Paediatric ACL Injuries

Introduction

[1]

Anterior cruciate ligament (ACL) injuries in children have increased over the past few years. [2][3] This is of great concern to clinicians who see and treat these patients. Various questions arise when confronted with a pediatric ACL injury, such as: Is the child mature with an ACL injury? Is it the same as its uninjured peers? [4] Should they continue playing sports or focus on their education and other interests? [4] Will an ACL rupture change the lives of these children? [4] Children with ACL injuries face challenges with a range of issues, such as having to deal with their knee problems for the rest of their lives, which in turn may compromise their quality of life. [4] Furthermore, this may increase their risk of further injury as well as meniscal tears and early-onset osteoarthritis. [5] In addition to all of these issues, there is limited high-quality evidence available for guidance Decision making in the treatment of pediatric ACL injuries. [6]

Children are a vulnerable population, and clinicians who engage with this population have a responsibility to provide accurate information and effective treatment. Long-term outcomes after childhood ACL injury remain uncertain, evidence-based research needed to help And increase confidence in clinical decision-making. [4] It is important to note that long-term outcomes after ACL injury in children, including the development of osteoarthritis, have not been studied. [4]

Therefore, managing these types of childhood injuries is challenging within the current range of clinical uncertainty and limited evidence-based scientific knowledge. Other compounding factors are the complexities involved in shared decision-making with children and the potential long-term and This injury has life changing effects. [4]

Prevention of Paediatric ACL Injuries

Anterior cruciate ligament (ACL) injuries in childhood have serious potential long-term consequences [4] and increase the risk of re-injury to both knees. [7] Therefore, it is imperative to prevent ACL injuries in children and incorporate injury prevention principles into Treating children with ACL injuries. [4]

Research shows that great progress has been made in the development and application of ACL injury prevention programs, especially in rotational sports such as football. [8] Reduce the number of athletes with primary ACL injuries and reduce the number of athletes with de novo ACL injuries Return to sport after reporting a primary ACL injury. [9] [10]

One modifiable risk factor for injury is the athlete’s biomechanical movement pattern [4]. These biomechanical movement patterns are the targets of specific injury prevention programs (IPPs). These injury prevention programs are designed to combine strength training plyometrics with specific sports Agility training. [11] Another key component of the program is coach and athlete education specifically focused on cutting and landing techniques (eg, wide foot position on a cut or bent knees on landing). These specific approaches avoid high-risk knee positions and are fundamental to achieving goals to prevent ACL injuries in children.

Advantages of Injury Prevention Programs

• straightforward to implement[4]
• require little or no equipment[4]
• Can be taken as part of regular team training or 2-3 times per week in PE class [4]

It is recommended that children be introduced to injury prevention programs early or during development. This provides the child with the best opportunity to develop and maintain strong and beneficial motor strategies. [4]

FIFA+ is an injury prevention program that reduces football-related lower body injuries by more than 50%. [12][13][14] Children who participated in and completed these programs showed better motor control as well as balance and agility compared to children who did not complete these programs program. [14]

Although these injury prevention programs have had successful outcomes, such as reductions in injury rates and time lost due to injury [12][15], their effectiveness may be affected by how often athletes train. [16][17] For these injury prevention programs to be successful, consistent Implement, exploit and comply at all levels of competitive play. [4] These factors represent the greatest challenges for clinicians. Equally important, injury is strongly advocated by clinicians involved in youth sports and pediatric athletes treating ACL injuries A preventive approach in all settings. [4]

Diagnosis of Paediatric ACL Injuries

As mentioned earlier, an injury prevention program is the first line of defense against the possible effects of an ACL injury. If these preventive strategies fail, a timely and accurate diagnosis must be made. [4] Accurate diagnosis is the starting point of effective management planning and shared decision-making. [4] Clinicians draw on their specific skills and glean knowledge from:

• patient history
• examination
• clinical tests
• imaging

With this combined information, clinicians can construct a clear clinical picture that enables diagnosis and assists in treatment planning. [4]

Clinical Pearls to Consider When Diagnosing Pediatric ACL Injuries

1. Hemarthrosis (acute swelling of the knee within 24 hours of trauma due to intra-articular bleeding) after acute knee injury suggests structural damage to the knee. [4]
2. Diagnosis is more challenging in children as they may be poor historians with greater physiologic joint laxity (check both knees!) and MRI interpretation is difficult due to developmental variability in children. [18]
3. Children’s skeletal immaturity predisposes them to knee injuries that differ from adults (eg, sleeve fractures in which the patellar epiphysis dissolves). [4]

