ACL Reconstruction Surgery

Transcription

1 ACL Reconstruction Surgery -Patient Return to Play Checklist- Clip this checklist to the patient chart and upon completion, insert in file. Patient s Name: Medical Record Number: Date of Birth: / / (Apply patient sticker over header if available) Date of Surgery: / / Post-operative anterior cruciate return-to-play protocol: Patient s graft incorporation and graft strength has been considered Patient s functional range of motion is restored Patient has a stable knee with no pivot Functional return of patient s core, hip, quadriceps and hamstring strength has occurred, as determined by clinician discretion (can be measured by a variety of methods) Patient s functional balance restored Patient attests or surgeon observes functional skills are performed adequately Patient is confident that they are ready to return to sport of interest Patient has been advised to participate in an ongoing ACL-prevention/ movement-retraining program Clinician Signature: Date/Time:

2 2000 IKDC SUBJECTIVE KNEE EVALUATION FORM Your Subject Full Name ID#: Today s Date: / / Date of Injury: / / Day Month Year Day Month Year SYMPTOMS*: *Grade symptoms at the highest activity level at which you think you could function without significant symptoms, even if you are not actually performing activities at this level. 1. What is the highest level of activity that you can perform without significant knee pain? 4 Very strenuous activities like jumping or pivoting as in basketball or soccer 3 Strenuous activities like heavy physical work, skiing or tennis 2 activities like moderate physical work, running or jogging 1 Light activities like walking, housework or yard work 0 Unable to perform any of the above activities due to knee pain 2. During the past 4 weeks, or since your injury, how often have you had pain? Constant 3. If you have pain, how severe is it? No pain Worst pain imaginable 4. During the past 4 weeks, or since your injury, how stiff or swollen was your knee? 4 Not at all 3 ly 2 ly 1 Very 0 ly 5. What is the highest level of activity you can perform without significant swelling in your knee? 4 Very strenuous activities like jumping or pivoting as in basketball or soccer 3 Strenuous activities like heavy physical work, skiing or tennis 2 activities like moderate physical work, running or jogging 1 Light activities like walking, housework, or yard work 0 Unable to perform any of the above activities due to knee swelling 6. During the past 4 weeks, or since your injury, did your knee lock or catch? 0 Yes 1 No 7. What is the highest level of activity you can perform without significant giving way in your knee? 4 Very strenuous activities like jumping or pivoting as in basketball or soccer 3 Strenuous activities like heavy physical work, skiing or tennis 2 activities like moderate physical work, running or jogging 1 Light activities like walking, housework or yard work 0 Unable to perform any of the above activities due to giving way of the knee

3 SPORTS ACTIVITIES: Page IKDC SUBJECTIVE KNEE EVALUATION FORM 8. What is the highest level of activity you can participate in on a regular basis? 4 Very strenuous activities like jumping or pivoting as in basketball or soccer 3 Strenuous activities like heavy physical work, skiing or tennis 2 activities like moderate physical work, running or jogging 1 Light activities like walking, housework or yard work 0 Unable to perform any of the above activities due to knee 9. How does your knee affect your ability to: Not difficult at all Minimally difficult ly Difficult ly difficult Unable to do a. Go up stairs b. Go down stairs c. Kneel on the front of your knee d. Squat e. Sit with your knee bent f. Rise from a chair g. Run straight ahead h. Jump and land on your involved leg i. Stop and start quickly FUNCTION: 10. How would you rate the function of your knee on a scale of 0 to 10 with 10 being normal, excellent function and 0 being the inability to perform any of your usual daily activities which may include sports? FUNCTION PRIOR TO YOUR KNEE INJURY: Couldn t perform No limitation daily activities in daily activities CURRENT FUNCTION OF YOUR KNEE: Cannot perform No limitation daily activities in daily activities

