Knee Cruciates EXAM 2

- Giving way

- buckling

What are the Functional implications after an ACL tear

Posterolateral femur to the anteromedial tibia

What is the origin and insertion of the ACL

geniculate artery

What artery supplies the ACL

Tibial Nerve

What nerve innervates the ACL

- To resist anterior translation of the tibia

- Resists rotation of the tibiofemoral joint

- Limits hyperextension

What are the functions of the ACL

plant and twist

What is the most common mechanism of injury for ACL tears

- Females

- Lower risk in cold weather

- Artificial floors/uneven playing surfaces

- No effectiveness found in research for use of braces to prevent ACL injury

What are ACL Tear Risk Factors

- Femoral anteversion

- Increase Q angle

- Excessive tibial torsion

- Smaller intercondylar notch and diameter of ACL

What are risk factors that make females more susceptible to ACL tears

- 70% of all ACL tears

- Rapid deceleration

- Cutting/jumping/plant-pivot

What are key points about ACL tears due to non-contact injury

- Direct blow to the knee

- Hyperextension

What are key points about ACL tears due to contact injury

MRI

gold standard imaging for ACL tear

meniscal

Presence of bone bruise is often associated with concurrent ______ tears

- ACL Tear

- MCL Tear

- Medial Meniscus Tear

What is the unhappy triad for knee ligamentous injuries

Surgery is typically indicated

What does treatment for the unhappy triad of ligamentous knee injuries typically entail

Lachman (then anterior drawer, then pivot shift under anesthetic)

Most accurate/gold standard ACL physical exam

Pivot shift special test for ACL physical exam

- tested under anesthesia

- Many false negatives because of muscle guarding

- Able to assess both anteromedial and posterolateral bundle

- Hemarthrosis

- Decreases ability to walk

- Crutches are commonly used early on

- Hinged brace at times

- May require stabilization to get off the field

- Variable complaints of pain

- Feelings of "giving way"

What is the patient presentation Immediately After ACL Injury

Hemarthrosis

significant edema; bloody when drained

Functional Instability

What is the strongest predictor of whether to operate or not for an ACL tear

- no surgery, rehab candidate

- able to return to prior level with nonoperative management

What does it mean to be a "Coper"

due to demands/needs of youths (can't listen to limitations or sit still)

Why are youth patients generally encouraged to have surgery for ACL injuries

willing to reduce activity level to prevent instability with nonoperative management

What does it mean to be an "adapter"

- Often avoid sports with jumping, cutting, pivoting

- Able to return to straight plane activities

what are key considerations for patients who may take the route of an "adapter" for ACL injuries

- higher rates of arthritic changes

- greater likelihood of Subsequent meniscal surgeries

- increased risk of Secondary meniscal tears

What did a 20 year follow up of those managed non-operatively find for ACL tear patients

- Hamstring

- Patella Tendon (Bone-patella tendon-bone graft)

- Some studies look at quad tendon

What are the options for autograft for ACL reconstruction

Achilles

What is the most common type of allograft used for ACL reconstruction

- Surgeon expertise?

- Patient Preference?

- Age of patient?

- Lifestyle of patient?

- Size of quad/hamstrings for allograft

- Goals: strong attachment, proper tension, minimize loss of knee extension ROM

What are the factors that help decide Graft Selection

Quadrupled fold of semitendinosus and/or gracilis (Ipsilateral tendon typically used)

Where on the hamstring does the autograft typically come from for ACL reconstruction

allografts

What type of graft used in ACL reconstruction has the greatest potential to retear

- higher strength

- lower retear rate

- earlier graft remodeling and healing

- better knee stability

What are the advantages of a patellar tendon graft for ACL reconstruction

- smaller incision/better cosmesis

- minor functional impairment from graft harvesting

- earlier regeneration of hamstring

What are the advantages of a hamstring graft for ACL reconstruction

- higher incidence of anterior knee pain and kneeling pain

- increased incidence of OA

- higher rate knee extension deficit due to adhesion

What are the disadvantages of a patellar tendon graft for ACL reconstruction

• Full, pain-free ROM

• No joint effusion

• Able to hop on the injured leg without pain

• Quadriceps strength ≥70% maximum voluntary isometric contraction (MVIC) compared to the uninvolved side

What are the screening criteria developed by Eastlack (1999) to identify potential "Copers" after an isolated ACL tear?

Because joint effusion contributes to quadriceps inhibition and atrophy

Why is the absence of joint effusion important when screening potential ACL "Copers"?

≥70% MVIC of the involved quadriceps compared to the uninvolved side

What quadriceps strength is required for a patient to qualify as a potential ACL "Coper"?

