Alpiner Skibreiten- und Skileistungssport

Alpine skiing is the most popular winter sport discipline in Germany and is performed by more than 4 million recreational sportsmen and ski racing athletes. Compared to other sports, however, the injury rate in alpine skiing is quite high. Especially the knee joint is the most commonly injured area of the musculoskeletal system. Knee injuries are classified as severe in a high percentage of cases. In this review article, epidemiologic data and typical injury patterns in recreational alpine skiing and in competitive alpine ski racing are compared. In addition, the potentials of preventive methods in alpine skiing are presented and evaluated with a special focus on orthotic devices and protection wear as injury prevention equipment.     

Consideration of the anterior cruciate ligament injury in skiing

The anterior cruciate ligament (ACL) injury of the knee is a common ski injury. At a typical ski area clinic in Wyoming, an average of one per day is diagnosed over the 120-day ski season. Other ski clinics report a similar incidence of ACL injuries. In view of the 570 registered ski slopes in the United States, the ACL injuries occur at epidemic proportions. Under consideration are causal factors involved in the typical skier's ACL injury, such as recent evolutions in skiing techniques, boot styles, the skier's environment, and the anatomic considerations relating to body mechanics that place the ACL in a position of compromise in the intercondylar notch. Clear identification of the mechanism of ski injury of the ACL is difficult. As the significant causative factors become identified, and with the stimulation of further interest and research, there is some promise for prevention in the future.     

Proposed practice guidelines for nonoperative anterior cruciate ligament rehabilitation of physically active individuals

Nonoperative management of anterior cruciate ligament (ACL) rupture has not been a successful option for those who participate in high-level physical activity. However, there are instances when patients may want to attempt to return to physically demanding activities with nonoperative rehabilitation for an ACL injury. The purpose of this commentary is to describe guidelines for nonoperative management of physically active individuals with ACL injuries who wish to return to preinjury levels of physical activity. The guidelines are based on the results of 2 clinical studies that improved the overall success of nonoperative management of physically active individuals with ACL ruptures. A decision-making process for selecting appropriate candidates for nonoperative management (rehabilitation candidates) is described. Individuals are classified as rehabilitation candidates if they have no concomitant ligament or mensical damage associated with the ACL injury, have a unilateral ACL injury, and meet all 4 of the following criteria: (1) timed hop test score of 80% or more of the uninjured limb, (2) Knee Outcome Survey Activities of Daily Living Scale score of 80% or more, (3) global rating of knee function of 60% or more, and (4) no more than 1 episode of giving way since the incident injury to the time of testing. Individuals meeting the criteria of a rehabilitation candidate undergo an intensive rehabilitation program before returning to high-level activity. The rehabilitation program consisting of lower extremity muscle strength training, cardiovascular endurance training, agility and sport-specific skill training, and a training program using balance perturbations is described.     

The anterior cruciate ligament: a review of recent concepts

The anterior cruciate ligament (ACL) consists of a small anteromedial band and a larger posterolateral band. Recent findings have shown the ACL to play a major role in the function of the knee joint. The ACL prevents anterior luxation of the tibia, limits tibial rotation, and resists valgus and varus stress to the knee. The most common mechanism of ACL injury involves hyperextension of the knee with a rotational component. Diagnosis of an ACL lesion consists of an accurate history, clinical tests and often, arthroscopic investigation. Treatment of an ACL injury may consist solely of a rehabilitation program, may involve surgical intervention, or a combination of the two. Many surgical procedures both intra-articular and extra-articular, have been used in the past. The most successful approach at this time appears to be a combination of intra-articular and extra-articular procedures. A contemporary trend in rehabilitation following surgery is the use of graduated stages of treatment beginning immediately postsurgery and continuing through to full return to activity. J Orthop Sports Phys Ther 1986;8(3):110-122.     

