Paul Thawley MSc (Sports Medicine), Pg Dip (Rehabilitation) ACL Rehabilitation Paul Thawley MSc (Sports Medicine), Pg Dip (Rehabilitation) Rehabilitated 250 ACLR (65 in Olympic athletes) over 15 years

Introduction This Lecture will cover the following: A very Brief overview of possible Biomechanics of ACL injury Intrinsic and extrinsic Factors Recent evidence on changing Intrinsic factors Prerequisites to good Clinical Rehabilitation The Phases of Rehabilitation and examples, How to progress from phase to phase The importance of Proprioception Return to Sport Strategies Possible Injury prevention

Learning Objectives Understand 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

ACL Injury

What does the ACL do?

Stabilising role

Screw home mechanism

Factors Relating to ACL Injury Intrinsic Factors Extrinsic factors

These are difficult to change These can be addressed with good rehabilitation / S&C Many more elements are unexplained.

Contributing 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 injury Knee Position Timing / Phase in athletic movement Central Fatigue Trunk Instability / Movement Poor Movement Pattern / Motor control Inadequate sports specific training / S&C

Knee Position Knee Close to Extension, Valgus Collapse / Knee Abduction frequent. Hewett et al 2005 Fast increase in valgus angle 3 or 4° 15 or 16° in ms Krosshaug et al 2007. Minimal Internal / External Rotation Olsen,Mykelbust et al (2004) Lateral trunk movement Hewett Torg and Boden (2009) Quatman and Hewitt (2009) Quadraceps firing hard (Anticipating?) Boden et al (2000)

Timing / Phase in Athletic movement Deceleration Change in direction. Besier et al (2003), Landing Strategies Plant & cut situations. De Morat (2004) Fixed Foot Position Multi Plane Mechanism with Trunk over compensation. Shifted Centre of Mass. Quatman et al (2010)

Lateral Angulation ? = Altered Knee Abduction Torque More Recently evidence exists to link the following Intrinsic variables to ACL injury Central fatigue Borotikar et al (2008), Hewett et al (2005), Mclean and Samorezov (2009), Van Hecke (2009) ? Many Factors Kapreli (2009) Plasticity, Becomes a Neurophysiological Impairment Trunk instability Lateral Angulation ? = Altered Knee Abduction Torque Zazulak et al (2005), Zazulak et al (2007) Poor movement patterns Linked to variables above, but may also poor technique / previous Injury ????????????????? (Chappell, and Limpisvasti (2008), Hewett et al (2002) Inadequate sports specific training / S&C McLean (2008), Shaw et al (2005)

“Dynamic stability of an athlete’s knee depends on accurate sensory input and appropriate motor responses to meet the demands of rapid changes in trunk position during cutting, stopping, and landing movements” Hewitt et al (2002), Hewitt et al (2005) Are these Athletes weak? “Inadequate neuromuscular control of the body’s trunk or “core” may compromise dynamic stability of the lower extremity and result in increased abduction torque at the knee, which may increase strain on the knee ligaments and lead to injury”. Zazulak et al (2005)

Weak Glutei muscles create pelvic shear and alter kinetics Weak Glutei muscles create pelvic shear and alter kinetics. Hewitt et al (2005)

Outcome 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 injury Good Biomechanical assessment Prioritise & Address problems identified Tissue Healing knowledge vital Progression Based on Physical and Clinical reassessment Have a long term Injury prevention / protection strategy in place.

The Phases Of Rehabilitation with Goals Keep it Simple and Measureable ! Pre op Early Phase Middle Phase Late Phase Return To Play Strategy

PRE 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 following Normal gait AROM 0 to 120 degrees of flexion Strength: 20 x SLR with no lag Minimal effusion Athlete 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,

Aims of Rehabilitation- early stage Manage Pain Manage inflammation Protection Joint / injured tissue / healing Joint Range of movement Normalise movement / gait Muscle Control/ Recruitment Proprioception

Avoid 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 (2005 Loss 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

ACL 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 pattern PHASE 2: Early Rehabilitation Phase (Approximate timeframe: weeks 2 to 6) Full ROM No quadriceps / hamstring inhibition Progress neuromuscular retraining  Improve proprioception

Knee Extension And Gluteal Activation

Early Hamstring activation, very important? Work Mid Range Initially then Extend range to Inner and Outer ranges.

