acl reconstruction healing and return to play randy clark acknowledgements: glenn williams, mike...
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ACL reconstruction ACL reconstruction healing and Return to healing and Return to
PlayPlay
Randy ClarkRandy ClarkAcknowledgements: Glenn Williams, Mike Shaffer, Acknowledgements: Glenn Williams, Mike Shaffer,
Danny Foster, Brian WolfDanny Foster, Brian Wolf
IntroductionIntroduction
100,000 new ACL injuries each year (1/3000 people)100,000 new ACL injuries each year (1/3000 people)
Young women 3 times more likely to suffer an ACL Young women 3 times more likely to suffer an ACL injury compared to a male cohort groupinjury compared to a male cohort group
Young female participating in sports year round has a Young female participating in sports year round has a 5% 5% risk for tearing her ACLrisk for tearing her ACL
No more than 15- 30% of ACL deficient individuals No more than 15- 30% of ACL deficient individuals typically return to running, jumping, and pivoting typically return to running, jumping, and pivoting activities without experiencing subsequent episodes activities without experiencing subsequent episodes of of knee instabilityknee instability
ACL Defficiency and Return to ACL Defficiency and Return to PlayPlay
832 ACL injuries
10% declined, 40% other knee injuries
432 Remaining patients
87 unable to regain ROM, strength, pain control
345 patientsScreening exam eliminates 199 as Non-copers
146 patients60% chose to undergo surgery
88 patients attempt return to sport
ACL Defficiency and Return to ACL Defficiency and Return to PlayPlay
88 Patients return to sport
63 patients
72% successful
29 patients remain
36 went onto reconstruction
Hurd et al., A 10 year progressive trial of a patient management algorithm and Screening examination for highly active indicituals with ACL injury, Part 1 Outcomes., Am J Sports Med. 36:40-47
•24% return to sport without subsequent instability
Fitzgerald et al., Knee Surg Sports Traumatol Arthrosc., 2000
How long until I can play?How long until I can play?
The healing process-The healing process- It’s a dead piece of tissue!It’s a dead piece of tissue! Graft needs to be re-vascularizedGraft needs to be re-vascularized
• ““Ligamentization” occursLigamentization” occurs Vascular Synovial layer wraps around graft in 4-Vascular Synovial layer wraps around graft in 4-
6 weeks6 weeks
Healing TimeHealing Time
Autologous ACL grafts don’t Autologous ACL grafts don’t
Transition through necrotic stageTransition through necrotic stage Weakest link fixation 4-6 weeksWeakest link fixation 4-6 weeks Complete re-vascularizationComplete re-vascularization
of the graft takes ~20 weeksof the graft takes ~20 weeks Remodeling occurs:Remodeling occurs:
By one year histological and By one year histological and
biochemical properties of biochemical properties of
ACLR ~ native ACLACLR ~ native ACL
Graft RemodelingGraft Remodeling
Gradual loss of graft Gradual loss of graft strength during initial strength during initial remodelingremodeling
Then strength of ACL Then strength of ACL graft improves graft improves graduallygradually
Allografts Allografts Slightly slower Slightly slower
process process
Graft RemodelingGraft Remodeling
Patellar tendonPatellar tendon Bone to bone within Bone to bone within
the ACL tunnelsthe ACL tunnels 4-8 weeks usually4-8 weeks usually
Graft RemodelingGraft Remodeling
• • Hamstring graftHamstring graft
-Bone to tendon healing-Bone to tendon healing
-Sharpey’s fibers-Sharpey’s fibers
-Usually complete at 12 weeks-Usually complete at 12 weeks ACL autograft resemblesACL autograft resembles
normal ACL at 12 monthsnormal ACL at 12 months Concern for increased allogenicConcern for increased allogenic
graft incorporation time doesn’t graft incorporation time doesn’t
warrant modification of PTwarrant modification of PT
protocolprotocol
Pre-Operative RehabilitationPre-Operative Rehabilitation
Initial Initial focus on eliminating swelling and focus on eliminating swelling and restoring pre-injury range of motion and restoring pre-injury range of motion and strengthstrength
RehabilitationRehabilitation
Slight variations depending on age, Slight variations depending on age, history, activity level, graft source and history, activity level, graft source and associated injuries.associated injuries.
RehabilitationRehabilitation Bracing:Bracing:
““There is little evidence to support the use of a post-There is little evidence to support the use of a post-operative brace following isolated reconstruction of the operative brace following isolated reconstruction of the ACL.”ACL.”