Incidence and treatment of fresh connective tissue injuries of the knee in winter sports

For the last 18 years 21,808 alpine skiing injuries have been treated at the hospital of Davos. There is a great decline in the incidence of lower leg fractures with a contrary development of knee ligament injuries. Today half of the lower leg injuries are knee injuries. To ameliorate the documentation of all patients with acute injuries of the knee ligaments we are using a detailed questionnaire, including the mechanism of injury, release of the safety binding, skiing ability, pattern of instability and the techniques of treatment. We report of the evaluation of 145 patients with knee ligament injuries. It is the aim of that protocol to follow up all these cases up to 5 years.     

Neuromuscular rehabilitation of a female Olympic ice hockey player following anterior cruciate ligament reconstruction

STUDY DESIGN: Case study. OBJECTIVE: To demonstrate the unique aspects of rehabilitating a female athlete participating in ice hockey following anterior cruciate ligament (ACL) reconstruction. BACKGROUND: The patient was a 28-year-old female who sustained a traumatic injury to her left knee while playing ice hockey. After 6 weeks of rehabilitation (15 visits), the athlete elected to undergo ACL reconstruction following buckling episodes that she experienced during both skating and walking. METHODS AND MEASURES: Following ACL reconstruction using a patellar tendon autograft, the patient was treated for 6 months in 44 visits. Initial treatments consisted of effusion management, neuromuscular control of lower extremity muscles, and regaining passive range of motion, especially extension. Although instability testing revealed a negative pivot shift and a 2-millimeter side-to-side difference on KT-1000 examination, the patient reported a sensation of buckling when she attempted skating at 4 months (27 visits) following ACL reconstruction. Off-ice strength and functional testing of the lower extremity did not demonstrate deficits. At that time, a specific neuromuscular program for returning a patient to ice hockey was implemented. RESULTS: Following 17 physical therapy visits, which combined sport-specific and sex-specific neuromuscular rehabilitation, the patient was able to return to competitive ice hockey. Six months following ACL reconstruction, the patient reported no feeling of instability during skating. The patient reported a Lysholm score of 100 and Tegner activity score of 9. An on-ice functional test revealed the athlete's score was 80% of her pre-injury score. CONCLUSIONS: Failure of static knee stabilizers can be a cause of instability. Following ACL reconstruction, a neuromuscular rehabilitation program may prevent residual knee instability once the static stabilizers have been restored. A sport-specific neuromuscular rehabilitation program for the athlete participating in ice hockey should be considered.     

Allograft anterior cruciate ligament reconstruction: indications, techniques, and outcomes

The anterior cruciate ligament (ACL) is an important stabilizer of the knee against translational and rotational forces. The goal of anatomic reconstruction of the ACL-deficient knee is to re-create a stable knee that will allow for return to sport and prevent recurrent injury. Multiple graft options exist for ACL reconstruction, and each option has unique advantages and disadvantages. With appropriate patient selection, each graft can be utilized to optimize patient outcomes. Allograft options limit morbidity following ACL reconstruction, but care must be taken with surgical technique and postoperative rehabilitation to allow for graft incorporation. An understanding of the surgical technique and differences between graft options will allow the patient, surgeon, and physical therapist to maximize outcomes following ACL reconstruction.     

What I have learned about the ACL: utilizing a progressive rehabilitation scheme to achieve total knee symmetry after anterior cruciate ligament reconstruction

Anterior cruciate ligament surgery and rehabilitation have changed drastically during the past 30 years. The patellar tendon autograft fixed with buttons provides tight bone-to-bone placement of the graft and quick bony healing, which allows accelerated rehabilitation to obtain full range of motion and strength. Although surgical stability is easily reproducible, long-term patient satisfaction is difficult to guarantee. Full knee range of motion should be compared to that of the contralateral normal knee, including full hyperextension. We followed the progress of all patients to gauge the utility of our rehabilitation program. In order of importance, the lack of normal knee range of motion (within 2° extension and 5° of flexion compared with that of the normal knee), partial or total medial meniscectomy, partial or total lateral meniscectomy, and articular cartilage damage were related to lower subjective scores. Rehabilitation after ACL reconstruction must first strive to achieve full symmetrical knee range of motion before aggressive strengthening can begin. Our current perioperative rehabilitation starts at the time of injury and preoperatively includes aggressive swelling reduction, hyperextension exercises, gait training, and mental preparation. Goals after surgery are to control swelling while regaining full knee range of motion. After quadriceps strengthening goals are reached, patients can shift to sport-specific exercises. When using a graft from the contralateral knee, the conflicting goals of strengthening the donor site and achieving full knee range of motion are divided between the knees. Thus, normal range of motion and strength can be achieved more easily and more quickly than when using an ipsilateral graft. Regardless of the graft source, a systematic rehabilitation program that emphasizes the return to symmetrical knee motion, including hyperextension, is necessary to achieve the optimum result.     

