ACL reconstruction; deconstructing the reconstructions rehabilitation. ACL injury

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1 ACL reconstruction; deconstructing the reconstructions rehabilitation Lee Herrington PhD MCSP Senior Lecturer in Sports Rehabilitation, University of Salford Senior Physiotherapist, English Institute of Sport (NW Region) ACL injury ACL injury Limited statistics in UK related to sport Rugby Union (Fuller et al 2005) 14 injuries (0.48 injuries per 1000 player hours) Football figures season 14 ACL injuries (Physioroom.com) 15 ACLi in premiership Women's sport far worse x3-9 greater risk, full time athletes 5% (Prodromos et al 2007) England Netball 5 of senior squad (4 in junior squad in last 12 weeks) GB women s basketball 4 out 12 at OGS England woman s FA (U19 senior) 25 ACLi 1

2 ACL injury ACL injury & OA 32-51% ACLR symptomatic OA yr (Hui et l 2010; Kessler et al 2008; Lohmander et al 2004; Oiestad et al 2010) Uninjured knee 22-28% (10yr) (Holm et al 2010) 47% ACLR (hams) PFJ OA 7-10yr (Crossley et al 2011) 30% have PFP at 12/12 (Culvenor et al 2015) 17% PFJ OA 12/12 (Culvenor et al 2015) Bruise 80% ACL cases associated with bony bruising (Beynnon et al 2005) high frequency of radiographic changes is rule after ACL injury (Micklebust & Bahr, 2010) Strong association with osteochrondral lesions & future articular damage (Davies Tuck et al 2010; Dore et al 2010; Filson 2009; Lotz 2010) ACL injury ACLR & return to sport Average return to sport across 48 studies 44% (Arden et al 2012) In non elite 40% returned to pre injury level (Ardern et al 2014) Younger (<25yrs) likely to return to high risk sport older (>25yrs) 26% returned to same level (Shelbourne et al 2008) Elite sport: 10% soccer (Zaffagnini et al 2014) NFL 22-37% (Carey et al 2014; Shah et al 2010) NBA 14-22% (Busfield et al 2009; Harris et al 2013) WNBA 22% (Namdari et al 2011) did not return to same level Average time to RTS was 50 (Harris et al 2013) 52 (Zaffagnini et al 2014) 55 (Carey et al 2014) weeks Those returning significantly reduced game impact (Carey et al 2014; Harris et al 2013; Namdari et al 2011) 2

3 ACL injury ACLR & return to sport Brody et al (2012) male & female soccer ACLR (age 24.2yr) 60% cohort returned same level taking average 12.2+/ months 7yrs PO only 12% cohort playing at same level McCulloch et al (2012) high school-college American football 38-45% RTP same level, 26-29% RTP lower level 28-33% did not RTP, 50% citing fear major contributing factor Lentz et al (2012) varsity athletes 55% RTP same level Non RTP 45% cite fear, 40% knee symptoms ACL injury ACLR & return to sport Across age groups ipsilateral injury 2-10%, contralateral 8-16% (Andernord et al 2014; Webster et al 2014; Wright et al 2011) 10x increased likelihood tearing graft or contralateral ACL following initial ACLR surgery (Marshall et al 2010) Secondary injury rate in young about 24% (Paterno et al 2010) to 29% (Webster et al 2014) Younger age associated with increased risk subsequent contralateral ACL injury (Wasserstein et al 2013) Under 20 s x6 more likely re-rupture ACL graft & x3-5 more likely rupture contralateral ACL than over 20 s (Andernord et al 2014; Webster et al 2014) 3

4 ACL injury ACLR & return of functional activity IKDC subjective; 6 out of 8 studies reviewed all patients failed to reach norm KOOS; no study reviewed return patients to norm score ACL injury ACLR & its rehabilitation IS REHABILITATION FAILING THE PATIENT? Why? 4

5 Absence of clear criteria for progression Current criteria for return to sport vague & rely on personal interpretation. Majority criterion values available are not empirically based (Schmitt et al 2012) Example: recommended LSI required for quads strength varies between 10-35% Absence of clear criteria for progression Typical of literature (Wilk et al 2012) Once satisfactory strength & neuromuscular control has been demonstrated functional activities such as running & cutting may begin weeks & weeks after surgery respectively Rarely is satisfactory strength & neuromuscular control defined 5

