ACL Reconstruction Rehabilitation Tyler Opitz, DPT, SCS, CSCS March - - PowerPoint PPT Presentation

ACL Reconstruction Rehabilitation

Tyler Opitz, DPT, SCS, CSCS March 1st, 2019 Andrews Institute‐Gulf Breeze, FL

Objectives

1.Review criteria for progression to each phase following ACL reconstruction 2.Discuss integration of performance training throughout the rehabilitation process 3.Discuss progressive return to athletic participation testing following ACL reconstruction

Disclosures

• I have nothing to disclose that pertains to this

presentation.

ACL Injuries

• ACL injuries are extremely common and also

costly.

• Most commonly injured ligament in the knee

(Gordon, AAOS, 2004)

• Females > males except 17 & 18 year olds in

adolescents (Beck et al., 2017)

• Estimated 250,000 ACL injuries each year in USA
• Average cost for an ACL repair $25,000‐50,000
• Estimated cost of $1 Billion/yr for high school

athletics

Joseph et al. J Athletic Training 2013

ACL Fiber Orientation

ACL Injuries

Contact vs Non‐contact

Contact

• Greater incidence of Grade

IV Chondral injury

• 2 fold increase in incidence
• f collateral ligament injury
• 24.6% of ACL injuries

Non‐Contact

• >75% of ACL injuries
• More common
• Associated with

neuromuscular control deficits, weakness, age, sex, sport, higher activity level, allograft reconstruction

Salem et al., 2018, Kaeding et al., 2015, Zebis et al., 2016

Contact vs Non‐Contact

Contact Non‐Contact

Contact vs Non‐Contact

Contact Non‐Contact

Closed Chain vs. Open Chain

CKC OKC

Incidence‐ Beck et al., 2017‐

Why so much attention on Football?

ACL Prevention

• FIFA 11+ (Silvers‐Granelli et al., 2017)

– 25% of intervention group had knee injuries

• 16% ACL injuries when stratified for ACL

– 75% of control group had knee injuries

• 84% had ACL when stratified for ACL
• Proper warm up prior to play (Daneshjoo et al., 2013)
• Neuromuscular and proprioceptive training

(Mandelbaum et al., 2005)

• Dynamic Movement Assessment (Nessler, 2014)

ACL injuries by Sport

College Athletics High School

Labella et al., 2104

ACL Injuries by Age

• ACL 3% of all injuries in

college sports

– ACL was 88% of injuries associated with 10 or more days time lost from sports participation.

Labella et al., 2104

ACL Re‐tear NFL

ACL injury

• From 2010‐2013 in NFL:

– 81.7% initial tears (n=179) – 12.3% were re‐tears – 2.28% suffered 3rd ACL tear (n=5) – 7.3% were contralateral tears

Dodson et al., 2016

By Position

Position ACL Injuries, n Total Players, n ACL Injury Incidence, %

Fullback 5 50 10.0 Guard 16 185 8.6 Wide receiver 38 473 8.0 Tight end 18 230 7.8 Linebacker 36 483 7.5 Running back 19 304 6.3 Center 6 97 6.2 Defensive back 37 651 5.7 Defensive tackle 16 296 5.4 Long snapper 2 44 4.5 Punter 2 55 3.6 Defensive end 11 314 3.5 Kicker 2 61 3.3 Offensive tackle 7 233 3.0 Quarterback 4 162 2.5 Dodson et al., 2016

By Significance

Position Group ACL Injuries, n Total Players, n Percent Injured P Value (vs Rest

• f NFL)

Receivers (WR, TE) 56 703 8.0 .004 Backs (LB, HB, FB) 60 837 7.2 .035 Interior linemen (G, DT, C) 38 578 6.6 .312 Defensive backs (CB, S) 37 651 5.7 .995 Specialists (P, K, LS) 6 160 3.8 .282 Perimeter linemen (DE, OT) 18 547 3.3 .009 Quarterbacks 4 162 2.5 .071 All NFL players 219 3638 6.0