Avoid isolated hamstring strengthening early in rehabilitation

What early rehabilitation precaution should be taken after an ACL reconstruction using a hamstring autograft

Risk of hamstring tendinitis

What tendon-related complication is associated with hamstring autografts

8-12 weeks

How long does it take for a hamstring autograft to become securely fixed

Bone–Patellar Tendon–Bone (BPTB) autograft using the middle 1/3 of the patellar tendon

What is considered the gold standard autograft for ACL reconstruction

anterior knee pain

What common rehabilitation issue should be monitored after a Bone–Patellar Tendon–Bone autograft

Regain full knee extension early

What ROM goal is especially important after a Bone–Patellar Tendon–Bone autograft?

Higher odds of graft retear, especially in adolescents

What is the major disadvantage of ACL allografts

Re-tear rates decrease as patient age increases and become similar to autografts around age 40

How does age affect ACL allograft re-tear rates

• tunnel widening

• flexors

disadvantages of a hamstring autograft for ACL reconstruction

• Higher incidence of ______

• Electromechanical delay and weakness of the knee _____

- cost

- slower graft incorporation

- risk of disease transmission

- inferior objective results and higher failure rate compared to autografts

What are the disadvantages of using allografts for ACL reconstruction

True

TRUE or FALSE: In a study comparing an early ACL surgery group to a group who underwent 3 months of rehab before surgery and found that 50% of delayed group did not need to undergo surgery

Bridge Enhanced ACL Repair (BEAR) Procedure

- Minimally invasive

- Implant to help heal your own ACL

- Stitch town ends of ACL

- Inject patient's blood into implant

- Place the implant to bridge the gap between the torn ends

- Partial Weight Bearing (up to 50% of body weight) x 4 to 6 weeks, brace locked in extension for weight bearing for 4 weeks.

- With clearance from PT and surgeon, patient may advance to WBAT with crutch wean at 4 to 6 weeks

What is the BEAR procedure post op protocol for weight bearing

WBAT with crutch

With clearance from PT and surgeon using the BEAR procedure, patient may advance to _______ at 4 to 6 weeks

extension

with the BEAR procedure, the brace is locked in _____ for weight bearing for 4 weeks

- able to walk with normal gait pattern

- no pain

- no extensor lag

- good quad control

In the BEAR procedure post op protocol for weight bearing, with clearance from PT and surgeon, patient may advance to WBAT with crutch wean at 4 to 6 weeks when what criteria are met?

- normal gait pattern

- ability to safely ascend/descend stairs without noteworthy pain or instability (reciprocal stair climbing)

In the BEAR procedure post op protocol for weight bearing, with clearance from PT and surgeon, patient may discontinue crutch use when what criteria are met?

0 degrees

What is the brace set to for ambulation for the first 4 weeks post op after the BEAR procedure?

0 degrees

What is the brace set to for sleep for the first 6 weeks post op after the BEAR procedure?

May unlock for range of motion (ROM) when seated or at PT

After the BEAR procedure, when can patients unlock the ROM for the knee brace during the day

if the patient is comfortable doing so, and if they demonstrate appropriate quadricep control

Under what conditions can the patient advance to unlock the brace for PWB ambulation at week 4 after the BEAR procedure

- Edema reduction

- Restore normal weight bearing

- Restore ROM: focus of knee extension first

- Improve quad strength (Goal is a deficit <20% compared to uninvolved side)

What does Non-operative Management of Individuals with an ACL Tear entail

- Pre-op

- Post-op

- Return to sport

What are the 3 main areas of PT for ACLR

- Age

- Prior level of function

- Immediate post-injury until surgery

History: Key items for ACL injury

- Sport?

- Functional Demands?

- Focus on full ROM prior to surgery

What do we want to know about prior level of function for ACL injuries

- MOI

- Initial management (ED, Assistive device, Brace, etc.)

- Timeframe regarding imaging, ortho consult, surgery

- Other injuries: meniscus? MCL?

what history items do we want to know about the timeframe of Immediate post-injury until surgery

- Goals: improve knee ROM, strength, edema, and ensure safety with AD

- Emphasis on compliance with HEP prior to surgery

- Education regarding what exercises to do immediately after surgery?

What are key points about Pre-op PT for ACLR

- does the patient have full AROM/PROM of the involved joint?

- is the quad strength within 20% of the uninvolved side?

- does the patient have a good understanding of initial post-op exercises?

What are Key Pre-Op Considerations for ACLR

- Assistive device?

- Exercises prescribed by surgeon or nurse?

- Type of graft used?

- Other structures involved? (meniscus repair vs. resection)

- Brace guidelines?

- Post-op protocol?

- ADL's?

- Edema management?

- Sleep?

