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ACL Reconstruction

ACL Reconstruction. Anatomy and Methods. ACL Tear Anatomy 1. Patellar Tendon Graft Ipsilateral middle third patellar tendon. 1. Hamstring Graft 4-strand gracilis/semitendinosus tendons 1. ACL Repair Anatomy. Arthroscopy pictures. In tact ACL Torn ACL. ACL Repair

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ACL Reconstruction

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  1. ACL Reconstruction Anatomy and Methods

  2. ACL Tear Anatomy1

  3. Patellar Tendon Graft Ipsilateral middle third patellar tendon.1 Hamstring Graft 4-strand gracilis/semitendinosus tendons1 ACL Repair Anatomy

  4. Arthroscopy pictures In tact ACL Torn ACL

  5. ACL Repair Patellar Tendon vs Hamstring

  6. ACL Reconstruction Timeline and Goals + Rehabilitation exercises

  7. General Guidelines • Conservative and Accelerated programs • Accelerated programs are today’s trend7 • Supervised or Home physical therapy for 6-9 months • Differences found in supervised versus home physical therapy were insignificant.8 • Accelerated program timeline 9 • Phase I = 0-2 weeks • Phase II = 2-8 weeks • Phase III = 2-6 months • Phase IV = 6 months to released

  8. Phase I (1-2 weeks) • Educate patient on the goals of each phase of rehabilitation • Crutches for 1 week and non-weight bearing; then add weight bearing as tolerated up to full weight bearing by 2 weeks • No driving for 1 week with surgery on left knee and 4 weeks with surgery on right knee • Brace locked in full extension for 1 week, then kept on unlocked • Protect the graft • Control inflammation (swelling) • Full extension PROM by 2 weeks • 90° flexion PROM or assisted AROM by 2 weeks • Immediately begin quadriceps strengthening open chained and isometrically • Patellar mobilization exercises (graft donor site)

  9. Braces

  10. Phase I (1-2 weeks) ROM exercises: • Knee flexion: heel slides, seated pull backs, wall slides, prone quad stretch (10,11) • Knee extension: prone hangs, heel prop, manual knee extension (10,11,12) • Patella mobs: superior/inferior, medial/lateral (10,11,12,13) Strengthening: • Quadriceps: quad sets, knee extension isometrics (60° & 30°) (10,11,13,14,15,16,17) • Hamstrings: standing hamstring curls (10,12,13) • Hip: flexion, extension, abduction, adduction (10,11,14,15,16,17) • Calves: heel toe rocking sitting/standing (10,11,13) Proprioception: • Weight shifts: side to side, diagonal, front/back (11,12) • Gait training with crutches (12,13,17) Cardiovascular conditioning: • Upper body ergometer (UBE) – 10-30min depending on the sport of the athlete

  11. Phase II (3-12 weeks) • Protect graft fixation points by avoiding quick motions in any direction at the knee and avoiding using heavy weights • Avoid all rotational motions of the knee • Strengthen quadriceps with closed chain exercises and perform a full body weight squat properly • Hamstring exercises increased as tolerated • Restore normal gait • Regain good balance; proprioception exercises • Full flexion AROM restored (130°) • Full extension AROM

  12. Phase II (3-4 weeks) ROM exercises: • Continue previous exercises as needed • Hamstring & calf stretching (11) Strengthening: • Knee extension (AROM 90-30°): concentric & eccentric (10,12,13,15,16,18) • Terminal knee extension (TKE) with sports cord (10,11,13) • Step-ups: forward & lateral (10,11,13,18) • Leg press: double leg (0-60°) (12,15,16,17,18,19) • Mini PWB squats (0-45°) with wall / swiss ball (10,13,17,18,19) Proprioception: • Single leg stance: eyes open/closed, foam, plyoback (11,12,17,18,20) • Gait training without crutches (12,13,17) Cardiovascular conditioning: • Stationary bike, if knee flexion > 100° (10,11,13,17,18) • Aquatic jogging (10,18)

