ACL RECONSTRUCTION AND MENISCAL REPAIR USING A PATELLA TENDON

GRAFTABBY JONES

SPRING 2017

PATIENT HISTORY

• DOB: 6/27/1995

• 21 years old

• Height: 5’7”

• There is no history of surgery.

• The patient had a previous injury that could have possibly torn the ACL. She reports playing rugby 4 years ago when she hurt it and heard a “pop”. She went to the doctor and they claimed that it was an MCL sprain. When her orthopedic surgeon went in, he said that there is typically a stub where the ACL is, but it was not there, so he believes she tore it prior to her most recent injury.

• The most recent injury occurred in November when she was at semiformal. She reported that she jumped and landed wrong and heard her knee “pop” again and this was the exact pop she heard and felt with her previous injury.

ABOUT THE ACL

• The anterior cruciate ligament prevents anterior translation of the tibia on the femur. The main function of this ligament is to work with the posterior cruciate ligament to provide stability in the knee joint where the tibia and femur meet.

• The ACL is a cruciate ligament meaning that it is a ligament that runs inside the knee joint.

• There are three grades of ACL sprains:

• Grade I Sprain: the ligament is minimally stretched, but can still provide stability of the joint

• Grade II Sprain: the ligament is stretched to where it is loose. This can be termed as a partial tear of the ACL.

• Grade III Sprain: the ligament was stretched so much that it tears into two pieces causing the knee joint to be unstable. This is known as an ACL tear.

• When the ACL is injured, patients typically report hearing or feeling a “pop”.

• Some common causes of ACL tears are:

• Cutting/change of direction

• Pivoting with your foot firmly planted

• Landing from a jump incorrectly

• Stopping suddenly

• Receiving a direct blow to the knee or a collision

ABOUT THE ACL

• Studies show that there are differences in men and women’s risk for tearing their ACL.

• Muscular differences

• Jumping/landing technique

• When repairing the ACL, the surgeon typically uses a graft, which is taking a piece of tendon from another part of the body or a cadaver (known as an allograft) and placing it where the ACL runs so new ligament tissue can grow. The tendons typically used are the hamstring tendon or the patellar tendon.

• Why wait on surgery? Surgery can be immediately after the injury, but with the chance of increased fibrous tissue causing loss of motion after surgery. Some surgeons wait until the patient can regain range of motion and can contract the quadriceps muscle. This can help for osteoarthritis purposes and to prevent the build up of fibrous tissue.

SURGERY

• The patient had surgery to repair her right anterior cruciate ligament and meniscus. The doctor used a patella tendon graft for the repair.

• The surgery was completed in Nashville, Tennessee on December 21, 2016.

• She was required to be on crutches for 1 week and to wear a brace for 8 weeks. Protocol was to see the doctor at 3 and 6 weeks, but because she is away from home, she saw him 2.5 weeks out from surgery, and saw him again 11 weeks out from surgery.

• She was 10 weeks out from surgery on the day of her progress evaluation.

EVALUATION

• Consent for Care and Treatment

• Medical History

• Functional Assessment

• Lower Extremity Functional Scale (LEFS)

• Physical Therapy Evaluation/Assessment

INITIAL EVALUATION• Subjective:

• Feels better when: resting or activity modification

• Feels worse when: walking or doing stairs

• Patient reports that she has increased pain when she is ascending/descending stairs and when she is weight bearing for long periods of time. The pain she is having is constant, but it is getting better. She has had no radiating pain and reports no dizziness ornumbness. She reports that on a scale from 0-10, 10 being the worst and 0 being no pain, that the worst pain she has is a 2 and the best she has had in the past week is a 1. When she was being questioned, her pain was at a 2.

• Objective:

• Palpation: TTP right medial knee joint line

• Manual Muscle Testing: Patient scored a 5/5 in all planes of the manual muscle tests on her left extremity. When testing her right extremity, she was a 3+/5 in hip abduction, a 3+/5 in knee extension/flexion. She had moderate muscle atrophy in her right lowerextremity compared to her left. She also had minimum joint infusion in the medial/lateral knee. Joe noted that she also had mild/moderate edema and that the incisions had healed well.

• Gait: Patient demonstrated poor right quad control when descending 6” step. She also ambulates with a decreased right terminal knee extension during her push off. Her Right step length and stance were decreased and there was no Trendelenburg noted.

• Function: Limitations were found in movement about the knee. Impairments included muscle weakness, range of motion, gait instability, impaired balance. The patient’s participation restrictions were walking and sports. She scored a 65/80 on her LEFS recording a 16.75% disability.

• Assessment: Dx- post op ACL meniscal repair

• Patient has signs/symptoms that are consistent with her diagnosis. The patient will benefit from PT to address functional deficits and return them to a prior level of function.

