ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited...

20
23/05/2015 1 ACL reconstruction; deconstructing the reconstructions rehabilitation Lee Herrington PhD MCSP Senior Lecturer in Sports Rehabilitation, University of Salford Senior Physiotherapist, English Institute of Sport (NW Region) ACL injury ACL injury Limited statistics in UK related to sport Rugby Union 2002-2004 (Fuller et al 2005) 14 injuries (0.48 injuries per 1000 player hours) Football figures 2009-10 season 14 ACL injuries (Physioroom.com) 15 ACLi in premiership 2014-15 Women's sport far worse x3-9 greater risk, full time athletes 5% (Prodromos et al 2007) England Netball 5 of senior squad (4 in junior squad in last 12 weeks) GB women’s basketball 4 out 12 at OGS England woman’s FA (U19 – senior) 25 ACLi

Transcript of ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited...

Page 1: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

1

ACL reconstruction; deconstructing the reconstructions rehabilitation

Lee Herrington PhD MCSP Senior Lecturer in Sports Rehabilitation, University of Salford

Senior Physiotherapist, English Institute of Sport (NW Region)

ACL injury • ACL injury • Limited statistics in UK related to sport

• Rugby Union 2002-2004 (Fuller et al 2005) – 14 injuries (0.48 injuries per 1000 player

hours)

• Football figures 2009-10 season 14 ACL injuries (Physioroom.com)

– 15 ACLi in premiership 2014-15

• Women's sport far worse – x3-9 greater risk, full time athletes 5%

(Prodromos et al 2007)

– England Netball 5 of senior squad (4 in junior squad in last 12 weeks)

– GB women’s basketball 4 out 12 at OGS

– England woman’s FA (U19 – senior) 25 ACLi

Page 2: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

2

ACL injury • ACL injury & OA • 32-51% ACLR symptomatic OA 10-15 yr (Hui et l

2010; Kessler et al 2008; Lohmander et al 2004; Oiestad et al 2010)

• Uninjured knee 22-28% (10yr) (Holm et al 2010)

• 47% ACLR (hams) PFJ OA 7-10yr (Crossley et al 2011)

• 30% have PFP at 12/12 (Culvenor et al 2015)

• 17% PFJ OA 12/12 (Culvenor et al 2015)

• Bruise

• 80% ACL cases associated with bony bruising (Beynnon et al 2005)

• high frequency of radiographic changes is rule after ACL injury (Micklebust & Bahr, 2010)

• Strong association with osteochrondral lesions & future articular damage (Davies –Tuck et al

2010; Dore et al 2010; Filson 2009; Lotz 2010)

ACL injury • ACLR & return to sport • Average return to sport across 48 studies 44% (Arden et al

2012)

• In non elite 40% returned to pre injury level (Ardern et al

2014)

• Younger (<25yrs) likely to return to high risk sport older (>25yrs) 26% returned to same level (Shelbourne et al

2008)

• Elite sport: 10% soccer (Zaffagnini et al 2014) NFL 22-37% (Carey

et al 2014; Shah et al 2010) NBA 14-22% (Busfield et al 2009; Harris et al 2013) WNBA 22% (Namdari et al 2011) did not return to same level

• Average time to RTS was 50 (Harris et al 2013) 52 (Zaffagnini et al 2014)

55 (Carey et al 2014) weeks • Those returning significantly reduced game

impact (Carey et al 2014; Harris et al 2013; Namdari et al 2011)

Page 3: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

3

ACL injury • ACLR & return to sport • Brody et al (2012) male & female soccer ACLR (age 24.2yr)

– 60% cohort returned same level taking average 12.2+/-14.3 months

– 7yrs PO only 12% cohort playing at same level

• McCulloch et al (2012) high school-college American football – 38-45% RTP same level, 26-29% RTP lower level – 28-33% did not RTP, 50% citing fear major contributing

factor • Lentz et al (2012) varsity athletes

– 55% RTP same level – Non RTP 45% cite fear, 40% knee symptoms

ACL injury • ACLR & return to sport

• Across age groups ipsilateral injury 2-10%, contralateral 8-16% (Andernord et al 2014; Webster et al 2014; Wright et al 2011)

