http://elynsgroup.com
Copyright: © 2016 Avila ME, et al.
http://dx.doi.org/10.19104/jorm.2015.110
Journal of Orthopedics, Rheumatology and Sports Medicine
Research Article
Open Access
Behavior of Risk Factors for ACL Injury in Amateur Soccer Players
Eduardo M. Avila1, Jacqueline V. Castro2, Kelly Scaramussa2* and Joao L. Ellera Gomes2
Departament of Orthopedics and Traumatology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
2
Departament of Orthopedics and Traumatology, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
1
Received Date: April 06, 2016, Accepted Date: May 10, 2016, Published Date: May 20, 2016.
*Corresponding author: Kelly Scaramussa, Departament of Orthopedics and Traumatology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil,
Tel: 114-156-091-617; E-mail: [email protected]
Abstract
Background: An anterior Cruciate Ligament (ACL) tear is a very
common injury, especially in individuals who participate in pivoting
sports like soccer. Many factors that contribute to the risk of anterior
cruciate ligament injuries have been investigated, but there is no
consensus among them yet.
Purpose: The goal of this study was to note the behavior of femoral
intercondylar notch, posterior tibial slope and hip rotation range of
motion in male patients with ACL noncontact injury, suffered while
practicing soccer.
Materials and Methods: We recruited 66 male patients aged 18 to
35 who had suffered noncontact ACL injuries while playing soccer. They
were assessed for intercondylar Notch Width Index (NWI), posteriorinferior tibial slope, and internal and external Hip Rotation Range of
Motion (HROM).
Results: Mean NWI was 0.281(0.033), mean slope was 8.85° (2.26)
and the mean sum HROM was 64.8° (10.87). 13.6% of the patients had
NWI 0.25, 31.8% had a 10° slope and 60.6% had HROM below 60°.
Conclusion: The results of this study may suggest an association
between decreased hip rotation range of motion with the noncontact ACL
injury. Otherwise, there is no association between both intercondylar
notch width and posterior tibial slope with this kind of injury.
Keywords: ACL Injury; Intercondylar Notch; Posterior Tibial Slope;
Soccer Players
Introduction
de Clínicas of Porto Alegre for this cross-sectional study. All participants
signed an informed consent form in accordance with ethical standards
in sports and exercise science research [24].
Inclusion criteria were male sex, self-reported habit of playing soccer
at least twice a week, age from 18 to 35, noncontact ACL injury history
suffered while playing soccer and no more than two years between the
injury itself and the assessment. Patients were excluded from the study
if they had any other sort of lower limb orthopedic pathology, including
a previous ACL injury.
To avoid interference in the results from a possible degenerative
joint disorder caused by aging process, data leakage and elapsed time
since surgery were both controlled. No control group was used in this
study because we focused on searching the most prevalent factors
capable of contributing to the event in patients who already suffered the
ACL injury.
The assessment of intercondylar notch width and tibial slope
posterior was performed by X-ray image. For each patient, X-ray was
taken of both knees in standing AP view, lateral view and intercondylar
notch view at 45 degrees of flexion. An independent qualified assessor
evaluated images.
The intercondylar notch was assessed using the intercondylar Notch
Width Index (NWI), which is obtained by dividing the intercondylar
notch width by the width of the condyles (Figure 1) [15]. The posterior
tibial slope was assessed on the lateral X-ray by drawing two lines: the
first one indicating the longitudinal axis of the tibia and the other line
taking a tangent from the mid-tibial plateau (Figure 2) [16,25]. Besides
ACL is a very common injury [1,2]. It is estimated that more than
80,000 individuals face this injury annually only in United States [1-3].
The highest incidence occurs in individuals who participate in pivoting
sports like soccer [1,3,4]. Often more males than females sustain this
injury because of the greater absolute number of male participants in
sports activities [2]. With an estimated cost for these injuries of almost
a billion dollars per year, the ability to identify risk factors and develop
prevention strategies has widespread health and fiscal importance [1-5].
