ACL REHAB GUIDELINES Clinic/Gym Exercise Program - PHASE I (Weeks 1-2 Post-Op) 2-3 x per week

Transcription

1 ACL REHAB GUIDELINES Clinic/Gym Exercise Program - PHASE I (Weeks 1-2 Post-Op) 2-3 x per week Isolated ACL Reconstruction (without meniscus repair or other ligamentous repair) This protocol details general guidelines for standard ACL rehab with some key exercises/goals in each phase. It should not replace a clinician's professional judgment or assessment of individual patient needs. *If you are an outside therapist and have questions, please contact us. Wake Forest Baptist Health, Sports Medicine, Phone: (336) * Work toward full knee extension * Active Range of Motion Knee Flexion > 90 deg by 2 weeks * Good quadriceps contraction * Good seated Straight Leg Raise Bike PROPRIOCEPTION TRAINING Double and Single Leg Balance Avoid hyperextension, Avoid trunk/pelvis/le compensations Quads engaged. Static and Dynamic. Look for phases of gait Weight Shifting Quad Sets Terminal Knee Extension Proximal Strengthening Leg Press Prone knee flexion B Heel Raises Straight Leg Raise Mini Squats MANUAL THERAPY Patellar mobilizations Heel Slides Others as needed For example: good heel strike, loading, push-off Full terminal knee extension without hyperextension To facilitate progressive weight-bearing without compensation Use biofeedback and/or NMES (Neuromuscular Electrical Stimulation) Focus on regaining good terminal knee extension. WB and NWB. Quad Sets. Prone quad sets. Standing TKE. For example: sidelying/supine hip abd/add, prone hip ext, isometrics <= 30deg knee flexion Active motion only, avoid pain. * Not with hamstring graft. Assisted at first. Do not start until able to perform good quad set. May modify position (ie standing/sitting) 0-30deg As needed Active, Active Assisted, Passive * Early emphasis should be on regaining full knee extension and improving quad contraction/quad control. Ensure appropriate wound care, including bathing restrictions and suture removal within appropriate timeframe If physician follow-up is more than days post-op, then ensure proper removal occurs * Brace locked in extension until patient demonstrates good quad set, good control with weight-shifting exercises, and able to perform single leg stance for at least 5sec * With hamstring autograft: NO resisted hamstring strengthening or hamstring isometrics * No active or resisted OKC Knee Extension before week 2 * Use modalities, including vasopneumatic compression, as indicated, to decrease edema and pain.

2 Clinic/Gym Exercise Program - PHASE II (Weeks 3-4 Post-Op) 2-3 x per week * Full passive knee extension * Active Range of Motion Knee Flexion > 110 deg * Good Straight Leg Raises (no quad/extensor lag) * Good MINI Squat 0-45 deg without compensation or weight shift * Walk without crutches Bike PROPRIOCEPTION/BALANCE TRAINING Double and Single Leg Balance Avoid hyperextension, Avoid trunk/pelvis/le compensations Quads engaged. Static and Dynamic. Progress Difficulty Look for phases of gait Regain full active TKE Squats Step Exercises Proximal Strengthening Leg Press Seated Leg Extension B Heel Raises Bridges Hamstrings For example: good heel strike, loading, push-off Full terminal knee extension without hyperextension Quad Sets w/ heel towel roll, SAQ, Stand TKE, prone quad sets, etc. Shallow depth, May use unstable surface such as rocker board Facilitate equal and symmetrical weight bearing, good mechanics Focus on good quad control Utilize mirror and cues. Avoid knee-forward posture. Avoid compensations (trunk/pelvis/le), emphasize good use of quads No more than 2-4 inches initially Forward Step-Ups, Lateral Step-Ups For example: sidelying/supine hip abd/add, prone hip ext, isometrics Single Leg, Partial ROM Start with AROM only; 30-40deg block (from full ext) with resistance Look for pelvis symmetry/equal height Prone, Standing, Seated (no leg curl machine yet) Caution with resistance with Hamstring graft for first 6 weeks MANUAL THERAPY Gentle scar mobilization, patellar mobilization, soft tissue mobilization as indicated Knee Flexion/Heel Slides Others as needed Active, Active Assisted, Passive * A strong emphasis should be placed on quad control and looking for quad avoidance. * Work on technique and avoiding trunk/pelvis/le compensations. * Wean brace/crutches with above criteria AND: able to perform small range single leg closed chain exercise without upper extremity support with good control; able to perform 10 reclined straight leg raises without lag. * Caution with quad strengthening and watch for anterior knee pain, especially with patellar tendon graft. * NO knee flexion resistance with hamstring graft * Use modalities, including vasopneumatic compression, as indicated, to decrease edema and pain.

