Carrie Cruciate Rehabilitation Carrie Cruciate Rehabilitation ProgramProgram

Lakehead Health & Lakehead Health & Wellness CentreWellness Centre

Kinesiologists: Shayne, Carly, Meggan, Katie, Luke

Client Review Name: Carrie Cruciate Age: 23 Occupation: university student Current Medical history: major tear of ACL, MCL, & medial meniscus (see

slide 4) Short Term: muscle strength & hyperthrophy of quads, full ROM in knee joint,

prevent deconditioning of injured & non-injured leg, plus cardiovascular system, reduce pain in knee and lower back, lower risk of secondary damage (intra-articular deterioration can lead to osteoarthritis)

Long Term: full participation in fall volleyball season, lose 15 lbs, prevent excessive drinking, healthy eating mindset

Physical activity level/hobbies: (prior to injury) active athlete -volleyball player, provincial level Trained & played: 4x for 2 hrs per week

Physical health: past month gained 15 lbs Physical complaints: knee injury - pain, loss of mobility - mild to moderate

lower back pain Diet: inconsistent eating habits, unhealthy selection of foods, excessive

alcohol intake (esp. Thursday nights)

Rehabilitation Approach based on Fowler protocol (note: some variations in therex design

will be applied, see below) Pt.’s knee injury will take at least 6 months to fully heal (Fowler

protocol) full participation with exception of practices in fall volleyball season not

likely until at least 2 months in 2 schools of thought on ACL rehabilitation applied in this program:

accelerated post-op program full recovery in 5-6 months, delayed post-op program 8-12 months (Houglum, 2005) pt.s program may be accelerated or delayed or a combination of the two

programs

Program progression in sequence (Houglum, 2005): Flexibility & range of motion Strength & muscle endurance Proprioception, coordination, and agility, e.g. sport-specific

skills/full functional activities

Anterior Cruciate Ligament

Select Connective Tissue of the Knee (Anterior View)

Medial Meniscus

Anterior Cruciate Ligament

Medial Collateral Ligament

Therapeutic Exercise Prescription Design

Normal PROM slightly higher than AROM (Clarkson, 2000) Methods/procedures used for assessment are basically the same

for treatment (Clarkson, 2000)

Range of Motion Measurement

Name of Exercise Normal ROM (Clarkson, 2000)

PROM Knee Flexion 135

PROM Knee Extension N/A

PROM Int. Tibial Rot. 33 (at 5 knee flexion)

PROM Ext. Tibial Rot. N/A

AROM Knee Flexion 135

AROM Knee Extension N/A

Connective Tissue Testing

Name of Test Tissue Tested

Lachman’s Test Anterior Cruciate Ligament

Pivot Shift Test Anterior Cruciate Ligament

Valgus Stress Test Medial Collateral Ligament

Lachman’s Test

Pivot Shift Test

Muscle Testing & Measurement

Name Tissue

Knee Flexion Hamstrings (Biceps Femoris, Semitendinosus, and Semimembranosus

Knee Extension Quads (Rectus Femoris, Vastus Intermedius, Vastus Lateralis, and Vastus medialis

Measure for Muscle Atrophy

Calf (Gastrocnemius, Soleus)

Measure for Muscle Atrophy

Ham’s & Quads

General Safety Considerations

Warm Up Always prior to physical activity, incl. Stretching 5-10 min., slow jogging, recreational game, brisk walk, etc. goal is to increase HR gradually

Stretching stretch before and after activity never stretch to point of pain proper stretch; stretch to the point of tension, ease of slightly, until

readjusted, then stretch to full hold stretch 10-15 sec. static stretching (stretch-and-hold) for beginners & novices ballistic & PNF (Proprioceptive neuromuscular facilitation)(contract

