anterior cruciate ligament rehabilitation

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Updated Consideration for Anterior Cruciate LigamentReconstruction Rehabilitation

Anterior Cruciate Ligament Rehabilitation

Updated Consideration for Anterior Cruciate Ligament Reconstruction RehabilitationTerry Trundle, PTA, ATC, LAT

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Function of the ACL

• Primary restraint to anterior displacement of tibia relative to the femur

• Secondary stabilizer of rotation, mainly with internal and external tibial rotation

• Cruciates cross with tibial internal rotation

ACL: In Review• ACL reconstruction is one of the most common

orthopedic surgical procedures in the United States

• “It is estimated that 400,000 people have ACL reconstruction each year, of those 18,000 to 35,000 repairs will fail.”

• 65% - 70% of individuals return to their pre-injury level of activity

• 200,000 ACL injuries occur annually in the US, leading to 100,000 ACL reconstructions

Reference: Hewett, TE (2009)Albaugh J, Friedman J, Cody S, Ganley T (2010)Wilk, Macrina, Cain, Dugas, Andrews JOSPT (3) 2012

• Annual incidence of 35 per 100,000 people

• Females are 2-3 times more likely than males

• 40%-90% will have radiographic OA 7-12 years post-op

Reference: Gianotti, Marshall, Hume, Bunt J. Sci Med Sport (2009)Walden, Hagglund, Werner, Ekstrand Surg Sports Tramatol

Arthrosc (2011)Liden et. al. Arthroscopy (2008)

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Female: ACL Injury – What do we think we know?

• Female injury risk is somewhere in the range of 4 to 8 times that of male participants in the same or comparable activities: Non-contact

• Highest risk sports for females are basketball and soccer• Biomechanical risk factors:

– Ligament laxity– Hormonal influences– Muscle firing patterns– Landing strategies– Proprioceptive characteristics

Reference: Clinical CommentaryAlbaugh J, Friedman J, Cody S, Ganley T: Training – Conditioning April 2010

• Women suffered more injuries than men to contralateral knee (7.8% to 3.7%)

• Injuries to reconstructed knee not significantly different (4.3% vs 4.1%)

• No difference in those returning to sports sooner than 6 months compared to those after 6 months

• Risk– 17% < 18– 7% 18-25– 4% > 25

Reference: Shelbourne KD et. al. Am J Sports Med 2009

Considerations for the Female ACL Patients

• A-shaped notch – higher risk for ACL injury• With ER ACL gets caught against notch and is cut by

LFC• Females are quadriceps dominant (muscle firing

patterns)• Balanced landing position – knees stay well centered

over the toes on firm foot/ankle platform, flexed hip and knee in neutral rotation without excessive Abduction or Adduction (Valgus position with external rotation)

• Preventive training programs:– Warm-up and functional mobility– Strengthening of the hamstrings and hip core muscles to change

the firing patterns– Proprioceptive/balance neuromuscular control

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ACL – Where does it fail

• 80% Mid Substance• 18% Femur• 2% Tibia• Younger patients often have an avulsion of

the tibial spine which is the insertion of the ACL

ACL Injury – Younger Patients• Pre-pubescent – Adolescent concerns of the growth

plates and smaller anatomical features• Post-operative rehabilitation is typically slower with

longer periods of regaining motion and strength: pre-pubescent may be 3 months slower than older adolescents.

• Balance and proprioceptive activities are just as important

• Most challenging concerns for this age group is some patients are often less compliant

• Bracing may be good intervention for safe return to athletic activities

Graft Size• MRI studies have found that the mean

width of the ACL to be 5.7±1.1mm for women and 7.1±1.2mm for men

• Average size of replacement graft is 10mm (patellar tendon)

Reference: Shelbourne KD (2009)

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Principle of Graft Selection• Top 10 Factors:

1. Patient’s preference2. Age3. Gender4. Activity level5. Physical requirement6. Expected outcomes7. Timeline to return to play8. Previous surgery – revisions9. Tissue availability – Allograft10. Surgeon preference and experience

ACL – Graft Selection

• Patellar tendon– Bone-IPT-bone procedure– Gold standard– Central 1/3 of IPT (10mm) on average

