Non-operative Treatment of ACL Injury: Difference between revisions
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== Description == | == Description == | ||
The main objective of ACL reconstruction is to restroe the normal joint mechanics for successful return to sports. The majority of ACL- | The main objective of ACL reconstruction is to restroe the normal joint mechanics for successful return to sports and prevention on instability. The majority of ACL-deficiencies undergo surgical treatment<ref name=":0">Paterno MV. Non-operative care of the patient with an ACL-deficient knee. Current reviews in musculoskeletal medicine. 2017 Sep 1;10(3):322-7.</ref>. | ||
Despite the wide use of reconstruction, the rate of recurrence is still high particularly in the first 24 months following the operation<ref> | Despite the wide use of reconstruction, the rate of recurrence is still high particularly in the first 24 months following the operation<ref>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.</ref>. A systematic review investigated the rate of return to sports after reconstruction and reported 82% of participants return to sports, 63% returning to pre-injury level with only 44% had returned to competitive sport<ref>Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011 Jun 1;45(7):596-606.</ref> despite successful outcome on knee impairment-based function scales. | ||
For these reasons | For these reasons some patients elict to undergo conservative treatment but due to the complexity and complications of ACL-deficiency there should be some crietria to identify the right candidates for nonoperative treatment. | ||
The “rule of thirds” was described by Noyes et al. in 1983, stating that at least 1/3 of patients will benefit from nonoperative treatment without instability <nowiki>''giving way''</nowiki> | The “rule of thirds” was described by Noyes et al. in 1983, stating that at least 1/3 of patients will benefit from nonoperative treatment without instability <nowiki>''giving way''</nowiki><ref name=":0" />. | ||
== Screening to Identify Copers == | |||
Potential | <nowiki>''Potential Copers''</nowiki> are those who can potentially return to pivoting/cutting sports with conservative treatment. To identify them a cluster of screening tests<ref>A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture</ref> was developed: | ||
* | * Four one-legged hop tests; single leg hop for distance, single leg triple hop, single leg triple cross over hop, and the 6-m timed hop test | ||
* | * Incidence of knee giving way | ||
* | * Self-report functional survey ([[Knee outcome survey|Knee outcome survey-Activity of Daily Living Scale—KOS-ADLS]]) | ||
* | * Self-report global knee function rating | ||
https://www.youtube.com/watch?v=ACRD1uAZ2_4 | https://www.youtube.com/watch?v=ACRD1uAZ2_4 | ||
| Line 27: | Line 27: | ||
https://www.youtube.com/watch?v=QBppGOIb3iI | https://www.youtube.com/watch?v=QBppGOIb3iI | ||
Potential copers are those who | Potential copers are those who: | ||
* Presented without concomitant injuries | * Presented without concomitant injuries | ||
* | * Achieved a minimum score of 80% limb symmetry on all hop testing | ||
* >80% on the KOS-ADLS, | * >80% on the KOS-ADLS, | ||
* >60 on the self-report of knee function | * >60 on the self-report of knee function | ||
* ≤1 subjective report of knee giving way | * ≤1 subjective report of knee giving way | ||
Filure to meet these criteria | Filure to meet these criteria results in patient identified as non-coper and hence surgery will be recomended<ref name=":0" />. | ||
Meeting the screening tests is essential if patient is willing to return to pivoting/cutting sports. The other option is to return to modified activity or lower load sports. A 10-year cohort follwed up with ACL patients who were identified as potential copers and found very little return to sport rates among this category<ref>A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: | === Activity Modification === | ||
Meeting the screening tests is essential if patient is willing to return to pivoting/cutting sports. The other option is to return to modified activity or lower load sports. A 10-year cohort follwed up with ACL patients who were identified as potential copers and found very little return to sport rates among this category<ref>Hurd WJ, Axe MJ, Snyder-Mackler L. A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: part 2, determinants of dynamic knee stability. The American journal of sports medicine. 2008 Jan;36(1):48-56.</ref>. | |||
Sports such as football, basketball, soccer, and skiing are identified as level I/II pivoting and cutting activities requiring high level of stability and may not be suitable for patients who chose not to undergo surgical treatment. Sedentary occupations or those who participate in less demanding sports (straight-line sporting) such as jogging and cycling have better chance successful return to their sports with a non-operative course<ref name=":0" />. | |||
Sports such as football, basketball, soccer, and skiing | |||
== Rehabilitation == | == Rehabilitation == | ||
=== Neuromuscular training === | === Neuromuscular training === | ||
Also known as perturbation training, neuromuscular training is an essential phase in nonoperative rehabilitation with the aim of improving knee stability. Prior to starting this pahse, patient must meet the following criteria: | |||
* Full ROM | |||
* Full resolution of swelling | |||
* Sufficient lower limb strength | |||
Developed by investigators at the University of Delaware,designed to challenge the patient with ACL deficiency through a series of balance tasks enhanced with unanticipated perturbations to the unstable surface. Classically described as a 10-session program, the patient begins with stance on a rocker board and then progresses to a roller board (Fig. (Fig.5).5). While standing on the unstable surfaces, progressive perturbations are applied, challenging the patient to maintain balance, enhancing dynamic knee stability. Ideally, the task is designed to assist in the development of individualized patterns of muscle contraction, rather than global co-contraction, to facilitate dynamic knee stability. Multiple studies investigating the effects of perturbation training in the ACL-deficient population have reported improved knee kinematics [24], improved gait mechanics [25], and a reduction in episodes of giving way [26]. | |||
Completion of these series of exercises without giving way is essential prior to return to sports. In addition, the patient must present with sufficient quadriceps and hamstring strength, as demonstrated by isokinetic strength symmetry of >90% compared to the contralateral limb | Completion of these series of exercises without giving way is essential prior to return to sports. In addition, the patient must present with sufficient quadriceps and hamstring strength, as demonstrated by isokinetic strength symmetry of >90% compared to the contralateral limb | ||
Revision as of 21:51, 18 September 2019
Original Editor - Mariam Hashem
Top Contributors - Mariam Hashem, Kim Jackson, Jess Bell, Simisola Ajeyalemi and Tarina van der Stockt
Description[edit | edit source]
The main objective of ACL reconstruction is to restroe the normal joint mechanics for successful return to sports and prevention on instability. The majority of ACL-deficiencies undergo surgical treatment[1].
