ACL Rehabilitation: Re-injury and Return to Sport Tests: Difference between revisions

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Exercise intensity should be changed constantly to challenge balance and proprioception. Modifications of body posture, switching between various unstable surfaces, speed modifications, adding a sport-specific skill and/or adding unanticipated movement can all be ways of challenging stability and balance.  
Exercise intensity should be changed constantly to challenge balance and proprioception. Modifications of body posture, switching between various unstable surfaces, speed modifications, adding a sport-specific skill and/or adding unanticipated movement can all be ways of challenging stability and balance.  


Examples of exercises to be used in this stage:
Examples of exercises to be used in this stage:  


Myer et al<ref name=":4" /> recommends checking for proficiency in the following criteria before progressing to the next stage:
=== Stage II: Functional strengthening ===
'''Goals of this stage:'''
* Increasing lower extremity non weight-bearing strength. 
* Improving load distribution pattern over both lower extremities in activities requiring double-leg stance.
* Improvement of single-limb landing force attenuation strategies.
With core strengthening and dynamic stabilization exercises continuing throughout this stage, progressive lower extremity strengthening is introduced. Gradually and frequently adding more resistance without compromising good form.


1. Single-limb squat and hold symmetry (minimum of 60° knee flexion with 5-second hold).
Retrograde training, for example backward running on treadmill or backward jumping, has been shown to increase functional quadriceps


2. Audibly rhythmic foot strike patterns without gross asymmetries in visual kinematics when running (treadmill 6–10 mph; 10–16 km).
activation and to limit patellofemoral stress<ref>Flynn TW, Soutas-Little RW. Mechanical power and muscle action during forward and backward running. Journal of Orthopaedic & Sports Physical Therapy. 1993 Feb;17(2):108-12.</ref><ref>Flynn TW, Soutas-Little RW. Patellofemoral joint compressive forces in forward and backward running. Journal of Orthopaedic & Sports Physical Therapy. 1995 May;21(5):277-82.</ref>


3. Acceptable single-limb balance scores on stabilometer (women < 2.2° of deflection and men < 3.0° of deflection total sway tested for 30 seconds at level 8).
=== Stage III: Power development ===
At this stage power production of lower extremity is the main aim. Additionally, athletes are trained to resist fatigue and perform plyomterics with good biomechanics<ref name=":4" />. Training incorporates mid-level intensity double-limb multi-planar plyometric jumps and  low-intensity single-limb hops.
 
Provide feedback and educate the athlete to land softly with coronal plane knee control.
 
Combining plyometrics with strength training improved jump performance and leg strength<ref>Fatouros IG, Jamurtas AZ, Leontsini D, Taxildaris K, Aggelousis N, Kostopoulos N, Buckenmeyer P. Evaluation of plyometric exercise training, weight training, and their combination on vertical jumping performance and leg strength. The Journal of Strength & Conditioning Research. 2000 Nov 1;14(4):470-6.</ref>. The addition of neuromuscular training with plyomterics, CORE and speed training resulted in great outcomes in performance measures 
 
A number of studies examined the effects of neuromuscular training combined with plyomtwe (back squat, single-leg hop and hold distance, vertical jump, speed), as well as several biomechanical factors related to increased lower extremity injury risk (increased knee flexion-extension ROM, decreased abduction moments during the landing phase of a vertical jump, and increased single-leg postural stability)<ref>Myer GD, Ford KR, Palumbo OP, Hewett TE. Neuromuscular training improves performance and lower-extremity biomechanics in female athletes. The Journal of Strength & Conditioning Research. 2005 Feb 1;19(1):51-60.</ref><ref name=":3" /><ref>Paterno MV, Myer GD, Ford KR, Hewett TE. Neuromuscular training improves single-limb stability in young female athletes. Journal of Orthopaedic & Sports Physical Therapy. 2004 Jun;34(6):305-16.</ref>
 
=== Stage IV: Sport Performance Symmetry ===


== References  ==
== References  ==


<references />
<references />

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ACL Re-injury[edit | edit source]

Despite advancement in surgical procedures, outcomes following ACL-reconstruction continue to be poor. less than 50% of athletes is able to regain their pre-injury level of performance[1], and for those who returned successfully to sport re-injury remains a risk factor.