““Although the exact mechanism for any beneficial effect Although the exact mechanism for any beneficial effect of functional bracing remains unknown, ACL deficient of functional bracing remains unknown, ACL deficient athletes commonly report improved confidence with use athletes commonly report improved confidence with use of a functional knee brace.”of a functional knee brace.”
““The use of functional bracing should perhaps be The use of functional bracing should perhaps be reserved for return to sport following revision surgery or reserved for return to sport following revision surgery or in athletes who have suffered a multiple ligament injury.”in athletes who have suffered a multiple ligament injury.”
CORR 07’ systematic review 12 RCT’s- no support for CORR 07’ systematic review 12 RCT’s- no support for bracingbracing
RehabilitationRehabilitation
Five phasesFive phases Phase I- Immediate post-op (0-2 weeks)Phase I- Immediate post-op (0-2 weeks) Phase II- Early Rehabilitation Activities (2-6 Phase II- Early Rehabilitation Activities (2-6
weeks)weeks) Phase III- Advanced Rehabilitation Activities Phase III- Advanced Rehabilitation Activities
(6-10 weeks)(6-10 weeks) Phase IV- Advanced Functional Activities (10 Phase IV- Advanced Functional Activities (10
weeks- 6 months)weeks- 6 months) Phase V- Return to Sport (6-12 months)Phase V- Return to Sport (6-12 months)
RehabilitationRehabilitation
Phase I- Immediately Post- Surgery Phase I- Immediately Post- Surgery (POST-OPERATIVE WEEKS 0-2)(POST-OPERATIVE WEEKS 0-2) The goals of the early rehabilitation period are The goals of the early rehabilitation period are
to control pain and post-operative swelling, to control pain and post-operative swelling, and begin to restore range of motion. and begin to restore range of motion. • Control inflammation: cryotherapy, elevation, Control inflammation: cryotherapy, elevation,
compression, limitation of activitiescompression, limitation of activities• Restore ROM: importance of regaining Restore ROM: importance of regaining
hyperextension. (Importance of regaining motion hyperextension. (Importance of regaining motion pre-op)pre-op)
RehabilitationRehabilitation
Phase I continued….Phase I continued…. ROMROM
• Stretches: extension bridges, prone hangsStretches: extension bridges, prone hangs ROM expectations:ROM expectations:
• 0-900-90°° 2 weeks 2 weeks• 0-1200-120° 4 weeks° 4 weeks• Full range 6 weekFull range 6 week
•Muscle strengthening•Isometric quad contractions, straight leg raises, stim
treatments
•Ambulation- crutches, WBAT, avoid “quad avoidance” gait pattern
RehabilitationRehabilitation
Criteria to Progress to Phase IICriteria to Progress to Phase II Knee effusion well controlledKnee effusion well controlled Adequate quadriceps control demonstrated by Adequate quadriceps control demonstrated by
the ability to do a hip flexion straight leg raise the ability to do a hip flexion straight leg raise without extensor lagwithout extensor lag
Normal gait pattern without use of assistive Normal gait pattern without use of assistive devicesdevices
Knee range of motion of at least 0- 90°Knee range of motion of at least 0- 90°
RehabilitationRehabilitation
Phase II – Early Rehabilitation Phase II – Early Rehabilitation Exercises (POST-OPERATIVE WEEKS Exercises (POST-OPERATIVE WEEKS 2-6)2-6) The focus of Phase II rehabilitation is to The focus of Phase II rehabilitation is to
restore full knee range of motion and advance restore full knee range of motion and advance early strengthening exercisesearly strengthening exercises
Light weights, remember creep (low load Light weights, remember creep (low load prolonged stretches), manual overpressure, prolonged stretches), manual overpressure, stationary bicycle (half moon), lunges, squatsstationary bicycle (half moon), lunges, squats
•Supervised vs. Home rehab program•We feel that a minimum of 6 visits with a rehabilitation professional is necessary for
successful outcome following ACL reconstruction.
RehabilitationRehabilitation
Open vs. closed chain excercisesOpen vs. closed chain excercises• Open chain and infrapatellar painOpen chain and infrapatellar pain• Graft lengtheningGraft lengthening
RehabilitationRehabilitation
Criteria to Advance to Phase IIICriteria to Advance to Phase III Full knee range of motionFull knee range of motion Able to ascend and descend stairs normally Able to ascend and descend stairs normally Successfully completing regular exercise Successfully completing regular exercise
program of Phase II activitiesprogram of Phase II activities
RehabilitationRehabilitation Phase III- Advanced Rehabilitation Phase III- Advanced Rehabilitation
Exercises (POST-OPERATIVE WEEKS 6-10) Exercises (POST-OPERATIVE WEEKS 6-10) Build on the limb strength gained in Phase IIBuild on the limb strength gained in Phase II
• Traditional strengthening exercises combined with Traditional strengthening exercises combined with additional challenges to the nervous system: pertubations, additional challenges to the nervous system: pertubations, mental distraction tasks, activities which progressively mental distraction tasks, activities which progressively force the center of gravity away from the base of support. force the center of gravity away from the base of support.
