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7/25/2019 The First 3 Months of Acl Rehabilitation Factors That Influence Success-paine
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Russ Paine, PTMemorial Hermann Ironman
Sportsmedicine Institute
Houston, Texas
ACL Rehabilitation
Adrian Peterson NFL Running Back
NFL MVP 2012 2,097 yds.
6th fastest player toreach 8,000 rushingyards
150 yds. 7 games
ACL PTG, MCLIII8 mos prior to beginof season
Jointcondition/intensity.genetics
Phase I ACL Rehab. ROM and
Strength
ACL/MCL injuryon December 24,2011
Grade III MCL
Surgery: Dec. 30,2011 Dr.Andrews
Returned toHouston for rehab
on January 10
Quad Atrophy Still Enigma
Rehabilitation
AJSM March2005
VL, VI smallerin ACL def.knee
VMO stilldifficult toactivate
Pre-op and Immediate Post-op
Training Quad Re-cruitment
biofeedback 10
Stimulate Proprioception(gait training, balancingactivities) cone amb.
Extension ROM techniques
ERMI device SLRs up to 10# 5
Flexion contracture = locatepain
Ant. Or Post.
Ant = fat pad impingement
Post = capsular scarring or hsspasm
Ligament Unloading Exercises
Quad setting, SLR kneein full extension - Drez,Paine Journal of KneeSurgery
Knee extension limitingROM 90 - 40 Grood -JBJS 84
Leg Press = 90 - 40 =decreased strain in thisROM no need forextension = decreasedquad contraction
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ACL Tear = Loss of
Proprioceptive Function must be
Restored before return to sports Primary goal
Rehabilitation
Enhance muscle
reaction time
Stabilization/Recruit
ment
Proprioception
Carter et al, Br J Sports
Med, 1997 Loss of proprioception after
ACL rupture
Roberts et al, J Orthop Res,
2000
Loss of proprioception after
ACL reconstruction
Gait Abnormalities
Acute ACL Tears
Decreased NMinput
Delayed quadfiring heelstrike
Result = flexedknee gait pattern
Increased PFJRF
Force patient tosqueeze quad atheel strikeTreadmill amb.
Revascularization of ACL Graft
4 phases Avascular graft
Revascularization
Cellular repopulation
Remodeling &Reorganizationcollagen fibers(ligamentizationAmiel 86 AJSM)
Recent studies =intraarticular portionrevascularizes fasterthan bone interface
sitesNtoulia AJSM2011
Early Phase
Inflammatory response:macrophages, cytokines
produce scar betweengraft and bone 4-10
days 6 weeks graft hasvascular synovialenvelope
20 weeks intrinsic graftrevascularization
Fat pad, synovial tissue,bone tunnels =vascularity
Animal Studies Bone Tunnel Healing
12 weeks Sharpeysfibers into graft = bonehealing
Pull out failure prior to12 weeks = tunnelfailure, after 12 weeks= midsubstanceRodeoJBJS 93
BPTB 6 weekscompleteincorporationPapageorgiou AJSM2001
Bracing 4-6 hyperflexion
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Immobilization
Decrease in
proteoglycan content
Reduces stiffness of
cartilage
Cant withstand
shearing forces
Compression & Fluid Flow
Matrix - CPM As compression
increases,resistance to fluid
flow in matrixincreases
GAGs slow downfluid flow in &out of matrix
Result = increasedstiffness ofcartilage
Stiffness = allowsresistance tocompression
Passive ACL Strain
Passive ROM 0% strain 0-
60, 70-120 1-2% strain in
normal ACL
Push extension wait on
flexion (swelling)
Renstrom AJSM 86
Motion Complications Increasing flexion
Restricted flexion =increased PF Compression
Flexionator
Provides hydraulicresistance
5 min. on 5 min.off, repeat
6 x per day
HS Biofeedback ProneHangs
Steps To Avoid Extension LOM
Recognize early factors:
Poor quad function no SLR
Flexed knee ambulation
Poor pain tolerance
MCL/Meniscus repair
Reversing Lack of
Extension
1cm = 1 HHD Daniel
AJSM 89
Infrapatellar Fat Pad Tunnel Pain -
Activity Source of pain
post-op ACL
ATS portals passthrough fat pad
Cause fibrotic
hematoma in somepatients
May affect p.tracking with ATS
Early intervention= US,Laser,manualsoft tissuerelease,scar
Injection tunnel
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ACL/MCL
Combined ligament injury
Limits ROM and
WB 1st 4-6 weeks
Locked inextension for 1week, increasedflexion 30d perweek
WB with crutchesgradual increase,D/C crutches 4-6weeks
Stability = No DJD? In a 2004 study of male former
soccer players 14 years after anACL injury, Swedishinvestigators found nodifference between surgicallytreated and conservativelytreated athletes with regard toradiographicallydetected OA
ACL reconstruction did notaffect prevalence of knee OAin female soccer players 12years after ACL injury
Lohmander LS, Ostenberg A, Englund M, Roos H. High prevalence of
knee osteoarthritis, pain, and functional limitations in female soccer
players twelve years after anterior cruciate ligament injury. Arthritis
Rheum 2004;50(10):3145-3152.
ACL Deficient Rehabilitation
Risks
Increased articular cartilage loss
long-term
Murrell AJSM 01
130 pts. ACL tears
ATS exam. Reconstruction
Time = increased cartilage &
meniscus loss
9 x greater cartilage damage 2 yrs.
