Ugharadar 1
Naeem Ugharadar
Eng 3010-10
Annotated Bibliography: Managing Patients with ACL/MCL injuries.
Alford J, Bach B. Managing ACL tears: Evaluation and diagnosis. Journal Of Musculoskeletal
Medicine [serial online]. 2004; 21(7): 381G. Available from: CINAHL Plus with Full Text,
Ipswich, MA. Accessed October 1, 2012.
This article is an informative piece that explains the different ways that cause an injury to
Anterior Cruciate Ligament (ACL). ACL is a ligament inside one’s knee that provides stability
during movement. Injury to ACL results in awkward landing or twisting of the knee. Evaluating
an ACL injury includes the Lachman test for laxity, pivot test and X-ray. In Lachman test, the
knee is bent 20 to 30 degrees. The examiner then places one hand on the femur and applies force
anteriorly on the calf with the other hand. The examiner then should estimate the displacement in
mm and assess the presence or absence of an end point. In Pivot test, axial and valgus force is
applied to the knee as it is slowly flexed. Pivot test evaluates rotation and translation of the tibial
plateau. A simple x-ray test is used to find how bad the injury is to the ligament and also if there
are any fractures in the bone structure. The techniques of evaluating an ACL injuries listed in
this article are still used in present. Knowing the severity of the injury is very important. So, on
top of performing the above tests, they use technology like MRI and anesthetics that make
evaluation of the injury even more accurate. This article is very valuable and gives background
information about existing diagnostic and evaluation techniques of ACL.
Alford J, Bach B. Managing ACL tears: When to treat, when to refer. Journal Of
Musculoskeletal Medicine [serial online]. 2004; 21(10): 520. Available from: CINAHL Plus with
Full Text, Ipswich, MA. Accessed October 1, 2012.
This informative article reflects upon different treatment choices that physical therapists choose
depending on the severity of the injury to ACL. This article explains two treatments: nonoperative and surgery. In more active and young patients, surgery is recommended because nonoperative treatment has less chances of success. In older patients no-operative treatment is
recommended because older people are willing to degrade their activity level while tratment. In
non-operative treatment and pre-surgery procedures, application of braces and splints is common
in order to keep the injured knee immobilized. In a surgical approach to treat the injury, the
middle patellar tendon is autograft with attached bone blocks from the tibia and patella. This
allows bone-to-bone fixation of the graft. These techniques are still used today. Now days more
places in the body are fond from where tendon tissue can be harvested for ACL reconstruction.
Recently research is done to use tissue engineering for ACL reconstruction.
Chen L, Kim Paul D, Ahmad C, Levine W. Medial collateral ligament injuries of the knee:
Current treatment concepts. Musculoskelet Med [serial online]. 2008; 1: 108-113. Available
from: NCBI-PMC, Ipswich, MA. Accessed October 1, 2012.
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This article goes on to explain the main cause of Media Collateral Ligament (MCL) injury,
diagnostics and treatment plans. The most common cause of MCL injury is valgus force applied
on the knee. Valgus force on the knee can also cause other ligaments in the knee to tear such as
ACL. Increased frequency of MCL injury in US is due to participation in contact related sports
such as football, hockey, skiing. Use of knee brace can prevent injury but can affect
performance. Majority of treatment is non-operative. Surgical treatment is only preferred in
severe chronic MCL injuries where non-operative treatment is unsuccessful. The treatment
techniques explained in this article are quite recent and are still in use. There are not many
studies done regarding MCL injuries. This article is valuable and has very good information
about the management of MCL injury.
Freeman J, Woods M, Laurencin C. Tissue engineering of the anterior cruciate ligament using a
braid-twist scaffold design. J Biomech [serial online]. 2007; 40(9): 2029-2036. Available from:
NCBI-PMC, Ipswich, MA. Accessed October 1, 2012.
This article reflects upon the use of tissue engineering to reconstruct ACL. The insufficient
vascularization around ACL ligament prevents it from recovering by its own if ruptured severely.
So engineered tissue is placed in the knee that mimics the functions of the actual ACL. This
research is trying to construct a Poly L-lactic acid braid-twist scaffold tissue using the techniques
of polymer fiber braiding and twisting. Results showed significant increase in strength and strain.
This study shows promising future in tissue engineering for ACL reconstruction. This technique
is not tested on humans and is still on animal trial. This Article gives very valuable information
about the upcoming future of the topic.
Hastings D. Diagnosis and management of acute knee ligament injuries. Can Fam Physician
[serial online]. 1990; 36: 1169-1172. Available from: NCBI-PMC, Ipswich, MA. Accessed
October 1, 2012.
This article goes on to explain different treatment methods involving the ACL/MCL injury. ACL
injury normally is repaired non-operatively but combined ACL/MCL injury requires surgical
intervention. Isolated PCL tears are treated non-operatively unless there is bony avulsion present.
