1Paul Thawley MSc (Sports Medicine), Pg Dip (Rehabilitation) ACL RehabilitationPaul ThawleyMSc (Sports Medicine), Pg Dip (Rehabilitation)Rehabilitated 250 ACLR (65 in Olympic athletes) over 15 years
2Introduction This Lecture will cover the following: A very Brief overview of possible Biomechanics of ACL injuryIntrinsic and extrinsic FactorsRecent evidence on changing Intrinsic factorsPrerequisites to good Clinical RehabilitationThe Phases of Rehabilitation and examples, How to progress from phase to phaseThe importance of ProprioceptionReturn to Sport StrategiesPossible Injury prevention
3Learning ObjectivesUnderstand Possible mechanisms for injury and the need to address these factors within Rehabilitation.Understand the roles of rehabilitation and its phases.Have the ability to create a simple ACLR program.Have an a grasp on current research concepts relating to ACLR and current rehabilitation strategies
8Factors Relating to ACL Injury Intrinsic Factors Extrinsic factors
9These are difficult to change These can be addressed with good rehabilitation / S&CMany more elements are unexplained.
10Contributing Injury Factors To ACL Injury Factors are Multiple and varied; difficult to measure due to effect of these variables on individual Biomechanics and Movement Patterns.However we need to create a framework based on current evidence and best practice, to do this we need to understand possible causes.Possible contributing factors to injuryKnee PositionTiming / Phase in athletic movementCentral FatigueTrunk Instability / MovementPoor Movement Pattern / Motor controlInadequate sports specific training / S&C
11Knee PositionKnee Close to Extension, Valgus Collapse / Knee Abduction frequent.Hewett et al 2005Fast increase in valgus angle 3 or 4° 15 or 16° in msKrosshaug et al 2007.Minimal Internal / External RotationOlsen,Mykelbust et al (2004)Lateral trunk movementHewett Torg and Boden (2009)Quatman and Hewitt (2009)Quadraceps firing hard (Anticipating?)Boden et al (2000)
12Timing / Phase in Athletic movement DecelerationChange in direction. Besier et al (2003),Landing StrategiesPlant & cut situations. De Morat (2004)Fixed Foot PositionMulti Plane Mechanism with Trunk over compensation. Shifted Centre of Mass. Quatman et al (2010)
13Lateral Angulation ? = Altered Knee Abduction Torque More Recently evidence exists to link the following Intrinsic variables to ACL injuryCentral fatigueBorotikar et al (2008), Hewett et al (2005), Mclean and Samorezov (2009),Van Hecke (2009) ? Many Factors Kapreli (2009) Plasticity, Becomes a Neurophysiological ImpairmentTrunk instabilityLateral Angulation ? = Altered Knee Abduction TorqueZazulak et al (2005), Zazulak et al (2007)Poor movement patternsLinked to variables above, but may also poor technique / previous Injury ?????????????????(Chappell, and Limpisvasti (2008), Hewett et al (2002)Inadequate sports specific training / S&CMcLean (2008), Shaw et al (2005)
14“Dynamic stability of an athlete’s knee depends on accurate sensory input and appropriate motor responsesto meet the demands of rapid changes in trunk position duringcutting, stopping, and landing movements”Hewitt et al (2002), Hewitt et al (2005)Are these Athletes weak?“Inadequate neuromuscular control of the body’strunk or “core” may compromise dynamic stability of thelower extremity and result in increased abduction torque atthe knee, which may increase strain on the knee ligamentsand lead to injury”.Zazulak et al (2005)
15Weak Glutei muscles create pelvic shear and alter kinetics Weak Glutei muscles create pelvic shear and alter kinetics. Hewitt et al (2005)
16Outcome depends on good Rehabilitation The ACL Guidelines which will be on MOODLE are a combination of current Research and Rehabilitating over 200 ACL reconstructions, (60 in Olympic Athletes)Clinically reasoned approach.Understand the Mechanism of injuryGood Biomechanical assessmentPrioritise & Address problems identifiedTissue Healing knowledge vitalProgression Based on Physical and Clinical reassessmentHave a long term Injury prevention / protection strategy in place.
17The Phases Of Rehabilitation with Goals Keep it Simple and Measureable !Pre opEarly PhaseMiddle PhaseLate PhaseReturn To Play Strategy
18PRE OP Very important Phase 0: Pre-operative Recommendations Following diagnosis, specialist consultation and a surgery date is set.(Normally a minimum of 6 weeks from injury to reconstructive surgery)Pre - operatively the athlete requires the followingNormal gaitAROM 0 to 120 degrees of flexionStrength: 20 x SLR with no lagMinimal effusionAthlete education on the post-operative rehabilitation process, a fixed appointment for Physiotherapy no later than 10 days post op.A MDT discussion / meeting pre op to discuss and plan early phase rehabilitation,
19Aims of Rehabilitation- early stage Manage PainManage inflammationProtection Joint / injured tissue / healingJoint Range of movementNormalise movement / gaitMuscle Control/ RecruitmentProprioception
20Avoid Loaded uncontrolled OKC exercise Why is immediate AROM is Vital?To prevent Arthrofibrosis: Which may lead to painful permanent loss of range of motion. Perry et al (2005Loss of knee extension and hyperextension which has shown poor Quadriceps recruitment patterns. Also prevents scar between intercondylar notch and graft. Shelbourne et al (2006)Loss of knee flexion, related to Patella femoral joint pain. Shaw (2005)Early recovery of full active and passive range of motion has been proven to prevention of Arthrofibrosis. Shelbourne et al (1998)Avoid Loaded uncontrolled OKC exercise
21ACL Rehabilitation Guidelines (9 months protocol) PHASE 1:Immediate Post-operative Phase (Surgery to 2 weeks)GOALS:Full knee extension ROM (very important)Good quadriceps control (≥ 20 no lag SLR) Minimize pain Minimize swelling Normal gait patternPHASE 2:Early Rehabilitation Phase (Approximate timeframe: weeks 2 to 6)Full ROMNo quadriceps / hamstring inhibitionProgress neuromuscular retraining Improve proprioception
23Early Hamstring activation, very important? Work Mid Range Initially then Extend range to Inner and Outer ranges.