Pulley system isokinetic training in knee rehabilitation--initial results

AIM: The purpose of this study was to evaluate the results of a knee rehabilitation program after knee surgery, based on an isokinetic pulley System (Moflex, Recotec/Bernina, Switzerland). METHOD: In this prospective study, 73 patients participated in a standardized rehabilitation program (ACL reconstruction, ACL/all: n = ;51; patellar tendon, ACL/P: n = 30; semitendinosus tendon, ACL/S: n = 21; arthroscopic meniscus resection: n = 22). The major aspect of the program was an isokinetic pulley system with an implemented, linearly working knee device. RESULTS: Isokinetic training with the used device affords strict monitor feed-back to avoid critical torque values. Concentric training strength and workload which were attained without relevant pain were increased by about 130% within a mean of 16 rehabilitation days. At the end of the rehabilitation program, the maximum concentric strength of the affected knee measured by a rotating isokinetic system (Cybex, Kaphingst, Lahntal) increased by about 69% and amounted to about 90% of that of the unaffected knee. CONCLUSION: These first results demonstrate the value of the isokinetic pulley system in the rehabilitation after knee surgery as described above. The equipment may be used already in an early postoperative stage by the use of a passive or active-assistive mode. First results of strength increases using an isokinetic pulley system in knee rehabilitation are presented.     

A review of ski injuries resulting in combined injury to the anterior cruciate ligament and medial collateral ligaments

Alpine skiing is a global winter recreational sport with 15 million participants in the United States alone, and an overall injury rate of 2.5 per 1,000 ski person-days. Isolated injury to the anterior cruciate ligament (ACL) or the medial collateral ligament (MCL) is common among ski injuries; however, combined injury to these structures is rare. Controversy in the management of ACL instability following alpine ski injury is diminishing with improvements in the techniques of intra-articular cruciate reconstruction. However, the management of the combined ACL–MCL injury remains something of an enigma. Evidence exists to support both surgical and nonsurgical management strategies for the medial structures, but little consensus exists for the timing of the repair. This paper highlights the mechanisms of ski injuries that can result in combined injury to the ACL and MCL. The anatomy and biomechanics of the medial complex as it relates both to stability and operative repair are reviewed, and literature on the techniques and indications used for MCL repair in the setting of a combined injury is presented. On the basis of this review, we believe that an injury to the MCL does not need to be repaired if the ACL is reconstructed after a combined injury.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp 194–202     

Anterior tibial translation during different isokinetic quadriceps torque in anterior cruciate ligament deficient and nonimpaired individuals

STUDY DESIGN: Factorial quasi-experimental design. OBJECTIVES: To quantify the effect of different levels of isokinetic concentric and eccentric knee extensor torques on the anterior tibial translation in subjects with anterior cruciate ligament (ACL) deficiency. Electromyogram (EMG) activity of 4 leg muscles was recorded in order to detect any co-activation of extensors and flexors. BACKGROUND: The rehabilitation after an ACL injury is of importance for the functional outcome of the patient. In order to construct a rehabilitation program after that injury, it is important to understand the in vivo relationships between muscle force and tibial translation. METHODS AND MEASURES: Twelve patients with unilateral ACL injury and 11 uninjured volunteers performed 36 repetitions of a quadriceps contraction at different isokinetic concentric and eccentric torque levels, on a KinCom machine (60 degrees x s(-1)), with simultaneous recordings of tibial translation (CA-4000) and EMG activity from quadriceps and hamstrings muscles. Tibial translations and EMG levels were normalized to the maximum of each subject. RESULTS: The individual anterior tibial translation increased with increased quadriceps torque in a similar manner in both quadriceps contraction modes in all legs tested. During concentric mode, translation was similar in all groups, but during eccentric mode, the mean translation was 38% larger in the ACL injured knees. No quadriceps-hamstrings co-activation occurred in any test or group. CONCLUSIONS: An ACL deficient knee can limit the translation within a normal space during concentric muscle activity but not during eccentric activity. That limitation depends on other mechanisms than hamstrings co-activation.     

