Anterior Cruciate Ligament Rehabilitation. Rehab Summit Omni Orlando Resort at ChampionsGate Speaker: Terry Trundle, PTA, ATC, LAT

Transcription

1 Anterior Cruciate Ligament Rehabilitation Rehab Summit Omni Orlando Resort at ChampionsGate Speaker: Terry Trundle, PTA, ATC, LAT

2 ACL Graft Selection 1. Autograft Bone-Patella Tendon Bone Hamstrings: Semitendinosus gracilis 2. Allograft Bone-Tendon-Bone Achilles Tendon with bone Anterior Tibialis 3. Contra-Lateral Transplant Reference: Paris MJ, Wilcox R, Millett P: Anterior Cuciate Ligament Reconstruction: Surgical Management and Post Operative Rehabilitation Considerations. Orthopedic Practice. 2005; 17(4) Coccaro J, Wilmarth MA. Use of an Accelerated ACL Rehabilitation Program For Patients with ACL Reconstruction Using an Anterior Tibialis Allograft: A Case Report. Orthopedic Practice (3); 20-25

3 Phases of ACL Rehab I Pre-Functional II Return to Function III Return to Activity

4 ACL: Pre-Functional Phase I Early motion full passive extension Leg Control Extension mobilization Pre-functional Recruitment i.e. co-contraction Normal Patella Mobility Normal Gait No Flexed Knee Ambulation Begin Core Stabilization Closed Kinetic Chain (Progression) Balance Proprioception Hamstrings Strengthening (Eccentric) Reference: Decarlo MS, McDivitt R. Rehabilitation of Patients Following Autogenic Bone-Patella Tendon-Bone ACL Reconstruction: A 20 Year Perspective. No. Am. Journ. Sports Phys. Ther (3)

5 Core Stabilization PHASE I Multi-directional hip strengthening Standing SLR X 4 Bridging Swiss ball Assisted to unassisted Positional Extension-Quad sets Seated on ball leg raises Reference: Lundy J. Gluteus Medius Stimulates Lower Extremity Movement. Biomechanics, July

6 Hamstrings - Revisited Based on EMG studies Hamstrings are more active at the hip during forward and backward walking, running and cycling Most hamstring injuries occur during the late swing phase of running Hamstrings create a posterior directed force on the tibia when the flexion angle is 30 or greater Hamstrings function as an eccentric control of hip flexion Reference: Cipriani, D. Pulling Through. Training and Conditioning, Dec

7 Functional Phase II EXERCISES Advanced core stabilization Hamstrings Bridge Roll P.R.E. hamstrings and quadriceps: short arc range of 90-45, Mini-squats, lunges; lateral and retro step-ups Unilateral wall slides Leg press (double and Single) total gym Total leg strengthening including hip and ankle Closed chain progression: balance vectors Isokinetics if available high speed training Retro treadmill Elliptical Retro stepper Single leg proprioception uneven surface Reference: Ayotte NW, Stetts DM, Keenan G, Greenway EH. Electromyographical Analysis of Selected Lower Extremity Muscle During Five Unilateral Weight Bearing Exercises. J. Orthop Sports Phys Ther. 37(2) 48-55; 2007

8 Anterior Translation - ATT Least Amount of ATT 75 Deg. Knee Flexion Maximum Amount of ATT Deg. Flexion (Based on Maximum Isometric Quadriceps Contraction) References: Gross, MT, Tyson AD, Burns CB: Effect of Knee Angle and Ligament Insufficiency On Anterior Tibial Translation During Quadriceps Muscle Contraction: A Preliminary Report. J. Orthop, Sports Phys. Ther. 7: , 1993

9 Exercises that are high in Co- Contraction Squats 0-30 Lateral Lunges Balances on uneven surfaces Slide board Fitter High speed Isokinetics

