of knee impairment and function than the KOOS following ACL injury and reconstruction (van Meer et al., 2013). The ACL-RSI may be a more useful tool for measuring psychological influences on return-to-sport activities than the TSK-11 because it was devel- oped specifically in relation to return to sport following ACL injury, whereas the TSK-11 was developed to assess pain- related fear of movement and reinjury not specific to the ACL population (Kvist et al., 2013). The SF-36 is an important measure to use in assess- ing a patient’s general health status and the comorbidities that may impact progress through rehabilitation following ACL injury or reconstruction.
variety of knee disorders, but it is useful in the ACL population to assess whether patients have returned to preinjury activities at previous frequency levels. The Marx scale is scored from 0 to 16, with a score of 0 indicating completion of the four activity items less than one time per month and 16 indicating completion of the four activity items at least four times per week (Marx et al., 2001). The Marx scale is reliable and inversely correlated with age (Marx et al., 2001). It is important to select an outcome measure according to the construct it measures in relation to what information the therapist is attempting to gather. The IKDC 2000 is a more useful measure
DIFFERENTIAL DIAGNOSIS AND CONCOMITANT INJURIES
excessive knee valgus and tibial internal rotation, which places increased tension on the MCL (Schein et al., 2012). Because the MCL is attached to the medial meniscus, it is also at increased risk of injury (Schein et al., 2012). However, the lateral meniscus is more likely to be injured in acute ACL injuries and in younger athletes, whereas the medial meniscus is more likely to be injured in chronic ACL-deficiency injuries and in older athletes (Kilcoyne, Dickens, Haniuk, Cameron, & Owens, 2012; Tandogan et al., 2004; Yeh, Starkey, Lombardo, Vitti, & Kharrazi, 2012). healing. Following ACL rupture, patients with grade III MCL inju- ries treated surgically demonstrate no difference in impairment- based or functional outcomes from those treated conservatively 2 years following injury (Halinen, Lindahl, Hirvensalo, & Santavirta, 2006). However, if chronic valgus instability is present following standard rehabilitation, surgical repair of the MCL may be war- ranted (Grant, Tannenbaum, Miller, & Bedi, 2012). during ACL reconstruction (Magnussen et al., 2010). However, the frequency of surgical meniscal repair is expected to increase as a result of improving surgical techniques and increasing evi- dence of a higher risk of osteoarthritis following meniscectomy (Noyes & Barber-Westin, 2012). Indeed, Espejo-Reina and col- leagues (2019) found in a study of over 2,000 patients that 55.6% of meniscal tears accompanied by ACL injuries were repairable. Herzog and colleagues (2018) reported that from 2002 to 2014, the rates of concomitant meniscus repairs with ACLR increased 73% while the rate of concomitant meniscectomy with ACLR in- creased only 34%, although meniscectomy remained the most common concomitant procedure. Concomitant meniscal injury, especially those treated by resection (meniscectomy), profoundly increases the risk for osteoarthritis. Furthermore, movement pat- terns (i.e., gait biomechanics, including those associated with fu- ture osteoarthritis development) differ according to concomitant medial meniscus treatment (Capin, Khandha, et al., 2019; Capin, Khandha, Zarzycki, Manal, et al., 2018). quent and intense episodes of pain (Fok & Yau, 2013), along with poorer patient-reported outcomes (Kowalchuk et al., 2009). Car- tilage debridement (chondroplasty) is the most common surgical technique employed during ACL reconstruction to treat cartilage lesions, but microfracture surgery and observation are also used (Magnussen et al., 2010). Microfracture surgery is a procedure in which small subchondral holes or fractures are created to stimu- late cartilage repair (Mithoefer et al., 2005).
Injury to the ACL often occurs concomitantly with damage to other static knee joint structures, and differential diagnosis can be difficult. Meniscus (~50-65%), articular cartilage (~50%), and MCL pathology (~30%) commonly occur with ACL injuries. Inci- dence rates of injury to the PCL (1.4%) and lateral collateral liga- ment (LCL; 2.2%) with ACL injury is low, with these injuries usually resulting from traumatic events involving knee joint dislocation (Fanelli, Orcutt, & Edson, 2005; Majewski et al., 2006). Damage to the ACL, MCL, and medial meniscus can occur secondary to the common biomechanical positioning during ACL injuries, with Medial collateral ligament Concomitant MCL injury (30.3%) is more common than LCL injury (2.2%) with ACL rupture (Majewski et al., 2006). Seventy-four per- cent of patients who sustain a complete tear to the MCL also sus- tain an ACL injury (Fetto & Marshall, 1978). MCL injuries are often treated nonoperatively regardless of severity and whether ACL reconstruction is performed. If ACL reconstruction is performed, it is typically postponed until the MCL has had the opportunity to heal, because valgus instability is detrimental to optimal graft Meniscus Meniscus injuries negatively affect patient-reported functional outcomes, with higher rates of knee arthrosis following ACL re- construction compared to patients without meniscal damage (Co- hen et al., 2007; Eitzen, Holm, & Risberg, 2009). Previous litera- ture has reported that the odds of meniscus injury being present at the time of ACL reconstruction increase as time increases from initial injury (Fok & Yau, 2013; Granan, Bahr, Lie, & Engebretsen, 2009; O’Connor, Laughlin, & Woods, 2005), and the risk of sec- ondary meniscal tear is reduced after ACL reconstruction (Kes- sler et al., 2008). However, no differences have been shown in rates of meniscal surgery with ACL reconstruction in patients who chose an early or delayed surgical date (Frobell et al., 2013). It is estimated that 50% to 65% of patients choosing ACL reconstruc- tion demonstrate meniscal tears at the time of surgery (Granan et al., 2009; Magnussen et al., 2010; Majewski et al., 2006). Sur- gical resection (meniscectomy) followed by meniscus repair or observation only is the traditional and currently the most com- mon approach in the United States used to treat meniscal injuries Articular cartilage Nearly 50% of ACL injuries also result in damage to the articular cartilage (Magnussen et al., 2010), and patients with articular car- tilage lesions have an increased likelihood of meniscal injuries, and vice versa (Fok & Yau, 2013; Granan et al., 2009). For patients who undergo ACL reconstruction, older age and time from injury to surgery increase the odds of having cartilage lesions in the in- volved knee at the time of surgery (Fok & Yau, 2013; Granan et al., 2009; O’Connor et al., 2005). ACL injuries combined with articu- lar cartilage damage are associated with complaints of more fre- Osteoarthritis Patients are at increased risk of knee osteoarthritis following ACL injury. Factors associated with early post-traumatic osteoarthritis include subsequent surgery, meniscal pathology (especially men- iscectomy, and chondral injury (Claes et al., 2013; Jones & Spin- dler, 2017). Interestingly, there are no differences in the incidence of knee osteoarthritis whether early or delayed ACL reconstruc-
tion is chosen (Frobell et al., 2013). Although time from ACL injury to ACL reconstruction does not affect the incidence of osteoar- thritis, rates of osteoarthritis may be comparable or higher in pa- tients following ACL reconstruction compared to those who had nonoperative treatment (Luc et al., 2014; Wellsandt et al., 2018).
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