kneeling position that may result in patellar tendon pain (Spindler et al., 2004). STG autografts provide slightly fewer postoperative complications compared to patellar tendon autografts (Keays et al., 2007; Leal- Blanquet et al., 2011; Li et al., 2011). Furthermore, the remnant parts of hamstrings tendons eventually regenerate, and strength improves to within normal limits between 6 and 12 months after ACL reconstruction (Krych, Jackson, Hoskin, & Dahm, 2008; Wil- liams, Snyder-Mackler, Barrance, Axe, & Buchanan, 2004). Some advanced surgical techniques use quadruple-bundle semitendi- nosus graft and double-bundle STG for ACL reconstruction. Stud- ies have shown that using double or quadruple-bundle grafts re- sults in decreased anterior and rotational knee joint laxity (Ardern, Webster, Taylor, & Feller, 2010; Branch, Siebold, Freedberg, & Ja- cobs, 2011). When an STG autograft is used, hamstrings strength- ening training is delayed, allowing soft-tissue healing and mini- mizing irritation of the hamstrings donor site (Adams et al., 2012). Regardless of the source of the autograft tissue that has been har- vested, donor site morbidity exists (Foster et al., 2010). A meta- analysis comparing functional outcomes between patellar tendon and STG autografts has failed to show any significant long-term differences (Biau, Tournoux, Katsahian, Schranz, & Nizard, 2006). Allograft tissues are less commonly used in ACL reconstruction surgery for highly active patients (Cohen & Sekiya, 2007). The ad- vantages of allografts include a low risk of donor site morbidity, preservation of knee extensor and flexor muscle strength, and a lower incidence of arthrofibrosis (Foster et al., 2010; Marrale et al., 2007). However, there has been concern regarding poten- tial allograft complications, such as graft elongation and graft failure, over time (Pinczewski et al., 2007). Meta-analysis studies have compared the results of the autograft and allograft tissues in terms of their functional outcomes, failure rates, and stability. Autografts were favored over patellar tendon allograft because patients who received autograft tissue experienced a lower rate of graft rupture and demonstrated higher performance on hop tests when compared to those patients who received allograft tis- sue. However, when irradiated and chemically processed grafts were excluded, results were not significantly different between the graft types (Krych et al., 2008; Tibor et al., 2010). Functional outcomes have been shown to be similar between autografts and allografts (Foster et al., 2010; Reinhardt et al., 2010). tendon autograft (Corry et al.,1999; Li et al., 2011). Most patients complain of local anterior knee pain (described as pinpoint pain); others complain of diffuse pain. Cryotherapy and electrical stimulation may be applied in an at- tempt to alleviate joint or anterior knee pain after ACL injury and reconstruction surgery. Noxious electrical stimulation (2,500 Hz, 50 bursts/second, 12 on/8 off) for 10 to 15 minutes can be used to manage localized pain (Manal, 2001). The noxious stimulation device has two pads (typically 2 × 3 cm) that can be placed on the painful area with 1 to 2 cm between the pads. The therapist instructs the patient that the treatment will be painful (noxious), with an initial tingling sensation progressing to noxious pain. In addition, patients are instructed to inform the therapist if the nox- ious stimulation feels like a ‘hot poker’ or if it causes a burning sensation. In cases of more diffuse pain, a transcutaneous electrical nerve stimulation (TENS) can be used (4,500 Hz, 50 bursts/second, con- tinuous [set off time to 0]) for 15 to 20 minutes (Bjordal, Johnson, & Ljunggreen, 2003). The TENS device has the option of a con- figuration of either two or four pads, depending on the size of the painful area. The noxious electrical stimulation and TENS can be administered for multiple times (two to three times) during the first week after surgery for patients presenting with severe knee pain. However, the number of times of using the noxious stimula- tion and TENS can be decreased based on the patients’ needs. There are no restrictions on the intensity and the patients’ po- sition during the administration of noxious electrical stimulation
