Criteria to Return to Play Kevin E. Wilk, PT, DPT, FAPTA ACL INJURIES Introduction ACL injuries common in sports & strenuous work» So frequent that the seriousness is often forgotten Totally disrupted more than any other knee ligament 200,000 ACL injuries annually Fu: AJSM 99 148,714 ACL surgeries in 2013 19 yrs: 58% increase in number ACL surgeries Wilk: JOSPT 15 Rehab has changed in the past 10 yrs Evidence Based Rehab Return to Normal Function ACL Injuries Introduction Over 200,000 ACL injuries annually 62-66% sports related, usually non-contact 70% Over 60% in males 67% occurs in individuals 15-29 yrs of age 26% occurs in 30-44 yrs 7% occurs in individuals above 45 yrs of age Carey et al: AJSM 06 Effects of ACL injury on running backs & wide receivers in the NFL players (N=33) 80% returned to NFL play Performance of those returning performance was reduced by 1/3 ACL Injuries Return to Play 78% of NBA players returned to play following ACL surgery Of the players returning: 44% experienced a decrease in in standard statistical categories & player efficiency ratings Busfield et al: Arthroscopy 09 1
2007 Shah, Andrews, Fleisig: AJSM 10 49 NFL players underwent ACL/PTG 63% returned to NFL play (31/49) Average length of time to return 10.8 mos Age, position & number of procedures not a factor in return rate Players who had more than 4 yrs of experience higher rate of return Players drafted in first 4 rounds higher rate of return to play 2
How Do You Know When Your ACL Patient is Ready to Run? Return to Sports? How Do You Know When Your ACL Patient is Ready to Run? Return to Sports? Post-Op ACL Reconstruction Functional Screening Test Return to Play Criteria Sport Specific Testing LE 1990 s ACL Testing Subjective Patient Assessment KT Test Isokinetics Hop testing Agility Runs Sport Specific Testing LE 2001,07, 09,12, 16, 18 Subjective Patient Assessment KT Test Isokinetics Hop testing Front step down Jump down Agility L run 4 corners Y balance FMS (?) Shuttles runs 3
AJSM 12 Isokinetic Testing Interpretation Data: 180 /s & 300 /s Q PT / BW ratio: (180 0 /sec) Males: 60-65% Females: 50-55% H/Q ratio: (180 0 /sec) Males: 66-72% Females: 75% > HPT / BW ratio: (180 0 /sec) Males: 40-43% Females: 37-40% Isokinetic Testing Interpretation of Data Bilateral comparison 75-80%??? Endurance ratio (300 0 /sec) Extensors: 12% or less Flexors: 9% or less Acceleration rates (180 0 /sec): QPT at.2 sec 80% or greater PT Acceleration rates (180 0 /sec) HPT at.2 sec (females) 4
Return to Sports After ACL Reconstruction: Systematic review of 48 studies reporting return to sports of 5770 individuals after ACL reconstruction at mean follow-up of 41.5 months Return to Some Form of Sports Return to Pre- Injury Level of Sports Return to Competitive Sports 82% (95% CI 73 to 90%) 63% (95% CI 54 to 71%) 44% (95% CI 34 to 56%) Men > Woman Seasonal Sports > Year Round Ardern CL et al. 2011 Kinesiophobia Fear of movement/reinjury I m afraid that I might injure myself if I play a sport or exercise Tampa scale for kinesiophobia Woby et al: Pain 05 Interventions which improve self efficacy may improve knee function short term Chmielewski et al: JOSPT 08 Chmielewski et al: Phys Ther 11 Lentz et al: JOSPT 12 Return to Preinjury Sports Participation Following ACLR Why Didn t They Return to Sports (n=42) * - more present in low level athletes elite athletes Instability* 31 patients responded they had instability 68% Quad PT/BW ratio* important test parameter quads are shock absorbers Wilk et al: JOSPT 94 correlation b/w QPT/BW IKDC scores (15 pts difference)* Knee effusion (present in 9 pts)* - 21% Pain scale difference* Tegner scale differences JOSPT 2014 5
