ACL Section Flashcards
One big negative of non-operative ACL management
We see higher incidence of meniscus tears but we don’t see the same incidence of articular cartilage or knee stability issues.
Who is considered a coper?
- Have to start resuming your sporting activity again within 1 year
- No episodes of giving
- Do not require surgery
- Have good joint stability and less joint play
- Normal knee ROM with functional activities
Delaware Study Suspected Copers
- > 80% on timed hop test
- > 80 on knee outcome surgery
- > 60% for global rating of knee function
- < or = 1 episode of giving way
All these test were done about 60 days post-tear a Norway study showed that we don’t want to test these people acutely though. They will change groups sometimes if tested too early.
When would you want to test to see if someone is a coper?
Probably around 10 sessions of PT and >60 days but less than 6 months
ACL and PCL Bundles?
ACL: Anteromedial (more taught in flexed position), posterolateral (more taught in extension), and intermediate
PCL: Posteromedial, anterolateral (makes up 95% of substance; more taught in flexion)
Best Special Tests For ACL
Lachman’s Sn 85% Sp 94
Pivot Shift Sn 24% Sp 98
Lachman’s one of better test of all of them
Pivot shift good under anesthesia
Anterior drawer maybe best over time because people guard at first
Best Tests For PCL
Posterior Drawer: Sn 90, Sp 99
Posterior Sag Sign: Sn 79 Sp 100
How is PCL Managed
Usually non-operative. Grade I and II can usually return within 2-4 weeks. Grade III a little slower, may immobilize in extension to reduce posterior subluxation and allow soft tissue healing.
Things to be careful with during PCL surgery rehab
Be careful with knee flexion ROM, this puts more stress on the graft. Also, may hold off on isolated hamstring strengthening in open chain until up to 12 weeks (pulls tibia posteriorly).
OA and ACL injuries
Higher incidence of OA in knees that have torn ACL. OA levels are similar if you had ACLR vs. no ACLR. Substantially higher risk of knee OA if you had cartilage or meniscus lesions.
Reconstruction related factors: May have more PF OA with patellar tendon graft, more OA if you didn’t get full knee ext, had more laxity after surgery, >6 months to get surgery, and poor performance with hop test at 1 year post-op.
Operative vs. Non-Operative ACL Outcomes At 5 Years
No Difference In:
Quad strength
Hop tests
Pain/symptoms
ADL’s/quality of life
OA
Mild increase in global rating of knee function and lower fear for ACLR
Graft Types For ACL’s
Allograft: Use more for older adults. Some higher failure rates.
BPTB: Some say more anterior knee pain the first few months
Hamstring: Have to be more careful with hamstring loading the first few months
Study that looks at ACL tears showed what people are doing when they tear. Most common things?
- Knee valgus with landing
- Knee stays relatively straight
- Most of the weight on that leg
- Trunk tilts laterally and forward
Likelihood to get back to sport
81% = any sport (or some sport)
65% = preinjury level
55% = competitive level
Retear Rates
1/4 to 1/3 retear rates (same side)
6x likelihood to tear either side
Things that come back / don’t come back within 12 months after ACLR
Ligamentization, full quad strength, neuromuscular control can take 2 years to come back
Rates of re-injury if going back at certain times?
7x more likely to re-injure if going back before 9 months
Recommendations From MOON Guidelines?
1. CPM
2. Early WB
3. Post-Operative Bracing
4. Home-Based Rehab
5. OKC vs. CKC Exercise
6. NMES
7. Accelerated Rehab
8. Neuromuscular Control
- CPM’s: No lasting long-term ROM gains
- Early WB: 1 study showed decreased patellofemoral pain c immediate WB
- Post-Operative Bracing: 17 studies overall have shown no clinical significant or relevant improvement in safety, extension ROM, or other outcome measures
- Home-Based Rehab: No study showed this had deleterious effects
- OKC: Most studies are done after 6 weeks and show no adverse affects to graft (insufficient evidence prior to 6 weeks and may want to do lighter load and restricted arc)
- NMES: Unable to comment fully due to the research out there
- Accelerated Rehab: Didn’t have research to support
- Neuromuscular Control: Recommended
Ligament Dominance
Imbalance between neuromuscular and ligamentous control of knee joint stability. Demonstrated by inability to control LE frontal plane motion.
Faults seen with female athletes compared to males
- Ligament dominance (greater knee valgus)
- Quad dominance (more than hamstrings)
- Leg dominance (preferred leg seen)
- Trunk dominance, core dysfunction
Females also have less glute/more quad EMG compared to males
Is knee valgus predictive of future ACL injury
Yes.
Neuromuscular Training Programs and ACL Injuries
Successful at decreasing valgus and they decrease ACL injury rates
What ligaments of the knee are injured during hyperextension force?
The ACL is first injured, the intercondlyar shelf comes in contact with the midsubstance ACL. This will result in isolated ACL tear and positive Lachman’s.
What Needs to Be Torn For Positive Pivot Shift?
Anterolateral capsule
Where might occult osteochondral lesion occur with ACL rupture?
Found at either the lateral femoral condyle on sulcus terminalis (where the femoral condyle and trochlear notch meet) or the posterolateral tibial plateau.
What is a Segond fracture?
Avulsion fracture of the anterolateral tibial plateau, associated with ACL tears. Caused by varus/IR force that puts excessive tension on the central portion of lateral capsular ligament.
BPTB vs Hamstring Graft?
Neither is consistently better than the other. BPTB more likely to result in normal Lachman’s and Pivot Shift after surgery and fewer incidences of reinjury and fewer instances of flexion loss.
Hamstring tends to have less episodes of PF crepitus, less kneeling pain, and fewer incidences of significant residual extension loss.
BPTB allograft vs autograft?
Allograft 3 fold increase in rerupture rates.
Female compared to male risk rates for ACL tear?
Females 2.4-9.5 times more likely to rupture.
Tuck Jump Assessement
Repeated tuck jumps for 10 seconds. Record from the front and the side.
- feet shoulder width (on line 35 cm apart)
- slight crouch with arms extended behind her
- jump straight up and pull knees as high as possible
- immediately jump when landing
- encourage athlete to land softly
Knee and thigh motion:
1. LE valgus at land
2. Thighs do not reach parallel
3. Thighs not equal during flight
Foot Position During Land:
4. Foot placement not shoulder width apart
5. Foot placement not parallel
6. Foot contact timing not equal
7. Excessive landing contact noise
Plyometric Technique
8. Pause between jumps
9. Technique declines prior to 10 seconds
10. Does not land in same footprint