Many risk factors of an ACL injury have been investigated, but
there is no a consensus yet. Some of the most highlighted anatomic
risk factors [1,3,6] mentioned are intercondylar notch width [7-16] and
posterior tibial slope angle [6,16-18], since that most of the ACL injuries
came from noncontact situations [1-5]. Recent studies have shown that
hip rotation range of motion also plays an important role in noncontact
ACL injuries in soccer players [19-23].
The goal of this study was to note the behavior of femoral
intercondylar notch, posterior tibial slope and hip rotation range of
motion in male amateur soccer players with noncontact ACL injury.
Materials and Methods
We recruited patients, who underwent ACL reconstruction surgery,
in the Knee Surgery Unit at the Department of Orthopedics of Hospital
J Orth Rhe Sp Med
Figure 1: Measurements for calculating the NWI (26/83 = 0.313).
ISSN: 2470-9824
Page 1 of 4
ISSN: 2470-9824
J Orth Rhe Sp Med
Vol. 1. Issue. 2. 35000110
were no statistically significant correlations between NWI, slope,
HROM and age.
Discussion
ACL injuries clearly came from a different number of etiologies
[1,3-5]. The role of environmental factors has been well established,
particularly those that interfere with the degree of the foot adherence to
the ground. Preventive measures are already in place in many different
sports [2,19]. Several variables like hormonal, neuromuscular and
anatomic factors have also been studied and all of them predispose to
ACL injuries in some way [3,13,19]. Many of these risk factors have
been studied to prevent sequels, like the osteoarthritis, because of their
high cost of treatment as well as physical and psychological suffering of
patients [1,3,4,19].
Figure 2: Measurement of the posterior tibial slope.
the knee analysis, the internal and external hip rotation range of motion
of both hips were clinically measured using a goniometer and recorded
in degrees, with the aid of an assistant (who supported the lower limb
evaluated).
Patients were in a supine position with the knee and hip in 90°.
Internal and external hip rotation was measured from the neutral point
(zero degree) to the upper limit, when the pelvis started to moving it
20-22°. The average for the two hips was determined for each variable in
order to minimize the effects of any measurement errors.
Statistical methods
Continuous variables were expressed as mean and standard
deviation. Categorical variables were expressed as absolute and relative
frequencies. Pearson’s or Spearman’s rank correlation coefficients was
used to test the correlation between continuous or ordinal variables.
The significance level was set at 5% (p ≤ 0.05). All data were analyzed
in the software SPSS (Statistical Package for the Social Sciences – IBM
Software- Armonk-NY/USA) version 19.0.
Results
Sixty-six patients were enrolled on the study. Mean age was 28.4
(4.36) years old. Mean NWI was 0.281 (0.033). Nine patients (13.6%)
had NWI ≤ 0.25 and none of the participants had NWI < 0.2 (Table 1).
Mean posterior tibial slope was 8.85° (2.26) and 21 of the patients
(31.8%) had slopes greater than or equal to 10°. Mean sum of hip
rotations (HROM) was 64.8° (10.87). Forty patients (60.6%) had sum of
the mean hip rotations less than 60°.
Table 1 lists descriptive statistics for these parameters. There
Variable
Age (years)
NWI
Tibial Slope (Degrees)
IR Hip ROM (Degrees)
ER Hip ROM (Degrees)
HROM (Degrees)
Descriptive statistics (n = 66)
28.4 ± 4.36
0.281 ± 0.03
8.85 ± 2.26
22.66 ± 5.57
42.14 ± 5.30
64.8 ± 10.87
Table 1: Descriptive statistics for parameters investigated.
