ACL reconstruction healing and Return to Play Randy Clark Acknowledgements: Glenn Williams, Mike Shaffer, Danny Foster, Brian Wolf

ACL reconstruction ACL reconstruction healing and Return to healing and Return to

PlayPlay

Randy ClarkRandy ClarkAcknowledgements: Glenn Williams, Mike Shaffer, Acknowledgements: Glenn Williams, Mike Shaffer,

Danny Foster, Brian WolfDanny Foster, Brian Wolf

IntroductionIntroduction

100,000 new ACL injuries each year (1/3000 people)100,000 new ACL injuries each year (1/3000 people)

Young women 3 times more likely to suffer an ACL Young women 3 times more likely to suffer an ACL injury compared to a male cohort groupinjury compared to a male cohort group

Young female participating in sports year round has a Young female participating in sports year round has a 5% 5% risk for tearing her ACLrisk for tearing her ACL

No more than 15- 30% of ACL deficient individuals No more than 15- 30% of ACL deficient individuals typically return to running, jumping, and pivoting typically return to running, jumping, and pivoting activities without experiencing subsequent episodes activities without experiencing subsequent episodes of of knee instabilityknee instability

ACL Defficiency and Return to ACL Defficiency and Return to PlayPlay

832 ACL injuries

10% declined, 40% other knee injuries

432 Remaining patients

87 unable to regain ROM, strength, pain control

345 patientsScreening exam eliminates 199 as Non-copers

146 patients60% chose to undergo surgery

88 patients attempt return to sport

ACL Defficiency and Return to ACL Defficiency and Return to PlayPlay

88 Patients return to sport

63 patients

72% successful

29 patients remain

36 went onto reconstruction

Hurd et al., A 10 year progressive trial of a patient management algorithm and Screening examination for highly active indicituals with ACL injury, Part 1 Outcomes., Am J Sports Med. 36:40-47

•24% return to sport without subsequent instability

Fitzgerald et al., Knee Surg Sports Traumatol Arthrosc., 2000

How long until I can play?How long until I can play?

The healing process-The healing process- It’s a dead piece of tissue!It’s a dead piece of tissue! Graft needs to be re-vascularizedGraft needs to be re-vascularized

• ““Ligamentization” occursLigamentization” occurs Vascular Synovial layer wraps around graft in 4-Vascular Synovial layer wraps around graft in 4-

6 weeks6 weeks

Healing TimeHealing Time

Autologous ACL grafts don’t Autologous ACL grafts don’t

Transition through necrotic stageTransition through necrotic stage Weakest link fixation 4-6 weeksWeakest link fixation 4-6 weeks Complete re-vascularizationComplete re-vascularization

of the graft takes ~20 weeksof the graft takes ~20 weeks Remodeling occurs:Remodeling occurs:

By one year histological and By one year histological and

biochemical properties of biochemical properties of

ACLR ~ native ACLACLR ~ native ACL

Graft RemodelingGraft Remodeling

Gradual loss of graft Gradual loss of graft strength during initial strength during initial remodelingremodeling

Then strength of ACL Then strength of ACL graft improves graft improves graduallygradually

Allografts Allografts Slightly slower Slightly slower

process process


Patellar tendonPatellar tendon Bone to bone within Bone to bone within

the ACL tunnelsthe ACL tunnels 4-8 weeks usually4-8 weeks usually


• • Hamstring graftHamstring graft

-Bone to tendon healing-Bone to tendon healing

-Sharpey’s fibers-Sharpey’s fibers

-Usually complete at 12 weeks-Usually complete at 12 weeks ACL autograft resemblesACL autograft resembles

normal ACL at 12 monthsnormal ACL at 12 months Concern for increased allogenicConcern for increased allogenic

graft incorporation time doesn’t graft incorporation time doesn’t

warrant modification of PTwarrant modification of PT

protocolprotocol

Pre-Operative RehabilitationPre-Operative Rehabilitation

Initial Initial focus on eliminating swelling and focus on eliminating swelling and restoring pre-injury range of motion and restoring pre-injury range of motion and strengthstrength

RehabilitationRehabilitation

Slight variations depending on age, Slight variations depending on age, history, activity level, graft source and history, activity level, graft source and associated injuries.associated injuries.

RehabilitationRehabilitation Bracing:Bracing:

““There is little evidence to support the use of a post-There is little evidence to support the use of a post-operative brace following isolated reconstruction of the operative brace following isolated reconstruction of the ACL.”ACL.”