• 10x increased likelihood tearing graft or contralateral ACL following initial ACLR surgery (Marshall et al 2010)

• Secondary injury rate in young about 24% (Paterno et al 2010) to 29% (Webster et al 2014)

• Younger age associated with increased risk subsequent contralateral ACL injury (Wasserstein et al 2013)

• Under 20’s x6 more likely re-rupture ACL graft & x3-5 more likely rupture contralateral ACL than over 20’s (Andernord

et al 2014; Webster et al 2014)

Page 4: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

4

ACL injury

• ACLR & return of functional activity • IKDC subjective; 6 out of 8 studies reviewed all patients

failed to reach “norm” • KOOS; no study reviewed return patients to “norm” score

ACL injury • ACLR & its rehabilitation

•IS REHABILITATION FAILING THE PATIENT? •Why?

Page 5: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

5

ACL Injury • Absence of clear criteria for progression

• “Current criteria for return to sport vague & rely on personal interpretation. Majority criterion values available are not empirically based” (Schmitt et al

2012)

• Example: recommended LSI required for quads strength varies between 10-35%

ACL Injury

• Absence of clear criteria for progression

• Typical of literature (Wilk et al 2012)

• “Once satisfactory strength & neuromuscular control has been demonstrated…functional activities such as running & cutting may begin 10-12 weeks & 16-18 weeks after surgery respectively”

• Rarely is “satisfactory strength & neuromuscular control” defined

Page 6: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

6

ACL Injury • ACL injury management project • Consensus panel

– Greg Myer, Lee Herrington, Ian Horsley, Simon Spencer, Ashleigh Wallace, Phil Glasgow, Linda Hardy, Raph Brandon

• The goal of the consensus exercise was to agree on a series of generic markers for progression for each of rehabilitation stages along with monitoring tools to assess loading stress on the athlete’s knee

ACL Injury • Rehabilitation stages

• Pre-Op

• Post-op recovery

• Progressive limb loading

• Unilateral load acceptance

• Sport specific task training

• Unrestricted sport specific training

Page 7: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

7

ACL Injury

Pre op

ACL Injury • Pre-op

• Targets

– Full quadriceps activation (no lag on straight leg raise)

– Full range of movement (symmetrical)

– Minimal activity related effusion (<1cm change supra patella)

– Normal gait walk

– Straight line jogging (8-10min/mile)

– Leg press LSI < 5%

– Lysholm – IKDC subjective or KOOS questionnaire score

Page 8: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

8

ACL Injury

Post op

ACL Injury • Monitoring • Daily: • Athlete reports numeric rating scale of pain (0-10) post each

rehabilitation session along with score at end of day & in morning on first weight bearing

• Athlete rates stiffness of knee on first mobilising in morning – Score 0= free movement 1=some restriction to movement

2=significant restriction 3= unable move to painfully restricted

• Athlete measures knee circumference (around patella) on waking (1st hour of day) & in evening

Patient scores Saturday Sunday Monday Tuesday Wednesday Thursday Friday

NRS Pain am

post rehab

pm

Stiffness squat

stairs

Swelling am

pm

Page 9: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

9

ACL Injury • Monitoring

• Weekly (biweekly):

• Knee range of movement – Supine, sitting & prone

• Patella mobility – medial glide & tilt, inferior glide (20 degrees knee flexion)

– scoring: free; restriction; significantly limited

• Quadriceps strength (handheld dynamometer) 90deg flexion

• QASLS score (appropriate task to phase)

ACL Injury • Monitoring

• QASLS: unilateral tests

– Single leg squat

– Single leg land

– Single hop for distance

• Tuck jump test

Page 10: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

10

ACL Injury

• Monitoring • Hop tests • One leg hop for distance

– 80-90% height (males) – 70-80% height (females) (Ellenbecker 2001)

