Patellofemoral Pain 1

Running head: REVIEW OF LITERATURE

What effect does grafting from the contralateral patellar

tendon in primary anterior cruciate ligament reconstruction

have on the presence and severity of patellofemoral pain?

HPER 6610

Middle Tennessee State University

Patellofemoral Pain 2

LITERATURE REVIEW

In this section, the functional anatomy of the healthy knee joint, including the placement and structural role of the anterior cruciate ligament, will be analyzed as well as the mechanisms that cause the knee and the ACL to be injured. Additionally, demographical information including sex, sports affiliation, and injury statistics related to ACL injuries will be examined.

Current options for managing ACL injuries will also be discussed including both reconstructive surgery, and non-surgical physical rehabilitation. Finally, complications associated with ACL reconstruction will be presented along with methods of measuring the severity and duration of patellofemoral pain.

Functional Anatomy

Within the human anatomy, points of contact between skeletal elements are known as joints (Pease, et al., 1995). The articulation of the femur and the tibia make up the tibiofemoral joint, better known as the knee joint. In addition to being structurally complex, the knee is also the largest joint in the body.

As mentioned earlier, the skeletal structure of the knee is primarily comprised of the articulation between the femur (thighbone) and the tibia (shinbone). Housed between the femur and the tibia and within the patellar tendon and quadriceps muscle group is the patella, or the

“kneecap.” The patella is also called a sesamoid or “floating” bone because of its location within

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surrounding tendons (Thompson & Floyd, 2001). These bony structures serve as attachment

points for the muscles and ligaments that move and protect the joint. The knee’s musculature is

made up of muscles from both the quadriceps and the hamstrings. These muscle groups work

synergistically to provide protection as well as flexion, extension, and rotary movements of the

knee joint.

The ligamentous arrangement of the knee is divided into two main subgroups; collateral ligaments and cruciate ligaments. The collateral ligaments, including the medial collateral ligament (MCL) and the lateral collateral ligament (LCL), are located adjacent to one other on both the medial and lateral surfaces of the knee joint. They provide stability, help direct movement in a correct path, and prevent exaggerated side-to-side movements of the femur and the tibia (Arnheim & Prentice, 2001).

Similarly, the cruciate ligaments are responsible for overall joint stability and help prevent anterior/posterior translation or gliding of the femur over the tibia. They also keep the knee from hyperextending, or extending past its normal range of motion (Arnheim & Prentice,

2001). The term “cruciate derives from the word crux, meaning cross, and crucial” (American

Academy of Orthopaedic Surgeons [AAOS], 2000, ¶ 3). The cruciate ligaments are positioned in a crisscross fashion deep within the joint capsule. These ligaments include the posterior cruciate ligament (PCL), which is located toward the back of the knee, and the anterior cruciate ligament

(ACL), which is located near the front of the knee.

Cooperatively, the structures that make up the knee are designed to provide stability in weight bearing and mobility in locomotion (Arnheim & Prentice, 2001). However, the extreme Patellofemoral Pain 4

stress associated with many sports has caused the knee to be one of the most traumatized joints

in the body. The previously mentioned anterior cruciate ligament is one of the most frequently

injured structures in the knee (Marieb, 2001).

Etiology and Pathophysiology of ACL Injury

Anterior cruciate ligament injuries are prevalent in sports and fitness settings. However, stretching or tearing of the ACL is not always the result of contact with other players. In fact,

70% of [acute] ACL injuries occur via non-contact mechanisms (Maguire & Cross, 2002). These

include playing on an uneven surface, suddenly slowing down, landing from a jump (especially

on one foot), changing direction rapidly, and pivoting on a fixed foot (AAOS, 2000).

Hyperextension from a force to the front of the knee with the foot planted can also tear the ACL

(Arnheim & Prentice, 2001). In some cases, ACL injuries are chronic in nature, involving

repeated episodes of effusion (swelling) or instability during physical activity. With either of

these mechanisms, when the ACL is stretched beyond its normal elasticity, it is medically

considered to be sprained (Marieb, 2001).