• Semitendinosis/gracilis– Double, triple, or quadruple looped for reinforcement

• Quadriceps tendon

Reference: Macaulay, Perfetti, Levine Sports Health 2012 4(1)

Allograft

• Advantages– Biological graft – cadaveric tissue retrieved

from tissue bank which is capable of remodeling and repair

– Decreased surgical morbidity with endoscopic placement, no compromise of normal anatomy

– May require less intense of rehabilitation– No other options

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Indications for Allograft

• Previous surgery – revisions• Age: Example – 40 years old and greater• Multi-ligament injuries• Autograft tissue is inadequate

Reference: Vyas, Rabuck, Harner JOSPT (3) 2012

Double-Bundle ACL Reconstruction

• Biomechanical studies, reconstruction of AM and PL bundle better in ant and rotational stability

• Several clinical trials in progress but none have shown superiority oversingle bundle technique

• Important technical issuesmust be overcome to adoptprocedure

The Anatomic Double-Bundle ACL Reconstruction

• “Anatomic ACL reconstruction techniques aim to better restore the normal anatomy and biomechanics of the knee and are hypothesized to potentially decrease the incidence of osteoarthritis after ACL reconstruction.”

Dr. Daniel Heusler MDDr. Carola F. Van Eck MDDr. Freddie H. Fu MDDr. James J. Irrgang P.T. Ph.D. ATC

JOSPT (3) 2012

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Principles of the Double-Bundle ACL Reconstruction

1. Appreciate the native anatomy (2 – bundles)2. Graft placement in the center of the foot print3. Physiological function of the grafts by applying

appropriate tension to mimic the native ACL as closely as possible

• PL bundle tensioned at 0° of flexion• AM bundle tensioned at 45°-60° of flexion

4. Rehabilitation may need to be slower with the return to functional activities 9-12 months

Reference: Anderson, Westerhaus, Pietrini Am J Sports Med (2010)

Technical Hurdles - Tibia• Average AP length of tibial footprint is 14mm

(range 9 to 18mm)• Natural center of AM and PL bundles are only

5mm apart• “Experts” recommend

2mm bone bridge between tunnels

• Tibial footprint is generally too narrow to place 2 separate bone tunnels in the ML direction

Technical Hurdles - Tibia

Original sagittal coursesof both footprints need to be changed in order to place2 bone tunnels

In order to reproduce DB tibial anatomy tunnels must be less than 5 or 6mm and communicate

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Technical Hurdles - Femur• Due to limitations in tunnel

angles footprints less than 18mm in prox/dist diameter render anatomic placement of femoral tunnels impossible

• Basically…With standard graft sizes there’s NOT ENOUGH ROOM for 2 femoral tunnels without convergance

Technical Hurdles – Notch/PCL Impingement

• Grafts larger than 7-8mm will impinge in extension without notchplasty

• More superior AM tunnel will impinge against PCL in both flexion and extension

• Combined diameter of grafts 12-14mm may cause “overstuffing of intracondylar notch”

Double-bundle clinical results• Zhao et al. Knee 2006, 43 pts, chronic ACL ruptures, 4

tunnels and 8-stranded hamstring grafts, 95% patients with neg pivot shift, and 1mm man max KT-1000 tests

• Colombet et al. Knee Surg Sports Traumaol Arthrosc. 2006, 33 pts, 4 tunnel with autologous hamstrings, 2 yr f/u, 84% neg pivot shift, KT-1000 .9 mm, return to previous sports 75%

• Siebold et al. Arthroscopy 2008, 70 pts, prospective, randomized clinical trial, SB vs DB 4-tunnel with autologous hamstrings, 19 month f/u, 97% neg pivot shift in DB group, 71% neg in SB group, KT-1000, 1mm in DB group, 1.6 mm in SB group, no sig difference in IKDC scores between groups, 1 traumatic DB failure at 11 mo

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Pre-operative Goals

• Reduced or absent effusion• Full terminal extension in comparison• Normal flexion• Leg control – symmetrical quadriceps

strength• Hamstrings strength compared to opposite

knee• Co-contraction and hip core strengthening

Phases of ACL Rehab• I Pre-Functional

– Immediate post-op early motion – 4 weeks– Controlled Ambulation

• II Return to Function– Muscle re-education – OKC/CKC progression– Early proprioception

