Posts tagged knee injury
Reducing Your Risk Of Alpine Skiing Injuries
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Alpine skiing remains one of the most popular outdoor winter sports in Colorado. It is estimated over 6.8 million skiers participated in the sport over the 2016/2017 winter season. There are inherent risks of death and injury in both skiing and snowboarding, but thankfully due to technological updates and innovations overall injuries have fallen by half over the last 30-40 years. Although injuries on the whole have decreased some traumatic cases, such as ACL tears, remain common today. A recent article summarized the available evidence on the most common ACL tears, as well as, offered an update on injury prevention strategies in alpine or downhill skiing.

Davey and colleagues published the review article recently in the journal Sports Health (2018). Authors reviewed the available evidence on ski injury prevalence including injury location, known risk factors, and ski injury prevention. Data was available from a total of 64,667 ski injuries over a 25 year period. They reported the average age of skiers injured was 30 years old with a range of 24 to 35 years. Those found at highest risk included both the young, adolescents and children, as well as, older adults (>55 years). While males were more likely to experience lower extremity fracture, consistent with other sports females are more prone to ACL tears.

As expected, the lower extremity remains the most commonly injured area of the body accounting for up to 77% of all injuries. Further, 14% of injuries involve the thumb and shoulder and 13% involve the head and neck. The knee ligaments (ACL and MCL) remain the most common injury followed by thumb and head and facial injuries. Trend data showed a drop in tibial fracture, but an increase in ACL tears. Most common mechanisms included deep knee flexion with rotation or knee hyper extension and forward movement of the thigh over the stationary leg in the boot. In addition, despite advances in helmet use and technology, the number of traumatic skiing fatalities remained constant.

Ski technological advances, including helmets, bindings, and ski poles, deserve the most credit for the 50% reduction of ski injuries. Helmet use has increased to 80% of all skiers and has been a significant advancement in the safety of participants and reduction of head and face injuries. As expected, helmets have consistently been shown to reduce both the prevalence and severity of head injuries without a subsequent increase in “risky skiing”. The risk of death with head injury has stayed relatively constant either because the forces of impact exceed the protective capacity of the helmet or the skier sustained other bodily injury causing death despite sparing their head and face.

Ski boot binding systems have contributed to the large decrease in leg fractures and contusions due to improved release mechanisms. In addition, skiers who routinely have their bindings checked by certified ski shops sustain fewer injuries than those who ski without inspected bindings. These bindings are designed to prevent fracture and leg injuries, not knee ligaments, and bindings often do not release with common ACL injury mechanisms in skiing.

Established programs such as “lids on kids” and “heads up” remain effective at improving the awareness and utilization of helmets. ACL prevention programs (Vermont Ski Safety Equipment) have focused on educating skiers to avoid situations most associated with knee sprain, as well as, instructions in how to fall with decreased risk to your knee. These programs have been shown to reduce a skier’s risk of knee injury by 60%. Interestingly, ski lessons have not been shown to reduce the risk of knee injury among skiers. In our practice, strength also remains a key component of injury prevention programs. Skiers are recommended to work with a local Physical Therapist to design an effective ski injury prevention exercise program.

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When will my knee tendinitis get better?
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Knee tendinopathy, either in the quadriceps or patellar tendon, is a common source of knee pain among jumping athletes, but can occur in non jumping athletes as well. This overuse injury is caused by repetitive sub maximal loading of the knee through a bending range of motion. If the loading is faster and/or greater than the tendon’s capacity to tolerate this tensile loading pattern, tendinopathy can occur leading to pain and decreased knee function. Our current understanding of these tendon injuries has moved from passive care (rest, anti inflammatories) to an active Physical Therapy approach focused on optimal loading of the tendon to promote remodeling and healing of the injured tissues. A new article sheds light on when patients can expect to recover from their knee tendinopathy.

van Ark and colleagues randomized 29 volleyball and basketball players with patellar tendinopathy to a 4 week full range of motion or isometric exercise program (Am J Phys Med Rehab. 2018). Patients were assessed for symptoms and function, as well as, each player underwent a baseline and 4 week ultrasound scan of the injured tendon. Interestingly, although players reported decreased pain and improved function after the exercise program, no structural changes were detected in the injured tendon. This study is consistent with the research on achilles tendinopathy which demonstrated improved clinical symptoms after 8-12 weeks of Physical Therapy treatment, but continued healing of the injured tendon up to 12 months after the onset of symptoms.

Physical Therapy exercises are the gold standard treatment for tendinopathy but should be continued after resolution of symptoms for optimal recovery of the tendon.

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Reducing ACL Injury Risk With Physical Therapy Exercise Programs
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ACL injuries are one of the most common sports medicine injuries encountered in a Physical Therapy practice. These injuries can be treated successfully with either conservative or surgical interventions depending on the athlete’s presentation and athletic goals. In addition to the post injury management of these athletes, researchers and clinicians have also focused on reducing an athlete’s risk for future ACL injury. Successful prevention programs for knee injury, including ACL tears, have been developed by numerous researchers and clinicians. Strong evidence supports their utilization in both pre season and in season athletes, especially among female athletes who are 6-8 times more likely to injure their ACL compared to a male in the same sport.

