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ACL Reconstruction. Jasmine Chan, SPT Andy Chiu, SPT Brandon Higa , SPT Bryce Keyes, SPT Minsu Kim, SPT Derek Matsui, SPT Adrian Ruiz, SPT Traci Yamashita, SPT. Introduction.
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ACL Reconstruction Jasmine Chan, SPT Andy Chiu, SPT Brandon Higa, SPT Bryce Keyes, SPT Minsu Kim, SPT Derek Matsui, SPT Adrian Ruiz, SPT Traci Yamashita, SPT
Introduction • Despite anticipation of positive surgical results based on current technical methodology, even well performed ACL surgery can result in a poor outcome if rehabilitation is not conducted appropriately. ~Shelbourne
Postsurgical Orthopedic PT1,2 • Understanding the mechanics causing the injury and potential risk factors • Respecting the healing process • Making clinical decisions re: modifications or progression of the patients PT program • Designing a program for the patient using functional training and avoiding excessive stress on the joint
Pre-Operation1,2 • Higher risks resulting in complication ACL reconstruction surgery • Limited ROM • Inadequate muscle contraction of quadriceps and hamstrings • Postponing reconstruction • Risk for meniscal and chondral surface damage
Surgical Consideration1,2 • Bone-Patella Tendon-Bone (BPTB) • Rapid revascularization • Ability to return to high demand activities • Anterior knee pain • Knee extensor mechanism/patellofemoral dysfunction • Long term quad weakness • Semitendonosus-GracilisAutograft • HS strain in early rehab • Knee flexor muscle weakness
Signs & Symptoms1 • Inflammation • Pain • ROM • Quad control • WBAT • Complications1 • Pain & Edema limiting motion Acute Inflammatory (Necrosis): 1-4 weeks1,3,4 Morphologic Findings Tendonous Ligamentous1 http://www.jmarshallfreeman.com/images/pages/knee_surgery_web.png
Revascularization: 6-8 weeks4 • Morphologic Findings • Angiogenesis • Scar • Signs & Symptoms • ROM (125-135 ̊ flexion)1 • FWB • SLS • Complications1 • ROM deficits • Edema • ↑Pain • Arthrofibrosis • PF dysfunction
Proliferative Phase: 8-16 weeks4 Morphologic Findings Signs & Symptoms1 Full ROM SLS No pain No edema Running • Proliferation • Differentiation • Extracellular matrix production
Collagen remodeling Phase4: up to 1-2 years Morphologic Findings Signs & Symptoms1 Full ROM Return to activity • Remodeling
Deviations • Edema and Pain1 • Swelling pain, inhibit muscle function, limit motion • Anterior knee Pain1 • Arthrofibrosis1,5,6 • PF pain • Limited ROM1 • Patellar entrapment (if no 4-6 weeks no full extension) • Cyclops lesion (fibroproliferative nodule)
Equipment7 • Continuous Passive Motion (CPM) Machine • Improve ROM • Slow motions • Used at home • 6 hrs/day • 1-2 weeks
Equipment8 • Power Plate • Acceleration Training • Vibratory waves • Increase healing
Equipment9 • Compression Boots • Inflatable coverings • Increase blood circulation • Crutches/walker/brace • Bike • Treadmill • Weight machines • Therabands • Neuromuscular Electrical Stimulation
Equipment10 • Total Gym • Multiple exercises • Adjustable levels
Modalities9 • Cold/cool packs • Ultrasound • Electrical Stimulation • Transcutaneous Electrical Nerve Stimulation (TENS)
Risk Factors1 • Anatomical • Joint laxity • Tibial rotation internally • Pronated feet • Physiological • Poor core strength • LE deficits • Strength and coordination • Neuromuscular deficit • Valgus collapse position
Static Posture11 • Static postural faults • Anterior pelvic tilt • anteverted hips • Shortened hamstring length • genu recurvatum • subtalar pronation • Genu recurvatum along with subtalar pronation • Increases stress on the ACL
Forces Applied on the Knee12 • ACL more vulnerable when knee near full extension • Sakane et al study • Anterior shear force applied on the tibia at different knee flexion angles • Shear force highest at 30° of knee flexion • Shear forces decreased with increased knee flexion
Quads and Hamstrings12 • Quads • Increased ACL tensile force during quads contractions • Hamstrings • Hamstring contraction decreases ACL tensile force from quad contraction • Hamstring strength important to decrease tensile force applied on the ACL during deceleration motions
Ankle11 • ACL injury is associated with hyperpronation of the subtalar joint • Abnormal pronation increases passive knee internal rotation • Quad contraction and knee internal rotation = 2x increase of ACL tensile force
