Who Really Needs ACL Reconstruction? I Have the Answers - Fact - - PowerPoint PPT Presentation

Who Really Needs ACL Reconstruction? I Have the Answers - Fact versus Fiction

Lynn Snyder-Mackler ScD, PT, SCS, ATC, FAPTA University of Delaware Newark, DE

University of Delaware Disclosure: I DO NOT have a financial relationship with any commercial interest.

Learning Objective

Introduce evidence-based treatment pathways management of Acute ACL injury in Level I-II athletes that incorporates ACLR, temporary return to play (to finish a competitive season) and non-operative management

What are successful outcomes? (Lynch BJSM 2015)

• Return to sports (previous activity)

– Does this really happen? – MOON cohort

• 63% college AFB and 69% HS FB. 43% of the players were able to

return to play at the same self-described performance level. Approximately 27% felt they did not perform at a level attained before their ACL tear, and 30% were unable to return to play at all.

• 72% of soccer players

– Ardern et al meta analysis 2011

• 63% return to pre-injury level of sports, 44% to competitive sports

R37HD037985-12 NIH MERIT AWARD

What are successful outcomes? (Lynch BJSM 2015)

• Return to sports (previous activity)

– NFL

• Shah et al AJSM 2010
• 61% 31/49 returned to the NFL a mean of 11 months

after surgery

Feucht et al. 2014 94% of primary and 84% of revision expect to return to the same level of activity with no (A) or slight (B) restrictions

What are successful outcomes? (Lynch BJSM 2015)

• No re-injury (Does this really happen?)

– Contralateral ACL

• 12-25% - higher in younger and females

– OA

• 45-70% at 15 years. Higher in those who returned to

strenuous sports (98% say they have no or slight increased risk

– Revision ACL

• Worse outcomes short term
• More OA and disability long term

This is what non-operative management or delayed reconstruction outcomes should be compared to!

Are PTs/Surgeons appropriately counseling patients?

RTS activity progression (i.e., practice, contact drills, etc.)

NO

Has patient had > 1 episode

• f giving way?

Is patient planning accelerated RTS? Progressive neuromuscular and strength training and running progression without agilities (10 perturbation training sessions) Functional testing to guide HEP instruction 10 perturbation training sessions with agilities, strength training, running, and return to sport progressions Functional testing for return to sport (QI, 4 hops, KOS-ADLS, and GRS all > 90% Screen once impairments are resolved (QI > 70%, effusion < trace, full ROM, pain- free hopping, and no repairable meniscus) Integration of progressive agilities and sport specific progression as appropriate, instruct in HEP; re-check monthly

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes

NO YES

No screening necessary D/C after impairments resolved; provide post-op instructions, including how/when to Schedule post-op IE Return for post-op PT Surgery Pre-rehabilitation including progressive neuromuscular and strength training

Non-Operative Management Temporary RTS/Delayed ACLR Operative Management

Is the patient planning ACLR?* All patients educated on outcomes of operative or non-operative management

YES YES NC** NO NC** PC**

RTS activity progression (i.e., practice, contact drills, etc.)

NO

Has patient had > 1 episode

• f giving way?

Is patient planning accelerated RTS? Progressive neuromuscular and strength training and running progression without agilities (10 perturbation training sessions) Functional testing to guide HEP instruction 10 perturbation training sessions with agilities, strength training, running, and return to sport progressions Functional testing for return to sport (QI, 4 hops, KOS-ADLS, and GRS all > 90% Screen once impairments are resolved (QI > 70%, effusion < trace, full ROM, pain- free hopping, and no repairable meniscus) Integration of progressive agilities and sport specific progression as appropriate, instruct in HEP; re-check monthly

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes

NO

Non-Operative Management Temporary RTS/Delayed ACLR

Is the patient planning ACLR?* All patients educated on outcomes of operative or non-operative management

YES YES NC** NO NC** PC**

Why Consider Non-Operative Management?

• Some patients may wish to delay or avoid surgery
• Different practice patterns in different parts of the

world

• Surgical reconstruction and return to sports

activities are not an effective strategy for preventing early onset knee OA

• Not all patients need to have reconstructive

surgery

Does surgical delay help/hurt/ make no difference?

• Frobell et al BMJ 2013 (5 year)
• FINDINGS : The 5 year report shows that there was no

difference in any outcome between those who were

• perated on straight away, those who were operated on

later and those who did not have an operation at all. The message to the medical experts who are treating young, active patients with ACL injuries is that it may be better to start by considering rehabilitation rather than

• perating right away

What about prehab?

