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Return to Sport after ACL Reconstruction

Return to Sport after ACL Reconstruction. Sara Cordell Ithaca College. Challenge of Deciding Return to Sport. Protocol timeline Concomitant injuries or complications Knee stability and strength Objective vs. subjective data Reliability, validity, accuracy, functional relevance of tests

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Return to Sport after ACL Reconstruction

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  1. Return to Sport after ACL Reconstruction Sara Cordell Ithaca College

  2. Challenge of Deciding Return to Sport • Protocol timeline • Concomitant injuries or complications • Knee stability and strength • Objective vs. subjective data • Reliability, validity, accuracy, functional relevance of tests • Individual circumstances, fears, values, motivation, etc • Demands of particular sport(s) • Clinical experience/judgment

  3. Many Factors Involved

  4. General Return to Sport Guidelines • ≥90% symmetry between involved and uninvolved sides for objective testing (isokinetic testing, hop testing, etc) • Full, nonpainful ROM • No joint effusion • Joint stability- KT test ≤3mm side-to-side difference • MD and PT opinions

  5. Return to Sport Algorithm According to Myer et al.

  6. Objective Testing Options • BiodexIsokinetic Testing • KT Testing • Agility testing- Modified T-test • Balance testing- Stabilometer • Goniometry to measure symmetry of movement • Compare symmetry of GRFs • Deceleration testing • Hop testing

  7. Hop Testing • Common tests- single leg hop for distance, 6m timed hop, triple hop for distance, crossover hops for distance • Limb symmetry index (LSI=involved/uninvolved x100% for distance measures, opposite for time) • Begun ~12-16weeks post-op • Pros- test many aspects of LE movement at once, time efficient, minimal equipment • Cons- learning curve, functional relevance, don’t address quality of movement, measurement error

  8. Hops in Reid et al.

  9. Characteristics of Hop Tests Four tests together- sensitivity= 82% Single hop test alone- sensitivity= 38-52%

  10. Hops in Gustavsson et al. • Vertical jump • Single hop for distance • Drop jump followed by double hop • Square hop • Side hop

  11. Hop Test Evaluation

  12. Hop Test Battery • Vertical jump, single hop for distance, side hop • Sensitivity: 91% for identifying patient as abnormal when at least 1 of the 3 tests was abnormal • Accuracy: 84% for truly normal subjects and 88% for truly abnormal subjects

  13. At 6 months post-op… • 54% had abnormal LSI in ALL 3 tests • 91% had an abnormal value in at least one of the 3 tests • Only 9% had all normal LSI values

  14. Patient Example Reid Test Battery Gustavsson Test Battery

  15. Effect of Testing in Fatigued State • Augustsson et al. evaluated effect of fatigue on single hop testing results • Fatigue- repeat as many reps as possible at 50% 1RM • All patients included in study had ≥90% symmetry in non-fatigued conditions • After pre-exhaustion exercise, 68% demonstrated abnormal hop symmetry

  16. Take Home Messages • Do not use only one or two testing methods • Consider whole athlete and demands of sport • Reference protocol timeline but also use functional goals as criteria for progression • No objective tests are perfect, supplement with clinical judgment and experience • Consider testing athlete in non-fatigued and fatigued conditions

  17. What is your opinion? • Criteria based algorithm as proposed by Myer? • Can you identify the most important factors when deciding return to sport? • Most clinically useful objective measures? • Most reliable/valid hop tests? • Testing in fatigued vs. non-fatigued state? • Commonly overlooked factors?

  18. References • Augustsson J, Thomeé R, Karlsson J. Ability of a new hop test to determine functional deficits after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal Of The ESSKA. Sept 2004;12(5):350-356. • Gustavsson A, Neeter C, Karlsson J, et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal Of The ESSKA. August 2006;14(8):778-788. • HartiganEH, Axe MJ, Snyder-Mackler L. Time line for noncopersto pass return-to-sports criteria after anterior cruciateligament reconstruction. J Orthop Sports Phys Ther. 2010; 40: 141-154. • Kvist J. Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Medicine. 2004;34(4):269-280. • Myer G, Paterno M, Ford K, Quatman C, Hewett T. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. The Journal Of Orthopaedic And Sports Physical Therapy. June 2006;36(6):385-402. • Reid A, Birmingham T, Stratford P, Alcock G, Giffin J. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Physical Therapy. March 2007;87(3):337-349.

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