Elizabeth A. Arendt

Knee Injury Patterns Among Men and Women in Collegiate Basketball and Soccer NCAA Data and Review of Literature

Womens participation in intercollegiate athletics has increased dramatically in recent years. Greater par ticipation has increased awareness of health and medical issues specific to the female athlete. Some reports have noted a higher susceptibility to knee in jury, specifically injuries to the anterior cruciate liga ment, in female athletes as compared with their male counterparts. We performed a 5-year evaluation of anterior cruciate ligament injuries in collegiate mens and womens soccer and basketball programs using the National College Athletic Association Injury Sur veillance System. Results showed significantly higher anterior cruciate ligament injury rates in both female sports compared with the male sports. Non contact mechanisms were the primary cause of an terior cruciate ligament injury in both female sports. Possible causative factors for this increase in anterior cruciate ligament injuries among women may be ex trinsic (body movement, muscular strength, shoe- surface interface, and skill level) or intrinsic (joint lax ity, limb alignment, notch dimensions, and ligament size).

Understanding and Preventing Noncontact Anterior Cruciate Ligament Injuries A Review of the Hunt Valley II Meeting, January 2005

The incidence of noncontact anterior cruciate ligament injuries in young to middle-aged athletes remains high. Despite early diagnosis and appropriate operative and nonoperative treatments, posttraumatic degenerative arthritis may develop. In a meeting in Atlanta, Georgia (January 2005), sponsored by the American Orthopaedic Society for Sports Medicine, a group of physicians, physical therapists, athletic trainers, biomechanists, epidemiologists, and other scientists interested in this area of research met to review current knowledge on risk factors associated with noncontact anterior cruciate ligament injuries, anterior cruciate ligament injury biomechanics, and existing anterior cruciate ligament prevention programs. This article reports on the presentations, discussions, and recommendations of this group.

Anterior Cruciate Ligament Injury in National Collegiate Athletic Association Basketball and Soccer A 13-Year Review

Background Female collegiate athletes have been reported to have a higher rate of anterior cruciate ligament injury compared to male collegiate athletes. This finding has spawned a branch of research focused on understanding and preventing this injury pattern. Purpose To determine if the trends reported in 1994 have continued. Study Type Descriptive epidemiology study. Methods The National Collegiate Athletic Association Injury Surveillance System database was reviewed for all data relating to mens and womens basketball and soccer anterior cruciate ligament injuries for 1990 to 2002. Results No significant difference was seen in basketball comparing frequency of contact versus noncontact injuries between men (70.1%) and women (75.7%). Male basketball players sustained 37 contact injuries and 78 noncontact injuries. Female basketball players sustained 100 contact injuries and 305 noncontact injuries. In soccer, there was a significant difference in frequency of injury for male (49.6%) and female (58.3%) athletes when comparing contact and noncontact injuries (χ2 = 4.1, P <. 05). Male soccer players sustained 72 contact injuries and 66 noncontact injuries. Female soccer players sustained 115 contact injuries and 161 noncontact injuries. The magnitude of the difference in injury rates between male and female basketball players (0.32-0.21, P =. 93) remained constant, whereas the magnitude of the difference in the rate of injuries between male and female soccer players (0.16-0.21, P =. 08) widened. Comparing injury within gender by sport, soccer players consistently sustained more anterior cruciate ligament injuries than did basketball players. The rate of anterior cruciate ligament injury for male soccer players was 0.11 compared to 0.08 for male basketball players (P =. 002). The rate of anterior cruciate ligament injury for female soccer players was 0.33 and for female basketball players was 0.29 (P =. 04). The rates for all anterior cruciate ligament injuries for women were statistically significantly higher (P <. 01) than the rates for all anterior cruciate ligament injuries for men, regardless of the sport. In soccer, the rate of all anterior cruciate ligament injuries across the 13 years for male soccer players significantly decreased (P =. 02), whereas it remained constant for female players. Conclusions In this sample, the rate of anterior cruciate ligament injury, regardless of mechanism of injury, continues to be significantly higher for female collegiate athletes than for male collegiate athletes in both soccer and basketball. Clinical Relevance Despite vast attention to the discrepancy between anterior cruciate ligament injury rates between men and women, these differences continue to exist in collegiate basketball and soccer players. Also demonstrated is that although the rate of injury for women is higher than for men, the actual rate of injury remains low and should not be a deterrent to participation in sports.

