Injury Management of TheInjury Management of The

Anterior Anterior Cruciate Cruciate

InjuryInjury

Sprains Sprains Anterior cruciateAnterior cruciate Posterior cruciatePosterior cruciate Medial collateralMedial collateral Lateral collateralLateral collateral

Injury PreventionInjury Prevention

Knee TapingKnee Taping

Knee EvaluationKnee Evaluation

CHECK LIFE THREATENING SITUATIONSCHECK LIFE THREATENING SITUATIONS_____ABC'S (usually not a problem)_____ABC'S (usually not a problem)_____check for traumatic shock_____check for traumatic shock

HISTORY OF THE INJURYHISTORY OF THE INJURY_____where doe’s it hurts? point to the spot._____where doe’s it hurts? point to the spot._____when did it happened?_____when did it happened?_____how did it happened?_____how did it happened?_____what was the position of foot and knee before _____what was the position of foot and knee before

injury?injury?_____what was the position of foot and knee after _____what was the position of foot and knee after

injury?injury?_____what activity bothers you most?_____what activity bothers you most?_____did you hear or feel a pop, snap, crack_____did you hear or feel a pop, snap, crack_____does your knee lock_____does your knee lock_____were you able to continue your activity after _____were you able to continue your activity after

the injurythe injury HISTORY OF THE INDIVIDUALHISTORY OF THE INDIVIDUAL

_____have you had a previous knee injuries? when?_____have you had a previous knee injuries? when?_____ -did you see a physician_____ -did you see a physician_____ -what was your rehab._____ -what was your rehab._____have you made any training changes_____have you made any training changes

OBSERVATIONOBSERVATION_____compare opposite sides of the body_____compare opposite sides of the body_____observe for swelling_____observe for swelling_____observe for deformity_____observe for deformity_____observe for muscle atrophy_____observe for muscle atrophy

((observe the position of the patella)_____-patella alta_____-patella alta_____-patella baja_____-patella baja

((observe for alignment)observe for alignment)_____-genu valgum_____-genu valgum_____-genu varum_____-genu varum_____-Q angle_____-Q angle

PALPATEPALPATE_____tell athlete it will hurt and why_____tell athlete it will hurt and why_____palpate for pain or point tenderness_____palpate for pain or point tenderness_____palpate for bumps, deformity, and effusion (swelling _____palpate for bumps, deformity, and effusion (swelling

in joint)in joint)_____start away from suspected injury_____start away from suspected injury_____palpate the bones (femur, tibia, fibula, patella) _____palpate the bones (femur, tibia, fibula, patella) _____palpate ligaments (MCL, LCL, )_____palpate ligaments (MCL, LCL, )_____palpate joint lines_____palpate joint lines_____palpate muscles/tendons (hamstring, quads, _____palpate muscles/tendons (hamstring, quads,

gastroc, )gastroc, )_____palpate bursae_____palpate bursae

TEST STRUCTURAL INTEGRITYTEST STRUCTURAL INTEGRITY_____sensory nerves_____sensory nerves_____motor nerves_____motor nerves

_____circulation_____circulation

_____Reflexes_____Reflexes

_____ -patellar reflex (L3 and L4)_____ -patellar reflex (L3 and L4)

_____ -medial hamstring reflex (L5)_____ -medial hamstring reflex (L5)

Active ROMActive ROM

_____ -flex, extend knee_____ -flex, extend knee

Passive ROMPassive ROM

_____ -flex, extend knee_____ -flex, extend knee

Resistive ROMResistive ROM

_____ sartorius_____ sartorius

_____quadriceps_____quadriceps

_____biceps femoris_____biceps femoris

_____semitendinosus/ semimembranosus_____semitendinosus/ semimembranosus_____popliteus_____popliteus

Special TestsSpecial Tests_____ -valgus stress test (straight and _____ -valgus stress test (straight and 20 flex)20 flex)_____ -varus stress test (straight and _____ -varus stress test (straight and 20 flex)20 flex)_____ -figure 4 test_____ -figure 4 test_____ -Lachman's test_____ -Lachman's test