  13. Phase II (5-8 weeks) ROM exercises: • Quadriceps, hamstrings, and calf stretching Strengthening: • Hamstrings: machine – prone & seated curls (10,11,12,13,17) • Multi-hip: machine – flexion, extension, ABD, ADD (10,11) • Leg press: double leg eccentric, single leg (11,15,16,17,18,19) • Calf: heel raises (standing; DL/SL) (10,11,13,17,18) • Vertical FWB squats @ 0-60° (10,13,17,18,19) • Step-downs: forward & lateral (11,13) Proprioception: • Single leg stance: foam with plyoback and ball toss (11,17,18,20,21) • Gait training: treadmill walking; backward and lateral stepping (12,13) Cardiovascular conditioning: • Stationary bike, aquatics • Stair stepper: forward/retro (10,11,12,13,17)

  14. Phase II (9-12 weeks) ROM exercises: • Continue previous exercises Strengthening: • Leg press: eccentrics & single leg (11,18,19) • Cable/sports cord: retro walking & lateral stepping (10,11,13) • Lunges: anterior & lateral (10,11,13) Proprioception: • Single leg stance: foam with plyoback and ball toss, perturbation (11, 17, 18, 21) • Lateral hops: single and multiplane (11,17,18) Cardiovascular conditioning: • Stationary bike, stair stepper, aquatics • Slide board & jump ropes (11,12,13) Running program: • Treadmill jogging (7, 10, 13, 17, 18)

  15. Phase III (4-6 months) • Avoid overstressing the graft by avoiding quick lateral motions and avoiding quick rotational motions at the knee • Continue full ROM • Improve strength, endurance and proprioception of the lower extremity to prepare for functional activity • Progress strengthening exercises to eccentric and advanced closed chain activities • Progress to advanced proprioceptive exercises • Begin agility drills gently (brace may be recommended) • Begin plyometric drills gently

  16. Phase III (13-18 weeks) ROM exercises: • Quadriceps, hamstrings, and calf stretching Strengthening: • Continue exercises from week 11-12 Proprioception: • Lateral hops: multiplane with rotation, multiplane with sports cord Cardiovascular conditioning: • Continue with stationary bike, stair stepper, and/or jogging Plyometrics: (10, 11, 19, 22, 23) • Level I: 4-5 exercises, 50-60 foot contacts, 3x6reps • Level II & III: 4-5 exercises, 80-100 foot contacts, 5x5reps Agility drills:(10, 11, 19, 24) • Level I: focus on mechanics then speed; 10 reps each • Level II: focus on speed; 10 reps each

  17. Phase III (13-18 weeks) Plyometrics: • Level I:Power hops, tuck jumps, 4 corner hops, zig-zag hops,box jumps, squat jumps, SL box push-offs, lateral box push-offs • Level II: Split squat jumps, depth jumps, SL jump off box, lateral box shuffle, lateral box jumps, SL power hops, alternating bounding • Level III: SL depth jumps, depth jumps with 180° turn, depth jumps with sprint, box-to-box jumps (DL/SL), SL hops and bounding

  18. Phase III (13-18 weeks) Agility drills: • Level I: Ladder drills, high knees, butt kicks, skipping, backward striding, lateral shuffles, figure 8’s, 45° cone cuts, 3 cone shuffles • Level II: Ladder drills, 20 yard shuttle, 45° cone cuts, 3 cone shuffles, box drill, T-drill, 5 cone drills

  19. Phase IV (6-12 months) • Return to sport and full activity • Sport specific functional and agility testing (brace may be recommended) • 90% single leg hop test.25 • Isokinetic testing for full strength • 90% quadriceps strength25 • Full pain free ROM • Physician’s release from rehabilitation to return to sport • Educate patient on any possible future risks or complications • Verified graft failure rate = 2% 7 • Recent outcome measures show a decline in sport participation after 2-3 years26 • Factors include surgical details, physical therapy, and social and psychological factors

