4/17/2015. Objectives. Current Concepts in ACL Rehabilitation: From Prehab through Return to Sport. Incidence. What causes ACL tears?

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1 Current Concepts in ACL Rehabilitation: From Prehab through Return to Sport ADAM MEIERBACHTOL PT, DPT, SCS, ATC ERIC PAURPT DPT SCS ATC Objectives Anatomy and biomechanics Variables affecting rehab Rehab progression Return to sport programs Incidence 200,000 injuries/year, female > male, up to 90% have surgery Occurs frequently in sports, although no guarantee of full return to activity 76% of patients expect to return to prior level of sports participation after ACL reconstruction (Feucht M et al) Significant re-tear rates Significant cost (time and money) ACL Anatomy and Biomechanics ACL is attached at anterior tibial spine and attaches to posteromedial aspect of lateral femoral condyle Primary function is prevention of anterior translation and medial rotation of tibia relative to femur By inducing or minimizing ACL strain, muscle recruitment and neuromuscular control have a significant effect on dynamic knee stability With proper training, it is possible to change movement patterns to decrease risk of future re-injury What causes ACL tears? Improper technique Poor body mechanics Majority of ACL tears are non-contact Specific weakness Female? Increased genu valgum Poor hamstring-quad ratio Extended knee during activity Quad dominance Hip/core weakness Female college basketball players are 8x more likely to injure their ACL vs men in same sport (Malone et al) Female soccer players are 6x more likely to injury ACL compared to men in same sport (Lindenfeld et al) 1

2 Prehab Crucial for optimal outcome Goal is quiet knee time frame can vary greatly Goals Full extension ROM and flexion > 120 Normal gait Minimal effusion Good quad activation Factors Affecting Rehab Graft choice Autograft BTB Patellar tendon Hamstring Patellar tendon is approx 37% stronger than native ACL Bone tunnel healing is approx 8 weeks -Graft 6-10 months Quadrupled hamstring is approx 91% stronger than native ACL Tendon to bone healing is approx 12 weeks -Graft 8-12 months The theoretical advantage of having a larger, stronger graft that allows more aggressive rehabilitation remains unproven Hamstring grafts may have slightly increased laxity More pain with kneeling in BTB No subjective differences in Tegner, Cincinnati, Lysholm or IKDC scores Allograft Full incorporation of Allocan be 2x longer (4-6 months) -Graft 10 months to over a year Less surgical trauma, feel better sooner Initial rehab is similar but should have slower return to aggressive activities Generally not recommended for young athlete secondary to increased re-tear rates Frequently used with older athlete Factors con t Meniscus tears Occur in approx 64%-77% of ACL injuries Meniscectomy doesn t significantly alter progression Meniscus repair (controversy) MD guidance is crucial Initially WBingand ROM may be limited by protocol Brace locked in full extension for WBing Complex and root tears are progressed much slower than peripheral tears Limit squat depth and isotonic hamstring contraction Factors, con t MCL Injuries MCL involved in 13% of ACL tears Excessive scar tissue for grade 1-2 so be more aggressive into full extension Surgical treatment is rare Concurrent multi ligament injuries (PCL, LCL or PLC reconstructions) will necessitate slower rehab 2

3 Factors, con t Articular Cartilage 70-90% of ACL injuries also sustain a bone bruise (typically LFC and LTP) Persistent pain during rehabilitation is indication of over aggressive approach May need to delay progression of WB and impact activities, but unloading and immobilization have been shown to have a negative affect Specific articular cartilage procedures (commonly microfracture) will alter rehab Quelard 2010 Factors con t Older patient age weekend warrior Will generally need to progress slower through each phase Typically take longer to reach end goal Careful with plyometric activities (if desirable) May have underlying degenerative changes which can be pain generator Phase I ACL Rehabilitation (0-2 weeks) Phase I Goals: Range of Motion Full extension and flexion >90 degrees by 1 week Quad activation (Kyung-min et al, 2010) NMES + exercise > exalone to restore quad strength Effect on functional performance and patient oriented outcomes inconclusive Inconsistency in parameters and application Control effusion (allow ROM, decrease quad inhibition) As little as 20 ml of joint effusion will inhibit quad activation Phase I = Extension ROM Focus is on full passive extension Most common complication and cause of poorer outcomes is loss of full knee extension (Austin JC 2007, Irrgang 1995) Do not progress to aggressive strengthening until full extension obtained Increased risk of arthrofibrosis Low load, long duration stretching Phase I ACL Rehab cont d Patellar mobility Infrapatellarcontracture syndrome adhesions of med/lat retinaculum - will limit ROM and cause difficulty with quad activation Normalize gait once quad allows (2-3 weeks) Brace until independent SLR Crutch(es) until normal gait Focus on TKE during gait Basic neuromuscular control Weight shifting, single leg stance, soft surface, simple movements with opparm and/or leg Minimize number of visits if ptdoing well 3

