AWARENESS AND KNOWLEDGE OF ANTERIOR CRUCIATE LIGAMENT INJURY AMONG GENERAL POPULATION IN THE NORTHERN REGION, SAUDI ARABIA

Dr. Majed G Alrowaili^1*, Dr. Bader Majed Aljadaan², Abdulaziz Mohammed Almalki³, Omar Mosab Alenazi³, Sultan Shayish Alanazi³, Rakan Awad Alenzi³, Sultan Mohammed Alanazi³, Mohammed Abdullah Alanazi³ and Prof. Manal S. Fawzy^4
*Correspondence: Dr. Majed G Alrowaili, Department of Surgery (Orthopedic Division), Faculty of Medicine, Northern Border University 91431, Arar, Saudi Arabia, Email:

Keywords

Awareness; ACL injury; risk factors; treatment perceptions; sports Injuries

Resumen

Antecedentes: Las lesiones del ligamento cruzado anterior (LCA) son comunes, pero a menudo no se reconocen lo suficiente en la población general, lo que lleva a medidas de prevención y tratamiento inadecuados. Este estudio evalúa la conciencia y el conocimiento de las lesiones del LCA entre los residentes de la región norte de Arabia Saudita.

Materiales y métodos: Se realizó una encuesta transversal con 417 participantes, utilizando un cuestionario validado para evaluar las características demográficas, el conocimiento de la gravedad de la lesión del LCA, los factores de riesgo, los síntomas, las percepciones del tratamiento y las experiencias personales con las lesiones del LCA.

Resultados: La edad media de los participantes fue de 25,4 ± 7,5 años, con predominio de varones (79,6%). Mientras que el 64,3% reconoció las lesiones del LCA como graves, el 80,8% mostró un conocimiento general deficiente sobre la afección. Con respecto a las percepciones de los participantes sobre los factores que contribuyen a las lesiones del LCA, se identificaron el suelo o los zapatos inadecuados (45,6%), la colisión corporal (38,6%), el ejercicio excesivo (36,9%) y las causas combinadas (46%). Solo el 3,8% informó lesiones previas del LCA; entre ellos, el 68,8% experimentó dolor intermitente intenso y el 54,9% favoreció la cirugía como la mejor opción de tratamiento. La tasa de satisfacción posoperatoria fue del 55,6%.

Conclusiones: El estudio destaca importantes lagunas en la concienciación y el conocimiento sobre las lesiones del LCA en la región norte de Arabia Saudita. Las intervenciones educativas específicas son cruciales para mejorar la comprensión pública, promover estrategias preventivas y mejorar la alfabetización sanitaria en relación con el tratamiento de las lesiones del LCA.

Palabras clave: Concientización; lesión del ligamento cruzado anterior; factores de riesgo; percepciones del tratamiento; lesiones deportivas

Conscientização e conhecimento sobre lesões do ligamento cruzado anterior entre a população em geral na região norte, Arábia Saudita

Histórico: Lesões do ligamento cruzado anterior (LCA) são comuns, porém frequentemente subdiagnosticadas na população, resultando em cuidados inadequados. Este estudo investiga a conscientização e o conhecimento sobre lesões do LCA entre residentes da Região Norte da Arábia Saudita.

Materiais e métodos: Foi realizada uma pesquisa transversal com 417 participantes, utilizando um questionário validado para avaliar características demográficas, conhecimento sobre a gravidade da lesão, fatores de risco, sintomas, percepções do tratamento e experiências pessoais.

Resultados: A média de idade dos participantes foi de 25,4 ± 7,5 anos, com predominância de homens (79,6%). Embora 64,3% reconhecessem a gravidade das lesões do LCA, 80,8% apresentaram conhecimento geral deficitário. Entre os fatores de risco percebidos, mencionaram-se piso ou calçados inadequados (45,6%) e colisões (38,6%). Somente 3,8% relataram lesões anteriores do LCA; destes, 68,8% sofreram dor intensa e 54,9% preferiram cirurgia como tratamento, com uma taxa de satisfação pós-operatória de 55,6%.

Conclusões: O estudo evidencia a falta de conscientização e conhecimento sobre lesões do LCA na Região Norte da Arábia Saudita, destacando a necessidade de intervenções educativas específicas.

Palavras-chave: Conscientização; lesão do LCA; fatores de risco; percepções de tratamento; lesões esportivas

Introduction

The "anterior cruciate ligament (ACL)" is an essential component of knee joint stability. This robust band of connective tissue originates from the posterior-medial region of the lateral femoral condyle and inserts into the anterior portion of the tibial intercondylar eminence [1]. The ACL's primary function is to restrict excessive displacement of the tibia forward in relation to the femur, thus maintaining proper knee biomechanics [2,3].