Vs. 1 mo. ACL rec.
P-F Cyclic compression exercises
Difficulty with post-op recovery
Cycling - properseat ht., 90-100Rpm's, dont standon pedals
Total gym -allows bodyweight to bereduced
Pool therapy -load, unload
EFX ?
Step 2
Begin Gradual Loading Exercises
Leg Press Best MR Leg Press
supine squat low load
high endurance
activity 60 secondcontractions
Begin with 5Kg
Quad EMG WB & NWB
Wilk AJSM knee extension =highest EMG = 25 degrees
Wilk AJSM leg press =highest EMG = 85 degrees
Knee extension = requires highEMG due to lack of patellarheight near extension
Huberti = Fpt > Fquad 1st 20d.45d Fquad > Fpt = Carefulwith minisquats
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Step 3
Body Weight Control
Functional Squat
MR Systems
Squat Control
Chair Squats
3x20
New Device
Primal 7
Allows
patient toassume
normal
body
positions
early
using
assisted
strapping
Testing Functional Hip
Abductor Strength
Crossley AJSM 2011
A- participant demonstratesgood performance
B- participant demonstratespoor overall and trunkperformance
C- participant demonstratespoor pelvis and hipperformance
D- participant demonstrates
poor hip and kneeperformance
Chris Powers JOSPT
2003
Controlling
femoral position
Hip ABDuctor,
G.Max, Lateral
Rotation,
NWB routine
Hewitt AJSM
07 pelvic
control - ACL
Powers: Controlling Hip Internal
Rotation, Knee Adducton
WB routine
ABD, GMAX,
Lateral rotation
Core Strengthening = Strengthens
Kinetic Chain
Rotational plyoball: hold
VMO contraction Lower Abdominal Trunk
flexion/extension usingSwiss Ball
Hewitt AJSM 07 Corecontrol may be assoc.with ACL tear = pelviccontrol = kinetic chain =PF control
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Hip Flexor Stretch
Sidelying
Safe and unsafe closed vs open
kinetic chain
Is closed chain safer?
challenged with strain-gaugestudies
What is primary reason for
description of open and
closed chain?
Terminology should describe
what is happening to specific
anatomical structure
Ligament loading exercises
ACL
Knee extension 30 to 0 degrees with
resistance
Pivoting, twisting activities -
Markolf - JBJS - no protection
Squatting - Beynnon - 97 AJSM-
loads comparable to open chain - no
increase in strain with increased
load during squat. Knee extension
= increased strain with increasedload
Ligament Loads
Peak Loads
ACL
Exercise
-ACL = 1725-2160N beforefailure
-PCL = 4000N
Graft load
sharing?
ACL tear = loss of HS reflex
Rehab. = re-gain
Tsuda AJSM 01
Stim. ACL = reflex HSactivity
Response = Humans
versus Solomonow =
animal model
High Speed Biodex
Speeds 180-300deg./sec.
May stimulate NMcontrol
Rapid reversal fromext./flexion
HS curls, goodmornings
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Strength
Load and Volume
Set load and
volume to meet
goals of phase
Periodization
Model
Strength Preparation for plyometrics and sport
specific skills
Vary Load and Volume Involve The Core
MAKE IT PROPRIOCEPTIVELY
CHALLENGING!!!!!
Phase II Functional StrengtheningRunners Pose
Cone Reach ACL Knee Bracing
Used
primarily
during
rehabilitation
Ave. time for
use after
return = 8
weeks.
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Combination Core/LE/UE
Slide Board End Stage RehabWhen to Run?
PTG 2 - 3 mos.
Treadmill
Allograft ACL 3-
4 mos.
Timeframes
dependent on
quad strength and
symptoms
Phase III Plyometrics and Sports
Specific Training
Plyometrics Develop:
Strength
Speed
Power
Good ProprioceptiveTraining
Injury Prevention
Not everyone needs tojump!
Plyometrics
Jumps
2 footed landing
Hops
1 foot landing
Bounds
Jumping form
one foot to the
other
Proprioceptive
When To Start
Full PROM
Normalized Quadriceps
Control Appropriate Time Period
Controlled Joint Effusion
Normal LigamentousExam
Quad Re-education
Take-Off
Recruitment =plyometric
routine, singleleg plyos
Sportsmetric
FunctionalDrills
Isokineticstrength, leg
press 90-40
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Bilateral Cone Hop Stick Broad Jumps
Progression to
Single Leg Hop Maintain
mechanics
Mustundergodouble leg
jumps
Must haveadequatecore/quadcontrol
Agilities/Sports Specific
The ability to change
direction rapidly
without loss of body
control
Uses
Technique
Conditioning
Functional Assessment Return to
Sports
Single leg hop for distance = 90%normal
Figure of 8 = 9.5s (male normal)
Isokinetic test = 85% normal Proprioceptive function = restored
ROM = 90% normal decreasedmotion = articular cartilage stress
KT-1000 within normal limits(
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Return to full competition in NFL
8 mos
Timetables werenot unusual
Level of playwas veryunusual
Skill position,ability tocut/pivot with nofear superhumaneffort
Conclusions
Rehabilitation = team
effort
Must know healingconstraints
Progression = strength,
proprioception/balance,
plyometrics/agilities
Never progress patient
until ready for next phase
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