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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
ACL Rehabilitation in Youth Sports 05
• 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
ACL Rehabilitation in Youth Sports 07
• 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
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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.
ACL Rehabilitation in Youth Sports 11
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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
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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
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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
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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
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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
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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!
ACL Rehabilitation in Youth Sports 23
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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
ACL Rehabilitation in Youth Sports 25
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
ACL Rehabilitation in Youth Sports 27
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
ACL Rehabilitation in Youth Sports 29
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.
ACL Rehabilitation in Youth Sports 31
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
ACL Rehabilitation in Youth Sports 33
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 - 2
Anderson's all-epiphyseal ACL reconstruction - 3
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
ACL Rehabilitation in Youth Sports 35
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
ACL Rehabilitation in Youth Sports 37
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
ACL Rehabilitation in Youth Sports 39
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.
ACL Rehabilitation in Youth Sports 41
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
ACL Rehabilitation in Youth Sports 43
Neuromuscular imbalances associated with ACL injury mechanisms18
Figure 818
7
Neuromuscular imbalances associated with ACL injury mechanisms18 (cont.)
Figure 818
8
Neuromuscular imbalances associated with ACL injury mechanisms18 (cont.)
Figure 818
9
Neuromuscular imbalances associated with ACL injury mechanisms18 (cont.)
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
ACL Rehabilitation in Youth Sports 45
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 Rehabilitation in Youth Sports 47
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
Copers vs. Noncopers (cont.)
• 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
Copers vs. Noncopers (cont.)
• 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
ACL Rehabilitation in Youth Sports 49
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
Early ACLR Rehabilitation (cont.)
• 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
Early ACLR Rehabilitation (cont.)
• 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
Early ACLR Rehabilitation (cont.)
• 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
ACL Rehabilitation in Youth Sports 51
Intermediate ACLR Rehabilitation (cont.)
• Soreness rules to guide progressive strengthening
Table 385 55
Intermediate ACLR Rehabilitation (cont.)
• 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
Intermediate ACLR Rehabilitation (cont.)
• 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
Intermediate ACLR Rehabilitation (cont.)
• 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
Intermediate ACLR Rehabilitation (cont.)
• 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
Late ACLR Rehabilitation (cont.)
• 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
ACL Rehabilitation in Youth Sports 53
Late ACLR Rehabilitation (cont.)
• 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
Late ACLR Rehabilitation (cont.)
• 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
Late ACLR Rehabilitation (cont.)
• 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
Late ACLR Rehabilitation (cont.)
• 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
73
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
ACL Rehabilitation in Youth Sports 55
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
82
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
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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.
86
ACL Rehabilitation in Youth Sports 57
58
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
ACL Rehabilitation in Youth Sports 59
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
Modified Star-Excursion/Y-Balance
Purposes: • Determine limb symmetry • Assess all 4 predictive factors • Determine balance • Strength assessment
Plisky et al, 2009, Garrison et al 2015
ACL Rehabilitation in Youth Sports 61
Modified Star-Excursion/Y-Balance
• 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
Modified Star-Excursion/Y-Balance
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
Drop Landing Vertical Jump
• 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
Drop Landing Vertical Jump
• Video
Drop Landing Vertical Jump
“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
ACL Rehabilitation in Youth Sports 63
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
Psychological Readiness
• 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
Psychological Readiness
• Treatment options: • Positive self talk • Guided imagery • Relaxation • Goal setting • Counseling
Christino et al 2015
Psychological Readiness
• 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
ACL Rehabilitation in Youth Sports 65
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
ACL Rehabilitation in Youth Sports 67
• 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
ACL Rehabilitation in Youth Sports 69
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