Biomechanical Analysis of ACL Tears Adam Killmeyer, Tyler Harvey, Nick Freeman, George Seignious

Problem Description: In the todays sports, athletes are prone to getting all sorts of injuries on their body ranging from minor cuts and bruises up to shattering bones and ligaments. One of the more catastrophic injuries is tearing the anterior cruciate ligament (ACL). Two of the most common causes of ACL tears are a result of taking a hard hit to the side of the knee and making a quick change in direction, causing an over-extension of the knee joint.1 These injuries frequently plague many of todays star NFL football players such as Adrian Peterson, who has already recovered from it, and Sam Bradford who just recently fell victim to the injury. The anterior cruciate ligament is one of the most important supporting structures of the knee joint due to its ability to stabilize the femur and the tibia during flexion and extension of the knee. The ACL is made up of dense connective tissue divided into two bundles, the anteromedial and the posterolateral bundles. The bundles, primarily consisting of collagen and fibroblasts, Figure 1: Illustration showing the ACL run side-by-side, originating at the lateral posterior part during knee extension and flexion (lateral of the femur (femoral condyle), and connect to the view of knee)5 anterior tibia. This ligament, as a whole, averages a cross-sectional area of 36-44 square millimeters and a length of 22-41 millimeters.2,3,4 The position and the structure of the ACL also prevent rotation between the femur and tibia, which comprise the joint. Because of its dense, fibrous nature, the ACL can withstand loads in a variety of directions, although thought to be stronger with longitudinal forces than transverse forces due to the direction of fibers that make up the ligament. It also stretches and contracts to increase the flexibility of the joint. The ACL endures greater forces when the knee is extended than when it is flexed (close to 90 degrees) due to its geometry and its natural orientation in the knee joint, where the posterolateral bundle undergoes greater change in force than the anteromedial bundle. If an ACL becomes damaged or torn, it results in poor weight and force transfer in the joint as well as a lack of stability, leading to excess movement and inflammation.1,6 Research Question: In football, a receiver can take a hit in many scenarios. When jumping to catch a ball, they are sometimes hit immediately when they hit the ground. If their legs are extended, it can result in a torn ACL because the larger strain due to the extended leg position puts more stress on the ligament. In other scenarios, they can be hit while they are running or escaping tackles. In these cases, the knee will be bent, placing less strain on the ACL. In theory, the lower strain due to the bent leg position should allow the ACL to experience a greater impact force without tearing. The goal of this research is to determine what effect knee flexion has on the probability of a tear by calculating the lateral force (transferred to the ACL through impact) required to exceed the ultimate tensile strength of the ACL both at full (180 degrees) and partial (60 degrees) extension of the knee.

Analysis:

Assumptions:

1) The ACL is a visco-elastic solid, and will be represented by a Kelvin-Voigt model. 2) The impact force is assumed to hit the femur laterally, approximately at the ACLs femoral insertion. 3) In both cases, the foot is planted and the tibia is treated as a fixed surface. The femur is treated as a beam of arbitrary length which remains vertical throughout impact 4) Impact is assumed to occur instantaneously. This has the important consequnce that the angle of flexion is not changing during the hit and thus strain in the ACL (prior to impact) can assumed to be constant as well. 5) Twist does occur in the ACL during flexion of the knee, which contributes a negligible amount of strain. Therefore, we disregard this and assume strain is only due to the elongation of the ACL. 6) The ACL is considered unstrained at full flexion(90) as this is when the ACL is shortest. The initial length of the ACL (l0) is 26.8 mm.6 Figure 2: Free Body Diagram of 7) When the knee is viewed anteriorly, the ACL forms an angle System (Anterior view of knee) showing impact force but no () with the horizontal axis of 60.7 initial stress in ACL (see Figure 8) The elastic modulus (E) of the ACL is assumed to be 345 3 for resolved stress) 4 MPa. 9) The ultimate failure load (Fy) of the ACL is assumed to be 2160 N.2 10) The cross sectional area (A) of the ACL is assumed to be 40 mm2.2 1) The stress (i) in the ACL according to the Kelvin-Voigt model is given by: ( ) ( ) ( ) , where E is the elastic modulus, is the strain, t is time, and is viscosity of the element. Since we are assuming a constant strain prior to impact in case 1, this equation simplifies to: 2) Strain () is given by: 3) Stress () is given by: the force. , where lf is the stretched length and l0 is the initial length. , where F is a force and A is the cross sectional area normal to

Equations:

Case 1: Fully extended leg

The stretched length of the ACL (lf) when the knee is fully extended is 29.4mm.6

Thus i is the stress applied to the ACL prior to impact. Knowing the ultimate failure of the ACL, the yield stress (y) is given by:

cos( ) Figure 3: Free Body Diagram with resolved stress in ligament due to extension of the knee

Therefore, the additional stress required to tear the ligament is given by: Finally, the magnitude of the impact force component which translates to the ACL that is necessary to achieve this stress is determined:

Case 2: Partially flexed leg

The stretched length of the ACL (lf) when the knee is only partially extended (60) is 27.4mm.6

Thus i is the stress applied to the ACL prior to impact. The yield stress is the same as in case 1. Therefore, the additional stress required to tear the ligament is given by: Finally, the magnitude of the impact force component which translates to the ACL that is necessary to achieve this stress is determined: Discussion: It is important to note that the forces calculated in this analysis are not the impact forces a player is capable of withstanding. Rather, these are the components of the impact force which are fully translated to the ACL (i.e. not dissipated by other ligaments, muscles, tendons, etc). Even so, from this analysis it is clear that a partially flexed knee is capable of withstanding a larger impact before ACL damage than a fully extended knee. This is an important conclusion for players to prevent injury. As they anticipate a hit to the leg coming, they should flex their knees rather than locking them straight and this could, to some degree, reduce their chances of an ACL tearing. References:
1. Medline Plus. Anterior Cruciate Ligament (ACL) Injury. Medline Plus. http://www.nlm.nih.gov/medlineplus/ency/article/001074.htm. Published August 14, 2011. Accessed October 23, 2013. 2. Dargel J, Gotter M, Mader K, Pennig D, Koebke J, Schmidt-Wiethoff R. Biomechanics of the anterior cruciate ligament and implications for surgical reconstruction. Strategies Trauma Limb Reconstr. 2007;2(1):1-12. 3. McKinley M, O'Loughlin V. Human Anatomy. McGraw-Hill Science/Engineering/Math; 2011. 4. Lujan T. Multiscale Biomechanical Relationships in Ligament. University of Utah. Published December 2007. Accessed November 11, 2013 5. Jacobson K. Anterior Cruciate Ligament Injuries. Hughston. http://www.hughston.com/hha/a_11_3_1.htm . Accessed November 11, 2013. 6. Li G. In vivo kinematics of the ACL during weight-bearing knee flexion. Journal of Orthopedic Research. 2005;23:340-344. 7. Danylchuk, Kenneth. Studies on the Morphometric and Biomechanical Characteristics of Ligaments of the Knee Joint. ProQuest Dissertations and Theses. 1975; 1-184. Print.