REHABILITATION AFTER ANTERIOR CRUCIATE

LIGAMENT RECONSTRUCTION

H SELCUK KUCUKOGLUULUDAG UNIVERSITY

SCHOOL OF MEDICINEDEPARTMENT OF PM&R AND SPORTS MEDICINE

EPİDEMİOLOGY

• Yearly incidence of ACL injuries has been reported to be 3/10,000 inhabitants in Denmark (Nielsen, 1991),

• In Sweden, ACL injuries comprise 43% of all soccer related injuries (Roos,1995),…

Type of

graft

Age(Year)

Weight(kg)

Operation time after the injury (months)

SexLevel of Sportive Activity

Injury level Injured extremity

M F Sp Sed Ak Sub Kr Right Left

PT 25.66.9

75.19.4 21.732.6

53 2 36 19 2 9 44 29 26

SG 26.35.6

75.910.8

14.719.1

24 1 5 20 1 4 20 13 12

GOAL• The goal of ACL

reconstruction is to improve the patients level of function, with in the hope of allowing them to return to an active life style, with minimal disability, while protecting them from further injury to the knee.

why treat

• After an ACL lesion, knee instability is common and may produce progressive functional changes and damage to other joint structures (meniscal damage,articular cartilage damage,and degenerative arthritis) which may also affect daily life activities.

why TREAT• The ACL has poor

potential for spontaneous healing after complete rupture,and therefore conservative treatment aims to develop joint motion patterns that help control abnormal knee motions which can arise in the absence of functional ACL.

why TREAT

• In the years following an ACL injury additional meniscus ruptures frequently occur. 80% of ACL deficient patients were found to have a torn meniscus within 2 years of ACL injury.

» Gillquist-Messner (Sports Med. March 1999)

why REHABILITATION

• Optimal healing of an ACL graft and the knee is dependent on rehabilitation,

• The strains applied to an ACL graft by body weight, muscle activity, and joint motion affect its healing response,

ACCELERATED REHABILITATION

• Investigations of ACL grafts that have been done in animals indicate that they lose their ultimate failure strength and undergo a decrease of stiffness and the knees have an increase in anterior laxity develop during healing.

Accelerated rehabilitation

• The exact cause of above mentioned changes and the application of this data to humans are unclear.Rougraff-Shelbourne reported that large proportion of the tendon survives and ACL graft healing in humans may not undergo the same complete necrotic stage that has been reported in animals.

» Knee Surg Sports Traumatol Arthrosc 1999

ACLRehabilitation

• Preoperative Phase:– Goals

• Diminish inflammation,swelling, and pain• Restore normal range of motion (extension)• Restore voluntary muscle activation• Provide patient education to prepare for surgery• Brace-elastic wrap or knee sleeve to reduce

swelling• Weight bearing-as tolerated with or without

crutches

ACL Rehabilitation2

• Preoperative phase– Exercises

• Ankle pumps• Passive knee extension to zero• Passive knee flexion to tolerance• Straight leg raises (3-way, flexion, abduction,

adduction• Quadriceps setting• Closed kinetic chain exercises: mini squats,

lunges, step-ups

ACL Rehabiltation3

• Preoperative Phase– Muscle stimulation-electrical muscle

stimulation to quadriceps during voluntary quadriceps exercises (4-6 hours/day)

– Cryotherapy/elevation-apply ice 20 minutes of every hour, elevate leg with knee in full extension

– Patient education- review postoperative rehabilitation program

BIOMECHANICS

• Isometric exercises that strain the ACL involve contraction of the dominant quadriceps muscle group with the knee between extension and 60° flexion, or involve isotonic contraction of the quadriceps between extension and 50° flexion,

Biomechanics2

• The largest ACL strain magnitudes that have been measured and produced by isometric and isotonic contraction of the quadriceps muscles with the knee near extension.

Biomechanics3

• Squatting, stationary bicycling,and closed kinetic chain exercises that involves body weight loading and substantial cocontraction of the muscles does not create an appreciable change in ACL strain values.

