ACL Rehabilitation in Youth Sports - Seattle Children's · ACL Rehabilitation in Youth Sports 03...

ACL Rehabilitation in Youth SportsA Field to Field Examination

Main Campus4800 Sand Point Way NE Seattle, WA 98105206-987-6400

Bellevue Clinic and Surgery Center 1500 116th Ave NEBellevue, WA 98004206-987-6400

South Clinic34920 Enchanted Pkwy. SFederal Way, WA 98003253-838-5878

Mill Creek Clinic12800 Bothell Everett HighwaySuite 150Everett, WA 98208206-987-6400

Clinics

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Seattle Children’s Sports Physical Therapy

All of the Sports Physical Therapists at Seattle Children’s have specialized training in pediatric orthopedics and rehabilitation. Additional advanced training includes ankle, hip, and knee injuries, ACL rehabilitation, and return to play/sport testing. Therapists perform biomechanical analysis for upper extremity issues such as overhead sports and throwing, and for lower extremity, including video gait analysis for running and jumping. We treat spine issues such as spondylolisthesis, scoliosis, non-specific back pain, and cervical pain, as well as concussion, fractures, overuse injuries, and patients with pre- and post-operative care protocols. There are four therapists who are certified in the Schroth method for man-agement of idiopathic scoliosis. Three therapists are licensed athletic trainers, and six are APTA-board-certified clinical specialists in sports or orthopedics.

Speciality Clinics

ACL Class, Bellevue and South Clinics

The ACL class is designed for patients who have had an ACL reconstruction or other knee surgery. This is a 1 hour and 20 minute session with 4-5 kids. They are taken through a pro-gram involving warm-up, strengthening, plyometrics, functional training, endurance, core control, and stretching. The program is based on Sportsmetrics, which is an ACL injury prevention program. Participation in the ACL group helps kids rehabilitate their injured leg as well as working to reduce the chance of injury on the non-operative side. Once a patient is able to jog and do controlled jumping in their one-on-one PT sessions they can begin the group.

Athletes with Disabilities, All Clinics

We focus on helping school-age children and adolescents with disabilities heal after sports injuries or sports injury–related surgery. We work with athletes at any skill level who want to return to play, prevent injuries and improve overall performance.

Schroth Method for Scoliosis, Main Campus and Bellevue Clinic

The Schroth Method uses physical therapy to treat scoliosis. The goals of the Schroth Method are to prevent curve progression and improve posture through exercises based on the patient’s curve. The Schroth Method is not recommended for all patients with scoliosis. Patients must be at least 11 years old, have a cobb angle of 20 to 45 degrees, and be Risser 4 or lower.

Therapeutic Core Strengthening Class, Bellevue Clinic

The therapeutic core class is designed for patients with diagnosis of back and hip pain. This is a 55 minute class with maximum of 5 patients that is based in the Pilates method. The focus of this class is to improve core and glute strength and improve stability in a group setting. This may be appropriate for patients that do require formal 1:1 physical therapy as well as patients that are transitioning from physical therapy to the community as a stepping stone to discharge.

Learn More

www.seattlechildrens.org/sports-physical-therapy

ACL Rehabilitation in Youth Sports 03

04 On the Field Injuries Shanlyn Souza, MS, ATC, LAT Amanda Lipke, MS, ATC, LAT

12 Pediatric Sports Medicine Provider Panel Monique Burton, MD, FAAP Tom Jinguji, MD Celeste Quitiquit, MD, FAAP Shelly Post, PA-C

24 Sport Psychology Principles for Rehab & Return to Play Julie Vieselmeyer, MS, MA, CC-AASP

32 Surgical Intervention Gregory Schmale, MD, MEd

42 Evidence-Based Physical Therapy Following ACL Injury Jordan Snetselaar, PT, DPT

58 Return to Play Recommendations Ellie Somers, PT, MSPT, DPT

66 Return to Field Following Rehabilitation Shanlyn Souza, MS ATC, LAT Amanda Lipke, MS, ATC, LAT

70 Appendix - Special Tests

Contents

ACL Rehabilitation in Youth SportsMay 7, 2014

VenueWright AuditoriumSeattle Children’s Hospital4800 Sand Point Way NESeattle, WA 98105

Planning CommitteeJanet Morton, PTWhitney Marois, PT, MSPT, OCSSummer Ice-Tseng, PT, DPTNatalie Johnson, PT, DPTSteve McKenzie, PT, MSPTRichard Ford, Admin Assistant

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On the Field Injuries8:00 AM

Shanlyn Souza, MS, ATC, LAT

Shanlyn Souza, MS ATC, AT/L, is a certified Athletic Trainer at Seattle Children’s Hospital. In addition to being the Fitness Consultant for the Child Wellness Clinic, she is also the Head Athletic Trainer for Woodinville High School.

Amanda Lipke, MS, ATC, LAT

Amanda Lipke, MS ATC, AT/L, is a certified Athletic Trainer at Seattle Children’s Hospital. She received her Bachelor’s degree in Athletic Training and her Master’s degree in Human Performance. She is currently the head athletic trainer at Interlake High School in Bellevue, WA.

• Athletic Trainers (ATs) are health care professionals who collaborate with physicians to provide preventative services, emergency care, clinical diagnosis, therapeutic intervention and rehabilitation of injuries and medical conditions.1

• ATs are described as individuals most directly responsible for all phases of health care in an athletic environment.2

• Includes broad roles and responsibilities encompassing a variety of specialties under the sports medicine umbrella. – Injury prevention, first aid, injury management,

rehabilitation

• Commission on Accreditation of Athletic Training Education (CAATE) – 4 year Bachelor’s degree – 2 year Master’s degree

• Board of Certification (BOC) Exam1. – Individual State Department of Health requires

licensure or credentials • Moving towards Professional degree

– Baccalaureate programs may not admit, enroll, or matriculate students into the athletic training program after the start of the fall term 20221


• Evidence-based practice • Prevention and health promotion • Clinical examination and diagnosis • Acute care of injury and illness • Therapeutic interventions • Psychosocial strategies and referral • Health care administration • Professional development and responsibility3

• Certification maintenance period = 2 years

• 50 CEUs • Minimum 10

Evidence Based Practice (EBP) CEUs

• Conducted and published by the Board of Certification, Inc. (BOC)

• Defines minimum knowledge and skills • Blueprint for developing the BOC

Examination5

1. Injury/Illness Prevention and Wellness Protection

2. Clinical Evaluation and Diagnosis 3. Immediate and Emergency Care 4. Treatment and Rehabilitation 5. Organizational and Professional Health and

Well-being5

5 Domains of RDS

• Implementing standard evaluation techniques and formulating a clinical impression for the determination of a course of action.

• Employing standard care procedures and communicating outcomes for efficient and appropriate care of the injured.

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• Reconditioning participants for optimal performance and function.

• Understanding and adhering to approved organizational and professional practices and guidelines to ensure individual and organizational well-being.

Organizational and Professional Health and Well-being

• 9 members create the Board – 6 Certified ATs – 1 Physician Director – 1 Public Director – 1 Corporate/Educational Director

• The BOC is the only accredited athletic training program for certification in the US2

ATs Work In: • Public and private secondary schools • Colleges and universities, professional and Youth leagues • Municipal and independently owned youth sports facilities • Physician offices as physician extenders, similar to nurses, physician assistants, • Rural and urban hospitals, hospital emergency rooms, urgent and ambulatory care • Clinics with specialties in sports medicine, cardiac rehab, medical fitness, wellness • Occupational health departments in commercial settings, which include police and

fire departments • Branches of the Performing arts including professional and collegiate level dance

and music • Olympic sports • Physical therapy clinic • Manufacturing, distribution and offices to assist with ergonomics • Military3

19%

18%

17%

27%

2% 2% College/University

Secondary Schools

Clinic and Hospital

Students

Professional Sports

Military/OccupationalHealth

• 27 ATs in Puget Sound area high schools • Also found in:

– Ergonomics – Wellness clinics – Cystic fibrosis clinic – Outreach – Community ImPACT testing


• SCH – Provide full coverage for all practices and home events – Work primarily at the high school

• Clinic/Hospital – Work part time at the clinic – Work home events at local high school

• Direct Hire – Hired through school or district to work only for the

high school(s)

• Each site and sport have own specific EAP

• AT, Coaches, AD and site administrator all have specific roles

• NATA position statement available on website

• AED • Vacuum splint kit • Crutches • Medical kit • Treatment table • Ice

• At the school following classes until games/practices are done.

• In-season and post-season play includes the responsibility for the daily health care of 100-400 athletes.

• Daily duties: – Evaluate/diagnose a wide variety of injures – Taping and rehabilitation

Video Initial Assessment

• Gold standard to treatment of athletic injury is: – Early detection

• To avoid muscle guarding and special test false negatives, evaluate injury right after it occurred

– The nature of the injury = mechanism – Degree of severity

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• Do a primary survey for life threatening conditions

• Ask yourself: – What is the level of injury – Do I need to activate EMS – Is the athlete able to get off field by themselves or

is assistance needed

• Airway/breathing • Consciousness • Severe bleeding • Position of limb • Athlete’s response to injury • Obvious deformity • Watch for signs or symptoms of shock • Remove athlete appropriately to the sideline for a

more thorough evaluation as needed = Secondary Survey

• History: – Chief complaint, mechanism of injury (MOI), unusual

sounds • Observation:

– Immediate swelling, deformity, willingness to move injured extremity

• Palpation: – Tenderness, pain

• Special Tests – Rule out Fx before performing special tests

• Application of skills

• Anterior Cruciate Ligament (ACL) Injury

Best Practices

• Ruptures occur in a position of max stress • Valgus stress,

lateral rotation with foot planted position and deceleration

• Sudden hyperextension with rotation

• Can be contact or non-contact

• Q-Angle – Angle femur enters hip

socket • Different landing

strategies – Females use less knee

and hip flexion during landing/jump to stop

– Causes an increase in quad activation and decrease in hamstring stressing the ACL

Predisposition and Factors


Lachman’s • Uniplanar

instability test Knee in 20-30o flexion (loose-packed position)

• Isolates ACL

• Anterior Drawer – Not as sensitive as Lachman’s due to knee flexion

angle – Increase knee flexion pulls open capsular and

ligamentous structures taut and positions hamstrings to oppose tibial translation

– May produce false negative – Normal translation is 4-6mm

• Lelli’s Lever Test • Make a fist and put

underneath the athlete’s tibia, inferior to the tibial tuberosity. With other hand apply a posterior force on quadriceps

• With intact ACL, the foot comes up off the table

• If the ACL is not functioning, the foot remains on the table6

Video Sideline Evaluation

• Patient Education – Athlete is an active participant in evaluation and

“game plan” – Answer questions – Prognosis: Short and long term

• Next 24 hours • What to expect • Who to call • ER or no? • R.I.C.E.

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• Proper Referral

• Referral

1. Commission on Accreditation of Athletic Training Education. CAATE, n.d. Web. 4 Apr. 2016. <http://caate.net/>.

2. Board of Certification. BOC, n.d. Web. 4 Apr. 2016. <http://www.bocatc.org/about-us>. Path: http://www.bocatc.org/about-us/defining-athletic-training.

3. Prentice, William E. Principle's of Athletic Training: A Competency-Based Approach. N.p.: McGraw-Hill Higher Education, 2006. Print.

4. National Athletic Trainers' Association. NATA, n.d. Web. 4 Apr. 2016. <https://www.nata.org/>. Path: https://www.nata.org/about/athletic-training/education-overview; https://www.nata.org/about/code-of-ethics.

5. Role Delineation Study. 6th ed. Omaha, NE: Board of Certification; 2009. 6. Lelli, Alessandro, Rita Paola Di Turi, David B. Spenciner, and Marcello

Dòmini. "The “Lever Sign”: a new clinical test for the diagnosis of anterior cruciate ligament rupture." European Society of Sports Traumatology, Knee Surgery, Arthroscopy (2014). Print.


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Pediatric Sports Medicine Provider Panel9:00 AM

Monique Burton, MD, FAAP

Monique Burton, MD, FAAP, is a board-certified pediatrician with additional certification in Sports Medicine. She is the Director of the Sports Medicine Program at Seattle Children’s and the Chair of USA Track and Field’s Sports Medicine and Sports Science Committee. Dr. Burton has been a volunteer team physician at numerous international competitions with the United States Olympic Committee and USA Track and Field.

Tom Jinguji, MD

Tom Jinguji, MD, is a physician in the Division of Orthopedics and Sports Medicine Department and General Pediatrics at Seattle Children’s Hospital. He is an Associate Clinical Professor of Orthopedics and Sports Medicine at the University of Washington School of Medicine.

Celeste Quitiquit, MD, FAAP

Celeste Quitiquit, MD, FAAP, is a board-certified pediatrician with additional certification in Sports Medicine at Seattle Children’s South Clinic. She has served as a team physician at the collegiate level with UCLA and at the high school level both locally and regionally. She is an active member of the American Medical Society for Sports Medicine and the American College of Sports Medicine.