““Although the exact mechanism for any beneficial effect Although the exact mechanism for any beneficial effect of functional bracing remains unknown, ACL deficient of functional bracing remains unknown, ACL deficient athletes commonly report improved confidence with use athletes commonly report improved confidence with use of a functional knee brace.”of a functional knee brace.”

““The use of functional bracing should perhaps be The use of functional bracing should perhaps be reserved for return to sport following revision surgery or reserved for return to sport following revision surgery or in athletes who have suffered a multiple ligament injury.”in athletes who have suffered a multiple ligament injury.”

CORR 07’ systematic review 12 RCT’s- no support for CORR 07’ systematic review 12 RCT’s- no support for bracingbracing


Five phasesFive phases Phase I- Immediate post-op (0-2 weeks)Phase I- Immediate post-op (0-2 weeks) Phase II- Early Rehabilitation Activities (2-6 Phase II- Early Rehabilitation Activities (2-6

weeks)weeks) Phase III- Advanced Rehabilitation Activities Phase III- Advanced Rehabilitation Activities

(6-10 weeks)(6-10 weeks) Phase IV- Advanced Functional Activities (10 Phase IV- Advanced Functional Activities (10

weeks- 6 months)weeks- 6 months) Phase V- Return to Sport (6-12 months)Phase V- Return to Sport (6-12 months)


Phase I- Immediately Post- Surgery Phase I- Immediately Post- Surgery (POST-OPERATIVE WEEKS 0-2)(POST-OPERATIVE WEEKS 0-2) The goals of the early rehabilitation period are The goals of the early rehabilitation period are

to control pain and post-operative swelling, to control pain and post-operative swelling, and begin to restore range of motion. and begin to restore range of motion. • Control inflammation: cryotherapy, elevation, Control inflammation: cryotherapy, elevation,

compression, limitation of activitiescompression, limitation of activities• Restore ROM: importance of regaining Restore ROM: importance of regaining

hyperextension. (Importance of regaining motion hyperextension. (Importance of regaining motion pre-op)pre-op)


Phase I continued….Phase I continued…. ROMROM

• Stretches: extension bridges, prone hangsStretches: extension bridges, prone hangs ROM expectations:ROM expectations:

• 0-900-90°° 2 weeks 2 weeks• 0-1200-120° 4 weeks° 4 weeks• Full range 6 weekFull range 6 week

•Muscle strengthening•Isometric quad contractions, straight leg raises, stim

treatments

•Ambulation- crutches, WBAT, avoid “quad avoidance” gait pattern


Criteria to Progress to Phase IICriteria to Progress to Phase II Knee effusion well controlledKnee effusion well controlled Adequate quadriceps control demonstrated by Adequate quadriceps control demonstrated by

the ability to do a hip flexion straight leg raise the ability to do a hip flexion straight leg raise without extensor lagwithout extensor lag

Normal gait pattern without use of assistive Normal gait pattern without use of assistive devicesdevices

Knee range of motion of at least 0- 90°Knee range of motion of at least 0- 90°


Phase II – Early Rehabilitation Phase II – Early Rehabilitation Exercises (POST-OPERATIVE WEEKS Exercises (POST-OPERATIVE WEEKS 2-6)2-6) The focus of Phase II rehabilitation is to The focus of Phase II rehabilitation is to

restore full knee range of motion and advance restore full knee range of motion and advance early strengthening exercisesearly strengthening exercises

Light weights, remember creep (low load Light weights, remember creep (low load prolonged stretches), manual overpressure, prolonged stretches), manual overpressure, stationary bicycle (half moon), lunges, squatsstationary bicycle (half moon), lunges, squats

•Supervised vs. Home rehab program•We feel that a minimum of 6 visits with a rehabilitation professional is necessary for

successful outcome following ACL reconstruction.


Open vs. closed chain excercisesOpen vs. closed chain excercises• Open chain and infrapatellar painOpen chain and infrapatellar pain• Graft lengtheningGraft lengthening


Criteria to Advance to Phase IIICriteria to Advance to Phase III Full knee range of motionFull knee range of motion Able to ascend and descend stairs normally Able to ascend and descend stairs normally Successfully completing regular exercise Successfully completing regular exercise

program of Phase II activitiesprogram of Phase II activities

RehabilitationRehabilitation Phase III- Advanced Rehabilitation Phase III- Advanced Rehabilitation

Exercises (POST-OPERATIVE WEEKS 6-10) Exercises (POST-OPERATIVE WEEKS 6-10) Build on the limb strength gained in Phase IIBuild on the limb strength gained in Phase II

• Traditional strengthening exercises combined with Traditional strengthening exercises combined with additional challenges to the nervous system: pertubations, additional challenges to the nervous system: pertubations, mental distraction tasks, activities which progressively mental distraction tasks, activities which progressively force the center of gravity away from the base of support. force the center of gravity away from the base of support.

