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ACL Reconstruction

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

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  1. 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

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. Proliferative Phase: 8-16 weeks4 Morphologic Findings Signs & Symptoms1 Full ROM SLS No pain No edema Running • Proliferation • Differentiation • Extracellular matrix production

  9. Collagen remodeling Phase4: up to 1-2 years Morphologic Findings Signs & Symptoms1 Full ROM Return to activity • Remodeling

  10. 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)

  11. Equipment7 • Continuous Passive Motion (CPM) Machine • Improve ROM • Slow motions • Used at home • 6 hrs/day • 1-2 weeks

  12. Equipment8 • Power Plate • Acceleration Training • Vibratory waves • Increase healing

  13. Equipment9 • Compression Boots • Inflatable coverings • Increase blood circulation • Crutches/walker/brace • Bike • Treadmill • Weight machines • Therabands • Neuromuscular Electrical Stimulation

  14. Equipment10 • Total Gym • Multiple exercises • Adjustable levels

  15. Modalities9 • Cold/cool packs • Ultrasound • Electrical Stimulation • Transcutaneous Electrical Nerve Stimulation (TENS)

  16. Risk Factors1 • Anatomical • Joint laxity • Tibial rotation internally • Pronated feet • Physiological • Poor core strength • LE deficits • Strength and coordination • Neuromuscular deficit • Valgus collapse position

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. Neuromuscular Training17 • Training includes • Plyometrics • Dynamic Posturing • Perturbation Training • Proper Mechanical Technique • Strength and Flexibility

  25. 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

  26. 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

  27. Rehab/Exercise Prescription • Considerations • Surgery-specific • Patient population-specific • Structural/functional contributions • Early vs Delayed rehab18 • Accelerated vs Non-accelerated rehab18

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. Would you like to know more? • Questions? • Visit our website at: http://dakinept.yolasite.com/

  37. References • Maxey L, Magnusson J. Rehabilitation For The Postsurgical Orthopedic Patient. St. Louis, MO: Mosby; 2007. • Kisner C, Colby LA. Therapeutic Exercise. Philadelphia, PA: F.A. Davis; 2007. • Cross MJ. Anterior Cruciate Ligament Injuries: Treatment and Rehabilitation Page. http://www.sportsci.org/encyc/aclinj/aclinj/html. Updated April 18, 1998. Accessed July 19, 2009. • Lattermann C, Koyonos L, & Whalen JD. Basic science/biology. In: Fu F & Cohen S. Current Concepts in ACL Reconstruction. Thorofare, NJ: Slack Inc; 2008: 35-44. • Noonan B & Chung KS. A practical review of the mechanisms of pain and pain management following ACL reconstruction. Orthopedics. 2006; 29(11): 999-1005. • McReynolds JG, Meyer MH, &Rea JB. Infrapatellar contracture syndrome following ACL reconstruction. JAAPA. 2009; 22(3): 23-25. • Plone Foundation.  Post-operative ACL Reconstruction Guidelines. http://www.nismat.org/orthocor/acl_postop.  Updated March 8, 2007.  Accessed July 20, 2009.  • Power Plate.  Technology: What is Power Plate? http://www.nyphysicaltherapy.net/Home/PatientEducation/tabid/3433/ctl/View/mid/5695/Default.aspx?ContentPubID=196.  Updated 2009.  Accessed July 24, 2009  • NY Physical Therapy and Wellness.  ACL Tear and Reconstruction – Knee Ligament Injury. http://www.nyphysicaltherapy.net/Home/PatientEducation/tabid/3433/ctl/View/mid/5695/Default.aspx?ContentPubID=196.  Updated 2009.  Accessed July 20, 2009.  • Total Gym.  Rehabilitation Facilities – Benefits of Total Gym.  http://www.totalgym.com/rehabilitation/rehab.clinics.html.  Updated 2002.  Accessed July 24, 2009. • Loudon JK, Jenkins W, Loudon KL. The relationship between static posture and ACL injury in female athletes. J orthop Sport Phys. 1996; 24(2): 91-97. • Shimokochi Y, Shultz S. Mechanisms of Noncontact Anterior Cruciate Ligament Injury. J Athl Training. 2008; 43(4): 396-408. • Fehnel, David J. & Johnson, Robert. Anterior cruciate injuries in the skeletally immature athlete. Sports Medicine Journal. 2000; 1: 51-63. • Henry, Julien et al. Rupture of the anterior cruciate ligament in children: early reconstruction with open physes or delayed reconstruction to skeletal maturity. Knee Surgery Sports Traumatol Arthroscopy. 2009; 17: 748-755. • Moksnes, Havard, Engebretsen, Lars, & Risberg, Mary Arna. Performance-based functional outcome for children 12 years or younger following anterior cruciate ligament injury: a two to nine-year follow-up study. Knee Surgery Sports Traumatol Arthroscopy. 2008; 16; 214-223. • Wells, Lawrence et al. Adolescent anterior cruciate ligament reconstruction: A retrospective analysis of quadriceps strength recovery and return to full activity after surgery. Journal of Pediatric Orthopedics. 2009; 29: 486-489. • Fischer, Donald V. Neuromuscular training to prevent anterior cruciate ligament injury in the female athlete. Strength and Conditioning Journal; 28: 44-54. • Andersson D, Samuelsson K, Karlsson J. Treatment of Anterior Cruciate Ligament Injuries with Special Reference to Surgical Technique and Rehabilitation: An Assessment of Randomized Controlled Trials. Arthroscopy. 2009; 25(6):653-685. • Logerstedt D, Sennett BJ. Case Series Utilizing Drop-out Casting for the Treatment of Knee Joint Extension Motion Loss Following Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther. 2007; 37(7):404-411. • Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2005; 13(5): 393-397. • Giugliano DN, Solomon JL. ACL tears in female athletes. Physical Medicine & Rehabilitation Clinics of North America. 2007: 18(3), 417-438. • Shelbourne KD, Sullivan AN, Bohard K, Gray T, Urch SE. Return to basketball and soccer after anterior cruciate ligament reconstruction in competitive school-aged athletes. Physical Therapy.  2009; 1(3): 236-241. • Shelbourne KD, Klotz C. What I have learned about the ACL: utilizing a progressive rehabilitation scheme to achieve total knee symmetry after anterior cruciate ligament reconstruction.  Journal of Orthopaedic Science. 2006; 11: 318-325.

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