• III Return to Activity– Advanced strengthening and sports-specific

training

Interactive Outcomes

• Pain report and reduction of swelling• Mobility – ROM goals met• Leg control – muscle recruitment• Progressive ambulation (ADL Report)

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Common Clinical Outcome Scores

• Objective measurements• Strength – Isotonic vs isokinetic testing• Laxity – Example: KT 1000 testing• Balance – proprioception• Hop test – function• Patient-reported outcomes – LEFSReturn to sports is the secondary goal.Fulfilling the criteria of the protocol for the return to

sports is the primary goal.Reference: Wacek, A. Cyber PT 2011

Functional Progression – ACLPre-functional – phase one• Mobility

– Full normal extension– Flexion as tolerated – but not pushed

• CPM is for extension not flexion– Patella mobility – all direction– Hip mobility to assist with core stabilization– Hamstring re-lengthening– Heel cord re-lengthening– Manual over pressure mobility toward extensionReference: Wilk et. al. JOSPT (3) 2012

Functional Progression – ACLPre-functional – phase one• Recruitment

– Core stabilization – swiss/plyo-ball exercises– Co-contraction hamstrings over the quadriceps– Leg control – standing SLR– Quadriceps isometrics (reestablish quadriceps

control)– eccentric hamstrings control 30°→ 90°– Sub-max eccentric quads manual application– Ankle pumps

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Pre-functional – Phase One

• Optional treatments: Swelling and pain reduction– Electrical stimulation– Infrared-Anodyne– Dry needling for swelling

Hamstrings - Revisited• Hamstrings create a posterior directed force on

the tibia when the flexion angle is 30° or greater• Hamstrings function as an eccentric control of

hip flexion• Is the hamstrings the true core muscle group of

the lower extremity?

Reference: Cipriani, D. Pulling Through. Training and Conditioning, Dec 2006. 13-19, T Trundle 2009

Functional Progression – ACLPre-functional – phase one• Tri-plane stabilization – proprioception re-

training– Mini squats – double leg – trunk tilted forward – BW

only– Standing terminal extension (STE)– Balance weight shift exercises – balance board/BOSU– Leg press sub-max double leg

• Co-contraction vs Closed Kinetic Chain• Terminal extension 0°-45° loading

References: Gerber, et. al. 2007Wilk et. al. 2012

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Functional Progression – ACLReturn to Function – Phase Two

• Mobility– Full ROM extension & flexion– Hamstrings – functional re-lengthening

• Recruitment– PRE – hamstrings 30°→ 90°– PRE – quadriceps 45°→ 90°– PRE – hip strengthening – all planes– Advanced core exercises – hamstrings – bridge row– High speed isokinetics

Anterior Translation - ATT• Least Amount of ATT – 75 Deg. Knee

Flexion• Maximum Amount of ATT 45 – 15 Deg.

Flexion(Based on Maximum Isometric Quadriceps Contraction)

References: Escamilla, Macleod, Wilk, Paulos, Andrews JOSPT (3) 2012

Open- or Closed-Kinetic Chain Exercises After Anterior Cruciate

Ligament Reconstruction?• OKC and CKC Exercises both produce strains

on the ACL in terminal extension• OKC with increase of resistance does increase

ACL strain• CKC does not increase the ACL strain with

increase load

Reference: Fleming, BC, Oksendahl, H, and Beynnon, BD: Exercise and Sports Sciences Reviews, Vol. 33(3) 134-140, July 2005.

