quick start and stop, side-to-side shuffling, carioca, figure-eight running, and 45° cutting and sprinting. Agility training should be initiated with simple unidirectional activities (e.g., forward and backward running with quick start and stop, side-to-side shuffling) and then progressed to multidirectional activities (e.g., carioca, figure-eight running, and 45° cutting). Patients should start performing agility training at 35% to 50% of their maximum effort and progress to full-effort training. Agility progression is based on the patient’s tolerance for activity and the presence or absence of knee pain and effusion. Operative management Patients who experience multiple episodes of knee instability and impaired knee function following conservative rehabilitation are ideal candidates for ACL reconstruction. The goals of ACL reconstruction surgery are to restore mechanical knee stability, protect against further knee joint damage, and increase the likelihood of returning to preinjury sport levels (E. H. Hartigan et al., 2010; Myklebust & Bahr, 2005). Preoperative knee status influences patient functional recovery and outcomes after ACL reconstruction surgery, so preoperative rehabilitation programs should focus on resolving the common knee impairments as a result of the ACL injury. It is suggested that the patient should demonstrate full knee ROM, no or minimum joint effusion, no knee extension lag during a straight leg raise, and isometric quadriceps strength index > 90% prior to the reconstruction surgery (Adams, Logerstedt, Hunter-Giordano, Axe, & Snyder- Mackler, 2012). A systemic review and multidisciplinary consensus were conducted 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: impairment-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, including 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; Leal-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, Howell, Hull, & Gregersen, 2002), and STG autografts were recommended 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 provide 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; Impairment-based interventions Although ACL reconstruction is performed in the attempt to restore 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
Sport-specific skills (basketball dribbling, ball throwing, ball kicking) may also be integrated into agility training when the patient is able to tolerate full-effort training without pain or swelling. Before adding sport-specific skills, therapists should supervise their patients to provide feedback and ensure a proper activity performance. Agility training has been shown to decrease the time to peak muscle torque in healthy individuals (Wojtys, Huston, Taylor, & Bastian, 1996). It might be beneficial for patients with ACL injury who exhibit dynamic knee instability, because muscles that cross the knee join can provide enough force within a short time to control the knee stability during dynamic activities. Leal-Blanquet et al., 2011; Pinczewski et al., 2007), which can pose challenges to therapists when choosing quadriceps strengthening exercises. During rehabilitation following a patellar tendon autograft, the therapist should be aware of exercises and activities, such as overly aggressive quadriceps strengthening exercises and activities in the 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; Williams, Snyder-Mackler, Barrance, Axe, & Buchanan, 2004). Some advanced surgical techniques use quadruple-bundle semitendinosus graft and double-bundle STG for ACL reconstruction. Studies have shown that using double or quadruple-bundle grafts results in decreased anterior and rotational knee joint laxity (Ardern, Webster, Taylor, & Feller, 2010; Branch, Siebold, Freedberg, & Jacobs, 2011). When an STG autograft is used, hamstrings strengthening training is delayed, allowing soft-tissue healing and minimizing irritation of the hamstrings donor site (Adams et al., 2012). Regardless of the source of the autograft tissue that has been harvested, 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 advantages 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 potential 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 tissue. 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).
due to the presence of postoperative impairments (Ardern et al., 2011a; Chmielewski, 2011). Postoperative impairments may include 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
EliteLearning.com/ Physical-Therapy
Page 55
Powered by FlippingBook