The intercondylar notch stenosis could be a non-modifiable
anatomic factor [8-10]. Some studies have associated this variable with
noncontact ACL injuries [8-10], but there is no consensus about this
correlation [7-15]. Intercondylar notch width might be associated with
race and sex too [26,27]. African Americans, on average, have wider
mean intercondylar notch widths than their white counter parts, as well
as men when compared with women. This could explain the higher
prevalence of ACL injury in whites and women [26,27].
In addition, there are other variables that must be taken into
consideration about intercondylar notch width. Some studies have used
computerized tomography, others magnetic resonance imaging and
some have relied only on simple X-rays [9,13], but the measurement
results may vary considerably [7,9,12]. Hoteya, etal. [12], used X-rays
and two different coronal magnetic resonance imaging slices to compare
patients with bilateral ACL injuries, unilateral damages and people with
no previously ACL injury. All three measurement methods results
diverged and there was association only between bilateral injured and
no injured groups. These authors suggested a cutoff point of 0.25 for
magnetic resonance imaging measured NWI [12].
This considerable variation between studies may be due to
variations in the X-ray angle and the measurement technique. Even
when measured in millimeters, this assessment may lead to very
different results, with consequent misinterpretation [7]. In other words,
the difference between a patient with stenosis of the intercondylar notch
and patient without stenosis is only about few millimeters, and errors
can occur due to factors that are beyond the control of the examiner,
such as X-ray angle and quality material.
The use of computerized tomography could be a possible way to fix
these problems. This resource could indeed minimize the often-visual
variance interpretation of X-rays and those measuring angles and linear
distances related issues. On the other hand, this solution would require
a standardized image acquisition and measurements and it imposes a
significantly higher cost, which is very undesirable when the objective is
prevention and detection of risk factors.
In common with the intercondylar notch, the posterior tibial slope
is an anatomic factor associated with noncontact ACL injuries [6,1618,25]. It seems to be acceptable that an increase in the posterior tibial
slope would increase anterior tibial translation when subjected to an
axial load, thereby increasing tension on the ACL [17]. In the same
way, there is a huge number of papers that link a slope angle rise with
ACL injury, but there is also a similar number of papers that denied
this association [16,17,25]. In our study, the results point out a very
weak association between injury of the ACL and changes in tibial slope.
One-Third of our sample has shown a posterior tibial slope equal or
greater than 10°. It seemed that both the intercondylar notch width and
posterior tibial slope were variables that are difficult to be measured,
standardized and subject to many errors and this may restrict their
reproduction.
Citation: Avila EM, Castro JV, Scaramussa K, Gomes JL (2016) Behavior of Risk Factors for ACL Injury in Amateur Soccer
Players. J Orth Rhe Sp Med 1(2): 110 http://dx.doi.org/10.19104/jorm.2015.110.
Page 2 of 4
J Orth Rhe Sp Med
ISSN: 2470-9824
The influence of sports activities in hip mobility and the incidence
of hip osteoarthritis in sports players over time have been studied by
many authors [28-31]. Even though some authors have not observed the
association of certain sporting activities with the decreased hip rotation
range of motion [31], some studies showed lower IR (Internal Rotation)
in senior soccer players than both controls and younger soccer players.
These results may suggest that playing soccer could influence the
decrease of hip IR and it could be observed early [29]. The limited hip
rotation could result in increased rotational stress on the knee, there by
contributing to ACL rupture [20,21]. This hip mobility decrease could
be consequence of structural changes [22]. It was observed that many
patients with hip mobility restrictions and ACL injuries had abnormal
findings when their hips were X-rayed [22], and some recent papers
have confirmed those findings [19,20,23,32].
The hip range rotation mean in non-soccer players could vary
according to some studies. We can find values of ER (External Rotation)
from 43° to 45° and IR means from 43 to 45.5° in senior and young
control groups respectively [29] or even values between 68 and 80° in
the sum of rotations [33]. The current sample shows that three in each
five patients had the sum of the average of the hip rotation below 60°.
This variable had a higher prevalence than other investigated factors in
our study.
