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ACL injury-- the undetected epidemic!!

Posted by Dr Jayant Arora on December 27, 2011 at 12:50 AM

As a society we are gradually beginning to become obsessed with sports apart from cricket. This phenomenon is amply evident by emergence of star sports persons in various fields like tennis, boxing, hockey, golf, badminton, athletic, wrestling etc. They are adored and looked upon as role models by young and old alike.

At recreational level, sports allows an escape from pressures of daily life and at elite level, sports is well established as a part of entertainment industry with enormous rewards for the professionals. At both these levels, sports related injuries especially knee ligament injuries remain a constant threat of a prolonged layoff or even a career ending event. These injuries are not only commonly seen in contact sports like football and rugby but also in noncontact sports like golf(Tiger Woods), Cricket (Yuvraj Singh), Badminton (Gopichand), all three sustained an ACL (Anterior Cruciate Ligament ) injury, the commonest ligament to be injured (60% of all ligament injuries) in the knee.

The number of women suffering ACL tears has dramatically increased. This is due in part to the rise in women's athletics. But studies have shown that female athletes are two to four times more likely to suffer ACL tears than male athletes in the same sports. Recent research has shown several factors that contribute to women's higher risk of ACL tears. Women athletes seem less able to tighten their thigh muscles to the same degree as men. This means women don't get their knees to hold as steady allowing them to twist easily. Also, shape of their thigh bone(Femur) puts them at a higher risk of the ACL rubbing on the bone in the event of a twisting injury.

Data from the western world clearly show that knee injuries may require surgical treatment, prolonged rehabilitation and are the most common cause of permanent disability after a sporting injury. A study done in USA on the prevalence of ACL injuries in the general population has estimated the incidence as 1 case in 3,500 people, resulting in 95,000 new ACL ruptures per year. National Health Service UK (NHS) website reports a similar incidence of 30 cases of ACL injuries for every 100,000 people or a total of approximately 18000 ACL injuries across a population of 60 million every year. At a similar rate we should see 3.6 lacs patients of ACL injuries per year. This may be a conservative estimate due to low average age of our population compared to the western world. So we may already be in the midst of an epidemic!!

These injuries are easily missed since X-rays are usually normal. A study from British Medical Journal showed an average delay of 22 months before these injuries were diagnosed despite the fact that the patients were seen in the emergency departments of the Hospitals at the time of injury. Infact, 30 % of these patients were assessed by an Orthopedic surgeon without the diagnosis having been recognised. So we may be in the midst of an undetected epidemic!!!

The symptoms following a tear of the ACL can vary. Usually, the knee joint swells within a short time following the injury. This is due to bleeding into the knee joint from torn blood vessels in the damaged ligament. The instability caused by the torn ligament leads to a feeling of insecurity and giving way of the knee, especially when trying to change direction on the knee. The knee may feel like it wants to slip backwards.

The pain and swelling from the initial injury will usually be gone after two to four weeks, but the knee may still feel unstable. The symptom of instability and the inability to trust the knee for support are what require treatment. Also important in the decision about treatment is the growing realization by orthopedic surgeons that long-term instability leads to early arthritis of the knee.

Diagnosis needs a careful clinical evaluation by an expert knee surgeon as ligaments and tendons do not show up on X-rays. Magnetic Resonance imaging (MRI) is probably the most accurate test for diagnosing a torn ACL without actually looking into the knee.

Treatment of ACL injury does not necessarily involve surgery in all patients. Physiotherapy and bracing may be attempted initially. If the symptoms of instability are not controlled by a brace and rehabilitation program, then surgery may be suggested. The main goal of surgery is to keep the tibia from moving too far forward under the femur bone and to get the knee functioning normally again.

Even when surgery is needed, most surgeons will have their patients attend physical therapy for several visits before the surgery. This practice also reduces the chances of scarring inside the joint and can speed recovery after surgery.

Arthroscopic Reconstruction (Keyhole surgery) of ACL injury is the standard of care and open surgery is not recommended. Key-hole surgery is most often done with the aid of the arthroscope, although small incisions are usually still required around the knee, but the surgery doesn't require the surgeon to open the joint. The arthroscope is used to view the inside of the knee joint as the surgeon performs the work. The torn ACL ligament is reconstructed with a piece of Hamstring muscles tendon or with a part of patellar tendon. This tendon connects the kneecap (patella) to the tibia.

Most ACL surgeries are now done on an outpatient basis, and many patients go home the same day as the surgery. Some patients stay one or two nights in the hospital if necessary. Recovery after ACL reconstruction involves in a progressive rehabilitation program for four to six months to ensure the best results. During first few weeks following the surgery supervised physiotherapy may be needed followed by self administered exercises at home over the four to six month period.

This is an epidemic which most of us be happy to bear through as it would take its roots from a bettter, healthier lifestyle of the population at large but would also lead to a better medal tally in the coming Olympic games.

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