LachmanLachman

Varus stressVarus stress Valgus stressValgus stress

TEST FUNCTIONAL ACTIVITYTEST FUNCTIONAL ACTIVITY_____**only if you suspect a mild injury**_____**only if you suspect a mild injury**_____walk_____walk_____hop 10 times on injured leg (if walking _____hop 10 times on injured leg (if walking

is pain free)is pain free)_____jog (if hopping is pain free)_____jog (if hopping is pain free)_____run and cut (if jogging is pain free)_____run and cut (if jogging is pain free)

8. DECISION AND ACTION8. DECISION AND ACTION_____if it is a mild injury--tape & play_____if it is a mild injury--tape & play_____if it is a moderate injury--ICE & rest_____if it is a moderate injury--ICE & rest_____if it is a severe–refer to a physician_____if it is a severe–refer to a physician

9. RE-EVALUATE9. RE-EVALUATE_____after ICE, if used_____after ICE, if used_____throughout rehabilitation_____throughout rehabilitation

10. RECORD RESULTS10. RECORD RESULTS _____ enter injury report in records _____ enter injury report in records

First Aid First Aid CareCare

Ice, Ice, Compression, Compression, ElevationElevation

Knee Knee immobilizerimmobilizer

CrutchesCrutches

TRADITIONAL TRADITIONAL REHABILITATIONREHABILITATION

WEEKS 0-2WEEKS 0-2::

Non weightbearingNon weightbearing Brace locked at 30 and 60 degreesBrace locked at 30 and 60 degrees Quadricep and Hamstring isometricsQuadricep and Hamstring isometrics Electrical muscle stimulationElectrical muscle stimulation Ankle ROM and strengtheningAnkle ROM and strengthening Heel slidesHeel slides Patellar mobilizationPatellar mobilization

WEEK 4WEEK 4::

Non weightbearingNon weightbearing Brace locked at 30 and 90 degreesBrace locked at 30 and 90 degrees Quadricep and Hamstring isometricsQuadricep and Hamstring isometrics Straight leg raisesStraight leg raises Electrical muscle stimulationElectrical muscle stimulation Pool exercises (hip and ankle)Pool exercises (hip and ankle)

WEEK 6WEEK 6::

Non weightbearingNon weightbearing Brace locked at 0 and 90 degreesBrace locked at 0 and 90 degrees Quadricep and Hamstring isometricsQuadricep and Hamstring isometrics Straight leg raises with weightStraight leg raises with weight Hamstring curlsHamstring curls Hip progressive resistance exercisesHip progressive resistance exercises Pool ROMPool ROM Cycling for ROMCycling for ROM

WEEK 8WEEK 8::

Begin weightbearingBegin weightbearing Derotational brace without limitsDerotational brace without limits ROM should be 0 and 110 degreesROM should be 0 and 110 degrees CyclingCycling Hamstring curls Hamstring curls 

3 MONTHS3 MONTHS::

ROM 0 and 125 degreesROM 0 and 125 degrees Treadmill walkingTreadmill walking SLR with weight increaseSLR with weight increase CyclingCycling Quarter squatsQuarter squats

4 - 6 MONTHS4 - 6 MONTHS::

ROM 0 and l40 degreesROM 0 and l40 degrees Treadmill walking (taster)Treadmill walking (taster) Isotonic knee extensionsIsotonic knee extensions Isokinetics when 10% of body weight Isokinetics when 10% of body weight

can be done isotonically (90-240 can be done isotonically (90-240 degrees/second)degrees/second)

Step-upsStep-ups

6 MONTHS6 MONTHS::

Test isokineticallyTest isokinetically Begin terminal knee extensionBegin terminal knee extension Running (straight ahead)Running (straight ahead)

