Accelerated ACL Rehabilitation 2007_2

8/2/2019 Accelerated ACL Rehabilitation 2007_2

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Accelerated ACL

Rehabilitation

Hugh West, Jr., MD K. Donald Shelbourne, MD

Purpose

20 minute overview of one acceleratedACL rehabilitation techniqueu

Not intended to create a debate overtheories or practices

Due to time constraintsD

Will challeng

e current models andpractices


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ObjectivesO

Background on Dr. Shelbourne Shelboune-based rehabilitation protocolb

Rehabilitation considerations

Dr. Shelbourne

Practicing since 1982 with a knee onlyfocus

Currently limits practice to ACL repair,simple scopes, and realignments.

Reports a patient profile of >50%young athletes

Over 80 publications as primary author(knee related)Holds patent on the cryo-cuff


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Dr. Shel ne

"What I've Learned About the ACL", KDS, 2003

Claims that most physicians tend to focus onthe surgical techniqueStates rehabilitation is an afterthought left to the

physical therapist/athletic trainer to f i gure outu

Demands a long term follow up of patientsEmploys ~4 FTE researcherss

Performs all rehabilitation in-houseEmploys 5 PTs and/or ATCs

What Ive Learned About the ACL

, KDS, 2003


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04


ShelbourneSurgical

TechMini-Arthrotomy

Foroptimal graft placement

Has always used thistechnique, tomaintaincomparabilit y ofdata

Has allow rehabilitation tobe the dependentvariable in outcome

Button fixation

Pre


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vent

s

overtensioning

A


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llow

s

tig

ht

bone-fit

Utilizes a contralateral donorgraft, exclusively


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Stronggraft, allows B2B healing

Claims it allows for early return to

sports

WhatIveLearnedAbouttheACL,KDS,2003


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Reach symmetry between knees

Ran ge of Motion

Strength

Stability

Overall FunctionO

Would rather have two knees @ 90% ofpreop levels than a 100%/70% split ofpreop levels


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S ymmetr y

Symmetry is also necessary for all patients to beable to do normal every day activities

comfortably (stairs, squatting)

Many patients have a stable knee butnever achieve knee symmetry, and yet they

are told they have a good result

All these issues are a problem in some way,regardless of the graft source

W h a t I v e L e a r n e d A b o u t t h e A C L

, K D S , 2 0 0 3


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urgery IKDC values Lack ext/normal flex

Normal ext/lack flexion Lack ext/lack flexon

Normal ext/flex

Emphasize Full Extension/Hyperextension

Normal extension is defined by the normal knee preop levels

Aggressive use of extension exercises to return normal extension values

What Ive Learned About the ACL, KDS, 2003


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Rehabili Protocol

Rehabilitation Protocol

Calls into question the notion ofgraftstrength timelines

Idea that graft is strong/weaker depending on

point in time; related to vascularizationp

Protocol is built on criteria basedprogression rather than time basedprogression.

Shelbourne claims it now models many

things he told his patients not to do, they

did anyways, and still got bettersResults in 1wk, 2wk, 4wk, 8wk, 12wk, PRNfollow up visits / rehabilitation sessionsf

Relies on patients to follow guidelines and

perform exercises at homeAllows patients to make decisions regarding

what they can and cannot do; withadvisement


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Rehabilitation Cascade of Ev

Pre-op rehab: No sweling, f u l ROM, good leg control

Surgery: Fu l ROM after graft placement and fixation

Post-op- Fu l ROM and no sweling

Conf l ic t ing

Increase leg strength

goals

Pro prioce ption and agility drils

Sport-specific drils Competition

W h a t I v e

L e a r n e d

A b o u t t h e

ACL, K D S ,

2 0 0 3


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Pre-OpP

Patient EducationPHeel Slides Towel-Toe

Pull/Hyperextension Quad Sets

St ra i ght Leg Raisesh

Compression & Cold to prevent

hemarthrosish

CPM provides elevation &gently maintains availableROM


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Patients kept for a 23hr stay


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Good terminal extension, activelyG


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Flexion measured by patient using a yardstick

Excellent self-assessment tool

Helps when patients call w/ ?