Extension block secondary to partial anterior cruciate ligament tear on the femoral attachment of the posterolateral bundle

Purpose: The purpose of this investigation was to prove that a partial tear of the anterior cruciate ligament (ACL) at the femoral attachment of the posterolateral bundle can result in mechanical knee locking and trigger the injury mechanism of an isolated ACL injury. Type of Study: Case series. Methods: From February 1993 through June 1999, 19 cases of knee locking with observation of a torn ACL, confirmed under arthroscopy, were investigated. Patients’ ages ranged from 22 to 54 years. The causes of injury were sporting activities in 14 patients (8 skiing, 4 soccer, and 2 badminton); slipping and falling in 2 cases; a pedestrian car accident in 2 cases; and an unknown low-velocity injury in 1 case. Results: On physical examination, each patient indicated that the chief complaint was knee pain; all had a locked knee at 5° to 20° of full extension and 4 cases showed a locked knee at full flexion. Of the 19 cases, Lachman testing was positive in 3. With respect to intra-articular injuries, 3 patients had a tear in the medial meniscus and 1 had a tear in the lateral meniscus. The average time span between arthroscopy examinations was 3 months with a range of 1 to 10 months. Arthroscopic diagnosis and treatment were performed and meniscal tear was ruled out as the cause of locking in all patients. Conclusions: The mechanisms of injury for isolated ACL were knee hyperextension and internal rotation of lower extremity brought on especially by a low-velocity injury. The partial ACL tears were found on the femoral attachment site of the posterolateral bundle. The torn segment of the ACL was interposed between the lateral femoral condyle and the lateral tibial condyle and acted as a mechanical obstruction, giving rise to the locking symptom. In all 19 cases, the torn portion of the ACL was excised under arthroscopy and the locked knees were treated properly.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: pp 227–231     

Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction.

Neuromuscular training programs are increasingly integrated into clinical practice for lower extremity rehabilitation. A few rehabilitation programs have been evaluated for patients with anterior cruciate ligament (ACL) deficiency and for injury prevention, but there is limited scientific evidence of the effect of neuromuscular training following ACL reconstruction. Therefore, a neuromuscular training program was developed for patients after ACL reconstruction. The objective of the neuromuscular training was to improve the ability to generate a fast and optimal muscle firing pattern, to increase dynamic joint stability, and to relearn movement patterns and skills necessary during activities of daily living and sports activities. The main areas considered when designing the postoperative rehabilitation program after ACL reconstruction were: ACL graft healing and ACL strain values during exercises, proprioception and neuromuscular control, and clinical studies on the effect of neuromuscular training programs. The rehabilitation program consists of balance exercises, dynamic joint stability exercises, jump training/plyometric exercises, agility drills, and sport-specific exercise. The patients exercise 3 times a week for 6 months. The scientific and clinical evidence for the rehabilitation program are described and the main exercises in the program are outlined.     

Practice guidelines for anterior cruciate ligament rehabilitation: a criterion-based rehabilitation progression

Knowledge related to the anterior cruciate ligament (ACL) and its role in the stabilization of the knee has increased exponentially since the 1980 s. More precise and more anatomic surgical techniques have developed based on a growing body of literature on the anatomy and biomechanics of the anterior cruciate ligament. The rehabilitation arena has also risen to the challenge to provide state-of-the-art rehabilitation to complement advances in surgical stabilization. The understanding and integration of the abundance of literature on surgical reconstruction, graft biology, and behavior guides the design and progress of the rehabilitation program. Effective rehabilitation after anterior cruciate ligament reconstruction must balance the loading of tissues necessary to stimulate the recovery of the knee while at the same time avoiding stresses that compromise graft integrity. Historically, rehabilitation programs have been temporally based. A performance-based decision-making approach may prove to be more universally applicable and less confining. Achieving the critical clinical milestones, the basis for rehabilitation progression, ensures that all patients are adequately challenged while at the same time assuring that none are progressed too quickly. Combining contemporary surgical and rehabilitation techniques will maximize the patient's potential and ensure optimal patient function and satisfaction.     

