UNRAVELING THE CURRENT EVIDENCE TO MANAGING ANTERIOR CRUCIATE LIGAMENT

(ACL) INJURIES

Linda Truong, PTPhD Trainee, Faculty of Rehabilitation Medicine, University of AlbertaPhysical Therapist, Glen Sather Sport Medicine Clinic, University of AlbertaArthritis Research Canada

@LKTphysio

Oct 20, 2019Connect+Learn ConferenceCanmore, Alberta

CASE SCENARIO #1

Video

16 year old female1st time ACL surgery (also known as ACL reconstruction or ACLR)

Goal: 6 months to return to full training to secure ascholarship

Is this realistic? What would you say?

CASE SCENARIO #2

30 year old male2010 First ACL surgery2017 Re-tear of ACL on same knee

Goal: return to indoor/outdoor soccer and taekwondo

What management option would you recommend?

OBJECTIVES

Evidence-Based Management for ACL Tears 01

02

03Clinical Strategies to improve ACLRecovery

Criteria-Based ACL Rehabilitation

BACKGROUND

• Provide stability during twisting movements (side stepping, pivoting and landing from a jump)

• It is usually not required during normal daily living activities

BACKGROUNDEpidemiology

• 15-20% of reported sport injuries are kneeinjuries!

• Types of acute knee injuries:• Tibiofemoral ligaments (40%)• Patella (25%)• Meniscus (11%)• Other – tendon ruptures, bone bruises,

contusions, bursitis, etc. (25%) ACL, 46%MCL, 29%

ACL/MCL, 13%

PCL, 4%LCL, 2%

Complex Multilig,

6%

Emery et al. (2006); Emery et al. (2009); Bollen et al. (2000); Majewski et al. (2006)

• 250,000 ACL injuries per year in USA• Common injury mechanisms for ACL:• non-contact (70%)• indirect non-contact• direct contact

Hewett et al. (2006); Montalvo et al (2018); Majewski et al. (2006)

• Females more at risk • Age range:• 43% were 20-29 • 20% were 30-39• 17% were 10-19

BACKGROUNDEpidemiology

1 65% return to sport (RTS) within 2 years

Ardern et al (2014); Filbay et al (2016); Wiggins et al (2016); Øiestad et al (2009)

2 Reduced quality of life 5-20 years after injury

3 ~20% risk of re-injury to either knee after ACLR if RTS

4 ~50% will develop post-traumatic osteoarthritis (PTOA) 10 years after injury

BACKGROUNDConsequences of ACL Tears

Management of ACL TearsFrom Prevention to Osteoarthritis

01

Improve Function

INTE

RVEN

TIO

N

Joint injury to PTOA

TIM

ELIN

E

Prevent ACL Injuries

Optimize rehabilitation

Tertiary Prevention

Primary Prevention

Secondary Prevention

After PTOA diagnosis

Prior to joint injury

Evidence-Based Recommendations for ACL Rehabilitation01

Trial exercise rehabilitation for at least 3 months

Re-evaluate after 3 months of compliance with exercise:

Will this individual benefit from ACLR?

Exercises: progressively load quadriceps muscle

and contains neuromuscular training

Discuss surgical management

No instability?

Discussion of non-surgical

management

Continued instability?

A shared decision-making approach is needed in order to properly inform the patient of their options while

considering their goals and preferences

Surgical vs. Non-Surgical Management Who Should have surgery?

01

Surgical vs. Non-Surgical Management Who Should have surgery?

01

Frobell et al (2010); Frobell et al (2013)

Surgical vs. Non-Surgical Management Who Should have surgery?

01

Frobell et al (2010); Frobell et al (2013)

Surgical vs. Non-Surgical Management Should I have surgery?

01

Frobell et al (2010); Frobell et al (2013)

CHOOSING NON-SURGICAL MANAGEMENT IS NOT AN INFERIOR AND NEEDS TO BE PRESENTED AS AN OPTION

• Early ACLR is not superior than the option of delayed ACLR

• Surgical ACLR was avoided 61% of the time without compromising short and long term outcomes

Evidence-Based Recommendations for ACL RehabilitationResources

01

Open kinetic chain vs.

Closed kinetic chain

Predictors forPost Operative

success

Strengthand

Neuromuscular Training

The Evolution of ACL RehabilitationFrom Cast to Crutch to Criterion

02

De Carlo et al (1992);

Time-Based RehabilitationTime dictates progression

6 months

12 weeks

surgery

The Evolution of ACL RehabilitationFrom Cast to Crutch to Criterion

02

POST SURGERY OR ACUTE ACL INJURY1PHASE

STRENGTHTRAINING

PHAS

E2

DYNAMICTRAINING PH

ASE 3

@satherclinic @LKTphysio @yegphysio

SPORT SPECIFIC TRAINING4PHASE

RETURN TO ACTIVITY OR SPORTPH

ASE 5

PHAS

E

INJURY PREVENTION6

ACL REHAB

GSSMC ACL PROTOCOL

0-6 weeks

6 wks - 2 yr

> 3-4 months

> 6 months

> 9 months

> 1 year

Edited April.10.2017

A CRITERION AND GOAL BASED APPROACH TO KNEE REHAB

“ELEVATING ACL REHAB THROUGH RESEARCH AND CLINICAL EXPERTISE”REHAB IS DRIVEN BY CRITERIA AND GOALS

Criterion and Goal-Based ACL RehabilitationGlen Sather Sports Medicine ACL Protocol

