Rehabilitation in Athletes Post ACL Reconstruction

ACL Rehabilitation from a Physios perspective

¢  Young patient/ Athlete

¢  Active lifestyle/ Activity level

¢  Future Participation expectations

¢  Traumatic injury mechanism

¢  General health and presence of co morbidities

¢  Functional Goal Setting: Athlete may need to attain functional independence in BADL’s and also in relation to work demands and rarely to attain the sports activities being played.

¢  But these functional goals will be constantly changing based on aging, lifestyle and general health.

¢  Important is to prepare the athlete for a long term, not just for the coming season.

¢  Nyland J, 2010

Indications for Arthroscopic Repair/ Reconstruction:

¢  Injured ligament (different healing capabilities)

¢  Location & size of lesion

¢  Degree of instability experienced by patient

¢  Other associated injury – meniscal tear, articular damage etc

¢  Patients desired level of function

¢  Risk of re-injury

¢  Prevention of future impairment

ACL Recon – Physiotherapists consideration

— Indication for ligament surgery – Failed conservative mgmt, early degenerative changes seen, pain/ loss of function.

— Type of ligament surgery:

     Intra articular, extra articular, combined procedures

— Grafts used:

     Autograft, allograft, synthetic, area of harvesting etc.

¢ Type of fixation in bone tunnel/ socket

Pre operative physiotherapy

¢  Patients with ACL deficiency should participate in preoperative physical therapy before ACL reconstruction to maximize dynamic knee-stabilizing potential

                        Keays SL et al, 2006

¢  Deficits in pre-operative quadriceps strength influence function 6 months after ACL reconstruction

                        David Logerstedt et al, 2013

Pre-Operative management & goals

¢  Oedema Control

¢  Minimize muscular atrophy

¢  Maintain ROM as much possible

¢  Protected ambulation

¢  Patient education

Pre-Operative Exercises

¢  Open and closed kinetic chain exercises,

¢  Dynamic quadriceps-hamstring co-activation

¢  Calf muscle strengthening

¢  Small arc plyometrics

¢  Single-leg balance activities

¢  Lower extremity stretching

¢  Neuro-muscular training

¢  Patient education

Surgical Context

¢  Less invasive surgery reduces acute care and increases rehabilitation timetable decisions.

¢  Nyland J et al, 2010

¢  Repair, instead of reconstruction, with lesion-site scaffolding, innovative suturing methods and materials, and evolving use of biological healing mediators such as platelet- rich plasma and stem cells has prompted reconsideration of primary ACL repair.

¢  ACL repair rather than reconstruction is more likely to preserve the native neuro-sensory system, entheses, and ACL footprints.

¢  Nyland J. Knee Surg Sports Traumatol Arthrosc. 2017 Feb.

Post operative management & goals

¢  Restoration of joint stability & motion

¢  Pain free & stable weight bearing

¢  Sufficient post operative strength & endurance to meet functional demands

¢  Ability to return to pre injury activities

¢  ‘Injuries around the Knee’ Symposium: Sancheti Parag et al, Br J Sports Med, 2010

¢  Reduction of Kinesiophobia which common post ACL reconstruction.

¢  Shah RC, Sancheti PK. IJPR, 2017

Post operative management

Nyland J et al, 2010

	Phase	Goal	Duration
1	Maximum protection phase	Early acute care Re-establish independent activity of daily living function Sensori-motor training bias	0–4 wk
2	Moderate protection phase	Progressive transition from “patient” to “athlete” role Re-establish strength, power, and endurance Blend resistance and neuromuscular training	5–26 wk
3	Minimum Protection phase	Sport-specific training Neuromuscular training bias	27–36 wk
4	Return to Sports Phase	Return to play decision-making 1, highly controlled functional activities to individual tasks performed on the playing field with oversight by the clinician; 2, individual workouts with oversight by the coach and clinician; 3, workouts with two or three teammates with oversight by the coach and clinician; 4, return to unrestricted practice with full team; 5, release to competition.	37–52 wk

Maximum protection phase – weeks 0 – 4

            TREATMENT GOALS:

¢  Protect healing tissues and surgical wound care

¢  Prevent reflex inhibition of muscles with pain management

¢  Reduce joint effusion

¢  ROM 0 – 110°

¢  Active control of ROM

¢  Weight bearing 75% to tolerance (depends on specificity of tissue repaired)

¢  Early controlled weight bearing does not compromise knee joint stability and provides a better outcome in terms of VMO function

                        Tyler TF Clin Orthop Relat Res, 1998

Intervention

           

Early: Days 0 – 14

¢  Pain Management

¢  Gait training – crutches PWB

¢  Passive to active ROM (with range limiting braces if required)

¢  Using CPM for ROM does not offer any additional benefits

¢  Rosen MA Am J Sports Med, 1992

¢  Patellar mobilization

¢  Muscle setting exs. – Quads, hams, adductors at multiple angles

¢  Assisted SLR in supine (with brace when needed)

¢  Ankle pumps

Late: weeks 2 – 4

¢  Continue previous exs.

¢  Full weight bearing & closed chain exs for hip & knee muscles (with permission)

            (Not in meniscal injuries)

¢  Low resistance PRE in open chain activities

¢  Core stabilisation exs

¢  Aerobic conditioning – static cycles

¢  Side planks

¢  Optimal muscle lengthening (rectus femoris, TFL, Glutei, hip ext rotators, adductors, hamstrings)

Establishing the self confidence of the Athlete

¢  Functional exercises simulating the athlete’s role extremely important in the early phase.