Athletes who suffered ACL injuries are at risk of recurrence in the first year, and often in the second year, upon returning to play. The incidence of re-injury in the first two years following reconstruction is estimated to be 6 times greater than those who didn't suffer ACL injury, this incidence is much higher in female athletes[2]. A study reported 29.5% ACL re-injury in the second year with 20% sustaining a contralateral injury[2]. The risk of re-injury extends up to 5 years following injury[3].

Risk factors of primary and second ACL injury have been investigated widely in the literature. Biomechanical factors such as abnormal loading distribution patters around the knee, increased external knee abduction moment in females[4], side-to-side differences in lower extremities, frontal-plane displacement of the trunk[5] and reduced lower extremity aflexor activation in vertical jump[6] have been associated with ACL injury.

Re-injury Risk Factors[edit | edit source]

Quadriceps weakness is a common persisting issue after surgery[7] which is manifested through abnormal loading patterns in gait and sports activities.A deficit of about 20% of quadriceps strength compared to he opposite side is found in athletes after ACL recosntruction. However, even a 90% quadriceps index is not neccesarily associated with normal neuro-muscular control.

Asymetry in the kinematics and differences in moment arm between involved side joints compared to the other side is another factor that continues to manifest years following surgery[8].

Abnormal movement patterns are often present bilaterally. changes in kinetics and kinematics of both knees. Studies report higer peak knee angles, moments, and joint powers relative to controls[7]. 3-dimensional biomechanical analyses and postural stability testing reported hip rotation moment changes during landing in uninvolved side, frontal-plane knee motion during landing, sagittal-plane knee moment asymmetries at initial contact, and deficits in postural stability on the reconstructed limb[9].

The development of compensatory sttrategies of the uninvolved hip is considered to be the primary predictor of risk in athletes who sustained a second ACL injury within the first year of return to play[9]. Engaging both limbs in rehabilitaiton is a necceity[7].

Sex may be a contributing factor to secondary ACL injury. Graft rupture is more likely to occurin men, according to a 15 year cohort[10]. Another study reported no difference between sexes in graft rupure, however, contralateral injury was higher in female athletes[11].

Young athletes are at a higher risk of re-injury and also to contralateral injury [7].

Prevention of Re-injury[edit | edit source]

Revision of ACL reconstruction has poor outcomes with regards to functional performance and knee OA. However, about 25% of athletes undergo a second revision within 6 years of the primary ACL revision[12]. Efforts should be made to ensure the elimination of such process.

Quadriceps symmetry is essential to return to sport and prevention of future re-injury. Hasmtrins/Quadriceps strength ratio is another important factor to be considered in rehabilitation. The aim is to achive at least 85% strength symmetry before returning to sport[7].

Single-leg plyometric tests can give the clinician an overview on how the injured limb is functioning and on the asymmetries between both sides. Findings on single-limb tests should be considerd when setting up the rehabilitaiton plan[7].

Four neuromuscular control deficits were considered to be risk factors for second ACL injury[4]:

  • Hip rotational control deficits
  • Excessive frontal-plane knee mechanics
  • Knee flexor deficits
  • Postural control deficits

With the high incidence of re-injury and the evidence of poor outcomes of revision reconstruction, a need for a return to sport protocol has developd.

Return to Sport[edit | edit source]

The study by Myer et al [13] proposes a four stages advanced rehabilitation protocol to address common deficits found in athletes after ACL-reconstruction:

Stage 1: Dynamic stabilization and core strengthening

Stage 2: Functional strengthening

Stage 3:Power development

Stage 4: Sports performance symmetry.

