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ACL reconstruction healing and Return to Play

ACL reconstruction healing and Return to Play. Randy Clark Acknowledgements: Glenn Williams, Mike Shaffer, Danny Foster, Brian Wolf. Introduction. 100,000 new ACL injuries each year (1/3000 people) Young women 3 times more likely to suffer an ACL injury compared to a male cohort group

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ACL reconstruction healing and Return to Play

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  1. ACL reconstruction healing and Return to Play Randy Clark Acknowledgements: Glenn Williams, Mike Shaffer, Danny Foster, Brian Wolf

  2. Introduction • 100,000 new ACL injuries each year (1/3000 people) • Young women 3 times more likely to suffer an ACL injury compared to a male cohort group • Young female participating in sports year round has a 5% risk for tearing her ACL • No more than 15- 30% of ACL deficient individuals typically return to running, jumping, and pivoting activities without experiencing subsequent episodes of knee instability

  3. ACL Defficiency and Return to Play 832 ACL injuries 10% declined, 40% other knee injuries 432 Remaining patients 87 unable to regain ROM, strength, pain control 345 patients Screening exam eliminates 199 as Non-copers 146 patients 60% chose to undergo surgery 88 patients attempt return to sport

  4. ACL Defficiency and Return to Play 88 Patients return to sport 72% successful 63 patients 36 went onto reconstruction 29 patients remain • 24% return to sport without subsequent instability Hurd et al., A 10 year progressive trial of a patient management algorithm and Screening examination for highly active indicituals with ACL injury, Part 1 Outcomes., Am J Sports Med. 36:40-47 Fitzgerald et al., Knee Surg Sports Traumatol Arthrosc., 2000

  5. How long until I can play? • The healing process- • It’s a dead piece of tissue! • Graft needs to be re-vascularized • “Ligamentization” occurs • Vascular Synovial layer wraps around graft in 4-6 weeks

  6. Healing Time • Autologous ACL grafts don’t Transition through necrotic stage • Weakest link fixation 4-6 weeks • Complete re-vascularization of the graft takes ~20 weeks • Remodeling occurs: • By one year histological and biochemical properties of ACLR ~ native ACL

  7. Graft Remodeling • Gradual loss of graft strength during initial remodeling • Then strength of ACL graft improves gradually • Allografts • Slightly slower process

  8. Graft Remodeling • Patellar tendon • Bone to bone within the ACL tunnels • 4-8 weeks usually

  9. Graft Remodeling • Hamstring graft -Bone to tendon healing -Sharpey’s fibers -Usually complete at 12 weeks • ACL autograft resembles normal ACL at 12 months • Concern for increased allogenic graft incorporation time doesn’t warrant modification of PT protocol

  10. Pre-Operative Rehabilitation • Initial focus on eliminating swelling and restoring pre-injury range of motion and strength

  11. Rehabilitation • Slight variations depending on age, history, activity level, graft source and associated injuries.

  12. Rehabilitation • Bracing: • “There is little evidence to support the use of a post-operative brace following isolated reconstruction of the ACL.” • “Although the exact mechanism for any beneficial effect of functional bracing remains unknown, ACL deficient athletes commonly report improved confidence with use of a functional knee brace.” • “The use of functional bracing should perhaps be reserved for return to sport following revision surgery or in athletes who have suffered a multiple ligament injury.” • CORR 07’ systematic review 12 RCT’s- no support for bracing

  13. Rehabilitation • Five phases • Phase I- Immediate post-op (0-2 weeks) • Phase II- Early Rehabilitation Activities (2-6 weeks) • Phase III- Advanced Rehabilitation Activities (6-10 weeks) • Phase IV- Advanced Functional Activities (10 weeks- 6 months) • Phase V- Return to Sport (6-12 months)

  14. Rehabilitation • Phase I- Immediately Post- Surgery (POST-OPERATIVE WEEKS 0-2) • The goals of the early rehabilitation period are to control pain and post-operative swelling, and begin to restore range of motion. • Control inflammation: cryotherapy, elevation, compression, limitation of activities • Restore ROM: importance of regaining hyperextension. (Importance of regaining motion pre-op)

  15. Rehabilitation • Phase I continued…. • ROM • Stretches: extension bridges, prone hangs • ROM expectations: • 0-90° 2 weeks • 0-120° 4 weeks • Full range 6 week • Muscle strengthening • Isometric quad contractions, straight leg raises, stim • treatments • Ambulation- crutches, WBAT, avoid “quad avoidance” gait pattern

  16. Rehabilitation • Criteria to Progress to Phase II • Knee effusion well controlled • Adequate quadriceps control demonstrated by the ability to do a hip flexion straight leg raise without extensor lag • Normal gait pattern without use of assistive devices • Knee range of motion of at least 0- 90°

  17. Rehabilitation • Phase II – Early Rehabilitation Exercises (POST-OPERATIVE WEEKS 2-6) • The focus of Phase II rehabilitation is to restore full knee range of motion and advance early strengthening exercises • Light weights, remember creep (low load prolonged stretches), manual overpressure, stationary bicycle (half moon), lunges, squats • Supervised vs. Home rehab program • We feel that a minimum of 6 visits with a rehabilitation professional is necessary for • successful outcome following ACL reconstruction.

