Returning children, adolescents, and adults with ACL tears back into the game
Tears of the knee anterior cruciate ligament (ACL) are common in agility sports that require jumping and twisting. The injury causes persistent instability of the knee. Unfortunately, return to agility sports without surgical reconstruction is usually not possible. Without proper treatment of an ACL tear, injury to the meniscus or cartilage and arthritis of the knee can result. At University Sports Medicine in Rochester, NY, diagnosis of an ACL tear is normally made by physical examination by a physician experienced in the examination techniques. Plain X-rays are taken. But, MRIs are usually not necessary to make the diagnosis. So, the decision to obtain such a study is individual and based on many factors.
ACL Tears in Children
As recently reported in the New York Times, (A Big Time Injury Striking Little Players Knees, Feb 18, 2008), ACL tears were thought to occur primarily after the growth plates at the bone ends closed. ACL injuries were thought to happen in growing children by pulling off a piece of immature bone rather than the more common ligament tear that occurs after growth plate closure. Confounding matters, development of leg bones is highly variable. Growth plates may close at age 13 or remain open for 18 years.
We now know that ligament tears can occur at any age. Mirroring a national trend, the orthopaedic surgeons of University Sports Medicine are seeing more children with ACL tears. Also mirroring national trends are the increased level of competition in these young athletes compared to just 15 years ago and the virtually year-round opportunities for athletic competition.
Children with ACL tears need to be treated differently than older adolescents and adults, as the “gold standard” ACL reconstruction surgery involves drilling tunnels in the femur (thigh bone) and tibia (shin bone). This standard technique can cause growth disturbance if performed before the growth plates close, potentially leading to deformity or limb length discrepancy. Therefore, pediatric and adolescent athletes with an ACL tear cannot and should not be treated as “little adults.”
Since 1993, orthopaedic surgeons at University Sports Medicine have been refining techniques for ACL reconstruction in young children that minimize the risk of growth plate disturbance. In 2002, they presented their experience on these methods to an international audience of orthopaedic surgeons at the American Orthopaedic Society for Sports Medicine Annual Meeting.
ACL Tears in Older Age Groups
The number of ACL tears seen in teenagers has increased in the last 15 years as well. Female adolescent athletes are at four times the risk of suffering a noncontact ACL tear. The reasons for this are probably many and are not completely understood. However, it is felt that one factor may be a natural difference in the running and jumping mechanics of the female athlete compared to the male. Robert Bronstein, MD of University Sports Medicine is careful to point out that these differences are evident only after the onset of adolescence. A few groups around the country developed exercise protocols in an attempt to teach athletic teenaged girls methods that may decrease their risk of sustaining an ACL tear.
The sports medicine physicians at the University of Rochester have been looking at these risk-reduction techniques for many years. Funded by a grant from Excellus, in 2004 and 2005 the physicians, therapists, and athletic trainers at University Sports Medicine set up an ACL injury prevention program at 16 Rochester area high schools.
The program utilized training techniques developed by Dr. Bert Mandelbaum at the Santa Monica Sports Medicine Institute. As a result of a Community Education Grant from the Greater Rochester Health Foundation in 2007, the injury prevention program was expanded to involve many more area high schools.
Rehabilitation of Pediatric ACL Patients
A critical factor in successful treatment and return to sports following an ACL injury at any age is rehabilitation. “While we do have methods of surgical reconstruction that avoid or minimize the risk of growth plate disturbance in young children, there are additional factors not discussed in the New York Times regarding the decision to use these surgical methods and the timing of surgery” Dr. Bronstein points out. To maximize the chance of excellent results with successful return to sports, it is imperative that the patient participates in this rehabilitation process. Some very young children may not be able to. Current surgical techniques and rehabilitation methods attempt to minimize pain. However, there are parts of the process that are uncomfortable, and this may affect the participation of young children. In these cases, other measures such as bracing and rehabilitation may be taken in an attempt to delay the surgery until a time that the child is psychologically mature enough to go through a reconstruction. “The thought should not be to delay a reconstruction until growth plate closure, as this would most likely lead to further damage to the joint” Bronstein says. Such concomitant injuries can lead to degenerative changes over the long term and affect the outcome of a future ACL reconstruction surgery.
Therefore, extensive and specialized training in rehabilitation of children is also needed to insure the best results for pediatric patients. “It is important that the rehabilitation address neuromuscular control and include activity modification and counseling.” Says Andrew Duncan, Chief of Sports Rehabilitation at University Sports Medicine.
Patients, together with their parent or guardian should seek out a rehabilitation professional knowledgeable in the proper “do’s and don’ts” of exercise and rehabilitation for the pediatric and adolescent ACL patient. It is important to prepare them for surgery but also to ensure that their knee remains as healthy as possible until the time for surgery comes whether it be 3 months or 3 years” Says Duncan.
Conveniently located alongside the surgeons in URMC Orthopaedics’ Clinton Crossings Clinic, the physical therapists and athletic trainers at University Sports Medicine have special training in rehabilitation following ACL reconstruction in children, adolescents, and adults. Because each case is individual, the athlete who has sustained a knee injury is encouraged to discuss treatment options including rehabilitation with his or her surgeon.
Relate Links:
ACL Reconstruction
University Sports Medicine
Sports Rehabilitation at University Sports Medicine
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