Although the age range of the recruited patients was relatively
narrow, there was no correlation between age and HROM, suggesting
that mobility does not reduce with age, in opposite of previous studies
[20,29]. Furthermore, it seems that there was an association between
ACL injury and hip rotation restriction in soccer players. If this reduced
mobility is a consequence of soccer practice, perhaps prevention
programs, including stretching exercises and hip mobility exercises
could prevent or delay this outcome, but we did not find a specific
exercise program for this disorder [20]. Nevertheless, if someone already
has a hip rotational restriction when starting to play soccer, maybe the
most appropriate strategy could be counseling and perhaps reconsider
the choice of the sport in order to avoid ACL injury.
Hip rotational restrictions could be easily detected with a simple
physical assessment, and this seemed to be the most associated variable
with ACL injury in our sample, if compared with other variables
investigated. On the other hand, intercondylar notch width and the
posterior tibial slope angle showed a poor association with this injury.
Those last two anatomic factors require a complex measuring system
and they also show reproducibility problems that make them harder to
apply in clinical practice.
The small number of our sample, with no control group limits this
cross-sectional study. In order to confirm the results and answer many
questions that remain, a prospective study is needed, investigating
multiple potential risk factors.
Conclusions
The findings of this study showed that intercondylar notch width
and posterior tibial slope might not be the most indicated tools to
predict the risk for ACL injuries, perhaps because of the lack of the
reproducible pattern of exam.
However, results of this study suggest that hip rotation decreased
could be associated with noncontact ACL injury. Furthermore, the
clinical measurement of hip range of motion seemed to be the easier
assessment to search for risk factors of this injury than the other ones.
Future researches could focus on variables like race and sex to predict
the risk of ACL tears, especially because this is a multifactorial injury.
References
1. Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D, Lázaro-Haro
C, et al. Prevention of non-contact anterior cruciate ligament injuries
Vol. 1. Issue. 2. 35000110
in soccer players. Part 1: Mechanisms of injury and underlying risk
factors. Knee Surg Sports Traumatol Arthrosc. 2009;17(7):705-29. doi:
10.1007/s00167-009-0813-1.
2. Beaulieu ML, Oh YK, Bedi A, Ashton-Miller JA, Wojtys EM. Does limited
internal femoral rotation increase peak anterior cruciate ligament strain
during a simulated pivot landing? Am J Sports Med. 2014;42(12):295563. doi: 10.1177/0363546514549446.
3. Griffin LY, Albohm MJ, Arendt EA, Bahr R, Beynnon BD, Demaio M, et al.
Understanding and preventing noncontact anterior cruciate ligament
injuries: a review of the Hunt Valley II Meeting, January 2005. Am J
Sports Med. 2006;34(9):1512-32.
4. Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, et
al. Noncontact anterior cruciate ligament injuries: risk factors and
prevention strategies. J Am Acad Orthop Surg. 2000;8(3):141-50.
5. Uhorchak JM, Scoville CR, Williams GN, Arciero RA, St Pierre P, Taylor DC.
Risk factors associated with noncontact injury of the anterior cruciate
ligament: a prospective four-year evaluation of 859 West Point cadets.
Am J Sports Med. 2003;31(6):831-42.
6. Terauchi M, Hatayama K, Yanagisawa S, Saito K, Takagishi K. Sagittal
alignment of the knee and its relationship to noncontact anterior
cruciate ligament injuries. Am J Sports Med. 2011;39(5):1090-4. doi:
10.1177/0363546510393305.
7. Anderson AF, Anderson CN, Gorman TM, Cross MB, Spindler KP.
Radiographic measurements of the intercondylar notch: are they
accurate? Arthroscopy. 2007;23(3):261-8, 268.e1-2.
8. Anderson AF, Dome DC, Gautam S, Awh MH, Rennirt GW. Correlation of
anthropometric measurements, strength, anterior cruciate ligament size,
and intercondylar notch characteristics to sex differences in anterior
cruciate ligament tear rates. Am J Sports Med. 2001;29(1):58-66.