Escamilla et. al. 2012

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Clinical Application of the Research

• OKC short arc flexion moment angle continues to be suggested (90° – 40°)

• Increase external compression (weights) with increase strain on the ACL toward extension

• Early use of CKC is still recommended

Functional Progression – ACLReturn to Function – Phase Two

• Tri-plane stabilization– Balance activities – balance board – BOSU– Progress to single leg squat on uneven surfaces– Balance vector – 3 planes– Leg press total gym single leg – increase flexion angle– Lateral step-up, retro step-ups and front step downs– Slide board – FITTER– Plyo-toss with squat – progress to single leg– Lateral cross-overs– Lateral and forward lunges

Reference: Risberg, Holm, Myklebust, Engebretsen 2007

Case for Proprioceptive Re-Training

• Incidence of recurrent injury to the operative knee ranges 3.6% in adults to 17% in patients younger than 18 years

• ACL injury increases the risk of osteoarthritis ranging from 0% to 13% for patients with isolated ACL deficient knees and 21% to 48% for patient with combined injuries

• Proprioceptive defects after ACL injury may be a factor related to both giving way (instability) and higher incidence of subsequent injuries which in turn contribute to the development of osteoarthritis

Reference: Gokele, Benjaminse, Hewett, Lephart, et. al. Br. J Sports Med (2012)

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Functional Progression – ACLReturn to Activity Phase three

• Mobility– Any incomplete motion concerns mobilization as

needed– Advanced functional LE re-lengthening

• Recruitment– Advanced quadriceps strengthening

• Wall squats with ball single leg– Open kinetic chain progression– Isokinetic testing

Reference: Ayotile, Steets, etal. (2009)

Functional Progression – ACLReturn to Activity Phase three

• Tri-plane stabilization– Advanced plyo-toss on uneven surfaces – BOSU– Perturbation training– Advanced balance vector training – eyes closed– Fitter, stepper, elliptical, versa climber, slide board for

endurance training– Step-jump balance hold on balance pad– Plyometric jumps – double to single leg– Lunges with weights – lateral lunges with

bands/tubing– Sports Specific Training

• Box Runs, Lateral Running, Retro sprinting, Vertical Jumps, Figure 8 run/cuts, running program.

FUNCTIONAL LOWER EXTREMITY TESTING

• Balance testing – eyes open and closed• Balance vector testing• Leg press test• Isolated strength assessment (Isotonic vs. Isokinetic)• Return to Sports – Functional Testing

• Hop test – Time and distance – Single leg (Reid)• Lower limb symmetry index (Noyes)• Functional movement screen (G. Cook)

Reference: Reid A, Birmingham TB, Stratford PW, Alcock GK, Griffin RJ. Hop Testing Provides a Reliable and Valid Outcome Measure During Rehabilitation After Anterior Cruciate Ligament Reconstruction. Phys Ther (87) 337-349; 2007

Noyes, F.R. et. al. Sports Med (2004)

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Plyometric TrainingProgressive in nature• Increased number of exercises• Increase repetitions and sets• Decrease rest periods

– Straight jumps -> Sagittal– Lateral jumps -> Frontal– Combination -> Transverse

• Frequency – three times a week• Intensity – double leg jumps to single leg jumps• Low intensity – 100 - 200 fast contacts• Moderate intensity – 200 - 400 fast contacts• High intensity – 400 – 600 fast contacts• Sports specific training

– Progressive running– Agility drills– Sudden starts and stops

• 45° cutting then 90° cutting

What Changes the Protocol?

• Articular Cartilage Lesions– Micro-fracture– OATS – donor plug (allograft)– Autologous Chondrocyte Implantation– Denovo – natural tissue graft juvenile minced

cartilage• Meniscus Repair

– Complex Tears and Peripheral TearsMcCormick, Yanke, Provencher, Cole Sports Med Arthrosc (2008)

Articular Cartilage

• Functions of the Articular Cartilage– Distribute load– Absorb shock

• Defects progress to:– Degenerative arthritis– Long-term disability

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Articular Cartilage Defectsa treatment challenge

• Most full-thickness defects are symptomatic– Pain, swelling, locking, catching, grinding

• Left untreated, significant articular defects progress

Articular Cartilage Repair -Rehabilitation

• Three Biological Healing Phases1. Initial Protection and joint activation2. Progressive joint loading and functional

restoration3. Activity restoration

Reference: Mithoefer, Hambly, Logerstedt, Ricci, Silvers, Della Villa JOSPT (3) 2012

Micro-Fracture Rehab Guidelines

Phase One – Pre-Functional• Protection of healing articular cartilage• Re-gain full resting extension• Pre-ambulation leg control and core

stabilization – hip strengthening• Re-establish hamstrings and quadriceps

control.

