REHABILITATION AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTIONH SELCUK KUCUKOGLUULUDAG UNIVERSITYSCHOOL OF MEDICINEDEPARTMENT OF PM&R AND SPORTS MEDICINE
Yearly incidence of ACL injuries has been reported to be 3/10,000 inhabitants in Denmark (Nielsen, 1991),In Sweden, ACL injuries comprise 43% of all soccer related injuries (Roos,1995),
Type of graftAge(Year)Weight(kg)Operation time after the injury (months)SexLevel of Sportive ActivityInjury levelInjured extremityMFSpSedAkSubKrRightLeftPT25.66.975.19.421.732.6532361929442926SG26.35.675.910.814.719.124152014201312
GOALThe goal of ACL reconstruction is to improve the patients level of function, with in the hope of allowing them to return to an active life style, with minimal disability, while protecting them from further injury to the knee.
why treatAfter an ACL lesion, knee instability is common and may produce progressive functional changes and damage to other joint structures (meniscal damage,articular cartilage damage,and degenerative arthritis) which may also affect daily life activities.
why TREATThe ACL has poor potential for spontaneous healing after complete rupture,and therefore conservative treatment aims to develop joint motion patterns that help control abnormal knee motions which can arise in the absence of functional ACL.
why TREATIn the years following an ACL injury additional meniscus ruptures frequently occur. 80% of ACL deficient patients were found to have a torn meniscus within 2 years of ACL injury.Gillquist-Messner (Sports Med. March 1999)
why REHABILITATIONOptimal healing of an ACL graft and the knee is dependent on rehabilitation,The strains applied to an ACL graft by body weight, muscle activity, and joint motion affect its healing response,
ACCELERATED REHABILITATIONInvestigations of ACL grafts that have been done in animals indicate that they lose their ultimate failure strength and undergo a decrease of stiffness and the knees have an increase in anterior laxity develop during healing.
Accelerated rehabilitationThe exact cause of above mentioned changes and the application of this data to humans are unclear.Rougraff-Shelbourne reported that large proportion of the tendon survives and ACL graft healing in humans may not undergo the same complete necrotic stage that has been reported in animals.Knee Surg Sports Traumatol Arthrosc 1999
ACLRehabilitationPreoperative Phase:GoalsDiminish inflammation,swelling, and painRestore normal range of motion (extension)Restore voluntary muscle activationProvide patient education to prepare for surgeryBrace-elastic wrap or knee sleeve to reduce swellingWeight bearing-as tolerated with or without crutches
ACL Rehabilitation2Preoperative phaseExercisesAnkle pumpsPassive knee extension to zeroPassive knee flexion to toleranceStraight leg raises (3-way, flexion, abduction, adductionQuadriceps settingClosed kinetic chain exercises: mini squats, lunges, step-ups
ACL Rehabiltation3Preoperative PhaseMuscle stimulation-electrical muscle stimulation to quadriceps during voluntary quadriceps exercises (4-6 hours/day)Cryotherapy/elevation-apply ice 20 minutes of every hour, elevate leg with knee in full extensionPatient education- review postoperative rehabilitation program
BIOMECHANICSIsometric exercises that strain the ACL involve contraction of the dominant quadriceps muscle group with the knee between extension and 60 flexion, or involve isotonic contraction of the quadriceps between extension and 50 flexion,
Biomechanics2The largest ACL strain magnitudes that have been measured and produced by isometric and isotonic contraction of the quadriceps muscles with the knee near extension.
Biomechanics3Squatting, stationary bicycling,and closed kinetic chain exercises that involves body weight loading and substantial cocontraction of the muscles does not create an appreciable change in ACL strain values.