ACL ACL Rehabilitation Rehabilitation

ProgramProgramChehalem Physical Therapy, Inc. ,   120 - C N. Everest Rd.,   Newberg, Oregon   97132

Day 1 – 3Day 1 – 3 Range of motion with emphasis on knee Range of motion with emphasis on knee

extension.extension. Cold therapy (with compression and Cold therapy (with compression and

elevation).elevation). Weight bearing to comfort with crutches using Weight bearing to comfort with crutches using

long-leg brace locked at 0 degrees.long-leg brace locked at 0 degrees. Patellar, scar, and soft-tissue mobilization.Patellar, scar, and soft-tissue mobilization.

Exercises:Exercises: Quad/Hamstring setting.Quad/Hamstring setting. Heel slides.Heel slides. Knee extension stretch with heel pillowKnee extension stretch with heel pillow Ankle pumps.Ankle pumps. SLR (in long-leg brace; locked).SLR (in long-leg brace; locked). Patellar mobilization.Patellar mobilization.

Day 4 – 14Day 4 – 14 Weight bearing as tolerated with full weight Weight bearing as tolerated with full weight

bearing.bearing. Continue with pain control, range of motion, Continue with pain control, range of motion,

and mobilization treatment.and mobilization treatment. Begin balance and position-sense exercises Begin balance and position-sense exercises

(tandem stance, single stance, mini-tramp (tandem stance, single stance, mini-tramp balance).balance). Exercises:Exercises:

Quarter squats/weight shifts.Quarter squats/weight shifts. Hamstring curls.Hamstring curls. Stationary bike for range of motion and early endurance.Stationary bike for range of motion and early endurance. Lateral step-ups.Lateral step-ups. Calf raises.Calf raises.

Week 2 - 6 Week 2 - 6

Push for full extension range of Push for full extension range of motion.motion. Exercises:Exercises:

Leg pressLeg press Sport cord drillsSport cord drills Swimming, cycling, functional exercises Swimming, cycling, functional exercises

(squats, lunges)(squats, lunges) Fit for custom sports brace (per MD).Fit for custom sports brace (per MD).

Week 7 – 11Week 7 – 11

Exercise progression (intensity, Exercise progression (intensity, resistance, and aerobic work).resistance, and aerobic work).

Begin lateral resistance drills (sport Begin lateral resistance drills (sport cord, carioca).cord, carioca).

Straight-line jogging.Straight-line jogging.

Week 12 – 16Week 12 – 16

Advanced closed kinetic chain Advanced closed kinetic chain functional exercises.functional exercises.

Sport-specific exercises.Sport-specific exercises. Isokinetic knee evaluation 90 - 40 Isokinetic knee evaluation 90 - 40

degrees.degrees.

Week 16 +Week 16 +

Progressive cutting/pivoting.Progressive cutting/pivoting. Progressive running.Progressive running. Progressive plyometrics.Progressive plyometrics.

Criteria for return to Criteria for return to competitioncompetition::

Full range of motion.Full range of motion. Normal balance and proprioception.Normal balance and proprioception. 90% or better functional strength.90% or better functional strength.

University of Oregon Athletic University of Oregon Athletic

MedicineMedicine Anterior Cruciate Anterior Cruciate

Ligament Rehabilitation Ligament Rehabilitation ProtocolProtocol

Purpose: The purpose of having a written Purpose: The purpose of having a written protocol for the rehabilitation of knees after protocol for the rehabilitation of knees after ACL reconstructive surgery is not to create a ACL reconstructive surgery is not to create a "cook book" formula, but to have an outline "cook book" formula, but to have an outline that can be followed as a consistent guideline that can be followed as a consistent guideline for progression of the athlete. The time frames for progression of the athlete. The time frames may change depending on the goals of each may change depending on the goals of each athlete and the philosophy of the surgeon. athlete and the philosophy of the surgeon. Ideally, surgery would be delayed until knee Ideally, surgery would be delayed until knee motion and quadriceps control are restored and motion and quadriceps control are restored and effusion is minimal.effusion is minimal.

