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)
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
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
72% successful
63 patients
36 went onto reconstruction
29 patients remain
24% return to sport without subsequent instability
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. 36:40-47
Fitzgerald et al., Knee Surg Sports Traumatol Arthrosc., 2000

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

6. Healing Time Autologous ACL grafts don’t
Transition through necrotic stage
Weakest link fixation 4-6 weeks
Complete re-vascularization
of the graft takes ~20 weeks
Remodeling occurs:
By one year histological and
biochemical properties of
ACLR ~ native ACL

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

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

9. Graft Remodeling • Hamstring graft -Bone to tendon healing
-Sharpey’s fibers
-Usually complete at 12 weeks
ACL autograft resembles
normal ACL at 12 months
Concern for increased allogenic
graft incorporation time doesn’t
warrant modification of PT
protocol

10. Pre-Operative Rehabilitation
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.

12. Rehabilitation Bracing:
“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.”
“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 RCT’s- no support for bracing

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

14. Rehabilitation
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.
Control inflammation: cryotherapy, elevation, compression, limitation of activities
Restore ROM: importance of regaining hyperextension. (Importance of regaining motion pre-op)

15. Rehabilitation Phase I continued…. ROM
Stretches: extension bridges, prone hangs
ROM expectations:
0-90° 2 weeks
0-120° 4 weeks
Full 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
Knee effusion well controlled
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
Knee range of motion of at least 0- 90°

17. Rehabilitation
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
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 chain and infrapatellar pain
Graft lengthening

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

20. Rehabilitation
Phase III- Advanced Rehabilitation Exercises (POST-OPERATIVE WEEKS 6-10)
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.
Restore neuromuscular control: mechanoreceptor repopulation is most active between 2 and 8 weeks post-operatively
RCT’s 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
Regularly completing isotonic strengthening program in supervised physical therapy
Starting to transition strengthening activities to local gym or athletic team’s weight room
Approximately 70-80% strength vs. contralateral (uninvolved) lower extremity
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)
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 ACL’s.
be cognizant of other tasks which are important parts of the sport to which the athlete hopes to return

23. Rehabilitation Phase IV continued
ladder drills or other simulated running tasks, then advance to interval jogging.
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

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

25. Rehabilitation Phase V- Return to Sport (6-12 months)
subjective and objective information considered.
Athlete pain free during performance
Athlete 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.
Athlete should feel confident about their return to sport.

26. Rehabilitation 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
single leg hop test to measure knee joint function and strength
single leg vertical jump, single leg hop for distance, single leg timed hop

27. Rehabilitation Criteria to Return to Sport
No complaints of pain or knee instability
Full ROM
No new effusion
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
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

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

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

31. Rehabilitation
Bone scan?
Scott Dye talk

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

33. What to expect?
10-14% of ACL R patients need another surgery at some point in the future
Risk of re-rupture
3% on ACLR knee
3% on other 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
Only 54% still at that level by ~3 yrs

34. Lit Review on Return to Play

35. Lit Review on Return to Play

36. Home vs Formal PT Grant et. Al, AJSM 2005
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
Measured: ROM, knee motion walking, KT, quad and hamstring strength
Results: 67% vs 47% flexion, 97% vs 83% ext, others no diff.
Conclusion: OK for weekend warrior to do home PT

37. Propioception Knee Before and After ACL Reconstruction
Reider et al. Arthroscopy 2003
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”
Reconstruction has positive impact on propioception