Non-contact ACL injuries in female athletes: an International Olympic Committee current concepts statement

The incidence of anterior cruciate ligament (ACL) injury remains high in young athletes. Because female athletes have a much higher incidence of ACL injuries in sports such as basketball and team handball than male athletes, the IOC Medical Commission invited a multidisciplinary group of ACL expert clinicians and scientists to (1) review current evidence including data from the new Scandinavian ACL registries; (2) critically evaluate high-quality studies of injury mechanics; (3) consider the key elements of successful prevention programmes; (4) summarise clinical management including surgery and conservative management; and (5) identify areas for further research. Risk factors for female athletes suffering ACL injury include: (1) being in the preovulatory phase of the menstrual cycle compared with the postovulatory phase; (2) having decreased intercondylar notch width on plain radiography; and (3) developing increased knee abduction moment (a valgus intersegmental torque) during impact on landing. Well-designed injury prevention programmes reduce the risk of ACL for athletes, particularly women. These programmes attempt to alter dynamic loading of the tibiofemoral joint through neuromuscular and proprioceptive training. They emphasise proper landing and cutting techniques. This includes landing softly on the forefoot and rolling back to the rearfoot, engaging knee and hip flexion and, where possible, landing on two feet. Players are trained to avoid excessive dynamic valgus of the knee and to focus on the “knee over toe position” when cutting.

Current concepts of lateral patella dislocation

Surgical treatment of patellar dislocations, acute and chronic, has evolved significantly over the past decade with the advance of biomechanical knowledge of patellofemoral restraints and injury patterns identified by physical examination and improved imaging techniques. There continues to be no consensus on treatment parameters. Despite the presence of predisposing factors, such as dysplasia or generalized hyperlaxity, medial retinacular injury associated with primary (first-time) patellar dislocations represents a ligament injury, which may result in residual laxity of the injured structure. This residual laxity is defined objectively by an increase in passive lateral excursion of the patella. Repair or reconstructive procedures to restore this medial constraint is considered paramount in any procedure to stabilize the patella against subsequent dislocations. How best to accomplish this continues to be a matter of debate. The establishment of a medial check-rein by either repairing or reconstructing the MPFL is the procedure of choice for stabilizing a kneecap after first-time dislocation, largely because the literature to date does not provide clear guidelines about when more extensive surgery is indicated. Whether or not all first-time dislocators have improved outcome after surgical repair remains speculative, however. Improved outcome would involve both the elimination of recurrent instability episodes and continued satisfactory function of this patella in activities-of-daily-living and sporting activities. These outcomes have not been studied critically in operative versus nonoperative treatment of first-time patellar dislocation. For the first-time dislocator, most investigators would agree that an arthroscopy should be performed if intra-articular chondral damage is suspected. Nonoperative management of first-time patellar dislocations continues to be the preferred practice pattern in the United States. If surgical management is elected, because of individual characteristics of the injury pattern or the patients lifestyle, it is important to inspect the MPFL along its length and repair any or all ligamentous disruptions. If the ligament is avulsed from the medial epicondyle, reattachment to bone is necessary to restore passive restraint to lateral patella motion. MRI may be useful in order to identify the location and degree of medial soft tissue injury preoperatively. The establishment of a medial check-rein by either repairing or reconstructing the MPFL is a necessary component of all surgical procedures performed to correct objective lateral instability of the patella. The addition of a LRR should be additive to this procedure only when it facilitates other procedures to recenter the patella or when objective lateral tilt by physical examination measurements is present. A practical approach to surgery after patellar dislocation is the minimal amount of surgery necessary to re-establish objective constraints of the patella. Correcting dysplastic factors, in particular tibial tubercle transfers and trochleoplasties, are best reserved if more minimal surgery has failed. This failure is defined as continued functional instability of the kneecap.

The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes.

Based on experience, the authors believe that MR imaging is a useful tool in the assessment and management of stress fractures and stress phenomenum of bone. The use of standard, graded MR evaluation aides the assessment of a repetitive stress injury to bone by allowing a more accurate diagnosis of bone injury. This more accurate assessment has predictive value in estimating the duration of disability. The use of a standard, graded MR evaluation aides the management of repetitive stress injuries to bone by defining a low grade of stress fracture (i.e., grade 1 and 2) injuries and a high grade of stress fracture (i.e., grade 3 and 4). This grading system has implications in the management of stress fractures, allowing more individualized treatment for the elite athlete.

Anterior knee pain in females.

There are clear differences between men and women regarding anterior knee pain. Anatomic factors including increased pelvic width and resulting excessive lateral thrust on the patella are primary factors that predispose females to anterior knee pain. Effects of estrogen on connective tissue synthesis have been reported, but there is no clear mechanism by which this would affect anterior knee pain. Postural and sociologic factors such as wearing high heels and sitting with legs adducted can influence the incidence and severity of anterior knee pain in women.

