Anterior cruciate ligament (ACL) rupture is a common injury [16]. However,
subjects reduced their activity levels on average by 21% following injury.
Injury to ACL results in mechanical and functional instability [17]. ACL is
a critical component of the knee joint. ACL injury can lead to an impairment
of postural control during upright stance in both double- and single-leg
stance and on either the injured or uninjured-leg [18].
It has been theorized that when ACL is torn, kinesthesia of the knee joint
will be decreased [19]. It may contribute to disability and result in
progressive degeneration of the knee and balance deficits when receptors are
damaged or destroyed [20]. Rupture of ACL results in increased tibio-femoral
laxity in the knee, thereby ultimately resulting in knee instability and
dysfunction [21]. Loss of neurophysiologic function in an ACL deficient of
knee leads to deterioration in postural control and irregularities in
neuromuscular coordination [22].
In the present study, incidence of non-contact ACL injury was 70% of our
cases. There was a significantly increase of means (± SD) of COG sway
velocity on left or right leg standing with eyes open and eye closed in ACL
tear group as compared to control group (p<0.05). Also, there was a
significantly increase of means (± SD) of the percentage difference score of
COG sway velocity during standing on left and right foot with eyes open and
eyes closed in ACL tear group as compared to control group (p< 0.001).
Our results are in agreement or consistent with other studies that incidence
of non-contact ACL injury was high and poor postural stability is associated
ACL group. Griffin et al. [23] reported that approximately 70% of ACL
injuries occur through non-contact mechanisms. The mechanism of ACL injury
often involves deceleration coupled with cutting, pivoting, or awkward
landings.
Katayama et al. [24] reported that the amount of postural sway increased
significantly on injured leg standing with eyes closed, and that vision in
the ACL-injured knee. In other study of 19 patients with untreated ACL
injuries, an increase in postural sway in the frontal plane was found for
both the injured and non-injured legs when compared with a control group
[25].
Lysholm et al. [26] reported that patients with a continuing chronic ACL
insufficiency several years after injury have an impaired postural control
in the antero-posterior direction in single-limb stance on their injured
leg. They also demonstrated statistically significant deficits of the
postural control in the patient group with chronic ACL insufficiency
compared to the control group. There was a significantly higher body sway
within the patient group when standing on a stable support surface on the
injured limb than standing on the uninjured limb with the eyes open, but no
difference with the eyes closed. When standing on a stable support surface,
there was a significantly higher body sway in the patient group standing on
the injured leg than in the control group, both with eyes open and closed.
Moezy et al. [27] suggested that postural sway may be increased by
proprioception loss in ACL injuries. ACL injuries not only cause instability
and disability in a high percentage of ACL-deficient athletes but also
reduce proprioceptive ability and postural stability. In other study,
postural sway had been significantly increased on the ACL-injured leg in the
ACL injured group. They concluded that an ACL deficiency or dysfunction was
present, which resulted in increased need for proprioceptive input [21].
Other authors reported that impaired postural stability has been
demonstrated in ACL deficient patients and the persistence of poor stability
control may be correlated to impairment in proprioception [28].
However, our results are in contrast to some previous studies. Katayama et
al. [24] reported that in healthy young women who are in their twenties no
significant differences were observed in any parameter of sway they measured
in eyes-open tests in the ACL-injured knee. They could not show a
significant relation between postural sway and the lower extremity muscle
power strength they measured. However, their studies could not measure the
contribution of vision to postural sway while standing. Other study found no
significant difference between the operated and uninjured knees of patients
or between patients and healthy controls in the ACL-injured knee (p>or=0.05)
[29].
In addition, other authors also found that there was no significant
difference between the injured and uninjured legs regarding postural sway
during one-leg standing with eyes open, but the amount of postural sway
increased significantly with eyes closed. However, there were no significant
differences with respect to sex or general joint laxity and no correlation
with the anterior translation of the tibia or the knee muscle strength [9].
Other study found no differences in postural sway during single-leg standing
between dominant and non-dominant legs between the non- ACL -inured group
and ACL - injured group [21].
The potential explanation for the deficits in postural control after ACL
tear may be due to several biomechanical factors. ACL has both mechanical
and proprioceptive (sensory) functions [29], but, the variability of
postural sway generally increased in ACL tear because of the lack of
proprioceptive information resulting from the ACL lesion [30]. Injury of ACL
is associated not only with mechanical joint destabilization but also damage
of receptors in the ligament responsible for joint proprioception. Sensory
disorders associated with damage of receptors in the ligaments may produce
abnormalities in the posture control [31]. Joint position sense was impaired
in ACL deficient knees and osteoarthritis of knees [32].
One possible explanation with ACL injury is that sensory stimuli from the
injured leg signaling position and movement of this leg are reduced and as a
result larger body sway is exhibited [31]. Sensory and motor behavior
changes were still observed resulting from the ACL lesion. This may be
because of the lack of proprioceptive information resulting from the ACL
lesion [31]. Bilateral deficits in knee joint proprioception were documented
after unilateral ACL injury [33]. Some authors suggest that reduction in
postural control performance in individuals with ACL injury would be due to
the reduction of sensory information provided by the ACL, but when sensory
information is enhanced, postural control performance improves. These
results have implications for novel approaches to improve stability in
individuals with ACL injury [34].
Finally, Okuda et al. [30] reported that the balance of dynamic tension in
the ligament is destroyed at the time of an ACL injury, and the peripheral
muscular coordination around the knee is reduced when the information
transfer from the mechanoreceptors in the ACL is disrupted. The net result
is a reduction in proprioception related to the sense of position, motion,
and gravitational stability [30]. Sensorial information is reduced in the
injured leg due to ACL lesion and the motor control system would have
difficulties in controlling two limbs with different properties [35].
Conclusion: This study represents the first attempt in use of the
computerized dynamic posturography equipment as diagnostic tool in
assessment of postural control and balance deficit in chronic ACL injury
patient in Kuwait. The unilateral stance test may be used to identify
quantitatively postural sway and balance deficits on each leg standing
patients with chronic ACL injury. Chronic ACL injury patients have high COG
sway velocity and impaired balance than normal subjects.
Our study identifies quantifiably how much of impairment in postural control
and balance that may help to predict which patients are predisposed to
developing long-standing functional knee instability. The ligamentous
damage, knee muscle strength deficits and proprioception deficits at the
knee joint may explain poor balance in ACL injury.
Future research should include the effect of surgical intervention and
various rehabilitation exercises by using the posturography equipment among
patients with chronic ACL injury. Clinicians should focus on promoting rapid
and appropriate test during rehabilitation.
We acknowledge to our colleagues in Physical Medicine and Rehabilitation
Hospital, Kuwait for their assistance in this study. No funds were received
in support of this study.
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