• Eitzen et al JOSPT
• FINDINGS : A 5-week progressive exercise therapy

program in the early stage after ACL injury led to significantly improved knee function before the decision making for reconstructive surgery or further non-operative management. The compliance to and tolerance for the program was high, with few adverse events.

300 patients followed prospectively – 150 at each location

• Screening
• 10 sessions of perturbation
• Functional testing
• Surgery or no surgery
• 6 month, 1 year, 2 year, 5

and 10 year follow-up

12 AM June 6, 2010 Lofoten Islands, Norway

Benchmarked to MOON (Failla et al AJSM 2016)

Benchmarked to NKLR and IKDC norms

(Grindem et al BJSM 2015)

• DOC showed superior 2-year patient-reported
• utcomes compared with NKLR (usual care).
• 86–94% of the ACLR patients who underwent

progressive preoperative and postoperative rehabilitation at the sports medicine clinic had 2-year postoperative patient-reported

• utcomes (IKDC) comparable to the IKDC

norm of a general population.

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes

All patients educated on outcomes of operative or non-operative management

• Some athletes can return without ACLR
• Just because you have ACLR, doesn’t mean you

will return to sports at all, and most likely not at the same level of performance

• Your risk of re-injury is high in the near term,

higher if you are younger, higher (ipsilateral) if you are male and (contralateral) if you are female

• Regardless of surgery, your risk of OA is high in

the long term

• If you need revision surgery risk of OA is higher

Has patient had > 1 episode

• f giving way?

Is patient planning accelerated RTS?

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes

NO

Non-Operative Management Temporary RTS/Delayed ACLR

Is the patient planning ACLR?* All patients educated on outcomes of operative or non-operative management

YES

Giving Way Episodes

• Must inquire about true giving way episodes with

ADLS

– Outside of initial injury or continued sports participation

• True giving way includes:

– Tibiofemoral shifting – Usually associated with pain and subsequent swelling – May lead to LOB or fall

• Does not include:

– Pseudo-buckling – Uncontrolled hyper-extension

Impairment resolution

• If no, begin PT treatments to achieve full range of motion
• Re-measure
• If yes, proceed
• If no, continue treatment

Full Range

• f Motion

In Knee

• If < 70%, start NMES and treat for strength deficits
• Re-measure strength with Burst test
• If > 70%, proceed but patient needs NMES and TEs until > 80%
• If > 80%, maintain current TE program and proceed

Quad Strength Assessment

• If yes, proceed
• If more than trace, begin PT treatments to resolve;

then re-measure Effusion Trace or Less

• If unrepairable, proceed
• If repairable, discuss with physician to determine if

non-op rehab should be pursued

• 1. No

Repairable Meniscal Tear on MRI

• Hop bilaterally on a mini-tramp
• If no pain, hop on involved leg on a mini-tramp
• If no pain, hop bilaterally on the floor
• If no pain, hop on involved leg on the floor
• If pain, begin PT treatments and retest until no

pain

• 5. Ability to

Hop on One Leg Pain-free

• If no, begin PT treatments to achieve full range of

motion

• Re-measure
• If yes, proceed
• If no, continue treatment
• 2. Full Range
• f Motion

In Knee

• If yes, proceed
• If more than trace, begin PT treatments to resolve;

then re-measure

• 4. Effusion

Trace or Less

• If < 70%, start NMES and treat for strength deficits
• Re-measure strength with Burst test
• If > 70%, proceed but patient needs NMES and TEs

until > 80%

• If > 80%, maintain current TE program and proceed
• 3. Quad

Strength Assessment

Criteria to Screen for Temporary Return to Sport After ACL Injury

Screening Exam: Includes hop testing series, objective questionnaires (KOS ADLs, global rating), number of giving way episodes Potential Coper (PC): < 1 episode of giving way with ADLs since initial injury; > 80% timed hop; > 80% KOS ADL score; > 60% GRS score Treatment: 10 visits of progressive perturbation training, agilities and strength training; then retest for return to sport criteria (Temporary RTS track) Non-Coper (NC): Failure to meet any 1 (or more) criteria from above and/or > 1 episode of giving way Treatment: Discussion on 10 visits of progressive perturbation and strength training with later integration of agilities and/or surgery (Non-operative vs.

• perative management track)

Level 3 athletes are screened on a case-by-case basis. If they are attempting to return to sport, consult.