& stretching)(contract/relax) more advanced for athletes & alike

Weight/Cardio Room “no pain no gain” is outdated & can be dangerous, therefore, lift weight

according to your strength and not sacrificing form for extra few reps stay mindful of proper form & technique when lifting weights or own body do not hold breath; rhythmic breathing progress gradually avoid unnecessary stress on joints and small m groups (work the bigger

mm groups first then smaller mm groups) maintain neutral spine (tighten abs to have stable core plus allows upper or

lower-body extremities to be used as sources of strength) look to maintain 5 points of contact (btw body & surface) (shoulder, hips,

feet, etc) when supine or sitting on a bench back pressed into pad don’t use momentum be aware of ppl & equipment around you use spotters use collars and securing devices. E.g. collars use only properly working equipment proper hydrated before starting cardio esp. intense session (15 min. before

start, drink a cup or 2)(during only a bit not to initiate cramping)(wet lips & gums stimulates physiological response)

be mindful of HR or RPE (rate of perceived exertion)

Therapeutic Exercise PrescriptionName of Exercise

Duration

(weeks)

Phase Location Frequency

(per week)Reps/ Sets

Rest Period

Equip. Required

Pool Walking

1-4 Full ROM & Muscle Strengthening

Pool, Lake

3x 1-20 min. N/A Pool, body of water

Recumbent Stationary Bicycle

1-4 Full ROM & Muscle Strengthening

Gym, Home

3-4x 10 min. to start

N/A Recumbent Stationary Bicycle

(if at home)

Knee-Flexion ROM Passive Stretch

1-4 Full ROM

& Muscle Strengthening

Clinic 5-6x 3-4x per side

30 sec. between stretches

Therapist

Wall Squat

5-8 Controlled Ambulation & Moderate Protection

Home, Gym

4-5x 2x hold for 30 sec./ Sets 2x

1 min per set

Wall

Name of Exercise

Duration

(weeks)

Phase Location Frequency

(per week)Reps/

Sets

Rest Period

Equip. Required

Calf Strengthening

5-8 Controlled Ambulation & Moderate Protection

Home, Gym

4-6x per week

Reps 6-8/ Sets 2-3

30 sec. between sets

Ledge to balance body on toes

Seated Hamstrig Stretch

5-8 Controlled Ambulation & Moderate Protection

Home, Gym

5-6x per week

3-4x hold for 30 sec./ 2

30 sec. between sets

Chair, couch, …

GAIT Training on Treadmill

9-12 Continuig Moderate Protectin & Light Activity

Clinic 2-4x per week

15 min. sessions

2 days between each session day

Treadmill

Name of Exercise

Duration

(weeks)

Phase Location Frequency

(per week)Reps/ Sets

Rest Period

Equip. Required

Hamstrig

Leg Curls

9-12 Continuig Moderate Protectin & Light Activity

Gym 2-3x 5-6x for each side hold each 3 sec. / 2 sets

10 sec. btw reps & 30 sec. btw sets

Leg Curl Machine

Quad Lunge Walk

9-12 Continuig Moderate Protectin & Light Activity

Home, Gym

3-4x 15-20x total for both side / 2 sets

1 min. btw each set

N/A

Box Jumping

(plyometrics)

13-16 Moderate Activity & Return to Activity

Home/ Gym

3-4x 10x/ 2 sets

3 min. btw each set

1 sturdy box able to hold pt.’s weight (approx. 1 ft tall)

Name of Exercise

Duration

(weeks)

Phase Location Frequency (per week)

Reps/

Sets

Rest Period

Equip.

Required

Depth jumps

13-16 Moderate Activity & Return to Activity

Home, gym

3-4x 10x / 2 sets

3 min. rest btw each set

1 sturdy box able to hold pt.’s weight (approx. 1ft. tall)

Single-leg hopping

13-16 Moderate Activity & Return to Activity

Home, gym

3-4x Total distance covered for both legs btw 30-40 m / sets 1-3

3 min. btw each set

N/A

Testing & Evaluation (1st month)

The following criteria to be evaluated: Ability to single leg stand for 30 sec. No antalgia (limping) on level surfaces Normal ascend and minimal assist descending stairs ROM (range of motion) 0-115° with minimal discomfort Minimal to no pain or swelling with current program

If patient does not meet criteria, then she will continue with 1st month program until she is able to perform all above tests

Exercise Description & Teaching Points

Pool Walking Find a pool, lake, ocean, or other relatively large body of water. The water

temperature should be cool to warm - 78 to 88 degrees F. If you are just starting an exercise program, begin gradually with five minutes of slow

walking, preferably waist deep in an uncrowded body of water. Over several weeks, build up to at least 20 minutes per session, raising your speed, and lengthening by just a few minutes at a time.

