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ACL reconstruction healing and Return to Play Randy Clark Acknowledgements: Glenn Williams, Mike Shaffer, Danny Foster, Brian Wolf.

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Presentation on theme: "ACL reconstruction healing and Return to Play Randy Clark Acknowledgements: Glenn Williams, Mike Shaffer, Danny Foster, Brian Wolf."— Presentation transcript:

1 ACL reconstruction healing and Return to Play Randy Clark Acknowledgements: Glenn Williams, Mike Shaffer, Danny Foster, Brian Wolf

2 Introduction 100,000 new ACL injuries each year (1/3000 people) 100,000 new ACL injuries each year (1/3000 people) Young women 3 times more likely to suffer an ACL injury compared to a male cohort group Young women 3 times more likely to suffer an ACL injury compared to a male cohort group Young female participating in sports year round has a 5% risk for tearing her ACL Young female participating in sports year round has a 5% risk for tearing her ACL No more than % of ACL deficient individuals typically return to running, jumping, and pivoting activities without experiencing subsequent episodes of knee instability No more than % of ACL deficient individuals typically return to running, jumping, and pivoting activities without experiencing subsequent episodes of knee instability

3 ACL Defficiency and Return to Play 832 ACL injuries 10% declined, 40% other knee injuries 432 Remaining patients 87 unable to regain ROM, strength, pain control 345 patients Screening exam eliminates 199 as Non-copers 146 patients 60% chose to undergo surgery 88 patients attempt return to sport

4 ACL Defficiency and Return to Play 88 Patients return to sport 63 patients 72% successful 29 patients remain 36 went onto reconstruction Hurd et al., A 10 year progressive trial of a patient management algorithm and Screening examination for highly active indicituals with ACL injury, Part 1 Outcomes., Am J Sports Med. 36: % return to sport without subsequent instability Fitzgerald et al., Knee Surg Sports Traumatol Arthrosc., 2000

5 How long until I can play? The healing process- The healing process- Its a dead piece of tissue! Its a dead piece of tissue! Graft needs to be re-vascularized Graft needs to be re-vascularized Ligamentization occursLigamentization occurs Vascular Synovial layer wraps around graft in 4- 6 weeks Vascular Synovial layer wraps around graft in 4- 6 weeks

6 Healing Time Autologous ACL grafts dont Autologous ACL grafts dont Transition through necrotic stage Weakest link fixation 4-6 weeks Weakest link fixation 4-6 weeks Complete re-vascularization Complete re-vascularization of the graft takes ~20 weeks Remodeling occurs: Remodeling occurs: By one year histological and By one year histological and biochemical properties of ACLR ~ native ACL

7 Graft Remodeling Gradual loss of graft strength during initial remodeling Gradual loss of graft strength during initial remodeling Then strength of ACL graft improves gradually Then strength of ACL graft improves gradually Allografts Allografts Slightly slower process Slightly slower process

8 Graft Remodeling Patellar tendon Patellar tendon Bone to bone within the ACL tunnels Bone to bone within the ACL tunnels 4-8 weeks usually 4-8 weeks usually

9 Graft Remodeling Hamstring graft Hamstring graft -Bone to tendon healing -Bone to tendon healing -Sharpeys fibers -Usually complete at 12 weeks -Usually complete at 12 weeks ACL autograft resembles ACL autograft resembles normal ACL at 12 months Concern for increased allogenic Concern for increased allogenic graft incorporation time doesnt warrant modification of PT protocol protocol

10 Pre-Operative Rehabilitation Initial focus on eliminating swelling and restoring pre-injury range of motion and strength Initial focus on eliminating swelling and restoring pre-injury range of motion and strength

11 Rehabilitation Slight variations depending on age, history, activity level, graft source and associated injuries. Slight variations depending on age, history, activity level, graft source and associated injuries.