Aims of Rehabilitation middle stage Address Biomechanics Muscle flexibility Neurodynamics Muscle Strength Proprioception CV fitness

PHASE 3: Strengthening & Control Phase (Approximate timeframe: weeks 7 through 12) GOALS: Maintain full ROM Running without pain or swelling Hopping without pain, swelling or giving-way Increased inner range hamstring control and power PHASE 4: Training Phase (Approximate timeframe: weeks 13 to 17) Running patterns (Figure-8, pivot drills, etc.) at 75% speed without difficulty Jumping without difficulty Hop tests at 75% contralateral values Cybex H:Q ratio / Peak torque / Endurance (work completed within 25% of normal contra lateral side) Start Sports specific pattern work.

Middle Phase ACL Rehabilitation Video

Late Phase ACL Rehabilitation

Aims of Rehabilitation late stage Muscle strength / Endurance Speed and power Impact tolerance / Tissue hardening Direction change / Pivoting/ Agility Coordination Sports Specific work Future Joint protection and prevention of re injury

PHASE 5: Adaptive Phase (Approximate timeframe: weeks 18 to 26) Goals 85% contralateral strength 10RM Cybex Q:H ratio, Peak torque / endurance within 10% of uninjured leg 85% contralateral on hop tests Start controlled Randori without pain, swelling, or difficulty   PHASE 6: Advanced / Final Phase (Approximate timeframe: weeks 26 to 38) Goals Technical ++++ Sports Specific Complex Rotation Multi Segmental Tasks Unconstrained Ballistic / Plyometeric Tasks PHASE 5: Adaptive Phase (Approximate timeframe: weeks 18 to 26) Goals

Training 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?

Sports Specificity Know Your Sport!

“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

RETURN TO SPORT CRITERIA Final assessment from knee specialist   No functional complaints High level of Judo specific techniques and movements under rotational loading Normal isoskinetic knee assessment Confidence when jumping at full speed 90% contralateral values on hop tests Hop tests (single-leg hop, triple hop, cross-over hop, 6 meter timed-hop) 90% contralateral values Vertical jump 90% contralateral values Deceleration shuttle test

? Injury Prevention Lower Limb Control

Proprioception / Movement Pattern Acquisition Mechanoreceptors in ligaments / joint capsules Afferent nerves Tendon organs Muscle spindle Combined , these afferents help to give brain a position sense motor neuron pool for quadriceps and hamstrings Stimulation 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)

Proprioception / Movement Pattern Acquisition ? After Injury altered joint position sense ? Before ACL Injury, Previous Pelvic / LBP Change to motor control Altered latency onset of muscle contraction, Inadequate sequencing / Patterning

ACL Injury Pack   ACL Prevention Program: (PEP Program: Prevent injury and Enhance Performance) ACL Rehabilitation linked to tissue healing and Physiology ACL Rehabilitation Clinical Guidelines (9 months protocol)

What We Know The ACL is loaded by a variety of combined sagittal and non sagittal mechanisms during dynamic sport postures considered to be high risk.1–,6 In vivo strain of the ACL is related to maximal load and timing of ground reaction forces.7,8 Females typically display a more erect (upright) posture when contacting the ground during the early stages of deceleration tasks.9–,12 Maturation influences biomechanical and neuromuscular factors.13–,20 Fatigue alters lower limb biomechanical and neuromuscular factors suggested to increase ACL injury risk.2,21–,23 The effect of fatigue is most pronounced when combined with unanticipated landings, causing substantial central processing and central control compromise.24 Trunk and upper body mechanics influence lower extremity biomechanical and neuromuscular factors.12,25,26 Hip position and stiffness influence lower extremity biomechanical factors.2,10,27

We Don't Know We 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 screen We 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?