  20. References 1 Anterior Cruciate Ligament Injuries | eorthopod.com. 2010. Available at: http://www.eorthopod.com/content/anterior-cruciate-ligament-injuries. Accessed October 14, 2013. 2.Feller JA, Webster KE. A Randomized Comparison of Patellar Tendon and Hamstring Tendon Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2003;31(4):564–573. 3.Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc North Am Int Arthrosc Assoc. 2005;21(7):791–803. 4.Aglietti P, Giron F, Buzzi R, Biddau F, Sasso F. Anterior cruciate ligament reconstruction: Bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon graftsA prospective, randomized clinical trial. J Bone Jt Surg. 2004;86(10):2143–2155. 5.Roe J, Pinczewski LA, Russell VJ, Salmon LJ, Kawamata T, Chew M. A 7-Year Follow-up of Patellar Tendon and Hamstring Tendon Grafts for Arthroscopic Anterior Cruciate Ligament Reconstruction Differences and Similarities. Am J Sports Med. 2005;33(9):1337–1345. 6.Jansson KA, Linko E, Sandelin J, Harilainen A. A Prospective Randomized Study of Patellar versus Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2003;31(1):12–18. 7. Kvist J. Rehabilitation following anterior cruciate ligament injury. Sports Med. 2004;34(4):269–280. 8. Grant JA, Mohtadi NG. Two-to 4-year follow-up to a comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction. Am J Sports Med. 2010;38(7):1389–1394. 9. Pizzari T, Taylor N, McBurney H, Feller J. Adherence to rehabilitation after anterior cruciate ligament reconstructive surgery: implications for outcome. 2005. Available at: http://arrow.latrobe.edu.au:8080/vital/access/manager/Repository/latrobe:1191. Accessed October 7, 2013. 10. Beynnon BD, Uh BS, Johnson RJ, et al. Rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med. 2005;33(3):347-59. 11. Manske RC, Prohaska D, Lucas B. Recent advances following anterior cruciate ligament reconstruction: rehabilitation perspectives : Critical reviews in rehabilitation medicine. Curr Rev Musculoskelet Med. 2012;5(1):59-71. 12.Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sports Traumatol Arthrosc. 2000;8(6):337-42. 13.Heijne A, Werner S. Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc. 2007;15(4):402-14.

  21. References 14.Shaw T, Williams MT, Chipchase LS. Do early quadriceps exercises affect the outcome of ACL reconstruction? A randomised controlled trial. Aust J Physiother. 2005;51(1):9-17. 15.Perry MC, Morrissey MC, King JB, Morrissey D, Earnshaw P. Effects of closed versus open kinetic chain knee extensor resistance training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13(5):357-69. 16.Perry MC, Morrissey MC, Morrissey D, Knight PR, Mcauliffe TB, King JB. Knee extensors kinetic chain training in anterior cruciate ligament deficiency. Knee Surg Sports Traumatol Arthrosc. 2005;13(8):638-48. 17. Gerber JP, Marcus RL, Dibble LE, Greis PE, Burks RT, Lastayo PC. Safety, feasibility, and efficacy of negative work exercise via eccentric muscle activity following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2007;37(1):10-8. 18.Papandreou MG, Billis EV, Antonogiannakis EM, Papaioannou NA. Effect of cross exercise on quadriceps acceleration reaction time and subjective scores (Lysholm questionnaire) following anterior cruciate ligament reconstruction. J Orthop Surg Res. 2009;4:2. 19.Lorenz D, Reiman M. The role and implementation of eccentric training in athletic rehabilitation: tendinopathy, hamstring strains, and acl reconstruction. Int J Sports Phys Ther. 2011;6(1):27-44. 20. Cooper RL, Taylor NF, Feller JA. A randomised controlled trial of proprioceptive and balance training after surgical reconstruction of the anterior cruciate ligament. Res Sports Med. 2005;13(3):217-30. 21.Liu-ambrose T, Taunton JE, Macintyre D, Mcconkey P, Khan KM. The effects of proprioceptive or strength training on the neuromuscular function of the ACL reconstructed knee: a randomized clinical trial. Scand J Med Sci Sports. 2003;13(2):115-23. 22. Struminger AH, Lewek MD, Goto S, Hibberd E, Blackburn JT. Comparison of gluteal and hamstring activation during five commonly used plyometric exercises. Clin Biomech (Bristol, Avon). 2013;28(7):783-9. 23. Myer GD, Ford KR, Mclean SG, Hewett TE. The effects of plyometric versus dynamic stabilization and balance training on lower extremity biomechanics. Am J Sports Med. 2006;34(3):445-55. 24.Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. J Orthop Sports Phys Ther. 2006;36(6):385-402. 25. Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthrosc J Arthrosc Relat Surg. 2011;27(12):1697–1705. 26. Feller J, Webster KE. Return to sport following anterior cruciate ligament reconstruction. Int Orthop. 2013;37(2):285–290.

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