Disclosure. Russ Paine, PT UTPhysicians Sportsmedicine Rehabilitation. Phase I ACL Rehab. ROM and Strength. Return to full competition in NFL 8 mos

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1 Disclosure Russ Paine, PT UTPhysicians Sportsmedicine Rehabilitation ACL Rehab Houston, Texas Lite-cure mtrigger Phase I ACL Rehab. ROM and Strength ACL/MCL injury on December 24, 2011 Grade III MCL Surgery: Dec. 30, 2011 Dr. Andrews Returned to Houston for rehab on January 10 Return to full competition in NFL 8 mos Timetables were not unusual Level of play was very unusual Skill position, ability to cut/pivot with no fear superhuman effort Revascularization of ACL Graft 4 phases Avascular graft necrosis Revascularization Cellular repopulation Remodeling & Reorganization collagen fibers (ligamentization Amiel 86 AJSM) Recent studies = intraarticular portion revascularizes faster than bone interface sites -diffusion Ntoulia AJSM 2011 Early Phase Motion? The more you know the more your patient knows Inflammatory response: macrophages, cytokines produce scar between graft and bone 4-10 days 6 weeks graft has vascular synovial envelope 6 weeks BPlug 6 weeks Tendon Tomita Arthroscopy 2001 dog model Rehab Brace 6 weeks 20 weeks intrinsic graft revascularization Fat pad, synovial tissue, bone tunnels = vascularity 1

2 Passive ACL Strain Passive ROM 0% strain 0-60, % strain in normal ACL Push extension wait on flexion(swelling) Renstrom AJSM 86 Quad Atrophy Still Enigma Rehabilitation AJSM March 2005 VL, VI smaller in ACL def. knee VMO still difficult to activate Atrophy = effects antigravity muscles Why? Prevalence of type I or II muscle fiber types Most effective method of reversing arthrogenic inhibition Muscle Atrophy and Inhibition Biofeedback versus EMS 30 ACL reconstructed knee patients Voluntary, EMS Voluntary, Biofeedback Voluntary After 6 weeks biofeedback group significantly greater involved isometric strength than EMS Draper PhysTherapy 91 BFR Blood Flow Restriction Limits but does not stop blood flow Creates hypoxic state Proposed to improve recruitment Decreased O2 Increased lactic acid = increased protein synthesis Low load w/fatigue Pre-op and Immediate Post-op Training Quad Re-cruitment biofeedback 10 Stimulate Proprioception (gait training, balancing activities) cone amb. Extension ROM techniques ERMI device SLR s up to 10# 5 Flexion contracture = locate pain Ant. Or Post. Ant = fat pad impingement Post = capsular scarring or hs spasm 2

3 ACL Tear = Loss of ProprioceptiveFunctionmust be Restored before return to sports Primary goal Rehabilitation Enhance muscle reaction time Stabilization/Recruit ment Gait Abnormalities Acute ACL Tears Decreased NM input Delayed quad firing heel strike Result = flexed knee gait pattern Increased PFJRF Force patient to squeeze quad at heel strike Treadmill amb. Quad/lesion avoidance gait MFC large lesion Single stance to terminal stance Pain/loss of control Step 2 Begin Gradual Loading Exercises Leg Press Best MR functional squat supine squat low load high endurance activity 60 second contractions Begin with 5Kg Quad EMG WB & NWB Wilk AJSM knee extension = highest EMG = 25 degrees Wilk AJSM leg press = highest EMG = 85 degrees Knee extension = requires high EMG due to lack of patellar height near extension Huberti = Fpt > Fquad 1 st 20d. 45d Fquad > Fpt = Careful with minisquats Trend is all functional rehabilitation Don t forget to strengthen! Quad weakness may be masked with functional rehabilitation exercise Return to sports develops PF pain, tendonopathy, effusion Don t drop strengthening 3