3 Clinic/Gym Exercise Program - PHASE III (Weeks 5-8 Post-Op) 2-3 x per week * Full Active Knee Extension * Active Range of Motion Knee flexion <10% deficit vs. uninvolved * Normal Gait Pattern with good terminal knee extension * Able to perform > 6 inch step-up and >4 inch step down with good control, minimal/no pain Bike Elliptical, Stairmaster Consider at 6-8 weeks post-op, start with low intensity/duration PROPRIOCEPTION/BALANCE TRAINING Double and Single Leg Balance Avoid hyperextension, Avoid trunk/pelvis/le compensations Quads engaged. Static and Dynamic. Progress difficulty: Foam, BOSU, Minitramp, Rocker Board, etc. Normalize gait pattern Squats Leg Press Step Exercises Seated Leg Extension Hamstrings B Heel Raises Bridges Lunges >= 45deg, May use unstable surface such as rocker board Facilitate equal and symmetrical weight bearing, good mechanics Focus on good quad control Utilize mirror and cues. Single Leg Forward Step-Ups, Lateral Step-Ups, Step Downs 30-40deg block (from full extension) with resistance Caution with resistance with Hamstring graft Prone Leg Curls, Double Leg Swiss Ball Hamstrings Emphasize progression of repetitions, emphasize high reps Single leg progression when LE and core control demonstrated Weeks 6-8. Start with partial range, stationary. Progress to walking. Knee Flexion/Heel Slides Active, Active Assisted, Passive Quadriceps, Hamstrings, Calves, and Others as needed * A strong emphasis should be placed on quad control and looking for quad avoidance. * Work on technique and avoiding trunk/pelvis/le compensations. * Do not neglect working on good strength and control with terminal knee extension in weight bearing. * With proper healing of incisions, may utilize aquatic therapy as indicated. * Caution with quadriceps strengthening and watch for anterior knee pain. * Caution with knee flexion resistance with hamstring graft * Use modalities, including vasopneumatic compression, as indicated, to decrease edema and pain.

4 Clinic/Gym Exercise Program - PHASE IV (Weeks post-op) 2-3 x per week * Full Active Knee Extension * Full active assisted knee flexion * Quadriceps strength < 25-30% deficit vs. uninvolved * Able to perform single leg squat, 10reps, 40deg knee flex, with good biomechanics/balance Bike, Elliptical, Stairmaster Increase duration/intensity to improve endurance Encourage endurance training outside of the clinic: bike, elliptical, swimming, etc. PROPRIOCEPTION/BALANCE TRAINING Double and Single Leg Balance Avoid hyperextension, Avoid trunk/pelvis/le compensations Quads engaged. Static and Dynamic. Progress difficulty: Foam, BOSU, Minitramp, Rocker Board, etc. Normalize gait pattern Squats <= 100deg knee flex. May use unstable surface Facilitate equal and symmetrical weight bearing, Good mechanics Focus on good quad control Utilize mirror and cues. Single Leg: deg knee flexion Forward Step-Ups, Lateral Step-Ups, Step Downs deg block (from full knee ext) with resistance Prone Leg Curls, Double Leg Swiss Ball Hamstrings Emphasize progression to high reps Single leg progression when LE and core control demonstrated Walking Lunges, Split Squats Leg Press Step Exercises Seated Leg Extension Hamstrings Single leg Heel Raises Bridges Lunges Sidestepping with theraband Avoid hip/pelvis compensations Core and Proximal Strengthening as indicated Pre-Agility/Pre-Plyometric Activities: No jumping. Small controlled movements. Drop lands: start standing with heel raise and quickly drop to squat position. Progress to small 2-legged hops, progress to 6 in drop lands. BIODEX ISOKINETIC TRAINING (if available) Should be able to tolerate pain-free isotonics prior to progression to isokinetics Isokinetic Workouts: Start with deg/sec. 30 deg block until 12wks. Test: 60, 180, 300 deg/sec around 12wks Heel Slides Active, Active Assisted, Passive Quadriceps, Hamstrings, Calves, and Others as needed Prone child's pose stretch (prayer stretch/heel sit) * A strong emphasis should be placed on quad control and looking for quad avoidance. * Work on technique and avoiding trunk/pelvis/le compensations. * With proper healing of incisions, may utilize aquatic therapy as indicated.