Dodson et al., 2016

Grass vs Turf

In‐Game ACL Injuries, n Team Games Played, n Injury Rate Grass 74 1478 .050 Artificial turf 63 1178 .053

Dodson et al., 2016

Year by Year

2010‐2013 (4 seasons) By Month in NFL

Dodson et al., 2016

2017

Dr David Chao, San Diego Union Tribune, Published 5/23/2018 https://www.sandiegouniontribune.com/sports/profootballdoc/sd‐sp‐pfd‐hunter‐henry‐acl‐nfl‐ota‐ 0523‐story.html Steven Taranto, Published 2/6/2018 www.247sports.com

• 51 players had an ACL

injury

• 31 players had injury prior

to week 1

• Over last 5 years on

average = 23 ACL injuries before week 1

– End OTAs to Week 1.

• 2018 Data still being

populated

– Teams less willing to share data

Strangest MOI: As heard at Andrews

• “I was dropping it like it was

hot and tried to come back up and felt a pop.”

• “I was getting out of a

burning Humvee and my leg got caught and I lunged out and felt it buckle”

• “I was on the last run (ski)
• f the day and looked back

to see my friends and hit a bump and fell.”

• “I was celebrating a sack

and when I jumped I landed wrong.”

• “I was chasing my kids and

tripped over the dog.”

• “I don’t even have a clue…

my knees have been buckling one me for the last 3 years and they get sore.”‐ ended up having bilateral torn ACLs.

• “I was having the game of

my life (basketball) and when up for a dunk and got rim checked and landed wrong.”

Treatment Principles/Guidelines

• Age
• Sex
• MOI
• Sport/Activity
• Pain tolerance
• Level of athlete
• Tissue quality
• Number of prior surgeries

– Revision or not

• Time of year
• Patient expectations
• Type of graft
• Comorbidities
• Concomitant knee

pathologies

– Meniscus, collateral ligaments, etc.

• Duration since injury
• Condition of joint

– Swelling, quad control

• Surgeon

– Techniques, protocols, etc.

• Patient motivation

Phases of Rehab Reconditioning

• 1. Protection, Healing and Mobility
• 2. Work Capacity and Strength
• 3. Elastic Strength and Return to Function
• 4. Return to Performance

Promote a Positive Recovery

• Promote importance of sleep and proper

nutrition

• Reduce both Physical and Mental Stressors

– Stress and increased cortisol production delays healing response

• Positive attitude and engagement with patient

– “Better” and “Getting Better” knees – NOT “good” and “bad”

• Whole‐body strength and conditioning

Prehab

Goals

• 2‐4 weeks ideal
• Restore quad control
• Achieve full knee extension

– Flexion to min 120°

• Ambulation without deviations
• Retrain squat pattern

– Tolerate CKC with control

• Decrease joint effusion
• MANAGE EXPECTATIONS FOR

POST OPERATIVELY!!

Treatments

• Quad sets

– BFDB, NMES – SLR 4 way

• Cone walking
• Step ups/downs‐ Anterior/lateral
• SL balance

– >SL RDL

• Mini band walks‐ 4 way

– Base holds, shifts, skaters

• Vasopneumatic compression

Phase 1: Protection, Healing, and Mobility

• Protect the joint and guide healing response

– Control pain and joint effusion – Early‐phase muscle activation – Restore ROM – Normalize gait mechanics – Promote active recovery process

• Usually Day 1 to Week 4

Swelling and Quadriceps Inhibition

• Joint Distention resulted in quadriceps muscle

inhibition

DeAndrade et al

• Similar results in a study by Spencer et al.

– Threshold for inhibition of the Vastus Medialis to be approximately 20‐30 ml of joint effusion and 50‐60 ml for rectus femoris and vastus lateralis

Wilk et al 2003

E‐Stim to improve voluntary quadriceps control

• Fitzgerald et al. reported that the group receiving

NMES demonstrated moderately greater quad strength and higher levels of self reported knee function at 12 weeks post op.