• Restore neuromuscular control: mechanoreceptor Restore neuromuscular control: mechanoreceptor repopulation is most active between 2 and 8 weeks post-repopulation is most active between 2 and 8 weeks post-operatively operatively
• RCT’s show superiority of neuromuscular retraining when RCT’s show superiority of neuromuscular retraining when compared to standard strength training. (Beard JBJS 94’, compared to standard strength training. (Beard JBJS 94’, Risberg Aust J Phys 07’)Risberg Aust J Phys 07’)
RehabilitationRehabilitation
Criteria to Advance to Phase IVCriteria to Advance to Phase IV Regularly completing isotonic strengthening program Regularly completing isotonic strengthening program
in supervised physical therapyin supervised physical therapy Starting to transition strengthening activities to local Starting to transition strengthening activities to local
gym or athletic team’s weight roomgym or athletic team’s weight room Approximately 70-80% strength vs. contralateral Approximately 70-80% strength vs. contralateral
(uninvolved) lower extremity(uninvolved) lower extremity Demonstrates appropriate control of knee with Demonstrates appropriate control of knee with
neuromuscular retraining exercises in the physical neuromuscular retraining exercises in the physical therapy clinic therapy clinic
RehabilitationRehabilitation
Phase IV- Advanced Functional Phase IV- Advanced Functional Activities (10 weeks- 6 months)Activities (10 weeks- 6 months) The primary goal of the fourth phase of The primary goal of the fourth phase of
rehabilitation is to prepare the athlete for rehabilitation is to prepare the athlete for return to sport. Running, cutting, and jumping return to sport. Running, cutting, and jumping are near universal requirements of the sports are near universal requirements of the sports in which athletes most often tear their ACL’s. in which athletes most often tear their ACL’s. • be cognizant of other tasks which are important be cognizant of other tasks which are important
parts of the sport to which the athlete hopes to parts of the sport to which the athlete hopes to return return
RehabilitationRehabilitation
Phase IV continuedPhase IV continued ladder drills or other simulated running tasks, ladder drills or other simulated running tasks,
then advance to interval jogging.then advance to interval jogging. Once 70-80% of their pre-injury speed, cutting Once 70-80% of their pre-injury speed, cutting
drills begin. drills begin. Land based jumping, jumping up to a box Land based jumping, jumping up to a box
and/or completing all plyometrics activities by and/or completing all plyometrics activities by landing on two legs landing on two legs
RehabilitationRehabilitation
Criteria for Progression for Phase VCriteria for Progression for Phase V Regularly completing isotonic strengthening Regularly completing isotonic strengthening
programprogram Running at least 85% of pre-injury speedRunning at least 85% of pre-injury speed Cutting and jumping without hesitation or Cutting and jumping without hesitation or
obvious limitationobvious limitation
RehabilitationRehabilitation
Phase V- Return to Sport (6-12 months) Phase V- Return to Sport (6-12 months) subjective and objective information considered.subjective and objective information considered.
• Athlete pain free during performanceAthlete pain free during performance• Athlete not demonstrate limp or guarding Athlete not demonstrate limp or guarding • Effusion after rehabilitation or functional testing Effusion after rehabilitation or functional testing
viewed as a stark indication that neuromuscular viewed as a stark indication that neuromuscular system not adequately countering the high system not adequately countering the high stresses experienced within the joint.stresses experienced within the joint.
• Athlete should feel confident about their return to Athlete should feel confident about their return to sport. sport.