4 Functional Progression Testing Functional Hip/Core/LE Strength SL Squat Crossley AJSM 2011 A-participant demonstrates good performance B-participant demonstrates poor overall and trunk performance C-participant demonstrates poor pelvis and hip performance D-participant demonstrates poor hip and knee performance Chris Powers JOSPT 2003 Controlling femoral position Hip ABDuctor, G.Max, Lateral Rotation, NWB routine Hewitt AJSM 07 pelvic control - ACL Core Strengthening = Strengthens Kinetic Chain Rotational plyoball: hold VMO contraction Lower Abdominal Trunk flexion/extension using Swiss Ball Hewitt AJSM 07 Core control may be assoc. with ACL tear = pelvic control = kinetic chain = PF control ACL tear = loss of HS reflex Rehab. = re-gain Tsuda AJSM 01 Stim. ACL = reflex HS activity Response = Humans versus Solomonow = animal model Speeds deg./sec. May stimulate NM control Rapid reversal from ext./flexion HS curls, good mornings High Speed Biodex 4

5 Phase II Functional Strengthening Runners Pose Cone Reach PTG 2 ½ -3 mos. Treadmill Allograft ACL 3-4 mos. Timeframes dependent on quad strength and symptoms When to Run? Contact Forces PFJ Phase III Plyometrics and Sports Specific Training Plyometrics Develop: Strength Speed Power Good Proprioceptive Training Injury Prevention Not everyone needs to jump! 5

6 Quad Re-education Take-Off Bilateral Cone Hop Stick Recruitment = plyometric routine, single leg plyo s Sportsmetric Functional Drills Isokinetic strength, leg press Broad Jumps Progression to Single Leg Hop Maintain mechanics Must undergo double leg jumps Must have adequate core/quad control Agilities/Sports Specific The ability to change direction rapidly without loss of body control Uses Technique Conditioning Tracking post-op patient rehabilitation is critical to successful outcome. Each patient is objectively measured Y Balance ACL follow-up Day 6

7 Most Functional Tests: Quad Function Acceleration - no Deceleration Jump tests, running pivoting tests require minimum deceleration Quad functions most heavily during deceleration Brakes are vital to function Activity ACL Load (N)* ACL Strain (%) Squat/Sit to Stand Wall Squats 0 - Bicycle Step-Down Stair Climbing Single Leg Squat Walking Lachman test Isokinetic Knee Extension Isometric Knee Extension 396 (@ 35 o -40 o ) Double-Leg Drop Landing Single Leg Running Stop Adapted from Escamilla JOSPT 2007 Deceleration Ultimate Decelerator NBA Deceleration Rehabilitation = team effort Must know healing constraints Progression = strength, proprioception/balance, plyometrics/agilities Never progress patient until ready for next phase Conclusions Design Clinical Outcomes Following Arthroscopic Knee Surgery (COFAKS) High-Volume Single-Surgeon Clinical Database Prospective Cohort Data collection from August 2014-Present Currently over 1,100 patients Supports 5 ongoing clinical trials *Registered at ClinicalTrials.govID: NCT

8 Design PROJECT GOALS Capture objective data throughout the continuum of care for ACL reconstruction Establish normative data for clinical benchmarks Plot & Stratify recovery curves based on patient-specific factors odemographics o Surgical Procedures orehab Interventions Performance Criteria (0/10): 1. Tibial& Trunk Angle (Coronal) 0 yes 1 no 2. Tibial& Trunk Angle (Sagittal) 0 yes 1 -no 3. Knee Varus/Valgus 0 -neutral 1 -valgus 4. Number of steps 0 same as uninvolved 1 1 more than uninvolved 2 2 more than uninvolved 5. Symmetrical knee excursion Deceleration 0 same 1 reduced knee excursion 6. Symmetry of time 0 within 3% 1-3% -5% 2 -> 5% 7. Foot position 0 -Neutral 1 -Varus 2 -Valgus Performance Criteria (0/10): 1. Tibial& Trunk Angle (Coronal) 0 yes 1 no 2. Tibial& Trunk Angle (Sagittal) 0 yes 1 -no 3. Knee Varus/Valgus 0 -neutral 1 -valgus 4. Number of steps 0 same as uninvolved 1 1 more than uninvolved 2 2 more than uninvolved 5. Symmetrical knee excursion Deceleration 0 same 1 reduced knee excursion 6. Symmetry of time 0 within 3% 1-3% -5% 2 -> 5% 7. Foot position 0 -Neutral 1 -Varus 2 -Valgus Deceleration Results: Function at Release to Activity 7.8 mos *Responders(N = 301) 7.8 mos N = 301 Able To Participate (n = 212) Unable to Participate (n = 89) P-Value Extension ROM Deficits (deg) 1.9 ± ± * FlexionROM Deficits (deg) 4.1 ± ± Single Leg Squat Deficit (cm) 3.1 ± ±5.7 <.001* Single Leg Hop Deficit(cm) 4.6 ± ± * Quad Strength LSI (%)* 80.3 ± ± IKDC Score (0-87) 76.6 ± ±11.1 <.001* LSI Limb Symmetry Index Percentage of Uninvolved Limb at 60 deg/sec;*statistically Significant, Alpha =.05 8