• Restore neuromuscular control: mechanoreceptor Restore neuromuscular control: mechanoreceptor repopulation is most active between 2 and 8 weeks post-repopulation is most active between 2 and 8 weeks post-operatively operatively

• RCT’s show superiority of neuromuscular retraining when RCT’s show superiority of neuromuscular retraining when compared to standard strength training. (Beard JBJS 94’, compared to standard strength training. (Beard JBJS 94’, Risberg Aust J Phys 07’)Risberg Aust J Phys 07’)


Criteria to Advance to Phase IVCriteria to Advance to Phase IV Regularly completing isotonic strengthening program Regularly completing isotonic strengthening program

in supervised physical therapyin supervised physical therapy Starting to transition strengthening activities to local Starting to transition strengthening activities to local

gym or athletic team’s weight roomgym or athletic team’s weight room Approximately 70-80% strength vs. contralateral Approximately 70-80% strength vs. contralateral

(uninvolved) lower extremity(uninvolved) lower extremity Demonstrates appropriate control of knee with Demonstrates appropriate control of knee with

neuromuscular retraining exercises in the physical neuromuscular retraining exercises in the physical therapy clinic therapy clinic


Phase IV- Advanced Functional Phase IV- Advanced Functional Activities (10 weeks- 6 months)Activities (10 weeks- 6 months) The primary goal of the fourth phase of The primary goal of the fourth phase of

rehabilitation is to prepare the athlete for rehabilitation is to prepare the athlete for return to sport. Running, cutting, and jumping return to sport. Running, cutting, and jumping are near universal requirements of the sports are near universal requirements of the sports in which athletes most often tear their ACL’s. in which athletes most often tear their ACL’s. • be cognizant of other tasks which are important be cognizant of other tasks which are important

parts of the sport to which the athlete hopes to parts of the sport to which the athlete hopes to return return


Phase IV continuedPhase IV continued ladder drills or other simulated running tasks, ladder drills or other simulated running tasks,

then advance to interval jogging.then advance to interval jogging. Once 70-80% of their pre-injury speed, cutting Once 70-80% of their pre-injury speed, cutting

drills begin. drills begin. Land based jumping, jumping up to a box Land based jumping, jumping up to a box

and/or completing all plyometrics activities by and/or completing all plyometrics activities by landing on two legs landing on two legs


Criteria for Progression for Phase VCriteria for Progression for Phase V Regularly completing isotonic strengthening Regularly completing isotonic strengthening

programprogram Running at least 85% of pre-injury speedRunning at least 85% of pre-injury speed Cutting and jumping without hesitation or Cutting and jumping without hesitation or

obvious limitationobvious limitation


Phase V- Return to Sport (6-12 months) Phase V- Return to Sport (6-12 months) subjective and objective information considered.subjective and objective information considered.

• Athlete pain free during performanceAthlete pain free during performance• Athlete not demonstrate limp or guarding Athlete not demonstrate limp or guarding • Effusion after rehabilitation or functional testing Effusion after rehabilitation or functional testing

viewed as a stark indication that neuromuscular viewed as a stark indication that neuromuscular system not adequately countering the high system not adequately countering the high stresses experienced within the joint.stresses experienced within the joint.

• Athlete should feel confident about their return to Athlete should feel confident about their return to sport. sport.