24Aims of Rehabilitation middle stage Address BiomechanicsMuscle flexibilityNeurodynamicsMuscle StrengthProprioceptionCV fitness
25PHASE 3: Strengthening & Control Phase (Approximate timeframe: weeks 7 through 12)GOALS:Maintain full ROMRunning without pain or swellingHopping without pain, swelling or giving-wayIncreased inner range hamstring control and powerPHASE 4: Training Phase (Approximate timeframe: weeks 13 to 17)Running patterns (Figure-8, pivot drills, etc.) at 75% speed without difficultyJumping without difficultyHop tests at 75% contralateral valuesCybex H:Q ratio / Peak torque / Endurance(work completed within 25% of normal contra lateral side)Start Sports specific pattern work.
28Aims of Rehabilitation late stage Muscle strength / EnduranceSpeed and powerImpact tolerance / Tissue hardeningDirection change / Pivoting/ AgilityCoordinationSports Specific workFuture Joint protection and prevention of re injury
29PHASE 5: Adaptive Phase (Approximate timeframe: weeks 18 to 26) Goals 85% contralateral strength 10RMCybex Q:H ratio, Peak torque / endurance within 10% of uninjured leg85% contralateral on hop testsStart controlled Randori without pain, swelling, or difficultyPHASE 6: Advanced / Final Phase (Approximate timeframe: weeks 26 to 38)GoalsTechnical ++++Sports SpecificComplex Rotation Multi Segmental TasksUnconstrained Ballistic / Plyometeric TasksPHASE 5: Adaptive Phase (Approximate timeframe: weeks 18 to 26)Goals
30Training Principles- Progressive Overload This comes in the Rehabilitation Module, so you will feel Comfortable working and progressing with S&C.Simple what are the variables at end stage Rehabilitation that can be manipulated to progress?
32“Are there other criteria whereby we should measure treatment outcome other than the time to return to sport?” Myklebust and Bahr (2005)Return to sport criteria for my Athletes Is Closely linked to Assessing Lower limb function Regularly on Elite and Podium Athletes
33 RETURN TO SPORT CRITERIA Final assessment from knee specialistNo functional complaintsHigh level of Judo specific techniques and movements under rotational loadingNormal isoskinetic knee assessmentConfidence when jumping at full speed90% contralateral values on hop tests Hop tests (single-leg hop, triple hop, cross-over hop, 6 meter timed-hop)90% contralateral values Vertical jump90% contralateral values Deceleration shuttle test
35Proprioception / Movement Pattern Acquisition Mechanoreceptors in ligaments / joint capsulesAfferent nervesTendon organsMuscle spindleCombined , these afferents help to give brain a position sensemotor neuron pool for quadriceps and hamstringsStimulation of ACL gives decrease AP laxity. Iwasa and Kawasaki et al (2006)? Ligaments like ACL may have SENSORY role.Brain Plasticity and Movement pattern generators. Kapreli et al (2009)
36Proprioception / Movement Pattern Acquisition ? After Injury altered joint position sense? Before ACL Injury, Previous Pelvic / LBPChange to motor controlAltered latency onset of muscle contraction,Inadequate sequencing / Patterning
37ACL Injury PackACL Prevention Program: (PEP Program: Prevent injury and Enhance Performance)ACL Rehabilitation linked to tissue healing and PhysiologyACL Rehabilitation Clinical Guidelines (9 months protocol)
38What We KnowThe ACL is loaded by a variety of combined sagittal and non sagittal mechanisms during dynamic sport postures considered to be high risk.1–,6In vivo strain of the ACL is related to maximal load and timing of ground reaction forces.7,8Females typically display a more erect (upright) posture when contacting the ground during the early stages of deceleration tasks.9–,12Maturation influences biomechanical and neuromuscular factors.13–,20Fatigue alters lower limb biomechanical and neuromuscular factors suggested to increase ACL injury risk.2,21–,23The effect of fatigue is most pronounced when combined with unanticipated landings, causing substantial central processing and central control compromise.24Trunk and upper body mechanics influence lower extremity biomechanical and neuromuscular factors.12,25,26Hip position and stiffness influence lower extremity biomechanical factors.2,10,27
39We Don't KnowWe still do not know the biomechanical and neuromuscular profiles that cause noncontact ACL rupture.An understanding of the causes is central to identifying how to pre screenWe do not yet understand the role of neuromuscular and biomechanical variability in the risk of indirect or noncontact ACL injury.Are there optimal levels of variability, and do deviations from these optimal levels increase the risk of injury?Is noncontact ACL injury an unpreventable accident stemming from some form of cognitive dissociation that drives central factors and the resulting neuromuscular and biomechanical patterns?Is gross failure of the ACL caused by a single episode or multiple episodes?Is noncontact ACL injury governed by single or potentially multiple high-risk biomechanical and neuromuscular profiles?
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