Acl ppt

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Lebanese UniversityFaculty of Public HealthIV BranchPhysiotherapy (4th year)2013-2014

EFFECTIVNESS OF PHYSICAL THERAPY TREATMENT AFTER ACL RECONSTRUCTION

Presented to: Dr. MAHMOUD HALABLABDone by: SAJA KAHWAJIIntroductionFrom our training in the centers of rehabilitation, we found that the most common injuries in sport amateur and in young people is the anterior cruciate ligament tear.Patients , who undergo a surgical reconstruction, usually start physical therapy the first day post surgery in the hospital, progressed to continue their treatment in centers of rehabilitation.What are the most evident application for obtaining maximum benefit to enhance patients physical status after ACL reconstruction ?

Knee Anatomy

The knee is one of the largest and most complex joints in the body. The knee joins the thigh bone (femur) to the shin bone (tibia). The smaller bone that runs alongside the tibia (fibula) and the kneecap (patella) are the other bones that make the knee joint.

Tendons connect the knee bones to the leg muscles that move the knee joint. Ligaments join the knee bones and provide stability to the knee:Lateral collateral ligament(LCL) Medial collateral ligament(MCL)Anterior cruciate ligament(ACL)Posterior cruciate ligament(PCL)

Muscles surrounding knee joint QuadricepsHamstringTensor fascia lataHip adductorsSartorius Gracilis

Pathology Of Knee JointIntra-articular :Meniscal tear ACL and PCL injuriesOsteoarthritisSpondiloarthropathy

Extra- articular:Pre-patellar bursitisPatello femoral syndromeCollateral ligament injuriesiliotibial band syndromebakers cystosteonecrosis

Anatomy Of ACLThe ACL is a band of dense connective tissue that connects the femur and the tibia. The ligament originates at the medial side of the lateral femoral condyle and runs an oblique course through the intercondylar fossa distalanterior medial to the insertion at the medial tibial eminence.

Where its :

Length of 38mm ( range 25 to 41mm)Width of 10 mm(range 7 to 12mmMade up of multiple collagen fasciclesMicroscopically: interlacing fibrils (150 to 250 nanometer in diameter)Grouped into fibers (1 to 20 in diameter)Synovial membrane envelopeInfiltrates the capsule posteriorlyReceives its innervation from tibial nerveGolgi tendon receptors

ACL Biomechanics

The biomechanical function of the anterior cruciate ligament is complex for it provides both mechanical stability and proprioceptive feedback to the knee .In its stabilizing role, it has 4 main function:Restrains anterior translation of the tibiaPrevents hyperextension of the kneeActs as a secondary stabilizer to stress ,reinforcing the medial collateral ligamentControl rotation of the tibia on the femur in femoral extensions of 0 - 30 (4)

Pathology Of The ACL

Researchers believe there are external and internal factors associated with ACL injury.

External factors include any play where the injured athletes coordination is disrupted just prior to landing or slowing down (deceleration).

Internal factors include increased hamstring flexibility, increased foot pronation (flat-footed), hormonal effects, and variations in the nerves and muscles which control the position of the knee.ACL Clinical TestLachman TestPatient lie supine and flex the knee to 20-30. The examiner stabilizes the femur with one hand and pulls the tibia forward with the other hand, while estimating the amount of anterior movement. A distinct endpoint at which forward displacement stops suggests that the ACL is intact.Lachman Test

Anterior drawer test

Have the patient's tested leg bent to about 90 degrees of flexion. The examiner should sit on the foot of the patient's leg. Place a hand along each side of the patient's knee, while palpating the joint line. Apply a posterior-to-anteriorly directed force through the superior tibia. Compare the involved side to the non-involved side.A positive test includes the lack of an end-feel or excessive translation.Anterior Drawer Test

Surgical Treatment Allograft is most commonly used recreational athletes (as opposed to competitive athletes).

Patellar tendon graft used because it closely resembles the torn ACL. Hamstring tendons graft are used in ACL surgery, two of the tendons of these muscles are removed, and "bundled" together to create a new ACLPre Operative physical TreatmentMain Goals :

perturbation training and aggressive quadriceps strengtheningfull range of motion equal to the opposite kneeminimal joint swelling adequate strength and neuromuscular control positive state of mind

Immediate Postoperative Phase

Goals of this phase are to :

Eliminate swelling due to activityProgress from partial weight bearing to full weight bearing exerciseRegain normal range of motionIncrease quadriceps strengthIncrease Hamstring strength

16Early Postoperative Phase

The milestones of the early postoperative phase (week 2 post surgery) are: Walking without crutches(may be discontinued once a patient is able to ambulate without pain)The use of a cycle/stair climber without difficultyWalking with full knee extension Reciprocal stair climbing Straight leg raises without an extension lag Crutches. knee flexion greater than 110

