2011 Sports Medicine Conference
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1 Adolescent Rehabilitation: Late-phase Management of Post-operative Anterior Cruciate Ligament Reconstruction 2011 Sports Medicine Conference Kristin Allen PT, MSPT Cally Martin ATC, LAT Petra Place PT, BSPT, DPT Children s Bone, Joint and Spine Center
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3 Objectives Demonstrates a good understanding of late-phase ACL-R rehabilitation progression Knowledgable about ACL-R outcome measures Demonstrates a good understanding of Hop Test Administration
4 ACL-R Late-Phase Rehab (16-24 weeks) Factors Neuromuscular control Demands of sports Therapeutic intervention Sport specific drills Ensure a safe return to play
5 Neuromuscular Control Restore balance/reactive muscle activation. Functionally progress from low to high demand activities in controlled manner. Develop functional movements with appropriate control. Prepare for higher level return to sport activities.
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8 Cincinnati Return to Sport Progression: Stage 1 Improve symmetry in running mechanics. Improve single-limb WB strength at increasing knee flexion angles. Improve single-limb postural balance.
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18 Cincinnati Return to Sport Progression: Stage 2 Improve single-limb landing strategies. Improve force contribution symmetry during bipedal activities. Improve LE NWB strength.
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24 Cincinnati Return to Sport Improve LE biomechanics during plyometric activities. Progression: Stage 3 Improve LE muscular endurance. Improve single-limb power production.
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30 Cincinnati Return to Sport Progression: Stage 4 Equalize ground reaction force attenuation & generation strategies b/w limbs. Improve confidence & stability with highintensity cutting activities. Equalize power endurance b/w limb Utilize safe biomechanics during highintensity plyometric activity.
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35 Outcome Measures - Subjective Knee Outcome Survey (KOS) Activities of Daily Living Scale (ADLS) Sports Activity Scale (SAS) American Academy of Orthopedic Surgeons Sports Knee Rating Scale Knee Injury and Osteoarthritis Outcome Score (KOOS) Lysholm Knee Scale
36 Outcome Measures - Comprehensive Cincinnati Knee-Rating Scale International Knee Documentation Committee (IKDC) system
37 Cincinnati Knee Score Subjective Examination: symptoms, patient perception of overall knee function, ADL function, sports function, sports activity, & occupation. Physical Examination effusion, ROM, tibiofemoral & patellofemoral crepitus.
38 Cincinnati Knee Score Stability Testing arthrometer, pivot shift Radiographic Findings Functional Testing Hop testing
39 Outcome Measures Other Activity scales Cincinnati Activity Scale IKDC Marx Activity Scale Tegner Rehab Adherence Sports Injury Rehab Adherence Scales (SIRAS)
40 Timeline of Recommended Outcome Measures
41 Outcome Measures - Objective ROM Circumference Assessment of Laxity instrumented, manual Isokinetic Testing Functional Performance Testing hop, shuttle, figure-8
42 Administration of Hop Testing 16 weeks post operatively Two test occasions hours apart weeks post operatively One test occasion
43 For Each Hop Test: One practice trial on each limb Two measured and recorded trials Begin with non-operative limb Rest period offered between types of hop up to 2 minutes between individual hop test trials 30 seconds or less
44 Assessing Hops For Distance Successful Landing maintained 2 seconds Unsuccessful Touching down of contralateral LE Touching down of either UE Loss of Balance Additional Hop on Landing
45 Single Hop for Distance Stand behind marked line on LE to be tested. Hop maximal distance. Land on same LE. Hold landing 2 seconds.
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47 6-meter Timed Hop Large one-legged hops in series. Stand on tested limb behind starting line. Start timing when heel lifted from starting position. Stop timing when the tested foot crosses the finish line.
48 Triple Hop for Distance Stand behind starting line on test LE. Perform 3 consecutive hops as far as possible landing on same LE. Measure total distance for 3 consecutive hops from great toe.
49 Crossover Hop for Distance Stand behind starting line on test LE. Hop forward 3 times while alternately crossing over marking. Measure total distance hopped forward.