5 Clinic/Gym Exercise Program - PHASE V: Pre-Sport Training (Months 3 to 6+ post-op) 2-4x/month * Full Knee AROM * Quadriceps and Hamstrings <15% deficit vs. uninvolved with isokinetic test, especially 60deg/sec (or 10-rep max) * Hop Tests < 15% deficit vs. uninvolved * Good control with sport specific drills, running, cutting, jumping * Review expectations and correlate with patient with patient status years old: 9-12 mo; 18+ years old: 6-12 mo. Bike, Elliptical, Stairmaster Increase duration/intensity to improve endurance Encourage endurance training outside of the clinic: bike, elliptical, swimming, etc. PROPRIOCEPTION/BALANCE TRAINING Higher level. Activity specific as indicated. Should have normal gait pattern Continue as indicated. Full range of motion resisted OKC knee extension as tolerated. May use eccentrics. Progress with activity specific, job specific, sport specific strengthening *Do not stop strengthening activities when you start agility/sport specific drills. Emphasize home program.* AGILITY AND PLYOMETRIC TRAINING Begin with slower, controlled movements. Work on good LE biomechanics and control of body weight over plant leg Activities should not begin prematurely. Do not allow excess compensation. If unsure how to progress, ask the surgeon and/or an experienced PT. BIODEX ISOKINETIC TRAINING (if available) Test: 60, 180, 300 deg/sec Goal of <15% deficit on involved knee. Goal of 66% hamstring/quadriceps ratio, peak torque, at 180 deg/sec FUNCTIONAL TESTING see Appendix A Noyes Hop Tests, Drop Land on single leg, Cutting drills, Sport-specific drills As indicated * A very strong emphasis should be placed on a progressive, independent home program since patient may be seen less frequently as this stage progresses. * Jogging only after patient shows good, pain-free controlled CKC exercises, basic hopping drills, and isokinetic testing should show < 30% deficit vs. uninvolved side. Perform good single leg 6 in drop lands. Start with walk/jog program. * Sport specific training should progress to increasing difficulty at this stage, but should progress gradually and only with sufficient strength and control. For example, jumping activities should not begin until good control is demonstrated with step-ups, hopping drills, and drop lands from heel raise position.

6 Clinic/Gym Exercise Program - PHASE VI: Return to Sport (Months 6 to 12+ post-op) 2-4x/month * Full Knee AROM * Quadriceps and Hamstrings strength <10% deficit vs. uninvolved with isokinetic testing (or 10-rep max) * Hop Tests < 10% deficit vs. uninvolved * Good control with sport specific drills, running, cutting * Review expectations and correlate with patient status; years old: 9-12 mo, 18+ years old: 6-12 mo Bike, Elliptical, Stairmaster Increase duration/intensity to improve endurance Encourage endurance training outside of the clinic: bike, elliptical, swimming, etc. PROPRIOCEPTION/BALANCE TRAINING Higher level. Activity specific as indicated. Should have normal gait pattern Do not neglect, continue as indicated. Full range of motion resisted OKC knee extension as tolerated. Progress with activity specific, job specific, sport specific strengthening AGILITY AND PLYOMETRIC TRAINING Begin with slower, controlled movements Work on good LE biomechanics, alignment, and control of body weight over plant leg Activities should not begin prematurely. Do not allow excess compensation. If unsure how to progress, ask the surgeon and/or an experienced PT. BIODEX ISOKINETIC TRAINING (if available) Test: 60, 180, 300 deg/sec Goals: < 10% deficit at all speeds. Goal of 66% hamstring/quadriceps ratio, peak torque, at 180 deg/sec FUNCTIONAL TESTING see Appendix A Noyes Hop Tests, Drop Land on single leg (good control 6-12in), Cutting drills, Sport-specific drills As indicated Phase VI Goals must be achieved for patient to receive clearance for return to sport. * Continued very strong emphasis should be placed on a progressive, independent home program since patient may be seen less frequently as this stage progresses. * Isokinetic testing should show < 10% deficit vs. uninvolved side at all speeds, especially 60deg/sec. * Sport specific training should progress to increasing difficulty at this stage, but should progress gradually and only with sufficient strength and control. For example, jumping activities should not begin until good control is demonstrated with step-ups, hopping drills, and drop lands from heel raise position. * Specific focus on acceleration and deceleration drills for running