  18. Rehabilitation • Open vs. closed chain excercises • Open chain and infrapatellar pain • Graft lengthening

  19. Rehabilitation • Criteria to Advance to Phase III • Full knee range of motion • Able to ascend and descend stairs normally • Successfully completing regular exercise program of Phase II activities

  20. Rehabilitation • Phase III- Advanced Rehabilitation Exercises (POST-OPERATIVE WEEKS 6-10) • Build on the limb strength gained in Phase II • Traditional strengthening exercises combined with additional challenges to the nervous system: pertubations, mental distraction tasks, activities which progressively force the center of gravity away from the base of support. • Restore neuromuscular control: mechanoreceptor repopulation is most active between 2 and 8 weeks post-operatively • RCT’s show superiority of neuromuscular retraining when compared to standard strength training. (Beard JBJS 94’, Risberg Aust J Phys 07’)

  21. Rehabilitation • Criteria to Advance to Phase IV • Regularly completing isotonic strengthening program in supervised physical therapy • Starting to transition strengthening activities to local gym or athletic team’s weight room • Approximately 70-80% strength vs. contralateral (uninvolved) lower extremity • Demonstrates appropriate control of knee with neuromuscular retraining exercises in the physical therapy clinic

  22. Rehabilitation • Phase IV- Advanced Functional Activities (10 weeks- 6 months) • The primary goal of the fourth phase of rehabilitation is to prepare the athlete for return to sport. Running, cutting, and jumping are near universal requirements of the sports in which athletes most often tear their ACL’s. • be cognizant of other tasks which are important parts of the sport to which the athlete hopes to return

  23. Rehabilitation • Phase IV continued • ladder drills or other simulated running tasks, then advance to interval jogging. • Once 70-80% of their pre-injury speed, cutting drills begin. • Land based jumping, jumping up to a box and/or completing all plyometrics activities by landing on two legs

  24. Rehabilitation • Criteria for Progression for Phase V • Regularly completing isotonic strengthening program • Running at least 85% of pre-injury speed • Cutting and jumping without hesitation or obvious limitation

  25. Rehabilitation • Phase V- Return to Sport (6-12 months) • subjective and objective information considered. • Athlete pain free during performance • Athlete not demonstrate limp or guarding • Effusion after rehabilitation or functional testing viewed as a stark indication that neuromuscular system not adequately countering the high stresses experienced within the joint. • Athlete should feel confident about their return to sport.

  26. Rehabilitation • Phase V- Return to Sport (6-12 months) • No more than 10% asymmetry in terms of isokinetic variables between the involved and uninvolved lower extremity • single leg hop test to measure knee joint function and strength • single leg vertical jump, single leg hop for distance, single leg timed hop

  27. Rehabilitation • Criteria to Return to Sport • No complaints of pain or knee instability • Full ROM • No new effusion • Lower extremity strength/ function at least 85% vs. uninvolved LE • Adequate performance in physical therapy or with sport specific drills which simulate the intensity, frequency, and duration of the sport to which the athlete hopes to return • Athlete demonstrates a psychological readiness to return to sport, either verbally or with SANE score > 80/100

  28. Functional Testing • Full ROM, negative pivot-shift, symmetric quad and hamstring strength and functional testing scores

  29. Rehabiliation • Crucial input from.. • Physician • Athletic trainer • Physical Therapist • Coach • Athlete +/- parents

  30. Rehabilitation • Rehab time frame changed • Formally >12mos • Now generally ~6m • 2 RCT’s • Beynnon, Ekstrand • 8 mos vs ~5mos • No significant differences in: • Subjective outcome • Anterior knee laxity • Functional testing • Faster rehab (19 wks) seems safe • Programs faster than this….?

  31. Rehabilitation • Bone scan? • Scott Dye talk

  32. Rehabilitation • Functional score meta-analysis • No difference between BTB and hamstring grafts with respect to function (Biau CORR 07’) • 14 trials- 7 RCT’s

  33. What to expect? • 10-14% of ACL R patients need another surgery at some point in the future • Risk of re-rupture • 3% on ACLR knee • 3% on other knee • ~20% of patients note some subj functional impairment with ACLR knee • ~90% of athletes return to same level of sport by one year after ACLR • Only 54% still at that level by ~3 yrs

  34. Lit Review on Return to Play

  35. Lit Review on Return to Play

  36. Home vs Formal PT • Grant et. Al, AJSM 2005 • Hypothesis: no difference in home vs. structure PT program at 3 months for BTB reconstruct. • Study design: RCT, 145 pts, 4 vs. 17 PT sessions • Measured: ROM, knee motion walking, KT, quad and hamstring strength • Results: 67% vs 47% flexion, 97% vs 83% ext, others no diff. • Conclusion: OK for weekend warrior to do home PT

  37. Propioception Knee Before and After ACL Reconstruction • Reider et al. Arthroscopy 2003 • Compared proprioception before and after ACL reconstruction to healthy controls (contralateral knee) • Concluded: “At 6 months no difference in JPS and TDPM (threshold to detection of passive motion) compared to controls” • Reconstruction has positive impact on propioception

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