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52 Scoring of Hop Tests Take the mean score of 2 trials of each hop test. Measure absolute scores on each limb for each test. Calculate limb symmetry index (LSI) Average recorded trail surgical LE x100= % Average recorded trial non surgical LE
53 Fatigued State Hop Testing Hop performance decreased significantly During take-off Decreased hip/knee flexion angles more erect body position Decreased knee/ankle power During landing Decreased Hip moments more extended position Decreased ground reaction force
54 ACL-R Single Limb Hop Biomechanics Take-off on operative limb Decreased ROM at ankle/knee/hip Peak knee extension moment lower Peak ankle and hip extension moments higher Peak power generated at the knee lower Peak power at the ankle/hip higher Landing on operative limb decreased ROM at ankle/knee/hip Peak ground reaction forces not different Peak power absorption lower at knee and hip; higher at the ankle
55 Alternate Hop Test Battery Vertical jump Hop for distance Side hop
56 Strength Test Battery Open chain knee extension. Open chain knee flexion. Leg press muscle power test. Neeter C. et all. Development of a strength test battery for evaluating leg muscle power after anterior cruciate ligament injury and reconstruction. Knee Surgery Sports Traumatology Arthroscopy. (2006) 14:
57 Strength Test Battery Open chain knee extension. Open chain knee flexion. Leg press muscle power test. Neeter C. et all. Development of a strength test battery for evaluating leg muscle power after anterior cruciate ligament injury and reconstruction. Knee Surgery Sports Traumatology Arthroscopy. (2006) 14:
58 Strength Test Battery Open chain knee extension. Open chain knee flexion. Leg press muscle power test. Neeter C. et all. Development of a strength test battery for evaluating leg muscle power after anterior cruciate ligament injury and reconstruction. Knee Surg Sports Traumatol Arthrosc. (2006) 14:
59 In Conclusion Limited availability of evidence-based late-phase ACL-R rehab. Goal of late-phase rehab is to functionally progress pt from low to high-demand activities, ensuring good neuromuscular control to reduce risk of re-injury with return to sport. A variety of tests, incorporating both subjective and objective evaluation, is important to assess functional ability and outcomes following ACL-R Hop testing with optimal movement is a good predictor for return to play initiation
60 References Augustsson J et all. Single-leg hop testing following fatiguing exercise: reliability and biomechanical analysis. Scandinavian Journal of Medicine and Science in Sports. 2006:16; Barber-Westin SD, Noyes FR, McCloskey JW. Rigorous statistical reliability, validity, and responsiveness testing of the Cincinnati knee rating system in 350 subjects with uninjured, injured or anterior cruciate ligament-reconstructed knees. American Journal of Sports Medicine. 1999; 27: Beynonn BD, Uh BS, Johnson RJ, et al. Rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. American Journal of Sports Medicine. 2005; 33: Chmielewski TL, Jones D, Day t, Tillman AM, Lentz, TA, George SZ. The association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. Journal of Journal of Orthopaedic & Sports Physical Therapy. 2008;38:12: Filan, DK, Moran, R, Blake, C. Functional Measurement of knee proprioception six months after anterior cruciate ligament reconstruction. Physical Therapy Reviews. 2008;13:2: Ganley TJ. ACL Reconstruction in Adolescent and Preadolescent Patients. Orthopedics. 2009;32(1): Gustavsson A et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surgery Sports Traumatology Arthroscopy. 2006;14: Hewett TE, Paterno MV, Myer GD. Strategies for enhancing proprioception and neuromuscular control of the knee. Clinical Orthopaedics and Related Research. 2002; Hopper DM, Strauss GR, Boyle JJ, Bell J. Functional recovery after anterior cruciate ligament reconstruction: a longitudinal perspective. Archive of Physical Medicine in Rehabilitation. 2008; 89: Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, Richmond JC, Shelborne KD. Development and validation of the International Knee Documentation Committee Subjective Knee Form. The American Journal of Sports Medicine. 2001; 29: Irrgang JJ, Ho H, Harner CD, Fu FH. Use of the International Knee Documentation Committee guidelines to assess outcome following anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy :
61 Kilvan Ben. Treating the Young Athlete. Motivations, Inc. Course #190, A Workshop for Physical Therapists and Assistants, and Athletic Trainers. 2009: Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Relationship between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine. 2004; 32(3): Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surgery Sports Traumatology Arthroscopy. 2005; 13: Kvist J. Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Med 2004; 34(4): Laboute E, Savalli L, Puig P, Sabot G, Monnier G, Dubroca B. Analysis of return to competition and repeat rupture for 298 anterior cruciate ligament reconstructions with patellar or hamstring tendon autograft in sportspeople. Annals of Physical and Rehabilitation Medicine 2010; 53: Marx RG. Knee Rating Scales. Arthroscopy: The Journal of Arthoroscopic and Related Surgery 2003; 19: Marx RG, Jones EC, Allen AA, Altchek DW, O brien SJ, Rodeo SA, Williams RJ, Warren RF, Wickiewicz TL. Reliability, validity, and responsiveness of four knee outcome scales for athletic patients. The Journal of Bone and Joint Surgery. 2001; 83-A(10): McDevitt ER, et all. Functional Bracing After Anterior Cruciate Ligament Reconstruction. A Prospective, Randomized, Multicenter Study. American Journal of Sports Medicine. 2004;32(8): Mendoza M, Patel H, Bassett S. Influences of psychological factors and rehabilitation adherence on the outcome post anterior cruciate ligament injury/surgical reconstruction. New Zealand Journal of Pysiotherapy. 2007; 35(2): Myer, GD, Paterno, MV, Ford, KR, Hewett, TE. Neuromuscular Training Techniques to Target Deficits Before Return to Sport After Anterior Cruciate Ligament Reconstruction. Journal of Strength and Conditioning Research. 2008;22:3: Myer, GD, Paterno, MV, Ford, KR, Quantman CE, Hewett, TE. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sports phase. Journal of Orthopaedic & Sports Physical Therapy. 2006;36:6:
62 Neeter C et all. Development of a strength test battery for evaluating leg muscle power after anterior cruciate ligament injury and reconstruction. Knee Surgery Sports Traumatology Arthroscopy. 2006;14: Orishimo KF, Kremenic IJ, Mullaney MJ, McHugh MP, Nichols SJ. Adaptations in single-leg hop biomechanics following anterior cruciate ligament reconstruction. Knee Surgery of Sports Traumatolology and Arthroscopy. 2010:18; Reid A, Birmingham TB, Stratford PW, Alcock GK, Griffin JR. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Physical Therapy. 2007; 87(3): Risberg MA, Holm I, Myklebust G, Engebresten L. Neuromuscular Training Versus Strength Training During First 6 Months After Anterior Cruciate Ligament Reconstruction: A Randomized Clinical Trial. Physical Therapy. 2007;87(6): Risberg MA, Holm I, Steen J, Beynnon BD. Sensitivity to changes over time for the IKDC form, the Lysholm score and the Cincinnati knee score. Knee Surgery, Sports Traumatology, Arthoroscopy. 1999; 7: Sgaglione NA, Del Pizzo W, Fox JM, et al. Critical analysis of knee ligament rating systems. American Journal of Sports Medicine. 1995; 23: Shaw T, Chipcase LS, Williams MT. A users guide to outcome measurement following ACL reconstruction. Physical Therapy in Sport. 2004; 5: Shelbourne KD, Gray T. Minimum 10-Year Results After Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2009;37(3): Trees AH, Howe TE, Dixon J, White, L. Exercise for treating isolated anterior cruciate ligament injuries in adults (review). The Cochrane Library. 2009;1:1-50. Weitzel PP & Richmond JC. Critical evaluation of different scoring systems of the knee. Sports Medicine and Arthoroscopy Review. 2002; 10: Wright, RW et all. A Systematic Review of Anterior Cruciate Ligament Reconstruction Rehabilitation. Part II: Open Versus Closed Kinetic Chain Exercises, Neuromuscular Electrical Stimulation, Accelerated Rehabilitation and Miscellaneous Topics. Journal of Knee Surgery. 2008;21:
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