12 Rehabilitation Bracing: Bracing: There is little evidence to support the use of a post-operative brace following isolated reconstruction of the ACL. There is little evidence to support the use of a post-operative brace following isolated reconstruction of the ACL. Although the exact mechanism for any beneficial effect of functional bracing remains unknown, ACL deficient athletes commonly report improved confidence with use of a functional knee brace. Although the exact mechanism for any beneficial effect of functional bracing remains unknown, ACL deficient athletes commonly report improved confidence with use of a functional knee brace. The use of functional bracing should perhaps be reserved for return to sport following revision surgery or in athletes who have suffered a multiple ligament injury. The use of functional bracing should perhaps be reserved for return to sport following revision surgery or in athletes who have suffered a multiple ligament injury. CORR 07 systematic review 12 RCTs- no support for bracing CORR 07 systematic review 12 RCTs- no support for bracing

13 Rehabilitation Five phases Five phases Phase I- Immediate post-op (0-2 weeks) Phase I- Immediate post-op (0-2 weeks) Phase II- Early Rehabilitation Activities (2-6 weeks) Phase II- Early Rehabilitation Activities (2-6 weeks) Phase III- Advanced Rehabilitation Activities (6-10 weeks) Phase III- Advanced Rehabilitation Activities (6-10 weeks) Phase IV- Advanced Functional Activities (10 weeks- 6 months) Phase IV- Advanced Functional Activities (10 weeks- 6 months) Phase V- Return to Sport (6-12 months) Phase V- Return to Sport (6-12 months)

14 Rehabilitation Phase I- Immediately Post- Surgery (POST-OPERATIVE WEEKS 0-2) Phase I- Immediately Post- Surgery (POST-OPERATIVE WEEKS 0-2) The goals of the early rehabilitation period are to control pain and post-operative swelling, and begin to restore range of motion. The goals of the early rehabilitation period are to control pain and post-operative swelling, and begin to restore range of motion. Control inflammation: cryotherapy, elevation, compression, limitation of activitiesControl inflammation: cryotherapy, elevation, compression, limitation of activities Restore ROM: importance of regaining hyperextension. (Importance of regaining motion pre-op)Restore ROM: importance of regaining hyperextension. (Importance of regaining motion pre-op)

15 Rehabilitation Phase I continued…. Phase I continued…. ROM ROM Stretches: extension bridges, prone hangsStretches: extension bridges, prone hangs ROM expectations: ROM expectations: 0-90° 2 weeks0-90° 2 weeks 0-120° 4 weeks0-120° 4 weeks Full range 6 weekFull range 6 week Muscle strengthening Isometric quad contractions, straight leg raises, stim treatments Ambulation- crutches, WBAT, avoid quad avoidance gait pattern

16 Rehabilitation Criteria to Progress to Phase II Criteria to Progress to Phase II Knee effusion well controlled Knee effusion well controlled Adequate quadriceps control demonstrated by the ability to do a hip flexion straight leg raise without extensor lag Adequate quadriceps control demonstrated by the ability to do a hip flexion straight leg raise without extensor lag Normal gait pattern without use of assistive devices Normal gait pattern without use of assistive devices Knee range of motion of at least 0- 90° Knee range of motion of at least 0- 90°

17 Rehabilitation Phase II – Early Rehabilitation Exercises (POST-OPERATIVE WEEKS 2-6) Phase II – Early Rehabilitation Exercises (POST-OPERATIVE WEEKS 2-6) The focus of Phase II rehabilitation is to restore full knee range of motion and advance early strengthening exercises The focus of Phase II rehabilitation is to restore full knee range of motion and advance early strengthening exercises Light weights, remember creep (low load prolonged stretches), manual overpressure, stationary bicycle (half moon), lunges, squats Light weights, remember creep (low load prolonged stretches), manual overpressure, stationary bicycle (half moon), lunges, squats Supervised vs. Home rehab program We feel that a minimum of 6 visits with a rehabilitation professional is necessary for successful outcome following ACL reconstruction.

18 Rehabilitation Open vs. closed chain excercises Open vs. closed chain excercises Open chain and infrapatellar painOpen chain and infrapatellar pain Graft lengtheningGraft lengthening

19 Rehabilitation Criteria to Advance to Phase III Criteria to Advance to Phase III Full knee range of motion Full knee range of motion Able to ascend and descend stairs normally Able to ascend and descend stairs normally Successfully completing regular exercise program of Phase II activities Successfully completing regular exercise program of Phase II activities

