ACL - exam 3 Flashcards by Demond Fleming

ACL:
attaches:
runs:

attaches centrally and anteriorly on the tibial plateau and attaches to the lateral aspect of the intercondylar fossa
runs superior, posterior, and laterally

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ACL
primary restraint:
secondary restraint:

excessive anterior tibial glide
tibial IR

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ACL makes up ____% of knee injuries
mostly in ______ and ______ females

20
younger and active

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what are non-modifiable risk factors for a non contact ACL injury?

female
2 weeks following start of menstrual period (ligamentous laxity)
bony morphology
–> people can have different shaped bones

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what are modifiable risk factors for a non contact ACL injury?

high shoe surface interaction/friction (wearing the wrong shoe for the activity)
high BMI

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does bracing help prevent ACL injuries?

helps prevent hyperext.
so yes helps ACL but other surrounding things too

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Modifiable RF: Muscle Strength
__________ overall w/ ACL tears
ham to quad ratio strength:
–> lower in _____
–> predicts _______
hamstrings prevent _____

lower
–> lower in females
–> predicts LE control
ant movement of tibia

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modifiable RF: altered loading patterns
impaired LE control:
–> increased knee ______ and hip _____
–> good ability to visually identify high knee ______ with _______ test
____ and nearly 2x ____
decreased knee _____ with _____ landing

valgus and add
valgus with vertical drop
earlier; faster
flexion; harder

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poor control creates significant ______ movement.
knee is ______ to foot

valgus
medial

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reduced control creates some ______ movement.
knee NOT entirely _____ to foot

valgus
medial

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good control = no _____ movement
knee is _____ with toes

valgus
vertical

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modifiable RF: impaired trunk proprioception and kinesthesia
– greater trunk ______ and ______ toward support limb

lean and rotation

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modifiable RF:
greater activation of ____-_____ strategy vs sensory-motor strategy
this means ?

visual-motor
someone with impaired LE control uses their vision more (tries to use their eyes to balance)

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what is a risk factor for having a second ACL injury?

like primary ACL injury plus excessive femoral IR

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true or false. most ACL injuries occur from contact

false - non-contact (50-70%)

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symptoms of an ACL injury:

consistent with any ligament injury plus:
effusion, popping and giving way following trauma (high likelihood)
WBing activities limited with likely giving way

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signs of ACL injury:
- ROM:
- end feels:

limited and painful particularly into hyperext and IR
empty, soft, late end feels if acute

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what is the most useful special test for ACL injury?

anterior drawer

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will the pt feel pain if there is a complete rupture?

most likely not
nerves are torn

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what are 3 possible ways that could block the anterior glide causing possible false negatives of ACL special tests?

severe swelling tightens capsule
hamstring guarding
meniscal tear

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with an ACL injury, you would see arthrogenic muscle inhibition of quads. This could be due to:
NOT due to:

pain
effusion (joint swelling)
– involved knee inhibition (42%)
– uninvolved knee inhibition (21-33%)
– amount of swelling not always correlated with the amount of muscle inhibition
joint laxity or giving away
muscle weakness/incoordination

NOT due to denervation (no damage to nerve)

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with an ACL injury, you would see arthrogenic muscle inhibition of quads. This could lead to:

atrophy and more inhibition/weakness
– deficits common out to 2-4 years post op and even in both LE
determined by observation, palpation, muscle testing

true or false. MOST can return to lower risk activity without surgery and with good outcomes

true

what is the primary goal of Rx for ACL injury?
- immediate mobilization for ____, _____, & ____
- full ext no later than ______

full to nearly full ROM, esp ext
- ROM, P!, and minimizing immobilization effects
- 4 weeks; predicts ext at 12 weeks & contributes to lower risk of OA

what is the 2nd goal of Rx for ACL injury?

minimal to no swelling

what is the 3rd goal of Rx for ACL injury?

quads activation/endurance/coordination - SLR without ext lag - quad set > 90% of uninvolved side

what must you be careful of when comparing the injured side to the noninvolved side?

can get inhibition to both sides and you could be comparing an inhibited side to another inhibited side without knowing

