ACL RehabilitationPhysical Therapy Review and Evidence Based Practice An In-Service Presentation by Sara Walsh
How Strong is the Knee Joint? • The knee is joint is necessary for ADLs as well as many sports. • The knee is a weight bearing joint, and therefore, must be stable.
Anatomy of the Knee: Ligaments • The knee is stabilized by several ligaments. • Anterior Cruciate Ligament • Posterior Cruciate Ligament • Medial Collateral Ligament • Lateral Collateral Ligament • The ACL is deep to the articular capsule of the knee joint. • The ACL runs from the posterior femur to the anterior tibia.
Function of the ACL • When the knee is extended, the ACL is taught and prevents hyperextension • The ACL prevents the tibia from moving too far anteriorly on the femur • Limits posterior rolling of the femoral condyles on the tibial plateau during flexion.
Trivia • What is the role of the ACL?
Answer • Prevents Knee Hyper-Extension
Why Does the ACL Fail? • The ACL is the most commonly injured knee ligament. • It is also the thinnest of all the knee ligaments. • Relatively poor blood supply • Middle genicular branches of the popliteal artery
Unhappy Triad of Injuries • The most common injuries in contact sports are ligamentous injuries • Unhappy Triad • 78% of all ACL injuries • Injury to the MCL, medial meniscus, and ACL • Most common type of football injury • Illegal lateral blow to the knee • Tears MCL and medial meniscus • Without the support of these two structures, all pressure is put on the ACL • ACL often tears due to its inherent weakness
Trivia • What are the three structures that are damaged with the “unhappy triad” injury?
Answer • Anterior Cruciate Ligament • Medial Collateral Ligament • Medial Meniscus
Mechanism of Injury • Hyper-extension and severe force directed anteriorly against the femur with the knee semi-flexed may tear the ACL • Second most common mechanism of injury • Non-contact
Men Versus Women • When injury to the ACL occurs in a noncontact manner, women are 3x more likely to tear the ligament • Risk Factors and Prevention Strategies • Environmental Prevention Strategy • Anatomical Risk Factors • Hormonal Differences • Biomechanical Factors
2006 Study on Young Girls • Quad dominance over hamstring • Antagonist to ACL • Decrease abductor strength • Increased ligament laxity • Prepubescent girls are at an increased risk for ACL injury.
Injury Prevention • In 2009 a study was done on high school female basketball players. • Those who participated in the prevention program of stretching, strengthening, plyometric exercises, and agility drills showed increased knee flexion and decreased Q/H ratio. • It is believed that injury prevention pre-training for female athletes would decrease risk of ACL injury.
Trivia • What is one reason why female athletes are more likely to injure their ACL than male athletes?
Answer • Increased Q/H ratio • Increased Ligament Laxity • Decreased Abductor Strength • Size of Knee Structures • Such as the femoral notch and ACL • Hormones • Lower Extremity Alignment
Patients Often May Live Day to Day with and Injured ACL • Secondary complications arise after prolonged ambulation on a knee with an injured ACL. • LCL and posterior-lateral joint capsule are stressed and become lax. • Individuals may develop quadriceps avoidance gait. • Patient tries to keep knee still during loading. • Patient is trying to reduce quadriceps contraction because the structure that keeps the knee from extending too much is absent.
Why a Patient with an ACL Tear May Have Difficulty Ambulating • Knee extension occurs in heel strike (initial contact), mid-stance, and terminal stance (heel off).