Starting Position: Stand with your abdominal muscles firm, tailbone pointed toward the floor, buttocks tucked somewhat to brace your spine in position, shoulders back, and chest lifted (neutral position).

Action: Stride or jog forward eight steps, then back four steps. Maintain the neutral position throughout the exercise. Push relatively straight arms forward and back at your sides as you walk. Turn your hands each time so that the palms press against the water. Use your arms in opposition to your legs: When you step forward with your right leg, bring your left arm forward, and vice versa. Walk as you would on land, placing your heel down first. Keep your back straight and stomach muscles taut. Lifting your knees higher will increase the intensity of the exercise.

Variations 1: Walk forward and backward with short steps, long steps, average steps, or step kicks.

Variations 2: Move in a pattern of a circle or square. When you are ready to increase intensity, stride by taking very large, controlled steps

or bound by pushing off with your back foot to bounce up off the pool floor between strides

Recumbent Stationary Bicycling Studies have shown that bicycling on a recumbent stationary bike

decreases the amount of stress put on the ACL, compared to biking on a regular stationary bike. This is a preferred position because the chance that the patient has to re-injure the ACL again is much lower.

Before the patient begins the bicycling program, it is important to start the patient at a lower tension to lower the risk of re-injuring. Then to progressively increase the tension on the bike throughout the program.

Adjusting the seat is the second most important factor. The patients extended knee at the bottom of a revolution should have a slight bend. Improper seat adjustment could increase the risk of re-injuring the knee.

The patient should then bike for a total of 10 min starting out, and be aware of the amount of pain they are experiencing, and prepare to stop before the pain becomes too intense.

Knee Flexion PROM Stretch patient begins by laying down on their non-injured side with their non-injured

leg flexed at a 90 degree angle to prevent the body from rolling over. therapist then stands behind the patient while supporting the weight of the

knee in one hand and holding the ankle in the other hand. therapist must also stabilize the pelvis therapist then takes lower leg from full extension through the injured knee’s

ROM until it becomes mildly painful to patient. therapist then works the knee through several flexions and extensions. at this moment in time her knee has 80% flexion which is 108 degrees of

135 degrees. By the end of the month she should be able to flex the full 135 degrees (Normal ROM for knee) (Clarkson, 2000)

*Discontinue the water walking exercises, the knee should be able to support body in low-intensity exercises out of water.

Wall Squat Find a vertical, sturdy wall that can hold the patients weight. Instruct the patient to stand feet shoulder width apart, and to stand

approximately 2 foot lengths away from the wall, and to lean with the back against the wall

The patient then lowers her body (without the aid of her hands, but may use them if she’s at risk of falling over) bending at the knees, and stops until the quads are approximately 45 - 60 degrees to the horizontal.

Over the course of the program she will increase the angle of her quads as the knee becomes strengthened until she comfortably reaches a complete 90 degree angle.

Calf Strengthening The patient situates herself on the edge of a stair (anything with a ledge)

balancing on the balls of feet, shoulder width apart, while grasping something with her hands to keep her balance.

She then lowers her body by relaxing her gastroc’s, then raises her body by contracting the gastroc’s fully.

She can increase the intensity of this exercise by holding weights in her hands to increase the load on the calf’s.

*Change from recumbent bike to standard bike and increase the tension

Seated Hamstring Stretch Get the patient to seat on the edge of a chair and fully extend the injured

knee. Make sure the heel of the injured leg is on the ground and knee is fully

extended, then get the patient to slowly lean forward slowly Do not allow the patient to touch her toes even if she feels confident she

can. Also, make sure she keeps her back as straight as possible.