1. Markolf K. L, Burchfield D. M, Shapiro M. M, Shepard M 1. Markolf K.L, Burchfield D.M, Shapiro M.M, Shepard M.F, Finerman G.A, Slauterbeck J.L. Combined knee loading states that generate high anterior cruciate ligament forces. J Orthop Res. 1995;13((6)):930–935. [PubMed] 2. McLean S.G, Huang X, Su A, Van Den Bogert A.J. Sagittal plane biomechanics cannot injure the ACL during sidestep cutting. Clin Biomech (Bristol, Avon) 2004;19((8)):828–838. 3. Shimokochi Y, Shultz S.J. Mechanisms of noncontact anterior cruciate ligament injury. J Athl Train. 2008;43((3)):396–408. [PMC free article] [PubMed] 4. Withrow T.J, Huston L.J, Wojtys E.M, Ashton-Miller J.A. The effect of an impulsive knee valgus moment on in vitro relative ACL strain during a simulated jump landing. Clin Biomech (Bristol, Avon) 2006;21((9)):977–983. 5. Yu B, Garrett W.E. Mechanisms of non-contact ACL injuries. Br J Sports Med. 2007;41((suppl 1)):i47–i51. Aug. [PMC free article] [PubMed] 6. Shin C.S, Chaudhari A.M, Andriacchi T.P. The influence of deceleration forces on ACL strain during single-leg landing: a simulation study. J Biomech. 2007;40((5)):1145–1152. [PubMed] 7. Cerulli G, Benoit D.L, Lamontagne M, Caraffa A, Liti A. In vivo anterior cruciate ligament strain behaviour during a rapid deceleration movement: case report. Knee Surg Sports Traumatol Arthrosc. 2003;11((5)):307–311. [PubMed] 8. Withrow T.J, Huston L.J, Wojtys E.M, Ashton-Miller J.A. The relationship between quadriceps muscle force, knee flexion, and anterior cruciate ligament strain in an in vitro simulated jump landing. Am J Sports Med. 2006;34((2)):269–274. [PubMed] 9. Schmitz R.J, Kulas A.S, Perrin D.H, Riemann B.L, Shultz S.J. Sex differences in lower extremity biomechanics during single leg landings. Clin Biomech (Bristol, Avon) 2007;22((6)):681–688. 10. Pollard C.D, Sigward S.M, Powers C.M. Gender differences in hip joint kinematics and kinetics during side-step cutting maneuver. Clin J Sport Med. 2007;17((1)):38–42. [PubMed] 11. Decker M.J, Torry M.R, Wyland D.J, Sterett W.I, Steadman R.J. Gender differences in lower extremity kinematics, kinetics and energy absorption during landing. Clin Biomech (Bristol, Avon) 2003;18((7)):662–669. 12. Houck J.R, Duncan A, De Haven K.E. Comparison of frontal plane trunk kinematics and hip and knee moments during anticipated and unanticipated walking and side step cutting tasks. Gait Posture. 2006;24((3)):314–322. [PubMed] 13. Barber-Westin S.D, Galloway M, Noyes F.R, Corbett G, Walsh C. Assessment of lower limb neuromuscular control in prepubescent athletes. Am J Sports Med. 2005;33((12)):1853–1860. [PubMed] 14. Barber-Westin S.D, Noyes F.R, Galloway M. Jump-land characteristics and muscle strength development in young athletes: a gender comparison of 1140 athletes 9 to 17 years of age. Am J Sports Med. 2006;34((3)):375–384. [PubMed] 15. Hewett T.E, Myer G.D, Ford K.R. Decrease in neuromuscular control about the knee with maturation in female athletes. J Bone Joint Surg Am. 2004;86((8)):1601–1608. [PubMed] 16. Noyes F.R, Barber-Westin S.D, Fleckenstein C, Walsh C, West J. The drop-jump screening test: difference in lower limb control by gender and effect of neuromuscular training in female athletes. Am J Sports Med. 2005;33((2)):197–207. [PubMed] 17. Quatman C.E, Ford K.R, Myer G.D, Hewett T.E. Maturation leads to gender differences in landing force and vertical jump performance: a longitudinal study. Am J Sports Med. 2006;34((5)):806–813. [PubMed]

Questions