Phase V- Return to Sport (6-12 months) Phase V- Return to Sport (6-12 months) No more than 10% asymmetry in terms of No more than 10% asymmetry in terms of

isokinetic variables between the involved and isokinetic variables between the involved and uninvolved lower extremityuninvolved lower extremity

single leg hop test to measure knee joint single leg hop test to measure knee joint function and strengthfunction and strength

single leg vertical jump, single leg hop for single leg vertical jump, single leg hop for distance, single leg timed hopdistance, single leg timed hop


Criteria to Return to SportCriteria to Return to Sport No complaints of pain or knee instabilityNo complaints of pain or knee instability Full ROMFull ROM No new effusionNo new effusion Lower extremity strength/ function at least 85% vs. Lower extremity strength/ function at least 85% vs.

uninvolved LEuninvolved LE Adequate performance in physical therapy or with sport Adequate performance in physical therapy or with sport

specific drills which simulate the intensity, frequency, specific drills which simulate the intensity, frequency, and duration of the sport to which the athlete hopes to and duration of the sport to which the athlete hopes to returnreturn

Athlete demonstrates a psychological readiness to Athlete demonstrates a psychological readiness to return to sport, either verbally or with SANE score > return to sport, either verbally or with SANE score > 80/100 80/100

Functional TestingFunctional Testing

Full ROM, negative pivot-shift, symmetric Full ROM, negative pivot-shift, symmetric quad and hamstring strength and quad and hamstring strength and functional testing scoresfunctional testing scores

RehabiliationRehabiliation

Crucial input from..Crucial input from.. PhysicianPhysician Athletic trainerAthletic trainer Physical TherapistPhysical Therapist CoachCoach Athlete +/- parentsAthlete +/- parents


Rehab time frame Rehab time frame changedchanged Formally >12mosFormally >12mos Now generally ~6mNow generally ~6m

2 RCT’s2 RCT’s Beynnon, EkstrandBeynnon, Ekstrand 8 mos vs ~5mos8 mos vs ~5mos

No significant differences No significant differences in:in: Subjective outcomeSubjective outcome Anterior knee laxityAnterior knee laxity Functional testingFunctional testing

Faster rehab (19 wks) seems Faster rehab (19 wks) seems safesafe

Programs faster than this….?Programs faster than this….?


Bone scan?Bone scan? Scott Dye talkScott Dye talk


Functional score meta-analysisFunctional score meta-analysis No difference between BTB and hamstring No difference between BTB and hamstring

grafts with respect to function (Biau CORR grafts with respect to function (Biau CORR 07’)07’)• 14 trials- 7 RCT’s14 trials- 7 RCT’s

What to expect?What to expect?

10-14% of ACL R 10-14% of ACL R patients need another patients need another surgery at some point surgery at some point in the futurein the future

Risk of re-ruptureRisk of re-rupture 3% on ACLR knee3% on ACLR knee 3% on other knee3% on other knee

~20% of patients note ~20% of patients note some subj functional some subj functional impairment with ACLR impairment with ACLR kneeknee

~90% of athletes return to ~90% of athletes return to same level of sport by one same level of sport by one year after ACLRyear after ACLR

Only 54% still at that level Only 54% still at that level by ~3 yrsby ~3 yrs

Lit Review on Return to PlayLit Review on Return to Play

Lit Review on Return to PlayLit Review on Return to Play

Home vs Formal PTHome vs Formal PT

Grant et. Al, AJSM 2005Grant et. Al, AJSM 2005 Hypothesis: no difference in home vs. structure PT Hypothesis: no difference in home vs. structure PT

program at 3 months for BTB reconstruct.program at 3 months for BTB reconstruct. Study design: RCT, 145 pts, 4 vs. 17 PT sessionsStudy design: RCT, 145 pts, 4 vs. 17 PT sessions Measured: ROM, knee motion walking, KT, quad and Measured: ROM, knee motion walking, KT, quad and

hamstring strengthhamstring strength Results: 67% vs 47% flexion, 97% vs 83% ext, others Results: 67% vs 47% flexion, 97% vs 83% ext, others

no diff.no diff. Conclusion: OK for weekend warrior to do home PTConclusion: OK for weekend warrior to do home PT

Propioception Knee Before and Propioception Knee Before and After ACL ReconstructionAfter ACL Reconstruction

Reider et al. Arthroscopy 2003Reider et al. Arthroscopy 2003 Compared proprioception before and after Compared proprioception before and after

ACL reconstruction to healthy controls ACL reconstruction to healthy controls (contralateral knee)(contralateral knee)

Concluded: “At 6 months no difference in JPS Concluded: “At 6 months no difference in JPS and TDPM (threshold to detection of passive and TDPM (threshold to detection of passive motion) compared to controls”motion) compared to controls”• Reconstruction has positive impact on Reconstruction has positive impact on

propioceptionpropioception

Documents

ACL reconstruction healing and Return to Play Randy Clark Acknowledgements: Glenn Williams, Mike Shaffer, Danny Foster, Brian Wolf