Imaging

Key points with regards to imaging

• Consider initiating evaluation with knee radiographs in all pediatric patients with hemarthrosis or suspected structural knee injury
  • Tibial eminence fractures and ACL tears may have similar history and clinical findings
  • It is crucial to rule out any other possible pediatric fractures, such as patellar sleeve or epiphyseal fractures
• MRI may be performed to confirm the diagnosis of ACL injury and to evaluate other soft tissue structures [19]
• MRI may show other associated injuries, such as meniscal tears, osteochondral damage, and other ligamentous injuries
  • In pediatric patients with locked knee, MRI is required to evaluate for the possibility of a displaced bucket handle meniscus tear or osteochondral injury

Special tests

• Lachman test
• Anterior Drawer Test of the Knee
• Pivot shift test
• Slocum test
• Lateral Pivot Shift for Anterolateral Stability

Clinicians should be aware that no single problematic test or image will accurately identify an ACL injury every time. [4]

Management of Paediatric ACL Injuries

It is important for clinicians to be familiar with the treatment options available to children with ACL injuries. Options should be discussed with the child and the child’s parent/guardian to facilitate and enable a shared decision-making process on how to manage Knee hurt. [4]

Treatment goals

• Restoring a stable, well-functioning knee so you can live a healthy, active lifestyle throughout your lifespan
• Reduce existing impact and risk of further degenerative joint changes with meniscus or cartilage pathology and the need for future surgical intervention
• Minimizes the risk of growth arrest and deformities of the femur and tibia

Treatment options

• Only rely on high-quality rehabilitation (non-surgical treatment)
• ACL reconstruction plus quality rehabilitation

High-quality rehabilitation

Rehabilitation is critical to the management of ACL injuries. The principles of recovery are the same whether your child has had surgery or opted for non-surgical treatment. Whether adult principles apply to children remains uncertain. [20] Children are not little adults! [4] Therefore Rehabilitation exercises and functional goals should be modified rather than merely copied from adult-oriented rehabilitation programs. [4] Children cannot be expected to rehabilitate with perfect technique without supervision! A qualified experienced clinician should supervise Rehabilitation for children with ACL injuries. Additionally, recovery must work closely with the child’s parent/guardian. [4]

Rehabilitation focus

Dynamic multi-joint neuromuscular control is the most important area of focus. In younger patients with an open pelvis and less than 12 years of age, muscle strength development and hypertrophy are less important. Later during maturity and the onset of recovery during adolescence Protocols more akin to adult-oriented protocols are appropriate and can be implemented. These protocols can include heavier and external load strength training. [4]

• Rehabilitation must be thorough
• Rehabilitation must be individualized according to the child’s physical and psychological maturity
• Focus on exercises that promote dynamic lower body alignment
• Focus on biomechanical movement patterns
• Progression through Phases II and III of the Pediatric ACL Rehabilitation Program
• Be aware of re-injury anxiety and your child’s confidence in his/her injured knee
• Make sure to adjust your recovery plan accordingly after surgery
• Design a rehabilitation program that involves the child in his/her team training sessions to maintain the social benefits of being part of a team
• Parents or guardians should be actively involved in recovery on a daily basis

Rehabilitation phases

Ardern et al. [4] advocated that the rehabilitation of children with ACL injury be divided into four stages. Children undergoing surgery have an additional pre-rehabilitation phase. Most importantly, progress to The next stage of recovery. Children should avoid any cutting and spinning during free play and physical education during the first and second phases.

Recommended functional testing and return to sports criteria for ACL injuries in children and adolescents (from: 2018 International Olympic Committee Consensus Statement on the Prevention, Diagnosis and Treatment of Anterior Cruciate Ligament (ACL) Injuries in Children) [4] For patients who choose ACL Reconstruction pre-rehabilitation Full active extension and at least 120 degrees of active knee flexion Little or no effusion Ability to maintain distal knee extension during single-leg stance For adolescents: 90% of muscle strength tests Limb symmetry For patients choosing ACL reconstruction or non-surgical Treatment Phases I to II Full active knee extension and 120 degrees of active knee flexion Little to no effusion Ability to maintain terminal knee extension during single-leg stance Phases II to III Full knee range of motion 80% in single-leg hop test Limb symmetry and adequate landing Strategies Ability to jog for 10 minutes with good form and no subsequent effusion For adolescents: 80% limb symmetry in muscle strength test Stages III to IV: Sports participation (return to sport criteria) and sustained injury prevention Single-leg hop test : >90% of contralateral limbs (with Appropriate strategy and quality of movement) Gradually increase in the absence of pain and effusion Specific exercise training Confidence in knee function Knowing high-injury-risk knee positioning and the ability to maintain low-risk knee positioning during advanced sport-specific maneuvers mentally ready to return Exercise For Adolescents: 90% of Muscle Strength Testing Muscle strength testing for limb symmetry should be performed using isokinetic or hand-held dynamometer/rep max. The type of test and the experience of the tester will most likely affect the results. If using a handheld Dynamometric/1-rep max consider increasing the limb symmetry standard cutoff by 10% (i.e. 90% limb symmetry becomes 100% limb symmetry). Clinicians who do not have access to appropriate strength assessment equipment should consider referring patients elsewhere for strength assessment