9 Results: Return to Desired Activity Level *Responders (N = 301) Outcome SANE Score (0-100) 85.7 ±14.6 Reinjury(n) 2.3% (7) Ipsilateral(n) 5 Contralateral(n) 2 Able to Participate (%) 70.1% Post-Operative Physician Rounding Data collected On-Site Patients seen month until DC Approximately 20 patients/week Stratified based on healing timelines PT generated profile that includes the following factors: Setting Demographics N = 1181 Measure Age (yrs) 24.9 ±10.9 Gender (% male) 54.1% Height (in) 68.1 ±4.3 Weight (lbs) ±43.1 BMI (kg/m 2 ) 25.6 ±5.2 MARX (0-16) 11.1 ±4.5 Surgical Variables IKDC Change Over Time N = 1181 Surgical Setting Measure 80.7% -Primary 19.3% -Revision Meniscus Injury 66.5% Procedure Combined- Ligament Autograft- 72.8% Allograft % Repair - 3.5% 15.6% Staged (%) 3.6% 9

10 IKDC Change Over Time IKDC Change Over Time Knee ROM Y-Balance: Anterior Reach Return To Play Criteria ROM Symmetry 3 o deficit for Extension 5 o deficit for Flexion Strength Symmetry 90% LSI: 60, 180, 300 o /sec Single Leg Squat Symmetry Y-Balance Anterior Reach 4cm deficit Dynamic Jump Landing Landing Error Scoring System (LESS) Good, Fair, Poor Single Leg Hop Test 90% Symmetry of All 4 Tests Agility 95% Symmetry Figure of 8 Test 95% Symmetry Pro- Agility Deceleration Task Patient Reported Outcomes IKDC-2000 ACL-RSI MARX Deceleration N = 326 at 2.3 years ( ) SANE: 85.6 ±14.7 ReinjuryRate: 2.3% 5 Ipsilateral; 2 Contralateral Desired Level of Activity 70.3% Able to Participate Fully 29.7% Unable to Participate Fully Current Level of Participation 39.9% -Level % -Level % -Level % -Not Participating Follow-Up Data 10

11 Disclosure Objectives Lite-cure mtrigger Review current trends in ACL rehabilitation Review science of ACL rehabilitation Discuss early factors that make rehab successful Return to activity data Incidence of ACL Tears NCAA Dragoo AJSM 2012 Systematic review 10 studies 963 ACL injuries Artificial turf = 1.4 x higher than grass Players 10x more likely to tear ACL during gamethan practice Scrimmagesresulted in greater injury than regular practice ACL: Return to Play American Football Collegiate and HS Level McCollough AJSM % able to return Self reported subjective questionnaire: 43% able to resume pre-injury level 27% returned, but lower level 30% unable to return (67% other interests 50% feared re-injury) 165 players Risk of re-injury to ACL 78 patients followed 2 years after ACL Rec. 47 controls 27 of 125 = ACL tears 23 of 27 in ACL Rec. grp. 29% = 2 nd ACL tear 20% = opposite limb 9% re-tear of graft Female = 24%, Male =11% Opposite leg injury male = 11%, female 24% Paterno AJSM 2014 Flynn AJSM ACL reconstructed pts. 171 normal control Parents siblings children (first degree) 2x more likely to have ACL tear than non ACL family history Familial Predisposition to ACL Tears 11