A sprain is defined as “a sudden or violent twist or wrench of a joint causing the

stretching or tearing of ligaments and often the rupture of blood vessels with hemorrhage into

surrounding tissues” (Pease, et al., 1995, p. 654). A sprained ACL can be classified into one of

three degrees; (1) a partial tear, meaning only a portion of the ligament is torn or stretched; (2) a

complete tear, which involves the full tearing of the ligament; or (3) an avulsion, where the

ligament is completely ripped from its source, in this case, the tibial or the femoral condyles. Patellofemoral Pain 5

In either case, the ACL cannot heal itself due to poor vascularization, and ultimately leads to abnormal “kinematics” (Pease, et al., 1995, p. 355) of the knee in both sexes.

Demographics

The anterior cruciate ligament sprain is the most serious ligament injury in the knee

(McCarthy, Buxton, & Hiller, 1994). According to a recent article published in USA Today, there are an estimated 80,000 annual ACL tears in the United States; 56,000 occurring during sports. Soccer, basketball, running, skiing and volleyball are the sports and recreational activities frequently associated with ACL injuries in both sexes (Moeller & Lamb, 1997). However, although this type of injury occurs in both men and women, injury data reveal that female athletes injure the ACL more frequently than their male counterparts (Moeller & Lamb, 1997).

ACL Injuries in Women. According to a study done by Arendt and Dick (1995), the

National Collegiate Athletic Association (NCAA) injury rate for women soccer players is over two times higher than for men. The difference is even greater in basketball, where women are four times more likely to sustain anterior cruciate ligament injuries than men (Arendt & Dick,

1995). Researchers with the American Academy of Orthopaedic Surgeons (2002) have found that the majority of these injuries occur in females age 15-25 years. Several theories have been considered as to why women are more susceptible to ACL problems than men. One theory suggests hormonal differences. Many women tear their ACL’s near the time of their menstrual periods, suggesting that due to chemical changes, elasticity may be compromised during the Patellofemoral Pain 6

menstrual period (Patrick, 2003). Another theory places the blame on biomechanics. Researchers

have shown that women’s muscles, particularly the hamstrings, react differently in landing [from

a jump] (Patrick, 2003). Also, women tend to land with their legs straight which places the knee

in danger of hyperextension. Finally, one of the most acknowledged theories connects female

ACL injuries to anatomical structure. Researchers have noted women’s wider pelvises and

smaller ligaments as a possible risk factor for ACL injury (Patrick, 2003). Regardless of the cause, the number of ACL injuries in female athletes is rising (Moeller & Lamb, 1997). To

combat these problems, many physicians and sports medicine specialists are currently making an

effort to develop programs that teach women proper landing techniques, strength training

exercises, and other basic prevention practices to prevent ACL injuries in women before they

happen. However, whenever an ACL injury is sustained, there are several options available to

manage each injury.

Treatment Options

Because the severity of an ACL injury can range from stretching to complete laceration,

and also because there are different types of people who experience ACL injuries, there are both

non-operative and operative treatment plans available to suit individual goals and desires.

For persons who do not plan to participate in high-risk sports or vigorous fitness

activities, the non-surgical route may be the best option. In this case, the knee is stable enough to

complete normal daily activities with little discomfort and can be protected and strengthened by

(1) participating in physical therapy, which would help strengthen the muscles around the knee Patellofemoral Pain 7

to make up for the absence or instability of the ACL; (2) changing daily activities, meaning modifying any high-risk movements such as jumping and landing or sudden slowing down or stopping; and finally, (3) wearing a customized knee brace. Although a knee brace cannot take the place of the ACL, it can help stabilize the knee and prevent the joint from giving way (Mayo

Clinic Staff, 2003b).

In contrast, a defective ACL can be debilitating and result in significant instability, translation in the knee joint, and an increased risk of meniscal (cartilage) injury (Mayo Clinic

Staff, 2003b). Persons who have completely torn or avulsed the ACL or persons who wish to participate in competitive sports and return to pre-injury strength and stability may choose reconstructive surgery to repair the traumatized ligament.

History of ACL Reconstruction

Because a torn ACL does not heal, past attempts to repair, rather than replace, the torn ligament have not been successful (Mayo Clinic Staff, 2003a). As a result, surgeons have developed methods to reconstruct the defective ACL with other healthy tissues (autograft) from the patient’s own body.