Shelly Post, PA-C

Shelly Post, PA-C, is a Certified Physician Assistant in the department of Orthopedics and Sports Medicine at Seattle Children’s Hospital. Shelly graduated from George Washington University Physician Assistant Program in 2007 with a Master’s degree. She completed a surgical residency for Physician Assistants at Yale University/Norwalk Hospital. Shelly has a particular interest in sports injuries, trauma, fracture care, and orthopedic surgery.

The Knee: Pediatric Sports Medicine Provider Office Visit

Monique S. Burton, MD Tom Jinguji, MD Shelly Post, PA-C Celeste Quitiquit, MD

Overview

• History • Physical Examination • Imaging • Labs • Differential Diagnosis

History

History

• What happened? Acute event

o Mechanism of injury o Pop? o Able to bear weight o Onset & details of

swelling/effusion

Insidious onset o Duration of symptoms o Change in activity –

type, frequency, intensity

o Limitations in normal physical activities

History

• Pain • Constant or Intermittent • Location • Quality

o Throbbing, aching, burning • Radiation • Exacerbating Factors

o With activity & types of activity o Positions o Certain movements

• Alleviating factors

History

• Swelling Superficial:

o Contusion, sprain, bursitis Effusion:

o Ligamentous, meniscal, fracture, bone contusion

• Mechanical Symptoms Catching or locking (not clicking)

o Meniscus, loose body

• Instability v. Giving away Instability internal derangement Giving away Pain response


History

• Other Patient Age

o Remember physeal injuries in skeletally immature athlete Referred pain

o Hips! Systemic symptoms

o Fever, weight loss, night pain, etc Other joint symptoms

o Consider Rheum etiology Previous injury of knee pain Exercise Hx ROS, Meds, Allg, PMHx, FHx, SHx

Anatomy

Anatomy: Anterior

Anatomy: Posterior

Anatomy: Lateral Anatomy: Medial

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Anatomy: Transverse Cross Section

Physical Examination

Physical Exam

• Inspection • Palpation • Range of Motion • Strength • Special Tests • Neurovascular • Other – HIPS!

Inspection

• Gait • Alignment • Swelling/Effusion • Discoloration • Deformity • Asymmetry • Atrophy

Inspection Alignment

VALGUS

VARUS

RECURVATUM

Inspection Effusion


Effusion

Milk fluid Tap patella

Sweep fluid from medial aspect

With lateral pressure, watch for fluid wave medially

Inspection Atrophy

Palpation Palpation Anterior Knee

• Distal Quadriceps • Quad Tendon • Patella:

Medial & Lateral Facets

• Patella Tendon • Retinaculum:

Medial & Lateral

• Tibial Plateau • Tibial Tubercle • Femoral Condyles • Fibular Head

Palpation Lateral knee

• Lateral meniscus • LCL • ITB • Distal Biceps femoris

Palpation Medial knee

• Medial meniscus • MCL • Pes anserine bursa

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Palpation Posterior knee

• Popliteal Fossa • Distal hamstring • Proximal

gastrocnemius

Range of Motion

• Flexion: 135° to 150° • Extension: -10° to 0°

Flexibility

• Hamstrings Popliteal angle

o Hip flexed @ 90° o Extend leg to endpoint o Should be able to get

straight

• Quadriceps Standing or prone

HIPS!!!

• Always examine the hips!!! Hip pain can refer to the

knee

Strength

• Resisted flexion • Resisted extension • Single leg knee squat • Hip external

rotation/abduction

Strength

• Trendelenburg Test Hip external rotators/abductors


Patellar Tests

Patellar Tilt

Patellar Glide

Patellar Tests

• Grind/Compression • Inhibition

Patellofemoral

• Apprehension • Subluxation/Dislocation

Lateral Collateral Ligament (LCL)

• Varus Stress Test Performed @ 0° & 30° Varus directed force Assess for laxity &

endpoint Compare to opposite

side

Medial Collateral Ligament (MCL)

• Valgus Stress Test Performed @ 0° & 30° Valgus directed force Assess for laxity &

endpoint Compare to opposite

side

Varus/Valgus Stress Test Varus/Valgus Test

• Alternative Position

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Anterior Cruciate Ligament (ACL)

• Anterior Drawer

• Lachman

• Pivot shift

Anterior Drawer

• Patient supine • Knee flexed to 90° • Foot stabilized • Thumbs on tibial

tubercle • Fingers on calf • Encourage patient to

relax hamstrings • Pull anteriorly

Anterior Drawer Lachman Test

• Patient supine • Injured knee flexed to

~30° • Stabilize femur w/ upper

hand • Grasp proximal tibia w/

lower hand • Translate tibia in anterior

direction • Assess for endpoint &

anterior translation

Lachman Test Pivot Shift Test


Posterior Cruciate Ligaments (PCL)

• Posterior Drawer • Posterior Sag Test

Posterior Drawer

Normal Abnormal

Posterior Sag Sign Meniscus Tests

• McMurray Test • Apley Grind Test • Thessaly Test

McMurray Test

• Patient supine • Grasp knee in one hand,

heel in other • Thumb- medial joint Fingers- lateral join • Maximally flex knee • Extend knee w/ varus then

valgus force in internal & external rotation

• + if click, pop, or pain

Apley Grind Test

• Patient prone • Downward force on foot • “Grind” foot into table

pain suggest meniscus tear

• Retract foot pain suggest meniscus tear pain suggest collateral ligament

injury

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Thessaly

• Patient stands flat footed on floor

• Knee flexed 20 degrees • Internally & externally

rotate body

Special Tests

Neurovascular Status

• Pulse, Capillary refill • Sensation

Anterior L3, L4, L5 Posterior S1, S2

• Reflexes Patellar L2, L3, L4

Differential Diagnosis

Differential Diagnosis

Acute Subacute/Chronic !

Ligamentous Apophysitis Infection

Meniscus Tendinitis/Bursitis Hip pathology

Patellar dislocation Patellofemoral Tumor

Fractures Osteochondritis Dissecans

Traumatic bursitis Arthritis

Tendon strain

Acute

• Ligamentous +/- pop Effusion Instability Positive ligamentous exam

findings • Meniscus

Pain with deep knee flexion, squats

Effusion – slower onset Mechanical symptoms Positive McMurrays


Acute

• Patella Dislocation/Subluxation Effusion Positive patellar apprehension

• Fractures Apophyseal Avulsion

o Sudden onset of pain @ tibial tuberosity, distal patellar pole o Focal swelling o Pain with resisted knee extension

Tibial Spine o Effusion o Pain with anterior drawer/Lachmans

• Do not repeat these tests!!!

Acute

• Traumatic Bursitis Fall onto knee on hard

surface Large swollen water balloon

like fluid collection • Tendon Strain

Quad/Hamstring tendons Sudden onset of pain @

distal tendons

Subacute/Chronic

• Apophysitis Pain @ tibial tuberosity

o Osgood Schlatter Pain @ distal patellar pole

o Sinding-Larsen-Johannson

• Tendinitis Patellar Hamstring Quad

• Patellofemoral + Theater sign Diffuse Pain

• Osteochondritis Dissecans • +/- mechanical syx • Most common

location • lateral aspect of

medial femoral condyle

• Inflammatory • Lack of improvement

with treatment methods

• Erythema • Warmth • Swelling without injury

!

• Infection +/- fever Swelling, erythema, warmth

• Tumor Lack of improvement Night pain

• Hip Refers to knee Consider SCFE, toxic synovitis, septic hip

Imaging

Imaging

• When should you image? Concerning History

o Acute Injuries o Night pain o Unexpected course

Positive Exam findings o Swelling/effusion o Point tenderness

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Imaging: Radiographs

• Start with Radiographs AP, lateral, notch, sunrise

Why we do x-rays first?

Popliteal avulsion fracture Osteochondral fracture

Why we do x-rays first?

Tibial eminence fracture Segond fracture

Imaging: MRI

Normal MRI

ACL tear • MRI: For concerning history & exam findings

Laboratory Studies

• When are labs needed? Concern for

o Infection o Inflammatory condition o Other

• What labs do you start with? CBC with differential, ESR, CRP Blood cultures when appropriate

• Refer to appropriate provider for more detailed labs

Thank You!


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Sport Psychology Principles for Rehab & Return to Play10:45 AM

Julie Vieselmeyer, MS, MA, CC-AASP

Julie Vieselmeyer, MS, MA, CC-AASP, is a sport and performance psychology consultant based in Seattle. She has served as the sport psychology consultant for high school and collegiate teams. She is an active member of the American Psychological Association and Association for Applied Sport Psychology. Julie is an instructor at Western Washington University.

SPORT PSYCHOLOGY PRINCIPLES FOR REHAB & RETURN TO PLAY Julie Vieselmeyer, MS, MA Sport & Performance Psychology Consultant Seattle Pacific University

Agenda

Psychological impact of ACL injury

Psychological response & reactions to injury

Role of sport psychology

A biopsychosocial model

Protective & risk factors

Cognitive-behavioral interventions

A Case Study

Psychology of ACL Rehabilitation

Despite being physically recovered from ACL reconstruction 30-60% of athletes may not return to pre-injury participation level (Ardern, Osterberg, Tagesson, Gauffin, Webster, & Kvist, 2014)

ACL surgery has been found to have

many ramifications for psychological functioning (Brewer et al., 2007)

Psychology of Injury

The study of personal and situational factors, as well as cognitive, emotional, and behavioral responses of athletes to athletic injuries.

Psychological Response to Injury

Injury-relevant information processing Immediate negative consequences Attempts to understand how and why injury occurred

Emotional upheaval and reactive behavior Increased emotionality Denial Greatest need for social support

Positive outlook and coping Acceptance Adherence to treatment Feelings of hopefulness

Psychological Reactions: After Injury

Disappointment

Relief

Hopelessness

Dreams shattered

Isolation

Losing fitness

Pain

Performance decrements

Fear of treatment

Loss of motivation

Lack of confidence

Fear of re-injury

Identity loss

Grief


Psychological Reactions: After Injury

All of the previous responses listed including anxiety and depression are actually NORMAL reactions to injury.

IF psychological reactions persist: TWO weeks or more Interferes with life

THEN a referral to a sport psychologist or mental health professional is needed.

Treatment Goals for ACL Injury

Reconstruction & Rehab Physical restoration Rehabilitation Return to play Increased strength & health Ability to participate in

lifelong sport

Sport Psychology Mental restoration and

wellbeing To increase adherence to

rehabilitation Psychological readiness to

return to play Increased resilience for

recovery and to prevent future injury

Ability to participate in lifelong sport is a source of enjoyment and satisfaction

What is Sport Psychology?

A tool for helping athletes see their sport from a different perspective with the goal of helping them reach their potential

Addresses clinical issues, performance enhancement, and life concerns in athletes

Sport Psychology Utilizes a Cognitive-Behavioral (CBT) Approach

A cognitive-behavioral approach considers how an individual’s thoughts, feelings, and behaviors interact to cause and maintain problems

Sport Psychology for Injured Athletes

Recent survey of 800 sports medicine docs indicated that 80% often discuss psychological/ emotional factors related to injury

Research with high risk athletes shows fewer injuries in those who complete stress management training (Weinberg & Gould, 2011)

Help athletes return to sport more quickly

Educate athlete about themselves and performance – provide tools to take attention away from maladaptive thoughts, emotions, and behaviors

Improves future performance

Biopsychosocial Model of Post-Sport Injury Response and Recovery

Affect

Behavior Outcome

Cognition

(Weise-Bjornstal, 2010; Wierike et al., 2013)

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Cognition

Interpretations

Appraisals

Beliefs

Affect

Emotions

Feelings

Moods

Behavior

Efforts

Actions

Activities

Protective Factors for ACL Rehab

Cognition High health & sport locus of control High self-efficacy Athletic identity

Affect Adaptive emotion regulation Self efficacy of knee function

Behavior

Moderate avoidance coping Rehabilitation adherence Use of mental skills

Relational High social support

(Brewer et al., 2007; Tripp, Stanish, Ebel-Lam, Brewer, & Birchard, 2011)

Risk Factors for ACL Rehab Cognitive

Low health & sport locus of control Low self-efficacy Catastrophizing

Affective Fear of reinjury Negative mood Pain High optimism

Behavioral Poor knee function Avoidance coping

Relational Low social support

Wierike, van der Sluis, van den Akker-Scheek, Elferink-Gemser, & Visscher, 2013)

Goals of Sport Psychology

Sport psychology strives to understand personal and situational factors, as well as cognitive, emotional, and behavioral responses of athletes to athletic injuries. The sport psychologist strives to select interventions and provide support to:

Increase protective factors

Decrease risk factors


Cognitive-Behavioral Interventions

Coping skills training Mindfulness-based stress reduction Motivational Interviewing (MI) Acceptance-based interventions Emotion regulation Mental skills training Goal setting Relaxation Self-talk Imagery Routines

Motivational Interviewing (MI)

When injury occurs something has to CHANGE! Typically injury is not a welcome change but that’s

not always the case MI is an intervention or a “way of being with people” to facilitate change Fundamental tenets: Collaboration Evocation Autonomy

Motivational Interviewing (MI)

How does MI look in practice?

(1) Empathy

(2) Develop Discrepancy

(3) Roll with Resistance

(4) Support Self-Efficacy

Goal Setting

Build a strategic plan to achieve a desired result.