IF all 5 criteria are met,

• kay to screen

Screening Exam

• Number of giving way episodes
• Hop testing series
• Objective questionnaires

(KOS ADLs, global rating)

ACL screening and rehabilitation– extension of injury

• Do no harm/no further injury

– more than 2000 screenings

• two repairable menisci
• zero chondral defects

• If unrepairable, proceed
• If repairable, discuss with physician to determine if

non-op rehab should be pursued

• 1. No

Repairable Meniscal Tear on MRI

• Hop bilaterally on a mini-tramp
• If no pain, hop on involved leg on a mini-tramp
• If no pain, hop bilaterally on the floor
• If no pain, hop on involved leg on the floor
• If pain, begin PT treatments and retest until no

pain

• 5. Ability to

Hop on One Leg Pain-free

• If no, begin PT treatments to achieve full range of

motion

• Re-measure
• If yes, proceed
• If no, continue treatment
• 2. Full Range
• f Motion

In Knee

• If yes, proceed
• If more than trace, begin PT treatments to resolve;

then re-measure

• 4. Effusion

Trace or Less

• If < 70%, start NMES and treat for strength deficits
• Re-measure strength with Burst test
• If > 70%, proceed but patient needs NMES and TEs

until > 80%

• If > 80%, maintain current TE program and proceed
• 3. Quad

Strength Assessment

Criteria to Screen for Temporary Return to Sport After ACL Injury

Screening Exam: Includes hop testing series, objective questionnaires (KOS ADLs, global rating), number of giving way episodes Potential Coper (PC): < 1 episode of giving way with ADLs since initial injury; > 80% timed hop; > 80% KOS ADL score; > 60% GRS score Treatment: 10 visits of progressive perturbation training, agilities and strength training; then retest for return to sport criteria (Temporary RTS track) Non-Coper (NC): Failure to meet any 1 (or more) criteria from above and/or > 1 episode of giving way Treatment: Discussion on 10 visits of progressive perturbation and strength training with later integration of agilities and/or surgery (Non-operative vs.

• perative management track)

Level 3 athletes are screened on a case-by-case basis. If they are attempting to return to sport, consult.

IF all 5 criteria are met,

• kay to screen

RTS activity progression (i.e., practice, contact drills, etc.)

NO

Has patient had > 1 episode

• f giving way?

Is patient planning accelerated RTS? Progressive neuromuscular and strength training and running progression without agilities (10 perturbation training sessions) Functional testing to guide HEP instruction 10 perturbation training sessions with agilities, strength training, running, and return to sport progressions Functional testing for return to sport (QI, 4 hops, KOS-ADLS, and GRS all > 90% Screen once impairments are resolved (QI > 70%, effusion < trace, full ROM, pain- free hopping, and no repairable meniscus) Integration of progressive agilities and sport specific progression as appropriate, instruct in HEP; re-check monthly

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes

NO

Non-Operative Management Temporary RTS/Delayed ACLR

Is the patient planning ACLR?* All patients educated on outcomes of operative or non-operative management

YES YES NC** NO NC** PC**

Perturbation Training

UD Running Progression

TREADMILL RUNNING PROGRAM

LEVEL 1 0.1 mile walk / 0.1 mile jog- repeat 10 times LEVEL 2 Alternate 0.1 mile walk / 0.2 mile jog - 2 mile total LEVEL 3 Alternate 0.1 mile walk / 0.3 mile jog - 2 mile total LEVEL 4 Alternate 0.1 mile walk / 0.4 mile jog - 2 mile total LEVEL 5 jog 2 miles LEVEL 6 Increase workout to 2 1/2 miles LEVEL 7 Increase workout to 3 miles

.

LEVEL 8 Alternate between running /jogging every 0.25 miles

TRACK RUNNING PROGRAM

LEVEL I Jog straights / Walk curves - 2 miles total LEVEL 2 Jog straights / Jog 1 curve every other lap LEVEL 3 Jog straights / Jog 1 curve every lap LEVEL 4 Fast Walk 1 3/4 lap / Walk curve LEVEL 5 Jog all laps LEVEL 6 Increase workout to 2 1/2 miles LEVEL 7 Increase workout to 3 miles LEVEL 8 Increase speed on straights / Jog curves

Instructions

• Mandatory 2 day rest between workouts for first two weeks.
• Do not advance more than 2 levels per week.
• Two days rest mandatory between levels 1, 2, and 3 workouts.
• One day rest mandatory between levels 4-8 workouts.

Soreness Rules

• If sore during warm-up, take 2 days off and drop down 1 level.
• If sore during workout, take 1 day off and drop down 1 level.

If sore after workout, stay at same level.

• Temporary RTS track

– Incorporated starting first day with perturbation training

• Non-operative management

track

– Incorporated later (end of pert training or part of HEP)

• Progress:

– Intensity – Straight plane to multi- planar – Make sport specific

Agilities

• Run at ____ % effort of maximal effort. After running a distance of ____ feet, a 45° angle cut

• At ___ % of maximal effort, hop on your ___ leg for a distance of ____ feet. Repeat ___ times.