Despite the wide use of reconstruction, the rate of recurrence is still high particularly in the first 24 months following the operation[2]. A systematic review investigated the rate of return to sports after reconstruction and reported 82% of participants return to sports, 63% returning to pre-injury level with only 44% had returned to competitive sport[3] despite successful outcome on knee impairment-based function scales.
For these reasons some patients elict to undergo conservative treatment but due to the complexity and complications of ACL-deficiency there should be some crietria to identify the right candidates for nonoperative treatment.
The “rule of thirds” was described by Noyes et al. in 1983, stating that at least 1/3 of patients will benefit from nonoperative treatment without instability ''giving way''[1].
Screening to Identify Copers[edit | edit source]
''Potential Copers'' are those who can potentially return to pivoting/cutting sports with conservative treatment. To identify them a cluster of screening tests[4] was developed:
- Four one-legged hop tests; single leg hop for distance, single leg triple hop, single leg triple cross over hop, and the 6-m timed hop test
- Incidence of knee giving way
- Self-report functional survey (Knee outcome survey-Activity of Daily Living Scale—KOS-ADLS)
- Self-report global knee function rating
https://www.youtube.com/watch?v=ACRD1uAZ2_4
https://www.youtube.com/watch?v=iRdcsj2DRTI
https://www.youtube.com/watch?v=Uh-EDK1RezA
https://www.youtube.com/watch?v=QBppGOIb3iI
Potential copers are those who:
- Presented without concomitant injuries
- Achieved a minimum score of 80% limb symmetry on all hop testing
- >80% on the KOS-ADLS,
- >60 on the self-report of knee function
- ≤1 subjective report of knee giving way
Filure to meet these criteria results in patient identified as non-coper and hence surgery will be recomended[1].
Activity Modification[edit | edit source]
Meeting the screening tests is essential if patient is willing to return to pivoting/cutting sports. The other option is to return to modified activity or lower load sports. A 10-year cohort follwed up with ACL patients who were identified as potential copers and found very little return to sport rates among this category[5].
Sports such as football, basketball, soccer, and skiing are identified as level I/II pivoting and cutting activities requiring high level of stability and may not be suitable for patients who chose not to undergo surgical treatment. Sedentary occupations or those who participate in less demanding sports (straight-line sporting) such as jogging and cycling have better chance successful return to their sports with a non-operative course[1].
Rehabilitation[edit | edit source]
Neuromuscular training[edit | edit source]
Also known as perturbation training, neuromuscular training is an essential phase in nonoperative rehabilitation with the aim of improving knee stability. Prior to starting this pahse, patient must meet the following criteria:
- Full ROM
- Full resolution of swelling
- Sufficient lower limb strength
Developed by investigators at the University of Delaware,designed to challenge the patient with ACL deficiency through a series of balance tasks enhanced with unanticipated perturbations to the unstable surface. Classically described as a 10-session program, the patient begins with stance on a rocker board and then progresses to a roller board (Fig. (Fig.5).5). While standing on the unstable surfaces, progressive perturbations are applied, challenging the patient to maintain balance, enhancing dynamic knee stability. Ideally, the task is designed to assist in the development of individualized patterns of muscle contraction, rather than global co-contraction, to facilitate dynamic knee stability. Multiple studies investigating the effects of perturbation training in the ACL-deficient population have reported improved knee kinematics [24], improved gait mechanics [25], and a reduction in episodes of giving way [26].
Completion of these series of exercises without giving way is essential prior to return to sports. In addition, the patient must present with sufficient quadriceps and hamstring strength, as demonstrated by isokinetic strength symmetry of >90% compared to the contralateral limb
Return to Sport[edit | edit source]
In order to return to pivoting/cutting sports, a functional performance brace is recommended. marginal reduction in anterior tibial translation and enhanced proprioception, both of which may contribute to a feeling of stability by the patient.
Asessment[edit | edit source]
ACL reconstruction is superior to conservative treatment in the evidence[6].
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 Paterno MV. Non-operative care of the patient with an ACL-deficient knee. Current reviews in musculoskeletal medicine. 2017 Sep 1;10(3):322-7.
- ↑ 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.
- ↑ Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011 Jun 1;45(7):596-606.
- ↑ A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture
- ↑ Hurd WJ, Axe MJ, Snyder-Mackler L. A 10-year prospective trial of a patient management algorithm and screening examination for highly active individuals with anterior cruciate ligament injury: part 2, determinants of dynamic knee stability. The American journal of sports medicine. 2008 Jan;36(1):48-56.
- ↑ https://www.ncbi.nlm.nih.gov/pubmed/24238648/