4 Phase II ACL Rehabilitation (2-6 weeks) Range of Motion Progress into deeper flexion as swelling decreases Maintain full extension! Strength Progress double to single leg CKC as pttolerates Leg press, lateral step downs, retro step ups, single leg squats Posterior chain strength (hip extensors, abductors and ext rotators) Higher reps with lower weight (2-3 sets of reps) Gait: continue to normalize as needed (one crutch) Proprio/neuro re-ed: Perturbation training -core and lower extremity Forward reach, floor touch, etc Exercise Considerations OKC vs CKC ACL loading generally greater with OKC (90-60 is ok) Generally more stable with CKC (joint compression) With both OKC and CKC, ACL loaded at degrees flexion (10-30 most) Greatest amount of quad and hamstring co-contraction is at 30 degin CKC Loads change depending on form and technique Ant knee = more load Forward trunk lean = less load (hamstrings and glut activation) During squatting and lunging activities keeping heels on ground decreases stress on ACL by 3x Peak tensile force on ACL Strength vs Neuromuscular Control Open Chain Isometric seated knee extension: 396 N at degrees of extension Dynamic seated knee extension using 12 rep max: 158 N at 15 degrees Other measurements Walking: 303 N Double leg drop landing from 60cm platform: 253N Single-leg landing from a running stop: 1294N Closed Chain Leg press 0-90 using 12 rep max: 0 N Single leg squat with 12 rep max :59N Forward Lunge: 0 N Escamilla RF et al. JOSPT 2012 Mind s attempt to teach the body conscious control of a specific movement Requirement for dynamic joint stability strength not enough! Clinically: can have good objective strength but observing valgus motion indicates a potential control problem Neuro training vs. Strength training Look For Valgus Early in Rehab! Risberg MA 2009 Dynamic valgus in lateral step down exercise Initial emphasis on good technique, then increase step size and reps to build strength Images from Rabin et al, JOSPT

5 Functional Testing Non-sport specific testing at 3 months: Single leg squat (depth in degrees) Retro step up (height) with no external support Standing anteromedial and anterolateral reach Single leg stance Single leg bridges Front plank Anecdotal goal = 80% in all phases Good time to check in and gauge progress, identify and treat deficits before returning to higher phase activities Remember graft is relatively weak Phase III Walk to Jog (12 weeks post op) Walk to run program Standardized, progressive With allografts some surgeons may wait until weeks Increase tolerance to impact activities, continue icing to control effusion/pain Treadmill 3x/week, continue strengthening/proprio opposite days Lower reps, higher weights (1-2 sets of 6-8 reps) Increase squat depth Continue to progress strength and endurance to combat fatigueinduced poor neuromuscular control Agility Progression Once patient can tolerate running 20 minson treadmill without pain or effusion Agility ladders Double leg to single leg Forward to lateral Box drills Figure 8s Start to see pts more frequently, ideally weekly, to progress through most important phase Working on conditioning vs rehab Jump Progression Jump progression (Neuro Re-ed) Double leg Symmetric landing in terms of timing, body weight percentage and depth Deep knee flexion angles for hamstring recruitment and soften landing Stable to unstable surfaces (foam pad, bosuball); straight to lateral Progress to single leg with same principles Continue to focus on landing softly with good depth and frontal plane control Single leg hop and hold to single leg jump; unstable surface landings, 90 degree turns, etc Develop plyometric strength, return to sport Plyobox hops, scissor jumps, tuck jump progressions, etc Working out 3-5x/week Simple non reaction sport drills can be implemented 6-8 Month Functional Test Components: Hop testing Previous strength/proprio(single leg squat, retro step up, ant/med and ant/lat reach) Y Balance Plank Goal: >90% in all phases Modified testing (Single leg squat off platform,90/90 hamstring bridge, Y balance, tuck jumps, side planks) Quantitative and qualitative scoring In addition to: Symmetric and painfreerom Full quad and hamstring strength-isokinetic testing Symmetric laxity testing Other Functional Tests Landing Error Scoring System Vail Sport Test Tuck Jump Assessment FMS In a 2011 systematic review only 35/264 (13%) articles reviewed included some measurable objective criteria for RTS following ACLR (Barber-Westin and Noyes 2011) 5