10 Quadriceps Best Exercises Squat beyond 60 Leg Press Single Leg Squat Wall Slide Leg Extension 60-0 Lateral Step-ups Quad dominant 8:1 Q/H Reference: K. Wilk AJSM 1996, Follow-up Presentation APTA PT 2005, Boston, MA

11 Quick Summary on Quadriceps Training Level One: Low Demand Mini squats series Level Two: Moderate Demand Lateral step-ups Leg press 45 and higher Level Three: High Demand Squats with increased flexion moments Add wide stance

12 Open- or Closed-Kinetic Chain Exercises After Anterior Cruciate Ligament Reconstruction? OKC and CKC Exercises both produce strains on the ACL in terminal extension OKC with increase of resistance does increase ACL strain CKC does not increase the ACL strain with increase load Reference: Fleming, BC, Oksendahl, H, and Beynnon, BD: Exercise and Sports Sciences Reviews, Vol. 33(3) , July 2005.

13 Clinical Application of the Research OKC short arc flexion moment angle continues to be suggested (90 40 ) Increase external compression (weights) with increase strain on the ACL toward extension Early use of CKC is still recommended

14 ACL: Return to Activity Phase Preturbation Training III Total Leg Strengthening Plyometric Activity double to single leg Sports specific training Reference: Hartigan EH, Hurd WJ, Snyder-Mackler L. Return to Play Screening Strategy Directs Successful Rehab. Biomechanics, June

15 FUNCTIONAL LOWER EXTREMITY TESTING Balance testing eyes open and closed Balance vector testing Leg press test Isolated strength assessment (Isotonic vs. Isokinetic) Return to Sports Functional Testing Jump test Double leg Hop test Time and distance Single leg Reference: Reid A, Birmingham TB, Stratford PW, Alcock GK, Griffin RJ. Hop Testing Provides a Reliable and Valid Outcome Measure During Rehabilitation After Anterior Cruciate Ligament Reconstruction. Phys Ther (87) ; 2007

16 Closed Kinetic Chain Clinical Progression Lower Extremity Pre-Plyometrics Balance activities with eyes closed (30 sec) Slide board (LMT) Continue selected single leg unlevel balance activities Squat Control (30 sec) Lunges with weights Reference: Risberg MA, Holm L, Myklbust G, Engebretsen L. Neuromuscular Training Versus Strength Training During the First Six Months After Anterior Cruciate Ligament Reconstruction: Phys Ther. 2007, 87:

17 Plyometric Training Progressive in nature Increased number of exercises Increase repetitions and sets Decrease rest periods Straight jumps -> Sagittal Lateral jumps -> Frontal Combination -> Transverse Frequency three times a week Intensity double leg jumps to single leg jumps Low intensity fast contacts Moderate intensity fast contacts High intensity fast contacts

18 ATHLETIC REHAB INSTITUTE FUNCTIONAL PROGRESSION Walk Program 20 Minutes Treadmill-Retro (Backwards) Jog Program Goal Minutes Running Program Mix of Retro and Forward Straight Running 3-5 miles at 7/8 min/mile on track Goal: increase to sprint (Add any equipment once patient can sprint)

19 Closed Kinetic Chain Clinical Progression Lower Extremity Return to Sports Agility Drills Box Runs Lateral Running Carioca Retro Sprinting Figure Eight Lateral Cut Vertical Jumps Plyometrics (Advanced) Reference: Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Rehabilitation After Anterior Cruciate Ligament Reconstruction: Criteria-Based Progression Through the Return to Sport Phase. J. Orthop. Sports Phys. Ther (6)

20 What changes the protocol? Meniscal Repair - Transplantation

21 Meniscal Repair - Transplantation Weight Bearing Precautions Protective Active Hamstrings Posterior Medial Horn repair Delayed Closed Kinetic Chain activity Reference: Heckmann TP, Barber-Westin SD, Noyes FR. Meniscal Repair and Transplantation: Indications, Techniques, Rehabilitation, and Clinical Outcomes. J Orthop Sports Phys Ther (10)