Stephanie Blaum
Term Paper
April 22, 1998
Battle of Wounded Knees
Introduction
The date was October 25, 1995. The scene was a Regional volleyball game at Williamsville High School; Mt. Pulaski was playing Tri-City. A player went up to spike the ball. She jumped in the air, hit the ball and was on the way down. The landing was a bit unbalanced, and suddenly she heard a loud pop in her left knee. Immediately, she collapsed. With her kill, the game came to a halt, and the gym became quiet. She was helped off the court to her team's bench and could not continue. She had suffered the injury athletes today dread most: a torn anterior cruciate ligament.
The anterior cruciate ligament (ACL) is one of four major ligaments that provide stability to the knee joint. When the knee is bent, the ACL restrains the amount of motion between the femur and the tibia.(See Appendix A) It keeps them in proper relationship with each other. The main function of the ACL is stabilization during deceleration. Because of this it is the most important ligament to athletes. This injury is the most common disabling knee injury to the athlete (Gallivan 1). Sixty percent of all knee injuries involve at least a partial tear of the ACL (Hoffman 253). In the past few years, knees have become the second most frequently injured body part among athletes, the anterior cruciate ligament tear being the most serious.
Diagnosis
There are many different ways to tell an athlete has injured her ACL. The athlete herself may be able to tell by what it feels like and by what happened at the time of the injury. If the athlete does not know, there are a series of tests that can be done by a doctor. During activity the athlete may hear or feel a loud "pop" in the knee, then fall in a heap. Most of the time the athlete tries to "walk off" the injury but finds an unstable sensation and cannot continue. There may be pain at first, but most athletes claim a tear of the ACL hurts less than a sprain. This is because the ligament cannot be physically touched. Another sign of the ACL injury is swelling of the knee within a few hours of the initial injury (Hoffman 254).
If the athlete experiences the symptoms of a torn ACL, she should see a doctor for confirmation. There are several different tests that can be applied to tell for sure that it is torn. They include the anterior drawer test and the Lachman test.
Some doctors use an instrument called an athrometer to detect an ACL tear (Hoffman 254-55).The anterior drawer test is done by bending the patient's knee to ninety degrees. The doctor sits on the patient's foot and gently pulls the lower leg forward with both hands. This same test is applied to the uninjured knee. The movements are compared. If the movement in the injured knee is greater, there is a good chance of a torn ACL ("Tests Performed to Determine an ACL Injury" 1). The Lachman test is the best method for finding an ACL tear. It involves the doctor holding the patient's thigh keeping the leg at a slight bend. The thigh is held with the other. The doctor pulls the lower leg forward, and the movement is again compared to that of uninjured leg ("Tests Performed to Determine an ACL Injury" 1). This test is done on a zero to four scale; one signifies the ligament is torn. The Lachman test is ninety-two percent accurate because it is usually done while the patient is under anesthesia when the muscles are completely relaxed (Nicholas 687).
Athrometric testing measures, in millimeters, how far the tibia is out of place in comparison to the femur (Nicholas 193). Athrometry consists of a twenty-degree bend as the athrometer is positioned so the button is over the kneecap. The leg is then rotated to line it up with the bar. At this point, the doctor applies the anterior drawer test several times, and resets the tool each time. The more movement there is from side-to-side, the worse the injury (Nicholas 193, 688). Besides the anterior drawer test, Lachman test, and athrometric testing, the ACL tear can be diagnosed through Magnetic Resonance Imaging (MRI). In an MRI, a magnet large enough to accommodate the human body produces radio waves that form signals. The signals are then transferred to a computer where a very clear three-dimensional image is shown. MRIs show ligaments such as the ACL, whereas X-rays just show bones. An MRI is ninety percent accurate in diagnosing the injury (Hoffman 254).
Causes
The ACL is most commonly injured in twisting motions or direct blows to the knee when the foot is planted ("Anterior Cruciate Ligament" 1). Some of the tears happen with direct contact with another player, but the majority happen because of hyperextension or twisting. Seventy percent occur during jumping, cutting, or pivoting sports (Gallivan 1), such as skiing, soccer, volleyball, basketball, and football (Weinhouse 63). In a survey of 532 ACL injuries by the NCAA Injury Surveillance System, 256 happened with no contact, and only 20 were because of contact with another player. The rest were a result of coming down on another player, contact with the floor, or contact with the ball (Kraft 68). Ligaments are very elastic and cannot handle extreme force. If an athlete stretches a ligament too far, it is bound to rip, resulting in numerous doctor visits and extensive physical therapy ("No Weak Knees" 31).
