Download ACL Reconstruction - Dakine Physical Therapy

ACL Reconstruction
Jasmine Chan, SPT
Andy Chiu, SPT
Brandon Higa, SPT
Bryce Keyes, SPT
Minsu Kim, SPT
Derek Matsui, SPT
Adrian 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
1,2
PT
• 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
1,2
Pre-Operation
• 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
1,2
Consideration
• 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
http://www.jmarshallfreeman.com/images/pages/knee_surgery_web.png
Complications1
•Pain & Edema
limiting motion
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)
7
Equipment
• Continuous Passive Motion (CPM)
Machine
– Improve ROM
– Slow motions
– Used at home
– 6 hrs/day
– 1-2 weeks
8
Equipment
• Power Plate
– Acceleration Training
– Vibratory waves
– Increase healing
9
Equipment
• Compression Boots
– Inflatable coverings
– Increase blood circulation
•
•
•
•
•
•
Crutches/walker/brace
Bike
Treadmill
Weight machines
Therabands
Neuromuscular
Electrical Stimulation
10
Equipment
• Total Gym
– Multiple exercises
– Adjustable levels
9
Modalities
•
•
•
•
Cold/cool packs
Ultrasound
Electrical Stimulation
Transcutaneous
Electrical Nerve
Stimulation (TENS)
Risk
• Anatomical
– Joint laxity
– Tibial rotation
internally
– Pronated feet
• Physiological
– Poor core strength
– LE deficits
• Strength and
coordination
• Neuromuscular deficit
– Valgus collapse position
1
Factors
Static
11
Posture
• 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
12
Knee
• 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
12
Hamstrings
• 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
11
Ankle
• 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
13,14,15,16
Approach
• 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
17
Athlete
• Females 4-6 times more likely to obtain an ACL
injury
• Three major factors resulting in injury
– Ligament Dominance
– Quadriceps Dominance
– Leg Dominance
Neuromuscular
17
Control
• 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
• Training includes
– Plyometrics
– Dynamic Posturing
– Perturbation Training
– Proper Mechanical Technique
– Strength and Flexibility
17
Training
Neuromuscular Training
17
Goals
– 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
17
Training
• 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
–
–
–
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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
20
Education
• 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
22,23
Sport
• 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/
References
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