Rehabilitation after ACL Reconstruction

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1 Rehabilitation after ACL Reconstruction John Nyland, DPT, EdD Artur Proniewicz, MD Paul Mazzone, BS Athletic Training Program Kosair Charities College of Health and Natural Sciences Spalding University, Louisville, KY 40203, USA 1

2 Introduction The objective of this teaching module is to present an ACL rehabilitation progression based on restoration of normal active knee and hip range of motion, non-impaired locomotion form, lower extremity strength, and power with consideration for sport specific agility demands, tissue healing biology, biomechanics and psychobehaviors. 2

3 Create a healing environment Do no harm Educate the patient Tenets Develop self-efficacy and resilience Emphasize exercise movement quality over quantity (total sets/repetition volume and resistance) When in doubt leave it out Consider biological, biomechanical and behavioral healing timetables 3

4 Monthly General Emphasis Guidelines ROM Movement Form-Balance Strength Neuromuscular Control Power Agility Sport-Specific Training Return to Sport Decision-Making 4

5 Progressive Knee and Hip ROM Re-establish non-impaired active knee extension Perform knee flexion stretch in prone with hip slightly extended Progress knee flexion more slowly following posterior meniscus horn repair Non-impaired high knee flexion range of motion is key to prevent patellofemoral region irritation and dysfunction Focus knee flexion range early and revisit during power and sport-specific training 5

6 Examples a Prone knee flexion with hip extension (a) Flexed knee to chest (piriformis stretch)(b) b Functional frontal plane mobility (c) c 6

7 Slow, controlled, high-quality movements Low impact Safe Locomotion Form Create a frontal plane knee wobble and learn how to control it Teachable movements Welcome mistakes. Then discuss and correct potentially pathomechanical relationships 7

8 Form run Simulation (a) Examples Back step butt kick (b) Single leg lateral step stabilize (c) a b c Lateral stepweight shiftrotate x 3 (d) 8 d

9 Basic Strength Training Restore quadriceps function (BPTB, quadriceps tendon graft) Restore high knee flexion function (hamstring graft, BPTB, quadriceps tendon graft) Improve strength of hip and entire lower extremity Increase dynamic mid-range knee stability Progressive resistance exercises (with 8 repetition maximum 9

10 Examples Multi-directional straight leg raises (a) Single leg press (b) Single leg squat (c) Lateral step-ups (d) a b Single-leg flexed knee deadlifts (e) c d e Lateral plank with scissors (f) Supine heel walking (g) f g Swiss Ball Series (h) h 10

11 Integrate Strength Training with Neuromuscular Control and Balance Challenges Translate athletic ready position posture to sport specific maneuvers Evaluate consistency of appropriate technique Identify maintenance program needs 11

12 Examples Multi-planar lunges (a) Matrix movements (b) a b Bozu ball squats (c) c d Single leg stability with ball toss on stable and unstable surfaces (d) e Chop step Single leg hop Stabilization (e) 12

13 Power Plyometric progression Symmetrical neuromuscular control of postures Quality movement form Fast twitch bias, the good pop (< 0.2 sec) during propulsion Balanced loading with soft, controlled landings 13

14 Examples Kangaroo hopping (a) Frog hopping (b) b Single, double-leg bounding (c) a Backward zig-zag hop stabilize (d) Two-leg lateral hop with one-leg landing (e) c d Explosive sliding board intervals (f) e 14 f

15 Agility Training Slow-to-fast Small-to-large amplitude Exploratory-toperformatory Planned-tounplanned Quality technique throughout 15

16 3 cone agility ( short-balltall )(a) Examples Ball Short a Circuit board (b) Tall b c Pole cutting (c) 16

17 Sport Specific Training Considerations Small-to-large components (a) Physiological energy system matching (b) a b Falling, reverse falling, and getting up (c) c Individual-small group-large group Competition simulations 17