• Cross over hop; 4 hops – mean 4.5m (Goh & Boyle, 1997, Hopper et al 2003; Munro &

Herrington, 2009; Reid et al 2007)

Hop type Male (% leg length) Female (% leg length)

Single hop 188.9 (+/-17.9) 157.2 (+/-17.7)

four hop 584.8 (+/-60.7) 505.3 (+/-51.8)

Cross-over hop 554.5 (+/-56.5) 479.9 (+/-54.7)

ACL Injury • Monitoring

• Star excursion balance test (SEBT)

• Directions: – Anterior (quads)

– Posterior (hams)

– Medial & lateral (ACL)

Direction Reach Distance (% leg length)

Male Female

Anterior 80-92 73-92

Antero-medial 82-91 82-91

Medial 87 91 87 91

Postero-medial 87-107 87-99

Posterior 85-88 85-88

Postero-lateral 81-106 81-93

Lateral 71-76 71-76

Antero-lateral 73-78 73-78

Page 11: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

11

ACL Injury

Block 1:

Post op recovery phase

ACL Injury • Post op recovery phase

• Aims:

• overcome the effects of the operation

• regain range of movement

• regain muscle activation

• control effusion

• achieve normal walking gait

Page 12: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

12

ACL Injury • Post op recovery phase

• Typical activities

• Effusion control

– Compression, game ready etc

• Muscle activation

– Muscle stim & superimposed twitch

• Range of movement

– Patella & tibiofemoral

• Gait re-education

• Limb loading

ACL Injury • Target criteria to be achieved prior to progression to

progressive limb loading activity

• Full quadriceps activation (SLR no lag x10) • Range of movement 0-120 degrees (minimum) • Minimal am effusion (<1cm patella)

– Minimal change effusion with activity (<1cm patella)

• Bilateral squat to parallel (thighs relative to floor) even weight bearing • Gluteal activation

– Bilateral short lever bridge • X10 reps to neutral hip extension

• Hamstring activation – 0-90 deg knee flexion in standing on the uninjured limb – Bilateral long lever (straight leg bridge on chair:30cm)

• X10 reps to neutral hip extension

• Function: – Normal symmetrical gait – Static cycling

Page 13: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

13

ACL Injury

Block 2:

Progressive limb loading activities

ACL Injury • Progressive limb loading activity

• Aims:

• progressing athlete from bilateral weight bearing activities to full unilateral weight bearing activities

• undertake limited load acceptance activities (bilateral landing & jogging)

both in closed skill block practice manner.

• progress strength training & work capacity of key lower limb muscles.

Page 14: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

14

ACL Injury • Progressive limb loading activity

• Typical activities

• Muscle strengthening & work capacity training – Leg press (squat), mid thigh pull, heel raisers

– Open chain quads (120-60 degree) & hamstrings

– Bridging; extended & flexed knee

• Static movement dissociation – Static balance; multi-angle & vestibular

– Movement dissociation; T drills, SEBT

• Dynamic movement control (closed chain) – SLS, step up/down, forward & side lower, lunge

– Closed skill block practice

ACL Injury • Progressive limb loading activity

• Typical activities

• Bilateral load acceptance

– Closed skill block practice

Criteria bilateral leg press-squat 1.5BW

Single leg balance stability challenge 60deg flex

Single leg squat QASLS =0-1

• Cardiovascular training

– Cycle, cross trainer, jog

Page 15: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

15

ACL Injury • Target criteria to be achieved prior to progression to

unilateral load acceptance activity • Single leg squat to 90° (alignment control x10 reps; QASLS score 0-1) • Single leg stand 5, 45 & 90° knee flexion (10 second hold) on airex pad • SEBT

