Hip and knee joint kinematics during a diagonal jump landing in anterior cruciate ligament reconstructed females

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Abstract

Anterior cruciate ligament (ACL) injury is a common injury encountered by sport medicine clinicians. Surgical reconstruction is the recommended treatment of choice for those athletes wishing to return to full-contact sports participation and for sports requiring multi-directional movement patterns. The aim of ACL reconstruction is to restore knee joint mechanical stability such that the athlete can return to sporting participation. However, knowledge regarding the extent to which lower limb kinematic profiles are restored following ACL reconstruction is limited. In the present study the hip and knee joint kinematic profiles of 13 ACL reconstructed (ACL-R) and 16 non-injured control subjects were investigated during the performance of a diagonal jump landing task. The ACL-R group exhibited significantly less peak knee joint flexion (P = 0.01). Significant between group differences were noted for time averaged hip joint sagittal plane (P < 0.05) and transverse plane (P < 0.05) kinematic profiles, as well as knee joint frontal plane (P < 0.05) and sagittal plane (P < 0.05) kinematic profiles. These results suggest that aberrant hip and knee joint kinematic profiles are present following ACL reconstruction, which could influence future injury risk.

Introduction

Anterior cruciate ligament (ACL) rupture is a common injury encountered by clinicians involved in the prevention, treatment and rehabilitation of sports injuries. The ACL functions to provide mechanical stability to the knee joint by providing restraint to excessive anterior tibial translation as well as frontal and transverse plane movements (Andersen and Dyhre-Poulsen, 1997). The ACL, in addition to its role in providing mechanical stability to the knee joint also plays an integral role in knee joint sensorimotor control and proprioception (Johansson et al., 1991). Thus, rupture of the ACL can negatively influence knee joint function (Bonfim et al., 2003).

The aim of ACL reconstruction surgery is to restore knee joint mechanical stability such that the athlete can return to sporting participation. However, full restoration of knee joint function following ACL reconstruction is often limited, and future complications such as the development of knee joint osteoarthritis (Chaudhari et al., 2008), future knee joint injury (Waldén et al., 2006) and re-rupture are of particular concern (Shelbourne et al., 2009).

Reports in the literature suggest that female athletes have a higher incidence of non-contact ACL injuries when compared to male athletes participating in the same sports (Agel et al., 2005, Waldén et al., 2011). A high proportion of ACL injuries in female athletes are non-contact in mechanism and occur during sporting activities such as twisting, cutting and single-leg landing (Olsen et al., 2004, Krosshaug et al., 2007). Specific biomechanical measures that have been reported to contribute to the ACL injury mechanism in female athletes include, an increased knee valgus angle, and decreased knee flexion range of motion (Myer et al., 2011). Furthermore, a recent model-based image-matching study by Koga et al. (2010) indicated that ACL injury is characterized by a low knee flexion angle during initial contact followed by a sudden increase in knee joint valgus angular displacement.

Traditionally the success of ACL reconstruction has been assessed in terms of the anterior tibial translation (Daniel et al., 1985, Jonsson et al., 1993) and rotational laxity (Musahl et al., 2007, Lorbach et al., 2009) present following reconstruction. These methods of assessment measure passive knee joint laxity and do not replicate the loading patterns experienced during dynamic functional activities. Recently numerous studies has examined knee joint biomechanics during various activities such as walking (Butler et al., 2009, Gao and Zheng, 2010) and pivoting tasks (Ristanis et al., 2005, Claes et al., 2011, Lam et al., 2011). Two more recent studies have examined knee joint function during hopping tasks (Gokeler et al., 2010, Deneweth et al., 2010). Landing from a jump places higher demands on the knee joint than walking and is considered to be more representative of those demands experienced in sporting situations (McNair and Marshall, 1994, Decker et al., 2002). The majority of the aforementioned studies have concentrated solely on knee joint biomechanics. There is an increasing awareness in the literature of the influence of proximal structures in the mechanism associated with ACL injury (Quatman et al., 2010, Hashemi et al., 2010). Thus, the aim of the present study was to investigate patterns of hip and knee joint angular displacement during a diagonal jump landing in a group of female athletes who had previously undergone ACL reconstruction. The primary hypothesis was that female athletes who had previously undergone ACL reconstruction, but who had since returned to full sporting participation would exhibit altered hip and knee joint kinematic profiles, when compared to an age, sex and activity matched control group.