ACL RehabilitationImmediate postoperative Phase (1-7 days)GoalsRestore full passive knee extensionDiminish joint swelling and painRestore patellar mobilityGradually improve knee flexionReestablish quadriceps controlRestore independent ambulation
ACL RehabilitationEarly Rehabilitation Phase (2-4 weeks)Criteria to progress to phase 2Quad control (ability to perform good quad set and straight leg raisesFull passive knee extensionPassive ROM 0 -90Good patellar mobilityMinimal joint inflammationIndependent ambulation
ACL RehabilitationEarly Rehabilitation PhaseGoalsMaintain full passive knee extensionGradually increase knee flexionDiminish swelling and painMuscle trainingRestore proprioceptionPatellar mobility
ACL RehabilitationControlled ambulation Phase (weeks 4-10)Criteria to enter phase 3Active ROM 0 to 115Quadriceps strength 60%>contralateral side (isometric test at 60 knee flexion)Minimal to no joint inflammationNo joint line or patellofemoral pain
ACL RehabilitationControlled Ambulation Phase(2)GoalsRestore full knee ROM (0 -125)Improve lower extremity strengthEnhance proprioception,balance and neuromuscular controlImprove muscular enduranceRestore limb confidence and functionNo brace or immobilizer, may use knee sleeve
ACL RehabilitationAdvanced Activity Phase (10-16 weeks)Criteria to enter Phase 4Active ROM 0-125Quad strength 80% of contralateral sideKnee flexor:extensor ratio 70%-75%No pain or effusion*Satisfactory clinical exam*Satisfactory isokinetic test (values at 60/sec, 180/sec and 300/sec)*Hop Test (80% of contralateral leg) (4test)*Subjective knee scoring 80 points or better (Noyes)
ACL Rehabilitation Advanced activity phase (2)GoalsNormalize lower extremity strengthEnhance muscular power and enduranceImprove neuromuscular controlPerform selected sport-specific drills
ACL RehabilitationReturn to activity phaseCriteria to enter phase 5Full ROMIsokinetic test that fulfills criteriaQuad bil comparison (80% or greater)Hams Bil comparison (110% or greater)Proprioceptive test (100% of contralateral leg)Hamstring/quadriceps ratio (70% or greater)Functional test(85%or greater of contralateral side)Satisfactory clinical examSubjective knee scoring (Noyes) 90 points or better
ACL RehabilitationReturn to activity phase (2)GoalsGradual return to full unrestricted sportsAchieve maximal strength and enduranceNormalize neuromuscular controlProgress skill training
ComplicationsHemarthrosis; Operative trauma and repeated operationsPretension of the substitute ligamentSeptic arthritisPostoperative arthrofibrosisPatellafemoral painAll may lead to gonarthrosis in the long run
ROLE of PMRCheck for the goals and the criterias to upgrade the patientEvaluate the results of isometric and isokinetic testsEvaluate the results of four HOP testsExamine the patient when appropriate for the stabilityExamine the patient for the complications and progress
PROPRIOCEPTION AND BALANCE AFTER ACL RECONSTRUCTIONUfuk ekir , Bedrettin Akova , Hakan GrMedical School of Uludag University, Department of Sports Medicine , BURSA
THE AIM OF THE STUDYTo observe the changes in the proprioception and balance after ACL reconstruction.
PATIENTS AND METHODS31 patients, mean age 247 (17-44)Patellar tendon autograftTime period between injury and the operation: 12 months ( 1-96)Follow-up : At 1th, 2nd, 3rd, 4th, 6th, and 12th months after operationAccelerated rehabilitation program, includes proprioceptive exercises (which began in the first month): Single-leg stance on hard surface (eyes open-closed)Single-leg stance on soft surface (eyes open-closed ) Balance board exercises (eyes open-closed )
Joint Position Sense (JPS)Eyes closedIndex angles: 200,450 and 700 Angular velocity: 10/s Before matching an index angle, the examiner extends the knee passively to the index angle for 3 s. Three repetitions for each index angle was made. The mean of absolute error score (AES) for each index angle was calculated Mean AES= Sum of means of index angles /3
Single-limb Balance On a soft surface.Eyes open-closed.First on the uninjured and then on the injured side.Arms crossed, contralateral leg flexed.The subjects were required to stand 60s.Two repetition were made.Mean number of touchdowns and mean time to first touchdown were recorded.
STATISTICSTo compare injured-uninjured leg results; Wilcoxon test
- The results at the follow-up of the Single-limb Balance Test (Mean number of touchdowns) ** p
- The results at the follow-up of the Single-limb Balance Test (Mean time to first touchdown)** p
- Joint Position Sense at 200 of Flexion *p
- Joint Position Sense at 450 of Flexion** p
Joint Position Sense at 700 of Flexion
Joint Position Sense (Mean)
CONCLUSIONThe results of this study indicates that the proprioceptive capabilities of the ACL reconstructed knee can improved to the same level of the uninjured knee at 2 months after operation, with a rehabilitation program including proprioceptive exercises in early phase.
FUNCTIONAL CAPACITY AFTER ACL RECONSTRUCTION: RELATIONSHIPS WITH KNEE EXTENSOR AND FLEXOR MUSCLE STRENGTH1 Bedrettin Akova ,1 Hakan Gr, 1 Ufuk ekir, 2 Sefa Mezzinolu1Medical School of Uludag University,Department of Sports Medicine , BURSA 2 Medical School of Kocaeli University, Department of Orthopaedic Surgery, KOCAEL
THE AIM OF THIS STUDY;To determine 1) the functional capacity and 2) the relationships between the functional capacity and knee extensor, and flexor peak torque after ACL reconstruction.