LAW OF THE LADDER

LAW OF THE HARVEST

Goal Setting

Builds motivation Being goal oriented promotes a positive attitude Promotes adherence to rehabilitation plan Ensures athlete and treatment team have matching expectations: Set date for return to play Establish concrete plan for home program Determine other areas for improvement: sleep, nutrition,

mental skills

Note: Treatment team should emphasize the importance of sticking to the plan and not doing more even when athlete feels stronger

Self-talk

Refers to our internal dialogue. Many benefits to positive talk!

Enhances concentration

Improves confidence

Builds self-efficacy

Reinforces success

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Self-talk

THOUGHTS FEELINGS BEHAVIOR

Use cue words to trigger effectiveness Ex: “breathe” or “engage core - lift”

Use affirmations to improve self-efficacy “I am doing everything possible to get better.”

“I have a great team supporting me.” “I can do this!”

Relaxation

Being relaxed is an important state for body and mind to function optimally. Many benefits of relaxation for rehab and sport.

Decreases body tension

Improves coordination

Improves body awareness

Increased energy management

Improves ability to focus

Increases composure

Facilitates rest and recovery

Relaxation

Deep breathing

Progression Muscle Relaxation (PMR)

Autogenic Training

Meditation

Stretching

Other: Listening to music, reading, etc.

Imagery

Creating or re-creating an experience in one’s mind. Building an optimal image works to program our bodies and minds to engage the best response at critical moments.

Improves concentration

Reduces anxiety

Increases motivation

Builds confidence

Imagery

Rehearse specific sport skills Recall past successful performances Master rehabilitation exercises Healing imagery

Tips for Effective Imagery Polysensory

Controllability Vividness

Routines

Develop complementary physical and mental routines to facilitate goal achievement.

Increases adherence Builds concentration Increases motivation Maintains composure Builds confidence Cultivates purpose Enhances commitment to goals


Routines

Focus is on “doing” Routine behavior aids in minimizing negative thoughts or emotions Effective routines incorporate physical and mental skills

Why routines work?

A Case Study: Hannah

Hannah is 21 year old collegiate soccer player Presenting problem Right ACL reconstruction during her senior year of

high school Left ACL reconstruction during the first game of her

sophomore year of college Physical and psychological challenges in her sport,

school, and relationships as well as in changes in self-esteem and identity as a result of her injuries

Hannah wants to regain her past level of play for her senior year of college and regain enjoyment in her sport.

A Case Study: Hannah

Cognition “Am I ever going to play

again?” “What if I can’t achieve my

goals?” “What do others think of me?”

Affect Symptoms of anxiety and

depression Fear of reinjury Decrease in self-efficacy Reduced motivation

Behavior Sleep difficulties Change in appetite Avoidance of team

activities

Relationally Problems with teammates

and coach Problems with friends and

significant others

Treatment & Prognosis

Counseling Journaling Modeling Mental Skills Goal setting

Relaxation Imagery

Self-talk

Key Take-Aways

Following injury there is a typical pattern of response and psychological reactions but how athletes progress through these stages can vary widely

Identify coping problems early in rehabilitation and assess for psychological difficulties even after physical healing has occurred

Psychological functioning during rehabilitation predicts return to play and may impact future health and fitness

Utilize a biopsychosocial model to develop interventions such as motivational interviewing (MI), mindfulness based stress reduction, and mental skills training

Sport psychology interventions can help athletes return to sport, increase speed of recovery, reduce susceptibility to future injury as well as face adversity in future situations

Resources

Association for Applied Sport Psychology http://www.appliedsportpsych.org/ American Psychological Association Division 47 – Sport & Exercise Psychology http://www.apa.org/about/division/div47.aspx

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Thank You!

Julie Vieselmeyer, MS, MA Seattle Pacific University [email protected]

206.859.9881

References Ardern, C., Osterberg, A, Tagesson, S., Guaffine, H, Webster, K, Kvist, J., (2014). The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. British Journal of Sports Medicine, 48(22), 1613-U50. http://dx.doi.org/10.1136/bjsports-2014-093842

Brewer, B. W., Cornelius, A. E., Sklar, J. H., Van Raalte, J. L., Tennen, H., Armeli, S., & ... Brickner, J. C. (2007). Pain and negative mood during rehabilitation after anterior cruciate ligament reconstruction: A daily process analysis. Scandinavian Journal Of Medicine & Science In Sports, 17(5), 520-529.

Brewer, B. W., Van Raalte, J. L., Cornelius, A. E., Petitpas, A. J., Sklar, J. H., Pohlman, M. H., & ... Ditmar, T. D. (2000). Psychological factors, rehabilitation adherence, and rehabilitation outcome after anterior cruciate ligament reconstruction. Rehabilitation Psychology, 45(1), 20-37. doi:10.1037/0090-5550.45.1.20

Miller, W. R. & Rollnick S. (2002). Motivational Interviewing (2nd ed). The Guilford Press: New York.

te Wierike, S. M., van der Sluis, A., van den Akker-Scheek, I., Elferink Gemser, M. T., & Visscher, C. (2013). Psychosocial factors influencing the recovery of athletes with anterior cruciate ligament injury: A systematic review. Scandinavian Journal Of Medicine & Science In Sports, 23(5), 527-540.

Tripp, D. A., Stanish, W., Ebel-Lam, A., Brewer, B. W., & Birchard, J. (2011). Fear of reinjury, negative affect, and catastrophizing predicting return to sport in recreational athletes with anterior cruciate ligament injuries at 1 year postsurgery. Sport, Exercise, And Performance Psychology,1(S), 38-48. doi:10.1037/2157-3905.1.S.38

Weinberg, R. & Gould, D. (2011). Foundations of Sport & Exercise Psychology (5th ed). Human Kinetics: Champaign, IL.

Williams, J. M. (2010). Applied Sport Psychology (6th ed). McGraw Hill: New York.


32

Surgical Intervention12:45 PM

Gregory Schmale, MD, MEd

Gregory Schmale, MD, MEd, is a pediatric orthopedic surgeon with specialty certification in sports medicine. He is an Associate Professor in the Department of Orthopedics and Sports Medicine at the University of Washington School of Medicine. He serves as Clinic Chief for Sports Medicine and is the Program Director for Orthopedic Medical Education at Seattle Children’s Hospital. His specialty interests include knee injuries in the adolescent athlete and pediatric orthopedic trauma.

Youth ACL injuries

Gregory A. Schmale, MD Seattle Children’s Hospital

Seattle, Washington

Youth ACL Injuries are on the rise

• Increasing awareness – Increased reporting – Increased incidence

Treatment philosophies Protect the physis No surgery until mature

Reconstruct, but avoid the physis

intra/extra-articular procedure all epiphyseal reconstruction

Risk the physis and reconstruct More anatomic reconstruction Protect the knee

Observation Woods, 2004: “No evidence that intentionally delayed

anterior cruciate ligament reconstruction increased the rate of additional knee injuries.”

Risk of further injury – • Graf,1992: 8/12 skeletally immature patients with ACL tears returned

to sports with a brace after quad and HS rehabilitation. • After return to sports, all braced patients developed instability with

multiple episodes of "giving way,” by a mean of 7 months. • 7 patients sustained further meniscal damage an average of 15 months

(range 7-27 months) after initial injury.

• Brace management did not prevent instability or new meniscal tears.

Observation Mizuta, 1995

Conservative treatment for complete tears of the ACL in 18 skeletally immature patients, min 36 months f/u

Lysholm knee mean score of 64.3. Only one patient had returned to her pre-injury level of athletics. Secondary meniscal tears in 6 patients, and 3 more had the clinical

signs of a tear at follow-up. Radiological evidence of degenerative changes was found in 11 of the 18 patients.

The results of non-operative treatment for ACL injuries in this age group are poor and not acceptable.

- Lawrence, 2011: Patients < 14 yo who underwent surgical reconstruction of an acute ACL tear >12 weeks after the injury:

• Had a significant increase in irreparable medial meniscal tears and lateral compartment chondral injuries at the time of reconstruction.

• When a subjective sense of knee instability was present, this association was even stronger.

Physeal Sparing Techniques

Over-the-top ITBand reconstruction Kocher and Micheli

All Epiphyseal reconstruction Anderson


Kocher-Micheli extraphyseal ACL reconstruction

�

Kocher-Micheli extraphyseal ACL reconstruction

�

Kocher and Micheli results

Mean IKDC 97, mean Lysholm 96at 5.3 yrs mean f/u

Mean growth over 20 cm

2/44 failures

All patients Tanner 1 or 2

No identified growth abnormalities

OR?

Risks of Extra-physeal procedures

Non-anatomic reconstruction

A trough has to be made to encourage "ingrowth" since no tunnel is drilled

This trough on the anterior tibia for "graft-ingrowth" is near the apophysis of the proximal tibia

Anderson's all-epiphyseal ACL reconstruction - 1

34



Anderson's all-epiphyseal ACL reconstruction - 3 Anderson results

12 patients, 4 yrs mean f/u

Mean IKDC objective score = 97

All patients Tanner 1, 2, or 3

No identified growth abnormalities

Risks of all epiphyseal reconstructions

Proximity of the femoral tunnel to the germinal cell layer of the femoral physis

Proximity of the tibial tunnel to the germinal cell layer tibial physis

Oblique nature of the tunnels risks compromising large surface area of joint surfaces

Technically Demanding Procedure

Transphyseal reconstruction

UW and SCH: Soft-tissue grafts Hamstring autograft Tibialis anterior allograft

Single incision technique “Centrally” located tunnels No fixation across physes Endobutton femoral fixation Screw and washer tibia


Questions Do growth abnormalities occur with transphyseal

reconstructions?

What is the reinjury rate and rate of further surgery after ACL reconstruction in youth undergoing a transphyseal ACL reconstruction?

How do satisfaction and function correlate with return to prior level of sports after ACL reconstruction in youth?

What factors contribute to failure to return to pre-injury activity levels?

Retrospective Review (Schmale, Kweon, Bompadre, Larson, CORR, 2014)

50 patients skeletally immature at surgery invited for interviews, exams, and radiographs Pre-injury & current Tegner activity Current Lysholm functional score Height, weight, KT-1000 arthrometry IKDC guided physical exam Radiographs

All 29 living locally returned for interviews, exams, and radiographs

Demographics

Sex

Number of patients

Age at surgery

(yrs + stnd dev)

Increase in height post-

surgery*

< 3 cm

>3cm

Female 23 14 + 1 10 8 (mean 6 cm)

Male 6 14 + 1 2 4 (mean 8 cm)

*5 patients without pre-op heights

Results

n Range

Mean Satisfaction score 9 4-10

Mean Lysholm score 91 61-100

Re-ruptures 4/29 (14%)

Overall re-operations (index knee) 11/29 (38%)

Contralateral ACL ruptures 8/29 (28%)

IKDC scores A B C D Subjective 9 12 4

Symptom 14 6 4 1

Physical Exam 5 15 5

Radiographic Imaging 17 7 1

Overall IKDC 3 12 9 1

Results Tegner activity scores dropped from 7.6 to 6.8

(p=0.003) Only 12/29 (41%) returned to prior level of

sports High satisfaction correlated with return to sports Ipsilateral re-operation or contralateral ACL

disruption not associated with changes in return to prior level of sports

No relationship between function and activity Most who were less active indicated a change

in interest with increasing age

36

Tegner Activity Scores Male: 13 yo at reconstruction • 2 yr f/u, physes open, 15 cm increase in

height since surgery

No clinically obvious malalignment

4 yrs post-op • Physes closed

• 26 cm growth overall

No malalignment

No leg-length difference

7 yo, unstable knee, wouldn't wear a brace, recurrent giving way.

1 wk post-op films

Pre-op (age 7) & 3 yrs p-op 2 and 3 years post-op


Age 15, 8 yrs post-op Study Conclusions ACL reconstruction in the skeletally immature using soft tissue

grafts across open physes: No angular malalignments, no early physeal closures High satisfaction correlated with return to sports

But, less than 50% return to prior activities

Re-rupture rates high, contralateral rupture rates higher Repeat or contralateral knee injuries not associated with changes in return to prior level of sports Fresh-frozen tibialis anterior allograft may fail at higher rates than quadruple stranded hamstring autograft (odds ratio, 7.3; exact nonparametric 95% CI, 0.7–73; p = 0.13

No relationship between function and activity Patients who were less active indicated a change in interest with advancing age

Summary

ACL tears are common in youth.

Rehab and bracing programs may not prevent further injury in patients with an ACL deficient knee.

Rehab after surgery may not return the athlete to their pre-injury activity level.

