Additionally, a battery of clinical tests has demonstrated good predictability of sustaining a second knee injury after ACL recon- struction. The use of a comprehensive return-to-sports test battery consisting of quadriceps strength testing, single-legged hop test- ing, and two patient-reported measures demonstrated an 84% lower knee reinjury rate in patients who passed all criteria (Grin- dem, Snyder-Mackler, Moksnes, Engebretsen, & Risberg, 2016). Furthermore, for every month that return to sport was delayed, until 9 months after ACL reconstruction, the rate of knee reinjury was reduced by 51% (Grindem et al., 2016). Similar findings were reported by Kyritsis, Bahr, Landreau, Miladi, & Witvrouw (2016), demonstrating that not passing all criteria (thigh strength testing, hop testing, and an agility test) increases the risk of sustaining an ACL graft rupture by four times. Therefore, developing targeted interventions to address functional and movement pattern asym - metries may allow physical therapists to ensure a safer return to sports.
risk of knee injuries in male soccer players and in female athletes, particularly youth and adolescent athletes (Arundale et al., 2017). Other modifiable neuromuscular factors are predictive of a sec- ond injury once athletes have returned to their sporting activities after ACL reconstruction. Paterno and colleagues (2010) found that 23.2% of young athletes sustain a second ACL injury after ACL reconstruction within 12 months of testing around the time of return to sport; at 24 months after return to sport, 29.5% of young athletes sustain a second injury to either the ipsilateral or contralateral knee (Paterno et al., 2014). These researchers were able to identify factors that place athletes at risk for a retear of the ACL graft or the contralateral ACL. Neuromuscular control defi- cits of the hip external rotators, force absorption asymmetries by the quadriceps muscles, and involved limb single-legged balance deficits were able to predict second ACL injury risk with a high degree of sensitivity (92%) and specificity (88%).
EXAMINATION
sifying the patients’ impairments is critical for selecting the ap- propriate intervention strategy that provides the patients with op- timal outcomes (Kelley et al., 2013). However, it is important for clinicians to understand that the patient’s impairment pattern and relevant dysfunction and the associated intervention strategies often change during the patient’s course of care. Thus, continual re-evaluation of the patient’s impairment pattern and relevant dysfunction helps clinicians to adjust the intervention strategies as necessary throughout the patient’s course of care (Blanpied et al., 2017). also four-times more likely to reinjure the same ACL following re- construction and six-times more likely to sustain a contralateral ACL injury compared to their male counterparts (Paterno, Rauh, Schmitt, Ford, & Hewett, 2012). Many possible causes for this gen- der disparity have been reported, including differences in neuro- muscular control, knee laxity, lower limb flexibility and strength, jumping technique, hormone levels, and lower extremity anatomy and biomechanics, including a greater Q-angle and smaller inter- condylar notch often present in women (Uhorchak et al., 2003; Wild, Steele, & Munro, 2012). However, the exact mechanisms are not fully understood. In addition to higher risk of ACL injury, poor dynamic knee stability is more common in females than males following ACL injury, which can lead to inferior patient outcomes (Hurd, Axe, & Snyder-Mackler, 2008b). Finally, the patient’s previous activity levels, including sports par- ticipation or occupation, can be useful in developing an individu- alized and effective plan of care. levels are typically highest immediately after surgery (Brewer et al., 2007). Different origins of knee pain may be present, each of which may alter patient progress through rehabilitation. Be- cause anterior knee pain may come from several pain-generating tissues, it is essential to determine the source early in order to implement appropriate treatment techniques, given the relation- ship of pain to outcomes. For example, Heijne, Ang, and Werner (2009) found that anterior knee pain was an important predictor in patient-reported outcomes 12 months after ACL reconstruction. Patients should employ a visual analogue or numeric pain rating scale to assess their pain, both at rest and with activity levels. Worst and least pain ratings over the previous days or weeks may also be measured. Patients often report knee joint effusion shortly after initial ACL injury. Joint effusion is an excessive accumulation of fluid within a joint capsule, indicating inflammation or irritation (Sturgill, Snyder- Mackler, Manal, & Axe, 2009). Effusion is different from swelling and edema, which refer to fluid within the soft tissues outside of the joint capsule. Hemarthrosis causes acute joint effusion, where-
A primary goal of the examination is to match the patient’s sub- jective history and clinical presentation found on the examination with the most appropriate and effective treatment strategies and tactics. The examination is used to determine the impairments that may be contributing to a patient’s activity limitation but also to determine whether physical therapy management is appropri- ate (Childs et al., 2008). The following information is pertinent at various periods post injury. Some examination techniques are rel- evant immediately post injury; others are relevant to later points in the rehabilitation process. These periods will be identified later in the course. During the process of patient management, clas- Demographics and anthropometrics Patient demographics and anthropometrics have important im- plications for functional outcomes following ACL reconstruction. Patients with a body mass index (BMI) greater than 30 kg/m2 have lower odds of success following ACL injury, as do those with a history of smoking (Ahldén et al., 2012; Kowalchuk, Harner, Fu, & Irrgang, 2009; Uhorchak et al., 2003). It is also important to con- sider the age and sex of the patient because these factors may affect the course and outcome of treatment. The average age of those who choose to undergo reconstruc- tive surgery is 23 years (Magnussen et al., 2010). However, age has been shown to have only a weak relationship with scores on self-reported functional measures following surgery (Möller, Wei- denhielm, & Werner, 2009). Middle- aged adults are more likely to demonstrate dynamic knee instability following ACL injury (Hurd, Axe, & Snyder-Mackler, 2008b). Females have a higher risk of ACL injury, with an incidence six- to eight-times greater compared to their male counterparts (Hughes & Watkins, 2006; Mihata, Beutler, & Boden, 2006). Females are History and subjective examination Important components of initial documentation include a com - plete patient history, with the length of time from initial injury or onset of symptoms, mechanism of injury, frequency and du- ration of symptoms, pain patterns, presence of any mechanical symptoms (e.g., recurrent clicking or catching), previous history of lower extremity injuries, current use of medications, and reports of any previous diagnostic testing or imaging. Patients can of- ten recall the exact time and activity when injury occurred, usually reporting a “pop” with associated pain and effusion, indicating possible ligamentous injury. However, some patients may deny any pain or swelling but report an increasing frequency of knee instability and giving way. Most patients will present with complaints of pain following injury (Magnussen et al., 2010; P. Thomeé et al., 2008), although the levels are highly variable depending on the extent of joint effusion and concomitant injuries. Patients report that pain levels influence their current level of knee function regardless of the phase of re- habilitation, especially when pain levels are high (Chmielewski et al., 2008). For patients undergoing ACL reconstruction, pain
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