ACL ReconstructionJasmine Chan, SPT
Andy Chiu, SPTBrandon Higa, SPTBryce Keyes, SPTMinsu Kim, SPT
Derek Matsui, SPTAdrian Ruiz, SPT
Traci Yamashita, SPT
Introduction
• Despite anticipation of positive surgical results based on current technical methodology, even well performed ACL surgery can result in a poor outcome if rehabilitation is not conducted appropriately.
~Shelbourne
Postsurgical Orthopedic PT1,2
• Understanding the mechanics causing the injury and potential risk factors
• Respecting the healing process • Making clinical decisions re: modifications or
progression of the patients PT program• Designing a program for the patient using
functional training and avoiding excessive stress on the joint
Pre-Operation1,2
• Higher risks resulting in complication ACL reconstruction surgery– Limited ROM– Inadequate muscle contraction of quadriceps and
hamstrings• Postponing reconstruction– Risk for meniscal and chondral surface damage
Surgical Consideration1,2
• Bone-Patella Tendon-Bone (BPTB)– Rapid revascularization– Ability to return to high demand activities– Anterior knee pain– Knee extensor mechanism/patellofemoral dysfunction– Long term quad weakness
• Semitendonosus-Gracilis Autograft – HS strain in early rehab– Knee flexor muscle weakness
Acute Inflammatory (Necrosis): 1-4 weeks1,3,4
Morphologic Findings•Tendonous Ligamentous1
Signs & Symptoms1
•Inflammation•Pain•ROM•Quad control•WBAT
Complications1
•Pain & Edema limiting motion
http://www.jmarshallfreeman.com/images/pages/knee_surgery_web.png
Revascularization: 6-8 weeks4
Morphologic Findings•Angiogenesis•Scar
Signs & Symptoms•ROM (125-135 ̊flexion)1
•FWB•SLS
Complications1
•ROM deficits•Edema•↑Pain•Arthrofibrosis•PF dysfunction
Proliferative Phase: 8-16 weeks4
Morphologic Findings• Proliferation• Differentiation• Extracellular matrix
production
Signs & Symptoms1
• Full ROM• SLS• No pain• No edema• Running
Collagen remodeling Phase4: up to 1-2 years
Morphologic Findings• Remodeling
Signs & Symptoms1
• Full ROM• Return to activity
Deviations• Edema and Pain1
– Swelling pain, inhibit muscle function, limit motion
• Anterior knee Pain1
– Arthrofibrosis1,5,6
– PF pain• Limited ROM1
– Patellar entrapment (if no 4-6 weeks no full extension)
– Cyclops lesion (fibroproliferative nodule)
Equipment7
• Continuous Passive Motion (CPM) Machine– Improve ROM– Slow motions– Used at home– 6 hrs/day– 1-2 weeks
Equipment8
• Power Plate– Acceleration Training– Vibratory waves– Increase healing
Equipment9
• Compression Boots– Inflatable coverings– Increase blood circulation
• Crutches/walker/brace• Bike• Treadmill• Weight machines• Therabands• Neuromuscular
Electrical Stimulation
Equipment10
• Total Gym– Multiple exercises– Adjustable levels
Modalities9
• Cold/cool packs• Ultrasound• Electrical Stimulation• Transcutaneous
Electrical Nerve Stimulation (TENS)
Risk Factors1
• Anatomical– Joint laxity– Tibial rotation
internally– Pronated feet
• Physiological– Poor core strength– LE deficits
• Strength and coordination
• Neuromuscular deficit– Valgus collapse position
Static Posture11
• Static postural faults– Anterior pelvic tilt– anteverted hips– Shortened hamstring length– genu recurvatum– subtalar pronation
• Genu recurvatum along with subtalar pronation– Increases stress on the ACL
Forces Applied on the Knee12
• ACL more vulnerable when knee near full extension
• Sakane et al study– Anterior shear force applied on the tibia at
different knee flexion angles• Shear force highest at 30° of knee flexion • Shear forces decreased with increased knee flexion
Quads and Hamstrings12
• Quads– Increased ACL tensile force during quads
contractions• Hamstrings– Hamstring contraction decreases ACL tensile force
from quad contraction• Hamstring strength important to decrease tensile
force applied on the ACL during deceleration motions
Ankle11
• ACL injury is associated with hyperpronation of the subtalar joint– Abnormal pronation
increases passive knee internal rotation • Quad contraction and knee
internal rotation = 2x increase of ACL tensile force
Pediatric Approach13,14,15,16
• Pediatric population requires a more cautious approach