> 90% prior to the reconstruction surgery (Adams, Logerstedt, Hunter-Giordano, Axe, & Snyder-Mackler, 2012). A systemic review and multidisciplinary consensus were conduct - ed to develop evidence-based clinical practice guidelines for ACL rehabilitation (van Melick et al., 2016). The study suggested that ACL rehabilitation should include a preoperative rehabilitation program and three criterion- based postoperative phases: impair- ment-based, sport-specific training, and return-to-play phases (van Melick et al., 2016). These three criterion- based phases are emphasized in the postoperative rehabilitation section of this course: Impairment-Based Interventions and Running, Agility, and Return-to-Sport Training. There are many surgical graft options for ACL reconstruction, in- cluding the type of graft (autograft or allograft), the donor site (patellar tendon or hamstrings tendons), and the morphology of the new ligament, which can be single, double, or quadruple bundles (Leal-Blanquet, Alentorn-Geli, Tuneu, Valenti, & Maestro, 2011). Patellar tendon and hamstrings tendons (semitendinosus and gracilis; STG) are the most common graft sources used in ACL reconstruction surgery (Kartus, Movin, & Karlsson, 2001; Le- al-Blanquet et al., 2011). In the past, patellar tendon autografts were the graft of choice for younger, active patients who desired to return to a high level of functional activity (Haut Donahue, How- ell, Hull, & Gregersen, 2002), and STG autografts were recom- mended for older, inactive patients (Kartus et al., 2001; Reinhardt, Hetsroni, & Marx, 2010). However, there is currently no consensus on the best graft type to use (Foster, Wolfe, Ryan, Silvestri, & Kaye, 2010; Reinhardt et al., 2010). Patellar tendon autografts are easy to harvest and pro- vide improved knee joint stability compared to STG autografts (Leal-Blanquet et al., 2011; Li et al., 2011; Marrale, Morrissey, & Haddad, 2007; Reinhardt et al., 2010). However, using a patellar tendon autograft is associated with quadriceps strength deficits and pain caused by donor site morbidity (Keays, Bullock-Saxton, Keays, Newcombe, & Bullock, 2007; Leal-Blanquet et al., 2011; Pinczewski et al., 2007), which can pose challenges to therapists when choosing quadriceps strengthening exercises. During re- habilitation following a patellar tendon autograft, the therapist should be aware of exercises and activities, such as overly ag- gressive quadriceps strengthening exercises and activities in the Impairment-based interventions Although ACL reconstruction is performed in the attempt to re- store knee joint stability, many patients continue to present with poor functional performance after ACL surgery (Lohmander et al., 2004; Nawasreh et al., 2016; von Porat et al., 2004; Thoma et al., 2019). It has been estimated that up to 60% of patients fail to return to preinjury activity levels following ACL reconstruction due to the presence of postoperative impairments (Ardern et al., 2011a; Chmielewski, 2011). Postoperative impairments may in- clude pain secondary to surgery and at the donor site (Kartus et al., 2001), quadriceps strength deficits (Chmielewski et al., 2004; Hartigan et al., 2009), neuromuscular dysfunction (Hewett, Myer, Ford, & Slauterbeck, 2007), knee joint effusion, limited ROM (es- pecially into knee extension (Millett et al., 2001), and altered gait patterns (Rudolph et al., 1998; Capin, Zarzycki, Khandha, Arun- dale, et al., 2018; Capin, Zarzycki, et al., 2017; Capin, Zarzycki, et Knee pain related to the surgical incision or donor site morbidity is common after ACL reconstruction, especially in patients who have received patellar tendon autograft. Although anterior knee pain is common following ACL reconstruction, it is not restricted to those patients with patellar tendon autograft. Evidence suggests that patients with STG autograft may also experience moderate anterior knee pain after ACL reconstruction (Yunes, Richmond, En- gels, & Pinczewski, 2001). A study by Corry, Webb, Clingeleffer, & Pinczewski (1999) reported no significant differences between an- terior knee pain with patellar tendon and hamstrings autografts; however, pain with kneeling is commonly associated with patellar al., 2019; Hart et al., 2016; Kaur et al., 2016). Pain control and effusion management
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