Weeks 1-4Weeks 1-4 Goals:Goals: Decrease pain and swellingDecrease pain and swelling Increase ROM Increase ROM Progress from partial to full weight bearing with proper gaitProgress from partial to full weight bearing with proper gait Increase quadriceps andIncrease quadriceps and hamstring strength hamstring strength Promote proper patellofemoral function Promote proper patellofemoral function Initiate restoration of proprioceptionInitiate restoration of proprioception Promote crossover effect by exercising uninvolved kneePromote crossover effect by exercising uninvolved knee Specific Rehabilitation Techniques:Specific Rehabilitation Techniques:

Ice/electrical modalitiesIce/electrical modalities Quadriceps/hamstring sets (single & co-contraction)Quadriceps/hamstring sets (single & co-contraction) Biodex PROM (Pain-Free)Biodex PROM (Pain-Free) Patellar mobilization Patellar mobilization Prone hangs (Progress to ankle weights)Prone hangs (Progress to ankle weights) Supine passive terminal extension stretch Supine passive terminal extension stretch VMO training (starting w/QS & Russian EMS) VMO training (starting w/QS & Russian EMS) Lateral complex stretching & McConnell taping (If necessary) Lateral complex stretching & McConnell taping (If necessary) Ankle pumps & PNF Ankle pumps & PNF AROM leg extension (No resistance) AROM leg extension (No resistance) MRE for hip (Ext., ab., ad., flex. (bent knee)MRE for hip (Ext., ab., ad., flex. (bent knee)

Note: Adduction is contraindicated during this time for athletes who also injured their MCL Note: Adduction is contraindicated during this time for athletes who also injured their MCL Non-weight bearing to weight bearing step-up progression Non-weight bearing to weight bearing step-up progression Bike for ROM Bike for ROM ¼ Squats ¼ Squats Carpet Drags Carpet Drags Step-ups w/Russian EMS Step-ups w/Russian EMS Shuttle w/Russian EMS Shuttle w/Russian EMS Sport cord 1/3 squats (double & single leg) Sport cord 1/3 squats (double & single leg) Shuttle leg presses (double and single leg) Shuttle leg presses (double and single leg) Leg curls (single) Leg curls (single) Bridging with and without a physioball (Can be initiated after athlete has 45 degrees of flexion) Bridging with and without a physioball (Can be initiated after athlete has 45 degrees of flexion) Single leg balance (Begin on floor, progress to foam and then to trampoline) Single leg balance (Begin on floor, progress to foam and then to trampoline) UBE UBE Calf exercises (Seated machine, leg press, shuttle, standing) Calf exercises (Seated machine, leg press, shuttle, standing)

Weeks 5-12Weeks 5-12   Goals:Goals: Continue to strengthen the quadriceps muscles with closed chain exercises Continue to strengthen the quadriceps muscles with closed chain exercises

ONLY ONLY Continue to strengthen the hamstring muscles Continue to strengthen the hamstring muscles Facilitate proper gait patterns and joint mechanics Facilitate proper gait patterns and joint mechanics Continue to facilitate proprioception Continue to facilitate proprioception Initiate restoration of cardiorespiratory functionInitiate restoration of cardiorespiratory function Specific Rehabilitation Techniques:Specific Rehabilitation Techniques:

WWP (AROM)WWP (AROM) Leg curls (single) Leg curls (single) Hip & thigh machine Hip & thigh machine Step-downs w/Russian EMSStep-downs w/Russian EMS Backward walking on treadmill (Progress to 2.0 MPH at 12x % grade for 5 minutes) Backward walking on treadmill (Progress to 2.0 MPH at 12x % grade for 5 minutes) Shuttle leg presses (Double & single leg) Shuttle leg presses (Double & single leg) Leg press Leg press Tubing squats Tubing squats Biodex (Hamstrings only) Biodex (Hamstrings only) Eccentric hamstrings on Biodex Eccentric hamstrings on Biodex Squats (Back & overhead) Squats (Back & overhead) Pool Pool Bike Bike Form walking routine Form walking routine Balance squats Balance squats Single leg balance (Progress to trampoline: eyes open/closed w/wo body blade) Single leg balance (Progress to trampoline: eyes open/closed w/wo body blade) Stairmaster Stairmaster Slideboard Slideboard Treadmill walking Treadmill walking Treadmill walk/jog Treadmill walk/jog Treadmill jogging Treadmill jogging Treadmill walking/running Treadmill walking/running Seated calf raises Seated calf raises Ball toss Ball toss Chair scoots Chair scoots Calf exercises (seated machine, leg press, shuttle, standing) Calf exercises (seated machine, leg press, shuttle, standing)

Weeks 13-24Weeks 13-24   Goals:Goals:

Continue increasing strength, power, muscular enduranceContinue increasing strength, power, muscular endurance Restoration of cardiorespiratory function Restoration of cardiorespiratory function Further development of normal gait patterns Further development of normal gait patterns Progress from general sport movements to sport and position specific Progress from general sport movements to sport and position specific

drills drills Specific Rehabilitation Techniques:Specific Rehabilitation Techniques:

Stairmaster Stairmaster Bike Bike Treadmill Jogging Treadmill Jogging Leg curls (Single) Leg curls (Single) Biodex (Hamstrings only) Biodex (Hamstrings only) Eccentric hamstrings onEccentric hamstrings on Biodex Biodex Ball toss (Foam & trampoline) Ball toss (Foam & trampoline) Strides Strides Figure 8’s Figure 8’s Zig-zags Zig-zags Stadiums Stadiums Form walking/running routine Form walking/running routine Slideboard Slideboard Sport cord jogging Sport cord jogging Leg press Leg press Shuttle leg presses (Double & single leg) Shuttle leg presses (Double & single leg) Shuttle jumps (Double & single leg) Shuttle jumps (Double & single leg) Fitter Fitter Calf exercises (Seated machine, leg press, shuttle, standing) Calf exercises (Seated machine, leg press, shuttle, standing)

6-9 Months6-9 Months Goals:Goals:

Increase strength, power, muscular endurance to 90%+ of Increase strength, power, muscular endurance to 90%+ of uninvolved leg uninvolved leg

Increase running and cutting to meet demands of Increase running and cutting to meet demands of individual sport individual sport

Increase cardiorespiratory function to levels needed for Increase cardiorespiratory function to levels needed for particular sport participationparticular sport participation

Progress to partial of full sport activities Progress to partial of full sport activities Specific Rehabilitation Techniques:Specific Rehabilitation Techniques:

Biodex testing (180 degrees – 10 reps, 300 degrees – 15 reps) Biodex testing (180 degrees – 10 reps, 300 degrees – 15 reps) Return to activity drills Return to activity drills

Agilities Agilities Plyometric program Plyometric program Calf exercises Calf exercises Squats Squats Shuttle jumps (Double & single leg) Shuttle jumps (Double & single leg) Leg curls (Double) Leg curls (Double) Sprint Progression Sprint Progression Integrate into normal lifting and conditioning activities with Integrate into normal lifting and conditioning activities with

appropriate limitations appropriate limitations

9-12 Months9-12 Months

Goals:Goals: Continue rehabilitation of any deficient Continue rehabilitation of any deficient

areas of involved extremity (i.e. strength, areas of involved extremity (i.e. strength, power, muscular endurance, or power, muscular endurance, or cardiorespiratory function)cardiorespiratory function)

Maintenance program for non-deficient Maintenance program for non-deficient areas areas

Specific Rehabilitation Techniques:Specific Rehabilitation Techniques: Appropriate exercises from previous techniques Appropriate exercises from previous techniques Biodex Testing (If necessary) Biodex Testing (If necessary)