Anterolateral Ligament of the Knee: Diagnosis,Indications, Technique,Outcomes

In the context of anterior cruciate ligament reconstruction surgery, anterolateral ligament reconstruction is now recognized as a reliable option to control rotatory instability and should be considered in the knee surgeon's modern armamentarium. By highlighting its daily practical application, this infographic presents the indications for this specific additional lateral augmentation, the anatomic and biomechanical principles that underline its rationale, and the clinical outcomes from recent large series.In 2013, Claes et al. updated the anterolateral ligament (ALL) concept, and numerous subsequent studies detailed its precise anatomy. It is now accepted that the femoral insertion is located proximal and posterior to the epicondyle. The biomechanical behavior of the ALL during the knee flexion path has been reported to provide control of tibial internal rotation during the pivot shift and with increasing knee flexion angles (>35). Clinically, when a patient presents with an anterior cruciate ligament (ACL) injury, clinical examination (pivot shift test), radiography (Segond fracture), ultrasound, and 3-dimensional magnetic resonance imaging are useful to assess a combined ALL injury.The following indications for ALL reconstruction are now well established: ACL revision, high-grade pivot shift test, chronic ACL rupture, young patients, pivoting activities, and patients undergoing medial meniscus repair. It has been reported that anatomic and minimally invasive surgical techniques that control anterolateral rotatory instability can achieve successful outcomes without specific complications. Finally, the addition of ALL reconstruction does not delay postoperative rehabilitation, and no modification is required for an early rehabilitation protocol.     

Editorial Commentary: The Ratio of Tibial Slope and Meniscal Bone Angle is a Strong Predictor for Anterior Cruciate Ligament Injury: A Steep Hill and a Shallow Speed Bump are a Hazardous Combination

The lateral tibial posterior slope (LTPS) and the lateral meniscal bone angle (MBA) are important geometrical features of the knee joint and have therefore been of interest in the setting of anterior cruciate ligament injury (ACL) and ACL reconstruction. An emerging body of evidence suggests that LTPS is an independent risk factor for primary and recurrent ACL injury. Furthermore, biomechanical and clinical evidence is emphasizing the crucial contribution of the lateral meniscus to rotatory knee stability. Thus, not surprisingly, the MBA has also been shown to be an independent risk factor regarding ACL injury. The ratio of LTPS and MBA is a relatively new idea but has shown to be highly predictive for primary and recurrent ACL injury and may be used to identify patients at high risk of ACL reconstruction failure.     

Ruptur des vorderen Kreuzbands

Rupture of the anterior cruciate ligament (ACL) is the most common ligamentous knee injury. The knee is stabilized by the cruciate ligaments and the collateral ligaments. The ACL originates from the inner surface of the lateral condyle of the femur, runs in an anterior medial direction and inserts at the tibial plateau in the intercondyle area. The most common injury is an indirect knee trauma, typically a joint torsion in sports. Patients often describe a snapping noise followed by hemarthrosis. Concomitant injuries are lesions of the medial collateral ligament, the medial meniscus (unhappy triad) and chondral fractures. The age peak is between 15 and 30 years with a higher incidence in females. The cardinal symptom of the ACL rupture is the giving way phenomenon. The clinical diagnosis is provided by a positive Lachman test, a positive pivot shift test and the anterior drawer test. Fractures can be excluded by X-ray examination. Magnetic resonance imaging (MRI) allows the evaluation of the internal knee structures. ACL repair is carried out by arthroscopically assisted bone-tendon-bone or semitendinosus grafting techniques. Early rehabilitation is important for a good functional outcome.     

