sara cordell ithaca college. protocol timeline concomitant injuries or complications knee stability...
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Return to Sport after ACL Reconstruction
Sara CordellIthaca College
Protocol timeline Concomitant injuries or complications Knee stability and strength Objective vs. subjective data Reliability, validity, accuracy, functional
relevance of tests Individual circumstances, fears, values,
motivation, etc Demands of particular sport(s) Clinical experience/judgment
Challenge of Deciding Return to Sport
Many Factors Involved
≥90% symmetry between involved and uninvolved sides for objective testing (isokinetic testing, hop testing, etc)
Full, nonpainful ROM No joint effusion Joint stability- KT test ≤3mm side-to-side
difference MD and PT opinions
General Return to Sport Guidelines
Return to Sport Algorithm According to Myer et al.
Biodex Isokinetic Testing KT Testing Agility testing- Modified T-test Balance testing- Stabilometer Goniometry to measure symmetry of
movement Compare symmetry of GRFs Deceleration testing Hop testing
Objective Testing Options
Common tests- single leg hop for distance, 6m timed hop, triple hop for distance, crossover hops for distance
Limb symmetry index (LSI=involved/uninvolved x100% for distance measures, opposite for time)
Begun ~12-16weeks post-op Pros- test many aspects of LE movement at
once, time efficient, minimal equipment Cons- learning curve, functional relevance,
don’t address quality of movement, measurement error
Hop Testing
Hops in Reid et al.
Characteristics of Hop Tests Test Reliability (ICC) MDC (%)
Single hop .92 8.09
6m timed hop .82 12.96
Triple hop .88 10.02
Crossover hop .84 12.25
Overall combination .93 7.05
Four tests together- sensitivity= 82%Single hop test alone- sensitivity= 38-52%
Vertical jump Single hop for
distance Drop jump followed
by double hop Square hop Side hop
Hops in Gustavsson et al.
Hop Test Evaluation
Statistic Vertical jump
Hop for distance
Drop jump w/ double hop
Square hop
Side hop
Sensitivity 86 63 63 51 69
Specificity 87 100 100 67 87
Accuracy 86 74 74 56 74
Vertical jump, single hop for distance, side hop
Sensitivity: 91% for identifying patient as abnormal when at least 1 of the 3 tests was abnormal
Accuracy: 84% for truly normal subjects and 88% for truly abnormal subjects
Hop Test Battery
54% had abnormal LSI in ALL 3 tests 91% had an abnormal value in at least one
of the 3 tests Only 9% had all normal LSI values
At 6 months post-op…
Patient Example
Test *Left Right LSI
Single Hop 1.48m 1.62m 91.3%
Vertical Jump
10.43in 13.03in 80.0%
Side Hop 34in 49in 69.3%
Test *Left Right LSI
Single Hop 1.48m 1.62m 91.3%
6m Hop 2.5s 2.63s 105.2%
Triple Hop 4.72m 4.82m 97.9%
Crossover Hop
4.1m 4.8m 85.4%
Reid Test Battery
Gustavsson Test Battery
Augustsson et al. evaluated effect of fatigue on single hop testing results
Fatigue- repeat as many reps as possible at 50% 1RM
All patients included in study had ≥90% symmetry in non-fatigued conditions
After pre-exhaustion exercise, 68% demonstrated abnormal hop symmetry
Effect of Testing in Fatigued State
Do not use only one or two testing methods Consider whole athlete and demands of
sport Reference protocol timeline but also use
functional goals as criteria for progression No objective tests are perfect, supplement
with clinical judgment and experience Consider testing athlete in non-fatigued and
fatigued conditions
Take Home Messages
Criteria based algorithm as proposed by Myer?
Can you identify the most important factors when deciding return to sport?
Most clinically useful objective measures? Most reliable/valid hop tests? Testing in fatigued vs. non-fatigued state? Commonly overlooked factors?
What is your opinion?
Augustsson J, Thomeé R, Karlsson J. Ability of a new hop test to determine functional deficits after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal Of The ESSKA. Sept 2004;12(5):350-356.
Gustavsson A, Neeter C, Karlsson J, et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal Of The ESSKA. August 2006;14(8):778-788.
Hartigan EH, Axe MJ, Snyder-Mackler L. Time line for noncopers to pass return-to-sports criteria after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2010; 40: 141-154.
Kvist J. Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Medicine. 2004;34(4):269-280.
Myer G, Paterno M, Ford K, Quatman C, Hewett T. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. The Journal Of Orthopaedic And Sports Physical Therapy. June 2006;36(6):385-402.
Reid A, Birmingham T, Stratford P, Alcock G, Giffin J. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Physical Therapy . March 2007;87(3):337-349.
References
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