7 Appendix A LOWER EXTREMITY TESTING FINAL PHASE FUNCTIONAL Single Leg Hop for distance Want maximum hop distance. Start on one leg, stick the landing on the same leg. Quality matters; patient must stick the landing. Give 2 practice hops. Final score is average of 3 completed reps Patient should be given no more than 6 attempts maximum. Measure in meters to 2 decimal places Calculate LSI (leg symmetry index) Timed 6 meter Hop Looking at how fast patient can cross 6m with repeated single leg hops on same foot. Give patient 1 practice attempt on each leg at 75% speed. Final score is average of 3 reps Calculate LSI (leg symmetry index) Cross-over Triple Hop for distance Want maximum hop distance with 3 hops on same leg, crossing a line with each hop. Quality matters; patient must stick landing on final hop and only single contact on initial 2 hops Give patient 1 practice at 75% effort Final score is average of 3 completed reps Patient should be given no more than 6 attempts maximum. Measured in meters to 2 decimal places Calculate LSI (leg symmetry index) Timed Triple Lateral Hop Drill Looking at how fast patient can hop with single leg, laterally, through 3 box setup, 3 times. Give patient 1 practice attempt. Final score is average of 3 completed reps Patient should be given no more than 6 attempts maximum. Calculate LSI (leg symmetric index) Show good control with sport specific hopping, jumping, and agility drills Observe and note the following: Symmetry Quality of Movement, including alignment and biomechanical control Speed * If functional testing is performed on the same day as isokinetic testing, the isokinetic testing will be performed first. This will standardize our testing procedure. Also, any fatigue that the athlete has from isokinetic testing will help to simulate fatigue that the patient will feel when jumping, running, and cutting during athletic training and games.

8 Appendix B ISOKINETIC TESTING GUIDELINES 1 Warmup on Bike x6min 2 Perform Warmup Exercises 1 Leg Press, single leg, light to moderate weight, 1 set of 15reps on each leg 2 Leg Extension, single leg, light to mdoerate weight, 1 set of 15 reps on each leg 3 Leg Curls, single leg, light to moderate weight, 1 set of 15 reps on each leg 3 Educate patient on isokinetic test expectations, effort needed, and test protocol 4 Perform Isokinetic Testing Uninvolved lower extremity tested first, followed by involved lower extremity Knee Extension/Flexion, Concentric/Concentric 60deg/sec 5reps, x2 180deg/sec 15reps, x1 300deg/sec 25reps, x1 Set range of motion: Extension: 30deg block until 12wks post-op, then set to ~15deg block ('full') * Patient comfort/'full' active ext with positioning on machine Flexion: usually deg, set to comfort with positioning on machine * ROM may be adjusted to avoid pain or for other reasons based on clinician's discretion Allow a few practice reps at each speed to give them a feel for resistance and ROM Be sure that patient uses the full range of motion on each leg Give patient 30sec rest time between each set Keep test the same between legs (ie same rest time, same number of practice reps) * If functional testing is performed on the same day as isokinetic testing, the isokinetic testing will be performed first. This will standardize our testing procedure. Also, any fatigue that the athlete has from isokinetic testing will help to simulate fatigue that the patient will feel when jumping, running, and cutting during athletic training and games.