20 Rehabilitation Phase III- Advanced Rehabilitation Exercises (POST-OPERATIVE WEEKS 6- 10) Phase III- Advanced Rehabilitation Exercises (POST-OPERATIVE WEEKS 6- 10) Build on the limb strength gained in Phase II Build on the limb strength gained in Phase II Traditional strengthening exercises combined with additional challenges to the nervous system: pertubations, mental distraction tasks, activities which progressively force the center of gravity away from the base of support.Traditional strengthening exercises combined with additional challenges to the nervous system: pertubations, mental distraction tasks, activities which progressively force the center of gravity away from the base of support. Restore neuromuscular control: mechanoreceptor repopulation is most active between 2 and 8 weeks post- operativelyRestore neuromuscular control: mechanoreceptor repopulation is most active between 2 and 8 weeks post- operatively RCTs show superiority of neuromuscular retraining when compared to standard strength training. (Beard JBJS 94, Risberg Aust J Phys 07)RCTs show superiority of neuromuscular retraining when compared to standard strength training. (Beard JBJS 94, Risberg Aust J Phys 07)

21 Rehabilitation Criteria to Advance to Phase IV Criteria to Advance to Phase IV Regularly completing isotonic strengthening program in supervised physical therapy Regularly completing isotonic strengthening program in supervised physical therapy Starting to transition strengthening activities to local gym or athletic teams weight room Starting to transition strengthening activities to local gym or athletic teams weight room Approximately 70-80% strength vs. contralateral (uninvolved) lower extremity Approximately 70-80% strength vs. contralateral (uninvolved) lower extremity Demonstrates appropriate control of knee with neuromuscular retraining exercises in the physical therapy clinic Demonstrates appropriate control of knee with neuromuscular retraining exercises in the physical therapy clinic

22 Rehabilitation Phase IV- Advanced Functional Activities (10 weeks- 6 months) Phase IV- Advanced Functional Activities (10 weeks- 6 months) The primary goal of the fourth phase of rehabilitation is to prepare the athlete for return to sport. Running, cutting, and jumping are near universal requirements of the sports in which athletes most often tear their ACLs. The primary goal of the fourth phase of rehabilitation is to prepare the athlete for return to sport. Running, cutting, and jumping are near universal requirements of the sports in which athletes most often tear their ACLs. be cognizant of other tasks which are important parts of the sport to which the athlete hopes to returnbe cognizant of other tasks which are important parts of the sport to which the athlete hopes to return

23 Rehabilitation Phase IV continued Phase IV continued ladder drills or other simulated running tasks, then advance to interval jogging. ladder drills or other simulated running tasks, then advance to interval jogging. Once 70-80% of their pre-injury speed, cutting drills begin. Once 70-80% of their pre-injury speed, cutting drills begin. Land based jumping, jumping up to a box and/or completing all plyometrics activities by landing on two legs Land based jumping, jumping up to a box and/or completing all plyometrics activities by landing on two legs

24 Rehabilitation Criteria for Progression for Phase V Criteria for Progression for Phase V Regularly completing isotonic strengthening program Regularly completing isotonic strengthening program Running at least 85% of pre-injury speed Running at least 85% of pre-injury speed Cutting and jumping without hesitation or obvious limitation Cutting and jumping without hesitation or obvious limitation

25 Rehabilitation Phase V- Return to Sport (6-12 months) Phase V- Return to Sport (6-12 months) subjective and objective information considered. subjective and objective information considered. Athlete pain free during performanceAthlete pain free during performance Athlete not demonstrate limp or guardingAthlete not demonstrate limp or guarding Effusion after rehabilitation or functional testing viewed as a stark indication that neuromuscular system not adequately countering the high stresses experienced within the joint.Effusion after rehabilitation or functional testing viewed as a stark indication that neuromuscular system not adequately countering the high stresses experienced within the joint. Athlete should feel confident about their return to sport.Athlete should feel confident about their return to sport.

