ACL Reconstruction Rehabilitation Tyler Opitz, DPT, SCS, CSCS March 1 st , 2019 Andrews Institute ‐ Gulf Breeze, FL
Objectives 1.Review criteria for progression to each phase following ACL reconstruction 2.Discuss integration of performance training throughout the rehabilitation process 3.Discuss progressive return to athletic participation testing following ACL reconstruction
Disclosures • I have nothing to disclose that pertains to this presentation.
ACL Injuries • ACL injuries are extremely common and also costly. • Most commonly injured ligament in the knee (Gordon, AAOS, 2004) • Females > males except 17 & 18 year olds in adolescents (Beck et al., 2017) • Estimated 250,000 ACL injuries each year in USA • Average cost for an ACL repair $25,000 ‐ 50,000 • Estimated cost of $1 Billion/yr for high school athletics Joseph et al. J Athletic Training 2013
ACL Fiber Orientation
ACL Injuries
Contact vs Non ‐ contact Contact Non ‐ Contact • Greater incidence of Grade • >75% of ACL injuries IV Chondral injury • More common • 2 fold increase in incidence • Associated with of collateral ligament injury neuromuscular control • 24.6% of ACL injuries deficits, weakness, age, sex, sport, higher activity level, allograft reconstruction Salem et al., 2018, Kaeding et al., 2015, Zebis et al., 2016
Contact vs Non ‐ Contact Contact Non ‐ Contact
Contact vs Non ‐ Contact Contact Non ‐ Contact
Closed Chain vs. Open Chain CKC OKC
Incidence ‐ Beck et al., 2017 ‐
Why so much attention on Football?
ACL Prevention • FIFA 11+ (Silvers ‐ Granelli et al., 2017) – 25% of intervention group had knee injuries • 16% ACL injuries when stratified for ACL – 75% of control group had knee injuries • 84% had ACL when stratified for ACL • Proper warm up prior to play (Daneshjoo et al., 2013) • Neuromuscular and proprioceptive training (Mandelbaum et al., 2005) • Dynamic Movement Assessment (Nessler, 2014)
ACL injuries by Sport College Athletics High School Labella et al., 2104
ACL Injuries by Age • ACL 3% of all injuries in college sports – ACL was 88% of injuries associated with 10 or more days time lost from sports participation. Labella et al., 2104
ACL Re ‐ tear NFL ACL injury • From 2010 ‐ 2013 in NFL: – 81.7% initial tears (n=179) – 12.3% were re ‐ tears – 2.28% suffered 3 rd ACL tear (n=5) – 7.3% were contralateral tears Dodson et al., 2016
By Position Position ACL Injuries, n Total Players, n ACL Injury Incidence, % Fullback 5 50 10.0 Guard 16 185 8.6 Wide receiver 38 473 8.0 Tight end 18 230 7.8 Linebacker 36 483 7.5 Running back 19 304 6.3 Center 6 97 6.2 Defensive back 37 651 5.7 Defensive tackle 16 296 5.4 Long snapper 2 44 4.5 Punter 2 55 3.6 Defensive end 11 314 3.5 Kicker 2 61 3.3 Offensive tackle 7 233 3.0 Quarterback 4 162 2.5 Dodson et al., 2016
By Significance Position Group ACL Injuries, n Total Players, n Percent Injured P Value (vs Rest of NFL) Receivers (WR, 56 703 8.0 .004 TE) Backs (LB, HB, 60 837 7.2 .035 FB) Interior linemen 38 578 6.6 .312 (G, DT, C) Defensive backs 37 651 5.7 .995 (CB, S) Specialists (P, K, 6 160 3.8 .282 LS) Perimeter 18 547 3.3 .009 linemen (DE, OT) Quarterbacks 4 162 2.5 .071 All NFL players 219 3638 6.0 Dodson et al., 2016
Grass vs Turf In ‐ Game Team Injury Rate ACL Games Injuries, n Played, n Grass 74 1478 .050 Artificial 63 1178 .053 turf Dodson et al., 2016
Year by Year 2010 ‐ 2013 (4 seasons) By Month in NFL Dodson et al., 2016
2017 • 51 players had an ACL injury • 31 players had injury prior to week 1 • Over last 5 years on average = 23 ACL injuries before week 1 – End OTAs to Week 1. • 2018 Data still being populated – Teams less willing to share data Dr David Chao, San Diego Union Tribune, Published 5/23/2018 https://www.sandiegouniontribune.com/sports/profootballdoc/sd ‐ sp ‐ pfd ‐ hunter ‐ henry ‐ acl ‐ nfl ‐ ota ‐ 0523 ‐ story.html Steven Taranto, Published 2/6/2018 www.247sports.com
Strangest MOI: As heard at Andrews • “I was dropping it like it was • “I was chasing my kids and hot and tried to come back tripped over the dog.” up and felt a pop.” • “I don’t even have a clue… • “I was getting out of a my knees have been burning Humvee and my leg buckling one me for the last got caught and I lunged out 3 years and they get sore.” ‐ and felt it buckle” ended up having bilateral torn ACLs. • “I was on the last run (ski) of the day and looked back • “I was having the game of to see my friends and hit a my life (basketball) and bump and fell.” when up for a dunk and got rim checked and landed • “I was celebrating a sack wrong.” and when I jumped I landed wrong.”