WEEKS 1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

MOTIONCPMIntermittant passive motionEXERCISESPatellar mobilizationStraight leg raises (4-way)IsometricsStationary bike (if ROM>110º)RunningClosed chainIsokinetic Quadriseps (0º-40º not permitted)Isokinetic Quadriseps (0º-20º not permitted)Isokinetic HamstringPROPRIOCEPTIVE TRAININGBalance activities (eyes open-closedı, bilaterally)Balance activities (eyes open-closedı,unilaterally)Functional skill activites (low to high speed)WEIGHT BEARING/BRACERigid-hinged braceFull weight bearingMODALITIESElectrical muscle stimulationCold (4-6 times/day)Cold (after exercises)

ACL Rehabilitation

• Immediate postoperative Phase (1-7 days)– Goals

• Restore full passive knee extension• Diminish joint swelling and pain• Restore patellar mobility• Gradually improve knee flexion• Reestablish quadriceps control• Restore independent ambulation

ACL Rehabilitation

• Early Rehabilitation Phase (2-4 weeks)– Criteria to progress to phase 2

• Quad control (ability to perform good quad set and straight leg raises

• Full passive knee extension• Passive ROM 0° -90°• Good patellar mobility• Minimal joint inflammation• Independent ambulation

ACL Rehabilitation

• Early Rehabilitation Phase– Goals

• Maintain full passive knee extension• Gradually increase knee flexion• Diminish swelling and pain• Muscle training• Restore proprioception• Patellar mobility

ACL Rehabilitation

• Controlled ambulation Phase (weeks 4-10)– Criteria to enter phase 3

• Active ROM 0° to 115°• Quadriceps strength 60%>contralateral side

(isometric test at 60° knee flexion)• Minimal to no joint inflammation• No joint line or patellofemoral pain

ACL Rehabilitation

• Controlled Ambulation Phase(2)– Goals

• Restore full knee ROM (0° -125°)• Improve lower extremity strength• Enhance proprioception,balance and

neuromuscular control• Improve muscular endurance• Restore limb confidence and function• No brace or immobilizer, may use knee sleeve

ACL Rehabilitation• Advanced Activity Phase (10-16 weeks)

– Criteria to enter Phase 4• Active ROM 0°-125°• Quad strength 80% of contralateral side• Knee flexor:extensor ratio 70%-75%• No pain or effusion• *Satisfactory clinical exam• *Satisfactory isokinetic test (values at 60°/sec, 180°/sec and 300°/sec)• *Hop Test (80% of contralateral leg) (4test)• *Subjective knee scoring 80 points or better (Noyes)

ACL Rehabilitation

• Advanced activity phase (2)– Goals

• Normalize lower extremity strength• Enhance muscular power and endurance• Improve neuromuscular control• Perform selected sport-specific drills

ACL Rehabilitation

• Return to activity phase– Criteria to enter phase 5

• Full ROM• Isokinetic test that fulfills criteria• Quad bil comparison (80% or greater)• Hams Bil comparison (110% or greater)• Proprioceptive test (100% of contralateral leg)• Hamstring/quadriceps ratio (70% or greater)• Functional test(85%or greater of contralateral side)• Satisfactory clinical exam• Subjective knee scoring (Noyes) 90 points or better

ACL Rehabilitation

• Return to activity phase (2)– Goals

• Gradual return to full unrestricted sports• Achieve maximal strength and endurance• Normalize neuromuscular control• Progress skill training

Complications

• Hemarthrosis; Operative trauma and repeated operations

• Pretension of the substitute ligament• Septic arthritis• Postoperative arthrofibrosis• Patellafemoral pain

– All may lead to gonarthrosis in the long run

ROLE of PMR

• Check for the goals and the criterias to upgrade the patient

• Evaluate the results of isometric and isokinetic tests

• Evaluate the results of four HOP tests• Examine the patient when appropriate for

the stability• Examine the patient for the complications

and progress

PROPRIOCEPTION AND BALANCE AFTER ACL RECONSTRUCTION

Ufuk Şekir , Bedrettin Akova , Hakan Gür

Medical School of Uludag University, Department of Sports Medicine , BURSA

THE AIM OF THE STUDY

To observe the changes in the proprioception and balance after ACL reconstruction.