Anterior cruciate ligament injury in the skeletally immature

Although ACL injuries in truly skeletally immature patients are relatively uncommon events, they are experienced more frequently than initially reported--especially in the adolescent population. Natural history data is limited but appears to mirror the natural history in adults with this injury if return to high-risk activity is allowed. Treatment of this injury presents unique challenges because of the substantial growth that occurs through the distal femoral and proximal tibial physes. The physiologic skeletal maturity of the patient must be determined prior to deciding treatment. Techniques of reconstruction include physeal sparing, partial transphyseal, and transphyseal methods. Reconstruction is recommended for any patient with an "ACL +" knee (a complete ACL tear and concomitant meniscal injury) or one who is non-compliant with a nonoperative treatment program and develops symptoms of persistent instability. Short-term outcomes of functional return postreconstruction appear promising, but study numbers are small and follow-up times relatively brief in truly immature patients. Long-term outcome studies are still needed.     

Quadriceps protects the anterior cruciate ligament.

The aim of this study is to show that the quadriceps is the primary muscular restraint to anterior tibial translation during closed kinetic chain activities such as running, jumping, walking, and standing. It is my hypothesis that the quadriceps vector is directed superiorly during open kinetic chain knee extension and inferiorly during closed kinetic chain knee extension. My methods involve vector analysis based on a lateral radiograph of the normal human knee and muscle ultrasound. My results show that the quadriceps vector is directed superiorly for open kinetic chain knee extension and inferiorly for closed kinetic chain knee extension. The inferiorly directed quadriceps vector has an anterior femoral-tibial or posterior tibial-femoral component, which protects the anterior cruciate ligament (ACL) from anterior tibial-femoral shear. Therefore during closed kinetic chain activities, the quadriceps protects the ACL regardless of the activity of the hamstrings. Given that the quadriceps is much stronger than the hamstrings, has better leverage at low knee flexion angles, and a favorable vector with regard to the ACL during closed kinetic chain activities, and since most activities of daily living, sports, and non-contact ACL injuries occur with the foot on the ground, then it can be concluded that the quadriceps is the primary ACL protagonist. My findings have the following implications: (1) weak quadriceps are a risk factor for non-contact ACL injuries, (2) strong quadriceps are important for ACL injury prevention and rehabilitation, and (3) preservation of quadriceps strength is an important surgical goal.     

Long-term clinical review (10-20 years) after reconstruction of the anterior cruciate ligament using the Leeds-Keio synthetic ligament

Prosthetic ligament use for anterior cruciate ligament (ACL) reconstruction was popular in the 1980s and 1990s. Information from published studies regarding the long-term outcomes of this surgery is limited. This paper presents the long-term results of stabilization of the ACL deficient knee using the Leeds-Keio synthetic ligament formed from woven polyester. Fifty patients were seen in clinic at a mean follow-up of 11.9 years (range 8.7-19.7 years). The mean ages were: at injury 26.8 years (range 16-47 years), at surgery 29.9 years (range 18-47 years), and at review 42 years (30-56 years). Of the 50 patients included, 86% were male and 14% were female. The main causes of injury were football (42%), rugby (25%), and skiing (8%). The mean time from injury to surgery was 37.6 months (range 0-324 months). All patients received intra-articular (IA) ligaments placed in the anatomical position of the natural ACL. In addition, approximately 75% also had an extra-articular ligament placed so that it ran parallel to the IA component on the lateral aspect of the knee. At review, patients were thoroughly assessed with history, examination, and IKDC criteria. IKDC scores were excellent or good in 92% of patients seen while combined IKDC and thorough clinical history findings were good or excellent in 84% of patients seen. Patient satisfaction was high with 90% of patients being satisfied or very satisfied with the outcome of surgery. Activity levels were also high according to IKDC criteria. At one year postoperatively, approximately 66% of patients had returned to their preinjury level of activity. At review, almost half of all patients still maintained this level. Of those patients who did not, only 6% attributed this to knee instability. Furthermore, the vast majority of patients (92%) still had activity levels superior to that of postinjury/preoperatively. Rupture of the intra-articular component was confirmed in six cases (12%) and three of these patients continued to experience functional knee instability. These results demonstrate that synthetic ligament can provide long-term functional stability in the knee following a loss of the ACL.