Treatment Principles/Guidelines • Age • Type of graft • Sex • Comorbidities • MOI • Concomitant knee pathologies • Sport/Activity – Meniscus, collateral • Pain tolerance ligaments, etc. • Level of athlete • Duration since injury • Tissue quality • Condition of joint • Number of prior surgeries – Swelling, quad control – Revision or not • Surgeon • Time of year – Techniques, protocols, etc. • Patient expectations • Patient motivation
Phases of Rehab Reconditioning 1. Protection, Healing and Mobility 2. Work Capacity and Strength 3. Elastic Strength and Return to Function 4. Return to Performance
Promote a Positive Recovery • Promote importance of sleep and proper nutrition • Reduce both Physical and Mental Stressors – Stress and increased cortisol production delays healing response • Positive attitude and engagement with patient – “Better” and “Getting Better” knees – NOT “good” and “bad” • Whole ‐ body strength and conditioning
Prehab Goals Treatments 2 ‐ 4 weeks ideal Quad sets • • – BFDB, NMES Restore quad control • – SLR 4 way Achieve full knee extension • Cone walking • – Flexion to min 120° Step ups/downs ‐ Anterior/lateral Ambulation without deviations • • SL balance Retrain squat pattern • • – >SL RDL – Tolerate CKC with control Mini band walks ‐ 4 way Decrease joint effusion • • – Base holds, shifts, skaters MANAGE EXPECTATIONS FOR • Vasopneumatic compression POST OPERATIVELY!! •
Phase 1: Protection, Healing, and Mobility • Protect the joint and guide healing response – Control pain and joint effusion – Early ‐ phase muscle activation – Restore ROM – Normalize gait mechanics – Promote active recovery process • Usually Day 1 to Week 4
Swelling and Quadriceps Inhibition • Joint Distention resulted in quadriceps muscle inhibition DeAndrade et al • Similar results in a study by Spencer et al. – Threshold for inhibition of the Vastus Medialis to be approximately 20 ‐ 30 ml of joint effusion and 50 ‐ 60 ml for rectus femoris and vastus lateralis Wilk et al 2003
E ‐ Stim to improve voluntary quadriceps control Fitzgerald et al. reported that the group receiving • NMES demonstrated moderately greater quad strength and higher levels of self reported knee function at 12 weeks post op. • Snyder ‐ Mackler et al. found that the addition in NMES to postoperative exercises resulted in stronger quadriceps and more normal gait patterns. • The use of E ‐ stim and biofeedback on the quadriceps appears to facilitate the return of muscle activation and may be valuable additions to therapeutic exercises. Wilk et al. 2003
Pain and Joint Effusion • Pain – Increases reaction times – Increases performance errors during simple tasks • Joint Effusion: – Increases intra ‐ articular joint pressure and pain – Alters quadriceps muscle recruitment • Arthrogenic Muscle Inhibition (AMI) – Neural inhibition – Has been shown to occur bilaterally after unilateral injury » Quad activation deficits as high as 7 ‐ 26% in unaffected limb – Decreases the stability mechanics around the knee – Alters limb ‐ loading patterns with landing tasks • Increased ground reaction forces • Land in greater knee extension
Post Op ‐ Day 0 ‐ 7 Goals Treatment • Full knee extension • Manual knee extension – Comparable to contralateral • Quad set limb • Calf/HS stretch – Flexion 0 ‐ 90° • Quad control • Patella glides • Quad set with full knee – Emphasis on superior glides extension • SLR 4 ‐ way w/ NMES • Perform SLR ‐ no lag • Peanut bridging • Decrease swelling and pain • Weight shifts • Initiate weight bearing • TKE with NMES
Restore ROM • End ‐ range knee extension – Symmetrical to contralateral knee by Weeks 1 ‐ 2 • Decreases patellofemoral joint and soft tissue stress • Decreases quad inhibition • Gradual progression of knee flexion – Week 1: 90 – Week 2: 110 – Week 3 ‐ 4: Kneeling • Gradual progression ‐ desensitization – Week 8 ‐ 10: Full AROM • Emphasize self ‐ mobilization 6 ‐ 8 x daily for first 2 ‐ 3 weeks – Self ‐ knee extension mobilization – Patella accessory mobilization
Extension Variations • Some people don’t have full knee extension • Excessive extension can guillotine the ACL • Extension equal to the other side w/ control at that range.
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