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
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
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
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.
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.
Cincinnati Return to Sport Progression: Stage 2 Improve single-limb landing strategies. Improve force contribution symmetry during bipedal activities. Improve LE NWB strength.
Cincinnati Return to Sport Improve LE biomechanics during plyometric activities. Progression: Stage 3 Improve LE muscular endurance. Improve single-limb power production.
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.
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
Outcome Measures - Comprehensive Cincinnati Knee-Rating Scale International Knee Documentation Committee (IKDC) system
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.
Cincinnati Knee Score Stability Testing arthrometer, pivot shift Radiographic Findings Functional Testing Hop testing
Outcome Measures Other Activity scales Cincinnati Activity Scale IKDC Marx Activity Scale Tegner Rehab Adherence Sports Injury Rehab Adherence Scales (SIRAS)
Timeline of Recommended Outcome Measures
Outcome Measures - Objective ROM Circumference Assessment of Laxity instrumented, manual Isokinetic Testing Functional Performance Testing hop, shuttle, figure-8
Administration of Hop Testing 16 weeks post operatively Two test occasions 24-48 hours apart 22-24 weeks post operatively One test occasion
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
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
Single Hop for Distance Stand behind marked line on LE to be tested. Hop maximal distance. Land on same LE. Hold landing 2 seconds.
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.
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.
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.
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
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
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
Alternate Hop Test Battery Vertical jump Hop for distance Side hop
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: 571 580.
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: 571 580.
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: 571 580.
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
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