– Ant & Post symmetrical – Med & Lat <15% LSI

• Single leg press 1.5BW (10RM) – 0 to 90 deg knee flexion • Bilateral drop jump test [QASLS score 0-1] from 30cm box • Tuck jump test (score <3) • Gluteal muscle work capacity

– Unilateral short lever bridge on box (hip 45deg) (x25+ each leg no greater than 5 rep difference between sides)

• Hamstring muscle work capacity – Unilateral long lever on box (hip 45deg) (x25+ each leg no greater than 5 rep difference between sides)

• Calf muscle work capacity – Unilateral heel raise (x25+ no greater 5 rep difference between sides)

• Full range of movement • Minimal activity related effusion (<1cm change patella) • Function

– Straight line jogging treadmill – Stair ascent & descent (30cm); alignment control symmetry

ACL Injury

Block 3:

Unilateral load acceptance activity

Page 16: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

16

ACL Injury • Unilateral load acceptance activity

• Aim

• progress athlete from bilateral load acceptance activities to full unilateral load acceptance activities in multiple planes of movement

Including combination of closed & open skill practice

• progress strength & force development training & work capacity of key lower limb muscles

ACL Injury • Unilateral load acceptance activity

• Typical activities

• Muscle strengthening & work capacity training

• Unilateral load acceptance activities in multiple planes & reactive landings situations

• Bilateral multi-plane & unilateral single plane plyometric activities

Page 17: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

17

ACL Injury • Target criteria to be achieved prior to

progression to Sport specific task training activities

• SEBT symmetry & within norms • Single leg (hop) land (alignment control; QASLS score 0-1)

– Single leg hop for distance – Forward & side hop from 30cm box

• 10 RM Single leg press > 2.0BW – 0 to 90 deg knee ROM – 10 rep leg press to 90 degrees within 5-10% of contralateral leg

• Tuck jump test (score 0-1) • Cross over hop LSI <5% • Isokinetic extensors 300%BW total work 60deg/sec (average

over 5 rep) • Rate of force development; LSI <5%

ACL Injury

Block 4:

Sport specific task training activities

Page 18: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

18

ACL Injury • Sport specific task training activities

• Aim

• Improving athlete’s work capacity in ability to undertake unilateral load acceptance activities in multiple planes of movement with a reactive random element

• Develop athlete’s ability to carry out specific multi-directional running & landing tasks which are aligned to needs of their sport, along with any other sport skill based tasks

ACL Injury • Sport specific task training activities

• Typical activities

• Muscle strengthening & work capacity training

• Unilateral load acceptance activities in multiple planes & reactive landings situations (with fatigue element)

• Sports specific aligned running agility tasks

• Sports specific aligned skill tasks

Page 19: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

19

ACL Injury • Target criteria to be achieved prior to progression to

unrestricted sport specific training

• Following fatiguing task (sport specific intensity-duration) – SEBT symmetry & within norms

– Single leg (hop) land (alignment control; QASLS score 0-1) • Single leg hop for distance (LSI < 5%, & <5% pre op score)

• Forward & side hop from 30cm box (alignment control; QASLS score 0-1)

• Running speed – 10m sprint (<10% preop time)

– Agility run time symmetrical (modified T or alternate sport specific) < 10% preop time

• Function – sport specific tasks with alignment control under random

practice & fatigue scenarios (video analysis)

ACL Injury

Unrestricted sport specific training

Page 20: ACL reconstruction; deconstructing the reconstructions ... · ACL injury •ACL injury •Limited statistics in UK related to sport •Rugby Union 2002-2004 (Fuller et al 2005) –14

23/05/2015

20

ACLR deconstructing the reconstruction’s rehab

• Outcome from surgery is inconsistent & not

optimal

• Rehabilitation needs to consider & address these

historic performance short falls

• Rehabilitation needs to be task not time orientated

• Task needs to be specific & progressively more

challenging

• Progression is earned by meeting performance

markers

ACL Injury • Thank you

[email protected]

• Knee Biomechanics & Injury Research Group

• @leehphysio