REHABILITATION AFTER ANTERIOR CRUCIATE LIGAMENT

RECONSTRUCTION: CRITERIA-BASED PROGRESSION THROUGH THE

RETURN-TO-SPORT PHASE

Marcelo Vargas Z.

Kinesiólogo clínica MEDS Chile

marcelovargas@terra.cl

IntroductionAdvances in methods and techniques for fixingreconstruction with graft.

The athlete's return to its previous level.

Currently emphasize the movement's early recoveryand a return to sports activities after surgery.

The athlete to return to the business needs :

Stability graft Patient confidencePost surgery timeMedical team opinion

It is necessary to use a test objectives that measurequantitatively the functional ability of the patient.

Rehabilitation of LCA

Early Stages

- Postoperative periodimmediately

Late Stages- Functional Progression- Return sporting activity

Strict criteria:

- Recovering ROM

- Progression to full load

- Selected exercises

General categorizations:- Exercises and appropriateprogressions in intensity andvolume depending on eachpatient

The conservative therapy may limit the progression towards thelater stages of rehabilitation and possibly delaying the return ofsporting success.

Wilk KE, Andrews JR. Current concepts in the treatment of anterior cruciate ligament disruption. J Orthop .Sports PhysTher.1992;15.

Wilk KE, Reinold MM, Hooks TR. Recent advances in the rehabilitation of isolated and combined anterior cruciateligament injuries. Orthop Clin North Am. 2003;34:107-137.

Risk factors: :

- Neuromuscular control - Instability- Disruption functional articulation- Lack of strength graft

Progression should be based on functional stability andneuromuscular control, this could accelerate the return ofsports 2 to 3 months.

Increased risk of injuryin the later stages ofrehabilitation

Progression criteria for Sports Training Return

1. Ranking 70 in IKDC (international knee documentationCommittees).

A IKDC under 70, indicates the need for an additionalrecovery time for the patient.

2. No post-surgical history of instability perceived by thepatient or "pivot negative."

3. Minimum peak extension of the knee.

4. Mobility of the knee (110 ° flexion-extension 0 °). Higuchi H, Terauchi M, Kimura M, et al. The relation betwen static and dinamic knee stability afcter ACL reconstruction.

Acta Ortohop Bel. 2003;69:257-266.

Sernet N, Kartus J, Kohler K, et al. Analysis of subjetive , objetive and functional examination test after anterior cruciateligament reconstruction. A follow-up of 527 patients. Knee Surg Sports Traumatol Arthrosc.1999;7:160-165.

Stages for Return to Sport There are four stages in the rehabilitation of the ACL reconstruction and these should be combined:

Controlled maneuvers at low risk and high demand. Overloads. Development of functional abilities of the athlete. Improve neuromuscular function and level of athlete in order to minimize injury risks.

Myer G, Paterno M, Ford K, Quatman C, Hewet T. Rehabilation after anterior curciate ligamen reconstruction: criteria-based progression throuhgt the return –to-sport phase. J Orthop Sports Phys Ther.2006;36(6): 385-402.

Stage 1

1. Improving cargo weight affected limb, to higher angles of flexion of the knee. CCC

2. Improve symmetry between both lowerextremities during the running.

3. Improve postural balance the load weight on the affected lower limb.

OBJECTIVES

Improving the burden of weight

Stage 1Criteria for progression:

1. Sentadilla on one foot with a minimum of 60 ° of kneeflexion for 5 sec maintenance

2. Audible rhythmic pattern with your feet, Asymmetrieswithout cinematic thick on the treadmill jogging (8 to 10 km / h)

3. Scores acceptable balance on one foot with TOB (women less than 2.2 ° deflection, men with less than3 ° deviation for 30 sec up to level 8)

* Although the patient meets the criterion 1, it is necessary tomeet criterion 2 to move up next phase.

Stage 1

Adequate isolation ofquadriceps strength

Co-proper contractionQuadriceps andIsquiotibiales

Secure progress in stages ofrehabilitation

• The asymmetry in the dynamic functional tasks, such as jumping are risk factors for ACL injuries. To proceed to Phase 3, are recommended to begin

exercises pliométricos lower limb.

■ Unbalance at both endsof: Muscle strengthFlexibilityCoordination

Predictorsincrease injuries

Stage 2

OBJECTIVES

1. Improving the burden of weight in thelower limb.

2. Improving the strength symmetricalduring bipedestación activities.

Improve strength and load weight

3. Improve strategies for mitigating forceloading weight on one foot.

Stage 2

Stage 2Criteria for progression

1. Symmetry of both limbs in the peak torque of flexo-extension of the knee (60 ° / s 15% deficit)

2. Strong total symmetric load plant during sentadilla in biped with 90 ° of knee flexion. (less than 20% difference between limbs)

3. Symmetrical peak load to jump on one foot from a height of 50 cm (less than 3 times the body mass andwithin 10% compared with contralateral limb)

Stage 3Development of power and athletic symmetry

1. Improve energy production in thelower extremity

2. Improve muscle strength of thelower extremity

3. Improve the biomechanics of thelower extremity in the jumps pliometrics.

Stage 3

Stage 3Criteria for progression:

1. Hopping on one foot distance (within 15% of the healthy limb)

2. Crossed triple jump (within 15% of the healthy limb)

3. Synchronized jump over 6 m

4. Power hopping on one foot vertical (15% healthy limb)

5. Reassessing "jump Tuck" (15% improvement, or 80 points)

Stage 4Athletic ability and development

1. Equalizing force attenuation in reaction tothe ground between the two extremities.

2. Enhance confidence and stability withactivities of changes in direction of highintensity.

3. Improve and equalize power of resistancefrom both ends.

4. Using a secure biomechanics (higherrates and decreased knee flexion anglesabduction when implementing high-intensity exercises pliometrics).

Stage 4

Stage 4Criteria for progression:

1. Symmetry in bilateral landing forces in the vertical leap(within 15%)

2. Agility test using a modified time (within 10%)

3. Jump with a limb in the power test by 10 seconds. (bilaterally symmetrical within 15%)

4. Tuck jump reassess percentage (20 points ofimprovement or achieving a perfect score of 80)

Return to SportOnce the athletes meet the criteria of stage 4, could be ready to quit therapy and begin the reintegration into thesport.

However, it was suggested to start gradually and withsome restrictions on sporting events.

The return to the sport of the athletes may have periodsof high risk after ACL reconstruction because of the riskof graft failure and risk of injury against lateral limb, which can be greater than the side involved.

Asymmetry of both limbs could be potential risk of ACL injury, therefore must be minimized before returning to thesport, not just work force but also by incorporatingdifferent athletic activities.

The ability to attenuate forces and the ability to redirectthe movement in a limb reduces the risk of injury

Conclusion

The final stages of rehabilitation after ACL reconstructionhave not followed criteria based on protocols, they may have deficits in the lower extremity: propiocepción, strength, reaction mitigation and production of force, which can persist beyond the stages of rehabilitation .

These deficits can be transferred to the sporting activityof the patient and increase the risk of further injury orlimit the achievement of best performances.

Conclusion

The proposed steps are intended to identify gaps andpost surgical work of these through a systematicprogression that ends with the return of sports.

This approach would enhance the potential of athletes at the return to their sport and offers an optimalperformance by reducing the risk of further injury.