External Presentation of ACL Injury • Swelling occurs after several hours • If blood vessels are torn, swelling occurs immediately. • The patient will likely complain of pain and instability. • If swollen, the joint assumes a position of minimal stress: 25 degrees of flexion and quad contraction is inhibited by a the body’s protective mechanism
Physical Therapy Tests for ACL Pathology • Anterior Drawer Sign • How to Perform the Test: • Patient supine • Examiner holds patient’s knee at 90 degrees. • Stabilize femur with one hand while moving tibia anteriorly with other hand • Apply force to the posterior-medial aspect of the slightly laterally rotated tibia • Positive Sign: soft end feel and absence of infrapatellar slope
Physical Therapy Tests for ACL Pathology • Anterior Drawer Sign: Considerations • A torn PCL can lead to a false positive • Perform posterior sag sign test before the anterior drawer sign • Indicates possible injury of: • ACL (especially posterior lateral bundle) • Iliotibial band • MCL • Post-lat or Post-med joint capsule • posterior oblique ligament • Arcuate-popliteus complex • Can be done in various positions • Aka: Ritchie, Trillat, or Lachman Test.
Physical Therapy Tests for ACL Pathology • Lateral Pivot Shift Maneuver • How to Perform the Test: • Patient supine with hip flexed and abducted 30 degrees and medially rotated 20 degrees. • Examiner holds patient’s foot, slightly medially rotating the tibia while holding the knee with the other hand. • Valgus stress is applied as the knee is guided into flexion.
Physical Therapy Tests for ACL Pathology • Lateral Pivot Shift Maneuver: Considerations • Positive Test: • Tibia reduces or “jogs” posteriorly at 30-40 degrees of flexion • Patient states feeling of giving way. • A positive test is an indication of dynamic subluxation. • Protective muscle contractions in an apprehensive patient lead to a false negative test. • Tests for third degree sprains, or ruptures, of the ACL
Non-Operative Management Precautions • Exercises that should not be attempted: • Open chain terminal knee extension from 40-0 degrees with resistance applied to distal leg • Causes increased translation of the tibia • Squatting between 60 and 90 degrees • Causes increased translation of the tibia • Instead patient should do closed-chain exercises from 60-0 degrees and open chain exercises from 90-40 degrees
Non-Operative Management • Maximum Protection Phase (Weeks 1-3) • Interventions • PRICE • (pressure, rest, ice, cold, elevation) • Ambulation Training • Transfer Training • PROM/AROM • Grades 1 and 2 Patellar Mobilizations • Quad, Hamstring, and Hip Adductor Sets • Straight Leg Raises • Aerobic Conditioning
Non-Operative Management • Moderate Protection Phase (Weeks 3-6) • Interventions • Multiple Angle Isometrics • Progressive Resistance Exercises • Closed-Chain Strengthening • Lower Extremity Flexibility • Endurance Training • Perturbation/Balance Training • At the end of this phase, initiate • Walk/jog • Skill-Specific Drills
Perturbation Training • A 2000 study showed that perturbation training during non-operative rehab reduced the number of instances of the knee giving way and allowed patients to be active for longer periods of time. • Longer carry over of high scores on an ADL self scale and global knee rating self scale from post treatment to a 6 month follow up. • Longer carry over of high scores for single and double leg hop tests for distance.
Trivia • Name one way perturbation training helps patients who have an ACL pathology
Answer • Decreased Knee Giving Way • Longer Carry Over of High Self Scores on ADL Scale • Longer Carry Over of High Scores for Single and Double Leg Hop Tests for Distance.