9. Anderson AF, Lipscomb AB, Liudahl KJ, Addlestone RB. Analysis of
the intercondylar notch by computed tomography. Am J Sports Med.
1987;15(6):547-52.
10.Arendt EA. Relationship between notch width index and risk of noncontact ACL injury. In: Griffin LY, ed. Prevention of noncontact ACL
injuries. Rosemont: American Academy of Orthopaedic Surgeons; 2001.
p. 33-44.
11.Chandrashekar N, Slauterbeck J, Hashemi J. Sex-based differences in the
anthropometric characteristics of the anterior cruciate ligament and its
relation to intercondylar notch geometry: a cadaveric study. Am J Sports
Med. 2005;33(10):1492-8.
12.Hoteya K, Kato Y, Motojima S, Ingham SJ, Horaguchi T, Saito A, et al.
Association between intercondylar notch narrowing and bilateral
anterior cruciate ligament injuries in athletes. Arch Orthop Trauma Surg.
2011;131(3):371-6. doi: 10.1007/s00402-010-1254-5.
13.Schickendantz MS, Weiker GG. The predictive value of radiographs in the
evaluation of unilateral and bilateral anterior cruciate ligament injuries.
Am J Sports Med. 1993;21(1):110-3.
14.Shelbourne KD, Kerr B. The relationship of femoral intercondylar
notch width to height, and sex in patients with intact anterior cruciate
ligaments. Am J Knee Surg. 2001;14(2):92-6.
15.Souryal TO, Moore HA, Evans JP. Bilaterality inanterior cruciate ligament
injuries: associated inter condylar notch stenosis. Am J Sports Med.
1988;16(5):449-54.
16.Todd MS, Lalliss S, Garcia E, DeBerardino TM, Cameron KL. The relationship
between posterior tibial slope and anterior cruciate ligament injuries.
Am J Sports Med. 2010;38(1):63-7. doi: 10.1177/0363546509343198.
17.Brandon ML, Haynes PT, Bonamo JR, Flynn MI, Barrett GR, Sherman MF.
The association between posterior-inferior tibial slope and anterior
cruciate ligament insufficiency. Arthroscopy. 2006;22(8):894-9.
18.Hohmann E, Bryant A, Reaburn P, Tetsworth K. Does posterior tibial slope
influence knee functionality in the anterior cruciate ligament-deficient
and anterior cruciate ligament-reconstructed knee? Arthroscopy.
2010;26(11):1496-502. doi: 10.1016/j.arthro.2010.02.024.
Citation: Avila EM, Castro JV, Scaramussa K, Gomes JL (2016) Behavior of Risk Factors for ACL Injury in Amateur Soccer
Players. J Orth Rhe Sp Med 1(2): 110 http://dx.doi.org/10.19104/jorm.2015.110.
Page 3 of 4
J Orth Rhe Sp Med
ISSN: 2470-9824
Vol. 1. Issue. 2. 35000110
19.Alentorn-Geli E, Mendiguchía J, Samuelsson K, Musahl V, Karlsson J, Cugat
R, et al. Prevention of anterior cruciate ligament injuries in sports—Part
I: Systematic review of risk factors in male athletes. Knee Surg Sports
Traumatol Arthrosc. 2014;22(1):3-15. doi: 10.1007/s00167-013-2725-3.
27.Shelbourne KD, Gray T, Benner RW. Intercondylar notch width
measurement differences between African American and white men and
women with intact anterior cruciate ligament knees. Am J Sports Med.
2007;35(8):1304-7.
21.Gomes JL, de Castro JV, Becker R. Decreased hip range of motion and
noncontact injuries of the anterior cruciate ligament. Arthroscopy.
2008;24(9):1034-7. doi: 10.1016/j.arthro.2008.05.012.