• Run a figure eight around two cones placed ____ feet apart from one another. This should be

• Run a circle around a cone at ____ % of maximal effort. The circumferences of the circle should

• Run at ____ % of maximal effort for a distance of ____ feet, then make a 90° cut to the left.

• At ____ % of maximal effort, hop forward, left, backward, and right with both feet ___ inches

RTS activity progression (i.e., practice, contact drills, etc.)

NO

Has patient had > 1 episode

• f giving way?

Is patient planning accelerated RTS? Progressive neuromuscular and strength training and running progression without agilities (10 perturbation training sessions) Functional testing to guide HEP instruction 10 perturbation training sessions with agilities, strength training, running, and return to sport progressions Functional testing for return to sport (QI, 4 hops, KOS-ADLS, and GRS all > 90% Screen once impairments are resolved (QI > 70%, effusion < trace, full ROM, pain- free hopping, and no repairable meniscus) Integration of progressive agilities and sport specific progression as appropriate, instruct in HEP; re-check monthly

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes

NO

Non-Operative Management Temporary RTS/Delayed ACLR

Is the patient planning ACLR?* All patients educated on outcomes of operative or non-operative management

YES YES NC** NO NC** PC**

Functional Testing

• Same testing battery as the screening

exam, different “passing” criteria

MEASURE SCREENING EXAM (PC vs. NC) FUNCTIONAL TESTING FOR RETURN TO ACTIVTY Quadriceps Strength Index ≥70% to complete screen ≥90% All 4 Single Leg Hop Tests Timed Hop ≥60% to be PC ≥90% KOS-ADLs ≥80% to be PC ≥90% Global Rating Score (GRS) ≥60% to be PC ≥90%

RTS activity progression (i.e., practice, contact drills, etc.)

NO

Has patient had > 1 episode

• f giving way?

Is patient planning accelerated RTS? Progressive neuromuscular and strength training and running progression without agilities (10 perturbation training sessions) Functional testing to guide HEP instruction 10 perturbation training sessions with agilities, strength training, running, and return to sport progressions Functional testing for return to sport (QI, 4 hops, KOS-ADLS, and GRS all > 90% Screen once impairments are resolved (QI > 70%, effusion < trace, full ROM, pain- free hopping, and no repairable meniscus) Integration of progressive agilities and sport specific progression as appropriate, instruct in HEP; re-check monthly

ACL Injury Treatment Algorithm for Level 1 and 2 Athletes

NO

Non-Operative Management Temporary RTS/Delayed ACLR

Is the patient planning ACLR?* All patients educated on outcomes of operative or non-operative management

YES YES NC** NO NC** PC**

Following Functional testing

• Temporary RTS

– Once athlete meets RTS criteria: complete remaining activity progression, return to competition (90+ percent succeed=return with no episodes of giving way)

• Non-operative management

– Use test results to guide HEP progression, incorporate agilities – Re-check monthly and update HEP as indicated – Once athlete meets RTS criteria, begin phased progression back to sport

Phased Progression Back To Sports

• Full speed agility training 
• Unopposed practice of sport specific skill 
• One-on-one opposed practice of sport specific

skills 

• Full practice activity with team

ADAMS et al. 2012 (modified from Fitzgerald)

Delaware-Oslo ACL cohort data

• The differential response to ACL injury can be

affected by rehabilitation –

– 50% of non-copers become potential copers over the course of the 10 session program

• PCs who undergo ACLR have 4.5 times the

likelihood of successful outcome at 2 years than NCs

• PC’s who are managed non-operatively have a 6

times the likelihood of successful outcome at 2 years than NCs

Delaware-Oslo ACL cohort data

• Intent to return to previous level of

activity is not a predictor of actual return.

–Many who undergo ACLR intend to return and do not (consonant with other investigators) –Many who elect non-op expect to mitigate their activity and do not

Delaware-Oslo ACL cohort data

• Intent to return to previous level of

activity is not a predictor of actual return.

–Many who undergo ACLR intend to return and do not (consonant with other investigators) –Many who elect non-op expect to mitigate their activity and do not

It all depends

• n how their

knees feel!!

So…who needs surgery?

• Young (<25) participants in Level I sports who

intend to return to Level I sports and remain classified as non-copers after 10 sessions of prehab that includes progressive strengthening and neuromuscular training

• Those with repairable meniscus or full thickness

cartilage lesions (but maybe this is all they need)

Should Individuals Return to Sports after ACL Injury even if they have reconstruction?

If our goal is long term knee health, maybe not