ACL injuries are among the most serious sports-related injuries, affecting both professional and recreational athletes. These injuries typically occur during activities that involve sudden changes in direction or abrupt stops, such as in football and basketball [4]. While there is variation between studies and populations, the general trend shows increasing rates of ACL reconstruction surgery over the past two decades in many developed countries, with current annual incidence typically falling in the range of 40-80 per 100,000 population [5-7]

This type of injury is a significant concern in sports medicine. It predominantly impacts young, athletic individuals, particularly those engaged in high-activity sports like football, basketball, and soccer [2]. ACL tears require prompt attention, as failing to address them can lead to further knee damage, including meniscal tears and early-onset osteoarthritis [8]. Over recent decades, there has been a marked increase in ACL injuries attributed to both rising sports participation rates and the inherent risks associated with these activities [9]. Notably, women participating in these sports are two to ten times more likely to sustain an ACL injury compared to their male counterparts [10], highlighting a significant gender disparity in injury risk [11].

While most ACL reconstructions (ACLRs) enhance the mechanical stability of the affected knee, the risk of a second injury upon returning to sports (RTS) remains a significant concern. Despite many athletes resuming normal knee function post-surgery, there is a rising trend of athletes discontinuing their sports participation following ACL reconstruction [12]. This global concern is reflected in the Saudi Arabian context. Two surveys conducted in the Albah and Aseer regions found that while the public possesses a reasonable understanding of ACL injury severity, there are notable gaps in knowledge regarding associated risk factors. This underscores a need for improved health education to enhance public awareness and reduce the occurrence of ACL injuries [13,14]. However, these studies do not provide a comprehensive picture of ACL injury awareness across Saudi Arabia, particularly in the Northern Border Region. Given the potential regional variations in sports participation, healthcare access, and public health education, it is crucial to assess awareness levels in different parts of the country. Therefore, this study aims to assess the awareness and understanding of ACL injuries among the general population in the "Northern Border region of Saudi Arabia," an area where this issue has not been previously explored. The study results will contribute to a more comprehensive understanding of ACL injury awareness in Saudi Arabia and inform targeted public health interventions.

Material and methods

Study Design

This cross-sectional study utilized an online questionnaire that was shared with participants through various social media platforms (WhatsApp, Twitter, Facebook) and distributed in multiple settings, including malls, university campuses, and community campaigns throughout the Northern Border region of Saudi Arabia.

Sampling Technique

The convenience sampling technique was employed in this study to select participants. The simple size was calculated using Epi Info (https://www.openepi.com/SampleSize/SSCohort.htm). A margin of error of 5%, an expected proportion of 50%, a confidence interval of 95%, and a population size of 383,051 were used, resulting in a minimum calculated sample size of 384.

In the final analysis, we enrolled 417 participants. This increase in the sample size beyond the minimum requirement was implemented to enhance the robustness and representativeness of the findings, ensuring a more comprehensive understanding of the studied population. By enrolling additional participants, we aimed to mitigate any potential sampling bias and improve the statistical power of our analyses.

Inclusion and exclusion Criteria

Eligible participants consisted of males and females aged between 18 and 65 years who consented to participate in the study. Individuals younger than 18 or older than 65 were excluded, as were those who declined to complete the questionnaire. Also, healthcare workers who work in a related field were excluded to avoid the impact of their previous knowledge on the estimation of actual population knowledge.

Sampling tool

An adapted version of the questionnaire used by Gharbawi et al., a previous study conducted in regions of Saudi Arabia, was used [15]. It consists of questions related to demographic information (such as age, sex, residence, marital status, occupation, and educational level), anthropometric data (i.e., height and weight), physical activity (sports participation and type of sports), knowledge/awareness of ACL injury, perceived risk factors for ACL injury, symptoms and management of ACL injury, post-injury assessment, post-surgery satisfaction, and physiotherapy follow-up [15].

Ethical considerations

This study had the ethical clearance of the "Local Committee of Bioethics (HAP-09-A-043) of the Northern Border University, Arar, Saudi Arabia" (approval # 35/24/H) dated 25/03/2024. After discussing the aim and objectives of the research, consent was obtained from all participants before taking part. Data confidentiality and participant anonymity were strictly maintained throughout the study. All collected data were anonymized and stored securely, ensuring that no identifiable information could be linked to individual participants. Access to the data was limited to authorized research personnel only, and all findings are presented in aggregate form to protect participant privacy further.

Statistical analysis

The collected data were analyzed using SPSS version 20. The Shapiro-Wilk test was employed to assess the normality of numerical data. The categorical data were presented as numbers and percentages. To analyze the relationships between pairs of variables (poor versus good knowledge), we utilized "Pearson's Chi-Square" test or "Fisher's exact" test where appropriate. Statistical significance was established at a p-value less than 0.05.

