Symposium of Sport Medicine, 11 13 January 2013

ACL reconstruction

Rehabilitation after ACL reconstruction

Robert van Cingel,

Athlete:
When can I return to play?

Clinician: PT, OMT, PhD

Which criteria apply for rehabilitation? Which criteria apply for return to sport sport?

Sport Medisch Centrum Papendal, Arnhem, The Netherlands HAN University of Applied Sciences, Nijmegen, The Netherlands

Rehabilitation after ACL reconstruction

Rehabilitation after ACL reconstruction

Preoperative
Timing of surgery (> 6 weeks after trauma), arthrofibrosis Function: ROM, PF, swelling, pain, NM control, gait analysis Instruction of exercises, explanation of time schedule rehabilitation and the use of crutches Carry out VAS, hop tests (minimal 2), IKDC questionnaire and isokinetic measurement (option)

Period 1995 - 2007 Rehab programs with BPTB and ST/G

Rehabilitation after ACL reconstruction

Rehabilitation after ACL reconstruction

Postoperative phase 1: week 1

Control of pain (cryotherapie ), swelling, (cryotherapie), inflammation and wound healing NM control QQ-ceps, ceps, PF mobility Full knee extension, 90 90 knee flexion Use of crutches CKC isom. isom. QQ-ceps from 0 60 60 OKC isom. isom. QQ-ceps from 90 40 40 and Hamstrings Isom / conc without extra weight: MSE, SLR, heel slides, mini squads, shifting body weight N.B. In the long term no benefit of bracing

Criteria for phase 2:

No increase of pain / swelling PF mobility left = right Full knee extension 90 90 knee flexion Q-ceps control, SLR en mini squad 0 30 30 Normal gait pattern (crutches)

Rehabilitation after ACL reconstruction

Rehabilitation after ACL reconstruction

Postoperative phase 2: week 2 9

Use cryotherapy in case of pain Full knee extension and PF mobility 90 90 knee flexion and >, cycling home trainer from week 2/3 Crutches 10 days (normal gait pattern), start proprioceptive training (from static to dynamic) Isom, Isom, conc (Q(Q-H-G) en isokinetic exercises (180 (180/sec.) Conc CKC 0 60 60 and from week eigth 0 90 90 without extra weigth Conc OKC 90 40 40 from week 5 increase from 10 10 extension per week without extra weigth Jogging and outside cycling from week 8

Criteria for phase 3:

Decrease of pain (VAS) / swelling Full knee extension 130 130 knee flexion Normal gait pattern Good quality of performed exercises Carry out IKDC questionnaire

Rehabilitation after ACL reconstruction

Rehabilitation after ACL reconstruction

Postoperative phase 3: week 9 16

Maintaining ROM Increase OKC and CKC / > resistance from week 9 Increase NM control, propriocepsis through dynamic exercises Variation in surface /stability, complexity (perturbation), speed, visual input, 1 and 2 legs Kinetic chain exercises (core, hip, knee, ankle) Start plyometric / prestretch exercises Increase running from week 13

Criteria for phase 4:

No pain, minimal or no swelling Full ROM Exercises are well executed Q-ceps en HH-strings strength minimal 75% healthy side at 180 180/sec. Hop tests minimal 75% healthy side Carry out IKDC questionnaire

Rehabilitation after ACL reconstruction

Rehabilitation after ACL reconstruction

Postoperative phase: week 16 22

Increase (endurance) strength Plyometric exercises, agility, sport specific training (running, jumping, perturbation, acceleration and deceleration) to stimulate arhrokinetic reflexes

Criteria for return to sport sport:

No pain and swelling Full ROM Well executes exercises without complaints Q-ceps and HH-strings strength minimal 85% healthy side at 60, 180 en 180 180/sec. endurance Hop tests minimal 85% healthy side Carry out IKDC questionnaire

New insights in rehab and return to sports

Attentional demands

Attentional demands during rehab Return to sport, rere-injuries, age and criteria Which tests to perform before return to sports Quantity versus quality of movement

Rehab exercises often consists of 1 or 2 motor tasks Combination of a motor task with cognital loading decreases automaticity of postural control in FAI patients (Rahnama et al, 2010) Combination of a motor task with cognital loading during rehab could stimulate automatic movement patterns

Return to sport, age and rere-injuries

Return to sport criteria

Return to the previous level of sports

After 1 year 2/3 does not return (Ardern 2011) After 2 7 years 44 50% returns (Ardern, Ardern, 2011, 2012)

ReRe-injuries
ReRe-injuries ACL 2,4 22% Contra lateral ACL injuries 2,1 24% Within 2 years after reconstruction, women > man

Position Statement of the Members of the European Board of Sports Sports Rehabilitation (EBSR, 2011)

Type of sport Contact NonNon-contact

LSI strength 100% E en F 90% E en F

LSI hop tests 90% op OH + VJ + side hop 90% op OH of VJ of side hop

Age
Patients are constantly younger for reconstruction, up to 12 years (Bonnard 11, Hudges 12, Moksnes 12)
Should we allow patients return to sports after 6 9 months?

How many patients meet these criteria?

Which functional test to perform?

Compare injured versus healthy leg (LSI)
To discriminate the test battery should consist of 3 tests For strength: leg extension, leg curl en leg press or isokinetic flexion extension and leg press For hop tests use test battery of Gustavsson (2006): one leg hop, vertical jump and side hop for endurance Prognostic factor for return to sport (Ardern 2011)

Quantity versus quality of movement

Functional performance:
Quantity of movement (distance, strength, EMG activity etc.) Quality of movement (decreased knee flexion / hip flexion during landing, trunk and pelvic position, dynamic knee valgus, valgus, etc.)

Criteria for return to sport mostly based on the quantity of movement

Quantity versus quality of movement

Quantity versus quality of movement

Quality of movement

Measurements > 2 years after ACLACL-R consists of:

Conc or isom strength, OLH or a combination

No measurement of:
Endurance / eccentric strength 2 or more hop tests with preference for Gustavsson Quality of movement (video taping or observation)

Quantity versus quality of movement

Thank you for your attention!