Transcription:
How Can You Prevent and Treat ACL Injuries?

Melanie Cole (Host):  Tears of the anterior cruciate ligament or ACL can happen frequently among athletes. How could they reduce their risk for these types of injuries? My guest today is Dr. Miller. He’s board certified in orthopedic medicine and orthopedic sports medicine. He serves as the Division Head for Sports Medicine at UVA Health system. Welcome to the show, Dr. Miller. Tell us a little bit about the ACL or the anterior cruciate ligament. What is its function as part of the knee?

Dr. Mark Miller (Guest):  Well, first of all, thank you for inviting me, Melanie. The anterior cruciate ligament is a key ligament for stability of the knee. It allows young people and the athletes and all of us for that matter, to pivot, change direction and play pivoting type sports. So, it’s a critical factor and ability to turn and twist and pivot.

Melanie:  Why is it so easily injured?

Dr. Miller:  Well, because it’s vulnerable. So, the problem is it just takes the wrong amount of landing or pivoting or change of direction. The one tiny bit beyond normal and it can be vulnerable for injury.

Melanie:  So, what type of athletes or normal people are more likely to suffer an ACL injury?

Dr. Miller:  Well, for some reason, we’re only starting to figure out that female athlete is the most at risk, as much as 4 or 5 times the male athlete. Probably that has to do with the way that they land or their body habitus or the way that their ligament is situated in the notch of their knee.  So, we’re working really hard to try to figure that out and try to reduce the injuries in this female athlete population which is very much at risk right now.

Melanie:  They are. What does it feel like to injure your ACL? What happens?

Dr. Miller:  Well, patients describe landing funny and hearing a pop or feeling a pop or both and immediate swelling of their knee. Of course, they are unable to return to play in that same game.

Melanie:  So, what happens then afterwards? Is this a brace and ice situation? Is it emergent? Do you get right to the doctor? What do you do?

Dr. Miller:  Well, it’s certainly not emergent but we like to see this patient sooner rather than later because we want to confirm the diagnosis. We want to see if there are additional injuries which are common, such as meniscus tear or articular cartilage injuries and we want to get them on the road to recovery.

Melanie:  So, do we know why women are a little bit more susceptible to this? Does it have to do with hormones or you know, kinematics, gait? What does it have to do with?

Dr. Miller:  Yes. This question actually shows up on exams sometimes and the answer is always “all of the above” because there are so many factors that are involved. All those you mentioned plus just simply the way that women tend to land after they come from a jump. They land with their knees, more knock kneed and straight rather than absorbing the jump as they land. So, we’re doing jump training which is called plyometrics. We’re doing counseling. We’re doing injury prevention to try to reduce this risk.

Melanie:  So, if a girl, soccer player specifically, learns good biomechanics for the way that they pivot or the way that they land, then they could possibly reduce some of these injuries. What do you want coaches and parents to know about plyometrics and teaching some of this good biomechanical moves?

Dr. Miller:  Sure. There’s some exciting research going on right now at Southern California on this very issue. There are some programs that coaches could get online that could help reduce some injuries. Now, they are not going to go away but, hopefully, we could reduce them and the whole sports society has a program called the “Stop Injury” program that we’re trying to reduce these injuries. So, this is all available online and the American Orthopedics Society for sports medicine has vested interest in promoting this program.

Melanie:  What happens if it is torn? What’s an athlete to do? Does this require surgery or is it something that could heal itself?

Dr. Miller:  Now, unfortunately this is something that cannot heal itself because in the knee, for some reason, the joint fluid causes it to almost get like a rubberized coating over it. So, the ligament can’t attach to itself because of the in-the-joint mechanism. So, what we do is we place a tendon graft to replace the ligament. That’s what ACL reconstruction is. You use typically the center of one-third of the knee tendon or the hamstring tendon to replace the torn ligament. That’s what ACL reconstruction is all about.

Melanie:  Is this performed arthroscopically?