What Happens
The tearing of the ACL can be compared to stretching a rubber band so far that it eventually snaps. When extreme force is applied, the ligament tries to hold the bones together. If the force applied is greater than its strength, it stretches or snaps (Hoffman 254). For example, when an athlete makes a quick stop, and the rest of the body keeps going, the knee may not be strong enough to take the force of stopping the body from falling forward. The ACL will try desperately to hold the bones together, but when the force exceeds the strength, it will eventually tear. The ACL ruptures suddenly. In an instant, the one and a half inch long ligament can be ripped apart leaving the athlete helpless (Demak 52).
The ACL has been found to tear in one of three different places. It tears away from the tibia, away from the femur, and right in half, which is the most common tear location (Hoffman 254). When it tears away from one of the two bones, it is reattached
by drilling it back into that bone. This can be done because there is no interruption in the blood flow through the ligament. When the ACL is torn in half, it cannot be saved and has to be replaced with a new piece of tissue. No matter what type of tear it is the only way to fix it is to have surgery.
Treatment
Treatment of an ACL tear depends on factors such as the patient's age, presence of other injuries to the knee, and her future plans. Once the ACL is torn, it will not heal on its own because there is no longer blood flow through the joint ("Anterior Cruciate Ligament" 1). For this reason surgery is recommended. Someone not intending to continue being active in sports may be able to live a normal life without reconstructive surgery (Demak 56; "Stiff Penalties" 48). Under this circumstance, the muscles around the knee such as the quadriceps and hamstrings must be continuously strengthened, otherwise it may be unstable and give out periodically ("Stiff Penalties" 48). Some athletes continue playing their sport with the aid of a special brace that stabilizes the knee. There is still a risk of it going out again (McCallum 46) causing further damage to the knee if surgery is not performed. Without an ACL, the tibia and femur slip back and forth smashing the cartilage into pieces (Demak 57). To prevent cartilage damage, it may be better to have the surgery performed.
Most people that suffer a torn ACL go through with the surgery to have it fixed. There are different ways this can be done. The most used method is to replace the ACL with a piece of another tendon, then to reroot it in the same path of the torn ligament (Hoffman 257). This is called graft replacement. There are different places the graft can be taken from, including the patellar tendon, the semitendinosis-gracilis (the hamstring muscle), and cadaver tissue. The most common place to get a graft is the patellar tendon, which connects the kneecap to the tibia. The middle one-third of the tendon is used ("ACL Reconstruction" 1). In the graft procedure, a three-inch incision is made in the knee (Demak 55). A tool called an athroscope is inserted to find out if there is any extra damage, for example, a cartilage tear. Then two small holes are drilled through the bones, and the graft is threaded through them in the ACL path. The graft is then fixed into place with screws, and the incision is sewn together
(See Appendix A)(Demak 55). Using the patellar graft has resulted in a ninety percent success rate. The hamstring graft seems to be pretty successful too, whereas the use of cadaver tissue may result in the rejection of the tissue. Cadaver tissue is tissue from a dead person and may be rejected because the patient's body thinks it is "foreign"
tissue (Demak 55-56). No matter where the graft comes from, the graft procedure is the same.
Other surgical procedures sometimes used include the Ellison procedure, which involves a tough fascia outside the knee (Hoffman 257), and the extra-articular reconstruction, which compensates for the loss of the ACL (Pearl 32). In any procedure there is a small risk of infection and nerve or blood vessel injury. There is also a risk of the graft stretching and scar tissue forming around it. None of these reasons are ones to be alarmed over ("Reconstructive Procedure" 1). Surgery too soon after the initial injury could leave the patient with life-long stiffness. It is highly recommended to wait at least three weeks for the swelling to subside before surgery is done ("Stiff Penalties" 46).
In the past the ends of the ligament were just sewn together, but after extensive study, it is found that a total ligament reconstruction has better results ("Anterior Cruciate Ligament" 1). Replacing the ACL rather than repairing it enhances a shorter recovery time and greater recovery rate to the injury that was often career ending twenty years ago (McCallum 53).