Teenage boy, unstable knee

History – c/w ACL tear

Exam – c/w ACL tear

Imaging Radiographs

Assess the physis – still open? Look for fx – Segond fx is pathognomonic for ACL tear

MR Assess menisci, collateral and cruciate ligaments Assess the articular cartilage

Imaging Advanced Imaging

38

Advanced Imaging Advanced Imaging

ACL Reconstruction Arthroscopically assisted procedure

Typically using hamstring autograft

Similar techniques: transphyseal or with closed physes Exam under anesthesia Harvest the semitendinosus and gracilis Diagnostic arthroscopy Preparation of notch

clear soft tissues mark for femoral tunnel

Exam under anesthesia - ACL is deficient

Diagnostic Arthroscopy Set-up for harvest


Hamstring harvest approach

Hamstring Harvest for ACL reconstruction Graft preparation onto button

ACL Reconstruction Technique

Femoral tunnel Knee flexed, using accessory medial portal Guide pin followed by 4.5mm drilling Drilling socket Passing suture

Tibial tunnel Knee flexed 90 Tip aiming guide Check guide pin position Overdrill Rasp tunnel edges

Tunnel locations

40

Passing the graft

Thru tibial then femoral tunnel

Flipping the button

Cycling the graft, checking isometry

Fixing in full extension

Passing the ACL graft

Fixation Button on femur, screw and washer tibia

Summary

Hamstring autograft is our go-to ACL graft.

Transphyseal reconstructions deserve careful monitoring of post-op growth.

The surgery is straightforward; the rehab, challenging.

Controversies With regards to bracing, there are few facts:

No known study shows a knee with a torn ACL does better with a brace than without, with regards to further activity.

No known study shows post-op bracing after ACL reconstruction is advantageous and prevents re-tear. Repeated studies have shown that there is no advantage to post-op bracing.

However, hyperflexible patients are 1) more likely to tear their ACL’s in the first place, and

2) are more likely to re-tear after a reconstruction.

Hence, I brace these patients to avoid the position of hyperextension, a position that might put them at risk for further injury.

References Aichroth P.M, Patel D.V and Zorrilla P., The natural history and treatment of rupture of the anterior cruciate ligament in children and

adolescents. A prospective review, J Bone Joint Surg Br 84 (2002), pp. 618–619.

Anderson A.F, Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. A preliminary report. J Bone Joint Surg Am. 85 (2003), pp. 1255-63

Ballal, M.S, Bruce, C.E, Nayagam, S. Correction genu varum and genu valgum in children by guided growth. J Bone Joint Surg Br. (2010); 92:273-276

Castaneda, P., Urquhard, B. Sullivan, E. Haynes, R. Hemiepiphysiodesis for the correction of Angular Deformity About the Knee. JPediatr Orthop (2008); 28: 188-191

Gorman, T.M, Vanderwerff, R., Pond, M., MacWilliams, B. and Santora, S.D, Mechanical Axis Following Staple Epiphysiodesis for Limb-Length Inequality. J Bone Joint Surg Am. (2009); 91:2430-2439

Kocher M.S, Garg S, Micheli L.J. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am. (2005);87:2371-9.

Kocher M.S, Micheli J.S and Zurakowski D., et al., Partial tears of the anterior cruciate ligament in children and adolescents, Am J Sports Med 30 (2002), pp. 697–703.

Koman J.D, Sanders J.O. Valgus deformity after reconstruction of the anterior cruciate ligament in a skeletally immature patient. A case report. J Bone Joint Surg Am. (1999) ;81:711-5.

Lipscomb A.B and Anderson A.F, Tears of the anterior cruciate ligament in adolescents, J Bone Joint Surg Am 68 (1986), pp. 19–28.

Wijdicks C.A, Griffith C.J et al. Injuries to the medial collateral ligament and associated medial structures of the knee, J Bone Joint Surg Am 92 (2010), pp. 1266-80.


42

Evidence-Based Physical Therapy Following ACL Injury1:45 PM

Jordan Snetselaar, PT, [email protected]

Jordan Snetselaar, PT, DPT, is a Seattle Children’s Sports Physical Therapist. He specializes in functional treatment and acute management of sports orthopedic injuries with a focus on biomechanical analysis. He helped develop the injury prevention screen program and return to sports program.

Evidence-Based Physical Therapy Following Anterior Cruciate

Ligament (ACL) Injury Jordan Snetselaar, PT, DPT

May 7, 2016

Objectives

• Determine ACL injury risk factors • Understand principles of ACL injury prevention • Identify and understand copers vs noncopers • Understand principles of ACL reconstruction (ACLR)

“prehabilitation” • Understand principles of ACLR rehabilitation (early,

intermediate, and late phases) • Identify special considerations based on surgical

procedure and concomitant injuries

2

ACL Injury Risk Factors

3

Non-Modifiable Factors

• Gender • Females have two to six times greater ACL injury rate1

• No gender differences in ACL injury rates before onset of puberty2

• Anatomy

• Height3

• Femoral notch width3,4 • Q-angle3,4

• Joint laxity5 – Knee hyperextension increases the odds of an

ACL injury fivefold in young female athletes6

4

Modifiable Factors

• ACL injury occurs within 30-100 ms of initial contact during landing, deceleration, and/or lateral pivoting maneuvers7,8

• Biomechanical impairments leading to ACL injury: • Decreased knee, hip, and trunk flexion8,9,10 • Knee valgus8,9,11 • Hip and knee internal rotation8,9,10,11 • Anterior tibial shear10,11

5

Modifiable Factors (cont.)

• Neuromuscular deficits leading to ACL injury

• Female athletes often lack “Neuromuscular spurt” 12,13

• Decreased lower extremity force attenuation during landing14

• Decreased hamstrings to quadriceps torque ratios15

• Altered hip musculature recruitment16

• Proprioception deficits in trunk control17

6


Neuromuscular imbalances associated with ACL injury mechanisms18

Figure 818

7

Neuromuscular imbalances associated with ACL injury mechanisms18 (cont.)

Figure 818

8


Figure 818

9


Figure 818

10

Predicting Potential ACL Injuries

11

Prediction Algorithm for Female Athletes at High Risk for ACL Injury

• Measurements of knee valgus and knee flexion ROM during drop vertical jump, as well as body mass, tibia length, and quadriceps-to-hamstrings strength ratio predict high knee abduction moment in female athletes which has been linked to increased risk of ACL injuries19

• Predicts high knee abduction moment with 84% sensitivity and 67% specificity in female athletes19

12

44

Figure 919

13

Figure 919

14

The Landing Error Scoring System (LESS)

• The LESS utilizes video analysis of a drop vertical jump task. Shown to be valid and reliable for identifying high risk movement patterns10

• No relationship between risk of ACL injury and LESS score in male and female high school and collegiate athletes20

Figure 110 15

Drop Vertical Jump Predicts ACL Injuries

• Increased knee abduction during landing of drop vertical jump predict ACL injury with 78% sensitivity and 73% specificity for teenage female athletes21

Figure 425

• Physical therapists can identify high knee valgus angles during a drop vertical jump using real time observation22

16

Trunk Control Predicts Potential Knee Injuries

• Deficits in active trunk repositioning predict knee injury status with 90% sensitivity and 56% specificity in collegiate female athletes17

17

Tuck Jump Assessment • Tuck jump assessment tool may be useful in assessing

and training high risk movements23

Appendix 118

18


Predicting Potential ACL Injuries

• Females with low hamstrings strength and similar quadriceps strength relative to male controls may be at increased risk for ACL injury24

• Decreased hamstrings strength correlated to increased knee valgus during double and single leg leap landing in adolescent females resulting in increased loading at ACL25

19

Predicting Potential ACL Injuries (cont.)

• Isometric hip abduction and external rotation (ER) strength measures are able to predict noncontact ACL injury in male and female athletes26 • Cutoff for athletes at high injury risk: hip ER ≤ 20.3% of

body weight, hip abduction ≤ 35.4% of body weight26

20

Principles of ACL Injury Prevention

21

Training Strategies for ACL Injury Prevention

• Meta-analysis suggests that neuromuscular training and

education interventions decrease the incidence rate of ACL injury by approximately 50%27

• Plyometric training with biomechanical analysis and training appears to be key in reducing ACL injury rates28

22

Training Strategies for ACL Injury Prevention (cont.)

• Neuromuscular training programs that include

biomechanical, proprioceptive, and strength training have shown:

• Positive performance enhancements – improved strength and

power28,29,30,31,32

• Improved biomechanics and coordination leading to decreased ACL injury risk28,29,30

23 Table 118 24

46

Training Strategies for ACL Injury Prevention (cont.)

• Feedback with external focus of attention (focus on

movement effect not the movements themselves) may be more suitable for acquiring complex motor skills33

• Improved movement patterns found when using external focus of attention: • Greater knee flexion angles34 • Lower peak vertical ground reaction force35 • Improved neuromuscular coordination36

25

Figure 1 and 237

Feedback with External Focus of Attention

26

Timing of ACL Injury Prevention

• Systematic review of ACL injury prevention programs38 showed success with: • At least 6 weeks of preseason training 2-3 times per week • In-season training 1-2 times per week • focus on strength, plyometrics, balance, proprioception, and

education/feedback on proper technique

• Both high intensity preseason neuromuscular training

and medium intensity (warm up) in-season training have demonstrated decreased ACL injury risks28

27

Timing of ACL Injury Prevention (cont.)

• Preadolescence or early puberty seems to be a critical phase related to increase ACL injury risk in female athletes39

• Neuromuscular training programs may help to decrease the gender differences in biomechanical control and decrease adolescent female athlete ACL injury risk1

28

ACL Injury Prevention Programs

• Sportsmeterics • Training program including flexibility, plyometric, and strength

training shows significant decrease in non-contact knee injuries for high school female athletes29

• Santa Monica Prevent Injury and Enhance Performance (PEP) Program • Training program including education, strengthening, stretching,

plyometrics, and agility training showed decreased ACL injuries in female division I soccer players40,41

29

ACL Injury Prevention Programs (cont.)

• Knee Injury Prevention Program (KIPP) • Coach-led 20 minute neuromuscular warm up focusing on

strength, balance, plyometrics, agility, and education to avoid dynamic knee valgus showed significant reduction in noncontact lower extremity injuries for girls high school basketball and soccer42

• FIFA 11+ • Warm up including strengthening, education, and neuromuscular

training showed a trend toward lower extremity injury risk reduction in youth female soccer players, although not significant43

30


ACL Injury Prevention Programs (cont.)

• A systematic review44 found that the only programs to significantly reduce ACL injuries in adolescent female athletes were:

• Sportsmetrics

• Prevent Injury and Enhance Performance (PEP) Program

• Knee Injury Prevention Program (KIPP)

31

After ACL Injury http://www.newsday.com/sports/football/acl-injuries-no-longer-spelling-doom-for-football-careers-1.5335284

Copers and Noncopers Following ACL Injury

33

Copers vs. Noncopers

• Copers: • Able to resume all preinjury activities without episodes of giving

way and do not require surgery • Perform significantly better than noncopers on all four single leg

hop tests45

• Noncopers • Unable to return to previous level of activity or experience

episodes of giving way • Demonstrate worse gait kinematics and time-distance variables

when compared to copers at 4 months post injury, noncopers utilize a joint stiffening strategy46

34

Copers vs. Noncopers (cont.)

• Hurd et al 200847 • 832 highly active individuals with subacute ACL tears were

followed over 10 years • Screening exam around 6 weeks after injury determined

potential copers (146/345) and noncopers (199/345) • 6 meter timed hop at least 80% • Knee Outcome Survey ADL scale at least 80% • Global rating of knee function of at least 60 • No more than one episode of giving way

• 25 out of 63 (39%) of the individuals who passed all components of rehabilitation and the return to sports test did not undergo ACLR

• 89% (308/345) of the initial group eventually had surgery, only 7% (25/345) did not

35


• Ramski et al 201348

• Meta analysis of operative vs nonoperative treatment of child and adolescent ACL tears favors early surgical stabilization over nonoperative or delayed treatment

• Nonoperative or delayed treatment patients were 33.7 times more likely to have clinical instability or pathological laxity

• Risk of meniscal tear after operative treatment was 4%, risk after nonoperative treatment was 67%

• Significantly greater rate of return to activity, 92% with operative treatment, 43.75% with nonoperative treatment

36

48


• Surgical repair appears to be the preferred treatment for individuals who choose to return to high level pivoting sports49

• Early onset knee osteoarthritis (OA) is a risk after ACL injury with

or without surgical intervention50,51

• 70% reduction in high risk sports participation for those treated conservatively, only 44% reduction for those treated surgically at 10-13 year follow up52

37

Principles of “Prehabilitation”

• Reduce inflammation

• Restore normal range of motion – decreased risk of post-op arthrofibrosis with normalized AROM prior to surgery54

• Restore neuromuscular control – normalize gait pattern

• Prepare patient for surgery

38

Principles of “Prehabilitation” (cont.)

• Prevent muscle weakness • Pre-op quadriceps strength has significant impact on long term

knee functional outcomes following ACLR55,56 • Quadriceps strength within 20% of uninvolved leg recommended

prior to surgery55

• A progressive 5 week exercise therapy program has shown significant improvement in knee function following ACL injury57

39

Anatomy and Physiology of ACL Reconstruction (ACLR)

40

• Incorporation of graft at insertion site: • Bone autograft (patellar tendon) between 6-8 weeks58 • Soft tissue autograft (hamstring or quad tendon) between 8-12

weeks59 • Allografts between 4-6 months60

• Graft strength:

Table 361

41

Ligamentization

• Graft weakens during first 2-4 weeks, then begins progressive revascularization and maturation62,63

• Resembles a native ACL by 1 year62

Figure 264

42


Rehabilitation following ACL Reconstruction (ACLR)

43

Principles of Early ACLR Rehabilitation

• Goals of immediate post-op phase (~0-3 weeks) • Restore full passive knee extension • Progress knee flexion ROM • Reduce post-op inflammation and pain • Progress toward ambulation without assistive device • Re-establish voluntary quadriceps control • Protect reconstructed ACL and donor site

44

Early ACLR Rehabilitation (cont.)