ACL Rehabilitation Limb Confidence Perturbation Training to Enhance Neuromuscular Control Various levels of dynamic stability Stability Mobility Controlled Mobility Skill Perturbation skill one of highest level Improves clinical outcomes Wilk: J Athl Trn 99 Fitzgerald: Phys Ther 00 Must gradually progress to skill level drills!! Perturbation Training to Enhance NM Control Fitzgerald, Axe, Snyder-Mackler: Phys Ther : 00 Perturbation training ACL deficient knee patients (athletes) 26 patients isolated ACL rupture Randomly assigned to group:» A standardized program» Standardized program & pertubation training Results: 91% pertubation group return to play (6 months) 50% standardized group return to play (6 months) Perturbation Training to Enhance NM Control 6
Non-Operative Rehab Shoulder Instability The Weekend Warrior Knee Injuries ACL + The Weekend Warrior Movements with Poor Stabilization Linking LE & UE Linking Arms & Lower Extremity Linking LE & UE Movements Changing Directions 7
Movements & Change of Planes Lateral Slides Linking LE & UE Movements Changing Directions Reactive Drills Reactive Lateral Slides Movements with Stabilization Reactive Lateral Slides on Verbal 8
Movements with Stabilization Movements with Stabilization 4 Stages of Motor Skill Development Introduction Cognitive: new tasks & drills are introduced Associative: time spent thinking about new tasks Autonomous: automatic & efficient & develop skill Refining: refines the task to level of perfection Want to Reduce Re-Injury Rates 4 Things You Can Do! Chmielewski TL: Principles of neuromuscular control for injury prevention & rehabilitation. 2007 Reduce Re-Injury Rate by 84% Strict Criteria to Return to Sports Grindem, Snyder-Mackler, Engebretsen, et al: BJSM 16 Can we reduce re-injury rates in ACLR pts Delaware-Oslo ACL Cohort Study 106 patients ACLR 2yr FU 30% pts returning Level I sustained re-injury, 8% returning to a lower level (4x higher reinj rate) Every month delayed returned to sports until 9mos rate of re-injury was reduced 51% More symmetrical quadriceps strength prior to return to sports sign. Reduced re-injury rate 9
Paterno, Rauh,et al: AJSM 14 ACL reinjury rate following ACLR 78 subjects underwent ACLR return to sports 15x greater 2 nd ACL in subjects with ACLR if they return to sports during the first year 6x greater 2 nd ACL injury in subjects returning to sports within 12-24 mos Females ACLR 4x greater rate of injury 24 mos. 2x more likely to tear opposite knee ACL 30% athletes sustained 2 nd ACL inj 21% on contralateral side 9% opposite side Functional Movement Screen FMS Functional Movement Screen FMS Y Balance Test Post-Op ACL Reconstruction Return to Play Criteria 3 P Program: Performance Practice Play Post-Op ACL Reconstruction Return to Play Criteria 3 P Program: Performance Training: performance training sport specific drills plyometrics agility drills speed drills sport specific drills (cutting, deceleration, etc) 10