Surgical methods of reconstructing the anterior cruciate ligament have come a long way since 1917 when the first ACL reconstructive procedure was performed by Dr. Ernest W. Hey

Groves (Colombet, Allard, Bousquet, De Lavigne, & Flurin, 1993). At that time, Groves used an autograft from the iliotibial band to reconstruct the defective ACL. The procedure involved opening the leg laterally, detaching one end of the band from the tibial tubercle, and suturing the Patellofemoral Pain 8

graft to periosteum and the fascia of the femur (Colombet, et al., 1993). As the surgery has

evolved, physicians have sought to discover the best graft site and source for performing this

type of surgery. Because the goal is to regain stability and minimize post-operation complications, surgeons have experimented with several other graft harvest sites such as the

hamstrings tendon, the semitendinosus tendon, and the central quadriceps tendon, in hopes of

finding the optimal graft (Pearsall, n.d.). Cadaver tissue (allograft) and synthetic materials have

also been experimented with as possible substitutes for human autogenous tissue. It wasn’t until

1969 that Dr. Kurt Franke of Berlin pioneered the use of a free bone-patellar tendon-bone graft

(B-PT-B) consisting of one quarter of the patellar tendon and attached patellar and tibial bone

blocks (Colombet, et al., 1993). Even though several revisions have been made to Franke’s

original procedure, the free B-PT-B grafting technique is still the most common procedure used

today (Pearsall, n.d.).

Contemporary ACL Reconstruction

Arthroscopy. Along with the advances in tendon graft harvest have come innovative

technological methods of exploring and repairing joints. Arthroscopic surgery is now used to

look inside the knee and reconstruct the ACL. Arthroscopic surgery utilizes an “arthroscope”

(Pease, et al., 1995, p. 47) – a surgical instrument used for the visual examination of the interior of a joint – to look inside the knee and determine the problem and the severity of injury. In contrast to past incisions, the scope only requires two tiny incisions on either side of the patella just below the femoral condyles in the affected knee. Once the initial scopes are inserted into the Patellofemoral Pain 9

incisions, several other appliances can be fed through the tub-like instruments such as cameras or cutting devices. The scopes are also used in the latter part of the surgery to thread and anchor the new graft into place.

Ipsilateral patellar autograft. As was mentioned earlier, the free bone-patellar tendon- bone graft has become the most common graft source for anterior cruciate ligament reconstruction. Until recently, the ipsilateral patellar tendon was the graft of choice for primary

ACL reconstruction. The term “ipsilateral” (Pease, et al., p. 342) means appearing on or affecting the same side of the body. The procedure involves grafting a portion of the patellar tendon and two plugs of bone from the injured knee leaving the healthy knee untouched. However, the greatest obstacle of rehabilitation for patients reconstructed with an ipsilateral patellar tendon graft is the return of strength to both the patellar tendon donor site and the weakened extensor mechanism, which was already weakened as a result of the initial ligament injury (Rosenburg, Franklin, Baldwin, et al., 1994; Wilk, Andrew, & Clancy, 1993). Because of this, researchers and orthopaedists hypothesized other methods to divide the trauma of surgery and the rehabilitation program between both extremities to make the course of rehabilitation easier, quicker, and more reliable (Shelbourne & Urch, 2000).

Contralateral patellar autograft. In 1994, Rubinstein and Shelbourne reported results of using the contralateral patellar tendon graft for revision ACL reconstruction. The use of the contralateral patellar tendon graft for primary ACL reconstructions was proposed based on Patellofemoral Pain 10

“observations as to the ease with which patients could regained full knee range of motion and quadriceps muscle strength in both the ACL-reconstructed and donor knees” (Shelbourne &

Urch, 2000, p. 651) the term “contralateral” means occurring on the opposite side of the body

(Pease, R. W., et al., 1995, p. 138), thus suggesting that the contralateral bone-patellar tendon- bone graft procedure harvests a strip of patellar tendon and two bone plugs from the uninjured, or opposite knee. Shelbourne and Urch (2000) reported that the autogenous contralateral patellar tendon graft was an “excellent graft choice for use in ACL reconstruction, and the majority of complications associated with its use were primarily related to rehabilitation issues” (p. 658).

Although the use of the contralateral patellar tendon in primary ACL reconstruction has created an effective alternative for surgeons and patients, complications can still arise as a result of the operation.

Postoperative Complications

As with any other surgical procedures, anterior cruciate ligament reconstruction has the potential to leave patients with complications and obstacles that interfere with a timely rehabilitation. One of the most common complications associated with ACL reconstruction is patellofemoral pain (Sachs, Daniel, Stone, & Garfein, 1989).

