Presentation on theme: "REHABILITATION AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION"— Presentation transcript:
1 REHABILITATION AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION H SELCUK KUCUKOGLUULUDAG UNIVERSITYSCHOOL OF MEDICINEDEPARTMENT OF PM&R AND SPORTS MEDICINE
2 EPİDEMİOLOGYYearly incidence of ACL injuries has been reported to be 3/10,000 inhabitants in Denmark (Nielsen, 1991),In Sweden, ACL injuries comprise 43% of all soccer related injuries (Roos,1995),…
3 Operation time after the injury (months) Sex Type of graftAge(Year)Weight(kg)Operation time after the injury (months)SexLevel of Sportive ActivityInjury levelInjured extremityMFSpSedAkSubKrRightLeftPT25.66.975.19.421.732.653236199442926SG26.35.675.910.814.719.124152041312
4 GOALThe goal of ACL reconstruction is to improve the patients level of function, with in the hope of allowing them to return to an active life style, with minimal disability, while protecting them from further injury to the knee.
5 why treatAfter an ACL lesion, knee instability is common and may produce progressive functional changes and damage to other joint structures (meniscal damage,articular cartilage damage,and degenerative arthritis) which may also affect daily life activities.
6 why TREATThe ACL has poor potential for spontaneous healing after complete rupture,and therefore conservative treatment aims to develop joint motion patterns that help control abnormal knee motions which can arise in the absence of functional ACL.
7 why TREATIn the years following an ACL injury additional meniscus ruptures frequently occur. 80% of ACL deficient patients were found to have a torn meniscus within 2 years of ACL injury.Gillquist-Messner (Sports Med. March 1999)
8 why REHABILITATIONOptimal healing of an ACL graft and the knee is dependent on rehabilitation,The strains applied to an ACL graft by body weight, muscle activity, and joint motion affect its healing response,
9 ACCELERATED REHABILITATION Investigations of ACL grafts that have been done in animals indicate that they lose their ultimate failure strength and undergo a decrease of stiffness and the knees have an increase in anterior laxity develop during healing.
10 Accelerated rehabilitation The exact cause of above mentioned changes and the application of this data to humans are unclear.Rougraff-Shelbourne reported that large proportion of the tendon survives and ACL graft healing in humans may not undergo the same complete necrotic stage that has been reported in animals.Knee Surg Sports Traumatol Arthrosc 1999
11 ACLRehabilitation Preoperative Phase: Goals Diminish inflammation,swelling, and painRestore normal range of motion (extension)Restore voluntary muscle activationProvide patient education to prepare for surgeryBrace-elastic wrap or knee sleeve to reduce swellingWeight bearing-as tolerated with or without crutches
12 ACL Rehabilitation2 Preoperative phase Exercises Ankle pumps Passive knee extension to zeroPassive knee flexion to toleranceStraight leg raises (3-way, flexion, abduction, adductionQuadriceps settingClosed kinetic chain exercises: mini squats, lunges, step-ups
13 ACL Rehabiltation3 Preoperative Phase Muscle stimulation-electrical muscle stimulation to quadriceps during voluntary quadriceps exercises (4-6 hours/day)Cryotherapy/elevation-apply ice 20 minutes of every hour, elevate leg with knee in full extensionPatient education- review postoperative rehabilitation program
14 BIOMECHANICSIsometric exercises that strain the ACL involve contraction of the dominant quadriceps muscle group with the knee between extension and 60° flexion, or involve isotonic contraction of the quadriceps between extension and 50° flexion,
15 Biomechanics2The largest ACL strain magnitudes that have been measured and produced by isometric and isotonic contraction of the quadriceps muscles with the knee near extension.
16 Biomechanics3Squatting, stationary bicycling,and closed kinetic chain exercises that involves body weight loading and substantial cocontraction of the muscles does not create an appreciable change in ACL strain values.
