Transcript ACL reconstruction healing and Return to Play

ACL reconstruction
healing and Return to
Play
Randy Clark
Acknowledgements: Glenn Williams, Mike Shaffer,
Danny Foster, Brian Wolf
Introduction
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100,000 new ACL injuries each year (1/3000 people)
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Young women 3 times more likely to suffer an ACL injury
compared to a male cohort group
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Young female participating in sports year round has a
5% risk for tearing her ACL
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No more than 15- 30% of ACL deficient individuals
typically return to running, jumping, and pivoting
activities without experiencing subsequent episodes
of knee instability
ACL Defficiency and Return to
Play
832 ACL injuries
10% declined, 40% other knee injuries
432 Remaining patients
87 unable to regain ROM, strength, pain control
345 patients
Screening exam eliminates 199 as
Non-copers
146 patients
60% chose to undergo surgery
88 patients attempt return to sport
ACL Defficiency and Return to
Play
88 Patients return to sport
72% successful
63 patients
36 went onto reconstruction
29 patients remain
•24% return to sport without subsequent instability
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
Fitzgerald et al., Knee Surg Sports Traumatol Arthrosc., 2000
How long until I can play?
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The healing process
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It’s a dead piece of tissue!
Graft needs to be re-vascularized
• “Ligamentization” occurs
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Vascular Synovial layer wraps around graft in 46 weeks
Healing Time
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Autologous ACL grafts don’t
Transition through necrotic stage
Weakest link fixation 4-6 weeks
Complete re-vascularization
of the graft takes ~20 weeks
Remodeling occurs:
 By one year histological and
biochemical properties of
ACLR ~ native ACL
Graft Remodeling
 Gradual
loss of graft
strength during initial
remodeling
 Then strength of ACL
graft improves
gradually
 Allografts

Slightly slower
process
Graft Remodeling
 Patellar
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tendon
Bone to bone within
the ACL tunnels
4-8 weeks usually
Graft Remodeling
• Hamstring graft
-Bone to tendon healing
-Sharpey’s fibers
-Usually complete at 12 weeks
 ACL autograft resembles
normal ACL at 12 months
 Concern for increased allogenic
graft incorporation time doesn’t
warrant modification of PT
protocol
Pre-Operative Rehabilitation
 Initial
focus on eliminating swelling and
restoring pre-injury range of motion and
strength
Rehabilitation
 Slight
variations depending on age,
history, activity level, graft source and
associated injuries.
Rehabilitation
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Bracing:
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“There is little evidence to support the use of a
post-operative brace following isolated
reconstruction of the ACL.”
“Although the exact mechanism for any beneficial
effect of functional bracing remains unknown, ACL
deficient athletes commonly report improved
confidence with use of a functional knee brace.”
“The use of functional bracing should perhaps be
reserved for return to sport following revision
surgery or in athletes who have suffered a multiple
ligament injury.”
CORR 07’ systematic review 12 RCT’s- no
support for bracing
Rehabilitation
 Five
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phases
Phase I- Immediate post-op (0-2 weeks)
Phase II- Early Rehabilitation Activities (2-6
weeks)
Phase III- Advanced Rehabilitation Activities
(6-10 weeks)
Phase IV- Advanced Functional Activities (10
weeks- 6 months)
Phase V- Return to Sport (6-12 months)
Rehabilitation
 Phase
I- Immediately Post- Surgery
(POST-OPERATIVE WEEKS 0-2)