Dr. Miller:  Yes. And so, it’s certainly arthroscopically assisted. You have to actually make incision to obtain the graft. We’ve learned also to avoid donor grafts in young people—allografts--because there’s a high risk of failure with those grafts.

Melanie:  So, what’s recovery like for a torn ACL?

Dr. Miller:  Well, the recovery typically involves a physical therapy, working on range of motion and quadriceps activities. It’s often 3 to 4 months before they could return to even straight ahead running and at least 6 months before they could return to play.

Melanie:  Are there certain patients that ACL reconstruction is not recommended?

Dr. Miller:  Certainly. If you’re relatively sedentary and you don’t have an active lifestyle and you don’t do pivoting sports, then you’re probably not going to need to have an ACL reconstruction.

Melanie:  What about those athletes? You mention returning to play. Is soccer then out for a good long time? Do you skip a whole season into the next season? Do you advise they brace it for a long time? What happens for those athletes?

Dr. Miller:  Yes. Unfortunately, the female soccer athlete is one of our biggest dilemmas right now. We can get them back to play in 6 or as much as 12 months but the problem is they are still at risk for recurring injury. It’s alarming how high that risk is. Not only to the knee that you operate on, but to the other knee as well. So, this is a dilemma we haven’t quite solved. If the goal of the athlete is to try to preserve their knee health, probably it’s not the best sport for them. But, if they’re adamant about playing soccer, then we’ll do everything we can to get them back to the field.

Melanie:  So, if they get to have a reconstruction, is there a risk then for the surrounding ligaments and tendons after that fact? Is there a way to strengthen those up along with this new reconstructed ACL?

Dr. Miller:  Certainly. Quadriceps rehabilitation’s an important part of that. Bracing hasn’t been turned out to be as helpful as we would think because the braces simply don’t work at the speed or the rate that this injuries occur. So, there’s little  you can do, except for aggressively rehabilitate and try to dojump training and avoid re-injury but ,even with that, the risk is still high, especially in that sport.

Melanie:  Let’s talk about prevention again for a minute. When you talk about the jump training and the plyometrics, how can parents, coaches or athletes themselves work on this? What do you specifically want them doing? Going up and down on a box? Pivoting when they come down? What do you want them to do?

Dr. Miller:  Yes. The best thing is to find a program that is available online that will teach young people on how to do this. But, the bottom line is they learn to jump off a box and land with absorbing the blow, less extension of the knees, less where their knees go together knock-kneed. The best thing is to have somebody who is trained in this to help the athlete learn on how to do it better.

Melanie:  So, tell us why patients should come to UVA for their sports medicine care. Tell us about your team.

Dr. Miller:  Well, the coolest thing about UVA is we take care of 2 separate college teams. We take care a large community group. And, at UVA, we cover all of sports medicine. We have 5 surgeons. They are all specialized in each different area and we have the best care possible for all of our athletes and, even our everyday recreational athletes and patients who are not so athletic. So, we could cover the whole gamut of everything in sports medicine. Nothing gets referred elsewhere because we can take care of everything.

Melanie:  So, just in the last few minutes, best advice about this common injury that we’re hearing more and more about, especially with girl soccer players--an ACL injury. Kind of give your best wrap up for us.

Dr. Miller:  Sure. The certain sports where female athletes are at particular at risk. One of them is soccer, another is basketball. The best we could do is to try to prevent this injuries by learning how to jump with our knees more flexed and less knock-kneed and to go online and study about injury prevention and to remain as active and healthy and muscle-toned as possible and do whatever you can to avoid these injuries. If the injuries do happen, then we’re prepared to help and try not only to revise and reconstruct ligaments but also to help with the rehabilitation in getting people back to their sports that they love.

Melanie:  Thank you, Dr. Miller. It’s great information. You’re listening to UVA Health Systems Radio. For more information, you can go to UVAHealth.com. That’s UVAHealth.com. This is Melanie Cole. Thanks so much for listening.