• Restore full passive knee extension ROM • Patients who get and maintain full knee motion show decreased

prevalence of OA long term after ACLR65 • Loss of 3-5° knee extension compared to uninvolved knee had

worse subjective and objective outcomes a mean of 14.1 years post ACLR66

• Progress knee flexion ROM • Immediate motion is critical to avoid ROM complications67 • No significant difference for continuous passive motion and

standard treatment vs standard treatment alone on knee ROM and joint laxity68

45


• Reduce post-op inflammation and pain • Reduced effusion leads to increased ROM, decreased pain, and

improved function53 • Pain may play a role in quadriceps inhibition69 • Debate exists on joint effusions role in quadriceps inhibition56,70,71

• Progress toward ambulation without assistive device • Weight-bearing as tolerated • No significant benefits of bracing72 • Possible benefit of locked brace immediately post-op due to

quadriceps inhibition

46

Quadriceps Inhibition 1 Week Post-Op

47


• Re-establish voluntary quadriceps control • Inhibition of quadriceps is common initially after ACLR and can

persist long term74 • Weakness due to arthrogenic muscle inhibition and muscle

atrophy53 • Neuromuscular electrical stimulation (NMES) combined with

exercise was more efficient than exercise alone at increasing quadriceps strength75

• Open and closed chain exercises are as effective as each other for knee laxity, pain and function in short term after ACLR68

48

50

Straight Leg Raise with Mild Quadriceps Lag

49


• Protect reconstructed ACL • Seated knee extension between 10°-50° knee flexion loads the

ACL significantly more than weight bearing exercises73 • Facilitate hamstrings co-contraction: forward trunk tilt (30-40°),

heels on ground, knees over feet (sagittal plane), knees not moving more than 8-10 cm anterior to toes73,76,77

• Protect donor site • Potential for hamstring tendon regrowth following ACLR78,

consider delaying resistive hamstrings exercises 8 weeks61 • Donor site morbidity can occur with patellar tendon graft79, be

aware of patellar tendon pain

50

Squat Facilitating Hamstrings Co-Contraction

51

Protect Reconstructed ACL

Table 160 52

Principles of Intermediate ACLR Rehabilitation

• Goals of intermediate post-op phase (~3-12 weeks) • Restore full ROM • Progress quadriceps strength and control • Restore neuromuscular control and balance • Gradually increase loading at knee

53

Intermediate ACLR Rehabilitation (cont.)

• Restore full ROM – full knee ROM compared to uninvolved limb results in decreased risk of OA long term65

• Progress quadriceps strength and control • Initial focus on closed chain terminal knee extension control • Squat80 and lunge81 show minimal to no ACL loading, LAQ

against resistance increases ACL load82 (still less than walking83) • Progress eccentric loading84

54



• Soreness rules to guide progressive strengthening

Table 385 55


• Restore neuromuscular control and balance

• Address core and hip strength and

stability impairments

• Hip and core weakness may be predictive of second ACL injury86,87

• Target hip extensors, abductors, and

external rotators early in order to decrease second ACL injury risk86,88

56

Dynamic knee valgus during single leg hip hinge


• Restore neuromuscular control and balance (cont.)

• Address motor patterns that led to initial injury and decrease second injury risk

• Multi-planar neuromuscular impairments in both ACLR and

uninjured limbs combined to predict second ACL injury risk86

• Poor neuromuscular control of trunk position may increase the risk of ACL injury17,89

• Improved self-reported knee function after ACLR with

neuromuscular rehab program over strength training alone90

57

Altered Motor Control with Lateral Heel Tap

Operative Leg 58

Altered Motor Control with Single Leg Hip Hinge

Operative Leg Non-Operative Leg

59


• Gradually increase loading at knee

• Protect graft gradual increase in stress to knee • Davis’s law: soft tissue heals according to how it is mechanically

stressed

• Peak ACL force:76,81,82,91,92,93 • Leg press and barbell squat with max resistance = 0 N • Forward and lateral lunge = 0 N • Single leg squat = 124 N • Seated knee extension with max resistance = 248 N • Double-foot drop landing off 60 cm step = 253 N • Single leg landing from running to a stop = 1294 N

60

52


• Gradually increase loading at knee (cont.) • Progress from sagittal plane to multi-planar movements

• Persistent swelling or pain indicate over aggressive treatment61 • Introduce jogging in pool at 2 months • Progress hamstrings strength following hamstring autograft

• Hamstring tendons have the ability to regenerate following autograft78

• The use of hamstring autograft does not limit recovery of hamstrings strength94

• Prepare for late phase plyometrics – practice good habits!

61

Hamstrings Deficits Following ACLR

62

Principles of Late ACLR Rehabilitation

• Goals of Late post-op phase (~3-9 months) • Progress neuromuscular control • Normalize quadriceps and hamstrings strength • Introduce plyometric activities • Progress to sport specific training • Prepare for return to sport

• Seattle Children’s ACL group class

63

Late ACLR Rehabilitation (cont.)

• Progress neuromuscular control

• Biomechanical factors predict second ACL injury risk, 92% sensitivity, 88% specificity86:

• A net internal rotation moment of the uninvolved hip with landing drop vertical jump

• Increased frontal plane knee motion during landing drop vertical jump

• Sagittal plane knee moment asymmetries at initial contact on drop vertical jump

• Deficits in single leg postural stability

• Neuromuscular control deficiencies are the only known modifiable factors predictive of second ACL injury risk86

64

Neuromuscular Impairments Leading to Secondary ACL Injury Risk

Figure 586

65


• Normalize quadriceps and hamstrings strength • Recommended that prior to return to sports:

• quadriceps strength at least 85% of uninvolved leg30 • hamstrings:quadriceps strength ratio >66% for males, >75% for

females61 • Deficits in neuromuscular coordination of hamstrings and quads

following ACLR may manifest as excessive landing contact noise95

66

Soft single leg hop landings



• Introduce plyometric activities

• Recommended that prior to initiating late phase rehab:85 • Full pain free AROM • Minimal to no joint effusion • At least 70% strength symmetry

• Neuromuscular training including plyometric and strength training can improve speed, strength, and power while decreasing injury risk in teenage females96

• Control of dynamic knee valgus improves with plyometric training30

67

Biomechanical Flaws with Jumps

68


• Introduce plyometric activities (cont.)

• Alterations in force-attenuation and generation as well as multi-planar asymmetries at hips and knees noted up to 2 years after ACLR in males and females97,98

• Altered hip and knee biomechanics found on the involved limb following ACLR even though single leg hop test distance was within 93% of uninvolved limb99

• Altered trunk control during running found in females post-ACLR compared to matched controls100

69

Lunge Jumps

70


• Progress sport specific training

• Return to running program initiated at 3 months at our clinics • Debate exists on when to return to running85,61 • Keep in mind graft incorporation time frames

• Addition of on field rehabilitation may help to address deficits in return to sport101,102

• Female athletes who had returned to sport following ACLR showed significantly higher knee valgus during 45° cutting task compared to uninjured controls103

71


• Prepare for return to sport

• Return to sport assessment – 6 months post-ACLR at our clinics followed by gradual return to sports

• Single leg hop tests at 6 months post-ACLR demonstrate excellent accuracy for prediction of athletes with normal knee function at 1 year post-op104

• Within the first year post-ACLR 2/3 of athletes had not returned to their competitive sport105

• Individuals with very high preinjury activity level have a higher probability of not returning, due in part to fear of reinjury106

72

54

Seattle Children’s ACL Group Class

• Group treatment session • 80 minute weekly sessions with intensive plyometric,

strength, endurance, and agility training • Patients eligible once they are at least 3.5 months post-

op and: • Perform single leg squat to at least 60 degrees with good form • Able to jog for 5 minutes with proper gait • No reported feelings of instability

• Progressing toward return to sports assessment at 6 months

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Seattle Children’s ACL Group Class (cont.) • Dynamic warm up • Jump training

• Focus on proper biomechanics and correcting “high risk” movements

• Progress from DL SL, stationary multi-planar, increasing speed

• Strength and stability training • Focus on quadriceps, hips, and hamstrings strengthening • Focus on proper biomechanics

• Agility training • Progressing from sagittal plane multi-planar • Sport specific agility activities

• Cardiovascular endurance training • Core strengthening • Flexibility training

74

Special Considerations for ACLR

75

ACLR Using Allograft

• Morphology, maturation, and ligamentization of autograft is favorable to allograft at 3 and 6 months post-op107

• Meta-analysis of patellar tendon autograft vs allograft showed increased graft failure and decreased performance on single leg hop test for allograft108

• A slower progression to athletic activities is advised.61 Due to delayed graft incorporation (4-6 months)

76

ACLR With Meniscal Pathology

• Meniscal repairs performed at the time of ACLR have superior healing rates and better outcomes than isolated repairs109

• Immediate weight bearing and mobilization recommended84

• Limit deep knee flexion in weight bearing (specific guidelines based on location and extent of repair), no squatting past 60° for 8-12 weeks61

77

ACLR With Collateral Ligament Injury

• Medial Collateral Ligament (MCL) Injury • Grade I and II MCL sprains may not require surgical intervention • ACL with concomitant MCL injuries often present with excessive

scar tissue formation and may require an accelerated progression for ROM110

• Lateral Collateral Ligament (LCL) Injury

• Combined ACL and LCL injuries are relatively rare, 1% incidence111

• Avoid excessive varus stress at knee, as well as, isolated hamstrings strengthening up to 6-8 weeks61

78


ACLR With Articular Cartilage Lesions

• Occur in approximately 71%-85% of traumatic ACL injuries112,113, most commonly on lateral femoral condyle and lateral tibial plateau114

• Progress partial to full weight bearing and gentle ROM to assist articular cartilage healing61 • Avoid excessive compressive force early in rehab115 • Full unloading and immobilization may be harmful to healing

articular cartilage115

• Surgical articular cartilage repair will impact rehabilitation progression depending on size and location of repair

79

Take Home Messages

80

Take Home Messages

• Look for modifiable ACL injury risk factors in all patients • Decreased hip and knee flexion, knee valgus, heavy landings

with jumping tasks, and poor trunk control

• Neuromuscular training may help decrease the risk of ACL injuries and enhance athletic performance if: • Comprehensive training programs include plyometric, balance,

strengthening exercises, and education/feedback on technique • They are performed 2-3 times per week for at least 6 weeks at

high intensity

81

Take Home Messages (cont.)

• Adolescent athletes who desire to return to a high level of sport participation have the best success with surgical ACLR

• “Prehabilitation” to normalize knee ROM and quad strength has significant benefit for post-op outcomes

• Incorporation times of ACL graft: • Bone autograft (patellar tendon) between 6-8 weeks • Soft tissue autograft (hamstring or quad tendon) between 8-12

weeks • Allografts between 4-6 months

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Take Home Messages (cont.)

• In early post-op phase: • Get full knee extension and regain voluntary quad control

especially in terminal knee extension • Protect ACL graft by avoiding open chain knee extension

between 10°-50° • Safe to incorporate closed chain strengthening early

• In late post-op phase: • Biomechanical factors that predict second ACL injury risk during

drop vertical jump: • hip internal rotation on uninvolved limb, knee valgus, asymmetrical

knee flexion at initial contact; as well as deficits in single leg postural stability

83

References 1. Hewett TE, Myer GD, Ford KR, Paterno MV, Quatman CE. The 2012 ABJS Nicolas Andry Award: The sequence of prevention: a systematic approach to prevent anterior cruciate ligament injury. Clin Orthop Relat Res. 2012

Oct;470(10):2930-40. 2. Andrish JT. Anterior cruciate ligament injuries in the skeletally immature patient. Am J Orthop (Belle Mead NJ). 2001 Feb;30(2):103-10. 3. Scoville CR, Williams GN, Uhorchak JM, et al. Risk factors associated with anterior cruciate ligament injury. In: Proceedings of the 68th Annual Meeting of the American Academy of Orthopedic Surgeons. Rosemont, Il: American

Academy of Orthopedic Surgeons; 2001:564. 4. Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, Garrick JG, Hewett TE, Huston L, Ireland ML, Johnson RJ, Kibler WB, Lephart S, Lewis JL, Lindenfeld TN, Mandelbaum BR, Marchak P, Teitz CC, Wojtys EM.

Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2000 May-Jun;8(3):141-50. 5. Quatman CE, Ford KR, Myer GD, Paterno MV, Hewett TE. The effects of gender and pubertal status on generalized joint laxity in young athletes. J Sci Med Sport. 2008 Jun;11(3):257-63. 6. Myer GD, Ford KR, Paterno MV, Nick TG, Hewett TE. The effects of generalized joint laxity on risk of anterior cruciate ligament injury in young female athletes. Am J Sports Med. 2008 Jun;36(6):1073-80. 7. Koga H, Nakamae A, Shima Y, Iwasa J, Myklebust G, Engebretsen L, Bahr R, Krosshaug T. Mechanisms for noncontact anterior cruciate ligament injuries: knee joint kinematics in 10 injury situations from female team handball

and basketball. Am J Sports Med. 2010 Nov;38(11):2218-25. 8. Krosshaug T, Nakamae A, Boden BP, Engebretsen L, Smith G, Slauterbeck JR, Hewett TE, Bahr R. Mechanisms of anterior cruciate ligament injury in basketball: video analysis of 39 cases. Am J Sports Med. 2007

Mar;35(3):359-67. 9. Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr. Mechanisms of anterior cruciate ligament injury. Orthopedics. 2000 Jun;23(6):573-8. 10. Padua DA, Marshall SW, Boling MC, Thigpen CA, Garrett WE Jr, Beutler AI. The Landing Error Scoring System (LESS) Is a valid and reliable clinical assessment tool of jump-landing biomechanics: The JUMP-ACL study. Am J

Sports Med. 2009 Oct;37(10):1996-2002. 11. Markolf KL, Burchfield DM, Shapiro MM, Shepard MF, Finerman GA, Slauterbeck JL. Combined knee loading states that generate high anterior cruciate ligament forces. J Orthop Res. 1995 Nov;13(6):930-5. 12. Hewett TE, Myer GD, Ford KR. Decrease in neuromuscular control about the knee with maturation in female athletes. J Bone Joint Surg Am. 2004 Aug;86-A(8):1601-8. 13. Quatman CE, Ford KR, Myer GD, Hewett TE. Maturation leads to gender differences in landing force and vertical jump performance: a longitudinal study. Am J Sports Med. 2006 May;34(5):806-13. 14. Harrison AD, Ford KR, Myer GD, Hewett TE. Sex differences in force attenuation: a clinical assessment of single-leg hop performance on a portable force plate. Br J Sports Med. 2011;45:198–202. 15. Ahmad CS, Clark AM, Heilmann N, Schoeb JS, Gardner TR, Levine WN. Effect of gender and maturity on quadriceps-to-hamstring strength ratio and anterior cruciate ligament laxity. Am J Sports Med. 2006 Mar;34(3):370-4. 16. Mendiguchia J, Ford KR, Quatman CE, Alentorn-Geli E, Hewett TE. Sex differences in proximal control of the knee joint. Sports Med. 2011 Jul 1;41(7):541-57. 17. Zazulak BT, Hewett TE, Reeves NP, Goldberg B, Cholewicki J. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med. 2007 Jul;35(7):1123-30. 18. Hewett TE, Ford KR, Hoogenboom BJ, Myer GD. Understanding and preventing ACL injuries: current biomechanical and epidemiologic considerations - update 2010. N Am J Sports Phys Ther. 2010 Dec;5(4):234-51. 19. Myer GD, Ford KR, Khoury J, Succop P, Hewett TE. Development and validation of a clinic-based prediction tool to identify female athletes at high risk for anterior cruciate ligament injury. Am J Sports Med. 2010

Oct;38(10):2025-33. 20. Smith HC, Johnson RJ, Shultz SJ, Tourville T, Holterman LA, Slauterbeck J, Vacek PM, Beynnon BD. A prospective evaluation of the Landing Error Scoring System (LESS) as a screening tool for anterior cruciate ligament injury

risk. Am J Sports Med. 2012 Mar;40(3):521-6. 21. Hewett TE, Myer GD, Ford KR, Heidt RS Jr, 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. Am J Sports Med. 2005 Apr;33(4):492-501. 22. Nilstad A, Andersen TE, Kristianslund E, Bahr R, Myklebust G, Steffen K, Krosshaug T. Physiotherapists can identify female football players with high knee valgus angles during vertical drop jumps using real-time observational

screening. J Orthop Sports Phys Ther. 2014 May;44(5):358-65. 23. Myer GD, Ford KR, Hewett TE. Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk. Athl Ther Today. 2008 Sep 1;13(5):39-44. 24. Myer GD, Ford KR, Barber Foss KD, Liu C, Nick TG, Hewett TE. The relationship of hamstrings and quadriceps strength to anterior cruciate ligament injury in female athletes. Clin J Sport Med. 2009 Jan;19(1):3-8. 25. Wild CY, Steele JR, Munro BJ. Insufficient hamstring strength compromises landing technique in adolescent girls. Med Sci Sports Exerc. 2013 Mar;45(3):497-505. 26. Khayambashi K, Ghoddosi N, Straub RK, Powers CM. Hip Muscle Strength Predicts Noncontact Anterior Cruciate Ligament Injury in Male and Female Athletes: A Prospective Study. Am J Sports Med. 2016 Feb;44(2):355-61. 27. Gagnier JJ, Morgenstern H, Chess L. Interventions designed to prevent anterior cruciate ligament injuries in adolescents and adults: a systematic review and meta-analysis. Am J Sports Med. 2013 Aug;41(8):1952-62. 28. Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in female athletes: Part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med. 2006 Mar;34(3):490-8. 29. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999 Nov-Dec;27(6):699-706. 30. Myer GD, Ford KR, McLean SG, Hewett TE. The effects of plyometric versus dynamic stabilization and balance training on lower extremity biomechanics. Am J Sports Med. 2006 Mar;34(3):445-55. 31. Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric training in female athletes. Decreased impact forces and increased hamstring torques. Am J Sports Med. 1996 Nov-Dec;24(6):765-73. 32. Myer GD, Ford KR, Brent JL, Hewett TE. Differential neuromuscular training effects on ACL injury risk factors in"high-risk" versus "low-risk" athletes. BMC Musculoskelet Disord. 2007 May 8;8:39. 33. Benjaminse A, Otten E. ACL injury prevention, more effective with a different way of motor learning? Knee Surg Sports Traumatol Arthrosc. 2011 Apr;19(4):622-7. 34. Makaruk H, Porter JM, Czaplicki A, Sadowski J, Sacewicz T. The role of attentional focus in plyometric training. J Sports Med Phys Fitness. 2012 Jun;52(3):319-27. 35. Wu WF, Porter JM, Brown LE. Effect of attentional focus strategies on peak force and performance in the standing long jump. J Strength Cond Res. 2012 May;26(5):1226-31. 36. Wulf G, Dufek JS, Lozano L, Pettigrew C. Increased jump height and reduced EMG activity with an external focus. Hum Mov Sci. 2010 Jun;29(3):440-8. 37. Benjaminse A, Gokeler A, Dowling AV, Faigenbaum A, Ford KR, Hewett TE, Onate JA, Otten B, Myer GD. Optimization of the anterior cruciate ligament injury prevention paradigm: novel feedback techniques to enhance motor

learning and reduce injury risk. J Orthop Sports Phys Ther. 2015 Mar;45(3):170-82.

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References 38. Michaelidis M, Koumantakis GA. Effects of knee injury primary prevention programs on anterior cruciate ligament injury rates in female athletes in different sports: a systematic review. Phys Ther Sport. 2014 Aug;15(3):200-10. 39. Quatman-Yates CC, Quatman CE, Meszaros AJ, Paterno MV, Hewett TE. A systematic review of sensorimotor function during adolescence: a developmental stage of increased motor awkwardness? Br J Sports Med. 2012

Jul;46(9):649-55. 40. Gilchrist J, Mandelbaum BR, Melancon H, Ryan GW, Silvers HJ, Griffin LY, Watanabe DS, Dick RW, Dvorak J. A randomized controlled trial to prevent noncontact anterior cruciate ligament injury in female collegiate soccer

players. Am J Sports Med. 2008 Aug;36(8):1476-83. 41. Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, Kirkendall DT, Garrett W Jr. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in

female athletes: 2-year follow-up. Am J Sports Med. 2005 Jul;33(7):1003-10. 42. LaBella CR, Huxford MR, Grissom J, Kim KY, Peng J, Christoffel KK. Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial. Arch

Pediatr Adolesc Med. 2011 Nov;165(11):1033-40 43. Soligard T, Myklebust G, Steffen K, Holme I, Silvers H, Bizzini M, Junge A, Dvorak J, Bahr R, Andersen TE. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial.

BMJ. 2008 Dec 9;337:a2469. 44. Noyes FR, Barber-Westin SD. Neuromuscular retraining intervention programs: do they reduce noncontact anterior cruciate ligament injury rates in adolescent female athletes? Arthroscopy. 2014 Feb;30(2):245-55. 45. Eastlack ME, Axe MJ, Snyder-Mackler L. Laxity, instability, and functional outcome after ACL injury: copers versus noncopers. Med Sci Sports Exerc. 1999 Feb;31(2):210-5. 46. Button K, van Deursen R, Price P. Recovery in functional non-copers following anterior cruciate ligament rupture as detected by gait kinematics. Phys Ther Sport. 2008 May;9(2):97-104. 47. 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 1, outcomes. Am J Sports

Med. 2008 Jan;36(1):40-7. 48. Ramski DE, Kanj WW, Franklin CC, Baldwin KD, Ganley TJ. Anterior cruciate ligament tears in children and adolescents: a meta-analysis of nonoperative versus operative treatment. Am J Sports Med. 2014 Nov;42(11):2769-76. 49. Kaplan Y. Identifying individuals with an anterior cruciate ligament-deficient knee as copers and noncopers: a narrative literature review. J Orthop Sports Phys Ther. 2011 Oct;41(10):758-66. 50. Jones HP, Appleyard RC, Mahajan S, Murrell GA. Meniscal and chondral loss in the anterior cruciate ligament injured knee. Sports Med. Sports Med. 2003;33(14):1075-89. 51. Marx RG, Jones EC, Angel M, Wickiewicz TL, Warren RF. Beliefs and attitudes of members of the American Academy of Orthopaedic Surgeons regarding the treatment of anterior cruciate ligament injury. Arthroscopy.

2003;19:762-70. 52. Fink C, Hoser C, Hackl W, Navarro RA, Benedetto KP. Long-term outcome of operative or nonoperative treatment of anterior cruciate ligament rupture--is sports activity a determining variable? Int J Sports Med. 2001

May;22(4):304-9. 53. Palmieri-Smith RM, Thomas AC, Wojtys EM. Maximizing quadriceps strength after ACL reconstruction. Clin Sports Med. 2008 Jul;27(3):405-24. 54. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med. 1991 Jul-Aug;19(4):332-6. 55. Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. Br J Sports Med. 2009 May;43(5):371-6. 56. Lynch AD, Logerstedt DS, Axe MJ, Snyder-Mackler L. Quadriceps activation failure after anterior cruciate ligament rupture is not mediated by knee joint effusion. J Orthop Sports Phys Ther. 2012 Jun;42(6):502-10. 57. Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2010

Nov;40(11):705-21. 58. Walton M. Absorbable and metal interference screws: comparison of graft security during healing. Arthroscopy. 1999 Nov-Dec;15(8):818-26. 59. Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF. Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am. 1993 Dec;75(12):1795-803. 60. Jackson DW, Grood ES, Goldstein JD, Rosen MA, Kurzweil PR, Cummings JF, Simon TM. A comparison of patellar tendon autograft and allograft used for anterior cruciate ligament reconstruction in the goat model. Am J Sports

Med. 1993 Mar-Apr;21(2):176-85. 61. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Recent advances in the rehabilitation of anterior cruciate ligament injuries. J Orthop Sports Phys Ther. 2012 Mar;42(3):153-71. 62. Marumo K, Saito M, Yamagishi T, Fujii K. The "ligamentization" process in human anterior cruciate ligament reconstruction with autogenous patellar and hamstring tendons: a biochemical study. Am J Sports Med. 2005

Aug;33(8):1166-73. 63. Claes S, Verdonk P, Forsyth R, Bellemans J. The "ligamentization" process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med. 2011

Nov;39(11):2476-83. 64. Pauzenberger L, Syré S, Schurz M. "Ligamentization" in hamstring tendon grafts after anterior cruciate ligament reconstruction: a systematic review of the literature and a glimpse into the future. Arthroscopy. 2013

Oct;29(10):1712-21. 65. Shelbourne KD, Freeman H, Gray T. Osteoarthritis after anterior cruciate ligament reconstruction: the importance of regaining and maintaining full range of motion. Sports Health. 2012 Jan;4(1):79-85. 66. Shelbourne KD, Gray T. Minimum 10-year results after anterior cruciate ligament reconstruction: how the loss of normal knee motion compounds other factors related to the development of osteoarthritis after surgery. Am J

Sports Med. 2009 Mar;37(3):471-80. 67. Millett PJ, Wickiewicz TL, Warren RF. Motion loss after ligament injuries to the knee. Part II: prevention and treatment. Am J Sports Med. 2001 Nov-Dec;29(6):822-8. 68. Lobb R, Tumilty S, Claydon LS. A review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation. Phys Ther Sport. 2012 Nov;13(4):270-8. 69. Young A, Stokes M, Shakespeare DT, Sherman KP. The effect of intra-articular bupivicaine on quadriceps inhibition after meniscectomy. Med Sci Sports Exerc. 1983;15:154. 70. Spencer JD, Hayes KC, Alexander IJ. Knee joint effusion and quadriceps reflex inhibition in man. Arch Phys Med Rehabil. 1984 Apr;65(4):171-7. 71. DeAndrade JR, Grant C, Dixon AS. Joint distension and reflex muscle inhibition in the knee. J Bone Joint Surg Am. 1965 Mar;47:313-22. 72. Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am. 2012 Oct 3;94(19):1737-48. 73. Escamilla RF, Macleod TD, Wilk KE, Paulos L, Andrews JR. Cruciate ligament loading during common knee rehabilitation exercises. Proc Inst Mech Eng H. 2012 Sep;226(9):670-80.