Non-Operative Management • Minimum Protection Phase (Weeks 5-8) • Interventions • Continue LE Flexibility • Advance PRE Strengthening • Advance Closed-Chain Exercises • Advance Perturbation Training • Advance Endurance Training • Isokinetic Training (If Available) • Running Program
Non-Operative Management • Return to Activity (Weeks 6-10) • Interventions • Continue Flexibility and Strengthening • Advance Agility Skills • Advance Running Drills • Advance Perturbation Drills • Integrate Sport or Occupation-Specific Drills
Indications for ACL Surgery • Disabling instability • Frequent knee giving way that limits ADLs • Positive lateral pivot shift test • Injury to MCL as well • High risk of re-injury due to life style (sports)
Surgical Intervention • Joint Effusions Treated by Joint Aspirations • Decrease the amount of extra fluid in joint cavity due to infection or inflammation. • Arthroscopy • Endoscopic examination that allows visualization of the interior of the knee joint cavity with minimal disruption of tissue. • Mechanism for ligamentous repair/replacement
Types of Ligament Surgery • The ACL is the most frequently surgically repaired ligament. • Direct Repair • Re-oppose and suture the torn ligament • Associated with a long period of immobilization and restricted weight bearing due to tissue disruption and poor healing capacity of ligaments • Less often used • Graft • Form new ligament • Less tissue morbidity and strength is regained faster
Types of Grafts Auto-graft • Patient’s own tissue • Gold Standard: Bone-Patellar Tendon-Bone • Semitendinosus/Gracilis Tendon • These tendons are actually stronger than the natural ACL • Period of avascular necrosis • Revascularization occurs and then remodeling • Most vulnerable during the first 6-8 weeks • Because strength of graft is derived from fixation rather than graft itself • Post-op immobilization and non-weight bearing has been eliminated • However; progression of weight bearing is utilized.
Types of Ligament Surgery Allograft • Donor tissue Synthetic Graft • Man-made replacement • Allografts and synthetic grafts are only used when there are no available tissues from the patient.
Trivia • Which type of graft do doctors prefer to use? • Auto-graft • Allograft • Synthetic Graft
Answer • Auto-graft
Surgical Management • Maximum Protection • (Weeks 1-4) • Ankle Pumps • PRICE • Gait training • AROM/PROM • Weeks 3-4: • Progress to FWB • SLR in 4 Planes • Muscle Setting • Low Load Hamstring PREs • Initiate Open Chain Knee Ext (Between 90-40 degrees) • Trunk/Pelvis Stabilization • Stationary Cycle (Aerobic Conditioning) • Pain control
Eccentric Exercise • A 2009 study confirmed that eccentric exercise after ACL reconstruction surgery results in patient gains at a 1 year follow up. • Increased quad and gluteus muscle volume • Increased quad strength • Increased hopping distance
Electrical Stimulation • A 2008 study proved that the use of electrical stimulation for pain control in ACL rehab after surgery: • Shortened recovery time • Decreased joint inflammation • Faster return to normal range of motion • Less frequent use of NSAIDS
Surgical Intervention • Moderate Protection (Weeks 4-10) • Multiple Angle Isometrics • Advance Closed Chain and PRE • LE Stretching • Endurance • Proprioceptive Training • Stabilization • Weeks 7-10 • PNF for Endurance and Flexibility • Advance Proprioceptive Training • Initiate Walk/Jog Program • Initiate Plyometric Exercises
Surgical Intervention • Minimum Protection (Weeks 11-24) • LE Stretching • Advance PREs • Advance Closed-Chain and Plyometric Exercises • Advance Proprioceptive Training • Progressive Agility Drills • Simulated Work or Sport Specific Endurance Training • Progress Running Program to Full Speed Jogging, Sprints, and Cutting
Neuromuscular Training • A 2007 study showed that patients who performed dynamic joint stability exercises, plyometric, and agility drills: • had higher Cincinnati Knee Scores and • lower VAS scores than patients who performed strength training alone.
Trivia • How do patients benefit from neuromuscular training?
Answer • Decreased Pain • Increased Function • Increased ROM • Increased Strength • Decreased Swelling • Increased Activity Level
Surgical Intervention • Return to Activity • Progress PREs and Flexibility Exercises • Advance Agility Drills • Advance Running Drills • Determine need for protective bracing when returning to sport or work
Protective Bracing • In 2001, a study was done to assess the effectiveness of ACL braces in aiding knee proprioception and postural control. • It was found that bracing is helpful in patients who have somatosensory limitations (blindfolded.) • Patients who used braces had difficulty carrying over gains to functional use. • It was concluded that the use of bracing after ACL injury is questionable.
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