Intermediate Postoperative Phase

The milestones for the intermediate postoperative phase are knee flexion within 10 of the uninvolved side and a quadriceps index greater than 60%. Balance and neuromuscular re-education exercises begin in this time frame). Neuromuscular alterations (muscle inhibition, impaired sensorimotor function) Late Postoperative Phase

The milestones are:

a quadriceps index greater than 80% a normal gait patternfull knee ROMknee joint effusion equal to a grade of trace or lessModalities and techniques

Full Passive Knee Extension

Therefore, two of our goals are:

Achieve some degree of hyperextension during the first few days after surgeryEventually to work to restore symmetrical motion. Specific exercises include PROM exercises performed by the rehabilitation specialist: 1) Supine hamstring stretches with a wedge under the heel, and gastrocnemius stretches with a towel. 2)Passive overpressure just proximal to the patella may be used for a low-load , long-duration stretch as neededRestore Patellar Mobility

Mobilizations are performed by the rehabilitation specialist in the clinic and independently by patients during their home exercise program

Mobilizations are performed in the medial/lateral and superior/inferior directions, especially for those with a patellar tendon autograft, to restore the patellas ability to tilt, especially in the superior direction.

Reduce Postoperative Inflammation

Pain and swelling after surgery can be reduced through the use of:Cryo therapyAnalgesic medicationElectrical stimulationPROM Lasers to aid in the healing response.

Range Of Motion

Flexion ROM is also gradually progressed during the first week. Patient should exhibit 0 to 90 of knee ROM 5 to 7 days after surgery and 0 to 100 of knee ROM 7 to 10 days after surgeryThus, the primary focus at this time is on obtaining full knee extension. Over the course of the following month, flexion ROM may be progressed by approximately 10 per weekRe-establish Voluntary Quadriceps Control

Clinically, we use electrical stimulation immediately following surgery while performing isometric and isotonic exercises such as:Quadriceps setsStraight leg raisesHip adduction and abductionKnee extensions from 90 to 40 of knee flexion.

Restore Neuromuscular Control

This can be achieved by :Forward, backward, and lateral cone or cup step-over drills to facilitate gait trainingEnhance dynamic stabilityTrain the hip to help control forces at the knee joint Strengthening of the hip and knee to eccentrically control the lower extremity is imperative to a return to functionRaise the knee to the level of the hip and step over a series of cones, then landing with a slightly flexed knee.

Gradually Increase Applied Loads

The next principle of ACL rehabilitation is a gradual increase in the amount of stress applied to the injured knee. This simple concept is applied by :progression of ROM strengthening exercisesproprioceptive trainingneuromuscular control drillsfunctional drillsand sport-specific training.

It involves the restoration of function through sport-specific training for athletes returning to competition once the knee has returned to its normal.

Some sport-specific running and agility drills include side shuffling ,cariocas,sudden starts and stops, zigzags, 45 cutting, and 90 cuttingProgress To Sport-Specific Training

Conclusion

Rehabilitation protocols provide basic guidelines through which effective outcomes can be achieved. However, the rate and extent of recovery will depend on many patient and external factors. It is still questionable whether full recovery, or return to normality can be. The complex neuromuscular motor patterning, strength and control which are affected by the injury ,should return after the surgery . Isokinetic testing is reliable and reproducible method of evaluating muscle strength, endurance and antagonist/agonist balance.References1. Brown CH Jr, Carson EW: Revision anterior cruciate ligament surgery.Clin Sports Med 18:109-171, 1999

2.Reiman PR, Jackson DW: Anatomy of the anterior cruciate ligament, inJackson DW, DrezD (eds): The Anterior Cruciate Deficient Knee. St.Louis, CV Mosby & Co, 1987, pp 17-263.Dienst M, Burks RT, Greis PE: Anatomy and biomechanics of the anteriorcruciate ligament. Orthop Clin North Am 33:605-620, 20024.Cross.MJ.Anterior Cruciate Ligament injuries :Treatment and Rehabilitation. Sydney, Australia :North Sydney Orthopedic and Sports Medicine Center.5.Bradley JB , Klimkiewicz JJ , rytel MJ , Powell JW Anterior Cruciate Ligament Injuries In The National Football League6.Root ML , Weed JH , Sgarlato TE , et al : Axis of Motion Of The Subtalar Joint . J Am Podiatr Med Assoc 56:149-155 , 1966.7. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med. 1991;19:332336. [PubMed]8. Chmielewski TL, Stackhouse S, Axe MJ, Snyder-Mackler L. A prospective analysis of incidence and severity of quadriceps inhibition in a consecutive sample of 100 patients with complete acute anterior cruciate ligament rupture. J Orthop Res. 2004;22:925930. [PubMed]