The First 3 Months of Acl Rehabilitation Factors That Influence Success-paine

7/25/2019 The First 3 Months of Acl Rehabilitation Factors That Influence Success-paine

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Russ Paine, PTMemorial Hermann Ironman

Sportsmedicine Institute

Houston, Texas

ACL Rehabilitation

Adrian Peterson NFL Running Back

NFL MVP 2012 2,097 yds.

6th fastest player toreach 8,000 rushingyards

150 yds. 7 games

ACL PTG, MCLIII8 mos prior to beginof season

Jointcondition/intensity.genetics

Phase I ACL Rehab. ROM and

Strength

ACL/MCL injuryon December 24,2011

Grade III MCL

Surgery: Dec. 30,2011 Dr.Andrews

Returned toHouston for rehab

on January 10

Quad Atrophy Still Enigma

Rehabilitation

AJSM March2005

VL, VI smallerin ACL def.knee

VMO stilldifficult toactivate

Pre-op and Immediate Post-op

Training Quad Re-cruitment

biofeedback 10

Stimulate Proprioception(gait training, balancingactivities) cone amb.

Extension ROM techniques

ERMI device SLRs up to 10# 5

Flexion contracture = locatepain

Ant. Or Post.

Ant = fat pad impingement

Post = capsular scarring or hsspasm

Ligament Unloading Exercises

Quad setting, SLR kneein full extension - Drez,Paine Journal of KneeSurgery

Knee extension limitingROM 90 - 40 Grood -JBJS 84

Leg Press = 90 - 40 =decreased strain in thisROM no need forextension = decreasedquad contraction


2/10

ACL Tear = Loss of

Proprioceptive Function must be

Restored before return to sports Primary goal

Rehabilitation

Enhance muscle

reaction time

Stabilization/Recruit

ment

Proprioception

Carter et al, Br J Sports

Med, 1997 Loss of proprioception after

ACL rupture

Roberts et al, J Orthop Res,

2000

Loss of proprioception after

ACL reconstruction

Gait Abnormalities

Acute ACL Tears

Decreased NMinput

Delayed quadfiring heelstrike

Result = flexedknee gait pattern

Increased PFJRF

Force patient tosqueeze quad atheel strikeTreadmill amb.

Revascularization of ACL Graft

4 phases Avascular graft

Revascularization

Cellular repopulation

Remodeling &Reorganizationcollagen fibers(ligamentizationAmiel 86 AJSM)

Recent studies =intraarticular portionrevascularizes fasterthan bone interface

sitesNtoulia AJSM2011

Early Phase

Inflammatory response:macrophages, cytokines

produce scar betweengraft and bone 4-10

days 6 weeks graft hasvascular synovialenvelope

20 weeks intrinsic graftrevascularization

Fat pad, synovial tissue,bone tunnels =vascularity

Animal Studies Bone Tunnel Healing

12 weeks Sharpeysfibers into graft = bonehealing

Pull out failure prior to12 weeks = tunnelfailure, after 12 weeks= midsubstanceRodeoJBJS 93

BPTB 6 weekscompleteincorporationPapageorgiou AJSM2001

Bracing 4-6 hyperflexion


3/10

Immobilization

Decrease in

proteoglycan content

Reduces stiffness of

cartilage

Cant withstand

shearing forces

Compression & Fluid Flow

Matrix - CPM As compression

increases,resistance to fluid

flow in matrixincreases

GAGs slow downfluid flow in &out of matrix

Result = increasedstiffness ofcartilage

Stiffness = allowsresistance tocompression

Passive ACL Strain

Passive ROM 0% strain 0-

60, 70-120 1-2% strain in

normal ACL

Push extension wait on

flexion (swelling)

Renstrom AJSM 86

Motion Complications Increasing flexion

Restricted flexion =increased PF Compression

Flexionator

Provides hydraulicresistance

5 min. on 5 min.off, repeat

6 x per day

HS Biofeedback ProneHangs

Steps To Avoid Extension LOM

Recognize early factors:

Poor quad function no SLR

Flexed knee ambulation

Poor pain tolerance

MCL/Meniscus repair

Reversing Lack of

Extension

1cm = 1 HHD Daniel

AJSM 89

Infrapatellar Fat Pad Tunnel Pain -

Activity Source of pain

post-op ACL

ATS portals passthrough fat pad

Cause fibrotic

hematoma in somepatients

May affect p.tracking with ATS

Early intervention= US,Laser,manualsoft tissuerelease,scar

Injection tunnel


4/10

ACL/MCL

Combined ligament injury

Limits ROM and

WB 1st 4-6 weeks

Locked inextension for 1week, increasedflexion 30d perweek

WB with crutchesgradual increase,D/C crutches 4-6weeks

Stability = No DJD? In a 2004 study of male former

soccer players 14 years after anACL injury, Swedishinvestigators found nodifference between surgicallytreated and conservativelytreated athletes with regard toradiographicallydetected OA

ACL reconstruction did notaffect prevalence of knee OAin female soccer players 12years after ACL injury

Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence of

knee osteoarthritis, pain, and functional limitations in female soccer

players twelve years after anterior cruciate ligament injury. Arthritis

Rheum 2004;50(10):3145-3152.

ACL Deficient Rehabilitation

Risks

Increased articular cartilage loss

long-term

Murrell AJSM 01

130 pts. ACL tears

ATS exam. Reconstruction

Time = increased cartilage &

meniscus loss

9 x greater cartilage damage 2 yrs.