6 Importance of Functional Test MDs typically will judge return to play on these numbers! Quantitative analysis of symmetry MD viewpoint Qualitative analysis of movement to identify areas of specific weakness PT viewpoint Hopping numbers generally most important (most functional) Allows patient, therapist, parents, coach and MD to all be at common understanding Decide whether to continue formal PT, return to sport/acl bridging programs, or return to sport When Am I Done? 6 month functional test > 90% in all areas Good knee frontal/saggital plane stability and control at full speed movements requires: Sufficient cardiovascular conditioning Engaged quads/hams/gastrocs/hip abductors/trunk and core Dynamic knee stability with coordinated movement patterns Sports specific movements at full speed High confidence with no fear of re-injury during higher level tasks Return to sport based more on movement patterns and quantitative hop data vs time since surgery and passive laxity 4 measures of neuromuscular asymmetry highly predictive of second injury risk in athletes who underwent ACLR Return to Pre Injury Level: How Are We Doing? 67% returned to some form of sports by 12 months, 33% attempted competitive sport; patients with > 85% hop scores more likely to return (Arden AJSM 2010) 82% returned to some sports, 63% returned to pre injury level of function, 44% had returned to competitive sport at final follow (48 studies including pts at avg 41 months) (Arden Br J SM 2011) 22% of NBA players did not return to competition and 44% returned but at decreased level of performance following ACLR(Busfield 2009) Of 33 ACL injuries in NFL running backs and wide receivers, 1/5 never returned to NFL game; average player performance decreased by 1/3 (Carey 2006) Hewett TE 2013 Barber-Westin SD et al 2011 Barber-Westin SD et al

7 The Dreaded Re-Tear Dependent on age, sex and activity level IR following ACLR was 15x greater than that of control group; females were 4x more likely to have ipsilateral injury and 6x more likely to have contralateral ACL tear (Paterno et al) Rate of subsequent injury to the ACL on either side was age dependent, 17% for patients less than 18 years of age, 7% for patients aged 18 25, and 4% for patients older than 25 (Shelbourne et al) KaedingCC 2011 Why So Many Re-injuries? Rehab not effective in addressing deficits related to initial injury Criteria for RTS not adequate to address deficits Rehab does not address preinjury predisposing factors on injured and uninjured side Residual deficits on post surgical limb place uninjuired limb at greater risk Who Can t Make it Back? For some patients (11%) life (marriage, new job, children, decrease in previous desire) limits their return to pre injury sports participation For some patients their knee limits their return Fear of re-injury (19%) Problems with knee function/structure (13%) Population with underlying poor strength/neuromuscular control/confidence, along with a desire to return to competitive sport is ideal for ACL bridge program Barber-Westin SD et al 2011 TRIA Lower Extremity Agility Program Return competitive athletes to sport Based on two prevention ACL neuromuscular training programs: Mandelbaum et al (15 min neuromuscular warm up) Myer et al (60 min intensive strengthening and technique) Requirements: Minimum 5 months post op 75-80% symmetry on hop testing MD approval Set up: 2x/week for 6 weeks maximum of 6 participants PT/ATC for close monitoring of technique and form Progression through 5 stages of 10 exercises each Myer 2008 Video Analysis Qualifies movements Valgus, squat depth, trunk control Landing symmetry and timing of landing How athletes think they re moving vs how they re actually moving Real time visual feedback Components: Drop vertical jump landing (saggital and coronal) Crossover triple hop (saggital) Single leg squat (saggital and coronal) Deceleration (saggital) 7

8 Neuromuscular Control (or lack of) Dynamic valgus one objective indicator of poor neuromuscular control Concept of altered pelvifemoral control and weakness throughout lower extremity chain which puts knee in a highly vulnerable position Predict ACL injuries with high sensitivity and specificity (Hewett 05) Through training can be modified to reduce ACL injury risk (Hewett 99) Myer et al Clin Sports Med 2008 Hewett AJSM 2005 Qualitative vs Quantitative Improvements Neuromuscular programs are primarily geared towards improving qualitative patterning to decrease high risk positions (ie valgus during jump landings) Proven to decrease injury risk What about quantitative improvements? Hewett AJSM

9 TRIA PT Clinical Research Quantitative Improvements In Hop Test Scores Following A 6 Week Neuromuscular Training Program Retrospective analysis of ACLR patients who have completed LEAP Outcome measures: single leg hop, triple hop, crossover triple hop and timed hop Hypothesis: both legs will show absolute and relative improvement with the affected (surgical) leg showing relative greater improvement ISAKOS E-poster in Lyon, France June