RehabilitationRehabilitation
Phase V- Return to Sport (6-12 months) Phase V- Return to Sport (6-12 months) No more than 10% asymmetry in terms of No more than 10% asymmetry in terms of
isokinetic variables between the involved and isokinetic variables between the involved and uninvolved lower extremityuninvolved lower extremity
single leg hop test to measure knee joint single leg hop test to measure knee joint function and strengthfunction and strength
single leg vertical jump, single leg hop for single leg vertical jump, single leg hop for distance, single leg timed hopdistance, single leg timed hop
RehabilitationRehabilitation
Criteria to Return to SportCriteria to Return to Sport No complaints of pain or knee instabilityNo complaints of pain or knee instability Full ROMFull ROM No new effusionNo new effusion Lower extremity strength/ function at least 85% vs. Lower extremity strength/ function at least 85% vs.
uninvolved LEuninvolved LE Adequate performance in physical therapy or with sport Adequate performance in physical therapy or with sport
specific drills which simulate the intensity, frequency, specific drills which simulate the intensity, frequency, and duration of the sport to which the athlete hopes to and duration of the sport to which the athlete hopes to returnreturn
Athlete demonstrates a psychological readiness to Athlete demonstrates a psychological readiness to return to sport, either verbally or with SANE score > return to sport, either verbally or with SANE score > 80/100 80/100
Functional TestingFunctional Testing
Full ROM, negative pivot-shift, symmetric Full ROM, negative pivot-shift, symmetric quad and hamstring strength and quad and hamstring strength and functional testing scoresfunctional testing scores
RehabiliationRehabiliation
Crucial input from..Crucial input from.. PhysicianPhysician Athletic trainerAthletic trainer Physical TherapistPhysical Therapist CoachCoach Athlete +/- parentsAthlete +/- parents
RehabilitationRehabilitation
Rehab time frame Rehab time frame changedchanged Formally >12mosFormally >12mos Now generally ~6mNow generally ~6m
2 RCT’s2 RCT’s Beynnon, EkstrandBeynnon, Ekstrand 8 mos vs ~5mos8 mos vs ~5mos
No significant differences No significant differences in:in: Subjective outcomeSubjective outcome Anterior knee laxityAnterior knee laxity Functional testingFunctional testing
Faster rehab (19 wks) seems Faster rehab (19 wks) seems safesafe
Programs faster than this….?Programs faster than this….?
RehabilitationRehabilitation
Bone scan?Bone scan? Scott Dye talkScott Dye talk
RehabilitationRehabilitation
Functional score meta-analysisFunctional score meta-analysis No difference between BTB and hamstring No difference between BTB and hamstring
grafts with respect to function (Biau CORR grafts with respect to function (Biau CORR 07’)07’)• 14 trials- 7 RCT’s14 trials- 7 RCT’s
What to expect?What to expect?
10-14% of ACL R 10-14% of ACL R patients need another patients need another surgery at some point surgery at some point in the futurein the future
Risk of re-ruptureRisk of re-rupture 3% on ACLR knee3% on ACLR knee 3% on other knee3% on other knee
~20% of patients note ~20% of patients note some subj functional some subj functional impairment with ACLR impairment with ACLR kneeknee
~90% of athletes return to ~90% of athletes return to same level of sport by one same level of sport by one year after ACLRyear after ACLR
Only 54% still at that level Only 54% still at that level by ~3 yrsby ~3 yrs
Lit Review on Return to PlayLit Review on Return to Play
Lit Review on Return to PlayLit Review on Return to Play
Home vs Formal PTHome vs Formal PT
Grant et. Al, AJSM 2005Grant et. Al, AJSM 2005 Hypothesis: no difference in home vs. structure PT Hypothesis: no difference in home vs. structure PT
program at 3 months for BTB reconstruct.program at 3 months for BTB reconstruct. Study design: RCT, 145 pts, 4 vs. 17 PT sessionsStudy design: RCT, 145 pts, 4 vs. 17 PT sessions Measured: ROM, knee motion walking, KT, quad and Measured: ROM, knee motion walking, KT, quad and
hamstring strengthhamstring strength Results: 67% vs 47% flexion, 97% vs 83% ext, others Results: 67% vs 47% flexion, 97% vs 83% ext, others
no diff.no diff. Conclusion: OK for weekend warrior to do home PTConclusion: OK for weekend warrior to do home PT
Propioception Knee Before and Propioception Knee Before and After ACL ReconstructionAfter ACL Reconstruction
Reider et al. Arthroscopy 2003Reider et al. Arthroscopy 2003 Compared proprioception before and after Compared proprioception before and after
ACL reconstruction to healthy controls ACL reconstruction to healthy controls (contralateral knee)(contralateral knee)
Concluded: “At 6 months no difference in JPS Concluded: “At 6 months no difference in JPS and TDPM (threshold to detection of passive and TDPM (threshold to detection of passive motion) compared to controls”motion) compared to controls”• Reconstruction has positive impact on Reconstruction has positive impact on
propioceptionpropioception