PATIENTS AND METHODS• 31 patients, mean age 24±7 (17-44)• Patellar tendon autograft• Time period between injury and the operation: 12

months ( 1-96)• Follow-up : At 1th, 2nd, 3rd, 4th, 6th, and 12th

months after operation• Accelerated rehabilitation program, includes

proprioceptive exercises (which began in the first month): – Single-leg stance on hard surface (eyes open-closed)– Single-leg stance on soft surface (eyes open-closed ) – Balance board exercises (eyes open-closed )

Joint Position Sense (JPS)

•Eyes closed•Index angles: 200,450 and 700

•Angular velocity: 10/s• Before matching an index angle, the examiner extends the knee passively to the index angle for 3 s.• Three repetitions for each index angle was made. • The mean of absolute error score (AES) for each index angle was calculated• Mean AES= Sum of means of index angles /3

JPS active

JPS passive

Cybex 6000Cybex 6000

Single-limb Balance

• On a soft surface.• Eyes open-closed.• First on the uninjured and then on the

injured side.• Arms crossed, contralateral leg flexed.• The subjects were required to stand 60s.• Two repetition were made.• Mean number of touchdowns and mean

time to first touchdown were recorded.

STATISTICS

To compare injured-uninjured leg results;

– Wilcoxon test

The results at the follow-up of the Single-limb

Balance Test (Mean number of touchdowns)

0

1

2

3

4

5

6

1 2 3 4 6 12

Months

Mea

n to

uchd

owns

Eyes-openinjuredEyes-openuninjuredEyes-clodesinjuredEyes-closeduninjured

**

** p<0,01, *p<0,05** p<0,01, *p<0,05

The results at the follow-up of the Single-limb Balance Test (Mean time to first touchdown)

0

10

20

30

40

50

60

70

1 2 3 4 6 12

Months

Mea

n tim

e

Eyes-openinjuredEyes-openuninjuredEyes-clodesinjuredEyes-closeduninjured

** **

** ** ***

** p<0,01, *p<0,05** p<0,01, *p<0,05

Joint Position Sense at 200 of Flexion

0

2

4

6

8

10

12

14

1 2 3 4 6 12

Months

AE

S

injured-activeuninjured-activeinjured-passiveuninjured-passive

*

*p<0,05*p<0,05

Joint Position Sense at 450 of Flexion

0123456789

1 2 3 4 6 12

Months

AE

S

injured-activeuninjured-activeinjured-passiveuninjured-passive

**

**

** p<0,01, *p<0,05** p<0,01, *p<0,05

Joint Position Sense at 700 of Flexion

0

1

2

3

4

5

6

1 2 3 4 6 12

Months

AE

S

injured-activeuninjured-activeinjured-passiveuninjured-passive

Joint Position Sense (Mean)

0123456789

1 2 3 4 6 12

Months

Mea

n A

ES

injured-activeuninjured-activeinjured-passiveuninjured-passive

CONCLUSION

The results of this study indicates that the proprioceptive capabilities of the ACL reconstructed knee can improved to the same level of the uninjured knee at 2 months after operation, with a rehabilitation program including proprioceptive exercises in early phase.

FUNCTIONAL CAPACITY AFTER ACL RECONSTRUCTION: RELATIONSHIPS WITH KNEE EXTENSOR AND FLEXOR

MUSCLE STRENGTH

1 Bedrettin Akova ,1 Hakan Gür, 1 Ufuk Şekir, 2 Sefa Müezzinoğlu1Medical School of Uludag University,Department of Sports Medicine , BURSA 2 Medical School of Kocaeli University, Department of Orthopaedic Surgery, KOCAELİ

THE AIM OF THIS STUDY;

To determine 1) the functional capacity and 2) the relationships between the functional capacity and knee extensor, and flexor peak torque after ACL reconstruction.

PATIENTS AND METHODS

• Between January, 2000 and June, 2002• 21 male patients, mean age 24±7 (17-

44)• Patellar tendon autograft• Time period between injury and the

surgery: 7 months ( 1-48)• The follow-up was performed at 2nd, 3rd,

4th, 6th, and 12th months after operation

FUNCTIONAL TESTSTo

tal d

ista

nce

Tota

l dis

tanc

e

6 meters6 meters

Tota

l dis

tanc

eTo

tal d

ista

nce

Tota

l dis

tanc

eTo

tal d

ista

nce

Single Hop For DistanceSingle Hop For Distance Triple Hop For DistanceTriple Hop For Distance Cross-over Hop For DistanceCross-over Hop For DistanceTimed HopTimed Hop

ISOKINETIC TEST

• Cybex 6000 • Concentric test for knee

flexors and extensors at the angular velocity of 600 and 1800/seconds

• Peak torques (Pt) • Both legs

STATISTICS

• To compare injured-uninjured leg results; – Wilcoxon test

• Relationships between functional capacity and isokinetic test results;