• Dependent upon level of skeletal maturity– Open growth plates– Longitudinal bone growth from time of injury – ACL attaches to both distal femoral epiphysis and
proximal tibial epiphysis• Patients should undergo constant follow-up and
exam to track progress of knee • Treatment Protocol– Follow-up phone call every 3 months after
discharge from clinic for up to 2 years
The Female Athlete17
• Females 4-6 times more likely to obtain an ACL injury
• Three major factors resulting in injury– Ligament Dominance – Quadriceps Dominance – Leg Dominance
Neuromuscular Control17 • Ability to coordinate and control muscle activation
& dynamically stabilize the knee in response to sensory, visual, and physical stimulation
• In the absence of neuromuscular control– Decrease firing of dynamic stabilizers of knee
joint=Increase dependence on static stabilizers• Factors effecting neuromuscular control– Joint position – Core stability – Fatigue
Neuromuscular Training17
• Training includes – Plyometrics – Dynamic Posturing – Perturbation Training – Proper Mechanical Technique– Strength and Flexibility
Neuromuscular Training Goals17
– Decrease side to side kinematic differences in the lower extremities
– Increase proprioception of hamstrings – Improve balance– Facilitate protective patterns/stabilization of the
knee– Decrease the overall risk for injury/re-injury of ACL
Neuromuscular Training17
• This information has been well researched and should be implemented in every PT facility
• However, there is a widespread lack of implementation of this information by practicing PT’s
• If we want to see improvement in these athlete’s we can’t just treat the ACL. We need to fix the “why” of the problem
Rehab/Exercise Prescription
• Considerations– Surgery-specific– Patient population-specific– Structural/functional contributions– Early vs Delayed rehab18
– Accelerated vs Non-accelerated rehab18
Rehab/Exercise Prescription
• More Considerations• Knee brace18
– No effects on clinical outcomes– Doesn’t reduce risk of intra-articular injury post-ACLR– MD Orders
• Closed Kinetic Chain(CKC) vs Open Kinetic Chain(OKC)18
– CKC more functional, promote co-contraction, less laxity and patellofemoral pain
– OKC produce greater quad strength and doesn’t compromise further knee laxity
– Depends on phase of rehab
Exercise Prescription(Phase I, post-op-4 weeks)1,2,19
• Goals– Decrease joint effusion/edema– Full passive knee extension– ↑ knee flex ROM 0-110– WBAT without crutches
• Interventions– PRICE– Passive stretch– Gait training with obstacles– Patellar mobilization– Isometric/closed-chain exercises
Exercise Prescription(Phase II, 6-8 weeks)1,2,19
• Goals:– Full pain-free knee ROM– FWB (no limp)– Muscular strength 4/5– Normal gait pattern and
ADL function• Interventions– Progress in Phase I
interventions– Balances exercises– Aerobic conditioning
Exercise Prescription(Phase III, 8-16 weeks)1,2,19
• Goals– Increase muscular
strength, endurance, power
– Improve neuromuscular control
– Improve cardiopulmonary fitness
• Interventions– Progress in Phase I-II
interventions– Plyometric exercises
Exercise Prescription(Phase IV, 16 weeks-)1,2,19
• Goals– Reduce risk of re-injury– Patient education
• Interventions– Progress in Phases I-III exercises– Activity-specific exercises
Patient Education20
• A patient needs to be well educated to become a successful participant in the rehabilitation of an ACL injury– Fear of re-injury is associated with lower functional outcomes
• Patients need to be educated about re-injury prevention– Patients should be educated about graft
maturation and motions that stress the ACL
Re-injury Prevention Considerations21
• Re-injury rates are estimated at 2 to 13% in athletic populations
• Patellar tendon rupture and patellar fracture have occurred in rare occasions with extension exercises
• Coming back too soon- Jerry Rice
Return to Sport22,23
• A general guideline is return to sport is not allowed until 6 months post-op, but successful return to sport has been consistently seen before this time period
• Should be based on dynamic stabilization and strength
• ROM should be full and knees should be symmetrical
Would you like to know more?
