Algorithm Based ACL Algorithm Based ACL Rehabilitation Rehabilitation Justin Shaginaw MPT, ATC Justin Shaginaw MPT, ATC Revised 11/13/05 Revised 11/13/05
Introduction Introduction � Common contact and non-contact � Common contact and non-contact injury in athletes injury in athletes � 100,000 new cases annually (Bach, � 100,000 new cases annually (Bach, Boonos) Boonos) � Previously meant season ending, if � Previously meant season ending, if not career ending injury not career ending injury � Athletes are returning to pre injury � Athletes are returning to pre injury levels, at times within the same levels, at times within the same season season � Outcomes are accomplished through � Outcomes are accomplished through a post operative program focusing a post operative program focusing on functional rehabilitation and on functional rehabilitation and neuromuscular control activities neuromuscular control activities
Anatomy & Biomechanics Anatomy & Biomechanics � ACL � ACL • 2 bands: anteromedial & • 2 bands: anteromedial & posterolateral posterolateral • Functions • Functions • Primary restraint to • Primary restraint to anterior tibial anterior tibial translation translation • Significant restraint to • Significant restraint to hyperextension hyperextension • Limits tibial internal • Limits tibial internal rotation rotation • Secondary restraint to • Secondary restraint to varus/valgus stresses varus/valgus stresses
Anatomy & Biomechanics � MCL � MCL � PCL � PCL • 2 Layers: superficial and • 2 Layers: superficial and • 3 bundles: • 3 bundles: deep deep Anteriolateral, Anteriolateral, • Functions • Functions Intermediate & Intermediate & • Primary restraint to • Primary restraint to valgus stress valgus stress Posteriomedial Posteriomedial • 57 % at 0° • 57 % at 0° • Functions • Functions • 78% at 25° • 78% at 25° • Primary restraint to � LCL • Primary restraint to � LCL posterior tibial posterior tibial • Functions • Functions translation translation • Restraint to varus stress • Restraint to varus stress • Secondary restraint to • Secondary restraint to • 55% at 0° • 55% at 0° hyperextension & varus hyperextension & varus • 69% at 30° • 69% at 30° /valgus stress /valgus stress
Anatomy & Biomechanics � Medial Meniscus � Medial Meniscus • Semi lunar or C shaped • Semi lunar or C shaped • Extensive capsular • Extensive capsular attachment attachment � Lateral Meniscus � Lateral Meniscus • Circular shape • Circular shape • Minimal capsular • Minimal capsular attachment attachment � Meniscal functions � Meniscal functions • Shock absorption • Shock absorption • Joint lubrication and • Joint lubrication and nutrition nutrition • Joint stability • Joint stability
Surgical Considerations Surgical Considerations � Procedure � Procedure • “Mini-open” vs all • “Mini-open” vs all arthroscopic arthroscopic � Graft type � Graft type • Autograft vs allograft • Autograft vs allograft � Fixation � Fixation • Boney vs soft tissue • Boney vs soft tissue � Graft properties � Graft properties • Tensile strength • Tensile strength • Stiffnes • Stiffnes � Graft “Ligamentization” � Graft “Ligamentization”
Graft Properties Graft Properties Ultimate Strength (N) Stiffness (N/mm) Intact ACL 2160 242 Bone Patella Bone 2376 812 Quadruple Hamstring 4108 776 Quadriceps Tendon 2352 463 Posterior Tibialis 3391 302 Tendon From presentation by Arthur Bartolozzi MD From presentation by Arthur Bartolozzi MD
Fixation Properties Fixation Properties Ultimate Tensile Load (N) Ultimate Tensile Load (N) Direct Soft Tissue Direct Bone Direct Soft Tissue Direct Bone Metal Interference Screw 242 +/- 90 Metal Interference Screw 640 +/- 201 (7mm) (7mm) Metal Interference Screw 276 +/- 436 Bioabsorbable Screw 341 +/- 163 (9mm) (7mm) Metal Interference Screw 302 (11mm) Bone Mulch Screw 1126 Metal Interference Screw 328 (13mm) Tandem Soft Tissue 768 Metal Interference Screw 330-418 Washers (15mm) Bioabsorbable Screw (7mm) 330-418 Cross-pin Technique 725-1600 Bioabsorbable Screw (9mm) 565 Staples 588 From presentation by Arthur Bartolozzi MD From presentation by Arthur Bartolozzi MD
Post Op Evaluation Post Op Evaluation � ROM � ROM � Strength � Strength � Girth � Girth � Patella mobility � Patella mobility � Observation � Observation � Swelling/joint effusion � Swelling/joint effusion � Lachman’s � Lachman’s � Gait � Gait � Other special tests � Other special tests
