Presentation on theme: "Return to Sport after ACL Reconstruction"— Presentation transcript:
1Return to Sport after ACL Reconstruction Sara CordellIthaca CollegeWhy did I choose this topic? Difficult for students/new grads to decide this, so many factors involved, are there definitive tests that can help make the decision?, what does the evidence say?, is there a “right way” to decide or is it completely different for each patient?, improvements documented up to 2 years after reconstruction but cannot wait that long
2Challenge of Deciding Return to Sport Protocol timelineConcomitant injuries or complicationsKnee stability and strengthObjective vs. subjective dataReliability, validity, accuracy, functional relevance of testsIndividual circumstances, fears, values, motivation, etcDemands of particular sport(s)Clinical experience/judgmentProtocol given by MD- must follow timeline? Depends on MD philosophyInjuries/comp- meniscal/ligamentous tears/repairs, arthrofibrosis, etcKnee stab/str- graft stability, knee flexor/extensor strength/ratios usually according to BiodexObj/subj- may not match; obj good, subj bad or subj good, obj badTests- are they reliable/valid, do they apply to patient function? Do they mimic the demands of the sport? Can they show true deficits?Individual/family circumstancesClinical experience/judgment- most important?
3Many Factors InvolvedNo one test/factor that determines return to sportMany different areas to consider when making return to sport decisions
4General Return to Sport Guidelines ≥90% symmetry between involved and uninvolved sides for objective testing (isokinetic testing, hop testing, etc)Full, nonpainful ROMNo joint effusionJoint stability- KT test ≤3mm side-to-side differenceMD and PT opinionsThese are general guidelines for return to sport, but they are somewhat vague. One article discussed an algorithm that had a 4-step progression through the return to sport phase
5Return to Sport Algorithm According to Myer et al. Not validated algorithm but backed up by evidence- No time frame proposed, strictly based on criteria- IKDC subjective knee form assesses the patient’s perception of their knee injury- symptoms, function, ability to participate in sportHard to assess some of these specifically without the proper equipmentthoughts? Opinions? Are these the most important factors for each stage?Different criteria address subjective measures, strength, balance, equal joint loading, hop testing, agility, overall symmetry
6Objective Testing Options Biodex Isokinetic TestingKT TestingAgility testing- Modified T-testBalance testing- StabilometerGoniometry to measure symmetry of movementCompare symmetry of GRFsDeceleration testingHop testingGreat options available but we have limited time and equipment, cannot conduct every testDeceleration testing- run and full speed and stop suddenly on command, positive for rotary instability if the patient stops w/o using quads or stops in crouched position (>30deg knee flex)
7Hop TestingCommon tests- single leg hop for distance, 6m timed hop, triple hop for distance, crossover hops for distanceLimb symmetry index (LSI=involved/uninvolved x100% for distance measures, opposite for time)Begun ~12-16weeks post-opPros- test many aspects of LE movement at once, time efficient, minimal equipmentCons- learning curve, functional relevance, don’t address quality of movement, measurement errora lot of literature about hop testing so I wanted to research the reliability and validity of the measures and also determine the most clinically useful/relevant tests to useBasic criteria before hopping- no effusion, painfree hopping, ≥80% strength, full ROM, normal gait patternWhy use hop testing- neuromusc control, strength, confidence in limb, minimal equipment and timewant tests to “mimic demands of dynamic knee stability”
9Characteristics of Hop Tests Reliability (ICC)MDC (%)Single hop.928.096m timed hop.8212.96Triple hop.8810.02Crossover hop.8412.25Overall combination.937.05Article by Reid examined 4 common hop tests and investigated the reliability of the testsSingle hop was most reliable, but all four together proved to be the best especially when you look at the sensitivitiesUsing the single hop test alone could increase the risk of a false negativeICC (reliability)- measures degree of consistency, errorMinimal detectable change= MDCSensitivity- snout- good at ruling condition out good sensitivity here means that there will be few false negativesFour tests together- sensitivity= 82%Single hop test alone- sensitivity= 38-52%
10Hops in Gustavsson et al. Vertical jumpSingle hop for distanceDrop jump followed by double hopSquare hopSide hop5 hops examined by Gustavsson et al.