• Questions?
• Visit our website at: http://dakinept.yolasite.com/
References1. Maxey L, Magnusson J. Rehabilitation For The Postsurgical Orthopedic Patient. St. Louis, MO: Mosby; 2007.2. Kisner C, Colby LA. Therapeutic Exercise. Philadelphia, PA: F.A. Davis; 2007.3. Cross MJ. Anterior Cruciate Ligament Injuries: Treatment and Rehabilitation Page. http://www.sportsci.org/encyc/aclinj/aclinj/html. Updated April
18, 1998. Accessed July 19, 2009. 4. Lattermann C, Koyonos L, & Whalen JD. Basic science/biology. In: Fu F & Cohen S. Current Concepts in ACL Reconstruction. Thorofare, NJ: Slack Inc;
2008: 35-44.5. Noonan B & Chung KS. A practical review of the mechanisms of pain and pain management following ACL reconstruction. Orthopedics. 2006; 29(11):
999-1005.6. McReynolds JG, Meyer MH, &Rea JB. Infrapatellar contracture syndrome following ACL reconstruction. JAAPA. 2009; 22(3): 23-25.7. Plone Foundation. Post-operative ACL Reconstruction Guidelines. http://www.nismat.org/orthocor/acl_postop. Updated March 8, 2007. Accessed
July 20, 2009. 8. Power Plate. Technology: What is Power Plate? http://www.nyphysicaltherapy.net/Home/PatientEducation/tabid/3433/ctl/View/mid/5695/
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http://www.nyphysicaltherapy.net/Home/PatientEducation/tabid/3433/ctl/View/mid/5695/Default.aspx?ContentPubID=196. Updated 2009. Accessed July 20, 2009.
10. Total Gym. Rehabilitation Facilities – Benefits of Total Gym. http://www.totalgym.com/rehabilitation/rehab.clinics.html. Updated 2002. Accessed July 24, 2009.
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maturity. Knee Surgery Sports Traumatol Arthroscopy. 2009; 17: 748-755. 15. Moksnes, Havard, Engebretsen, Lars, & Risberg, Mary Arna. Performance-based functional outcome for children 12 years or younger following
anterior cruciate ligament injury: a two to nine-year follow-up study. Knee Surgery Sports Traumatol Arthroscopy. 2008; 16; 214-223. 16. Wells, Lawrence et al. Adolescent anterior cruciate ligament reconstruction: A retrospective analysis of quadriceps strength recovery and return to
full activity after surgery. Journal of Pediatric Orthopedics. 2009; 29: 486-489. 17. Fischer, Donald V. Neuromuscular training to prevent anterior cruciate ligament injury in the female athlete. Strength and Conditioning Journal; 28:
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Ligament Reconstruction. J Orthop Sports Phys Ther. 2007; 37(7):404-411.20. Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surgery,
Sports Traumatology, Arthroscopy. 2005; 13(5): 393-397.21. Giugliano DN, Solomon JL. ACL tears in female athletes. Physical Medicine & Rehabilitation Clinics of North America. 2007: 18(3), 417-438. 22. Shelbourne KD, Sullivan AN, Bohard K, Gray T, Urch SE. Return to basketball and soccer after anterior cruciate ligament reconstruction in competitive
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