ArticleLiterature Review

[The anterior cruciate ligament, an important structure of the knee joint]

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The anterior cruciate ligament (ACL) is a crucial structure for a normal kinematic of the knee joint. Its rupture has been thought to present the initiation of a sequel leading to secondary damage of the meniscus and finally to osteoarthritis. Diagnosis of an ACL rupture is based on the history as well as on the physical examination. A positive Lachman-sign is diagnostic for an ACL lesion. The question whether an ACL rupture should be operated or not must be decided individually and is based on the demands of the patient. Conservative treatment includes rigorous physical therapy emphasizing strengthening exercises of the hamstrings and the gastrocnemius muscles as well as prorioceptive training. The indication for reconstruction is given, should instability persist. The timing of the operation is important for the outcome. This paper presents an overview of the literature including the rehabilitation program and a diagnostic concept used by the authors.

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... Risk of bias of half (19 studies, 50.0%) of the included studies was medium [13,[33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50], six (15.8%) showed high methodological quality [51][52][53][54][55][56] and 13 studies (34.2%) were of low quality [57][58][59][60][61][62][63][64][65][66][67][68][69] (Table 2). The main reasons for a medium to low methodological quality were due to an unclear description of participants and prior interventions, confounding factors, and incompletely reported results. ...
... Some authors restricted study participation to either males [33, 34, 36, 39, 44-46, 50, 58, 60, 67] or females [50, 51, 64-66, 68, 69], others measured females and males [13, 35, 37, 40, 41, 47-49, 52, 54-57, 59, 61, 62]. Three studies did not provide any data about the gender of their participants [42,53,63]. More patient characteristics of included studies can be found in Table 3. ...
... The tasks used were very diverse: there were activities of daily life such as walking on even ground and downhill [33,47,53,57,58,62,63,68], and stair climbing [13,49]. Other activities went more towards sports such as running [44,45,60,67,68] and jumping [36, 37, 39-42, 48, 50-52, 54-56, 59, 61, 65, 66, 68] where mainly the singleleg hop for distance, drop jumps and countermovement jumps were used. ...
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Background Adequate neuromuscular control of the knee could be one element to prevent secondary injuries after an anterior cruciate ligament (ACL) injury. To assess neuromuscular control in terms of time, amplitude and activity, electromyography (EMG) is used. However, it is unclear which assessments using EMG could be used for a safe return to sports (RTS). Therefore, we aimed to summarize EMG-related assessments for neuromuscular control of the knee in adult patients after an ACL injury to decide upon readiness for RTS. Methods This systematic review followed guidelines of Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane recommendations. MEDLINE/PubMed, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database (PEDro), SPORTDiscus and the Web of Science were searched from inception to March 2019 and updated in November 2020. Studies identifying electromyographic assessments for neuromuscular control during dynamic tasks in adult, physically active patients with an anterior cruciate ligament injury were eligible and qualitatively synthesized. Two independent reviewers used a modified Downs and Black checklist to assess risk of bias of included studies. Results From initially 1388 hits, 38 mainly cross-sectional, case-controlled studies were included for qualitative analysis. Most studies provided EMG outcomes of thigh muscles during jumping, running or squatting. Outcomes measures described neuromuscular control of the knee in domains of time, amplitude or activity. Risk of bias was medium to high due to an unclear description of participants and prior interventions, confounding factors and incompletely reported results. Conclusions Despite a wide range of EMG outcome measures for neuromuscular control, none was used to decide upon return to sports in these patients. Additional studies are needed to define readiness towards RTS by assessing neuromuscular control in adult ACL patients with EMG. Further research should aim at finding reliable and valid, EMG-related variables to be used as diagnostic tool for neuromuscular control. Moreover, future studies should aim at more homogenous groups including adequately matched healthy subjects, evaluate gender separately and use sport-specific tasks. Registration The protocol for this systematic review was indexed beforehand in the International Prospective Register of Systematic Reviews (PROSPERO) and registered as CRD42019122188.
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