– Pearson correlation coefficient test

The results of the Single Hop test

*** p<0.001,** p<0.01 compared with uninjured leg at same month *** p<0.001,** p<0.01 compared with uninjured leg at same month ++++ p<0.01 compared with uninjured leg at 2p<0.01 compared with uninjured leg at 2nd nd monthmonth

020406080

100120140160180200

2 3 4 6 12months

dist

ance

(cm

)

InjuredUninjured

******+++

***++ *** **

The results of the Timed Hop test

0

50

100

150

200

250

300

2 3 4 6 12months

time

(mse

c)

InjuredUninjured

*** ***++

***** *

*** p<0.001,** p<0.01, *p<0.05 compared with uninjured leg at same month *** p<0.001,** p<0.01, *p<0.05 compared with uninjured leg at same month ++++ p<0.01 compared with uninjured leg at 2 p<0.01 compared with uninjured leg at 2nd nd monthmonth

The results of the Triple Hop test

0100200300400500600700

2 3 4 6 12months

dist

ance

(cm

) InjuredUninjured

***

***+++

***++

*** **

*** p<0.001,** p<0.01 compared with uninjured leg at same month *** p<0.001,** p<0.01 compared with uninjured leg at same month ++

++++p<0.001,p<0.001, ++ ++ p<0.01 compared with uninjured leg at 2 p<0.01 compared with uninjured leg at 2nd nd monthmonth

The results of Cross-over Hop test

0

100

200

300

400

500

600

700

2 3 4 6 12months

dist

ance

(cm

)

InjuredUninjured

******+++

***+++

***+ **

*** p<0.001,** p<0.01 compared with uninjured leg at same month *** p<0.001,** p<0.01 compared with uninjured leg at same month ++

++++ p<0.001, p<0.001, ++ p<0.05 p<0.05 compared with uninjured leg at 2 compared with uninjured leg at 2nd nd monthmonth

ResultsLimb Symmetry Index

05

10152025303540

2 3 4 6 12Months

Defi

cite

(%)

single hop for distance

triple hop for distance

Cross-over for distance

Timed hop

RESULTS

05

1015202530354045

2 3 4 6 12Months

Defi

cite

(%)

Quadriseps (60º/sn)

Quadriseps (180º/sn)

Hamstring (60º/sn)

Hamstring (180º/sn)

CONCLUSION

It is concluded that, the functional capacity can improve with a rehabilitation program used in this study up to four months after ACL surgery, and this improvement is significantly correlated by knee strength.

TIME

2nd week 1st month

2nd month

3rd month

4th month

6th month

12th month

TOTAL SCORE 2,81,2 3,6 1,1 5,4 1,6 6,8 1,3 7,7 1,4 8,7 1,1 8,9 1,1

DAILY ACTIVITY

14,1 9,1

22,7 7,5

32,0 6,6

36,0 3,7

38,3 2,5

38,9 2,6

38,6 2,6

SPORTS ACTIVITY

40,4 2,0

41,5 4,0

52,5 10,8

63,3 11,2

71,7 12,3

83,3 10,4

88,6 9,1

Outcome Measures – Patellar Tendon

TIME

2nd week 1st month

2nd month

3rd month

4th month

6th month

12th month

TOTAL SCORE 3,21,2 3,9 1,0 5,1 1,2 6,0 1,3 7,2 1,3 7,5 0,8 8,7 0,9

DAILY ACTIVITY

14,7 11,2

22,8 6,8

33,2 4,6

35,8 3,7

37,8 3,5

38,7 2,9

38,7 1,8

SPORTS ACTIVITY

41,4 5,6

41,7 5,7

49,2 10,0

55,1 9,1

64,5 13,9

74,9 9,9

85,3 15,2

Outcome Measures – SG

IKDC - Final Score(Patellar Tendon)

%POINT

A B C D

TIME

2nd week - - 4 96

1st month - 2 27 71

2nd month - 13 65 22

3rd month - 51 43 6

4th month 6 65 29 -

6th month 23 56 21 -

12th month 29 54 17 -

IKDC - Final Score(SG)

%POINT

A B C D

TIME

2nd week - - 29 71

1st month - 12 38 50

2nd month - 33 46 21

3rd month - 32 58 10

4th month 6 76 18 -

6th month 8 92 - -

12th month 20 80 - -

THANK YOU FOR YOURKIND ATTENTION