Section snippets

Subjects

Thirteen recreational female athletes (age, 23.69 ± 3.11 years; height, 1.63 ± 0.05 m; body mass, 64.96 ± 9.01 kg; BMI, 24.23 ± 2.34 kg/m2) who had previously undergone ACL reconstruction for a non-contact ACL injury volunteered to participate. Seven of the athletes had surgical stabilization using a hamstring auto-graft, with the remaining athletes having had a bone-patellar tendon-bone auto-graft surgical procedure. The mean time from surgical stabilization to the present study was 4.4 years. At the time

Subjective knee questionnaires

ACL-R subjects differed significantly from the control subjects on the IKDC (P < 0.01), as well as on the KOOSpain (P < 0.05), KOOSsymptoms (P < 0.01), KOOSsport (P < 0.01), and KOOSKQoL (P < 0.01). The associated effects sizes were all large. There was no statistically significant difference between the ACL-R subjects and the control subjects on the KOOSADL (P > 0.05). These results are presented in Table 1.

Peak hip and knee joint kinematics

No between group differences were noted for peak hip joint adduction–abduction (P = 0.09), peak hip

Discussion

The primary aim of the present study was to investigate hip and knee joint kinematic profiles of ACL-R female athletes during performance of a diagonal jump landing. The main, hypothesis was that female athletes who have previously undergone ACL reconstruction surgery but who have since returned to full sporting participation (same sporting level as that participated in prior to injury) would display altered hip and knee joint kinematic profiles, when compared to a non-injured sex and activity

Eamonn Delahunt graduated with a 1st Class Honours Degree from the UCD School of Physiotherapy in 2003. Upon graduation Eamonn was the recipient of a prestigious IRCSET post-graduate research scholarship. He was awarded his PhD from the UCD School of Physiotherapy and Performance Science in 2006. Eamonn has been the recipient of numerous research bursaries for his research on chronic ankle instability and has published on this topic in all the leading Sports Medicine/Science journals. He

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      It is unclear whether landing patterns become more normal (i.e. greater between limb symmetry or equivalent to control participants without ACL injury or reconstruction surgery) with time as strength and neuromuscular control are normalized, or instead become more abnormal with continued exposure to sporting activities that stress the knee joint. From the limited evidence available it would seem that abnormal landing biomechanics may persist over an extended period of time (Delahunt et al., 2012; Hébert-Losier, Schelin, Tengman, Strong, & Häger, 2018; Paterno, Ford, Myer, Heyl, & Hewett, 2007; Tengman, Grip, Stensdotter, & Häger, 2015). At a two-year follow up limb asymmetries were seen on landing in female ACL-reconstructed patients (Paterno et al., 2007) and at a 4-year follow up both hip and knee kinematic alterations were seen in ACL-reconstructed patients compared to controls (Delahunt et al., 2012).

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      The current understanding of psychological factors is limited to its impact on recovery (Chmielewski et al., 2008; Morrey et al., 1999), self-reported function (Chmielewski et al., 2011; Hartigan et al., 2013), and return to sport rates (Ardern et al., 2013b, 2014a, 2014b; Kvist et al., 2005) Currently, it is not known if psychological factors are associated with landing biomechanics in athletes with ACLR. Altered sagittal and frontal plane biomechanical and neuromuscular control at the hip and knee are persistent in athletes following ACLR (Delahunt et al., 2012a; Delahunt et al., 2012b; Paterno et al., 2010). Prospective biomechanical-epidemiological studies have reported that lower sagittal plane kinematics and greater frontal plane kinematics at the hip and knee during a jump-landing task off of a 31 cm tall box are associated with a greater risk of primary and secondary ACL injury (Hewett et al., 2005; Paterno et al., 2010).

