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Final Frontier MSK Content > ACL Rehab Protocol Daily Reading > Flashcards

ACL Rehab Protocol Daily Reading Flashcards

1
Q

What are three general phases we can break ACL Rehab down into?

A
  1. Max protection phase (Day 1-Week 4)
  2. Moderate protection phase (Week 4-Week 10)
  3. Minimum protection phase (Weeks 11-24)
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2
Q

How would we expect our patient to present during the “Max Protection Phase”? (3) Day 1-Week 4

A
  1. Pain & hemarthrosis
  2. Decreased ROM & diminished voluntary quad activation
  3. Ambulation w/crutches & use of protective brace (if prescribed)
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3
Q

What should be some key examination procedures during the “Max Protection Phase”? (4) Day 1-Week 4

A
  1. Pain scale
  2. Joint effusion: girth & patellar mobility
  3. Ligament stability (days 7-14) & ROM
  4. Muscle control & functional status
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4
Q

What should our goals be during the “Max Protection Phase”? (4) Day 1-week 4

A
  1. Protect healing tissue & decrease joint effusion
  2. Prevent reflex inhibition of muscle & ROM 0-110 degrees
  3. Active control of ROM
  4. Weight-bearing up to 75% or WBAT & establish HEP
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5
Q

What are some interventions we can utilize for Weeks 0-2 for s/p ACL? (6)

A
  1. PRICE principle
  2. PROM/A-AROM (range limiting brace, if prescribed)
  3. Muscle setting (iso: quads, hamstrings, adductors @ multiple angles)
  4. Assisted SLRs in supine & ankle pumps
  5. Patellar mobs (Grades 1 & 2)
  6. Gait training crutches from PWB to WBAT
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6
Q

What are some interventions we can utilize for Weeks 2-4 for s/p ACL? (5)

A
  1. Progress to FWB
  2. Closed chain squats, heel/toe raises
  3. SLRs in 4 planes
  4. Low load MRE to hamstrings & OKC knee extension from 90-40 degrees
  5. Trunk/core stabilization & aerobic conditioning (stationary bike)
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7
Q

How would we expect our patient to present during the “Mod Protection Phase”? (4) Weeks 4-10

A
  1. Pain and joint effusion controlled
  2. Full or near full knee ROM
  3. Good muscle strength (3+/5 to 4/5)
  4. Muscular control of joint & independent ambulation
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8
Q

What should be some key examination procedures during the “Mod Protection Phase”? (4) Weeks 4-10

A
  1. Pain scale & effusion (girth)
  2. Ligament stability & ROM
  3. Patellar mobility
  4. Muscular strength testing & functional testing
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9
Q

What should our goals be during the “Mod Protection Phase”? (4) Weeks 4-10

A
  1. Full, pain-free ROM
  2. 4/5 MMT & dynamic control of knee
  3. Improved kinesthetic awareness & normalized gait pattern/ADL function
  4. Adherence of HEP
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10
Q

What are some interventions we can utilize for Weeks 5-6 for s/p ACL? (5)

A
  1. LE stretching program
  2. Multiple-angle isometrics, MRE, CKC strengthening
  3. Endurance training (bike, pool, elliptical)
  4. Proprioceptive training in SLS, balance board, BOSU
  5. Stabilization exercises, elastic bands, band walking
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11
Q

What are some interventions we can utilize for Weeks 7-10? (3)

A
  1. Advanced strengthening (including PNF), endurance, and flexibility exercises
  2. Proprioceptive training, high-speed stepping drills, unstable surface challenge drills, balance beam
  3. Initiate a walk/jog program at the end of this phase
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12
Q

How would we expect our patient to present during the “Min Protection Phase”? (4) Weeks 11-24

A
  1. No joint instability, pain, or swelling
  2. Full knee ROM
  3. Muscle function: 75% of uninvolved extremity & symmetrical gait
  4. Unrestricted ADL & possible use of functional brace or sleeve
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13
Q

What should be some key examination procedures during the “Min Protection Phase”? (3) 11-24

A
  1. Ligament stability
  2. Muscle strength testing & functional testing
  3. Full clinical examination
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14
Q

What should our goals be during the “Min Protection Phase”? (5) Weeks 11-24

A
  1. Increase muscle strength, endurance, and power
  2. Improve neuromuscular control, dynamic stability, and balance
  3. Regain cardiopulmonary endurance
  4. Transition to maintenance phase
  5. Regain ability to function at highest desired level & reduce risk of re-injury
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15
Q

What are some interventions we can utilize for Weeks 11-24 for s/p ACL? (5)

A
  1. Continue LE stretching
  2. Advanced MRE (if desired initiate isokinetic training)
  3. Advanced CKC exercise
  4. Advance proprioceptive & balance training
  5. Initiate plyometric drills: bounding, jumping, bouncing, jumping rope, box jumps
  6. Progress agility drills (figure 8, skill specific patterns)
  7. Simulated work or sport specific training
  8. Transition to full speed at everything
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16
Q

What type of brace is typically used with post-op ACL?