Results

Study participant characteristics

A total of 417 participants with a mean age of 25.4 ±7.5 (17-62 years) were included in this study. They have a mean body mass index (BMI) of 23.7±3.9. The demographic characteristics of the study population are presented in Table 1. The majority of participants (67.1%) were under 25 years old, with males constituting 79.6% of the participants, indicating a predominantly young and male study population. Most participants (68.1%) were from Arar (the capital of the Northern Border area), single (72.4%), and students accounting for 52.8% of the participants (Table 1).

Participant's physical activity

The majority of participants (89.4%) reported engaging in sports activities, while only 10.6% did not participate in any sports (Table 2). Among those who practiced sports (n=373), the most popular activities were walking (83.9%) and jogging (66.0%).

Data are presented as frequencies (n) and proportion (%).

Knowledge about anterior cruciate ligament injury seriousness

Regarding the perceived seriousness of ACL injuries among the 417 participants, the findings reveal that the majority of respondents (64.3%) recognized ACL injury as a serious condition. At the same time, more than a quarter of the participants (28.1%) were uncertain about the seriousness of ACL injuries, responding, "I don't know," highlighting the presence of a significant knowledge gap.

Knowledge about risk factors that cause anterior cruciate ligament injury and the related risk

Concerning the participants' perceptions of factors contributing to ACL injuries and activities that may increase the risk of such injuries, participants most frequently identified unsuitable floor or shoes (45.6%), body collision (38.6%), over-exercising (36.9%), and the combined causes constitute about 46%. Interestingly, lack of knowledge about protective methods (35.0%), lack of preparation (27.6%), and lack of physical fitness (23.5%) were less frequently recognized as potential causes.

Regarding activities that may increase the risk of ACL injury, playing football (57.8%), old age (43.9%), and playing basketball (43.6%), were the most specified risk-related activities (Table 3).

Data are presented as frequencies (n) and proportion (%).

Knowledge about symptoms of anterior cruciate ligament injury

Participants were asked about symptoms they associate with ACL injuries (Table 4). The most commonly recognized symptom was pain at night in the knee (53.7%). Other symptoms were identified by approximately one-third of participants, including instability (34.5%), crackles (34.1%), locking (33.3%), and swelling (31.4%). Fewer participants associated ACL injuries with stiffness (30.5%) or leg weakness (26.4%).

Data are presented as frequencies (n) and proportion (%).

Treatment perceptions for anterior cruciate ligament injury

Participants were asked about methods to relieve symptoms and the best treatment options for ACL injuries (Table 5). The majority of participants identified prescribed medications as the most effective means of symptom relief (48.7%). Other options included rest (16.8%), ice application (11.8%), and over-the-counter medications (10.1%). Notably, only a small percentage considered hot compresses (8.4%) or alternative medicine (4.3%) effective. When asked about the best treatment for ACL injuries, surgery was favored by 54.9%, followed by physiotherapy (24.9%) and medication (13.9%). Herbal and alternative medicine received the least support (6.2%).

Data are presented as frequencies (n) and proportion (%).

Pain profiles and treatment experiences among participants with a history of ACL Injury

A small proportion of the study respondents had experienced ACL injuries, with only 3.8% (n=16) reporting that they had complained of such an injury. Among these participants, 43.8% reported experiencing injury more than once, 68.8% described their pain as severe and intermittent, and about two-thirds of them located this pain inside the knee (Table 6). In terms of activity level following their ACL injury, 75.0% indicated that they were partially affected, while 12.5% reported being not affected at all. Furthermore, over half of the participants (56.3%) underwent surgery to address their ACL injury, whereas 43.8% (n=7) did not require surgical intervention (Table 6). The most significant reason for avoiding surgery in the latter subgroup (n=7) was the belief that it was unnecessary (57.1%), followed by concerns about surgery-associated complications (28.6%) and the high cost of surgery for just one participant (14.3%).

Data are presented as frequencies (n) and proportion (%).

Among the nine participants who underwent surgery for their ACL injury, the level of satisfaction with the surgical outcomes was notably positive. About 55.6% reported being completely satisfied with the surgery results, while 44.4% (n=4) indicated that they were mostly satisfied. In terms of following a post-surgery physiotherapy program, 66.7% confirmed that they adhered to the program, whereas 33.3% reported following the program only partially.

Overall knowledge regarding anterior cruciate ligament injury among study participants

An assessment of respondents' overall knowledge regarding ACL injury reveals that most of the participants (80.8%; n=337) have poor knowledge and only 19.2% (n=80) demonstrated a good level of knowledge (Figure 1).