Vs. 1 mo. ACL rec.

P-F Cyclic compression exercises

Difficulty with post-op recovery

Cycling - properseat ht., 90-100Rpm's, dont standon pedals

Total gym -allows bodyweight to bereduced

Pool therapy -load, unload

EFX ?

Step 2

Begin Gradual Loading Exercises

Leg Press Best MR Leg Press

supine squat low load

high endurance

activity 60 secondcontractions

Begin with 5Kg

Quad EMG WB & NWB

Wilk AJSM knee extension =highest EMG = 25 degrees

Wilk AJSM leg press =highest EMG = 85 degrees

Knee extension = requires highEMG due to lack of patellarheight near extension

Huberti = Fpt > Fquad 1st 20d.45d Fquad > Fpt = Carefulwith minisquats


5/10

Step 3

Body Weight Control

Functional Squat

MR Systems

Squat Control

Chair Squats

3x20

New Device

Primal 7

Allows

patient toassume

normal

body

positions

early

using

assisted

strapping

Testing Functional Hip

Abductor Strength

Crossley AJSM 2011

A- participant demonstratesgood performance

B- participant demonstratespoor overall and trunkperformance

C- participant demonstratespoor pelvis and hipperformance

D- participant demonstrates

poor hip and kneeperformance

Chris Powers JOSPT

2003

Controlling

femoral position

Hip ABDuctor,

G.Max, Lateral

Rotation,

NWB routine

Hewitt AJSM

07 pelvic

control - ACL

Powers: Controlling Hip Internal

Rotation, Knee Adducton

WB routine

ABD, GMAX,

Lateral rotation

Core Strengthening = Strengthens

Kinetic Chain

Rotational plyoball: hold

VMO contraction Lower Abdominal Trunk

flexion/extension usingSwiss Ball

Hewitt AJSM 07 Corecontrol may be assoc.with ACL tear = pelviccontrol = kinetic chain =PF control


6/10

Hip Flexor Stretch

Sidelying

Safe and unsafe closed vs open

kinetic chain

Is closed chain safer?

challenged with strain-gaugestudies

What is primary reason for

description of open and

closed chain?

Terminology should describe

what is happening to specific

anatomical structure

Ligament loading exercises

ACL

Knee extension 30 to 0 degrees with

resistance

Pivoting, twisting activities -

Markolf - JBJS - no protection

Squatting - Beynnon - 97 AJSM-

loads comparable to open chain - no

increase in strain with increased

load during squat. Knee extension

= increased strain with increasedload

Ligament Loads

Peak Loads

ACL

Exercise

-ACL = 1725-2160N beforefailure

-PCL = 4000N

Graft load

sharing?

ACL tear = loss of HS reflex

Rehab. = re-gain

Tsuda AJSM 01

Stim. ACL = reflex HSactivity

Response = Humans

versus Solomonow =

animal model

High Speed Biodex

Speeds 180-300deg./sec.

May stimulate NMcontrol

Rapid reversal fromext./flexion

HS curls, goodmornings


7/10

Strength

Load and Volume

Set load and

volume to meet

goals of phase

Periodization

Model

Strength Preparation for plyometrics and sport

specific skills

Vary Load and Volume Involve The Core

MAKE IT PROPRIOCEPTIVELY

CHALLENGING!!!!!

Phase II Functional StrengtheningRunners Pose

Cone Reach ACL Knee Bracing

Used

primarily

during

rehabilitation

Ave. time for

use after

return = 8

weeks.


8/10

Combination Core/LE/UE

Slide Board End Stage RehabWhen to Run?

PTG 2 - 3 mos.

Treadmill

Allograft ACL 3-

4 mos.

Timeframes

dependent on

quad strength and

symptoms

Phase III Plyometrics and Sports

Specific Training

Plyometrics Develop:

Strength

Speed

Power

Good ProprioceptiveTraining

Injury Prevention

Not everyone needs tojump!

Plyometrics

Jumps

2 footed landing

Hops

1 foot landing

Bounds

Jumping form

one foot to the

other

Proprioceptive

When To Start

Full PROM

Normalized Quadriceps

Control Appropriate Time Period

Controlled Joint Effusion

Normal LigamentousExam

Quad Re-education

Take-Off

Recruitment =plyometric

routine, singleleg plyos

Sportsmetric

FunctionalDrills

Isokineticstrength, leg

press 90-40


9/10

Bilateral Cone Hop Stick Broad Jumps

Progression to

Single Leg Hop Maintain

mechanics

Mustundergodouble leg

jumps

Must haveadequatecore/quadcontrol

Agilities/Sports Specific

The ability to change

direction rapidly

without loss of body

control

Uses

Technique

Conditioning

Functional Assessment Return to

Sports

Single leg hop for distance = 90%normal

Figure of 8 = 9.5s (male normal)

Isokinetic test = 85% normal Proprioceptive function = restored

ROM = 90% normal decreasedmotion = articular cartilage stress

KT-1000 within normal limits(


10/10

Return to full competition in NFL

8 mos

Timetables werenot unusual

Level of playwas veryunusual

Skill position,ability tocut/pivot with nofear superhumaneffort

Conclusions

Rehabilitation = team

effort

Must know healingconstraints

Progression = strength,

proprioception/balance,

plyometrics/agilities

Never progress patient

until ready for next phase

The First 3 Months of Acl Rehabilitation Factors That Influence Success-paine

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