12 Lentz AJSM 2015 ACL return to sports: fear factor, quad function, other 1 year s/p ACL 73 pts. 43 YRTS 27 NRTS 13 NRTS other 14 NRTS Fear confidence Quad weaknessassoc. with NRTS Fear, lack of confidence Return to Sports 1 year Factors NFL ACL injuries return to play Shah, Andrews AJSM % returned to play 10.8 mos. After reconstruction High draft pick (4 th round or higher) Greater than 4 years of play in NFL Greater odds to RTP Quadriceps and calf muscle atrophy Proposed Causes Quad Inhibition Decrease in muscle fiber size Shortened position (extension) immobilization Inhibition due to effusion/pain Type I muscle fiber decrease Lack of volitional contraction Decrease in oxidative enzymes Anti-gravity muscles may have more slow twitch fibers Atrophy = reduction in ST & FT and decreased oxidative enzymes and reduced mitochondria and ATP Goal = Awake ST!! Order of recruitment volitionalactivation begins with small MU progressing to larger MU Allows smooth increase in muscle strength = Henneman size principle MU types Type I or S (slow) smallest F, slowest contraction Type IIa(FR) fast resistant to fatigue larger force faster contraction times Type IIB (FF) fast fatigue largest F fastest contraction Muscle Recruitment Biofeedback Enhances Voluntary Muscle Recruitment Voluntary recruitement = ST to FT progression Intensity of contraction evident with each set Visual feedback more motivational 12

13 mtrigger Hip Flexor Stretch/Strengthening Small amp connected to electrodes Sends signal to smartphone via bluetooth Software download Records mvolts, bar graph, games Elkington L-3, L-4 partial discectomy R quad weakness Excellent recovery Biofeedback Smartphone Tracking post-op patient rehabilitation is critical to successful outcome. Each patient is objectively measured Y Balance ACL follow-up Day Used primarily during rehabilitation Ave. time for use after return = 8 weeks. ACL Knee Bracing Combination Core/LE/UE Slide Board End Stage Rehab Rehabilitation = team effort Must know healing constraints Progression = strength, proprioception/balance, plyometrics/agilities Never progress patient until ready for next phase Conclusions 13

14 Plyometrics When To Start Jumps 2 footed landing Hops 1 foot landing Bounds Jumping form one foot to the other Proprioceptive Full PROM Normalized Quadriceps Control Appropriate Time Period Controlled Joint Effusion Normal Ligamentous Exam Functional Assessment 50n High School FB Paine, Chicas, Harari Skilled vs Non-skilled positions Skilleddemonstrated strong correlation (r=.70) 60d isokinetic & SLBJ Non-skilledlow correlation (r=.30) 60d isokinetic & SLBJ Correlational Data (p < 0.05) 40-yd Shuttle SLBJ D SLBJ ND VJ D VJ ND 60 deg/sec Flexion dominant deg/sec Extension dominant deg/sec Flexion dominant deg/sec Extension dominant deg/sec Flexion non-dominant deg/sec Extension non-dominant deg/sec Flexion non-dominant deg/sec Extension non-dominant Conclusions: Functional Testing HS Football Players Skilled versus Nonskilled positions will have effect on strength to function correlations Body type has and effect on functional performance during function testing SLBJ Average dominant SLBJ Average non-dominant yd Shuttle ACL follow-up Day Tracking post-op patient rehabilitation is critical to successful outcome. Each patient is objectively measured Y Balance ROM HHD YBal Isom. SLBJ 14

15 Functional Assessment Readiness Functional Testing Summary Ironman Sports Medicine Institute At Memorial Hermann 6400 Fannin Suite 1620 Houston, TX ph Name: Date: / / DOS: / / 1) FMS Score: 2) Isokinetic Data: % deficit (Quads) % deficit (Hams) % BW H/Q ratio 3) Single-Leg Hop for Distance: Trial 1 Trial 2 Trial 3 Ave. Right: Left: % Normal: From static SL stance, toes behind starting line, athlete jumps as far as possible, landing on same foot. Athlete must hold landing for 2 seconds. Distance is measured from starting line to heel. Roundtable discussion Wilk Moderator Panel discusses treatment of ACL injuries in athletic patients: Orthopedics Today, January 2015 Current trends in ACL early, late rehabilitation James Cooper, Eric Sugarman Functional Exercise Must have adequate strength 15

16 Return to full competition in NFL 8 mos Timetables were not unusual Level of play was very unusual Skill position, ability to cut/pivot with no fear superhuman effort Rehabilitation = team effort Must know healing constraints Progression = strength, proprioception/balance, plyometrics/agilities Never progress patient until ready for next phase Conclusions 16