Injuries to the knee ligaments such as ACL/MCL are very common. The most common injury
mechanism is when valgus force applied to your knee. Some of the other injury mechanisms
include blow from the medial side, and direct anterior and posterior forces applied to the knee.
This article provides a table of data, which explains the injury mechanism and the type of
treatment most appropriate for the knee. Ex. When ACL is tore from a valgus force, surgical
intervention is optimal for young person and hamstring exercise for an elderly person. This
article is very valuable because not a lot of studies are done regarding multiple ligament injuries.
Information on this article can be included in the background section of the research proposal.
James L, Donald J. Surgical treatment may be the answer for ACL tears in the aging athlete.
Orthopedics Today [serial online]. 2009; 29(8): 30-33. Available from: CINAHL Plus with Full
Text, Ipswich, MA. Accessed October 1, 2012.
In this article, research was done on elderly people above age 40 with ACL rupture. The research
was conducted in Mexico. The treatment plan included operative and non-operative treatment.
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Despite the surgical complications, results show that operative care is more successful than nonoperative care. Operative care is preferred because there are high chances of re-injuring the ACL
due to the weakness of the aging knee. The aging knee has higher potential knee instability
during pivoting. This article does not look very valuable because the type of treatment plan
chosen is depended on the activity level of the patient. Age does not really matter. If the patients
have higher activity level then operative care is optimal and non-operative treatment is preferred
for low activity level.
Jung H, Fisher M, Woo S. Role of biomechanics in the understanding of normal, injured, and
healing ligaments and tendons. Sports Med Arthrosc Rehabil Ther Technol [serial online]. 2009;
1: 9. Available from: NCBI-PMC, Ipswich, MA. Accessed October 1, 2012.
This informative article explains the healing process and the function of knee ligaments. This
article proposes that a better understanding of the function of a ligament together with the
healing potential may help improve and speed up the healing process. The biomechanics of knee
ligaments is very complicated and can be easily misinterpreted. The use of growth factors, gene
therapy and biological scaffolds to accelerate the healing process are looking very promising.
Seeding bone marrow derived cells followed by mechanical cyclic starching can further improve
the biomechanical properties of the tissue and speed up the healing process of ACL. This article
reflects excellent future plans and can be used to base my research proposal. This article contains
very valuable information about the future of the ACL/MCL injuries. It exactly resembles my
research topic regarding techniques to speed up the recovery process of ACL/MCL.
Kakarlapudi T, Bickerstaff D. Knee instability. West J Med [serial online]. 2001; 174(4): 266272. Available from: NCBI-PMC, Ipswich, MA. Accessed October 1, 2012.
This article explains the phenomenon of knee stability. It explains that knee stability depends on
the shape of the condyles and menisci in combination with supporting structures. The supporting
structures that maintain the stability of the knee are: ACL, MCL, PCL and LCL. If any of the
above supporting structures are injured, the knee become very instable and vulnerable to many
more complications. This article goes on to explain the anatomical functions and possible causes
of the injury to each of the supporting structures. The most common injury that occurs is to the
ACL. Results of ACL repair are very poor and the main purpose of the treatment is not to
reinjure it. There are two options operative and non-operative. The decision of the treatment plan
depends on age, activity level and the degree of laxity. This article is not very valuable because it
explains the anatomical functions of the knee ligaments. This article is not related to my topic.
Mangine R, Minning S, Eifert-Mangine M, Colosimo A, Donlin M. Management of the patient
with an ACL/MCL injured knee. N AM J Sports Phys Ther [serial online]. 2008; 3(4): 204-211.
Available from: NCBI-PMC, Ipswich, MA. Accessed October 1, 2012.
This article states that limited number of research is available about multiple ligament knee
injuries. This article focuses on how to manage a patient who has combine ACL and MCL
injury. Surgical intervention is not always the best option when it comes to multiple ligament
knee injury (MLKI). When valgus force is applied some of the other structures such as the
arteries, femur or fibula of the leg can be seriously injured. The treatment option chosen by the
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therapist is depended on the degree of the injury caused to the leg. Some of the other treatment
plans apart from the surgical intervention include extended immobilization, external fixators for
complete dislocations and immediate motion. In a young athlete, surgical intervention is
recommended and is used most commonly. Surgical intervention is recommended if there is
minimal damage to other structures of the leg. This article is very valuable for the topic because
it gives background information about MLKI. This article gives information about management
of patient with MLKI.
Murray M. Current status and potential for primary ACL repair. Clin Sports Med [serial online].
2009; 28(1): 51-61. Available from: NCBI-PMC, Ipswich, MA. Accessed October 1, 2012.
This article explains the potential of ACL repair in the future. This article starts out by describing
the possibility of osteoarthritis after ACL injury. The current technique used by the doctors to
repair the ACL includes replacement of torn ACL by tendon graft stems. This technique is
unsuccessful in many patients because the tendon graft has limited healing capacity and cannot
regenerate with suture repair. A new technique called enhanced primary repair has better results.