Association of demographic data with overall knowledge of ACL injury

The analysis of the demographic data in relation to overall knowledge of ACL injury revealed that although knowledge levels varied among age groups, particularly with 65.9% of participants under 25 having poor knowledge, this difference did not show statistical significance (p = 0.130). A significant gender disparity was identified, as males exhibited better knowledge (p = 0.000). Geographically, knowledge levels did not significantly differ among participants from various regions (p = 0.796), with the majority from Arar displaying poor knowledge (68.2%). Marital status likewise showed no significant relation to knowledge levels (p = 0.749), and most single participants (71.8%) reported poor knowledge. Occupationally, students represented a considerable segment, with 51.9% having poor knowledge, although no notable differences among other professions were observed (p = 0.109) (Table 7).

Data are presented as frequencies (n) and proportion (%). Pearson's Chi-Square" test or "Fisher's exact" test was applied appropriately. The level of significance was set at p-value < 0.05.

Discussion

The current study aimed to evaluate the awareness/knowledge of anterior cruciate ligament injury among the general population in the Northern Region of Saudi Arabia. Our findings revealed that a significant majority of participants displayed poor knowledge regarding ACL injuries, with 80.8% categorized as having inadequate understanding. This substantial gap in knowledge is concerning, particularly given the increasing incidence of ACL injuries in sports and physical activities. Previous studies have shown that increased awareness and education about such injuries can lead to improved preventive practices and better health outcomes [16-18].

Demographic analysis indicated a significant association between gender and overall knowledge, with males exhibiting higher levels of knowledge compared to females. This finding aligns with previous research that noted gender differences in health-related knowledge and attitudes. However, it's important to realize that gender differences in health knowledge can vary depending on the specific health topic and cultural context [19]. The predominance of male participants in our study (79.6%) could indeed influence the overall results. This underscores the need for balanced gender representation in health research and targeted educational initiatives for both genders [20].

Participant awareness of the mechanisms that could lead to ACL injuries further underscores the knowledge gap. Although a majority recognized factors such as unsuitable flooring and body collisions, less attention was paid to protective measures and physical fitness, suggesting a lack of comprehensive education on prevention. Studies have demonstrated that enhancing knowledge about injury prevention strategies can significantly reduce the risk of ACL injuries, particularly in high-risk sports activities [21-23].

Pain profiles among participants with a history of ACL injury revealed that a majority described their pain as severe and intermittent, emphasizing the debilitating nature of the injury. Despite this, only a small percentage of respondents (3.8%) reported a prior ACL injury. This finding aligns with previous studies that indicated the risk of ACL injuries is relatively low in the general population compared to athletes [15,24,25]. Moreover, the decision against surgical intervention was predominantly due to the belief that surgery was unnecessary, along with concerns about potential complications and financial implications. These findings reflect the need for better communication and counseling from healthcare providers regarding the management of ACL injuries [26].

Satisfaction levels following surgical interventions were reported positively, with 55.6% of participants completely satisfied with their surgical outcomes. These results indicate that when surgical options are pursued, they can lead to satisfactory recovery and improvements in quality of life, reinforcing the value of timely and appropriate treatment options [27]. However, adherence to post-operative physiotherapy was not universal, with one-third of participants reporting partial compliance. This finding raises concerns about the importance of reinforcing adherence to rehabilitation protocols to maximize recovery outcomes, as previous research indicates that compliance is key to successful rehabilitation after ACL surgery [28-31].

The findings of this study underscore the pressing need for education and awareness campaigns aimed at enhancing the general public's knowledge of ACL injuries, risk factors, and effective management strategies [32]. By addressing these gaps, healthcare providers can contribute to improved awareness, prevention, and overall health outcomes related to ACL injuries in the Northern Region of Saudi Arabia. Future studies should explore the effectiveness of targeted interventions and educational programs to increase knowledge and encourage injury prevention strategies within this population.

Conclusions and future perspectives

This study reveals significant gaps in awareness and understanding of anterior cruciate ligament injuries among the general population in the Northern Region of Saudi Arabia. The findings indicate that while some recognize the seriousness of ACL injuries, a large portion of respondents needed to demonstrate better knowledge regarding the injury's risk factors, symptoms, and effective treatment options. Given the prevalence of sports activities in this population, targeted educational initiatives are essential to enhance public knowledge about ACL injuries and their implications. These initiatives should aim to inform individuals about the significance of preventive measures, appropriate treatment pathways, and the importance of rehabilitation following injuries. By fostering a better understanding of ACL injuries, healthcare providers can significantly contribute to the reduction of injury incidence and improve overall health outcomes within the community. Future research should explore the effectiveness of educational programs in raising awareness and knowledge of ACL injuries and assess the long-term impacts of enhanced awareness on injury prevention behaviors.

healthcare providers can significantly contribute to the reduction of injury incidence and improve overall health outcomes within the community. Future research should explore the effectiveness of educational programs in raising awareness and knowledge of ACL injuries and assess the long-term impacts of enhanced awareness on injury prevention behaviors.

Funding

"The deanship of Scientific Research at Northern Border University, Arar, KSA, funded this research work through the project number "NBUFFR- 2024–966-02."

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