The goals of the early rehabilitation period are
to control pain and post-operative swelling,
and begin to restore range of motion.
• Control inflammation: cryotherapy, elevation,
compression, limitation of activities
• Restore ROM: importance of regaining
hyperextension. (Importance of regaining motion
pre-op)
Rehabilitation
 Phase
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I continued….
ROM
• Stretches: extension bridges, prone hangs
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ROM expectations:
• 0-90° 2 weeks
• 0-120° 4 weeks
• Full range 6 week
•Muscle strengthening
•Isometric quad contractions, straight leg raises, stim
treatments
•Ambulation- crutches, WBAT, avoid “quad avoidance” gait pattern
Rehabilitation
 Criteria
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to Progress to Phase II
Knee effusion well controlled
Adequate quadriceps control demonstrated by
the ability to do a hip flexion straight leg raise
without extensor lag
Normal gait pattern without use of assistive
devices
Knee range of motion of at least 0- 90°
Rehabilitation
II – Early Rehabilitation
Exercises (POST-OPERATIVE WEEKS
2-6)
 Phase
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The focus of Phase II rehabilitation is to
restore full knee range of motion and advance
early strengthening exercises
Light weights, remember creep (low load
prolonged stretches), manual overpressure,
stationary 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.
Rehabilitation
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Open vs. closed chain excercises
• Open chain and infrapatellar pain
• Graft lengthening
Rehabilitation
 Criteria
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to Advance to Phase III
Full knee range of motion
Able to ascend and descend stairs normally
Successfully completing regular exercise
program of Phase II activities
Rehabilitation
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Phase III- Advanced Rehabilitation
Exercises (POST-OPERATIVE WEEKS 610)
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Build on the limb strength gained in Phase II
• Traditional strengthening exercises combined with
additional challenges to the nervous system:
pertubations, mental distraction tasks, activities which
progressively force the center of gravity away from the
base of support.
• Restore neuromuscular control: mechanoreceptor
repopulation is most active between 2 and 8 weeks postoperatively
• RCT’s show superiority of neuromuscular retraining
when compared to standard strength training. (Beard
JBJS 94’, Risberg Aust J Phys 07’)
Rehabilitation
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Criteria to Advance to Phase IV
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Regularly completing isotonic strengthening program
in supervised physical therapy
Starting to transition strengthening activities to local
gym or athletic team’s weight room
Approximately 70-80% strength vs. contralateral
(uninvolved) lower extremity
Demonstrates appropriate control of knee with
neuromuscular retraining exercises in the physical
therapy clinic
Rehabilitation
 Phase
IV- Advanced Functional
Activities (10 weeks- 6 months)
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The primary goal of the fourth phase of
rehabilitation is to prepare the athlete for
return to sport. Running, cutting, and jumping
are near universal requirements of the sports
in which athletes most often tear their ACL’s.
• be cognizant of other tasks which are important
parts of the sport to which the athlete hopes to
return
Rehabilitation
 Phase
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IV continued
ladder drills or other simulated running tasks,
then advance to interval jogging.
Once 70-80% of their pre-injury speed, cutting
drills begin.
Land based jumping, jumping up to a box
and/or completing all plyometrics activities by
landing on two legs
Rehabilitation
 Criteria
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for Progression for Phase V
Regularly completing isotonic strengthening
program
Running at least 85% of pre-injury speed
Cutting and jumping without hesitation or
obvious limitation
Rehabilitation
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Phase V- Return to Sport (6-12 months)
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subjective and objective information considered.
• Athlete pain free during performance
• Athlete not demonstrate limp or guarding
• Effusion after rehabilitation or functional testing
viewed as a stark indication that neuromuscular
system not adequately countering the high
stresses experienced within the joint.
• Athlete should feel confident about their return to
sport.
Rehabilitation
 Phase
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V- Return to Sport (6-12 months)
No more than 10% asymmetry in terms of
isokinetic variables between the involved and
uninvolved lower extremity
single leg hop test to measure knee joint
function and strength
single leg vertical jump, single leg hop for
distance, single leg timed hop
Rehabilitation
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Criteria to Return to Sport
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No complaints of pain or knee instability
Full ROM
No new effusion
Lower extremity strength/ function at least 85% vs.
uninvolved LE
Adequate performance in physical therapy or with
sport specific drills which simulate the intensity,
frequency, and duration of the sport to which the
athlete hopes to return
Athlete demonstrates a psychological readiness to
return to sport, either verbally or with SANE score >
80/100
Functional Testing
 Full
ROM, negative pivot-shift, symmetric
quad and hamstring strength and
functional testing scores
Rehabiliation
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Crucial input from..
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Physician
Athletic trainer
Physical Therapist
Coach
Athlete +/- parents
Rehabilitation
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Rehab time frame
changed
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Formally >12mos
Now generally ~6m
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Beynnon, Ekstrand
8 mos vs ~5mos
Subjective outcome
 Anterior knee laxity
 Functional testing
Faster rehab (19 wks) seems
safe
Programs faster than this….?
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2 RCT’s
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No significant differences
in:
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Rehabilitation
 Bone
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scan?
Scott Dye talk
Rehabilitation
 Functional
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score meta-analysis
No difference between BTB and hamstring
grafts with respect to function (Biau CORR
07’)
• 14 trials- 7 RCT’s
What to expect?
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10-14% of ACL R
patients need another
surgery at some point
in the future
 Risk of re-rupture
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3% on ACLR knee
3% on other knee
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~20% of patients note
some subj functional
impairment with ACLR knee
~90% of athletes return to
same level of sport by one
year after ACLR
Only 54% still at that level
by ~3 yrs
Lit Review on Return to Play
Lit Review on Return to Play
Home vs Formal PT
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Grant et. Al, AJSM 2005
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Hypothesis: no difference in home vs. structure PT
program at 3 months for BTB reconstruct.
Study design: RCT, 145 pts, 4 vs. 17 PT sessions
Measured: ROM, knee motion walking, KT, quad and
hamstring strength
Results: 67% vs 47% flexion, 97% vs 83% ext, others
no diff.
Conclusion: OK for weekend warrior to do home PT
Propioception Knee Before and
After ACL Reconstruction
 Reider
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et al. Arthroscopy 2003
Compared proprioception before and after
ACL reconstruction to healthy controls
(contralateral knee)
Concluded: “At 6 months no difference in JPS
and TDPM (threshold to detection of passive
motion) compared to controls”
• Reconstruction has positive impact on
propioception