• Snyder‐Mackler et al. found that the addition in NMES

to postoperative exercises resulted in stronger quadriceps and more normal gait patterns.

• The use of E‐stim and biofeedback on the quadriceps

appears to facilitate the return of muscle activation and may be valuable additions to therapeutic exercises.

Wilk et al. 2003

Pain and Joint Effusion

• Pain

– Increases reaction times – Increases performance errors during simple tasks

• Joint Effusion:

– Increases intra‐articular joint pressure and pain – Alters quadriceps muscle recruitment

• Arthrogenic Muscle Inhibition (AMI)

– Neural inhibition – Has been shown to occur bilaterally after unilateral injury » Quad activation deficits as high as 7‐26% in unaffected limb

– Decreases the stability mechanics around the knee – Alters limb‐loading patterns with landing tasks

• Increased ground reaction forces
• Land in greater knee extension

Post Op‐ Day 0‐7

Goals

• Full knee extension

– Comparable to contralateral limb – Flexion 0‐90°

• Quad control
• Quad set with full knee

extension

• Perform SLR‐ no lag
• Decrease swelling and pain
• Initiate weight bearing

Treatment

• Manual knee extension
• Quad set
• Calf/HS stretch
• Patella glides

– Emphasis on superior glides

• SLR 4‐way w/ NMES
• Peanut bridging
• Weight shifts
• TKE with NMES

Restore ROM

• End‐range knee extension

– Symmetrical to contralateral knee by Weeks 1‐2

• Decreases patellofemoral joint and soft tissue stress
• Decreases quad inhibition
• Gradual progression of knee flexion

– Week 1: 90 – Week 2: 110 – Week 3‐4: Kneeling

• Gradual progression ‐ desensitization

– Week 8‐10: Full AROM

• Emphasize self‐mobilization 6‐8 x daily for first 2‐3 weeks

– Self‐knee extension mobilization – Patella accessory mobilization

Extension Variations

• Some people don’t have

full knee extension

• Excessive extension can

guillotine the ACL

• Extension equal to the
• ther side w/ control at

that range.

Reducing pain following surgery

• Pain blocks (0‐4 days post
• p)
• Femoral
• Adductor Canal

(Saphenous)

• Able to reduce pain

significantly following surgery

• Improved quad activity
• Psychological Impact

Day 0‐7‐ Pain Pump & Dressing Change

Clinical Observations

• Skill position players (WR,

DB, RB) who are lacking full extension tend to run <4.40 sec 40‐yd dash.

– However, if run <4.40 sec 40 yd‐ dash do NOT necessarily have flexion contracture though

• Lead leg of WR in stance

has LESS extension than back leg.

• OUR JOB IS TO NOT

SLOW THEM DOWN!!!

End Range Mobility & Stability

Partial Quad Control Full Quad Control

Curtesy of Hunter Stark, DPT, COMT, CSCS

Day 0‐7‐ Treatment

• Treatment starts day 1‐3
• WBAT
• B AC
• Brace locked in extension

for ambulation

– Until has adequate quad control and tolerance to WB

• Adequate = SLR no lag, hip

hinge, ability to perform SL stance.

– Typically 2 weeks

Day 0‐7‐ NMES

Day 0‐7‐Hemovac

Day 0‐7

Day 8‐14

Goals

• Full quad control

– With knee extension

• ROM 0‐120
• FWB pain free
• Able to perform SL stance
• Diminish swelling
• Normalize Gait

Treatment

• Progress Hip hinge

– Mini squats

• Corrective step up/over/to

– Cone walking

• Leg press 0‐60°
• LAQ 90‐45°
• SL stance
• Triple flexion
• Triple Extension
• Step up
• Recumbent stepper
• Initiate BFR

Normalize Gait

• Emphasize terminal knee extension at heel‐strike

with appropriate quad activation

– *Landing with increased knee flexion = greater loss of medial cartilage thickness at 5‐year follow‐up

