ACL - exam 3 Flashcards
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
ACL
primary restraint:
secondary restraint:
excessive anterior tibial glide
tibial IR
ACL makes up ____% of knee injuries
mostly in ______ and ______ females
20
younger and active
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
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
does bracing help prevent ACL injuries?
helps prevent hyperext.
so yes helps ACL but other surrounding things too
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
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
poor control creates significant ______ movement.
knee is ______ to foot
valgus
medial
reduced control creates some ______ movement.
knee NOT entirely _____ to foot
valgus
medial
good control = no _____ movement
knee is _____ with toes
valgus
vertical
modifiable RF: impaired trunk proprioception and kinesthesia
– greater trunk ______ and ______ toward support limb
lean and rotation
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)
what is a risk factor for having a second ACL injury?
like primary ACL injury plus excessive femoral IR
true or false. most ACL injuries occur from contact
false - non-contact (50-70%)
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
signs of ACL injury:
- ROM:
- end feels:
limited and painful particularly into hyperext and IR
empty, soft, late end feels if acute
what is the most useful special test for ACL injury?
anterior drawer
will the pt feel pain if there is a complete rupture?
most likely not
nerves are torn
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
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)
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