A

hinged orthosis with a locking mechanism that can restrict the allowable ROM

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17
Q

How long is a brace usually worn after ACL reconstruction?

A

6 weeks

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18
Q

When should the knee brace be worn?

A

-sleep during the first week for protection pre-op
-ambulation with crutches to prevent graft injury in event of a fall

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19
Q

What are our expectations for knee ROM during the 4-6 week window?

A

full, active knee extension and 90-110 degrees of flexion

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20
Q

When might the knee brace need to be worn longer than 6 weeks?

A

if stability of the knee is in question or if the surgery is combined with another procedure (i.e. collateral ligament, meniscus, or articular cartilage repair)

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21
Q

What does the literature say about protective bracing after ACL reconstruction during return to high-demand activities?

A

there is not enough conclusive evidence to support it and there hasn’t been any evidence to show a benefit for it

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22
Q

When is early weight bearing typically possible for ACL reconstruction?

A

-bone patellar tendon bone or hamstring tendon autograft because of advances in graft fixation

23
Q

When is full weight bearing & ambulation without crutches allowed in ACL reconstruction?

A

4 weeks if weight bearing is pain free and sufficient strength of the quadriceps is present to control the knee

24
Q

Progressions of weight bearing for ACL reconstruction are usually determined by what?

A

patient’s symptoms

25
Q

List the week by week guidelines for ROM with brace setting for s/p ACL

A

Week 1: 0/90
Week 2: 0/100
Week 3: 0/110
Week 4: 0/120
Week 5: 0/130
Week 6: 0/140

26
Q

What is the ideal approach to weight bearing s/p ACL and why?

A

According to Tyler and colleagues
-they compared two groups and the immediate weight bearing group was advised to WBAT and discontinue the crutch as soon as they felt comfortable in doing so

-^^^this group did not have anterior knee pain compared to the group that utilized delayed weight bearing until week 2

27
Q

If we work with the pt in a prehab phase of ACL surgery, what should our goals be? (3)

A
  1. Restore full knee ROM (focus on extension)
  2. Prevent atrophy & weakness of leg musculature
  3. Address strength & flexibility of hip & ankle muscles
28
Q

How soon should exercises begin after ACL surgery?

A

day 1 post-op

29
Q

Which grafts are considered “strong grafts” making early motion possible? (2)

A
  1. bone-patellar tendon-bone
  2. quadrupled hamstring autografts
30
Q

What has the research recently been saying about continuous passive movement (CPM) machines?

A

it is a valid mechanism for post-op pain & initiating early motion, but there isn’t really a long term benefit from them s/p ACL reconstruction

31
Q

If a tendon graft is used s/p ACL what should we be aware of?

A

it goes through a necrotizing process the 1st 2-3 weeks so exercises must be progressed cautiously during each phase of rehab and if protective bracing is prescribed it should be worn while performing exercises

32
Q

What are the 2 general precautions for resistance training s/p ACL reconstruction?

A
  1. Progress exercises more gradually for reconstruction w/hamstring tendon graft compared to bone-patellar tendon-bone graft
  2. Progress knee flexor strengthening exercises cautiously if hamstring tendon graft was used & knee extensor strengthening if patellar graft was used
33
Q

What are the two general precautions for closed-chain training s/p ACL reconstruction?

A
  1. When squatting make sure knees do not go over toes because this increases shear forces on the tibia & could potentially place excess shear on the autograft
  2. Avoid CKC strengthening of quads between 60-90 degrees of knee flexion
34
Q

What are the three general precautions for open-chain training s/p ACL reconstruction?

A
  1. During MRE training for hip musculature, make sure to place resistance above knee until knee stability & control is established
  2. Avoid RESISTED OKC knee extension (short-arc quad training) between 45-30 degrees to full extension for at least 6 weeks
  3. Avoid applying resistance to the distal tibia during quad strengthening
35
Q

What should our goals focus on during the Max Protection Phase of ACL reconstruction? (6) Weeks 1-4

A
  1. Control pain & swelling
  2. Prevent adhesions & restore knee mobility
  3. Prevent reflex inhibition of knee musculature
  4. Initate ambulation w/crutches
  5. Regain kinesthetic awareness and neuromuscular control of LE
  6. Improve strength & flexibility of hip & ankle musculature
36
Q

What are our ROM goals by the end of the first two weeks and by weeks 3 & 4? (2)

A

-90 degrees of flexion & full passive extension by end of first two weeks

-110-125 degrees of flexion by weeks 3-4

37
Q

We know how important it is to strengthen the quadriceps in s/p ACL; what other muscle group should be equally as important & why?

A

hamstrings as they provide a dynamic restraint to limit anterior translation of the tibia on the femur

38
Q

VERY IMPORTANT
What two exercises should be incorporated as soon as weight bearing is permissible?

