ACL Exercise Progression and RTS

options for ACL rehab

non-operative, temporary RTS (delayed ACLR), operative

progression timeline of non-op ACL rehab

pt has more than 1 giving way episode or does not want surgery → progressive neuromuscular training → function testing → progressive agilities and sport specific activity

progression timeline of temporary RTS

stable knee and needs to RTS quickly → screen for impairments → 10 perturbation sessions combined with agility/strength → functional testing → RTS progression

progression timeline of operative ACL rehab

pre-rehab → surgery → post-op PT

example of pseudo-buckling of knee

lack of control at terminal knee extension feels like the knee giving way

components of a giving way episode

tibiofemoral shift, pain and swelling, LOB/fall

impairments to fix in all ACL managements

full ROM of knee, quad strength, effusion

meniscus considerations of ACL rehab

surgery is preferred because it can reduce risk of unstableness and further damage

barriers to full ROM

meniscal and quad issues

requirements to begin perturbation training

QI of at least 80%, no more than 1 giving way episode

function of screenings like burst test and isokinetic quad strength

puts pts in buckets for management plan and guides how to address impairments

QI needed to start quad NMES

less than 70%

treatments to help active knee extension

stretching, patellar mobs, quad strengthening, gait training

potential reason for risk of another ACL even with surgery

uninvolved side weakens too

treatments to increase quad strength

progressive exercise, NMES

treatments to restore normal gait

neuromuscular training, perturbation

best evidence for success in RTS

strength and perturbation training

when is effusion used in ACL management

during temporary RTS and non-op rehab to track tolerance to activtiy

difference between effusion, swelling, and edema

effusion is in the capsule (ACL), swelling is outside of the capsule, edema is interstitially (TKA)

treatment to decrease effusion

RICE, active motion, using quad during gait

requirements to continue with temporary RTS protocol

QI greater than 70%, less than trace effusion, full ROM, pain free hopping, no repairable meniscus

why do we not need to perform hop testing for non-op management

there is a slower progression of RTS

criteria to be considered a potential coper

no more than 1 giving way episode, above 80% timed hop, above 80% KOS ADL, above 60% GRS

tests in the single leg hop series

single leg hop, crossover hop, triple hop, timed 6M hop

interpretation of hop test

average of the two trials, then calculate LSI

ACL rehab track for potential copers

temporary RTS

ACL rehab track for non-copers

non-op or operative

examples of perturbation training

roller board, rocker board, bosu ball, mini tramp, foam, balance beam

neuromuscular control

coordination of muscle firing (not just co-contracting)

feedback progression during perturbation training

begin with feed forward to allow pts to anticipate and set neuromuscular system → after/during give extrinsic feedback to improve form and performance

stages of learning

cognitive → associative → autonomous

cognitive stage of learning

initial understanding of task, development of strategies

associative stage of learning

skill refinement, improvement

autonomous stage of learning

skill is automatic

how to progress perturbation training

planes of motion, complexity of skill, intensity, volume of work, different environment, sport specific,

why is quad strength so important

knee joint protection

knee flexion angle for NMES post quad tendon graft ACLR

45 degrees

time it takes to return to running during non-op ACL rehab

7-9 weeks

requirements to begin return to running

quad strength above 80%, effusion less than trace, normal gait

time it takes to return to running post-op ACLR

12-16 weeks

how to progress agilities

intensity, multiplanar, sport specific

when is agilities done post-op ACLR

7-9 months

difference in passing criteria for non-op and operative strategies

higher for operative

characteristics of bad rehab

insufficient stimulus/load, lack sport specificity, fails to account for individual barriers, lacks appropriate progressions

characteristics of good rehab

organized, adaptable, progressive, sufficiently dosed, individualized

how to improve muscle strength

progressive overload

how to improve muscular endurance

constant workload in an aerobic state

how to improve speed

requires you to move fast

how to improve agility

requires you to react

myth about OKC exercise strain on ACL

no more strain than walking and is good because it targets only the quads

peak strain angle on the ACL

15-30 degrees of knee flexion

ACSM guidelines for strength and hypertrophy

65-85% of 1RM, 6-8/10 RPE

acceptable response for effusion after treatment

no more than 1 grade increase, reduce within 24 hours

what is considered a significant decrease in ROM

5-10 degrees

visual-cognitive control chaos continuum

high control → moderate control → control to chaos → moderate chaos → high chaos

progression of chaos continuum

task stability/movement quality → simultaneous working memory → decision making → processing and response inhibition → cross-modal sensory integration

factor that was most strongly associated with returning to sport

psychological readiness