6 ACL injury management project Consensus panel Greg Myer, Lee Herrington, Ian Horsley, Simon Spencer, Ashleigh Wallace, Phil Glasgow, Linda Hardy, Raph Brandon The goal of the consensus exercise was to agree on a series of generic markers for progression for each of rehabilitation stages along with monitoring tools to assess loading stress on the athlete s knee Rehabilitation stages Pre-Op Post-op recovery Progressive limb loading Unilateral load acceptance Sport specific task training Unrestricted sport specific training 6

7 Pre op Pre-op Targets Full quadriceps activation (no lag on straight leg raise) Full range of movement (symmetrical) Minimal activity related effusion (<1cm change supra patella) Normal gait walk Straight line jogging (8-10min/mile) Leg press LSI < 5% Lysholm IKDC subjective or KOOS questionnaire score 7

8 Post op Monitoring Daily: Athlete reports numeric rating scale of pain (0-10) post each rehabilitation session along with score at end of day & in morning on first weight bearing Athlete rates stiffness of knee on first mobilising in morning Score 0= free movement 1=some restriction to movement 2=significant restriction 3= unable move to painfully restricted Athlete measures knee circumference (around patella) on waking (1 st hour of day) & in evening NRS Pain Stiffness Swelling Patient scores Saturday Sunday Monday Tuesday Wednesday Thursday Friday am post rehab pm squat stairs am pm 8

9 Monitoring Weekly (biweekly): Knee range of movement Supine, sitting & prone Patella mobility medial glide & tilt, inferior glide (20 degrees knee flexion) scoring: free; restriction; significantly limited Quadriceps strength (handheld dynamometer) 90deg flexion QASLS score (appropriate task to phase) Monitoring QASLS: unilateral tests Single leg squat Single leg land Single hop for distance Tuck jump test 9

10 Monitoring Hop tests One leg hop for distance 80-90% height (males) 70-80% height (females) (Ellenbecker 2001) Cross over hop; 4 hops mean 4.5m (Goh & Boyle, 1997, Hopper et al 2003; Munro & Herrington, 2009; Reid et al 2007) Hop type Male (% leg length) Female (% leg length) Single hop (+/-17.9) (+/-17.7) four hop (+/-60.7) (+/-51.8) Cross-over hop (+/-56.5) (+/-54.7) Monitoring Star excursion balance test (SEBT) Directions: Anterior (quads) Posterior (hams) Medial & lateral (ACL) Direction Reach Distance (% leg length) Male Female Anterior Antero-medial Medial Postero-medial Posterior Postero-lateral Lateral Antero-lateral

11 Block 1: Post op recovery phase Post op recovery phase Aims: overcome the effects of the operation regain range of movement regain muscle activation control effusion achieve normal walking gait 11

12 Post op recovery phase Typical activities Effusion control Compression, game ready etc Muscle activation Muscle stim & superimposed twitch Range of movement Patella & tibiofemoral Gait re-education Limb loading Target criteria to be achieved prior to progression to progressive limb loading activity Full quadriceps activation (SLR no lag x10) Range of movement degrees (minimum) Minimal am effusion (<1cm patella) Minimal change effusion with activity (<1cm patella) Bilateral squat to parallel (thighs relative to floor) even weight bearing Gluteal activation Bilateral short lever bridge X10 reps to neutral hip extension Hamstring activation 0-90 deg knee flexion in standing on the uninjured limb Bilateral long lever (straight leg bridge on chair:30cm) X10 reps to neutral hip extension Function: Normal symmetrical gait Static cycling 12

13 Block 2: Progressive limb loading activities Progressive limb loading activity Aims: progressing athlete from bilateral weight bearing activities to full unilateral weight bearing activities undertake limited load acceptance activities (bilateral landing & jogging) both in closed skill block practice manner. progress strength training & work capacity of key lower limb muscles. 13