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Weight Bearing Status

• 0-2 weeks – non-weight bearing to touch down

• 2-4 weeks – partial weight bearing to full• >4 weeks – discontinue crutches with

normal gait and leg control


Phase One – Exercises – Protective Weight Bearing

• Core Stabilization – Swiss ball series• OKC – standing straight leg (SLRx4)• Hamstrings/Quadriceps co-contraction• Progressive flexion range of motion• CPM – for joint nutrition• Patella mobilization• Hamstrings functional re-lengthening


Phase Two – Return to Function• Progressive range of motion and flexibility• Bicycle for warm-up• Advanced core stabilization – hamstrings bridge roll• Early proprioception retraining• Balance board/Bosu - double to single leg• PRE – Hamstrings, Quadriceps and hip abduction• Closed kinetic chain progression – mini squat series –

balance vector training• Total gym – leg press progressionStrength Goal – 70% of contralateral

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Phase Three – Return to Activity• Progressive strengthening – total leg• CKC progression with functional testing• Advanced proprioception training• Strength goal 90% > quadriceps/hamstrings

– Low impact sports – 8 weeks– Moderate impact sports – 8-12 weeks– High impact sports – 12-16 weeks

Autologous Chondrocyte Implantation

• Biological treatment approach• Regenerates a durable hyaline-like articular surface• Repair tissue which matures, rather than deteriorates over time• Expected outcomes

– Symptom relief– Return of normal joint function– Return to previous level of functioning

• Goal: reduce further surgical interventions, claims expenditures, incidence of disability

Reference: Gillogly SD, Myers TH, Reinhold MM. Treatment of Full-Thickness Chondral Defects in the Knee with Autologous Chondrocyte Implantation. J Orthop Sports Phys Ther 2006 36(10) 751-764.

AUTOLOGOUS CHONDROCYTE IMPLANTATION

Post-Op Rehabilitation ProtocolPHASE I – Pre-functional• Non-weight bearing – 2 weeks – size of defect (< 2cm2 condyle)• Toe–touch weight bearing at approx. 3 weeks (25%-45% BW)• PWB – 4 to 6 weeks (50%-Full BW)• FWB – 6 to 8 weeks (depends on size of defect and rehab

response)• Regain full extension, slow flexion, total leg control, hamstrings re-

lengthening, patella mobilization, hamstrings/quadriceps co-contraction

• CPM for joint nutrition• Multi-Angle Isometrics• Core Stabilization – hip strengthening

Reference: Stroud R. CPM’s Therapeutic Benefits. Rehab Management August/September 2006 48-50.Nho SJ, Pensak MJ, Seigerman DA, Cole BJ. (2010)

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Range of Motion

• CPM as instructed – full extension to 40 degrees for 2 to 3 weeks. Increase 5° – 10° per day

• Positional Extension• Flexion to 90 degrees by 2 weeks• Flexion to 105 degrees by 3 weeks• Flexion to 115 degrees by 4 weeks• Flexion to 120+ degrees by 6 weeks• Patellar mobilization• Stationary Bicycle low resistance

PHASE II

Return to Function PhaseGoals• Increase ROM to functional limits• Improve quadriceps control• Begin functional activities

Return to Function Phase• Balance Board - BOSU• P.R.E. as tolerated for quadriceps & hamstrings open

kinetic chain extension cautiously• Begin closed kinetic chain terminal knee extension• Mini-squats, leg press & balance retraining, lateral &

front step-up• Continue bicycle• Treadmill if available – retro-training - Elliptical• Core Stabilization – Phase II – hamstrings bridge roll• Total Gym – Sub-max BW Loading

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PHASE IIIReturn to Activity Phase

• Increase functional activities• Increase strength and endurance• Promote kinetic stabilization

