ACL REHAB Steve Sanchez, PT, OCS, Cert MDT
Objectives Problems with the stiff ACL knee Importance of full knee extension early Identify loads during common exercises and activities Describe exs to achieve optimal movement and return to sport
General Concepts and Principles 1. Immediate motion 2. Early weight bearing 3. Full passive knee extension 4. Immediate muscle training 5. Closed kinetic chain exercises 6. Functional activities 7. Proprioception training
Factors related to ROM deficits Pre-operative motion loss 1 Injury Severity 2 Prolonged post operative immobilization 3 Delayed P.T. 2 Length of time between injury and surgery? 4 Surgical techniques 5 Therapy techniques
Complications Changes arthrokinematics and contact pressures Anterior knee pain Increase in quad and HS activity and early fatigue Quad muscle strain As little as 5 deg. alters gait 2 Increase OA 6
What is full Extension? 0 degrees? Some degree of hyperextension? Equal to opposite? Within 2 deg of contralateral (AAOSM)
Extension ROM Alternate measurement: Heel height difference 1 cm = 1 deg of knee flex contracture
Incidence True incidence unknown due to differences in definition of extension loss Mauro et al, 2008 1 25%: loss of extension 4 wks after ACL Of these 48% remained with deficit and/or required arthroscopic debridement Carneiro, Nakama, Luzo 7 : 7-17% incidence Improving now with improved surgical techniques and early motion/wb rehab
Extension Early ROM does NOT increase incidence of instability 8 Critical to normal painfree knee function 6 The earlier the better Goal: Week 1-2
Flexion Week 1: 90 deg Week 2: 105-115 Week 3: 115-125 Week 4: >125 Heel to glut at 4-6 wks
Flexion As little as 10 deg flexion loss: Changes in running speed Squat and kneel
Treatment Control swelling Compression Vasopneumatic device Patient education Scar mobs Flexibility training Patella mobility (Especially if bone-tendon-bone) Joint mobs (Caution with ant tib glides early on) Drop-lock bracing
Low load/long duration principles9-10
Easy to get them back, hard to keep them back -Bill Knowles
Neuromuscular Training It is the best brace we can give our patients!!
Mechanoreceptors 13 ACL Reflex Direct stress to normal ACL results in reflex hamstring activity Significant number of mechanoreceptors exist in the ACL These along with PCL, collateral, and capsular receptors play important role in proprioception Influenced by ROM loss
Proprioceptive training Perturbation training
Strength Training NMES Quad is inhibited Hamstring/Quad Muscle Ratios Recruitment order 14 Proximal Control
Weight Bearing vs Non-Weight Bearing Exercises CKC Functional Co-Contraction OKC Isolated Shearing forces
ACL forces during rehab15
Train the brakes
Train the brakes Stopping more important than starting Body positions Lean angles Decelerators Eccentric Training
Landing
Plyometrics One of the best tools to improve athleticism Explosive Focus on landing/eccentric phase
Agility MDSA (Multi-Directional, Speed and Agility)
Return to Sport Strength: Leg press 1 RM 10 RM
Return to Sport Balance: LE functional reach test
Return to Sport -Jumps 2-legged jump Single leg jump Hop for distance Cross-Over hop test Vertical Jumps
Speed and Agility tests Agility Tests T-test Illinois Test Speed Sport-specific testing
Take Home Points Early Extension=Less pain and less complications Avoid over-exercise early on Caution at 6-10 wks Takes time to recover 8 Train movements, not muscles MDSA and plyometric training
References 1. Mauro CS, Irrgang JJ, Williams BA, Harner CD. Loss of extension following anterior cruciate ligament reconstruction: analysis of incidence and etiology using IKDC criteria. Arthroscopy. 2008; 24: 146-53. 2. Magit D, Wolff A, Sutton K, Medvecky MJ. Arthrofibrosis of the knee. J AM Acad Orthop Surg. 2007; 15: 682-94. 3. Cosgarea AJ, Sebastialnelli WJ, DeHaven KE. Prevention of arthrofibrosis after anterior cruciate ligament reconstruction using the central third patellar tendon autograft. AJSM. 1995; 23: 87-92. 4. Kwok CS, Harrison T, Servant C. The optimal timing for anterior cruciate ligament reconstruction with respect to the risk of postoperative stiffness. Arthroscopy. 2013; 29: 556-65. 5. Millett PJ, Wickiewicz TL, Warren RF. Motion loss after ligament injuries to the knee. Part 1: Causes. AJSM. 2001; 29: 664-75.
References (continued) 6. Shelbourne KD, Urch SE, Gray T, Freeman H. Loss of normal knee motion after anterior cruciate ligament reconstruction is associated with radiographic arthritic changes after surgery. AJSM. 2012; 40: 108-13. 7. Carneiro M, Nakama GY, Luzo MV. Loss of extension after anterior cruciate ligament reconstruction treated with arthroscopic posteromedial capsulotomy. Ann Sports Med Res. 2015; 2: 1013-6. 8. Reid DC. Sports Injury Assessment and Rehabilitation. Philadelphia, PA: Churchill Livingstone; 1992. 9. Adams D, Logerstedt D, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. JOSPT. 2012. 42: 601-14. 10. Wilk KE, Reinold MM, Hooks TR. Recent advances in rehabilitation of isolated and combined anterior cruciate ligament injuries. Orthop Clin North Am. 2003. 32: 107-37.
References (continued) 11. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med. 2014; 42: 1567-73. 12. Shah VM, Andrews JR, Fleisig GS, McMichael CS, Lemak LJ. Return to play after anterior cruciate ligament reconstruction in National Football League athletes. AJSM. 2010; 38: 2233-9. 13. Solomonow M, Baratta R, Shou BH, el al. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. AJSM. 1987; 15: 207-13. 14. Barton CJ, Lack S, Malliaras P, Morrissey D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013; 47: 207-214. 15. Escamilla RF, Macleod TD, Wilk KE, et al. Anterior cruciate ligament strain and tensile forces for weight-bearing and non-weight-bearing exercise: A guide to exercise selection. JOSPT. 2012; 42: 208-20.