85

References 74. Hart JM, Pietrosimone B, Hertel J, Ingersoll CD. Quadriceps activation following knee injuries: a systematic review. J Athl Train. 2010 Jan-Feb;45(1):87-97. 75. Kim KM, Croy T, Hertel J, Saliba S. Effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: a systematic review. J Orthop

Sports Phys Ther. 2010 Jul;40(7):383-91. 76. Kulas AS, Hortobágyi T, DeVita P. Trunk position modulates anterior cruciate ligament forces and strains during a single-leg squat. Clin Biomech (Bristol, Avon). 2012 Jan;27(1):16-21. 77. Toutoungi DE, Lu TW, Leardini A, Catani F, O'Connor JJ. Cruciate ligament forces in the human knee during rehabilitation exercises. Clin Biomech (Bristol, Avon). 2000 Mar;15(3):176-87. 78. Tadokoro K, Matsui N, Yagi M, Kuroda R, Kurosaka M, Yoshiya S. Evaluation of hamstring strength and tendon regrowth after harvesting for anterior cruciate ligament reconstruction. Am J Sports Med. 2004 Oct-Nov;32(7):1644-

50. 79. Kartus J, Movin T, Karlsson J. Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts. Arthroscopy. 2001 Nov-Dec;17(9):971-80. 80. Wilk KE, Escamilla RF, Fleisig GS, Barrentine SW, Andrews JR, Boyd ML. A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises. Am J Sports Med. 1996 Jul-

Aug;24(4):518-27. 81. Escamilla RF, Zheng N, Macleod TD, Imamura R, Edwards WB, Hreljac A, Fleisig GS, Wilk KE, Moorman CT 3rd, Paulos L, Andrews JR. Cruciate ligament forces between short-step and long-step forward lunge. Med Sci Sports

Exerc. 2010 Oct;42(10):1932-42. 82. Wilk KE, Andrews JR. The effects of pad placement and angular velocity on tibial displacement during isokinetic exercise. J Orthop Sports Phys Ther. 1993 Jan;17(1):24-30. 83. Nagura T, Matsumoto H, Kiriyama Y, Chaudhari A, Andriacchi TP. Tibiofemoral joint contact force in deep knee flexion and its consideration in knee osteoarthritis and joint replacement. J Appl Biomech. 2006 Nov;22(4):305-13. 84. Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ, Godges JJ; Orthopaedic Section of the American Physical Therapist Association. Knee stability and movement coordination impairments: knee ligament sprain. J Orthop

Sports Phys Ther. 2010 Apr;40(4):A1-A37. 85. Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. J Orthop Sports Phys Ther. 2012

Jul;42(7):601-14. 86. 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. Am J Sports Med. 2010 Oct;38(10):1968-78. 87. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010 Feb;40(2):42-51. 88. Willson JD, Petrowitz I, Butler RJ, Kernozek TW. Male and female gluteal muscle activity and lower extremity kinematics during running. Clin Biomech (Bristol, Avon). 2012 Dec;27(10):1052-7. 89. Sheehan FT, Sipprell WH 3rd, Boden BP. Dynamic sagittal plane trunk control during anterior cruciate ligament injury. Am J Sports Med. 2012 May;40(5):1068-74. 90. Risberg MA, Holm I, Myklebust G, Engebretsen L. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Phys Ther. 2007 Jun;87(6):737-

50. 91. Escamilla RF, Fleisig GS, Zheng N, Barrentine SW, Wilk KE, Andrews JR. Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Med Sci Sports Exerc. 1998 Apr;30(4):556-69. 92. Pflum MA, Shelburne KB, Torry MR, Decker MJ, Pandy MG. Model prediction of anterior cruciate ligament force during drop-landings. Med Sci Sports Exerc. 2004 Nov;36(11):1949-58. 93. Shin CS, Chaudhari AM, Andriacchi TP. The influence of deceleration forces on ACL strain during single-leg landing: a simulation study. J Biomech. 2007;40(5):1145-52. 94. Carter TR, Edinger S. Isokinetic evaluation of anterior cruciate ligament reconstruction: hamstring versus patellar tendon. Arthroscopy. 1999 Mar;15(2):169-72. 95. Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. Am J Sports Med. 2013 Jan;41(1):216-24. 96. Myer GD, Brunner HI, Melson PG, Paterno MV, Ford KR, Hewett TE. Specialized neuromuscular training to improve neuromuscular function and biomechanics in a patient with quiescent juvenile rheumatoid arthritis. Phys Ther.

2005 Aug;85(8):791-802. 97. 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. J Orthop Sci. 2011

Sep;16(5):531-5. 98. Delahunt E, Prendiville A, Sweeney L, Chawke M, Kelleher J, Patterson M, Murphy K. Hip and knee joint kinematics during a diagonal jump landing in anterior cruciate ligament reconstructed females. J Electromyogr Kinesiol.

2012 Aug;22(4):598-606. 99. Orishimo KF, Kremenic IJ, Mullaney MJ, McHugh MP, Nicholas SJ. Adaptations in single-leg hop biomechanics following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010 Nov;18(11):1587-

93. 100. Noehren B, Abraham A, Curry M, Johnson D, Ireland ML. Evaluation of proximal joint kinematics and muscle strength following ACL reconstruction surgery in female athletes. J Orthop Res. 2014 Oct;32(10):1305-10. 101. Bizzini M, Hancock D, Impellizzeri F. Suggestions from the field for return to sports participation following anterior cruciate ligament reconstruction: soccer. J Orthop Sports Phys Ther. 2012 Apr;42(4):304-12. 102. Waters E. Suggestions from the field for return to sports participation following anterior cruciate ligament reconstruction: basketball. J Orthop Sports Phys Ther. 2012 Apr;42(4):326-36. 103. Stearns KM, Pollard CD. Abnormal frontal plane knee mechanics during sidestep cutting in female soccer athletes after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med. 2013 Apr;41(4):918-23. 104. Logerstedt D, Lynch A, Axe MJ, Snyder-Mackler L. Symmetry restoration and functional recovery before and after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2013 Apr;21(4):859-68. 105. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery. Am J

Sports Med. 2011 Mar;39(3):538-43. 106. Lee DY, Karim SA, Chang HC. Return to sports after anterior cruciate ligament reconstruction - a review of patients with minimum 5-year follow-up. Ann Acad Med Singapore. 2008 Apr;37(4):273-8. 107. Zhang CL, Fan HB, Xu H, Li QH, Guo L. Histological comparison of fate of ligamentous insertion after reconstruction of anterior cruciate ligament: autograft vs allograft. Chin J Traumatol. 2006 Apr;9(2):72-6. 108. Krych AJ, Jackson JD, Hoskin TL, Dahm DL. A meta-analysis of patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction. Arthroscopy. 2008 Mar;24(3):292-8. 109. Pyne SW. Current progress in meniscal repair and postoperative rehabilitation. Curr Sports Med Rep. 2002 Oct;1(5):265-71. 110. Robertson GA, Coleman SG, Keating JF. Knee stiffness following anterior cruciate ligament reconstruction: the incidence and associated factors of knee stiffness following anterior cruciate ligament reconstruction. Knee. 2009

Aug;16(4):245-7. 111. Hirshman HP, Daniel DM, Miyasaka K. The fate of unoperated knee ligament injuries. In: Daniel DL, Akeson WH, O’Connor JJ eds. Knee Ligaments: Sturcture, Function, Injury and Repair. New York, NY: Raven Press;

1990:481-503. 112. Graf BK, Cook DA, De Smet AA, Keene JS. "Bone bruises" on magnetic resonance imaging evaluation of anterior cruciate ligament injuries. Am J Sports Med. 1993 Mar-Apr;21(2):220-3. 113. Rosen MA, Jackson DW, Berger PE. Occult osseous lesions documented by magnetic resonance imaging associated with anterior cruciate ligament ruptures. Arthroscopy. 1991;7(1):45-51. 114. Fowler PJ. Bone injuries associated with anterior cruciate ligament disruption. Arthroscopy. 1994 Aug;10(4):453-60. 115. Vanwanseele B, Lucchinetti E, Stüssi E. The effects of immobilization on the characteristics of articular cartilage: current concepts and future directions. Osteoarthritis Cartilage. 2002 May;10(5):408-19.

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Return to Play Recommendations3:00 PM

Ellie Somers, PT, MSPT, [email protected]

Ellie Somers, PT, MSPT, DPT, is a Seattle Children’s Sports Physical Therapist. As a certified Sportsmetrics provider, she specializes in ACL injury prevention, as well as in the treatment of ACL repairs. She has helped to update our ACL protocol and was integral in updating our return to sports hop test.

Return to Sport Assessment Following Anterior Cruciate Ligament Repair

Dr. Ellie Somers Physical Therapist

Objectives

• Demonstrate understanding of the evidence on return to

sport testing and assessment • Understand the importance of managing patients as

individuals • Demonstrate proficiency in administering functional

return to sport testing

Meeting my idol…. Take Away Points

1. Treat the Individual

2. Cluster your exam

3. Get the WHOLE picture

When to return to sport?

SURGERY 3 MONTHS 6 MONTHS 7 MONTHS 9 MONTHS 12 MONTHS 24 MONTHS

? Assess Risk

Less than 25yrs old = 30-40X greater risk of sustaining

secondary ACL injury

Wiggins et al 2016


Assess Risk

Hip Rotational Control Deficits

Excessive Frontal Plane Knee Mechanics

Knee flexor Deficits Postural Control Deficits

Asymmetries

FEAR

Hewett et al 2013, Ardern et al 2014, Tjong et al 2014, Paterno et al 2010

Return to Sport Goals

Range of motion Strength Swelling Pain Pivot shift testing Time from surgery Function Power Stability of the knee Motor control Psychological Readiness Endurance Coordination

Cutting Pivoting Speed Functional Stability Biomechanics Graft choice Sport Proprioception Muscle girth Neuromuscular control Loading control Force generation Etc...

Evidence-Based Return to Sport Testing

1. Functional Performance

2. Strength

3. Psychological Readiness

Functional testing: • Hop testing • Star Excursion/Y-balance • Drop landing vertical jump • Agility testing

Evidence-Based Return to Sport Testing

Contraindications to RTS Functional Testing

• Marked knee effusion • Poor dynamic stability • Pain • Significant quadriceps weakness • ACL graft rupture • Any instability of the knee • Pregnancy

Hop Testing

60

Hop Testing

Purposes: • Determine limb symmetry • Assess symmetry in all 4 risk factors • Determine power • Coordination • Speed • Force generation

Reid et al, 2007

Hop Testing

• Passing score = • LSI >/= 85% • 4 factors on secondary risk schematic look good! Hip rotational control Knee flexor control Postural stability Frontal plane knee mechanics

• Fluid hopping

Hop Testing

• Video

Brandon’s Hop Test

Percentage

5. HOP TEST Trial 1 Trial 2 Average Right Left

Single HOP Right 5.10 4.90 5.00 105.26%

Single HOP Left 4.90 4.60 4.75 95.00%

Triple HOP Right 17.80 17.80 17.80 113.74%

Triple HOP Left 16.40 14.90 15.65 87.92%

Cross over Right 14.00 13.20 13.60 110.57%

Cross over Left 12.60 12.00 12.30 90.44%

Timed HOP Right 2.22 2.25 2.24 92.93%

Timed HOP Left 2.47 2.34 2.41 107.61%

Modified Star-Excursion/Y-Balance

Gribble et al 2012, Plisky et al, Clagg et al 2015

Anterior Posterolateral Posteromedial


Purposes: • Determine limb symmetry • Assess all 4 predictive factors • Determine balance • Strength assessment

Plisky et al, 2009, Garrison et al 2015



• Passing score = • Composite reach = 90% or better • Anterior reach distance <4cm side to side • No loss of balance • Stable trunk • Good knee alignment • Heel remains in contact with floor

Plisky et al 2006

• Video


Brandon’s Y-Balance Drop Landing Vertical Jump

Redler et al 2016

Drop Landing Vertical Jump

Purposes: • Determine RISK for ACL

injury : primary or secondary!