A recent clinical practice guideline, combining the available evidence and expert opinion, was released in the Journal of Orthopedic and Sports Physical Therapy documenting the impact of these risk reduction programs (Arundale et al. 2018). The practice guidelines highlighted the modifiable risk factors for future knee injury including abnormal muscle function and poor movement patterns in athletes. While bracing has continued to fall out of favor in preventing knee injury, Physical Therapy exercises have consistently been shown to effectively reduce injury risk.

Injury risk reduction programs are cost and clinically effective and can be easily implemented by Physical Therapists, coaches, parents, and athletes. Training should incorporate strength and agility training, plyometrics, and sport specific movements required during play. Ideally each program should be completed for 20 minutes, 3-4 times per week. These programs are appropriate for all youth athletes, athletes 12 to 25 years of age, and especially female athletes. Consistent with all exercise interventions, these programs require high degrees of compliance by coaches, clinicians, and athletes in order to reach optimal effectiveness.

Risk Factors for Second ACL Injury with Return to Sport
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We have written previously about the high rates of subsequent knee injuries after an athlete returns to sport and activity after ACL surgery.  Interestingly, the most common site of injury is on the opposite knee indicating athlete's are using a compensatory balance and coordination strategy during play.  Current research is working on developing physical therapy rehabilitation programs to reduce the risk of injury upon return to sport.  Some research has shown delaying a return to sport longer than 9 months can reduce re injury rates by as much as 84%.  A current study has identified other risk factors which may place an athlete at risk for future knee injury after returning to sport following ACL reconstruction surgery.

An article in the Orthopedic Journal of Sports Medicine followed 163 patients who underwent ACL reconstruction to determine risk factors for a second ACL injury (Paterno et al. 2017).  The authors reported 1 in 5 of the returning athletes sustained a second ACL injury.  These athletes were then examined to determine which factors correlated with their injury.  The authors placed these athletes in either a high or low risk pool based on established factors for ACL injury.  High risk athletes for a second tear included one of two groups

1.  < 19 years old, limited and asymmetrical triple hop distance

2. <19 years old, female sex, high knee confidence, limited and asymmetrical triple hop distance

Athletes in either high risk group were 5 times more likely to injure their ACL again compared to a lower risk athlete.

Athletes are encouraged to complete all of their prescribed physical therapy visits up to 9 months as well as successfully pass return to sport testing before considering a return to sport.  

ACL Risk and Re Injury with Return to Sport
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We written many blog posts on ACL injuries as they continue to be a risk to our youth and amateur athletes in Boulder County.  Thankfully, evidence shows we are able to screen athletes at risk for future injury as well as reduce their risk through Physical Therapy strength, balance, and conditioning programs.  Another group at risk of future ACL injury are those athletes who return to sport after surgery and Physical Therapy.  A percentage of these athletes are at risk for re injuring their knee, but they are also at risk for injury to their uninvolved knee.

A recent study in The American Journal of Sports Medicine documented the incidence of second ACL injuries either to the involved or uninvolved knee after the athlete returned to sports (Schilaty et al. 2017).  The authors followed over 1000 athletes over a ten year period to determine the number of 2nd ACL tears.  They reported 66 (6%) of repeat ACL injuries with a surprising 67% occurring on the opposite side.  A few factors including graft type, reconstruction vs. conservative care, and an athlete's sex were correlated with this 2nd injury.  Allografts were associated with higher re injury risk compared to ACL autografts with patellar tendon autografts having the lowest risk of re injury.  The highest risk of re injury was found in females younger than 20 years old.  This study highlights the importance of completing a full course of post operative Physical Therapy after ACL surgery as well as delaying return to sport until 9-12 months.  

The Impact of Pre Operative Physical Therapy on ACL Recovery
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ACL injuries  are becoming more common among both recreational and professional athletes.  The majority of these athletes who sustain complete tears of their ACL ligament will undergo ACL reconstruction and intensive post operative Physical Therapy.  Often, the ACL surgery is delayed after the injury to allow the athlete to regain their lost range of motion and strength, as well as, reduce signs of swelling and inflammation.  This pre operative period is an excellent opportunity for the patient to work with a Physical Therapist to address these impairments and improve their post operative recovery.  An athlete's condition entering surgery has a significant impact on their condition following surgery.

A recent review article studied 8 previous articles on pre operative Physical Therapy prior to ACL reconstruction (Alshewaier et al. Clin Rehab. 2017).  The 8 studies included 451 patients who underwent pre operative Physical Therapy from 3 up to 24 weeks.  The authors reported pre operative Physical Therapy was effective for improving strength and function prior to ACL surgery.  They concluded pre operative Physical Therapy is beneficial to patients with ACL injury and should be utilized to improve recovery and functional outcomes.