What are key points to consider about the Post-operative Phase of ACLR

- View incisions to assess for infection (may require removal of bandages and brace)

- Is the AD appropriately sized and used properly?

- Joint clearing above and below

- Education about precautions

- Girth measurements

- AROM/PROM

- Pain rating (with and without meds)

- MMT likely deferred of the knee

- No special tests needed

What are the Acute Post-op Knee Exam considerations for ACLR

- Observation

- Palpation

- Gait

- Functional asterisk

- ROM

- Strength: maybe hand-held dynamometer or 10RM?

- Special tests?

- Joint mobility

What is included in the Post-op Knee Exam After Acute Phase for ACLR

4 weeks by the latest

by point in time following ACLR do we want to achieve full extension

by week 6

by point in time following ACLR do we want to achieve full ROM

Open kinetic chain quad strengthening from 90-45 degrees can be initiated at week 4 to avoid overloading the graft site

What are graft considerations for B-PT-P Bone-Patellar Tendon-Bone graft

Open kinetic chain exercises 90-45 degrees without resistance until week 4

What are graft considerations for hamstring graft

- Focus on remaining impairments

- Progressive return to activity in conjunction with protocol

What is the focus of phase 2 rehabilitation post ACLR

biking/jogging at week 10-12

What are the parts of phase 2 aerobic rehabilitation post ACLR

when indicated on protocol: supervised agility training with focus on quality! (after 16 weeks)

what are key points about sport specific training during phase 2 post ACLR rehabilitation

6 weeks post op

When can scar massage begin after a BEAR procedure?

Passive knee flexion

What type of knee motion is restricted after a BEAR procedure

No driving until off narcotics

For right leg surgery, wait at least 2 weeks and achieve 60° of knee flexion.

What are the driving restrictions after a BEAR procedure

e-stim only

What modality is recommended for muscle stimulation after a BEAR procedure

non-operative treatment

How were copers managed in the ACL return-to-sport study?

non-operative group

Which group showed better hop testing, KOS-ADL scores, and quadriceps strength at 1 year?

• Patellofemoral joint mobilizations
• Active and passive exercises for knee extension
• Improve active knee flexion

What mobility interventions are included in Phase 1 ACLR rehabilitation?

Restore knee extension

improve active knee flexion

maintain patellofemoral mobility

What are the goals of mobility management during Phase 1 ACLR rehab?

Isometrics → Active Straight Leg Raise (SLR) → Eccentric strengthening

What is the progression of quadriceps strengthening during Phase 1 ACLR rehab

• Quadriceps re-activation
• Quad sets
• Manual facilitation if voluntary contraction is absent
• Closed kinetic chain exercises (leg press, mini squats, step-ups)

What strengthening interventions are included in Phase 1 ACLR rehabilitation

leg press

mini squats

step-ups

What closed kinetic chain exercises are introduced during Phase 1 ACLR rehab?

gluteals

hamstrings

calves

Which muscle groups besides the quadriceps should be strengthened during Phase 1 ACLR rehab

Walking without an assistive device

What gait milestone is required before Phase 2 ACLR rehab

• Incisions healed
• No pain with Phase 1 exercises
• Voluntary quadriceps contraction
• Minimal edema/effusion
• Patient ready to progress

What milestones must be met before progressing to Phase 2 ACLR rehabilitation

8 weeks post op

When are single-leg strengthening activities introduced during Phase 2 ACLR rehab?

8 weeks post-op

When is open-chain strengthening with full ROM introduced after ACLR

Safely increasing load while protecting the graft

What is the focus of Phase 2 strengthening after ACLR?

• Two legs → One leg
• Stable → Altered surfaces
• Static → Dynamic activities

What are the neuromuscular re-education progressions during Phase 2 ACLR rehabilitation?

normal ROM

What ROM is expected before entering Phase 2 ACLR rehab

1 RM or 10 RM within 90% of uninvolved limb

What do we check during a limb symmetry index for quad strength post ACLR

1 RM or 10 RM within 90% of uninvolved limb

What do we check during a limb symmetry index for hamstring strength post ACLR

- Return to sport or physically demanding job

- Maintain ROM, Strength

- Progress with sport-specific strengthening exercises, plyometrics, more advances proprioception

What are the goals of phase 3 post ACLR rehabilitation

- No pain

- No giving way/Fear of giving way

- limb symmetry index is > 90% for quad/hamstring strength

- Drop jump test

What are the Return to Play Criteria post ACLR

PCL

- dense band of connective tissue

- twice a thick as the ACL

- has two bundles

starts at anterolateral femur and runs diagonally to the posteromedial tibia

What is the origin and insertion of the PCL

middle geniculate artery

What artery supplies the PCL

articular branches of the tibial nerve

What nerve innervates the PCL