02

02 Criterion and Goal-Based ACL RehabilitationGlen Sather Sports Medicine ACL Protocol

02 Criterion and Goal-Based ACL RehabilitationGlen Sather Sports Medicine ACL Protocol

IN ORDER TO PRESCRIBE THE RIGHT EXERCISES, YOU NEED TO KNOW THE END GOAL

Quadriceps is a Key Criterion 02

van Melick et al (2016)

Quadriceps is a Key Criterion 02

Grindem et al (2016)

1%

TRAINING QUADRICEPS IS ESSENTIAL FOR SHORT AND LONG TERM RECOVERY

3% Quad

Symmetry Reinjury

Rate to the knee

=

Physical Criteria: Functional Testing02

Single Leg Squat Test 3 Rep Max Testing Strength

5-10-5 direction change test, T-testTimed Change of directionAgility

Functional hops: Single leg hops, triple single leg hops, lateral hops, single leg tuck jumps Power

Addressing the Non-Physical Side of Recovery02

Slide Adapted from Clare Ardern; Ardern et al (2013)

HOPPING

LOW FEAROF

REINJURY CONFIDENCE

Addressing the Non-Physical Side of RecoveryPsychological, Social, Contextual Factors

02

Truong et al (2019) submitted;

Addressing the Non-Physical Side of RecoveryPsychological, Social, Contextual Factors

02

Truong et al (2019) submitted

How to Assess Psychological Factors Using Patient Reported Outcome Measures

02

Tampa Scale for Kinesiophobia (TSK)Re-injury Anxiety Scale Fear

ACL Return to Sport after Injury Scale (ACL-RSI)

Psychological Readiness

Knee Injury and Osteoarthritis Outcome Score (KOOS)ACL-QoL HRQoL

Is Using a Criteria-Based Rehabilitation Really Effective?02

LESS KNEERE-INJURIES

38% 6%

Adapted from Clare Ardern; Grindem et al (2016)

Is Using a Criteria-Based Rehabilitation Really Effective?02

LESS KNEERE-INJURIES

38% 6%

Adapted from Clare Ardern; Grindem et al (2016)

Is Using a Criteria-Based Rehabilitation Really Effective?02

LESS ACL GRAFT RUPTURES

33% 10%

Adapted from Clare Ardern; Kyritis et al (2016)

PASSING RTS CRITERIA = 4x less risk of re-tearing ACL graft

Is Using a Criteria-Based Rehabilitation Really Effective?02

LESS ACL GRAFT RUPTURES

33% 10%

Adapted from Clare Ardern; Kyritis et al (2016)

PASSING RTS CRITERIA = 4x less risk of re-tearing ACL graft

What is Realistic Expectations for Criterion-Based Rehabilitation? 02

Welling et al (2019)

66% ~10 monthsMet 90%

Quadriceps Symmetry

02

Grindem et al (2016)

14% 6 mo.

55% 12 mo.

CRITERIA BASED HAS PUSHED TIME LINES LONGER

0% 5 mo.

What is Realistic Expectations for Passing Criteria?

02

Lai et al (2010)

8-13 mo.

11-12 mo.

6-12 mo.

What is Realistic Expectations for Return to Sport?

8-10 mo.

LEVEL 1• Learn to lift with good form (e.g., front squat, traditional deadlift)• Develop lower body strength

3

LEVEL 2• Continue strength training (e.g., 3RM front squat >80% body weight)• Introduce dynamic movement

LEVEL 4• Introduce and develop sport-specific movements (e.g., 1v1 shadow)• Continue injury prevention

LEVEL 3• Introduce power exercises• Introduce and develop dynamic movement (e.g., plant and cut)

Getting Creative with Rehabilitation03More info: uab.ca/FAST

Functional Agility Strength Training (FAST) Knee Program

Our Role as Therapists 03

Truong et al (2019) submitted; Podlog (2011)

Acknowledge both physical and non-physical barriers

Establish social support &shared-decision making

Ensure individual is ready to and support their decision

03

FOUNDATION: STRENGTH(EVERYONE will benefit from getting stronger)

DYNAMIC MOVEMENT(how does the patient need to move?)

SPORT-SPECIFIC TRAINING(situations the patient needs to move)

GUIDE BACK TO SPORT/ACTIVITY

(support the athlete)

LONG TERM MANAGEMENT

(reduce injuries)

What Should your ACL Rehabilitation Program Look Like?

03 Criterion and Goal-Based ACL Rehabilitation

03 Criterion and Goal-Based ACL Rehabilitation

03 Criterion and Goal-Based ACL Rehabilitation

Where can I go for more informationResources

03

RESEARCHRELATED

ACLPROTOCOLS

GSSMCRandall Cooper

Mick Hughes

PODCASTS

@PTInQuest@BJSM

Clinical Edge

Take Home MessagesClinical Strategies

03

NOT EVERYONE NEEDS ACL SURGERY TO RETURN TO ACTIVITIES

1

USE CRITERIA AND GOALS TO PROGRESS REHABILITATION

2

TREAT BOTH PHYSICAL AND NON-PHYSICAL ASPECTS FOLLOWING ACL INJURY3

Thank you

Credit: AVAGON PPT, Author: Ja Turna

@LKTphysiolltruong@ualbeta.ca