End‐Range Active Stability

Force Reduction

• Triple Flexion
• Absorption and

Deceleration Forces

• Eccentric Action

Force Production

• Triple Extension
• Propulsion and

Acceleration Forces

• Concentric Action

Day 8‐14

Triple Extension Triple Flexion

Blood Flow Restriction Therapy

• Restricted blood flow to musculature to simulates

physiological response with training under 80‐95% 1RM for muscle hypertrophy

– Systemic response – Has other healing benefits

• Perform exercises at 15‐30% of 1 RM

– Can perform with cardio exercises – Can go above 30% of 1 RM – Sets/reps: 30/15/15/15

• Decreased stress to joints
• Leads to systemic physiological response:

– ↑ Growth hormone and hypertrophic factors – ↓ catabolic elements

www.owensrecoveryscience.com, Nielsen et al., 2012, Abe et al., 2004, Abe et al., 2006, Evans et al., 2010, Fatela et al., 2016, Slysz et al., 2015, Burd et al., 2010

47

BFR

Metabolic Effects Metabolic and Hormonal Reactions Strength and Endurance Cardiovascular Increased protein synthesis “more muscle!” Increased Growth Hormone “more healing!” Improved strength with less joint stress/loading/ DOMS Increased VO2max Increased lactate concentrations “more energy stores!” Myogenic Stem Cell Proliferation Increased cross‐ sectional area; decreases post‐op atrophy Low load on central cardiovascular system

• Risks and limitations
• No indication of acute thrombotic reaction or other ill side effects
• Small percent of subcutaneous hemorrhage, acute muscle pain, temporary numbness

Venous occlusion  lower training load  Increases in Hypertrophy

Day 15‐28

Goals

• Discontinue AD
• Unlock brace partial range

for ambulation

• Initiate Aquatic Therapy
• Progress strengthening in

CKC

• Introduce Hip Loading

Treatment

• Aquatic therapy
• Mini Band walking
• Discontinue heel slides
• Mini lunges
• Bridge variations
• End Range Holds
• Compound movements
• Base position holds
• High Split Stance (HSS)

Crutches?

• May discontinue crutch use when:

– Minimal Joint Effusion – Full knee extension – SLR without extensor lag – Proper gait pattern without pain or limp

• Usually at 10‐14 day mark (but can be longer)

Discontinue Heel Slides?

• Swelling leads to quadriceps inhibition
• Quadriceps activation leads to swelling reduction
• Poor muscle tone leads to poor patellar tracking
• Clinical Pearl‐>

– If you get your quadriceps strong your flexion will increase

• Autogenic inhibition of quadriceps
• Patient’s innate mechanical advantage to move one’s joint

and afferent signals

• You can move you farther than I can move you

– Eliminates guarding – ROM is self modulated

Aquatic Therapy

• Benefits

– Hydrostatic pressure of the water is useful for controlling swelling. – Buoyancy of the water allows us to “unload” the body, giving the athlete the freedom to move more freely without overstressing the healing tissue. – Restoration of normal gait pattern is important during the early phases of ACL rehab. – Easier to correct faulty movement patterns and perform exercises that may be challenging on land secondary to muscle weakness

Day 15‐28‐ Aquatic Therapy

Day 15‐28

Movement Prep

Base Holds Skaters

Day 15‐28

HSS

Phase 1  Phase 2

• Pre‐requisites for Progression:

– Resolution of active inflammatory process – Pain‐free functional AROM

• Symmetrical knee extension
• May lack ~ 20 degrees flexion

– Good voluntary muscle activation – Normalized pain‐free gait pattern

Phase 2: Work Capacity and Strength

• Introduce:

– Progress strengthening utilizing compound movement patterns

• Utilize external cues for coaching

– “Protected” plyometrics and movement in pool

• Usually Week 4 to Week 12

Compound Movements

• Low‐load, high reps (early) and vary load and

repetition scheme as you progress

– Reintegrates the pathways between PNS/CNS – Proprioceptive‐rich training environment – Emphasize movement quality