14 Progressive limb loading activity Typical activities Muscle strengthening & work capacity training Leg press (squat), mid thigh pull, heel raisers Open chain quads ( degree) & hamstrings Bridging; extended & flexed knee Static movement dissociation Static balance; multi-angle & vestibular Movement dissociation; T drills, SEBT Dynamic movement control (closed chain) SLS, step up/down, forward & side lower, lunge Closed skill block practice Progressive limb loading activity Typical activities Bilateral load acceptance Closed skill block practice Criteria bilateral leg press-squat 1.5BW Single leg balance stability challenge 60deg flex Single leg squat QASLS =0-1 Cardiovascular training Cycle, cross trainer, jog 14

15 Target criteria to be achieved prior to progression to unilateral load acceptance activity Single leg squat to 90 (alignment control x10 reps; QASLS score 0-1) Single leg stand 5, 45 & 90 knee flexion (10 second hold) on airex pad SEBT Ant & Post symmetrical Med & Lat <15% LSI Single leg press 1.5BW (10RM) 0 to 90 deg knee flexion Bilateral drop jump test [QASLS score 0-1] from 30cm box Tuck jump test (score <3) Gluteal muscle work capacity Unilateral short lever bridge on box (hip 45deg) (x25+ each leg no greater than 5 rep difference between sides) Hamstring muscle work capacity Unilateral long lever on box (hip 45deg) (x25+ each leg no greater than 5 rep difference between sides) Calf muscle work capacity Unilateral heel raise (x25+ no greater 5 rep difference between sides) Full range of movement Minimal activity related effusion (<1cm change patella) Function Straight line jogging treadmill Stair ascent & descent (30cm); alignment control symmetry Block 3: Unilateral load acceptance activity 15

16 Unilateral load acceptance activity Aim progress athlete from bilateral load acceptance activities to full unilateral load acceptance activities in multiple planes of movement Including combination of closed & open skill practice progress strength & force development training & work capacity of key lower limb muscles Unilateral load acceptance activity Typical activities Muscle strengthening & work capacity training Unilateral load acceptance activities in multiple planes & reactive landings situations Bilateral multi-plane & unilateral single plane plyometric activities 16

17 Target criteria to be achieved prior to progression to Sport specific task training activities SEBT symmetry & within norms Single leg (hop) land (alignment control; QASLS score 0-1) Single leg hop for distance Forward & side hop from 30cm box 10 RM Single leg press > 2.0BW 0 to 90 deg knee ROM 10 rep leg press to 90 degrees within 5-10% of contralateral leg Tuck jump test (score 0-1) Cross over hop LSI <5% Isokinetic extensors 300%BW total work 60deg/sec (average over 5 rep) Rate of force development; LSI <5% Block 4: Sport specific task training activities 17

18 Sport specific task training activities Aim Improving athlete s work capacity in ability to undertake unilateral load acceptance activities in multiple planes of movement with a reactive random element Develop athlete s ability to carry out specific multidirectional running & landing tasks which are aligned to needs of their sport, along with any other sport skill based tasks Sport specific task training activities Typical activities Muscle strengthening & work capacity training Unilateral load acceptance activities in multiple planes & reactive landings situations (with fatigue element) Sports specific aligned running agility tasks Sports specific aligned skill tasks 18

19 Target criteria to be achieved prior to progression to unrestricted sport specific training Following fatiguing task (sport specific intensity-duration) SEBT symmetry & within norms Single leg (hop) land (alignment control; QASLS score 0-1) Single leg hop for distance (LSI < 5%, & <5% pre op score) Forward & side hop from 30cm box (alignment control; QASLS score 0-1) Running speed 10m sprint (<10% preop time) Agility run time symmetrical (modified T or alternate sport specific) < 10% preop time Function sport specific tasks with alignment control under random practice & fatigue scenarios (video analysis) Unrestricted sport specific training 19

20 ACLR deconstructing the reconstruction s rehab Outcome from surgery is inconsistent & not optimal Rehabilitation needs to consider & address these historic performance short falls Rehabilitation needs to be task not time orientated Task needs to be specific & progressively more challenging Progression is earned by meeting performance markers Thank you L.c.herrington@salford.ac.uk Knee Biomechanics & Injury Research 20