• Assess loading control • Determine movement

symmetry • Asses valgus

Paterno et al 2010


• Passing score = • Knee separation distance >80%

• 60% and below considered HIGH RISK • 60%-80% is better but still MOD risk

• Minimal asymmetry in sagittal plane, frontal plane and transverse plane

62


• Video


“There’s an app for that”

Agility Testing

Stearns et al, 2013

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Quality of Movement is Key

Agility Testing

Modified Pro Shuttle Modified agility T-Test

Myer et al, 2011

Agility Testing

• Purposes: • Assess QUALITY of dynamic sport movement:

• Cutting • Pivoting • Speed • Power • Stability • Agility • Coordination • Loading control

Strength Testing


Strength Testing

Purposes: • Determine strength symmetry • Determine quad/ham ratio • Determine hip strength

Strength Testing

• Picture/video

Strength Testing

• Passing = • >85% strength symmetry of quads, hams, hip

abd • Quad/ham ratio = 50% males, 60% females

(ideally even higher)

Schmitt et al 2015

Brandon’s Strength Testing

1. DYNAMETRIC STRENGTH TESTING

Trial 1 Trial 2 Average Right Left HS:Quad Ratio

Right Knee Extension 96.6 95.3 95.95 114.98% 42.78269932

Knee Flexion 42.4 39.7 41.05 96.82%

Hip Abduction 31.6 29.6 30.6 91.89%

Left Knee Extension 83.7 83.2 83.45 86.97% 50.80886759

Knee Flexion 41.8 43 42.4 103.29%

Hip Abduction 32.8 33.8 33.3 108.82%

Psychological Readiness

• Strongly associated with returning to preinjury activity

• FEAR • Associated with not returning to preinjury levels up to 7yrs after

ACLR • Commonly cited by athletes • Associated with altered movement patterns!!

Ardern et al 2014, Tjong et al 2013, Czuppon et al 2014


• Recognize Problematic Characteristics • Threatened athletic identity – particularly true for young athletes! • Low self efficacy or self esteem • Pessimism • Anxiety • Catastrophizing • Lack of motivation

Christino et al 2015

64


• Treatment options: • Positive self talk • Guided imagery • Relaxation • Goal setting • Counseling

Christino et al 2015


• Knee Self-Efficacy Scale (K-SES) • ACL-Return to Sport after Injury Scale (ACL-RSI) • Tampa Scale for Kinesiophobia (TSK) • ACL-Quality of Life Scale (ACL-QoL)

Assess Risk

Hip Rotational Control Deficits

Excessive Frontal Plane Knee Mechanics

Knee flexor Deficits Postural Control Deficits

Asymmetries

Hewett et al 2013, Ardern et al 2014, Tjong et al 2014, Paterno et al 2010

FEAR

Summary

1. Treat patients as individuals 2. Use a cluster of tests

Functional testing Hop testing Y-balance Drop down vertical jump Agility testing

Strength testing 3. Don’t forget the WHOLE patient

Patient’s first! Psychological readiness assessment

Thank you!!

References 1. Fitzgerald GK, Lephart SM, Hwang JH, Wainner MF. Hop tests as predictors of dynamic knee stability. J Orthop Sports Phys Ther.

2001;31:588-597 2. Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure during

rehabilitation after anterior cruciate ligament reconstruction. Phys Ther. 2007; 87:337-349. 3. Bandy W, Rusche K, Tekulve F. Reliability and limb symmetry for five unilateral functional tests of the lower extremity. Isokinet Exerc

Sci. 1994;4:108-111. 4. Bolgla LA, Keskula DR. Reliability of lower extremity functional performance tests. J Orthop Sports Phys Ther. 1997;26:138-142. 5. Logerstedt D, Lynch A, Risberg MA, Snyder-Mackler L. Single-legged hop tests as predictors of self-reported knee function after

anterior cruciate ligament reconstruction. Am J Sports Med. 2012 40: 2348. 6. Ericsson YB, Roos EM, Frobell RB. Lower extremity performance following ACL rehabilitation in the KANON-trial: impact of

reconstruction and predictive value at 2 and 5 years. Br J Sports Med. 2013;47:980-985. 7. Noyes 8. 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. Am J Sports Med. 2010;38:1968-1978.

9. Paterno MV, Fod KR, Myer GD, Heyl R, Hewett TE. Limb asymmetries in landing and jumping 2 years following anterior cruciate ligament reconstruction. Clin J Sport Med. 2007;17:258-262.

10. Hewett TE, Myer GD, Ford KR, Heidt RS, Colosimo AJ, McLean SG, van den Bogert AJ, Materno MV, Succop P. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes. Am J Sports Med. 2005;33:492-501.

11. Gribble PA, Hertel J, Plisky P. Using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train. 2012;47(3):339-357

12. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Recent advances in the rehabilitation of anterior cruciate ligament injuries. J Orthop Sport Phys Ther. 2012;42(3). 153-171.

13. Ardern CL, Wbster 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;45(7):596-606

14. Ellman MB, Sherman SL, Forsythe B, LaPrade RF, Cole BJ, Back BR. Return to play following anterior cruciate ligament reconstruction. J Am Acad Orthop Surg 2015;23:283-296.

15. Ithburn MP, Paterno MV, Ford KR, Hewett TE, Schmitt LC. Young athletes with quadriceps femoris strength asymmetry return to sport after anterior cruciate ligament reconstruction demonstrate asymmetric single-leg drop-landing mechanics. Am J Sports Med 2015 43:2727-2737.

16. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction and return to sport. Clin J Sport MEd. 2012:22(2):116-121


66

Return to Field Following Rehabilitation4:00 PM

Shanlyn Souza, MS, ATC, LAT

Shanlyn Souza, MS ATC, AT/L, is a certified Athletic Trainer at Seattle Children’s Hospital. In addition to being the Fitness Consultant for the Child Wellness Clinic, she is also the Head Athletic Trainer for Woodinville High School.

Amanda Lipke, MS, ATC, LAT

Amanda Lipke, MS ATC, AT/L, is a certified Athletic Trainer at Seattle Children’s Hospital. She received her Bachelor’s degree in Athletic Training and her Master’s degree in Human Performance. She is currently the head athletic trainer at Interlake High School in Bellevue, WA.

• Now What?

Now what? • Clearance note/restrictions • Insurance only covers 12-18 PT visits

– Partnership PT with the ATC – Work together to create a cohesive plan

• Athlete + PT + AT = Maximized Results

• Normal motion • Multiplanar motion and integration • Stabilization and acceleration changes • Proprioceptive stimulation • Agility and power • Activity specific skill development

• Specific instruction on desired performance • Perform activity slowly progressing with resistance • Add complexity once skill mastered • Increase intensity once performance improves • Repetition of correct pattern is key


• Plyos before sport specific • Consider pre-disposing factors and strengthening the

deficits as part of RTP • Difficulty can be increased by

– Distance – Multiple jumps – Speed – Height – Double leg vs single leg

• Running and jumping should mimic sport specific movements

• Patient is 100% to pre-injury • Has confidence in ability and previously

injured knee – No barriers in psychological or physical

performance

• Designed to decrease the likelihood and severity of an athletic injury – FIFA – Dynamic sport specific warm-up – 3 planar warm-up

4

68

• Sport specific functionality • Confident in abilities • Be a part of a cohesive sports medicine team

– Surgeon – Physical therapists – Athletic trainer – Parents – Coaches – Athlete

1. Prentice, William E. Principle's of Athletic Training: A

Competency-Based Approach. N.p.: McGraw-Hill Higher Education, 2006. Print.

2. Mensch, James M., and Gary M. Miller. The Athletic Trainer's Guide to Psychosocial Intervention and Referral. N.p.: SLACK Incorporated, 2008. Print.

3. Houglum, Peggy A. Therapeutic Exercise for Musculoskeletal Injuries. Third ed. N.p.: Human Kinetics, 2010. Print.

4. F-MARC. (2013) Fifa 11+ - a complete warm-up programme. Available from URL: http://f-marc.com


70

Appendix - Special Tests

Spec

ial T

est

Purp

ose

Posi

tive

Test

Te

chni

que

Sens

itivi

ty

Spec

ifici

ty

Ante

rior

Draw

er T

est

Inte

grity

of t

he A

CL

Incr

ease

d tib

ial d

ispla

cem

ent

com

pare

d to

uni

njur

ed si

de

With

pat

ient

in su

pine

, kne

e is

flexe

d to

60-

90 d

egre

es w

ith fo

ot

rest

ing

on ta

ble.

PT

plac

es b

oth

hand

s beh

ind

tibia

and

att

empt

s to

glid

e tib

ia a

nter

iorly

.

0.20

-0.7

8 0.

86-1

.00

Lach

man

's Te

st

Inte

grity

of t

he A

CL

Ante

rior s

ublu

xatio

n of

tibi

a co

mpa

red

to u

ninj

ured

kne

e W

ith p

atie

nt in

supi

ne, k

nee

is fle

xed

to 2

0-30

deg

rees

. PT

stab

ilize

s th

e fe

mur

with

one

han

d an

d an

terio

rly g

lides

the

tibia

with

the

othe

r.

0.82

-0.9

6 0.

91-1

.00

Pivo

t Shi

ft T

est

Ante

rior-

late

ral

rota

tory

inst

abili

ty,

poss

ibly

due

to A

CL

or m

enisc

us in

jury

Ante

rior s

ublu

xatio

n of

the

late

ral

tibia

l pla

teau

und

erne

ath

the

fem

oral

co

ndyl

e

With

pat

ient

in su

pine

, kne

e is

flexe

d 20

-30

degr

ees.

PT

rota

tes t

he

tibia

late

rally

whi

le a

pply

ing

a va

lgus

stre

ss. K

nee

is fle

xed

and

exte

nded

to fe

el fo

r sub

luxa

tion

and

redu

ctio

n.

0.24

-0.9

3 0.

83-1

.00

Post

erio

r Sag

Si

gn T

est

Inte

grity

of t

he P

CL

Tibi

a sa

gs o

n th

e fe

mur

or t

he m

edia

l tib

ial p

late

au d

oes n

ot e

xten

ds 1

cm

ante

riorly

bey

ond

the

fem

oral

con

dyle

With

pat

ient

in su

pine

, hip

is fl

exed

to 4

5 de

gree

s and

kne

e is

flexe

d to

90

degr

ees.

0.

79

1

Post

erio

r Dr

awer

Tes

t In

tegr

ity o

f the

PCL

In

crea

sed

post

erio

r tib

ial

disp

lace

men

t com

pare

d to

uni

njur

ed

side

With

pat

ient

in su

pine

, kne

e is

flexe

d 60

-90

degr

ees w

ith fo

ot

rest

ing

on ta

ble.

PT

puts

han

ds b

ehin

d th

e tib

ia a

nd th

umbs

an

terio

rly o

n th

e tib

ial p

late

au. P

T ap

plie

s a p

oste

rior f

orce

to ti

bia.

0.9

0.99

Post

erol

ater

al

Draw

er T

est

Post

erol

ater

al

rota

tory

inst

abili

ty

Incr

ease

d po

ster

olat

eral

mot

ion

of th

e la

tera

l tib

ial c

ondy

le c

ompa

red

to th

e m

edia

l tib

ial c

ondy

le

With

pat

ient

in su

pine

, the

hip

is fl

exed

to 4

5 de

gree

s and

the

knee

fle

xed

at 8

0 de

gree

s with

the

foot

pla

ced

on th

e ta

ble.

The

pos

terio

r dr

awer

test

is p

erfo

rmed

with

the

tibia

in n

eutr

al, i

nter

nal r

otat

ion

and

exte

rnal

rota

tion.

n/a

n/a

Thes

saly

Tes

t In

tegr

ity o

f the

m

enisc

us

Join

t lin

e pa

in, c

atch

ing

or lo

ckin

g Pa

tient

stan

ds o

n on

e le

g w

ith h

ands

supp

orte

d by

exa

min

er.

Patie

nt ro

tate

s his

body

and

kne

e in

tern

ally

and

ext

erna

lly th

ree

times

with

5 d

egre

es k

nee

flexi

on. P

erfo

rmed

aga

in w

ith k

nee

in 2

0 de

gree

s fle

xion

.

0.66

-0.9

0 0.

87-0

.98

McM

urra

y's

Test

In

tegr

ity o

f the

m

enisc

us

Clic

king

, pat

ient

repo

rts s

imila

r se

nsat

ion

to w

hen

knee

giv

es w

ay

With

pat

ient

in su

pine

, kne

e is

fully

flex

ed. T

he le

g is

inte

rnal

ly

rota

ted

on th

e th

igh

and

the

knee

is e

xten

ded

to a

righ

t ang

le. T

he

test

is re

peat

ed w

ith th

e tib

ia e

xter

nally

rota

ted.

0.16

-0.7

0 0.

71-0

.98

Valg

us S

tres

s Te

st

Inte

grity

of t

he M

CL

Med

ial j

oint

line

laxi

ty o

r gap

ping

co

mpa

red

to u

ninv

olve

d sid

e W

ith p

atie

nt in

supi

ne, k

nee

is fle

xed

to 3

0 de

gree

s. P

T gr

asps

late

ral

knee

with

one

han

d an

d an

kle

with

the

othe

r the

n ap

plie

s a v

algu

s st

ress

to th

e kn

ee. T

he te

st is

repe

ated

in fu

ll ex

tens

ion.

0.86

0.

93

Varu

s Str

ess

Test

In

tegr

ity o

f the

LCL

La

tera

l joi

nt li

ne la

xity

or g

appi

ng

com

pare

d to

uni

nvol

ved

side

With

pat

ient

in su

pine

, kn

ee is

flex

ed to

30

degr

ees.

PT

gras

ps

med

ial k

nee

with

one

han

d an

d an

kle

with

the

othe

r the

n ap

plie

s a

varu

s str

ess t

o th

e kn

ee. T

he te

st is

repe

ated

in fu

ll ex

tens

ion.

0.25

0.

99

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