18 Knee Bracing Protects graft during remodeling and knee during functional recovery Frontal, sagittal, transverse motion control considerations Changes knee kinematics May change lower extremity muscle activation patterns Provide enough, but too much protection Continue safe training out of the brace whenever possible 18

19 Return-to-play decision-making Patient successfully passes pre-determined evidencebased criteria Objective and subjective preponderance of readiness evidence (including psychobehavioral factors)! No limb favoring No knee effusion 19

20 20 m single-leg timed hop Examples 20 m single-leg timed crossover hop (a) 20 m shuttle-jump repeats (b) a b Double hop Hop-gostop for distance (c) c 20

21 Objective Field Testing Form (20 m) Dynamic Knee Stability (20 m) Lower Extremity Power (20 m) Agility-Reaction Time Endurant Speed/Skills Form run simulation 2-leg lateral hop with 1-leg landing Stationary tuck jumps x 10 3 cone triangle agility maneuver Full and ½ court line drills with free throws Bear-Crab Crawl Chop steplateral hop 1 leg landing Frog hops Modified T- agility test Dribble-drive lay-up, 3 point shot repeats Lateral Shuffles Single leg timed hop Bounding ½ court pick-roll lay-ups Full court weave Backstep-Butt kick Single leg timed crossover hop Bungee-resisted zigzag running (40 m) Ball roll-out from end line (retrieve, shoot) 10 m jog-20 m sprint-10 m jog x 10 Prisoner Lunge- Rotation Single leg hopgo-stop Kangaroo hops Quick to ball (prevent 2 nd bounce after toss) Full court drop step defense 21

22 Maintenance Weak point Training Everyone gets homework consisting of 3-6 movements! Everyone is offered periodic updates 22

23 "Knee Re-Injury Prevention Program Following Rehabilitation Improves Sports Performance and Patient Outcomes" N = 50 (28 males, 22 females) 20.2 ± 7.7 years of age s/p ACL reconstruction, patellofemoral chondroplasty or medial patellofemoral ligament reconstruction and outpatient physical therapy 8-9 sessions, hrs Knee Outcome Survey-Sports Activity Scale 23

24 Perceived Overall Knee Function during Sports Activities How would you rate the overall function of your knee during sports activities? 1 = normal 2 = nearly normal 3= abnormal 4 = severely abnormal abnormal normal 24

25 Hop-go-stop comparison Uninvolved side = ± 56.5 cm Involved side = 311 ± 60.7 cm 95.7%, P <

26 20 m single leg timed hop comparisons Single leg timed hop Uninvolved = 5.2 ± 1.2 sec Involved = 5.3 ± 1.3 sec Single leg timed crossover hop Uninvolved = 6.8 ± 2 sec Involved = 6.7 ± 1.9 sec No difference 26

27 "Knee Re-Injury Prevention Program Following Rehabilitation Improves Sports Performance and Patient Outcomes" 96% (48/50) reported improved overall knee function during sports 56% (28/50) had a two-level perceived overall sports activity knee function improvement (from abnormal to normal) 84% (42/50) 90% hop-go-stop test bilateral equivalence 84% (42/50) 90% 20 m single leg timed hop bilateral equivalence 80% (40/50) 90% 20 m single leg timed crossover hop bilateral equivalence By 2.8 ± 1.3 yrs post-return to sports only 1 of 50 (2%) has sustained another knee injury (patella dislocation after primary MPFL repair) 27

28 Summary Correct or minimize the influence of associated impairments and conditions such as hip weakness Develop an active neuromuscular control learning environment using social cognitive theory principles Become a rehab sherpa guiding the athlete through cognitive appraisals, emotional and behavioral responses in addition to neuromusculoskeletal functional recovery Combine perceived function assessments with evidence-based objective clinical and field testing Continue to improve criterion-based assessments (particularly psycho-behavioral readiness) Provide homework and update it periodically 28

29 Correspondence John Nyland DPT, SCS, EdD, ATC, CSCS, FACSM 29

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