Rehabilitation
After surgery is performed, the patient begins the rehabilitation process. Rehabilitation starts immediately after the patient wakes up from the anesthesia with a machine called a continuous passive motion (CPM) machine. This is used at the hospital for four hours. The CPM flexes and extends the knee once a minute. The immediate movement helps prevent stiffness, increases motion, reduces swelling and scar tissue, and helps stretch the new ligament (Demak 57; Nicholas 983). The patient is fitted with a brace and is sent home with a series of rehabilitation exercises to do. They include simple, yet not so simple activities, such as lifting the leg from the floor and bending the knee as far as possible. After a few weeks, weights are added, gradually increasing them as the patient progresses. After three to six weeks the patient can normally ride a stationary bicycle and after two or three months can begin jogging. The rehabilitation is mostly left to the patient, who has to do the work to ensure a complete recovery. Doing the exercises two to three times daily can be frustrating for the patient because recovery is long and progress is slow (Demak 57). For the average athlete, recovery time is six months, and after proper rehabilitation the reconstructed knee is often stronger than it was before the injury. According to Dr. Kenneth Meister, an assistant professor of medicine at the University of Florida, the chance of tearing the new ACL is no greater than tearing the one in the other knee (Kraft 67).
The long-term effects of the ACL injury followed by surgery are still being studied. Since the injury has just recently become numerous among athletes, there are not many cases to use as follow-ups to find out the long-term prognosis. Some predictions include knee stiffness five to ten years after surgery (Nicholas 151), or possibly patellar tendonitis (Demak 55). Arthritis in the knee is most likely to occur later in the patient's life. These hypotheses have not been researched enough to make an accurate prognosis on the long-term effects.
Females and the ACL
The ACL injury in women has increased immensely in the past six years and doctors, trainers, and coaches throughout the United States are trying to figure out why. Studies show women are six times more likely to suffer this injury than men. Reasons researchers have come up with vary from body structure to the competitiveness of sports the athlete competes at (McCallum 45-46). Women have a different body structure compared to men. They have wider hips, which causes the leg to slope at the knee; men's legs are straighter. Women's joints and ligaments are looser, and the space at the bottom of the knee that the ACL runs through is narrower than a man's. This same space is shaped like an upside-down "V", whereas a man's is more rounded (Kraft 68). Dan Silver, M.D. confirms these differences by saying, "Women's ligaments tend to be looser than men's making them more susceptible to overstretching or tearing when they participate in sports in which there is a lot of twisting, jumping, or side-to-side activity" (qtd. from Weinhouse 63).
Another reason specialists are coming up with is women's sports have become more competitive than they used to be (Kraft 66). This increase in competitiveness causes them to push harder and be more aggressive. Plays have been designed to have the athletes do more cutting and pivoting than in years past. It is said that it is often the best athletes who are the most vulnerable to the ACL injury because they are the ones who are the most explosive in their activity (McCallum 53).
Poor technique and poor fundamentals are being blamed for some of the ACL injuries. Tina Bonci, head of women's sports medicine at the University of Texas, says many athletes who are hurt lack the basic fundamentals of jumping and landing. She claims their bodies seem to be out of control. Two technical flaws found in these techniques and fundamentals include landing a jump with a straight leg and not keeping the feet under the hips when cutting, stopping, and landing (Kraft 68). Athletes frequently begin fundamental sports training at early ages, usually at the time of the growth spurt. Bone growth creates tightness between the muscles and tendons causing a loss in flexibility (Micheli 200).
Weight training may also be a factor. Women recently began intense weight training to jump higher. When the quadriceps are strengthened more than the hamstrings, it results in an imbalance between the two. This imbalance causes tension on the knee (Kraft 66; Weinhouse 66). A good exercise to strengthen both sets of muscles equally is jumping rope or running in figure-eight patterns ("No Weak Knees" 31). Because of a male dominated society, women used to be considered too weak to play sports. Now that competitiveness has changed, injuries among females have increased. It is important to keep the muscles strong and healthy, the leg muscles in this case. The quadriceps, hamstrings, and calves should be equally strengthened to prevent injury.
Prevention
Even when a well-conditioned athlete puts maximum force on the knee, it always has the potential to give. It is important to take some precautions that may help prevent injury. It is important to keep a strong base. This includes strengthening both the hamstrings and the quadriceps. Being introduced to motor learning skills in early development can help if they are done correctly. With a lack of early training, then the expectation for high performance; problems may arise (McCallum 48). Overuse of the body part by playing the same sport for a long period of time may wear out the body part (Micheli 200). It is important for the athlete to take a break when she feels worn out. It is not recommended for an athlete to play the same sport year-round.