• Fast Eccentric exercises for Type II muscle fiber

development – once movement quality is expressed

– Leg isotonics or movements at speed (1 rep/second)

• Progress from hip  knee dominant movements

Weeks 5‐8

Goals

• Progress resisted loaded

compound movements

• Progress training of

functional movements in controlled fashion

• Advance Aquatic Therapy
• Full knee ROM
• SL balance no deviations
• Initiate kneeling
• Progress Eccentric

training/deceleration Treatment

• Aquatic Therapy

– Protected plyometrics – Low impact fast action – Triple flexion/deceleration emphasis – Deep well jogging

• Quadruped ‐> ½ kneeling

progressions

• Resisted walking
• Agility ladder walking

Weeks 5‐8‐ Aquatic

Weeks 5‐8

Weeks 5‐8

Weeks 5‐8

Weeks 5‐8

Weeks 9‐16

Goals

• Progress strengthening

– Hypertrophy – Power development

• Increase complexity of tasks

– Compound multi‐plane movements

• Prepare for running

– Plyometrics – deceleration

• Initiate impact deceleration

Exercises

• Agility Aquatics
• Rapid Response, 2’’ runs
• Sled pushes
• Bounding
• Deceleration and hip

loading

• Movement prep

– Skips – Marching – Walk to jog if appropriate

Overload Principles

• Utilize overload principles
• ACSM and NSCA recommends:

– Training with 65‐85% 1RM performing 4‐6 sets of 6‐10 reps for hypertrophy – Training with 75‐95% 1RM performing 4‐6 sets of 4‐6 reps for power/strength training

Weeks 9‐16‐ Aquatic

Weeks 9‐16

Power Development Rapid Response‐

Weeks 9‐16

Weeks 9‐16

Phase 2  Phase 3

• Pre‐requisites:

– Full resolution of joint effusion – Full AROM

• May lack ~ 10 degrees flexion

– Good control of single‐leg squat

• SL Squat to 60 degrees knee flexion

– 3’ bound symmetrical without knee deviations – Ability to walk on Treadmill at fastest speed without deviations for 15 minutes – >70% Isokinetic strength: hamstring and quadriceps comparison

• SL Leg press >70% 1 RM of non surgical knee

– Pain‐free, symmetrical movement patterns:

• Functional Squat (2/3 FMS)
• In‐line Lunge
• Hurdle Step or single‐leg stance

Red = Walk to Jog Criteria Based on University of Pittsburgh Study in 2012

Type II Muscle Fiber

• Increased Type II muscle profile :

– Improves reactive balance – Improves rate of force development and velocity

• Type II muscle fibers contribute most to

protecting the knee under high stress and velocities.

– As most injuries occur at fast speeds this is necessary in order to attempt to counteract these sudden movements.

Return to “Running”

• Rehab should focus on increasing capacity to control

deceleration and change of direction

– Don’t create a Ferrari without breaks! – “If you can’t slow it down, don’t speed it up!”

• Bill Knowles, ATC/CSCS

– Should progress this over a period of ~ 1‐2 months

• Do not try to “tick all of the boxes” in too short of a period

Walk to Jog Progression‐ Phase I

1

• Low impact – High Repetition – Introduce force production and reduction
• Self‐directed – unstructured ‐‐ FUN
• Ex: Skipping, Jump Rope, Agility Ladder

2

• Low and slow – Low level eccentrics – Slower contact times
• Structured – Landing technique – Force Absorption ‐‐ Quality
• Ex: Squat Drop, Box Jumps, Depth Jump, Squat Jump, Broad Jump, Hop

and stick landing

3

• Higher forces – Intro. of low rate/high ROM SSC – Shorter contact time
• Introduction of true stretch‐shortening‐cycle and Force Generation
• Ex: Continuous Jumps/Hops, Small Hurdle Jumps, Alternating split jumps

4

• Maximal Effort – Low ROM / High SSC – Quick Rate of Force Development
• Quick Ground Contact – Improving stiffness and COD
• Ex: High Hurdle Jumps, Bounding, Distance hops