Post-Op ACL Reconstruction Return to Play Criteria 3 P Program: Practice situations: control practice gradual increase time, intensity, reps lower intensity to begin gradually increase intensity 50-60% 75% 80-90% 100% return to practice game (game simulation) Post-Op ACL Reconstruction Return to Play Criteria 3 P Program: Play: return to competition game situation 100% effort Return to Play Criteria What s New CATAPULT SPORTS DATABASE Acceleration 80 per player/day Velocity 80 IMA (inertial movement analysis) 80 Player Load 70 Metabolic 70 Heart Rate 80 TOTAL 300-400 data points per player per day GPS 8/27/2015 Tracking 15 8/26/2015 800 9000 EXPLOSIVE CHANGE OF DIRECTION TOTAL DISTANCE AND MAX PLAYER LOAD AND EXPLOSIVENESS VELOCITY 20 1.3 21.5 19 Hi Accels21.05 1.2 21 21 1.1 20.5 16 120 23 HI COD PLAYER 19.5 YARDAGE LOAD 0.9 EXP MAX RATIO HI COD 18 VEL Hi COD-R 19 0.8 18.5 25 0.7 18 17 0.6 EXPLOSIVE C.O.D. & SYMMETRY 7008500 25 Total distance 8000 20.16 20 4/3/2015 25 19.55 600 15 7500 19.47 Max velocity 3/27/2015 28 19.18 10 5007000 5 Player load 18.55 3/25/2015 6500 18 400 Hi COD-L 0 6000 Explosiveness 3/23/2015 26 3005500 High-speed yards 2014 AVG 5000 20 200 Inertial movement analysis (IMA) Other (metabolic, HR) 2014 AVG 3/23/2015 3/25/2015 3/27/2015 4/3/2015 0% 25% 50% 75% 100 8/26/2015 Hi Decels 8/27/2015 11
McGuine et al: AJSM 17 Sport specialization association with increased risk of lower extremity injuries in adolescent athletes 1544 participants (Grades 9-12) 29 Wisc HS 2843 athletic seasons (2015-16) 15% sustained LE injuries (n=235) Ankle 34%, Knee 25%, Upper Leg Inj 12% Sprains 41%, Strains 25% Athletes with moderate to high sport specialization were more likely to sustain LEI Reduce Re-Injury in Throwers Slower to Return to Play More Submax Throwing More time in ITP - Mechanics Strict Criteria to RTP/ITP Objective Functional Testing *%#^ Failla, Logerstedt, Grindem et al: AJSM 16 Does extended Pre-Op Rehab Influence Outcomes 2 years after ACLR MOON & Delaware-Oslo ACL Cohorts 150 patients in each group Criteria based when reconstruction is performed DOC group: strength training, ROM & NM drills The DOC group had significantly higher Return To Sports rate at 2 yrs 12-15% higher scores (IKDC, KOOS) DOC pre-op average Neuroplasticity Following ACL Injury Rehab Implications: Dual tasking Blindfolded Eyes closed Stroboscope glasses Visual elements Linking LE & UE Movements Changing Directions Reactive Drills Neuroplasticity 12
Neuroplasticity Following ACL Injury Rehab Implications: Dual tasking Blindfolded Eyes closed Stroboscope glasses Visual elements Unbalanced Bar Balance Drills Linking LE & UE Movements Changing Directions Reactive Drills Neuroplascity Unbalanced Balance Training 13
Linking LE & UE Movements Changing Directions Reactive Drills Neuroplascity Unbalanced Balance Training Motion Capture 14
ACL Injuries Linking LE & UE Movements Changing Directions Reactive Drills Neuroplascity Unbalanced Balance Training Motion Capture Proprioception & Neuromuscular Control Train Bilateral Not an isolated injury Injury affects both extremities For at least 3.6 mos Wilk, et al: CSM 03 Alters firing mechanism Wojtys, Huston: AJSM 94 9 8 7 6 5 4 3 2 1 0 Initial 2 weeks OVERALL 4 weeks 6 weeks 8 weeks 12 weeks 16 weeks 26 weeks 52 weeks Open Inv Open Non Closed Inv Closed Non Train the Uninjured Extremity Too!! Hamstring Exercises 15
Linking LE & UE Movements Changing Directions Reactive Drills Neuroplascity Unbalanced Balance Training Motion Capture Proprioception & Neuromuscular Control Immediate Stimulation of Receptors Co-Activation to Enhance Dynamic Stability Stabilization From ABOVE & BELOW Stimulation to Uninjured Extremity 16
Train the Uninjured Extremity Too!! Step Down Test Drop Vertical Jump 17