Pediatric Approach13,14,15,16 • Pediatric population requires a more cautious approach • Dependent upon level of skeletal maturity • Open growth plates • Longitudinal bone growth from time of injury • ACL attaches to both distal femoral epiphysis and proximal tibial epiphysis • Patients should undergo constant follow-up and exam to track progress of knee • Treatment Protocol • Follow-up phone call every 3 months after discharge from clinic for up to 2 years
The Female Athlete17 • Females 4-6 times more likely to obtain an ACL injury • Three major factors resulting in injury • Ligament Dominance • Quadriceps Dominance • Leg Dominance
Neuromuscular Control17 • Ability to coordinate and control muscle activation & dynamically stabilize the knee in response to sensory, visual, and physical stimulation • In the absence of neuromuscular control • Decrease firing of dynamic stabilizers of knee joint=Increase dependence on static stabilizers • Factors effecting neuromuscular control • Joint position • Core stability • Fatigue
Neuromuscular Training17 • Training includes • Plyometrics • Dynamic Posturing • Perturbation Training • Proper Mechanical Technique • Strength and Flexibility
Neuromuscular Training Goals17 • Decrease side to side kinematic differences in the lower extremities • Increase proprioception of hamstrings • Improve balance • Facilitate protective patterns/stabilization of the knee • Decrease the overall risk for injury/re-injury of ACL
Neuromuscular Training17 • This information has been well researched and should be implemented in every PT facility • However, there is a widespread lack of implementation of this information by practicing PT’s • If we want to see improvement in these athlete’s we can’t just treat the ACL. We need to fix the “why” of the problem
Rehab/Exercise Prescription • Considerations • Surgery-specific • Patient population-specific • Structural/functional contributions • Early vs Delayed rehab18 • Accelerated vs Non-accelerated rehab18
Rehab/Exercise Prescription • More Considerations • Knee brace18 • No effects on clinical outcomes • Doesn’t reduce risk of intra-articular injury post-ACLR • MD Orders • Closed Kinetic Chain(CKC) vs Open Kinetic Chain(OKC)18 • CKC more functional, promote co-contraction, less laxity and patellofemoral pain • OKC produce greater quad strength and doesn’t compromise further knee laxity • Depends on phase of rehab
Exercise Prescription(Phase I, post-op-4 weeks)1,2,19 • Goals • Decrease joint effusion/edema • Full passive knee extension • ↑ knee flex ROM 0-110 • WBAT without crutches • Interventions • PRICE • Passive stretch • Gait training with obstacles • Patellar mobilization • Isometric/closed-chain exercises
Exercise Prescription(Phase II, 6-8 weeks)1,2,19 • Goals: • Full pain-free knee ROM • FWB (no limp) • Muscular strength 4/5 • Normal gait pattern and ADL function • Interventions • Progress in Phase I interventions • Balances exercises • Aerobic conditioning
Exercise Prescription(Phase III, 8-16 weeks)1,2,19 • Goals • Increase muscular strength, endurance, power • Improve neuromuscular control • Improve cardiopulmonary fitness • Interventions • Progress in Phase I-II interventions • Plyometric exercises
Exercise Prescription(Phase IV, 16 weeks-)1,2,19 • Goals • Reduce risk of re-injury • Patient education • Interventions • Progress in Phases I-III exercises • Activity-specific exercises
Patient Education20 • A patient needs to be well educated to become a successful participant in the rehabilitation of an ACL injury • Fear of re-injury is associated with lower functional outcomes • Patients need to be educated about re-injury prevention • Patients should be educated about graft maturation and motions that stress the ACL
Re-injury Prevention Considerations21 • Re-injury rates are estimated at 2 to 13% in athletic populations • Patellar tendon rupture and patellar fracture have occurred in rare occasions with extension exercises • Coming back too soon- Jerry Rice
Return to Sport22,23 • A general guideline is return to sport is not allowed until 6 months post-op, but successful return to sport has been consistently seen before this time period • Should be based on dynamic stabilization and strength • ROM should be full and knees should be symmetrical
Would you like to know more? • Questions? • Visit our website at: http://dakinept.yolasite.com/
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