This technique includes preservation of the complex attachment sites, which retains
biomechanical function of the ACL. This new technique places a substitute provisional scaffold
in the injury site to enhance healing process. This article is valuable because it gives information
about the evolution of the ACL/MCL repairs. This article also gives me good background
information on the techniques used in the past and present.
Shin C, Chaudhari A, Andriacchi T. The effect of isolated valgus moments on ACL strain during
single-leg landing: A simulation study. J Biomech [serial online]. 2009; 42(3): 280-285.
Available from: NCBI-PMC, Ipswich, MA. Accessed October 1, 2012.
This article is about the effect of isolated valgus movements on ACL during single-leg landing.
In this study ACL strain, valgus angle, tibial rotation and MCL strain were measured using 3-D
dynamic knee model. The results showed that increased valgus movement increased ACL strain
non-linearly. As the valgus movement increased the tibial rotated externally. The results show
that peak ACL strain is unaffected by an increase in valgus movement for people who land with
neutral alignment. Valgus landers have higher chance of injuring their ACL the neutral landers.
In conclusion, the higher valgus movement of the knee, the greater the strain on the ACL.
Extreme strain on ACL can cause it to tear. This article is not very valuable because it is not
related to management of patient with ACL/MCL tears. It simply explains the cause of the injury
and how to prevent it.
Vavken P, Murray M. The potential for primary repair of the ACL. Sports Med Arthrosc [serial
online]. 2011; 9: 44-49. Available from: NCBI-PMC, Ipswich, MA. Accessed October 1, 2012.
This article focuses on finding a treatment plan for a torn ACL by tissue engineering. The
motivation behind this technique was the numerous cases of osteoarthritis post ACL
reconstruction. The treatment plan was possible due to the invention of an inhibitor that stops the
ACL from healing. The inhibitor stops the clot formation in a torn ligament. A biocompatible
scaffold is placed inside the wound, which enhances cellular proliferation. This technique has
been successful in large animal models and looks very promising in the future. This article is
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very valuable and vary recent. This technique provided in the article can give clues to further
investigation in speeding up the healing of ACL.
Walden M, Atroshi I, Magnusson H, Wagner P, Hagglund M. Prevention of acute knee injuries
in adolescent female football players. BMJ- British Medical Journal [serial online]. 2012; 344:
e3042. Available from: NCBI-PMC, Ipswich, MA. Accessed October 1, 2012.
This research article evaluated 230 female Swedish football (soccer) clubs. Some of them were
in control group and others were intervention group. The intervention group was given 15minute neuromuscular warm-up exercises targeting stability and proper knee alignment. 0.28%
of the intervention group and 0.67% of the control group had ACL injury. Neuromuscular warup exercises significantly reduced the probability of ACL tear or a severe knee injury in football
players. This study is not useful because it is not related to the management of ACL/MCL tears.
This study provides information on how to prevent ACL injury.
Wroble R, Brand R. Function of knee ligaments: A historical review of two perspectives. Iowa
Orthop J [serial online]. 1988; 8: 62-67. Available from: NCBI-PMC, Ipswich, MA. Accessed
October 9, 2012.
The article is an informative piece, which explains two different perspectives on the function of
the knee ligaments. According to surgeons and biomechanicians, (ACL) Anterior Cruciate
Ligament is only an anatomical structure that provides support to the knee while it is in motion.
Surgical treatments to an injured ACL were based on the above analogy. According to
anatomists and physiologists, ACL acts as a sensory organ that provides information regarding
the stress applied to the central nervous system. The information sent to the nervous system then
gets processed and an appropriate response is triggered, which can involve contraction and
relaxation of muscles. This article is outdated, but some of the surgical aspects are still in use
such as surgical replacement of the ACL. Now there is doubt that ACL acts as a sensory organ
and responses from CNS can control the stability of the knee.
Zhang J, Pan T, Im H, Fu F, Wang J. Differential properties of human ACL and MCL stem cells
may be responsible for their differential healing capacity. BMC Med [serial online]. 2011; 9: 68.
Available from: NCBI-PMC, Ipswich, MA. Accessed October 1, 2012.
This article talks about the difference between the healing capacity of ACL and MCL. Usually
when MCL is injured, it heals with non-operative treatment but when ACL is injured it does not
heal. The difference in the healing capacity is due to the stem cells. Stem Cells of ACL and
MCL, when they heal through proliferation and differentiation contain different properties that
could be responsible for different healing capacity. To test the argument, they obtained ligament
stem cells from a single donor. They grew the stem cell culture. They compared the growth
factors between the two types of stem cells. The results indicated that markers for vascular cell
were different in the cultures. ACL cultures grew much slower then MCL cultures. This study is
valuable because it reveals the different properties of ACL and MCL stem cells. This finding can
help in investigation of growth factors that speed up the healing process of the ligaments. This
can prove to be very promising lead in the future of ACL/MCL repairs.