29.Manning C, Hudson Z. Comparison of hip range of motion in professional
youth and senior team footballers with age-matched control: an
indication of early degenerative change. Phys Ther Sport. 2009;10(1):259. doi: 10.1016/j.ptsp.2008.11.005.
20.de Castro JV, Machado KC, Scaramussa K, Gomes JL. Incidence of
decreased hip range of motion in youth soccer players and response
to a stretching program: a randomized clinical trial. J Sport Rehabil.
2013;22(2):100-7.
22.Ellera Gomes JL, Palma HM, Becker R. Radiographic findings in restrained
hip joints associated with ACL rupture. Knee Surg Sports Traumatol
Arthrosc. 2010;18(11):1562-7. doi: 10.1007/s00167-010-1175-4.
23.Philippon M, Dewing C, Briggs K, Steadman JR. Steadman R. Decreased
femoral head–neck offset: a possible risk factor for ACL injury. Knee Surg
Sports Traumatol Arthrosc. 2012;20(12):2585-9. doi: 10.1007/s00167012-1881-1.
24.Harriss DJ, Atkinson G. Ethical standards in sports and exercise science
research: 2014. Int J Sports Med. 2013;34(12):1025-8. doi: 10.1055/s0033-1358756.
25.Kostogiannis I, Swärd P, Neuman P, Fridén T, Roos H. The influence of
posterior- inferior tibial slope in ACL injury. Knee Surg Sports Traumatol
Arthrosc. 2011;19(4):592-7. doi: 10.1007/s00167-010-1295-x.
26.Trojian TH, Collins S. The anterior cruciate ligament tear rate varies
by race in professional Women’s basketball. Am J Sports Med.
2006;34(6):895-8.
28.Drawer S, Fuller CW. Propensity for osteoarthritis and lower limb
joint pain in retired professional soccer players. Br J Sports Med.
2001;35(6):402-8.
30.Verrall GM, Slavotinek JP, Barnes PG, Esterman A, Oakeshott RD, Spriggins
AJ. Hip joint range of motion restriction precedes athletic chronic groin
injury. J Sci Med Sport. 2007;10(6):463-6.
31.Kettunen JA, Kujala UM, Räty H, Videman T, Sarna S, Impivaara O, et al.
Factors associated with hip joint rotation in former elite athletes. Br J
Sports Med. 2000;34(1):44-8.
32.Tainaka K, Takizawa T, Kobayashi H, Umimura M. Limited hip rotation
and non-contact anterior cruciate ligament injury: a case-control study.
Knee. 2014;21(1):86-90. doi: 10.1016/j.knee.2013.07.006.
33.Li X, Ma R, Zhou H, Thompson M, Dawson C, Nguyen J, et al. Evaluation
of Hip Internal and External Rotation Range of Motion as an Injury
Risk Factor for Hip, Abdominal and Groin Injuries in Professional
Baseball Players. Orthop Rev (Pavia). 2015;7(4):6142. doi: 10.4081/
or.2015.6142.
*Corresponding author: Kelly Scaramussa, Departament of Orthopedics and Traumatology, Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil, Tel: 114-156-091-617; E-mail: [email protected]
Received Date: April 06, 2016, Accepted Date: May 10, 2016, Published Date: May 20, 2016.
Copyright: © 2016 Avila ME, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: Avila EM, Castro JV, Scaramussa K, Gomes JL (2016) Behavior of Risk Factors for ACL Injury in Amateur Soccer Players. J Orth Rhe Sp Med 1(2): 110
http://dx.doi.org/10.19104/jorm.2015.110.
Elyns Publishing Group
Explore and Expand
Citation: Avila EM, Castro JV, Scaramussa K, Gomes JL (2016) Behavior of Risk Factors for ACL Injury in Amateur Soccer
Players. J Orth Rhe Sp Med 1(2): 110 http://dx.doi.org/10.19104/jorm.2015.110.
Page 4 of 4