Stress Injuries to Bone in College Athletes A Retrospective Review of Experience at a Single Institution

Background No comprehensive studies have been published on stress injuries to bone in college athletes. Purpose To review, in a college athlete population, the epidemiologic aspects of stress injuries to bone, and to examine a subset of patients who were treated with a uniform protocol for return to activities, with magnetic resonance imaging as the primary tool for diagnosis. Study Type Retrospective review. Methods Ten years of medical records from a Division I college institution were reviewed. Location and grade of stress injury to bone and duration of disability were recorded. All injured athletes followed the same treatment program, with the exception of football players, who were excluded from the return to sport analyses. Results Seventy-four athletes had lower extremity symptoms consistent with stress injury to bone. Diagnosis was confirmed in 68 of these athletes, 61 via magnetic resonance imaging, 6 via positive radiographs only, and 1 via bone scan only. Distance runners accounted for the most stress injuries to bone for both men and women. The tibia (37%) was the most frequently involved bone; however, as an anatomic region, the foot (44%) was the site of the most stress injuries. There was a significant correlation between grade of injury and time to full return to activity. Conclusions The grading system used at this institution is a standardized tool that can be used to predict time to return to sport. A standardized rehabilitation protocol allowed for an appropriate plan to return the athletes to pain-free competition.

Radiographic Identification of the Primary Medial Knee Structures

BACKGROUND Radiographic landmarks for medial knee attachment sites during anatomic repairs or reconstructions are unknown. If identified, they could assist in the preoperative evaluation of structure location and allow for postoperative assessment of reconstruction tunnel placement. METHODS Radiopaque markers were implanted into the femoral and tibial attachments of the superficial medial collateral ligament and the femoral attachments of the posterior oblique and medial patellofemoral ligaments of eleven fresh-frozen, nonpaired cadaveric knee specimens. Both anteroposterior and lateral radiographs were made. Structures were assessed within quadrants formed by the intersection of reference lines projected on the lateral radiographs. Quantitative measurements were performed by three independent examiners. Intraobserver reproducibility and interobserver reliability were determined with use of intraclass correlation coefficients. RESULTS The overall intraclass correlation coefficients for intraobserver reproducibility and interobserver reliability were 0.996 and 0.994, respectively. On the anteroposterior radiographs, the attachment sites of the superficial medial collateral ligament, posterior oblique ligament, and medial patellofemoral ligament were 30.5 +/- 2.4 mm, 34.8 +/- 2.7 mm, and 42.3 +/- 2.1 mm from the femoral joint line, respectively. On the lateral femoral radiographs, the attachment of the superficial medial collateral ligament was 6.0 +/- 0.8 mm from the medial epicondyle and was located in the anterodistal quadrant. The attachment of the posterior oblique ligament was 7.7 +/- 1.9 mm from the gastrocnemius tubercle and was located in the posterodistal quadrant. The attachment of the medial patellofemoral ligament was 8.9 +/- 2.0 mm from the adductor tubercle and was located in the anteroproximal quadrant. On the lateral tibial radiographs, the proximal and distal tibial attachments of the superficial medial collateral ligament were 15.9 +/- 5.2 and 66.1 +/- 3.6 mm distal to the tibial inclination, respectively. CONCLUSIONS The attachment locations of the main medial knee structures can be qualitatively and quantitatively correlated to osseous landmarks and projected radiographic lines, with close agreement among examiners.

The Female Knee: Anatomic Variations and the Female-specific Total Knee Design

AbstractThe concept and need for a gender-specific or female-specific total knee prosthesis have generated interest and discussion in the orthopaedic community and the general public. This concept relies on the assumption of a need for such a design and the opinion that there are major anatomic differences between male and female knees. Most of the information regarding this subject has been disseminated through print and Internet advertisements, and through direct-to-patient television and magazine promotions. These sources and a recent article in a peer-reviewed journal, which support the need for a female-specific implant design, have proposed three gender-based anatomic differences: (1) an increased Q angle, (2) less prominence of the anterior medial and anterior lateral femoral condyles, and (3) reduced medial-lateral to anterior-posterior femoral condylar aspect ratio. We examined the peer-reviewed literature to determine whether women have had worse results than men after traditional TKAs. We found women have equal or better results than men. In addition, we reviewed the evidence presented to support these three anatomic differences. We conclude the first two proposed differences do not exist, and the third is so small that it likely has no clinical effect. Level of Evidence: Level IV, systematic review. See the Guidelines for Authors for a complete description of levels of evidence.