11Hop Test Evaluation Statistic Vertical jump Hop for distance Drop jump w/ double hopSquare hopSide hopSensitivity86635169Specificity8710067Accuracy7456Assessed 6mo post-op- Vertical jump performed best in all 3Spin- better at ruling discrepancy in avoid false positives, won’t over reportGood spin, bad snoutIf positive test for deficiency, can be almost sure that they have the deficiency but if they test negative for deficiency you cannot be absolutely sure that it is a true negative
12Hop Test Battery Vertical jump, single hop for distance, side hop Sensitivity: 91% for identifying patient as abnormal when at least 1 of the 3 tests was abnormalAccuracy: 84% for truly normal subjects and 88% for truly abnormal subjectsSquare hop eliminated b/c of poor sensitivity/specificity and accuracy; drop jump eliminated b/c of high correlation with single hop, measured same ability
13At 6 months post-op… 54% had abnormal LSI in ALL 3 tests 91% had an abnormal value in at least one of the 3 testsOnly 9% had all normal LSI valuesUsed 3 hop test battery with athletes 6months post-op and found these results…Abnormal= <90%Interesting b/c in theory they should be about ready to resume sport
14Patient Example Reid Test Battery Test *Left Right LSI Single Hop 91.3%6m Hop2.5s2.63s105.2%Triple Hop4.72m4.82m97.9%Crossover Hop4.1m4.8m85.4%Applied to SallyAccording to the first test battery, subject is just about “normal”According to second, he has some work to doDoes this example indicate second test battery is better than the first?This example supports the research- the battery proposed by Reid had a sensitivity of 82% vs 91% in the Gustavsson battery. Therefore the first set of tests may have some false negativesGustavsson Test BatteryTest*LeftRightLSISingle Hop1.48m1.62m91.3%Vertical Jump10.43in13.03in80.0%Side Hop34in49in69.3%
15Effect of Testing in Fatigued State Augustsson et al. evaluated effect of fatigue on single hop testing resultsFatigue- repeat as many reps as possible at 50% 1RMAll patients included in study had ≥90% symmetry in non-fatigued conditionsAfter pre-exhaustion exercise, 68% demonstrated abnormal hop symmetryAugustsson et al.- rationale was that injuries occur in fatigued stateAll subjects included in the study had to demonstrate normal LSIs so it was shocking when only 32% were still designated as normal after fatigue testingShould athletes be tested in non-fatigued and fatigued environments?
16Take Home Messages Do not use only one or two testing methods Consider whole athlete and demands of sportReference protocol timeline but also use functional goals as criteria for progressionNo objective tests are perfect, supplement with clinical judgment and experienceConsider testing athlete in non-fatigued and fatigued conditions
17What is your opinion? Criteria based algorithm as proposed by Myer? Can you identify the most important factors when deciding return to sport?Most clinically useful objective measures?Most reliable/valid hop tests?Testing in fatigued vs. non-fatigued state?Commonly overlooked factors?
18ReferencesAugustsson J, Thomeé R, Karlsson J. Ability of a new hop test to determine functional deficits after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal Of The ESSKA. Sept 2004;12(5):Gustavsson A, Neeter C, Karlsson J, et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal Of The ESSKA. August 2006;14(8):Hartigan EH, Axe MJ, Snyder-Mackler L. Time line for noncopers to pass return-to-sports criteria after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2010; 40:Kvist J. Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Medicine ;34(4):Myer G, Paterno M, Ford K, Quatman C, Hewett T. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. The Journal Of Orthopaedic And Sports Physical Therapy. June 2006;36(6):Reid A, Birmingham T, Stratford P, Alcock G, Giffin J. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Physical Therapy . March 2007;87(3):