4 Knee injury and Osteoarthritis Outcome Score (KOOS), English version LK1.0 1 KOOS KNEE SURVEY Today s date: / / Date of birth: / / Name: Subject ID#: INSTRUCTIONS: This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to perform your usual activities. Answer every question by ticking the appropriate box, only one box for each question. If you are unsure about how to answer a question, please give the best answer you can. Symptoms These questions should be answered thinking of your knee symptoms during the last week. S1. Do you have swelling in your knee? Rarely Sometimes Often S2. Do you feel grinding, hear clicking or any other type of noise when your knee moves? Rarely Sometimes Often S3. Does your knee catch or hang up when moving? Rarely Sometimes S4. Can you straighten your knee fully? Often Sometimes Often Rarely S5. Can you bend your knee fully? Often Sometimes Rarely Stiffness The following questions concern the amount of joint stiffness you have experienced during the last week in your knee. Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint. S6. How severe is your knee joint stiffness after first wakening in the morning? S7. How severe is your knee stiffness after sitting, lying or resting later in the day?

5 Knee injury and Osteoarthritis Outcome Score (KOOS), English version LK1.0 2 Pain P1. How often do you experience knee pain? Monthly Weekly Daily What amount of knee pain have you experienced the last week during the following activities? P2. Twisting/pivoting on your knee P3. Straightening knee fully P4. Bending knee fully P5. Walking on flat surface P6. Going up or down stairs P7. At night while in bed P8. Sitting or lying P9. Standing upright Function, daily living The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A1. Descending stairs A2. Ascending stairs

6 Knee injury and Osteoarthritis Outcome Score (KOOS), English version LK1.0 3 For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A3. Rising from sitting A4. Standing A5. Bending to floor/pick up an object A6. Walking on flat surface A7. Getting in/out of car A8. Going shopping A9. Putting on socks/stockings A10. Rising from bed A11. Taking off socks/stockings A12. Lying in bed (turning over, maintaining knee position) A13. Getting in/out of bath A14. Sitting A15. Getting on/off toilet

7 Knee injury and Osteoarthritis Outcome Score (KOOS), English version LK1.0 4 For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) A17. Light domestic duties (cooking, dusting, etc) Function, sports and recreational activities The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your knee. SP1. Squatting SP2. Running SP3. Jumping SP4. Twisting/pivoting on your injured knee SP5. Kneeling Quality of Life Q1. How often are you aware of your knee problem? Monthly Weekly Daily Constantly Q2. Have you modified your life style to avoid potentially damaging activities to your knee? Not at all ly ly ly Totally Q3. How much are you troubled with lack of confidence in your knee? Not at all ly ly ly Q4. In general, how much difficulty do you have with your knee? ly Thank you very much for completing all the questions in this questionnaire.

8 IRB# ACL- Return to Sport Index Subject #: Session: Please answer the following 12 questions referring to your main sport prior to injury. For each question mark on the line between the two descriptions to indicate how you are feeling right now relative to the two extremes. 1. Are you confident that you can perform at your previous level of sport participation? Not at all Fully confident confident 2. Do you think you are likely to re-injure your knee by participating in your sport? ly Not likely at all likely 3. Are you nervous about playing your sport? ly Not nervous at all nervous 4. Are you confident that your knee will not give way by playing your sport? Not at all Fully confident confident 5. Are you confident that you could play your sport without concern for your knee? Not at all Fully confident confident 6. Do you find it frustrating to have to consider your knee with respect to your sport? ly Not at all frustrating frustrating

9 IRB# ACL- Return to Sport Index Subject #: Session: 7. Are you fearful of re-injuring your knee by playing your sport? ly No fear at all fearful 8. Are you confident about your knee holding up under pressure? Not at all Fully confident confident 9. Are you afraid of accidentally injuring your knee by playing your sport? ly Not at all afraid afraid 10. Do thoughts of having to go through surgery and rehabilitation again prevent you from playing your sport? All of the of the time time 11. Are you confident about your ability to perform well at your sport? Not at all Fully confident confident 12. Do you feel relaxed about playing your sport? Not at all Fully relaxed relaxed

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11 Subject: Session: Date: IRB: