Knee Ligament Injury ACLR Flashcards
What range is peak torque on the quadriceps
- 50-70 degrees of knee flexion
What position of the knee requires the most contractile force
- terminal knee extension due to shortened quad muscle & decreased mechanical advantage of the patella
Immediate impairments following initial ligament injury
- swelling for several hrs unless blood vessels are torn
- pain when injuries ligament is stressed
- instability if complete tear
- redistricted motion & quad inhibition if there is effusion
- impaired WBing & need for AD
- concern for concomitant injuries
MCL injury
- isolated injury with high valgus load
- grade I, II, III classification
LCL injury
- infrequent injury
- usually traumatic varus moment at the knee that loads the ligament
PCL injury
- “dashboard injury”
- caused by a forceful trauma to the anterior tibia while the knee is flexed
MOI of ACL tear contact versus non-contact
- Contact: blow to the lateral side of the knee resulting in large valgus moment
- Non-contact: rotational mechanism in which the tibia is rotated on the planted foot with forceful hyperextension of the knee
Risk factors for ACL tear
- high friction b/w the shoe & the surface
- narrow femoral notch, Increased BMI, increased joint laxity
- early & late follicular phases of menstruation in women
- dynamic valgus
Indications for surgery for ACL tear
- disabling instability
- frequent knee buckling
- high risk of re-injury
- rule of 3rds (1/3 compensate & return to physical activities, 1/3 compensate but must give up activities, & 1/3 can’t compensate
Contraindications for surgery for ACL tear
- inactive lifestyles
- advanced arthritis in the knee
- poor compliance
Patient selection for ACL to heal and stabilize the knee
- non-high athlete
- age >25
- acute proximal one bundle ACL rupture
Potential copers for ACL tear
- demonstrate sufficient dynamic knee stability
- ability to compensate following injury
- good potential to return to pre injury high level activities following a 1-year non-operative treatment
Potential non-copers for ACL tear
- poor potential to return to pre injury activities following non-operative treatment
- poor dynamic knee stability
- advised to consider surgical management
Pre-screening to determine if someone might be a coper for ACL tear
- no concomitant knee injuries
- zero to trace knee effusion, full knee ROM, & normal gait
- greater then 70% isometric quad strength
- no pain with hopping up & down
Criteria to be classified as a potential coper for ACL tear
- one or non giving way episode with ADLs
- single-legged 6 meter timed hop score greater than or equal to 80%
- KOS-ADLS score greater than or equal to 80%
- GRS score greater than or equal to 60%
Bracing non-operative ACL deficient knee
- for the ACL deficient knee every effort is made to prevent a giving way or shifting episode in order to avoid any further damage to the articular surfaces
Allograft for ACL reconstruction
- donor tissue
- used if an autograph is not available/previously failed
- greater risk of failure
- decreased graft strength
- potential disease transmission
- longer rehab times compared to autograph
Autograft for ACL reconstruction
- patients own tissue
- requires two surgical procedures
- damages & weakens healthy tissue at donor site
Gold standard for ACL reconstruction
- patellar tendon
- uses the central 1/3 of tendon bone plugs
Advantages of using the patellar tendon for ACL reconstruction
- high strength & stiffness
- secure bone to bone fixation (6-8 wks)
- permits accelerated rehab
- safe return to pre-injury levels
Disadvantages of using the patellar tendon for ACL reconstruction
-anterior knee pain at harvest site
- pain with kneeling
- long term quad weakness
- potential patellar fracture or rupture
Advantages of using hamstring for ACL reconstruction
- high tensile strength & stiffness
- no disturbance of epiphyseal plate in immature patients
- generally no problem with kneeling
- no pain at anterior knee
Disadvantages of using hamstring for ACL reconstruction
- tendon to bone devices are not as reliable as bone
- longer healing times
- hamstring muscle strain in early rehab
- knee flexor muscle weakness
- increased anterior knee translation
Precautions for patellar tendon autograft ACL reconstruction
- be aware of patellofemoral forces & possible irritation
- treat patellofemoral pain as it arises
- alter knee flexion angle b/w 45-60 degrees for MVIC assessment & NMES treatments
Precautions for hamstring autograft ACL reconstruction
- no resisted hamstring strengthening until wk 12
- may start AROM as early as wk 4-6
Precautions for an ACLR with meniscal repair
- no WBing flexion beyond 45 degrees for 4 wks
- WBing in full extension is allowed
- multi-angle quad isometrics can substitute for WBing exercises
Precautions for an ACLR with MCL tear
- restrict motion to sagittal plane until wks 4-6
- consider brace for patients with severe pain during exercise
Non-repaired MCL ROM restrictions
- Grade I = no ROM restrictions
- Grade II = 0-90 degrees in wk 1, 0-110 degrees in wk 2
- Grade III = 0-30 degree in wk 1, 0-90 degrees in wk 2, 0-110 degrees in wk 3
Ligamentization
- graft is its weakest at 6-8 wks post-op
- by 30 wks a graft will have tissue characteristics of a ligament
Open and closed chain exercise considerations for ACL repair
- Open chain: limit knee ROM to only 90-45 degrees for non-weight bearing exercises early on; progress to knee ROM from 90-10 degrees by wk 12
- Close chain: wall slides & step ups in pain free ranges typically 0-60 degrees
ACL loading/force in NWB and WBing exercises
- loading b/w 10-50 degree is greater in NWB knee extension exercises
- seated knee extension exercises b/w 10-50 degrees of knee flexion ROM with or without resistance produces greater ACL loading compared to WB exercises
ACLR rehab goals
- full knee extension ROM
- absent or minimal effusion
- no knee extension lag with leg raise
- quad strength deficit should be minimized (15-40%)
What sets the stage for successful rehab for ACLR post-op care
- achieving symmetrical full knee extension
- decreasing effusion
- quads activation
What sets the stage for successful rehab for ACLR post-op care
- achieving symmetrical full knee extension
- decreasing effusion
- quads activation
Patient presentation in max protect phase for ACLR
- pain
- hemarthrosis
- decreased ROM
- diminished quad activation
- crutch ambulation
- bracing if prescribed
Patient presentation in mod protect phase for ACLR
- pain & joint effusion are controlled
- full knee ROM
- 3+ or 4/5 muscle strength
- developing neuromuscular control
- independent ambulation
Patient presentation in min protect phase for ACLR
- no joint pain, instability, or swelling
- full ROM
- 75% function of non-involved LE
- symmetrical gait
- unrestricted ADL
- possible brace/sleeve
Interventions for max protect phase post ACLR
- PRICE
- gait training
- PROM/AAROM
- patellar mobs
- muscle setting/isometrics
- assisted SLR
- ankle pumps
- Wks 2-4: progress to FWB, SLRs in four planes, low load PRE hamstrings and knee extension (90-40 degrees), trunk/pelvis stabilization, & aerobic conditioning
Interventions for mod protect phase post ACLR
- multiple angle isometrics
- close chain strength/stretch of LE
- endurance training
- proprioceptive training in SLS
- trunk stabilization/band walks
- Wks 7-10: advance strength/endurance/flexibility, progress proprioceptive training, & initiate walk/jog program
Interventions for min protect phase post ACLR
- LE stretching
- advance PRE
- advanced close chain exercises
- introduce plyometrics
- introduce more advanced plyometric drills
- advance proprioceptive training
- progress agility drills
- simulated work/sport specific training
- transition to full speed jogging/sprints/running/cutting
Soreness rules during rehab
- Sore during warm-up that continues = 2 days off & drop 1 level
- Sore during warm-up that goes away = stay at level that led to soreness
- Sore during warm-up that goes away but redevelops during session = 2 days off & drop 1 level
- Sore the day after lifting (not muscle soreness) = 1 day off & don’t advance program to next level
- No soreness = advance 1 level per week or as instructed by healthcare professional
Return to running progression
- Level 1: 0.1 mi walk/0.1 mi jog repeat 10x = jog straights/walk curves for 2 mi
- Level 2: 0.1 mi walk/0.2 mi jog repeat for 2 mi = jog straights & 1 curve every other lap
- Level 3: 0.1 mi walk/0.3 jog repeat for 2 mi = jog straights & 1 curve every lap
- Level 4: 0.1 mi walk/0.4 mi jog repeat for 2 mi = jog 1.75 lap/walk curve
- Level 5: 2 mi jog
- Level 6: increase to 2.5 mi
- Level 7: increase to 3.0 mi
- Level 8: 0.25 mi jog/0.25 mi run
Minimum criteria post ACLR to begin return to sport progression
- min 12 wks post-op
- 90% or greater on quad index
- 90% or greater on all hop tests
- 90% or greater on KOS-ADL
- 90% or greater on global rating score of knee function
- follow up testing at 4 mo, 5 mo, 6 mo, & 1 year post
Criteria for post ACLR discharge
- isokinetic & functional hop test 90% or greater limb symmetry
- acceptable quality movement assessment
- lack of apprehension with sport specific movements
- flexibility to accepted levels of sort performance
- independence with gym program for maintenance & progression of therapeutic exercise program at discharge
PCL injury
- not commonly injured
- accompanied by damage to other structures to the knee
- High velocity = dashboard injury
- Low velocity = hyper flexion athletic injury with a plantar flexed foot
Post-op management for PCL reconstruction
- immobilization in a hinged range limiting protective brace locked in full extension
- 24/7 for first 4-8 wks post-op to avoid posterior tibial migration as a result of gravity
- can be removed for therapy but follow MD guidelines
- slower weight bearing progression than with ACL repair
Criteria for ambulation w/o crutches after PCLR
- minimal to no pain or joint effusion
- full active knee extension with a SLR
- passive & active knee flexion from 0-90 degrees
- quad strength about 70% or 4/5 MMT grade
- no hair deviations
General precautions for post-op PCLR
- avoid exercises that place excessive posterior shear forces & cause posterior displacement of the tibia
- limit the number of reps of knee flexion to minimize potential abrasion to the pCL graft
