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Patellofemoral Pain 1 Running Head: REVIEW of LITERATURE What Effect Does Grafting from the Contralateral Patellar Tendon in P

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Patellofemoral Pain 1 Running Head: REVIEW of LITERATURE What Effect Does Grafting from the Contralateral Patellar Tendon in P 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 Patellofemoral Pain 3 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
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