ACL Rehab (and other knee injuries)

Mechanism of AMI

joint receptor detect swelling/injury causing spinal inhibitory response, inhibits motor neuron drive to the quads

Treatment strategies for AMI

NMES, cryotherapy, jt mob, progressive strengthening exercises

clinical consequences of AMI

reduced voluntary contraction, muscle atrophy, prolonged weakness, delayed rehab

Central activation ratio

looking @ MVIC /c superimposed stim

can you strengthen through AMI

No

ways to address AMI

focal joint cooling (before exercise), NMES

Noyes rule of thirds

1/3 of pts with ACL tear will compensate well with conservative treatment, 1/3 will avoid s/s of instability through modification or substitution of activities (bracing), 1/3 do poorly and require reconstructive surgery

copers have

asymptomatic return to pre-injury activities for at least one year

non-copers have

symptomatic knee instability after ACL injury

criteria to be a coper

• timed hop test score 80% of uninjured limb

• Knee outcome survey activities of daily living scale score of 80% or more

• global rating of knee function 60% or more

• No more than one episode of giving way in the time from injury to testing

functional testing to find out if ACL coper/noncoper

MVIC @ 60° FLX >70-80%, Stroke test has no effusion, single leg hop testing, quad index (QI), hop limb symmetry index (LSI)

Who can we hop test

UL ACL tear, noncomitant meniscal or articular cartilage damage, full knee ROM, no swelling in joint, can tolerate hopping on affected limb, iso quad strength ≥70% of uninvolved

Best predictor of returning to sport if ACL deficient

6m timed hop test

non-operative treatment of ACL

perturbation training, strengthening, neuromuscular education

perturbation seeks to break up

rigid co contractions

Types of ACLR

patellar tendon graft (BPTB), semitendinosis graft, quad tendon graft, cadaveric graft (can be BPTB (achilles or quad), HS, ant tib, post tin, TFL)

BPTB autograft

• harvests middle 1/3 of patellar tendon

• heals fast due to properties of bone

• slightly higher risk of extensor issues (patellar tendinitis, PFPS, patellar fracture)

• No loss of quad strength at donor site

• knee laxity normal or close to normal

• tendon ligamentization through 18 months but generally strong at 8-12 weeks

Hamstring autograft

• semitendinosus and gracilis harvested to created 4 strand graft

• anchored proximally with endobutton

• fixation of tendon to bone is not as strong as BPTB

• Lower risk of athrofibrosus and EXT deficits

• Knee FLX weakness for 6-12months-forever

• NO HS strengthening for 8-12 weeks

• Begin multi-planar at 10-12 weeks

post ACLR with HS autograft HS strengthening can begin at

8-12 weeks

multiplanar motion after HS autograft can begin at

10-12 weeks

quad tendon graft is harvested through

4-6mm midline incision over the middle of the patella

quad tendon graft has greater… than BPTB

load to failure

Elite athletes should not have

ACLR autografts

common sites for allograft harvesting

tib post, semitendinosus, patellar tendon, achilles

After allograft you should wait… for multiplanar activities, twisting, and running

at least week 16

allograft is used most in people

mildly to moderately active, >40, with symptomatic instabiltiy, revision of prior ACLR, autograft tissue is inadequate or previously harvested

In multi-ligament reconstructions, the ACLR will be

allograft

because an allograft has no donor site morbidity or pain, there may be

premature return to activity

downside to ACLR allograft

risk of infectious disease, very expensive

ACLR in skeletally immature

transphyseal ACLR

BEAR

Bridge-enhanced ACL Restoration

ACL BEAR

enables ACL self-healing using a collagen scaffold

BEAR may have

better proprioception, lower post-op muscle atrophy and knee pain

Focuses of ACL rehab

Quad strengthening (PRE and NMES), perturbation training, visual-motor training, neuroplasticity after ACLR

perturbation training increases likelihood of

returning to play without episodes of giving way

neuroplasticity after ACLR reweights brain to

corticospinal tract

MVIC QI<80%

clinic program and NMES

MVIC QI 81-90%

clinic quad program

MVIC QI ≥90%

Independent gym program

modifiable aspects of perturbation training

speed, direction, magnitude

goals of perturbation training

breaking up rigid co-contraction, promotion of rapid selective muscular responses