Protocol vs Algorithm Protocol vs Algorithm Based Rehab Based Rehab � Protocols � Protocols • Rehab programs that are usually • Rehab programs that are usually time based time based • Often times separated into • Often times separated into accelerated and non-accelerated accelerated and non-accelerated programs programs � Algorithms � Algorithms • Allow all patients to follow the • Allow all patients to follow the same rehabilitation guidelines same rehabilitation guidelines progressing according to specific progressing according to specific goals irrespective of time frames goals irrespective of time frames • “Phases” of algorithm based • “Phases” of algorithm based rehab rehab
Protocol vs Algorithm Protocol vs Algorithm Based Rehab Based Rehab � Protocol � Protocol • Were developed according to • Were developed according to biological healing times biological healing times • Based on time frames • Based on time frames � Algorithm � Algorithm • Goal based rehab • Goal based rehab • Based on objective and • Based on objective and functional goals functional goals � Algorithm allows for a � Algorithm allows for a more appropriate more appropriate progression for each progression for each individual patient individual patient
Initial Post Op Phase Initial Post Op Phase Goals to be achieved Goals to be achieved • PROM 0°-110° • PROM 0°-110° • Full active extension • Full active extension • Minimal joint effusion • Minimal joint effusion • Normal gait • Normal gait • Good quad control/tone • Good quad control/tone • Normal patella mobility • Normal patella mobility
Gait Gait � Focus on normal heel � Focus on normal heel to toe pattern to toe pattern � Start with bilateral � Start with bilateral crutches and brace crutches and brace open to available open to available AROM AROM � Progress out of brace � Progress out of brace before off of crutches before off of crutches
Proprioception & Proprioception & Neuromuscular Control Neuromuscular Control � Three inputs: visual, tactile, � Three inputs: visual, tactile, vestibular vestibular • Try to challenge all three • Try to challenge all three � Unilateral standing activities: � Unilateral standing activities: slight knee flexion to eliminate slight knee flexion to eliminate stability from boney stability from boney congruence and screw home congruence and screw home mechanism mechanism � Look to progress to � Look to progress to activity/sport specific balance activity/sport specific balance exercises exercises � “Toys”: Dyandisc, wobble � “Toys”: Dyandisc, wobble board, foam pad, physioball, board, foam pad, physioball, BOSU, balance beam BOSU, balance beam
Strengthening and Strengthening and Muscle Re-Education Muscle Re-Education � Quad tone/control � Quad tone/control • Russian/neuromuscular electric • Russian/neuromuscular electric stimulation with quad set during stimulation with quad set during supine extension stretch supine extension stretch � Strengthening � Strengthening • Initiate exercises focusing on • Initiate exercises focusing on single plane/single muscle group single plane/single muscle group • Progress to multiple • Progress to multiple plane/multiple muscle group plane/multiple muscle group exercises exercises • Include proprioceptive/ • Include proprioceptive/ neuromuscular control neuromuscular control component component • Look to include activity/sport • Look to include activity/sport specific exercises specific exercises
Strengthening Progression Strengthening Progression � Mini Squats → Leg Press → � Mini Squats → Leg Press → Unilateral Leg Press → Leg Unilateral Leg Press → Leg Press on Disc/Foam Press on Disc/Foam Roll/Ball Roll/Ball � Leg Raises → Hip Machine � Leg Raises → Hip Machine → Walking/Stepping with → Walking/Stepping with Theraband Theraband � Prone Hamstring Curls → � Prone Hamstring Curls → Standing Curls → Resisted Standing Curls → Resisted Curls → Bilateral Curls on Curls → Bilateral Curls on Physioball → Unilateral Physioball → Unilateral Curls on Physioball Curls on Physioball
Joint Effusion Joint Effusion � Some benefit with modalities initially � Some benefit with modalities initially � Sign of healing within the joint � Sign of healing within the joint � Warmth sign of acute inflammation � Warmth sign of acute inflammation � Monitor changes in joint effusion to assess � Monitor changes in joint effusion to assess tolerance with rehab program tolerance with rehab program
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