al., 2013). In girls, the highest per-season injury risk levels are in gymnastics, soccer, basketball, and lacrosse (Agel, Rockwood, & Klossner, 2016; Gornitzky et al., 2016). In boys, the highest injury risk levels per season are in American football, lacrosse, and soc- cer (Gornitzky et al., 2016).
Injury to the anterior cruciate ligament (ACL) is the most preva- lent of internal knee lesions, with upwards of 250,000 ACL inju- ries occurring each year in the United States (Frank & Jackson, 1997; Griffin et al., 2000; Majewski, Susanne, & Klaus, 2006). The annual national incidence rate of ACL injury in different popula- tions ranges from 8 to 52 per 100,000 persons, with a median of 32 per 100,000 persons (Moses, Orchard, & Orchard, 2012). Men aged 19 to 25 years have the highest incidence rate, at 241.0 per 100,000 person-years (Sanders et al., 2016). The peak inci- dence rate for women is in the 14- to 18-year-old range (227.6 per 100,000 person-years; Sanders et al., 2016). Compared with boys, girls have a higher overall rate of ACL injury (relative risk [RR], 1.40, [95% CI 1.25-1.57]) with the largest disparity occurring in basketball (RR, 4.14 [95% CI, 2.98-5.76]; Bram et al., 2020), de- spite a greater number of ACL injuries in boys (Gornitzky et al., 2016). A tear is most likely to occur in the mid-substance (middle portion of the tissue) of the ACL during noncontact injuries, as seen in sporting activities (Kennedy, Hawkins, Willis, & Danylchuck, 1976;
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