Before injury pts have more… drive, after injury they have more… drive

cerebellar, cortical (relying more on visual memories)

soreness during warm-up that continues

2 days off, drop down 1 level

soreness during warm-up that goes away

stay at level that led to soreness

soreness during warm-up that goes away but redevelops during session

2 days off, drop down 1 level

soreness the day after lifting (not muscle soreness)

1 day off, do not advance program to next level

no soreness

advance 1 level per week or as instructed by healthcare professional

Stroke test 0

no wave of fluid produced with downstroke

stroke test trace

small wave of fluid on medial side with downstroke

stroke test 1+

larger wave of fluid on medial side with downstroke (Fills the sulcus)

stroke test 2+

effusion spontaneously returns to medial side after upstroke

stroke test 3+

so much fluid that it cannot be moved out of the medial aspect of the knee

Effusion rules

• pts should not be progressed when effusion >1+

• When pts holding anything above 2+, contact MD for anti-inflammatory meds or aspiration

• Any drastic change of 2 grades or reappearance of effusion when it was absent, decrease activity and reintroduce when possible

• Trace or zero required for hop testing

KT 1000 is used for

quantifying laxity/translation

arthrofibrosis

inferior pole and fat pad become scarred down and less mobile

Risk of arthrofibrosis

pre-op FLX/EXT contracture, acute reconstruction, multiple ligament injuries, keloid scarer, poorly positioned tibial tunnel (too anterior)

arthrofibrosis prevention

ROM, patella mob, aware of S/S, keep pt moving

Cyclops lesion

scarring of ACL graft in intercondylar notch

partial medial menisectomy restrictions

none additional from ACL

Stable meniscal repar restrictions

none

unstable meniscal repair restrictions

no CKC FLX >45° for 4 weeks, no HS strengthening for 8 weeks

micro fracture restrictions

gait NWB weeks 2-4, non CKC until weeks 4-6

PLC restrictions

no HS strengthening for 12 weeks, avoid hyperEXT, avoid varus and twisting motions until 8 weeks

ACL revisions restrictions

usually crutches and immobilizer for 2 weeks, delay running, hop testing, and agility by 4-8 weeks compared to first time ACLR

MCL grade I restriction

none

MCL grade II restrictions

wk 1 0-90°, wk 2 - 110°, wk 3 - no restrictions

Grade III MCL restrictions

wk 1 0-30°, wk 2 - 90°, wk 3 -110°

Isolated grade I & II PCL rehab weeks 0-3

WB 50% for 2 weeks, ROM 0-60°, ROM and CKC leg press and step ups to strengthen within protected ROM

Isolated grade I & II PCL rehab weeks 3-4

ROM and progress strengthening as tolerated

Isolated grade I & II PCL rehab weeks 5-7

utilization of soreness rules and effusion to guide progression, may be able to initiate pool running

Isolated grade I & II PCL rehab weeks 8-12

begin running program, hop test when QI criteria of 85% (90%) is met, can return to sport if hop testing LSI is ≥85%

Best position for ROM without stress on PCL

Prone, b/c gravity pulls the tibia forward, working with the PCL

Chronic grade II or acute grade III PCL rehab

brace in full EXT for 1 week, WB 50% for 1st 4 post-op weeks, no HS strengthening for 12 weeks, CKC strengthening 0-60° weeks 0-8, and 0-90° weeks 8-12

Rehab of isolated PLC injury

No HS for 12 weeks, avoid hyperEXT, varus, and twisting

Grade I MCL return to sport timeline

10 days

MCL grade II-III return to sport timeline

3-6 weeks depending on pt and which sport they are returning to

isolated MCL treatment

early ROM and protected strengthening, hinger brace to limit med/lat translation, follow joint soreness and effusion rules for progression, monitor and limit twisting and lateral movements, big focus on CKC strengthening