*This is an important phase as the therapist should introduce exercises that require improved balance

GAIT Training on Treadmill Begin the patient at walking speed on the treadmill. Allow her to adjust and

make sure she feels comfortable on the treadmill. As she begins walking, incline the treadmill to 3% grade and allow her to

walk for the rest of the allotted time Keep this exercise going until the end of the rehab program. Increase the

speed of treadmill 1 mph and inclination 1% every 2 weeks

Hamstring Leg Curls patient begins laying prone on the machine with both legs behind the leg

curl arms She then contracts her hamstrings to curl the arm towards her buttocks, and

holds it for 3 sec. She can then intensify this exercise by increasing the weight or just using

her injured knee to do the leg curl

* Again increase the amount of tension on the stationary bike, and get her to pedal backwards to intensify the work on the quads every other bike exercise

Quadriceps Lung Walk Begin the exercise with her hands on her hip, feet shoulder width apart patient then takes an exaggerate step forward and bend knees deeply into

the lunge, making sure that the knee that has lunged does not exceed 90 degrees, knee does not pass the front of the toes

While maintaining a low position, she takes another lunge forward with the opposite leg, all the while keeping a straight back

*In this phase agility exercises will be introduced to bring the athlete back to a level where she can practice at. A functional brace will be utilized in this phase to add stability during the agility exercises 3 basic types of braces; prophylactic, functional, rehabilitative (Houglum,

2005) *During this phase she should be at a jogging pace in her GAIT treadmill

exercises

Box Jumping (Plyometrics) Get the patient to stand beside the box, and get her to jump sideways onto

of box, then jump down to the other side Once the muscles become stronger she could progress to jumping over the

box to the other side The objective here is to be able to do this exercise while not wearing the

brace

Depth Jumps Get the patient to stand on the edge with toes close to it Drop from the box and land on the balls of feet, allow her to anticipate the

landing and jump/spring up as quickly as she can It is important to keep the feet in contact with ground in the shortest amount

of time

Single Leg Hopping Start by having the patient standing on her recovering leg, and get her to

take a leap forward on that leg, landing on the same leg. Use the opposite leg to forcefully swing through concentrating on more

height rather than length. Tell her to land on the ball of the foot so that elastic energy is stored in her

calf and immediately take off from the same foot. Tell her to keep her body as vertical as possible

Extra Prescriptions/Referrals

See nutritionist/dietician about weight loss Sport psychologist/school counsellor to help with negative lifestyle

and behavioural patterns – e.g. emotional eating?, excessive alcohol consumption CMHA recommendations for females: 1 standard drink per day;

12 ounces (340 ml) of beer, 5 ounces (140ml) of wine, or 1.5 ounces (42 ml); 7 drinks per week max.

Familiarize pt. with appropriate # and size of portions (see Health Canada Food Guide next pg.); several smaller meals a day rather than fewer larger meals, especially at dinner time; “eat breakfast like a prince … lunch like a king … dinner like a pauper”

Healthier alternatives for fast-food; Subway/Mr.Sub, Pita Pit, etc.

References

Clarkson, H. M. (2000). Musculoskeletal assessment : Joint range of motion and manual muscle strength (2nd ed.). Lippincott

Williams & Wilkins.

Evans, N. A., Chew, H. F., and Stanish, W. D. (2001, September). The natural history and tailored treatment of ACL injury. The

Physician and Sportsmedicine, 29, No.9. Retrieved November 27, 2006, from http://www.physsportsmed .com/issues/

2001/09_01/evans.htm

Houglum, P. A. (2005). Therapeutic exercise for musculoskeletal injuries (2nd ed.). Champaign, IL: Human Kinetics.

Oatis, C. A. (2004). Kinesiology : The mechanics and pathomechanics of human movement (1st ed.). Lippincott Williams &

Wilkins.

Sanchez, Joanna. Personal Interview. November 20, 2006.

Tortora, G. J. (2002). Principles of human anatomy (9th ed.). Wiley.

Wilk, K. E., Arrigo. C., Andrews J. R., Clancy, W. G. (1999, June). Rehabilitation after anterior cruciate ligament reconstruction in

the female athlete. Journal of Athletic Training, 34(2), 177-193. Retrieved November 27, 2006 from http://www.nata.org/jat

http://www.bigkneepain.com/knee-exercises.html

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http://www.ehealthmd.com/library/acltears/ACL_rehab.html

http://spas.about.com/od/philadelphia/l/blhtwaterwalk.htm