PROGRESS

• 3/17/17

• 10 weeks out from surgery

• The patients pain at the time was 1 out of 10. Her best pain was 0 out of 10 and her worst pain within the last week was 2 out of 10. She said that since her surgery, the pain has definitely decreased and she doesn’t have constant pain at all anymore, so nothing typically makes it feel better because it is not hurting in the first place. She reported that going up stairs is the only activity that really aggravates the knee or makes the pain worse. The patient indicates that she has no pain at night.

• When completing her manual muscle tests (MMT), her quad and hamstring were at a 5/5 BLE for flexion/extension and 5/5 BLE for hip abduction.

• The patient had a 127 degrees knee flexion of bilaterally.

• Current degree of flexion as of 4/17/17: 137 degrees on right leg and 138 degrees on the left leg

• Vascularizing therapeutic exercise- 66 squats to fatigue

• LEFS: 72/80= 10.0% disability

MEASURING FLEXION

PERSONAL GOALS

• Return to prior level of function with no pain or limitations.

• Two of the patient’s goals that she would like to meet that she is still unable to do are to jog at full body weight and to be able to go snow tubing.

• After seeing the doctor when home in Nashville for Spring Break, the only restrictions he gave her were no cutting and no jumping from high surfaces. This was due to the fact that the patient still has a good amount of atrophy in her right quadriceps.

• She would like to negotiate stairs without pain.

PHYSICAL THERAPY GOALS

• Short Term Goals:

• Patient will be independent with HEP in 3 weeks.

• Patient will independently negotiate 10x4” steps without upper extremity support pain-free.

• I want to re-introduce this goal. The patient is still having pain negotiating stairs, so I want to see if we can minimize that pain or eliminate the pain.

• New goal: Patient will be able to complete 30 single leg vertical and horizontal line hops in 2 weeks.

• New goal: Patient will be able to complete 10 single leg speed skater hops in two weeks without pain.

• New goal: Patient will be able to complete 80 squats before fatigue or breakdown in form in 2 weeks.

• Long Term Goals:

• Patient will be able to complete dynamic stability exercises such as resistive walking and SLS activities without pain in 8 weeks.

• Patient will demonstrate symmetrical strength at 5/5 BLE in 8 weeks.

• New goal: Patient will be able to complete exercises such as cutting, jumping, and negotiating stairs without pain or discomfort in 4 weeks.

POST-SURGERY/INJURY

• After an injury, you can often times see deficits in muscle recruitment ability. When starting the rehabilitation process, proprioceptive neuromuscular facilitation is the primary focus.

• Things like quad sets, knee extensions, straight leg raises, weight shifts/balance, and terminal knee extension (TKE). These are vital to regaining contraction of the surrounding lower extremity muscles. These help with neuromuscular control, stability, mobility, coordination, and strengthening.

• After the muscle has atrophied and has not been used, the neuromuscular function could be impaired causing certain muscles or fibers to not fire correctly and we have to regain this muscle recruitment control.

TREATMENT PLAN

• We will see the patient 2 times per week for 8 weeks. We will progress the patient towards her short and long term goals during this time.

• Treatment has consisted of balance training, Class 4 LASER, gait training, Graston technique, Manual Therapy, movement education, mobilization, cryotherapy, vascularizing therapeutic exercise, cardiopulmonary training, proprioception activities, myofascial release, and neuromuscular facilitation.

• You have to begin treatment with very light activities. You do not want to reinjure/re-tear the ligament. With soft tissue such as ligaments, there is a 10-12 week healing process. You want to ensure this healing before you get too aggressive with movements and exercises. You have to follow the correct protocol for ACL repair. You can have the patient start biking immediately for range of motion purposes and reach something like plyos around the 3 to 4 month mark. You can progress the patient into running at around 4 months from surgery.

• As we have surpassed the 8 week mark, we are continuing to work on strength, balance, and stabilization.

REACHING OUR GOALS

• To reach our new short-term goals for the patient, I want to implement some more single leg work, cutting, and plyometrics. Her muscle tone in her right lower extremity is still low, so I want to make sure we strengthen this. I also want to continue with stabilizing exercises.

• Current Exercises: bilateral calf raises, kettle bell squats, level 3 step ups, weight shifts on the tilt board, box jumps @ level 2, lateral band walks, single leg stand activities on the foam disc, resistive walking, hamstring curls on a physioball, RDLs

• Progressions: single/double leg line hops (vertical and horizontal), depth drops, single leg squats, single leg step downs, lateral lunge, single leg step-ups, ladder, level 2 box ickey shuffle, speed steps

LATERAL BAND WALKS

RESISTIVE WALKING

ROMANIAN DEADLIFT

WEIGHT SHIFTS

SINGLE LEG STANDS ON FOAM

BOX JUMPS

RESOURCES

• http://www.mayoclinic.org/diseases-conditions/acl-injury/home/ovc-20167375

• http://orthoinfo.aaos.org/topic.cfm?topic=a00549

• http://www.webmd.com/a-to-z-guides/anterior-cruciate-ligament-acl-surgery

• https://www.medpagetoday.com/orthopedics/sportsmedicine/47826

• http://www.stretching-exercises-guide.com/pnf-stretching.html