A
  1. CKC exercises
  2. Proprioceptive/neuromuscular control training
39
Q

List exercises that are advocated for in the Max Protection Phase

A
  1. Ankle pumps
  2. Muscle setting/pumping of quadriceps, hamstring, abductors, adductors, and extensors
  3. E-stim to augment quad activation (short-term this could be more of a benefit that exercise activation alone)
  4. 4 way SLRs
  5. Low intensity multi angle isometrics & co-contraction of hamstrings/quads
  6. Supine heel slides to a comfortable level & hamstring activation such as scooting forward on a rolling stool
40
Q

What is a really good hamstring exercise that doesn’t have resistance added?

A

SCOOTING ON A STOOL

41
Q

When focusing on ROM & patellar mobility what should we keep in mind? (5)

A
  1. Begin ROM in a protected range w/PROM & AAROM
  2. Include patellar mobs to prevent adhesions
  3. To increase PROM knee extension, have the pt assume a supine or long-sitting position & prop heel on a rolled towel/bolster w/o knee supported
  4. To increase knee flexion: supine, gravity-assisted wall slides or dangle leg while sitting on side of bed
  5. Stretch hip & ankle musculature if flexibility is limited
42
Q

When focusing on neuromuscular control, proprioception, stability, and balance what should we keep in mind? (3)

A
  1. Begin neuromuscular training w/trunk & LE stabilization exercises in bilateral stance (protective brace locked in extension, if prescribed). Weight should be equally distributed and some through UE, but change directions with the pelvis
  2. Weight shifts now and bilateral mini-squats from 0-30 degrees w/stepping & marching movements; progressing to unilateral
  3. Perform nonresisted, multijoint movements such as stationary cycling & exercise on a seated leg press or total gym at 3-4 weeks & if the incision site heals, begin exercise in the pool
43
Q

What is the criteria to progress to the moderate protection phase? (5)

A
  1. Minimal pain & swelling
  2. Full active knee extension (NO EXTENSOR LAG)
  3. At least 110 degrees of knee flexion
  4. Quadriceps strength at least 50-60% of contralateral side (measured isometrically at 60 degrees)
  5. No evidence of excessive joint laxity
44
Q

What is the emphasis of the moderate protection phase? (3) 4 weeks-12 weeks

A
  1. Full knee ROM
  2. Increase strength, dynamic stability, and endurance
  3. Normalize gait & neuromuscular control & balance for a transition to functional activities
45
Q

When can more vigorous exercises be performed?

A

8-10 weeks because the graft revascularization is becoming well-established

46
Q

When focusing on the ROM & joint mobility in the Moderate Protection Phase, what should be our focus? (3)

A
  1. Continue low-intensity, end range self stretching to gain full knee ROM
  2. Use grade 3 joint mobs to restore full knee flexion
  3. Continue flexibility exercises for hip & ankle (hamstrings, IT band, and PFs)
47
Q

When focusing on strength & muscle endurance in the Moderate Protection Phase, what should be our focus? (3)

A
  1. Continue CKC exercises againt body weight resistance (bridging, wall slides, partial squats, straight-line lunges, step ups/downs, heel raises)
  2. Progress from double leg to single leg exercises
  3. Initiate OKC hip ext/abd & knee ext/flex against light-grade elastic resistance between 45-30 degrees
48
Q

Which exercise type has been proven to be most beneficial in ACL reconstruction between OKC & CKC?

A

BOTH; best results have been shown when there is a mixture of them both at the appropriate time

49
Q

When focusing on neuromuscular control, proprioception, and balance in the Moderate Protection phase, what should be our focus? (2)

A
  1. Progress neuromuscular training w/stabilization and static & dynamic balance in bilateral stance, progressing to unilateral, and then unstable surfaces. Focus on developing quick responses to alternating resistance & unexpected perturbations in varying distances
  2. Emphasis on hip & lumbopelvic stability as well as awareness of LE alignment & knee control
50
Q

What type of gait training should we focus on in the Moderate Protection Phase?

A

-ambulation in a controlled environment w/o bracing and w/o crutches

51
Q

Where does activity-specific training come into play during the Moderate Protection Phase?

A

integrate simulated functional activities or components of activities into the exercise program

52
Q

What is the criteria for someone to progress to Minimum Protection phase/Return to function? (6)

A
  1. Absence of pain & joint effusion
  2. Full, active knee ROM
  3. At least 75% strength compared to the contralateral side
  4. Hamstrings/quads ratio >65%
  5. Functional hop test >70% of contralateral side
  6. No evidence of knee instability
53
Q

What are some interventions we can start to use in the Minimum Protection Phase/Return to Play? (4)

A
  1. MRE w/focus on eccentric training
  2. Advanced CKC strengthening (lunges, step up/downs against elastic resistance)
  3. Advanced agility training w/driectional changes, acceleration, and deceleration
  4. Plyometrics and activity specific drills coupled w/gradual return to progressively demanding activities
54
Q
A

Final Frontier MSK Content (3 decks)

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