duration (greater than 20 minutes), be done multiple times per week (two to three times per week in the preseason and one to three times per week in the competitive season), and be used with high compliance. Programs should not be used after training sessions or games (Arundale et al., 2017). Implementing exercise-based knee injury prevention programs carries little risk to the athlete, with the primary side effect being muscular soreness when the program is initiated. Implementation of exercise-based knee injury prevention programs can reduce the 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 second 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 deficits 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%). Additionally, a battery of clinical tests has demonstrated good predictability of sustaining a second knee injury after ACL reconstruction. The use of a comprehensive return-to-sports test battery consisting of quadriceps strength testing, single-legged hop testing, and two patient-reported measures demonstrated an 84% lower knee reinjury rate in patients who passed all criteria (Grindem, 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 asymmetries may allow physical therapists to ensure a safer return to sports.
EXAMINATION
A primary goal of the examination is to match the patient’s subjective 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 appropriate (Childs et al., 2008). The following information is pertinent at various periods post injury. Some examination techniques are relevant immediately post injury; others are relevant to later points in the rehabilitation process. These periods will be identified later in the course. During Demographics and anthropometrics Patient demographics and anthropometrics have important implications 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 consider 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 reconstructive 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, Weidenhielm, & 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). History and subjective examination Important components of initial documentation include a complete patient history, with the length of time from initial injury or onset of symptoms, mechanism of injury, frequency and duration 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 often 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.
the process of patient management, classifying the patients’ impairments is critical for selecting the appropriate intervention strategy that provides the patients with optimal 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). Females are also four-times more likely to reinjure the same ACL following reconstruction 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 gender disparity have been reported, including differences in neuromuscular 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 participation or occupation, can be useful in developing an individualized and effective plan of care. 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 rehabilitation, especially when pain levels are high (Chmielewski et al., 2008). For patients undergoing ACL reconstruction, pain 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. Because anterior knee pain may come from several pain-generating tissues, it is essential to determine the source early in order to implement appropriate treatment
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Book Code: PTNJ0824
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