Functional Tests

• Hamstrings 80% contralateral extremity• Quadriceps 70%-80% contralateral extremity• Balance testing within 10 seconds of contralateral

extremity• Isokinetic evaluation if available

• Less than 20% side to side deficit• 10% deficit – single leg hip test

Progressive Exercises• Leg press and all other closed kinetic chain

activities as before• Balance vector training• Lateral step-ups, 2” – 4” – 6” – 8”• Stepper – Elliptical - Swimming• P.R.E. open kinetic chain strengthening as

tolerated – Patella Protection 90° - 40°• Forward Lunges – lateral resistive lunges• BOSU – single leg• Fitter, slide board• Plyo-toss – balance training – uneven surfaces

Goals: • Return to full function• Strength to 90% of contralateral extremity• Balance – Proprioception

Functional Training Program:• Closed kinetic chain stabilization• Balance tri-plane• Return to light running• Sports specific agility training as neededCurrent evidence suggest 75%-85% experience subjective

improvementReference: Cole, Pascual-Garrido; Grumet JBJS Am (2009)

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Return to Sports• Return to sports programs:

• Low impact sports – 6 months• Swimming• Cycling• Skating

• High impact sports – 8 to 9 months• Jogging• Aerobics• Golf• Large lesions may be delayed to 9 to 12 months

• High impact contact sports – 12+ months• Football• Soccer• Basketball• Baseball

Meniscus Repair – Complex TearsPre-functional phase – 1 to 6 weeks• ROM guidelines

– Gradually increase PROM as tolerated– Week 2: 0-100 degrees– Week 3: 0-110 degrees– Week 4: 0-120 degrees

• Weight bearing guidelines – continue to lock brace– Week 2: 25-50% WB– Week 3: 50-75% WB– Week 4: FWB as tolerated

Reference: Noyes, Heekmann, Barber-Westin JOSPT (3) 2012

Meniscus Repair – Complex Tears

Pre-functional Phase Exercises• Hip-core exercises

– Standing SLR and side-lying SLR– CKC weight shifts between 4 and 6 weeks

• Mini-squat progression• Balance vectors• Leg press terminal extension

– Delayed co-contraction with hamstrings

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Return to function phase beyond 6 weeks• Normal ROM / gait control• Progressive CKC PRE – leg press and step-ups• Quadriceps and core PRE• Proprioceptive training – balance vectors• Initiate hamstrings strengthening 7-8 weeks

– With meniscus transplantation – 9-12 weeks with hamstrings and leg press

• Medial hamstring insertion along the posteromedial joint capsule


Return to activity phase• Endurance training• Advanced proprioception on uneven

surfaces• PRE / OKC and CKC including hamstrings• Advanced core exercises


Recommendations from the research literature

• Deep squats permitted at 5 ½ months• Initiate straight line running at 6 months• Initiate pivoting and cutting at 7 months• Initiate agility training at 7 months• Gradually return to sports at 7-8 months

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Meniscus Repair – Peripheral Tears

Pre-functional phase weeks 1 to 4• Use brace as instructed• Weight bear 25-50% with crutches up to 4

weeks• ROM guidelines

– Gradually increase PROM– Week 2: 0-100/105 degrees– Week 3: 0-115/120 degrees– Week 4: 0-125/135 degrees


Pre-functional phase exercises• Leg control through quadriceps recruitment• Isometric exercises (MAI as ROM improves)• Core exercises – hip control (side-lying SLR and

standing SLR)• Only hamstrings activity is limited to co-

contraction• Hamstrings and heel cord stretching • Patella mobilization as needed


Return to function phase 4 to 12 weeks• Normal gait and ROM• Progressive quadriceps strengthening – ROM 90°-30°• Begin CKC, mini-squats to progressive leg press – ROM

60°-10°• Balance vector training• Initiate light hamstrings strengthening between 6 and 8

weeks• Advanced proprioceptive training based on performance• Advanced core stabilization

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Return to activity phase• Advanced OKC strengthening• Progressive balance proprioception on uneven

surfacesReturn to activity criteria• Full non-painful ROM• Satisfactory clinical exam• Acceptable functional test• Running program at 20 weeks


Recommendations from research literature• Deep squats permitted at 4 months• Initiate straight line running: 4 months• Initiate pivoting and cutting: 5 months• Initiate agility training: 5 months• Gradually return to sports: 6 months

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