Examples of exercises in each stage of children’s anterior cruciate ligament rehabilitation

PHASE I

Stationary bikeActive knee extension

SquatSingle leg balance

OTHER EXERCISE EXAMPLES FOR PHASE I:

• Quads setting
• Closed-chain hip and pelvic control exercises

PHASE II

Single leg squatLunge onto Bosu

Squat on BosuBridging

Other examples of Phase 2 exercises;

• Step-ups (front and lateral)
• Single-leg stance control of dynamic knee extension

PHASE III

Split squat with dumbbellsLeg press

OTHER EXERCISE SAMPLES FOR PHASE III;

• Stair jumps
• Hopping and landing
• Agility exercises
• Running direction change exercises

PHASE IV

• Injury prevention programs like FIFA 11+

Rehabilitation progression

Progression of functional milestones was similar whether the child was undergoing ACL reconstruction or opted for nonsurgical treatment. People have different expectations about progressing and returning to sport, though. A full return to sport depends on the child trying to Successfully meet return to sport criteria[21]

Guidelines for time to return to sport

• Non-surgical – treatment should last at least 3 – 6 months [22]
• Surgery – postoperative treatment should continue for at least 9 months [23]
  • Young athletes are at higher risk for a second ACL injury after ACL reconstruction, and the risk is highest during the first 12 months after surgery [23] Consider advising children not to return to any rotational sports for at least 12 months after ACL reconstruction[ 4]
• Use of the convalescent period to train the uninjured leg, also at the risk of contralateral injury [24]
• A detailed, sport-specific injury prevention program should be part of the routine once your child is back in sports.

Considerations when designing a rehabilitation program for young children [4]

• Avoid Boredom – Design a Home-Based Program Focused on Games and Various Exercises
• Choose wisely what test to use – tests like the single-leg hop and isokinetic strength test have large measurement errors in young children [25]
• Focus on quality of movement rather than symmetry in tests such as hops
• Be a responsible clinician – quality of motion tests still need to be validated – if not, make sure you have the skills and experience to use them… ref!
• Current return-to-sport criteria were designed and tested in skeletally mature athletes, but it remains uncertain whether the same criteria can be used in prepubertal children.

See also:

ACL Rehabilitation: A Rehabilitation Program

ACL Rehab: Re-Injury and Return to Athletic Testing

Outcome Measures

• Child Health Questionnaire
• PedsQL
• Paediatric PROMIS
• Pedi – IKDC
• KOOS – Child
• Pediatric Functional Activity Brief Scale

Ethical Considerations

The fundamental question is: what are the roles and responsibilities of the clinician? [4] Clinical decision-making involving children is difficult and challenged by limited scientific knowledge. [4] While it is impossible to provide a specific code of ethics that applies to all Sports Injuries in Children and Adolescents It cannot be denied that knee and related injuries are not in the best interest of all children. [4]

Injury prevention programs are key to managing the best interests of the child, and clinicians should support and encourage policies and practices that prioritize injury prevention. However, the clinician’s main concern should be to preserve the integrity of the knee joint at all times. decide how To achieve this, clinicians should share it with the child and the parent or guardian. [4] With parental consent, clinicians are required to act in the best interest of the child in the shared decision-making process. [4] Furthermore, it is important that clinicians always obtain consent [4] Regardless of the parent/guardian’s desire to communicate at a level commensurate with the child’s abilities the child should always be present in discussions about his or her respect for the child’s autonomy. [4] All parties should reach a consensus Decisions are made based on a realistic assessment of risks and benefits. It is the clinician’s responsibility to guide these discussions and provide accurate information obtained from the best quality research. [4]

Resources

2018 IOC Consensus Statement on the Prevention, Diagnosis and Management of Anterior Cruciate Ligament (ACL) Injuries in Children