26 Rehabilitation Phase V- Return to Sport (6-12 months) Phase V- Return to Sport (6-12 months) No more than 10% asymmetry in terms of isokinetic variables between the involved and uninvolved lower extremity No more than 10% asymmetry in terms of isokinetic variables between the involved and uninvolved lower extremity single leg hop test to measure knee joint function and strength single leg hop test to measure knee joint function and strength single leg vertical jump, single leg hop for distance, single leg timed hop single leg vertical jump, single leg hop for distance, single leg timed hop

27 Rehabilitation Criteria to Return to Sport Criteria to Return to Sport No complaints of pain or knee instability No complaints of pain or knee instability Full ROM Full ROM No new effusion No new effusion Lower extremity strength/ function at least 85% vs. uninvolved LE Lower extremity strength/ function at least 85% vs. uninvolved LE Adequate performance in physical therapy or with sport specific drills which simulate the intensity, frequency, and duration of the sport to which the athlete hopes to return Adequate performance in physical therapy or with sport specific drills which simulate the intensity, frequency, and duration of the sport to which the athlete hopes to return Athlete demonstrates a psychological readiness to return to sport, either verbally or with SANE score > 80/100 Athlete demonstrates a psychological readiness to return to sport, either verbally or with SANE score > 80/100

28 Functional Testing Full ROM, negative pivot-shift, symmetric quad and hamstring strength and functional testing scores Full ROM, negative pivot-shift, symmetric quad and hamstring strength and functional testing scores

29 Rehabiliation Crucial input from.. Crucial input from.. Physician Physician Athletic trainer Athletic trainer Physical Therapist Physical Therapist Coach Coach Athlete +/- parents Athlete +/- parents

30 Rehabilitation Rehab time frame changed Rehab time frame changed Formally >12mos Formally >12mos Now generally ~6m Now generally ~6m 2 RCTs 2 RCTs Beynnon, Ekstrand Beynnon, Ekstrand 8 mos vs ~5mos 8 mos vs ~5mos No significant differences in: No significant differences in: Subjective outcome Subjective outcome Anterior knee laxity Anterior knee laxity Functional testing Functional testing Faster rehab (19 wks) seems safe Faster rehab (19 wks) seems safe Programs faster than this….? Programs faster than this….?

31 Rehabilitation Bone scan? Bone scan? Scott Dye talk Scott Dye talk

32 Rehabilitation Functional score meta-analysis Functional score meta-analysis No difference between BTB and hamstring grafts with respect to function (Biau CORR 07) No difference between BTB and hamstring grafts with respect to function (Biau CORR 07) 14 trials- 7 RCTs14 trials- 7 RCTs

33 What to expect? 10-14% of ACL R patients need another surgery at some point in the future 10-14% of ACL R patients need another surgery at some point in the future Risk of re-rupture Risk of re-rupture 3% on ACLR knee 3% on ACLR knee 3% on other knee 3% on other knee ~20% of patients note some subj functional impairment with ACLR knee ~20% of patients note some subj functional impairment with ACLR knee ~90% of athletes return to same level of sport by one year after ACLR ~90% of athletes return to same level of sport by one year after ACLR Only 54% still at that level by ~3 yrs Only 54% still at that level by ~3 yrs

34 Lit Review on Return to Play

35

36 Home vs Formal PT Grant et. Al, AJSM 2005 Grant et. Al, AJSM 2005 Hypothesis: no difference in home vs. structure PT program at 3 months for BTB reconstruct. Hypothesis: no difference in home vs. structure PT program at 3 months for BTB reconstruct. Study design: RCT, 145 pts, 4 vs. 17 PT sessions Study design: RCT, 145 pts, 4 vs. 17 PT sessions Measured: ROM, knee motion walking, KT, quad and hamstring strength Measured: ROM, knee motion walking, KT, quad and hamstring strength Results: 67% vs 47% flexion, 97% vs 83% ext, others no diff. Results: 67% vs 47% flexion, 97% vs 83% ext, others no diff. Conclusion: OK for weekend warrior to do home PT Conclusion: OK for weekend warrior to do home PT

37 Propioception Knee Before and After ACL Reconstruction Reider et al. Arthroscopy 2003 Reider et al. Arthroscopy 2003 Compared proprioception before and after ACL reconstruction to healthy controls (contralateral knee) Compared proprioception before and after ACL reconstruction to healthy controls (contralateral knee) Concluded: At 6 months no difference in JPS and TDPM (threshold to detection of passive motion) compared to controls Concluded: At 6 months no difference in JPS and TDPM (threshold to detection of passive motion) compared to controls Reconstruction has positive impact on propioceptionReconstruction has positive impact on propioception


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