10 Improvements following ACL aftercare program Myer GD et al. Neuromuscular Training improves performance and lower-extremity biomechanics in female athletes. Journal of Strength and Conditioning Research. 19(1), (2005). Is the Juice Worth the Squeeze? Effectiveness Quantitative Gains with single leg hop but still not as good as uninvolved Does improved hop testing LSI decrease ACL re-tear risk? Qualitative Improved neuro control = long term retention? Push athletes beyond comfort zone of traditional rehab into more sport specifics and conditioning Significant cost and time commitment Are gains made following program maintained at 3 mo? 6 mo? 2 yr? Conclusions Functional testing is a valuable tool to quantify outcomes but quality of movement patterns equally as important Progression through rehab stages is more function dependent than time dependent Concept of dynamic valgus and associated biomechanical weaknesses predispose (female) athletes to ACL injury LEAP type programs are becoming increasingly more common in an attempt to return athletes to pre injury level of function Video analysis provides tools for quantifying abnormal mechanics and also providing feedback to athletes Questions? References Arden CL et al. Return to Preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two thirds have not returned by 12 months after surgery. AJSM 39(3); (2010). Arden CL et al. Return to sports following ACLR surgery: a systematic review and meta analysis of the state of play. Br J Sports Med. 45(7) (2011). Arden CL et al. Return to sport outcomes at 2 to 7 years following anterior cruciate ligament reconstruction surgery. AJSM 40(1) 41-48; Barber-Westin SD et al. Objective criteria for return to athletics after anterior cruciate ligament reconstruction and subsequent reinjury rates: a systematic review. PhysSportsmed ( ). Carey JL et al. Outcomes after Anterior Cruciate Ligament Injuries to Running Backs and Wide Receivers in the National Football League. AJSM 34(12) (2006). Escamilla RF et al. Anterior Cruciate ligament strain and tensile forces for weight-bearing and Non-weight bearing Exercises: A guide to exercise selection. J Orhtop Sports PhysTher2012;42(3), Fitzgerald GK. Open versus Closed kinetic Chain exercise: Issues in rehabilitation after anterior cruciate ligament reconstructive surgery. JOSPT 77(12); Hewett TE et al. The Effect of Neuromuscular Training on the incidence of knee injury in Female athletes: A prospective study. Am J Sports Med 27(6), (1999). Hewett TE et al. Biomechanical measures of ofneuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: A prospective study. Am J Sports Med ; 33 (4) Hewett TE et al. Plyometric Training in Female Athletes: Decreased Impact Forces and Increased Hamstring torques. Am J Sports Med 24(6), (1996) Hewett TE et al. Current Concepts for Injury Prevention in Athletes after Anterior Cruciate Ligament Reconstruction. Am J Sports Med 41(1), (2013). References Jackson et al. A comparison of patellar tendon autograft and allograft used for anterior cruciate ligament reconstruction in the goat model. Am J Sports Med Kaeding CC, Aros B, Pedroza A, et al: Allograft versus autograft anterior cruciate ligament reconstruction: Predictors of failure from a MOON prospective longitudinal cohort. Sports Health 2011;3[1]:73 81.) Koga et al. Mechanisms of Noncontact anterior cruciate ligament Injuries: Knee joint kinematics in 10 injury situations from female handball and basketball. Am J Sports Med 38, (11) (2010) Myer, GD et al. Trunk and hip control neuromuscular training for the prevention of knee joint injury. Clinics in Sports Med 27; (2008). Myer GD et al. Tuck jump assessment for reducing anterior cruciate ligament injury risk. Athl TherToday. 13(5): (2008). Myer GD et al. Neuromuscular Training improves performance and lower-extremity biomechanics in female athletes. Journal of Strength and Conditioning Research. 19(1), (2005). Noyes, FR et al. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med 19 (5) (1991). Quelard B et al. Preoperative factors correlating with prolonged range of motion deficit after anterior cruciate ligament reconstruction. Am J Spots Med 38 (10) (2010). Risberg MA et al. Neuromuscular Training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. PhysTher 87 (6) (2007). Risberg MA et al. The long term effect of two post operative rehabilitation programs after ACLR: A RCT with two year follow up. AJSM Wilk KE et al. Recent advances in the rehabilitation of Anterior Cruciate Ligament injuries. J Ortho Sports PhysTher 2012;42(3),