There has been a controversy over whether types of shoes or ankle braces have anything to do with the ACL injury. Since shoes have been made with more traction, the athlete is able to stop at an instant and can change direction easily. This may be bad for the knee because even though the foot may stop instantly, the rest of the body is still going. It is the job of the knee to keep the athlete from falling over forward. It absorbs all the pressure and may injure the ACL. Ankle braces are used to take pressure off the ankle. If that stress is no longer absorbed by the ankle, it is transferred to the next closest part, which is the knee. Wearing ankle braces may relieve stress on the ankle, but may cause more on the knee; when one area is being protected, another may actually be suffering (Kraft 68).
Conclusion
The anterior cruciate ligament is one of the most important ligaments in the body. During aggressive activity, the ACL has the potential to be injured. If it is torn, the only way to fix it is to have it surgically repaired. The surgery is a long and technical procedure, but has shown good results. After the ACL is reconstructed, it has to be strengthened through a series of rehabilitation exercises over a six-month recovery period.
The ACL tear is becoming a serious problem for females. There are theories for why this may be happening, but there is no definite reason. It is not so alarming that all girls should quit sports, but it is important that female athletes take extra precautions during athletic activities. It is important to stay healthy and strong, but this is not a guarantee that an injury like this will not happen. For example, I am the athlete mentioned at the beginning of this paper. I am a very strong and healthy athlete. I just happened to land a jump wrong; one that I have done thousands of times before. I went through the surgery and had no problems with the recovery. I even returned stronger than ever to sports. Then the worst thing that could possibly happen, happened. I tore the ACL in my other knee. This time another player ran into me. There is nothing an athlete can do right before the injury to avoid it because it happens in an instant. There is always a risk of injury; some are worse than others, but that is no reason to not play sports.
Ways to help prevent the injury include keeping a strong base and using ideal equipment. Also, avoiding overuse of the knee may keep it from wearing out. Doing this may help avoid the injury, and there will not be any effects later in life such as stiffness or arthritis. Athletes never know when or if an injury may happen to them. Since there has been a recent incline of knee injuries, especially ACL tears, athletes should be a little cautious during athletics so they do not have to find out what an injury like this one feels like.
Works Cited
"ACL Reconstruction: Where the Replacement ACL Comes From."
A Medical Practice Near You. n.d. Online. http://www.scoi.com.
24 Feb. 1998.
"Anterior Cruciate Ligament." Sports Injuries. n.d. Online.
http://lac.laci.net. 12 Feb. 1998.
Demak, Richard. "One False Move." Sports Illustrated 29 Apr. 1991:
52-58.
Gallivan, William R., Jr. "Knee Injuries: The Anterior Cruciate
Ligament." MedSeek. n.d. Online. http:/medseek.com. 12 Feb.
1998.
Hoffman, Marshall, and William Southmayd. Sports Health. Ed.
William Southmayd. New York: Putnam, 1981.
Kraft, David. "On a Tear." Volleyball Dec. 1995: 64-68.
McCallum, Jack. "Out of Joint." Sports Illustrated 13 Feb. 1995:
44-48.
Micheli, Lyle J. Sportswise: An Essential Guide for Young
Athletes, Parents, and Coaches. Boston: Houghton, 1990.
Nicholas, James A., and Elliot B. Hershman. The Lower Extremity and
Spine in Sports Medicine. Vol.1. St. Louis: Mosby, 1995.
"No Weak Knees." Prevention Aug. 1996: 30-32.
Pearl, Arthur J. and John A. Bergfeld, eds. Extraarticular
Reconstruction in the Anterior Cruciate Ligament Deficient
Knee. Champaign: Human Kinetic, 1992.
"Reconstruction and Postoperation." Candor Webtech. 1996. Online.
http://www.candor.com. 12 Feb. 1998.
"Reconstructive Procedure." ACL Summary. n.d. Online.
http://akjunkan.stetson.edu. 12 Feb. 1998.
"Stiff Penalties." Prevention. Dec. 1995: 46-48.
"Tests Perfomed to Determine an Anterior Cruciate Ligament Injury."
MedNet. n.d. Online. http://www3.nothstar.com. 24 Feb. 1998.
Weinhouse, Beth. "Knee Injuries: Are You at Risk?" Glammour Apr.
1992: 63+.