Each of these phases has a minimum entering crieteria to guide clinicians when to start with their patients.for safe transition between stages

The aim of this protocol is to reconsition athletes to function optimally based on neurmuscular deficits upon returning to sport and allow safe play without re-injury.

Stage I :Dynamic stabilization and core strengthening[edit | edit source]

The athlete should meet the following crieteria in order to begin this stage[13]:

Goals of this stage:

1. Improving single-limb weight-bearing function and tolerance with greater knee flexion angles.

2. Improving symmetry of lower extremity running mechanics.

3. Enhancement of closed chain single-limb postural balance.

A strong core will allow the athlete to control the deceleration of the center of mass with balanced posture and accelerate their mass rapidly by controled force. Weakness and deficits in trunk and hip musculature are correlated with biomechanical abnormalities and ACL injuries particularily in female athletes[4][14].

Prior to intiating core strengthning targeted training, balance, proprioception, gait deviations should be well-addressed. It is important to note that an athlete may have full anatomical ROM but with functional activities, assymetries and deficits may present[13]. Addressing these deficits will allow progression in speed and intensity of running without pain and re-injury. problems in rythmic strides and symmetry can be detected by audible monitoring of foot contact. Pain, particularily patellofemoral pain, or ROM deficits are a contributing factors to unbalanced sprinting gait. Backward gait is a way of decreasing patellofemoral pain and help athlete progress in this stage and may also increase quad strength[13].

Targeted

Monitoring signs of overload in all stages is critical to prevent adverse effects[13].

Each athlete will need individulazed variations according to individual characteristics and sport.

Exercise intensity should be changed constantly to challenge balance and proprioception. Modifications of body posture, switching between various unstable surfaces, speed modifications, adding a sport-specific skill and/or adding unanticipated movement can all be ways of challenging stability and balance.

Examples of exercises to be used in this stage:

Stage II: Functional strengthening[edit | edit source]

Goals of this stage:

  • Increasing lower extremity non weight-bearing strength.
  • Improving load distribution pattern over both lower extremities in activities requiring double-leg stance.
  • Improvement of single-limb landing force attenuation strategies.

With core strengthening and dynamic stabilization exercises continuing throughout this stage, progressive lower extremity strengthening is introduced. Gradually and frequently adding more resistance without compromising good form.

Retrograde training, for example backward running on treadmill or backward jumping, has been shown to increase functional quadriceps

activation and to limit patellofemoral stress[15][16]

Stage III: Power development[edit | edit source]

At this stage power production of lower extremity is the main aim. Additionally, athletes are trained to resist fatigue and perform plyomterics with good biomechanics[13]. Training incorporates mid-level intensity double-limb multi-planar plyometric jumps and low-intensity single-limb hops.

Provide feedback and educate the athlete to land softly with coronal plane knee control.

Combining plyometrics with strength training improved jump performance and leg strength[17]. The addition of neuromuscular training with plyomterics, CORE and speed training resulted in great outcomes in performance measures

A number of studies examined the effects of neuromuscular training combined with plyomtwe (back squat, single-leg hop and hold distance, vertical jump, speed), as well as several biomechanical factors related to increased lower extremity injury risk (increased knee flexion-extension ROM, decreased abduction moments during the landing phase of a vertical jump, and increased single-leg postural stability)[18][4][19]

Stage IV: Sport Performance Symmetry[edit | edit source]

References[edit | edit source]