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Walking for bathroom privileges


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5 days of bed rest1d-5d s /p ALC- r

irst 5 days at homs

Bed rest except for bathroom privilegese

Heel prop extension exercises 10 min6x/dayy

Flexion exercises 6x/day

SLR

Quad Sets

CPM & Cryo/Cuff worn continually exceptduring exercises

Knee needs a period of rest, elevation, andcold/compression to prevent a hemarthrosisc

Without a hemarthrosis

Obtaining full ROM is easier when the knee does nothave an effusion

Knee is less painful

Quad control can be obtained easier


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1 week post-op1

If patient has beencompliant, Minimaleffusion will be present,ROM will be excellent,and NM control is

acceptableaTransition Exerciseswere possible

Heel slides wall slides

QS/SLR StepDowns/SAQ


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1 week post-op

Can return to daily activities

Use of cryo/cuff after exerciseso

Emphasis of a normal gaita

Monitor swelling

Adjust activities where needed to preventswellingg

Return of normal flexion/extension valuesemphasized


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2 weeks2

Instructions:

Maintain full hyperextension

Increase flexion

Emphasize a normal gait pattern

H i gh repetition exercise forgraft-donor site

Use Cryo/Cuff after exercise

Can return to daily activities

Monitor swelling and adjust activities to keepswelling to a minimum

2 weeks Post-op2

ROM should exceed 125 degreesIf>125, no longer a

primary emphasis

Progress strengthIncrease step h e ight Long Arc Quads Bench HamstringssIncrease proprioceptive challenges


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4 weeks post-op

By 4 weeks, ROM shouldbe normal or near-normal

Patient must be able to sit on

heels to progress

Sitting on heels will remain atest prior to activity


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4 weeks post-op

ADLs should pose no challengee

Patient has prerequisite strength to beginformal strength trainingg

Patients who advance quickly may be able tobegin basic sport-specific drillsi

Rules for new activity: No pain during or

after activity

, No increase in swelling

, Noaltering ofgait

Possible Exercises

All h i gh rep, low weight, initially

Commonly include:

Leg press

HS Curl

4-Way hip

SL Proprioception (i.e. Stork)S

May

Include:Slow/Light plyometrics

Basic sports skills (i.e., soccer = dribble, shortkick)


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4 8 weeks after surgeryy

Patient instructions for next 4 weeksAdditional strengthening with w e i ghts single leg

exercises

Begin functional agility program

Sport-specific agility drills

L i ght controlled sport-specific drillsh

Ifan athlete, may utilize ATC at homefacilityy

Ifno on-site ATC, support provided viaemail and phone


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8 weeks post-op8

If strength is around 70 to 80% (of normal kneepre-op), then begin more intense functional worki

Every other day to allow period of restE

Specific functional activity to increase strength

Example controlled jumping drills in basketball(rebounding, jump shot)

May need to do every other day, depending insoreness in tendon

Continue with we i ght traininggKeep it specific to the patient!


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"What I 've Learned About the ACL

", KDS , 2003

2-4 months fter surgery

Continue to progress strength

Continually adapt sport-specific drills tomore closely resemble actual sportWhen able to perform drills in a controlledenvironment, reintroduce to actualpracticesp

When able to practice without difficulty,reintroduce to game situationsaRemember, No pain, swelling, or alteredgait


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Important Note

Use Objective Feedback

Isometric Leg Press w/ tensiometer

1,2,4,8,12

Biodex when capable

4,8,12

3PQ; Leg Press Force Place

4,8,12


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Consideratio

Consideratio

RehabiliR

Ifyou try to do aggressive strengthening

immediately after ACL reconstruction, theknee will become swollen, stiff, and painful

So it is best to wait until full ROM has beenobtained before the patient beginsaggressive strengthening

What Ive Learned About the ACL, KDS, 2003,

Even then, when doing strengthening

exercises, ROM must be monitored daily tomake sure the knee is not losing motion

Patients h i ghest function will be at thelevel of the worst knee/legg

Must obtain sy

mmetry

with ROM andstrength for function to be totally normal

What Ive Learned About the ACL

, KDS, 2003


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Summaryy

Regardless ofgraft source, proper andcomplete pre-op and post-op rehabilitationis necessaryy

Patient must go through a progression ofsteps to achieve an optimum results

Full symmetrical ROM is required to obtainthe best long-term result

Obtaining full symmetrical ROM, strength,and function is possible

W h a t I v e L e a r n e d A b o u t t h e A C L

, K D S , 2 0 0 3

This presentation was created based on

oral & written communications with Dr. KDonald Shelborne. It also incorporatemuch information found on a powerpointauthored by Dr. Shelbourne, entitledWhat Ive Learned About the ACL, 2003version.

For more information regarding Dr.Shelbournes techniques or practice,please visit: www.aclmd.com
http://www.aclmd.com/http://www.aclmd.com/


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http://www.aclmd.com/

Accelerated ACL Rehabilitation 2007_2

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