9 Appendix C ACL PRE-OP REHABILITATION * Work toward full knee extension * Work on good knee flexion * Good quadriceps contraction * Closed kinetic chain and proprioception exercises as tolerated * Decrease edema * Educate in post-op expectations, give family guide handout

10 ACL TREATMENT GUIDELINES REFERENCE LIST Abrams, G. D., Harris, J. D., Gupta, A. K., McCormick, F. M., Bush-Joseph, C. a., Verma, N. N., Bach, B. R. (2014). Functional Performance Testing After Anterior Cruciate Ligament Reconstruction: A Systematic Review. Orthopaedic Journal of Sports Medicine, 2 (1), Dekker, T. J., Godin, J. A., Dale, K. M., Garrett, W. E., Taylor, D. C., & Riboh, J. C. (2017). Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury. The Journal of Bone and Joint Surgery, 99 (11), Fitzgerald, G. K., Lephart, S. M., Hwang, J. H., & Wainner, M. R. S. (2001). Hop Tests as Predictors of Dynamic Knee Stability. Journal of Orthopaedic & Sports Physical Therapy, 31 (10), Gokeler, A., Welling, W., Zaffagnini, S., Seil, R., & Padua, D. (2017). Development of a test battery to enhance safe return to sports after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 25 (1), Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L., & Risberg, M. A. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: The Delaware-Oslo ACL cohort study. British Journal of Sports Medicine, 50 (13), Kyritsis, P., Bahr, R., Landreau, P., Miladi, R., & Witvrouw, E. (2016). Likelihood of ACL graft rupture: Not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. British Journal of Sports Medicine, 50 (15), Logerstedt, D. S., Snyder-Mackler, L., Ritter, R. C., Axe, M. J., & Godges, J. J. (2010). Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain. Journal of Orthopaedic & Sports Physical Therapy. Omi, Y., Sugimoto, D., Kuriyama, S., Kurihara, T., Miyamoto, K., Yun, S., Hirose, N. (2018). Effect of Hip-Focused Injury Prevention Training for Anterior Cruciate Ligament Injury Reduction in Female Basketball Players: A 12-Year Prospective Intervention Study. The American Journal of Sports Medicine, Petschnig, R., Baron, R., & Albrecht, M. (1998). The Relationship Between Isokinetic Quadriceps Strength Test and Hop Tests for Distance and One-Legged Vertical Jump Test Following Anterior Cruciate Ligament Reconstruction. Journal of Orthopaedic & Sports Physical Therapy, 28 (1), Pinto, M. D., Blazevich, A. J., Andersen, L. L., Mil-Homens, P., & Pinto, R. S. (2017). Hamstring-toquadriceps fatigue ratio offers new and different muscle function information than the conventional nonfatigued ratio. Scandinavian Journal of Medicine and Science in Sports. Risberg, M. a, & Ekeland, a. (1994). Assessment of functional tests after anterior cruciate ligament surgery. The Journal of Orthopaedic and Sports Physical Therapy, 19 (4), Schelin, L., Tengman, E., Ryden, P., & Hager, C. (2017). A statistically compiled test battery for feasible evaluation of knee function after rupture of the Anterior Cruciate Ligament - Derived from long-term followup data. PLoS ONE, 12 (5). Toole, A. R., Ithurburn, M. P., Rauh, M. J., Hewett, T. E., Paterno, M. V., & Schmitt, L. C. (2017). Young Athletes After Anterior Cruciate Ligament Reconstruction Cleared for Sports Participation: How Many Actually Meet Recommended Return-to-Sport Criteria Cutoffs? Journal of Orthopaedic & Sports Physical Therapy,

11 Wilk, K. E., Romaniello, W. T., Soscia, S. M., Arrigo, C. A., & Andrews, J. R. (1994). The Relationship Between Subjective Knee Scores, Isokinetic Testing, and Functional Testing in the ACL-Reconstructed Knee. Journal of Orthopaedic & Sports Physical Therapy, 20 (2), Xergia, S. a, Pappas, E., Zampeli, F., Georgiou, S., & Georgoulis, A. D. (2013). Asymmetries in functional hop tests, lower extremity kinematics, and isokinetic strength persist 6 to 9 months following anterior cruciate ligament reconstruction. The Journal of Orthopaedic and Sports Physical Therapy, 43 (3),