Patellofemoral pain involves pain and sensitivity behind the patella at the articular surface of the patella and the femur. This type of tenderness is common outside the operating room in persons who participate in sports which require jumping and landing, or in other activities such as walking, bicycling, and running (University of Buffalo Sports Medicine, n.d.). Patellofemoral Pain 11

Because it is normally considered to be an overuse injury to the knee, it can be measured following ACL reconstruction by a variety of functional tools such as the Tegner Activity Scale and the Lysholm Knee Score (Tenger & Lysholm, 1995). Patellofemoral pain can also be measured subjectively by a Noyes Pain Score (Shelbourne & Urch, 2000) which allows subjects to fill out a questionnaire related to the amount of pain they have had in the past or are currently experiencing. This problem has been referred to as patellofemoral disorder, patellar malalignment, runner’s knee, and chondromalacia (University of Buffalo Sports Medicine, n.d.).

Researchers suggest that the presence of patellofemoral pain following ACL surgery is interrelated with other complications such a decrease in flexion; unsatisfactory knee motion and hyperextension after reconstruction; and altered patellar alignment (Fulkerson, 2002; & Sachs,

Daniel, Stone, & Garfein, 1989; Shelbourne & Trumper, 1997). Sachs et al. (1989) followed 126 patients who had undergone ACL reconstruction. Statistics were reviewed at one year post- operation for the presence of 13 different complications. Patellofemoral pain was present in 19% of the patients. Their conclusions were similar to the findings of Barber-Westin, Noyes, and

Andrews (1997) who examined and compared the results and complications of males and females following anterior cruciate ligament reconstruction. The authors found that 22% of the patients in their study experienced patellofemoral crepitus. Furthermore, in some cases, researchers have found the incidence of patellofemoral pain to be as high as 63% among patients who have undergone ACL reconstruction (Bach, Jones, Hagar, Sweet, & Luergans, 1994).

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Although each of the preceding authors concur that patellofemoral pain is a problem facing male and female ACL reconstruction candidates, the relationship between the incidence and severity of patellofemoral pain and the location of the autograft remains to be investigated.

In their studies, each of the researchers harvested the autogenous patellar tendon to reconstruct the deficient ACL; however, they did not indicate whether the grafts were harvested ipsilaterally or contralaterally. The proposed study investigates the effect of grafting from the contralateral patellar tendon in primary anterior cruciate ligament reconstruction on the presence and severity of patellofemoral pain.

Summary

The knee is a large and structurally complex joint. The musculature and ligamentous arrangement of the knee provides strength, protection, and stability in movement. However, despite its elaborate framework, the knee is one of the most traumatized joints in the body. One of the most common injuries, as well as one of the most debilitating injuries to the knee joint is the tearing or spraining of the anterior cruciate ligament, or the ACL. Over the years, researchers have reported an increase in the incidence of ACL injuries, especially in women athletes.

Because of this increase, alternative treatments and surgical techniques have become available.

For many, a decision is made to remove and reconstruct the injured ACL using arthroscopic instruments and a graft obtained from autogenous tissue. Grafts can be harvested from a number of locations on the anatomy including the hamstrings tendon, the quadriceps tendon, or the semitendinosus tendon. For several years, the most common source for grafting was the Patellofemoral Pain 13

ipsilateral patellar tendon. However, due to prolonged rehabilitation times and other functional complications, researchers speculated if there was a more efficient graft source for reconstructing the ACL. As a result, researchers began grafting from the contralateral patellar tendon during primary ACL surgery.

Although researchers have shown that the more contemporary methods are safe and effective, complications, such as patellofemoral pain and discomfort, are still prevalent.

Researchers have compared patellofemoral issues according to severity, duration, and between the sexes. Nonetheless, data concerning the direct effect of grafting from the contralateral patellar tendon for ACL reconstruction on the incidence and severity of patellofemoral pain remain to be collected. By researching this issue, athletic trainers, orthopaedic surgeons, and physical therapists will gain a better understanding of the etiology of patellofemoral complications as they relate to ACL reconstruction and therefore develop better methods of managing patellofemoral pain and the obstacles patellofemoral complications present during rehabilitation.

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