Elsevier

Clinical Biomechanics

Volume 30, Issue 10, December 2015, Pages 1094-1101
Clinical Biomechanics

Prospectively identified deficits in sagittal plane hip–ankle coordination in female athletes who sustain a second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport

https://doi.org/10.1016/j.clinbiomech.2015.08.019Get rights and content

Highlights

  • Coordination deficits exist in patients who sustain repeat knee injuries.

  • Altered postural coordination may lead to increased risk of future injury.

  • Altered postural coordination may need to be addressed post-operatively.

  • Postural coordination may need to be included in return to play decision making.

Abstract

Background

Athletes who return to sport after anterior cruciate ligament reconstruction are at increased risk of future ACL injury. Altered coordination of lower extremity motion may increase this risk. The purpose of this study was to prospectively determine if altered lower extremity coordination patterns exist in athletes who go on to sustain a 2nd anterior cruciate ligament injury.

Methods

Sixty-one female athletes who were cleared to return to sport after anterior cruciate ligament reconstruction were included. Hip–ankle coordination was assessed prior to return to sport with a dynamic postural coordination task. Within 12 months, 14 patients sustained a 2nd ACL injury. Fourteen matched subjects were selected for comparative analysis. Cross-recurrence quantification analysis characterized hip–ankle coordination patterns. A group × target speed (slow vs. fast) × leg (involved vs. uninvolved) analysis of variance was used to identify differences.

Findings

A main effect of group (P = 0.02) indicated that the single injury group exhibited more stable hip–ankle coordination [166.2 (18.9)] compared to the 2nd injury group [108.4 (10.1)]. A leg × group interaction was also observed (P = .04). The affected leg of the single injury group exhibited more stable coordination [M = 187.1 (23.3)] compared to the affected leg of the 2nd injury group [M = 110.13 (9.8)], P = 0.03.

Interpretation

Hip–ankle coordination was altered in female athletes who sustained a 2nd anterior cruciate ligament injury after return to sport. Failure to coordinate lower extremity movement in the absence of normal knee proprioception may place the knee at risk.

Introduction

An estimated 100,000–200,000 anterior cruciate ligament (ACL) injuries occur annually in the United States with the majority of patients electing to undergo ACL reconstruction (Kim et al., 2011) (ACLR). Athletes who attempt to return to sport (RTS) after ACLR are as much as 15 times more likely to sustain a second ACL injury to either knee in the first year after they return to sport (Paterno et al., 2012). Despite high second injury rates in ACLR, there is a lack of consensus regarding the underlying mechanism placing these athletes at increased risk for future injury. The current published literature has reported the relationship of various factors to second ACL injury rates, including demographic variables (Brophy et al., 2012), graft type (Kaeding et al., 2011), and biomechanical, neuromuscular, and proprioceptive factors (Paterno et al., 2010). Furthermore, other impairments in strength (Mattacola et al., 2002), balance (Mattacola et al., 2002, Paterno et al., 2013), proprioception (Mattacola et al., 2002), and limb symmetry with dynamic tasks (Paterno et al., 2007, Paterno et al., 2011) may extend for over 2 years after RTS from ACLR. Despite this extensive research, the effect of ACL injury and ACLR on postural coordination remains unknown.

Postural coordination has been defined as the coordination between various body parts that underlies the integration of the maintenance of upright stance (Bardy et al., 2002). The absence of joint position awareness at the knee joint may result in impairments to postural coordination due to altered muscle recruitment with dynamic movements, deficits in joint stability, and decreased ability to control normal movement (Chiu and Chou, 2013, Hamill et al., 1999, Kiefer et al., 2013a). Coordinated movements of the hip and ankle are critical to optimally position the knee joint in the absence of normal knee proprioception during dynamic athletic movements. Failure to coordinate the movements of the joints proximal and distal to the knee has the potential to place the knee joint in high-risk positions during dynamic movements. The failure to optimally position the knee may make the passive structures susceptible to pathologic stresses that increase the risk of subsequent ligament or graft failure following ACLR.

Abnormal sagittal plane joint coupling patterns between the hip and ankle in patients following ACLR have been identified in the literature when compared to healthy control subjects (Kiefer et al., 2013b). Coupling refers to the synergistic movement of multiple segments to coordinate a gross movement. Despite identification of this difference between ACLR patients and controls, current research has yet to identify whether unique patterns of abnormal postural coordination and joint coupling are residual impairments associated with a high risk for future ACL injury.

