ACL Rehabilitation Physical Therapy Review and Evidence Based Practice

1. ACL RehabilitationPhysical Therapy Review and Evidence Based Practice An In-Service Presentation by Sara Walsh

2. 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.

3. 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.

4. 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.

5. Trivia • What is the role of the ACL?

6. Answer • Prevents Knee Hyper-Extension

7. 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

8. 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

9. Trivia • What are the three structures that are damaged with the “unhappy triad” injury?

10. Answer • Anterior Cruciate Ligament • Medial Collateral Ligament • Medial Meniscus

11. 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

12. 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

13. 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.

14. 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.

15. Trivia • What is one reason why female athletes are more likely to injure their ACL than male athletes?

16. 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

17. 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.

18. 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).

19. 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

20. 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

21. 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.

22. 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.

23. 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

24. 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

25. 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

26. 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

27. 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.

28. Trivia • Name one way perturbation training helps patients who have an ACL pathology

29. 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.

30. 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

31. 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

32. 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)

33. 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

34. 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

35. 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.

36. 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.

37. Trivia • Which type of graft do doctors prefer to use? • Auto-graft • Allograft • Synthetic Graft

38. Answer • Auto-graft

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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.

45. Trivia • How do patients benefit from neuromuscular training?

46. Answer • Decreased Pain • Increased Function • Increased ROM • Increased Strength • Decreased Swelling • Increased Activity Level

47. 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

48. 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.

49. Works Cited • McKinley M, O’Loughlin VD. Human Anatomy. New York, New York. McHraw-Hill. 2008. • Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. Baltimore MD. Lippincott Williams & Wilkins. 2010. • Kisner C, Colby LA. Therapeutic Exercise. Philidelphia, PA. F. A. Davis Company. 2002 • Costello AR, Grey A, Chiarello C. Anterior cruciate ligament laxity and strength of quadriceps, hamstrings, and hip abductors in young prepubescent female soccer players over time. Orthopaedic PT Practice 23;1:11 7-12 • Lim B, Lee YS,Kim JG, An KO. Effects of sports prevention training on the biomechanical risk factors of anterior cruciate ligament injury in high school female basketball players. The American Journal of Sports Medicine. 37:9 1727-1734. • Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy of perturbation training in nonoperativeaclrehabilitaion programs for physically active individuals. PhysTher. (2000) 80(2): 128-140. • Gerber JP, Marcus RL, Dibble LE, Greis PE. Effects of early progressive eccentric exercise on muscle size and function after acl reconstruction. PhysTher (2009) 89(1): 51-59. • Benazzo F, Zanon G, Pederzini L. Effects of biophysical stimulation in patients undergoing arthroscopic reconstruction of acl. Knee Surg Sports TraumatolArthrosc. (2008)16: 595-601 • Risberg MA, Holm I, Myklebust G, Engebretsen L. Neuromuscular training versus strength training during first 6 months after acl ligament reconstruction. PhysTher. (2007)87(6): 737-750. • Birmingham TB Kramer JfKirdley A. Knee bracing after acl reconstruction. Med Sci Sports Exercise 2001; 33(8): 1253-1258.