Multi‐Directional Speed and Agility

Running and Sprint technique (Phase 1) Deceleration technique (Phase 2) Change of direction – Non‐reactive Agility (Phase 3) Linear Sprint Progression (Phase 3) Coordination and Reactive Agility (Phase 4 of ACL program)

Phase 3‐ Month 5‐9 Months

Phase 3: 5‐9 Months

Phase II Running: Running/Sprint Progression

Step Build‐up Sprint Deceleration 1 Long Short Long/No decel 2 Long Long Long 3 Short Short Long 4 Short Long Long 5 ‐‐‐‐‐‐ Short Long 6 ‐‐‐‐‐‐ Long Long 7 ‐‐‐‐‐‐ Short Short 8 ‐‐‐‐‐‐ Long Short

Phase 3  Phase 4

• Appropriate proprioceptive control of lower body
• Appropriate movement pattern testing
• >90% hamstring and quadriceps strength
• Horizontal Hop/Jump and Vertical Jump Testing

– Ability to produce lower body power and control with proper landing mechanics

• Completion of movement assessments with

adequate control and body mechanics

– Ability to control non‐reactionary change of direction to either side

Phase 4: Return to Performance

• Purpose: to condition the CNS to respond to

unpredictable stimuli during athletic activities

– Usually undertaken by performance coaches – Final phase in “rehab” process – Controlled and progressive return to team‐based activities – Limb performance should not be limited

• SHOULD be Week 32 ‐Week 36 at a minimum

Training Stimulus

• To be progressed on field or sport‐specific setting
• Variations in training stimuli:

– Surface

• Stable to unstable

– Body movement

• Gymnastics, movement on floor, rolling

– External load – Sensory cues

• Responding to sound, vision, touch

– Speed

• Both acceleration and deceleration

– Environmental obstacles

• Other athletes, cones, hurdles, etc..

Return to “Competition” Testing

• Functional tests should be objective, measurable and

quantifiable and include elements of:

– Balance and Neuromuscular Control – Strength – Power – Reactionary Agility – Pre‐injury athletic profile

• i.e., 5‐10‐5, 40 or 60‐yd sprint time, T‐testing, SL

Vertical Jump

ACL RTP

• Systematic Review, BJSM, Lai et al., 2018

– 83% RTS – 6‐13 months average RTS – 5.2% re‐rupture rate – No significant deterioration in performance

• 66% of studies with a non‐injured control group

showed this.

– Greater RTS associated with greater skill or value to team.

ACL RTP

• In a recent study by McCullough et al. – AJSM 2012

– 147 high school and collegiate athletes – 43% reported being able to return to previous level of play (self described) – 27% felt they did not perform at same level prior to ACL injury – 30% unable to return to play at all. – Fear of re‐injury/further damage reported by 50% who did not return to play

• Shah et al. ‐AJSM 2010

– 63% (31/49) of NFL athletes returned to NFL game play at an average of 10.8 months after surgery

ACL RTP

• Grindem et al., BJSM, 2016:

– Re‐injury rate was significantly reduced by 51% each month RTS was delayed until 9 months post op. – After 9 months no greater risk was present. – 38.2% of ACLR that failed RTS criteria suffered re‐ injuries. – RTS criteria: >9 months post op, symmetrical quad strength, adequate sport and body movement patterns. – 5.6% suffered re‐injury if passed RTS criteria.

Conclusion

• Success in the early phase of ACL rehab is

critical to later success. ‐Minimize swelling

‐Restore normal ROM‐Extension top priority ‐Improve voluntary quad contraction ‐Normalize gait ‐Restore Normal Symmetry

Summary

• Manage expectations‐ patient, family,

coaches, etc.

• Utilize strengthening, muscle control, and PNF

patterns to achieve ROM and minimize swelling

• Progressive overload principle
• We treat patients not protocols

Questions??? Thank You!!!

• Tyler.Opitz@theandrewsinstitute.com
• @tyleropitzpt11