ACL ReconstructionJasmine Chan, SPT

Andy Chiu, SPTBrandon Higa, SPTBryce Keyes, SPTMinsu Kim, SPT

Derek Matsui, SPTAdrian 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-Gracilis Autograft – HS strain in early rehab– Knee flexor muscle weakness

Acute Inflammatory (Necrosis): 1-4 weeks1,3,4

Morphologic Findings•Tendonous Ligamentous1

Signs & Symptoms1

•Inflammation•Pain•ROM•Quad control•WBAT

Complications1

•Pain & Edema limiting motion

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• Proliferation• Differentiation• Extracellular matrix

production

Signs & Symptoms1

• Full ROM• SLS• No pain• No edema• Running

Collagen remodeling Phase4: up to 1-2 years

Morphologic Findings• Remodeling

Signs & Symptoms1

• Full ROM• Return to activity

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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18, 1998. Accessed July 19, 2009. 4. Lattermann C, Koyonos L, & Whalen JD. Basic science/biology. In: Fu F & Cohen S. Current Concepts in ACL Reconstruction. Thorofare, NJ: Slack Inc;

2008: 35-44.5. Noonan B & Chung KS. A practical review of the mechanisms of pain and pain management following ACL reconstruction. Orthopedics. 2006; 29(11):

999-1005.6. McReynolds JG, Meyer MH, &Rea JB. Infrapatellar contracture syndrome following ACL reconstruction. JAAPA. 2009; 22(3): 23-25.7. Plone Foundation. Post-operative ACL Reconstruction Guidelines. http://www.nismat.org/orthocor/acl_postop. Updated March 8, 2007. Accessed

July 20, 2009. 8. Power Plate. Technology: What is Power Plate? http://www.nyphysicaltherapy.net/Home/PatientEducation/tabid/3433/ctl/View/mid/5695/

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http://www.nyphysicaltherapy.net/Home/PatientEducation/tabid/3433/ctl/View/mid/5695/Default.aspx?ContentPubID=196. Updated 2009. Accessed July 20, 2009.

10. Total Gym. Rehabilitation Facilities – Benefits of Total Gym. http://www.totalgym.com/rehabilitation/rehab.clinics.html. Updated 2002. Accessed July 24, 2009.

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maturity. Knee Surgery Sports Traumatol Arthroscopy. 2009; 17: 748-755. 15. 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. 16. Wells, Lawrence et al. Adolescent anterior cruciate ligament reconstruction: A retrospective analysis of quadriceps strength recovery and return to

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Sports Traumatology, Arthroscopy. 2005; 13(5): 393-397.21. Giugliano DN, Solomon JL. ACL tears in female athletes. Physical Medicine & Rehabilitation Clinics of North America. 2007: 18(3), 417-438. 22. Shelbourne KD, Sullivan AN, Bohard K, Gray T, Urch SE. Return to basketball and soccer after anterior cruciate ligament reconstruction in competitive

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