20 ACL Rehabilitation Early Rehabilitation Phase (2-4 weeks) Criteria to progress to phase 2Quad control (ability to perform good quad set and straight leg raisesFull passive knee extensionPassive ROM 0° -90°Good patellar mobilityMinimal joint inflammationIndependent ambulation
21 ACL Rehabilitation Early Rehabilitation Phase Goals Maintain full passive knee extensionGradually increase knee flexionDiminish swelling and painMuscle trainingRestore proprioceptionPatellar mobility
22 ACL Rehabilitation Controlled ambulation Phase (weeks 4-10) Criteria to enter phase 3Active ROM 0° to 115°Quadriceps strength 60%>contralateral side (isometric test at 60° knee flexion)Minimal to no joint inflammationNo joint line or patellofemoral pain
23 ACL Rehabilitation Controlled Ambulation Phase(2) Goals Restore full knee ROM (0° -125°)Improve lower extremity strengthEnhance proprioception,balance and neuromuscular controlImprove muscular enduranceRestore limb confidence and functionNo brace or immobilizer, may use knee sleeve
24 ACL Rehabilitation Advanced Activity Phase (10-16 weeks) Criteria to enter Phase 4Active ROM 0°-125°Quad strength 80% of contralateral sideKnee flexor:extensor ratio 70%-75%No pain or effusion*Satisfactory clinical exam*Satisfactory isokinetic test(values at 60°/sec, 180°/secand 300°/sec)*Hop Test (80% of contralateralleg) (4test)*Subjective knee scoring 80 pointsor better (Noyes)
27 ACL Rehabilitation Return to activity phase Criteria to enter phase 5 Full ROMIsokinetic test that fulfills criteriaQuad bil comparison (80% or greater)Hams Bil comparison (110% or greater)Proprioceptive test (100% of contralateral leg)Hamstring/quadriceps ratio (70% or greater)Functional test(85%or greater of contralateral side)Satisfactory clinical examSubjective knee scoring (Noyes) 90 points or better
28 ACL Rehabilitation Return to activity phase (2) Goals Gradual return to full unrestricted sportsAchieve maximal strength and enduranceNormalize neuromuscular controlProgress skill training
29 Complications Hemarthrosis; Operative trauma and repeated operations Pretension of the substitute ligamentSeptic arthritisPostoperative arthrofibrosisPatellafemoral painAll may lead to gonarthrosis in the long run
30 ROLE of PMRCheck for the goals and the criterias to upgrade the patientEvaluate the results of isometric and isokinetic testsEvaluate the results of four HOP testsExamine the patient when appropriate for the stabilityExamine the patient for the complications and progress
31 PROPRIOCEPTION AND BALANCE AFTER ACL RECONSTRUCTION Ufuk Şekir , Bedrettin Akova , Hakan GürMedical School of Uludag University,Department of Sports Medicine , BURSA
32 THE AIM OF THE STUDYTo observe the changes in the proprioception and balance after ACL reconstruction.
33 PATIENTS AND METHODS 31 patients, mean age 24±7 (17-44) Patellar tendon autograftTime period between injury and the operation: 12 months ( 1-96)Follow-up : At 1th, 2nd, 3rd, 4th, 6th, and 12th months after operationAccelerated rehabilitation program, includes proprioceptive exercises (which began in the first month):Single-leg stance on hard surface (eyes open-closed)Single-leg stance on soft surface (eyes open-closed )Balance board exercises (eyes open-closed )
34 Joint Position Sense (JPS) Eyes closedIndex angles: 200,450 and 700Angular velocity: 10/sBefore matching an index angle, the examiner extends the knee passively to the index angle for 3 s.Three repetitions for each index angle was made.The mean of absolute error score (AES) for each index angle was calculatedMean AES= Sum of means of index angles /3JPS activeJPS passiveCybex 6000
35 Single-limb Balance On a soft surface. Eyes open-closed. First on the uninjured and then on the injured side.Arms crossed, contralateral leg flexed.The subjects were required to stand 60s.Two repetition were made.Mean number of touchdowns and mean time to first touchdown were recorded.
44 CONCLUSIONThe results of this study indicates that the proprioceptive capabilities of the ACL reconstructed knee can improved to the same level of the uninjured knee at 2 months after operation, with a rehabilitation program including proprioceptive exercises in early phase.
45 FUNCTIONAL CAPACITY AFTER ACL RECONSTRUCTION: RELATIONSHIPS WITH KNEE EXTENSOR AND FLEXOR MUSCLE STRENGTH1 Bedrettin Akova ,1 Hakan Gür, 1 Ufuk Şekir, 2 Sefa Müezzinoğlu1Medical School of Uludag University,Department of Sports Medicine , BURSA2 Medical School of Kocaeli University, Department of Orthopaedic Surgery, KOCAELİ
46 THE AIM OF THIS STUDY;To determine 1) the functional capacity and 2) the relationships between the functional capacity and knee extensor, and flexor peak torque after ACL reconstruction.
47 PATIENTS AND METHODS Between January, 2000 and June, 2002 21 male patients, mean age 24±7 (17-44)Patellar tendon autograftTime period between injury and the surgery: 7 months ( 1-48)The follow-up was performed at 2nd, 3rd, 4th, 6th, and 12th months after operation
48 FUNCTIONAL TESTS 6 meters Total distance Single Hop For Distance Triple Hop For DistanceCross-over Hop For DistanceTimed Hop
49 ISOKINETIC TESTCybex 6000Concentric test for knee flexors and extensors at the angular velocity of 600 and 1800/secondsPeak torques (Pt)Both legs
50 STATISTICS To compare injured-uninjured leg results; Wilcoxon testRelationships between functional capacity and isokinetic test results;Pearson correlation coefficient test
51 The results of the Single Hop test *** p<0.001,** p<0.01 compared with uninjured leg at same month p<0.01 compared with uninjured leg at 2nd month
52 The results of the Timed Hop test *** p<0.001,** p<0.01, *p<0.05 compared with uninjured leg at same month p<0.01 compared with uninjured leg at 2nd month
53 The results of the Triple Hop test *** p<0.001,** p<0.01 compared with uninjured leg at same month p<0.001, ++ p<0.01 compared with uninjured leg at 2nd month
54 The results of Cross-over Hop test *** p<0.001,** p<0.01 compared with uninjured leg at same month p<0.001, + p<0.05 compared with uninjured leg at 2nd month
57 CONCLUSIONIt is concluded that, the functional capacity can improve with a rehabilitation program used in this study up to four months after ACL surgery, and this improvement is significantly correlated by knee strength.