¢  This helps in gaining an early neuromuscular control and functioning.

¢  More useful in re establishing patients self efficacy and confidence as movements closely resemble the athletes sports specific movements.

¢  May also be useful in reducing kinesiophobia post surgery.

BRACING

¢  Using a functional brace or a neoprene sleeve post arthroscopic repair helps in improving joint position sense in early rehab phase.

                        Beynnon BD, J Orthop Sports Phys Ther, 2002

                                Brandson S et al Scand J Med Sci Sports, 2001

¢  More useful for patients with innate ligamentous laxity.

¢  Useful in increasing patients’ confidence and lowering the kinesiophobia.

             

Moderate protection phase weeks 5 – 26

TREATMENT GOALS:

¢  Full pain free ROM

¢  Strength Gr. 5/5

¢  Dynamic joint (knee) control

¢  Improved kinesthetic awareness

¢  Normalise gait pattern & ADL function

¢  Home exercise program

Intervention

            Early – weeks 5 – 6:

¢  Multiple angle isometrics

¢  Advanced closed chain strengthening & PRE

¢  Stretching exs

¢  Endurance training

¢  Proprioceptive training – single leg, tilt board

¢  Stabilization exercise with elastic bands

Proprioceptive training and core strengthening

¢  Both form important aspects of phase 2 rehabilitation.

                            Lephart SM Am J Sports Med, 1997

¢  Lack of core strengthening and proprioceptive training post arthroscopic cruciate reconstruction have been found to be associated with reduced stability and performance in patients

                        Cinar-Medeni O, Am J Phys Med Rehabil, 2014

Intervention

            Late – weeks 7 – 10:

¢  Continue with previous exs

¢  Advance strengthening (PNF patterns)

¢  Endurance & flexibility training

¢  Advanced Proprioceptive training

¢  Walking/ jogging

¢  Initiate plyometrics training (with permission in athletes)

Virtual Reality Training

Non Immersive VRT can also be used as an effective mode of training for enhancement of balance and knee functions post ACL recon.

Wani S, Shah S, Sancheti PK, 2017 (Unpublished)

Minimum protection phase
 weeks 27 - 36:

TREATMENT GOALS:

¢  Increase strength, power & endurance

¢  Improve neuromuscular control, dynamic stability & balance

¢  Improve cardio pulmonary fitness

Joint stability achieved by Neuro-musculoskeletal system

Intervention

¢  Continue stretching program

¢  Advanced PRE. Initiate isokinetic training if desired.

¢  Advanced close chain exercises & plyometrics drills.

¢  Advanced Proprioceptive training.

¢  Progressive agility drills (fig of 8, specific drills)

¢  Progress running program

Sports specific training of a badminton player post ACL reconstruction Using a stability trainer, BOSU ball with dome up and with flat side up. Training with single ball, double balls and badminton racquet and shuttle cock. 

Return to Sports phase: 
6 months & beyond

TREATMENT GOALS:

¢  Increase strength, power & endurance

¢  Regain ability to function at highest desired level

¢  Maintenance program

¢  Reduce risk of re-injury

¢  Balance and Proprioception training for a sprint athlete

¢  Plyometrics training (Sports Specific)

¢  Sports specific training for a basket ball player using multi-planar motions and BOSU ball

Intervention

¢  Progress PRE & flexibility exercises

¢  Advanced agility drills

¢  Sports specific drills

¢  Need of protective bracing prior to return to sports.

Return to Sports Criteria

¢  Adequate restoration of operated limb strength, power, endurance and perceived function.

¢  Ability to perform 10 sec duration, maximal effort single leg hops on operated leg in multiple directions to overcome GRF.

¢  Nyland J. Knee Surg Sports Traumatol Arthrosc. 2013

¢  Force plates can be used to understand the reduction in torque production and need for additional rehabilitation.

¢  Nyland J. J Electromyogr Kinesiol. 2011.

¢  Acceptable is till 90% of force production as compared to the normal limb.

Sports Maintenance Therapy

¢  Continue Neuro-muscular conditioning.

¢  Monitor single leg press capability.

¢  Nyland J, Neurophysiol. 2003

¢  Perform regular pre-season and in-season neuromuscular training with special focus on the landing techniques.

¢  Training of neuromuscular responsiveness and balancing of the hip and the ankle-foot in addition to the knee.

¢  Nyland J, Knee 2014

Current trends in rehabilitation

¢  Shift towards individually tailored/ modified programs depending on functional requirement of the individual

¢  Functional training programs – exercises similar to sports specific requirements of the individual athlete.

¢  Limited Use of CPM machines

¢  Cryotherapy pre-op/ post-op beneficial to control pain and swelling

¢  Functional Testing to assess joint stability

¢  Emphasis on Proprioceptive and Neuromuscular Training

¢  Patient Perceived joint stability most important criteria for Prognosis

¢  Time not a major factor in determining treatment progression

¢  ROM, muscle strength and patient perceived joint stability most important criteria for exercise progression.

¢  Less invasive surgery reduces acute care and accelerates rehab.

¢  Nyland J. OAJSM. 2010

Things to remember!

¢  No fixed Protocol for rehab

¢  Modify Exercises by regular client evaluation

¢  Task Specific and Functional Exercises more effective. Train not just the knee, but also the brain.

¢  Return to sports is a biological, psycho-behavioural and biomechanical readiness factor.

¢  Rehabilitation greatly influenced by level of motivation of the patient and compliance to the exercise program.

References:

Available on request