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ACL Rehabilitation: A Review of Current Treatment Approaches: Summary
REVASCULARIZATION/REMODELING TIMELINE • Weeks 0-2 : Avascular necrosis ○ Significant reduction in graft strength • Weeks 3-20 : Revascularization • Weeks 6-12 : Disorganization of collagen ○ Careful with exercises • Weeks 12-24 : Remodeling and proliferation (collagen maturing) • Week 12-20 : Exercise progressions • Week 24 : Sport specific drills Early Rehabilitation Phase The evolution of ACL rehabilitation protocols has shifted towards more accelerated programs. Accelerated Programs: 1. Range of Motion : Aim to achieve unrestricted range of motion by week 4 post-surgery 2. Brace Weaning : Typically wean from the post- operative brace between 2 and 6 weeks 3. Open Chain Exercises : Introduce open chain full extension exercises as early as week 6 or even earlier 4. Closed Chain and Functional Tasks : Begin full range squatting and some functional sports-specific drills around 5-6 weeks Non-Accelerated Programs: 1. Range of Motion : Unrestricted range of motion is typically achieved around week 8 2. Brace Weaning : Usually occurs between 4 and 6 weeks post-surgery 3. Open Chain Exercises : Delay introduction of open chain full extension exercises until around week 12 4. Closed Chain and Functional Tasks : Full range squatting and functional drills are typically introduced around week 12 The majority of current practices lean towards accelerated protocols. The key differences lie in the timing of introducing certain exercises and achieving specific milestones. It is important to understand that these classifications are based on exercise introduction and range of motion goals, not on return-to-play timelines. Regardless of the protocol used, return-to-play decisions should be based on meeting functional criteria rather than solely on time from surgery. Accelerated protocols have shown similar outcomes to non-accelerated programs in terms of knee laxity, functional measures, and patient-reported outcomes. However, there is minimal to no scientific evidence supporting return to sport at less than four months post- surgery, regardless of the rehabilitation protocol used. The debate between accelerated and non-accelerated protocols may be becoming less relevant, as most clinicians now implement some form of accelerated protocol. The
INTRODUCTION
INTRODUCTION AND IMPORTANCE OF EVIDENCE-BASED PRACTICE
There is a big emphasis on the importance of staying current with the evolving literature in ACL rehabilitation. Learners are challenged to evaluate their current practices critically and be open to new evidence-based approaches. ACL rehabilitation practices have changed significantly over the years, including surgical techniques/ technology, graft choices, rehab-ilitation protocols, and return-to-play criteria . Clinicians need to update their knowledge and practices continually to provide the best care for their patients. Key statistics to underscore the importance of optimizing ACL rehabilitation: • Only about 55% of athletes return to competitive sport at their pre-injury level following ACL reconstruction • Up to 30% of young, active individuals who return to high-risk sports experience a second ACL injury within the first two years after returning to sport These sobering statistics highlight the need for improved rehabilitation strategies and return-to-play decision-making processes. Surgical Considerations and Graft Choices The literature supports ACL reconstruction in young, active adults due to the risk of: • Episodes of instability • Potential for pathological laxity • Injuries to other structures of the knee (i.e., meniscus) The various graft options available for ACL reconstruc- tion include: 1. Autografts : ○ Patellar tendon 2. Allografts: For young, competitive athletes, autografts are strongly preferred over allografts: ○ Autografts had a 6% failure rate ○ Non-irradiated allografts had a 9% failure rate ○ Irradiated allografts had a 34% failure rate (statistically significant) While there is some debate between patellar tendon and hamstring autografts, recent literature suggests a slight preference for patellar tendon grafts in terms of long-term outcomes and reduced failure rates. ○ Hamstring tendon ○ Quadriceps tendon
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