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      Such a consensus would be beneficial for the monitoring of an indiviudal's knee status and also to perform analysis over large groups to gain better evaluation of different treatment and rehabilitation protocols. The limited number of studies that have employed detailed kinematic analysis of more complex and demanding tasks such as hops and jumps and sport-like maneuvers, have mostly been conducted in the shorter terms of 6 months to 4 years following ACL treatment (e.g. Delahunt et al., 2012; Gokeler et al., 2010). A few studies have carried out kinematic analysis of more strenuous activities of long-term ACL-injured populations (Markström et al., 2017; Ortiz et al., 2008; Tengman et al., 2015; von Porat et al., 2004).

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    Eamonn Delahunt graduated with a 1st Class Honours Degree from the UCD School of Physiotherapy in 2003. Upon graduation Eamonn was the recipient of a prestigious IRCSET post-graduate research scholarship. He was awarded his PhD from the UCD School of Physiotherapy and Performance Science in 2006. Eamonn has been the recipient of numerous research bursaries for his research on chronic ankle instability and has published on this topic in all the leading Sports Medicine/Science journals. He currently works as a college lecturer in the UCD School of Public Health, Physiotherapy and Population Science, and acts as the Programme Co-ordinator for the B.Sc. Health and Performance Science Degree Programme. Eamonn also has extensive clinical experience having previously worked as a Chartered Physiotherapist in ExWell Medical. Eamonn also currently works as the Academic Mentor to the UCD Elite Athlete Academy.

    Anna Prendiville was a final year under-graduate student at the time of completion of the current paper. She graduated in September 2011, obtaining a 2H1 degree classification in the B.Sc. Health & Performance Science programme, University College Dublin. Anna has previously published papers relating to lower limb kinematics following anterior cruciate ligament surgery. Anna was part of a research group who were the recipient of the award for best poster presentation at the 8th Annual Scientific Conference of the FSEM, RCPI & RCSI.

    Lauren Sweeney was a final year under-graduate student at the time of completion of the current paper. She graduated in September 2011, obtaining a B.Sc. Health & Performance Science from University College Dublin. Lauren has previously published papers relating to lower limb kinematics following anterior cruciate ligament surgery. She was part of a research group who were the recipient of the award for best poster presentation at the 8th Annual Scientific Conference of the FSEM, RCPI & RCSI.

    Mark Chawke graduated from University College Dublin B.Sc. Health & Performance Science programme in 2011. At the time of completion of the current research project he was an under-graduate student. Since graduation he has continued his involvement in lower limb biomechanical research with a particular emphasis on anterior cruciate ligament injury epidemiology and prevention. Mark was part of a research group who were the recipient of the award for best poster presentation at the 8th Annual Scientific Conference of the FSEM, RCPI & RCSI.

    Judy Kelleher was a final year under-graduate student at the time of completion of the current paper. She graduated in September 2011, obtaining a 2H1 degree classification in the B.Sc. Health & Performance Science programme, University College Dublin. At the time of completion of the current research project she was an under-graduate student. Judy was part of a research group who were the recipient of the award for best poster presentation at the 8th Annual Scientific Conference of the FSEM, RCPI & RCSI.

    Matt Patterson attained a B.Sc. in Kinesiology from the University of Waterloo in 2003. After graduation Matt spent several years in industry, designing motion analysis tools based on inertial sensor technology. This technology was used by top professional sports teams in North America. In 2009, based on his in-depth knowledge of human movement and signal processing Matt was the recipient of a prestigious SFI-CLARITY graduate research scholarship to work on a Ph.D. at University College Dublin. He currently is in the final year of his PhD.

    Katie Murphy was a final year under-graduate student at the time of completion of the current paper. She graduated in September 2011, obtaining a 2H1 degree classification in the B.Sc. Health & Performance Science programme, University College Dublin. At the time of completion of the current research project she was an under-graduate student. Katie was part of a research group who were the recipient of the award for best poster presentation at the 8th Annual Scientific Conference of the FSEM, RCPI & RCSI. Katie is current enrolled as an under-graduate physiotherapy student at University College Dublin.

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