  1. ↑ Dunn WR, Spindler KP, Moon Consortium. Predictors of Activity Level 2 Years After Anterior Cruciate Ligament Reconstruction (ACLR) A Multicenter Orthopaedic Outcomes Network (MOON) ACLR Cohort Study. The American journal of sports medicine. 2010 Oct;38(10):2040-50.
  2. ↑ 2.0 2.1 Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. The American journal of sports medicine. 2014 Jul;42(7):1567-73.
  3. ↑ Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2005 Aug 1;21(8):948-57.
  4. ↑ 4.0 4.1 4.2 4.3 Hewett, T.E., Myer, G.D., Ford, K.R., Heidt Jr, R.S., Colosimo, A.J., McLean, S.G., Van den Bogert, A.J., Paterno, M.V. and Succop, P., 2005. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. The American journal of sports medicine, 33(4), pp.492-501.
  5. ↑ Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in neuromuscular control of the trunk predict knee injury risk: prospective biomechanical-epidemiologic study. The American journal of sports medicine. 2007 Jul;35(7):1123-30.
  6. ↑ Hewett TE, Myer GD, Ford KR, Heidt Jr RS, Colosimo AJ, McLean SG, Van den Bogert AJ, Paterno MV, Succop P. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. The American journal of sports medicine. 2005 Apr;33(4):492-501.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. The American journal of sports medicine. 2013 Jan;41(1):216-24.
  8. ↑ Castanharo R, Da Luz BS, Bitar AC, D’Elia CO, Castropil W, Duarte M. Males still have limb asymmetries in multijoint movement tasks more than 2 years following anterior cruciate ligament reconstruction. Journal of Orthopaedic Science. 2011 Sep 1;16(5):531.
  9. ↑ 9.0 9.1 Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, Hewett TE. Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. The American journal of sports medicine. 2010 Oct;38(10):1968-78.
  10. ↑ Leys T, Salmon L, Waller A, Linklater J, Pinczewski L. Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospective study of hamstring and patellar tendon grafts. The American journal of sports medicine. 2012 Mar;40(3):595-605.
  11. ↑ Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. The American journal of sports medicine. 2009 Feb;37(2):246-51.
  12. ↑ Battaglia MJ, Cordasco FA, Hannafin JA, Rodeo SA, O'brien SJ, Altchek DW, Cavanaugh J, Wickiewicz TL, Warren RF. Results of revision anterior cruciate ligament surgery. The American journal of sports medicine. 2007 Dec;35(12):2057-66.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 Myer GD, Paterno MV, Ford KR, Hewett TE. Neuromuscular training techniques to target deficits before return to sport after anterior cruciate ligament reconstruction. The Journal of Strength & Conditioning Research. 2008 May 1;22(3):987-1014.
  14. ↑ Padua DA, Marshall SW, Beutler AI, DeMaio M, Boden BP, Yu B, Garrett WE. Predictors of knee valgus angle during a jump-landing task. Medicine & Science in Sports & Exercise. 2005 May 1;37(5):S398.
  15. ↑ Flynn TW, Soutas-Little RW. Mechanical power and muscle action during forward and backward running. Journal of Orthopaedic & Sports Physical Therapy. 1993 Feb;17(2):108-12.
  16. ↑ Flynn TW, Soutas-Little RW. Patellofemoral joint compressive forces in forward and backward running. Journal of Orthopaedic & Sports Physical Therapy. 1995 May;21(5):277-82.
  17. ↑ Fatouros IG, Jamurtas AZ, Leontsini D, Taxildaris K, Aggelousis N, Kostopoulos N, Buckenmeyer P. Evaluation of plyometric exercise training, weight training, and their combination on vertical jumping performance and leg strength. The Journal of Strength & Conditioning Research. 2000 Nov 1;14(4):470-6.
  18. ↑ Myer GD, Ford KR, Palumbo OP, Hewett TE. Neuromuscular training improves performance and lower-extremity biomechanics in female athletes. The Journal of Strength & Conditioning Research. 2005 Feb 1;19(1):51-60.
  19. ↑ Paterno MV, Myer GD, Ford KR, Hewett TE. Neuromuscular training improves single-limb stability in young female athletes. Journal of Orthopaedic & Sports Physical Therapy. 2004 Jun;34(6):305-16.
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