PT Rx for ACL injury:

- early WBing in both sides - POLICED - weak support for cryotherapy - functional bracing ---> more beneficial than not with ACL deficiency. conflicting support with ACL reconstruction - MT - initiate post op

what modality is effective when combined with MET? - significant increase in _____ strength - NO significant changes with ______ - ______ @ varying angles - discontinue once quad index is ______ of ______ side

Neuromuscular Electrical Stimulation (NMES) for activation/coordination/strength - quad - function - isometrics - > 80% of uninvolved

what should you focus on with MET for ACL Rx?

assumptions must be made about arthrogenic muscle inhibition intense resistive training without inducing P! must eventually be performed emphasize both concentric and eccentric training

what are general exercise guidelines for ACL loading? - greater with ______ exercises - _____ or _____ activities less of a concern - greatest loads _______ - squatting, lunging, leg press: - walking:

greater with non-WBing exercises -- isolated load on quads. In CC other muscles around the knee are working Non-WBing or OC activities less of a concern greatest loads within 50 deg of full ext with both squatting, lunging, and leg press -- increased with knee beyond toes -- decreased with forward trunk lean walking -- as much load as non-WBing knee ext due to repetitive terminal knee ext -- several times greater than other WBing activities

to just work the quads, what could you have your patient do?

leg ext - start 90-45 deg squat - start 0-45 deg

overall, what kind of activities are good to do early and often for someone with an ACL injury?

OC and CC, esp if they are walking and using correct trunk and LE control

MET Rx: emphasize _______ strength and coordination goals: - males -females if quads remain inhibited, __________

hamstring - hams > 66% of quad activity - hams > 75% of quad activity hamstrings will look like they're strong enough but may not be

MET Rx: Neuromuscular training - _____ strength DOES NOT EQUAL proper _______ or _____ control - trunk _____ and ______ minimize lean and twist ** emphasize _____ activities

normal; neuromuscular or LE proprioception and kinesthesia balance

MET Rx: Neuromuscular training LE proprioception and kinesthesia - minimize _____ and _______ plane motion - promote sagittal plane knee and trunk _____ - decrease GRF with _______ landing - progressive _____ and ______ - emphasis on jump _____ and _______

frontal; transverse flexion softer speed and difficulty landing and balance

MET needs to be at least _______/week for _____ months

2-3x 6-10

should you exercise the involved AND uninvolved side?

yes

what does blood flow restriction do for ACL healing? - similar - increased - decreased

similar strength and hypertrophy as high intensity training increased growth hormone, myogenic stem cells decreased myostatin which would limit m. growth

when you start the healing process you start with internal focus which is:

focusing on the movement itself learning pace is slower less carryover more feedback

external focus is progress so you're focusing on:

effect of movement faster learning pace more carryover less feedback

what are examples of motor learning with external focus?

improved balance higher vertical jump more force production greater knee flexion softer landing improved coordination

what are other ways you can further add motor learning with observation?

with others by competition post and real time feedback

what are ways to add plyometrics to Rx for an ACL injury?

vertical drop jump increased loading with rate of deceleration

what percentage of ACL injuries occur with meniscal tears?

22-86%

how would you change your Rx for an ACL injury with a meniscal repair?

slower progressions due to slower healing process because PT can't touch until meniscus is healed due to greater protection needed makes achieving ROM more difficult

____ % of ACL injuries also occur with a bone bruise

80%

on average, how long does it take to heal a bone bruise with ACL/PCL and meniscal injuries?

3.2 months

how does a bone bruise with ACL injury with PCL and/or meniscal injury affect healing?

delaying factor that leads to more difficulty reaching full ext and proper quad function

are MCL tears surgically repaired most often?

no some will not repair ACL until MCL is healed

what are precautions for a MCL tear?

only sagittal plane activity for 4-6 weeks limit tibial ER and valgus stresses

____% have an articular cartilage defect with an ACL injury

36%

if articular cartilage gets repaired, will it delay ACL rehab?

most likely OATS outcomes > ACI > Microfx