The purpose of this prospective study was to determine if there are altered sagittal plane postural coordination patterns in female athletes who subsequently go on to suffer a second ACL injury to either limb after ACLR and RTS. The hypothesis tested was that athletes who subsequently sustained a second ACL injury would demonstrate altered sagittal plane, hip–ankle postural coordination patterns indicative of persistent sensorimotor deficits leading to abnormal joint coupling patterns at the time of RTS compared to female athletes who would not subsequently sustain a second ACL injury.

Section snippets

Participants

Sixty-one female pivoting and cutting athletes with a primary, unilateral ACLR were prospectively tested and then tracked for 12 months following RTS to identify those who went on to a second ACL injury. Testing occurred when the subject was medically cleared to return to pivoting and cutting sports after ACLR by their physician and rehabilitation specialist. All subjects returned to a Level I/II pivoting or cutting sport (Daniel et al., 1994). Within 12 months of RTS, 14 subjects (11 soccer

Summary measure of variability

A main effect of group was observed for SDankle, F(1,26) = 4.235, P = .05, η2 = 0.14, which indicated that the ACL2 group exhibited a decreased amount of variability, or more rigid posture, in overall ankle movement [0.001 (0.0001°)] compared to the ACL1 group [0.002 (0.0005°)] (Table 2). The interactions were not significant (P > .05). No significant differences were found for SDhip (P > .05).

CRP features

Fig. 4 shows sample CRPs for an ACL1 athlete (left) and an ACL2 athlete (right). There are notable visual

Discussion

The results of this investigation support the stated hypothesis that female athletes who subsequently sustained a second ACL injury after ACLR and RTS would present with altered patterns of postural coordination at the time of RTS following initial ACLR. Specifically, females who subsequently sustained a second ACL injury demonstrated a more rigid posture (decreased variability of movement) at the ankle, less coordinated movements, and weaker coupling of movements between the hip and ankle

Conclusion

This study indicates that female patients who suffer a second ACL injury after ACLR and return to a pivoting and cutting sport present with altered hip–ankle coordination when compared to similar patients who did not suffer a second ACL injury. Failure to appropriately coordinate lower extremity movement between the adjoining proximal and distal hip and ankle in the absence of normal knee proprioception may place the knee in a high-risk position and increase the likelihood of a second ACL

Acknowledgements

The study was supported by the National Football League Charities and the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases grants R01-AR049735, R01-AR05563, R01-AR056259, and F32-AR055844.

References (38)

  • N. Stergiou et al.

    The effect of the walking speed on the stability of the anterior cruciate ligament deficient knee

    Clin. Biomech.

    (2004)
  • B.G. Bardy et al.

    Dynamics of human postural transitions

    J. Exp. Psychol. Hum. Percept. Perform.

    (2002)
  • R.H. Brophy et al.

    Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group

    Am. J. Sports Med.

    (2012)
  • D.M. Daniel et al.

    Fate of the ACL-injured patient. A prospective outcome study

    Am. J. Sports Med.

    (1994)
  • L.M. Decker et al.

    New insights into anterior cruciate ligament deficiency and reconstruction through the assessment of knee kinematic variability in terms of nonlinear dynamics

    Knee Surg. Sports Traumatol. Arthrosc.

    (2011)
  • S. Di Stasi et al.

    Neuromuscular training to target deficits associated with second anterior cruciate ligament injury

    J. Orthop. Sports Phys. Ther.

    (2013)
  • S.F. Donker et al.

    Children with cerebral palsy exhibit greater and more regular postural sway than typically developing children

    Exp. Brain Res.

    (2008)
  • B.C. Heiderscheit et al.

    Variability of stride characteristics and joint coordination among individuals with unilateral patellofemoral pain

    J. Appl. Biomech.

    (2002)
  • C.C. Kaeding et al.

    Allograft versus autograft anterior cruciate ligament reconstruction: predictors of failure from a MOON prospective longitudinal cohort

    Sports Health

    (2011)
  • Cited by (0)

    The Cincinnati Children's Hospital Medical Center Institutional Review Board approved this study.

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