Returning the Injured Athlete to Sports: New Concepts in ACL Rehabilitation Robert Donatelli, PhD, PT
Course Materials
New Concepts in ACL Rehab
Robert Donatelli PT PhD drbob@modernathleticscience
Rehab of ACL • • •
Non-contact injuries 67% Greater during competition 82.3% Last 15min 35% Strong Evidence for increased hip adduction moment – poor strength of hip abductor/external rotation
http://pediatricsportsmed.blogspot.com/2009/05/ac l-injury-contact-vs-non-contact.html
Mechanism of Injury Typically non-contact deceleration situation with hyperextension or rotational component ***Rotational Component****
Mechanics of ACL Tears Hyperextension
http://extras.springer.com/2004/978-1-4757-8105-2/ACLFinal
Forces to ACL NWBE vs WBE •
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ACL loading occurs primarily between 0 – 50E knee flexion. 50-100E knee flexion reduces ACL strain Higher ACL loads between 0 and 30E peak 150N in NWBE compared to 50N WBE Squatting and Lunge techniques can alter ACL strain •
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Forward trunk tilt recruits the hamstrings = reduced anterior tibial translations compared to a erect trunk Anterior knee movement beyond the toes 8cm = increase ACL loading during squat and lunge
ACL Reconstruction The primary goal of the reconstruction is to restore stability to the knee and restore its function allowing the patient to return to normal activities, including sports and prevent OA Weakness of the quadriceps after reconstruction of the anterior cruciate ligament primarily reflects a deficit in neural activator drive from the central nervous system rather than a pure muscle weakness – neuromuscular rehab
ACL Post-op Results Rehabilitation out comes: 49% overall of re-injury of the ACL reconstruction or ACL contra lateral knee •
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Review of 48 studies – more than 5700 patients 63% returned to pre-injury levels & 2/3’s were not back 12 months post-op. 44% returned to competitive sports
Ardern et al Br J Sports Med 2011
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40-90% of patients exhibiting radiographic OA 7-12yrs following the surgery
Barber-Westin, Noyes Objective criteria for return to sport following ACL & re-injury rates a systematic review Phys SportsMed 2011
Balance Strength/Neuromuscular Four Systems •
Musculoskeletal Strength of the Hip and Lower Leg = Posterior GM, GM, and external rotators - MMT Dynamic and Static LE testing
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Somatosensory Star Excursion Balance Test
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Vision
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Vestibular
Factors in Females for Increased Risk •
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Over powering Quad strength Hamstring less effective in reducing anterior translations when knee is extended most protective 15-30 degrees flex Posture of the knee in landing valgus / hyperextension Muscle Imbalances – hip Foot Mechanics
Which runner is at increased risk and why?
Perturbation Training Improves Knee Kinematics and Reduces Muscle Co-contraction After Complete Unilateral ACL Rupture Chmielewski, Hurd, Rudolph Axe, Synder-Mackler Physical Therapy 2005 Aug
Copers •
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Prior to training potential copers stiffened their knees with higher co-contraction and slightly lower peak flexion angles Increased compressive forces from strong co-contraction can contribute to degeneration of articular cartilage The use of joint stiffening strategy = unopposed quad contraction that can cause anterior tibial translation = increased shear forces with over powering Quad Normal knee kinematics = knee flexion angles increased in copers
Dynamic and Static Movement Testing Eccentric • • • • •
Step-Down – Step UP Test Jump Down Test Full Squat Test Single Leg Squat Test – Unstable knee Knee Flexion Angles - Hop Test unstable surface R-L– Activation of hamstrings
Isometric • •
Single Leg bridge with Dorsi-flexed Ankle Side Plank Test - Prone Plank
Functional Testing
Jump Down Valgus Knee
Single Leg Squat Valgus Knee
Step up Tests
Pronated Foot Position
Hyper-extended
Step Down – Test •
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Stool or step 8-inch (20.3 cm) Lower R/L leg, so heel touches the ground return to platform touch top of platform Continue sequence for 30 seconds Criteria to watch Do not push off ground as lowering heel/touching •
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Heel must make contact with slight hesitation both @ down phase & start phase
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Do not allow vaulting up with their touch leg
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Greater than 10% difference is significant
Single Leg Hop •
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Single leg hop on unstable surface Straight leg position does
not bring in hamstring protection •
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20-30 degree angle is necessary for hamstring activation
Poor angle
Full & Single Leg Squat in Sports Lateral shift
Restricted mobility
Single leg squat knee over foot
Full squat Full Range
Restoring Neuromuscular Control Balance in the Athlete Somatosensory- Vestibular – Vision The muscle must be set on a higher state of readiness to prevent injury by protecting joints from perturbation forces and be able to perform exceptionally skilled activities performed at high velocities. This higher state of readiness of the neural control of the musculoskeletal system can be achieved through neuromuscular training such as perturbation, plyometrics and vestibular exercises.
Neuromuscular Control Defined: Subconscious integration of sensory information that is processed by the CNS resulting in controlled, coordinated muscular activity Quadriceps
Motor neuron stimulating hamstrings
Motor neuron stimulating quadriceps
Spinal Cord
Sensory Neurons Sensory Neuron
Patellar tendond Motor Neurons
Neuromuscular Three Systems to Maintain Balance Conscious Sense of Orientation •
Somatosensory – mechanoreceptors • • •
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Two reflex arcs Myototic ( GTO – Spindle) Stretch Reflex Functional Stretch response – provides coordinated limb and trunk movements across joints
Vestibular apparatus
Two Groups of sensory receptors Semicircular canals 6 total = 3 in each ear Otolithic organs • •
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Vision – Eyes aid in maintenance in upright posture and orientation •
Three Visual Reflex Arcs Optokinetic Saccades Smooth Pursuit • • •
Theory of neuro-muscular mechanisms in perturbation training: “Readiness” Johansson and Sjolander
Neuromuscular training results in more efficient processing of sensory input as well as faster selection of the correct motor program resulting in relatively fast but more appropriate movement
Results in a higher state of readiness of muscles and joints to respond to perturbing forces applied to the joints.
Somatosensory Testing Star Excursion Balance Test/Y Reach Test to Predict LE Injures in Basketball Players Plisky et al. J Orthop Sports Phys Ther 2006;36(12):911-919 • •
Results: The reliability of the SEBT excellent Athletes with anterior right/left reach distance difference greater than 4 cm were 2.5 times more likely to sustain
Posterolateral
Posteromedial
Anterior
Classic Test for Sensory Integration and Balance CTSIB Somatosensory – Vestibular – Vision Test Positions: 1. Single leg stance – eye open – all three systems (SL stress to Hip Abduction) 2. Single leg stance - eyes closed on firm surface (Somatosensory – Vestibular) 3. 4. 5.
Single leg stance – eyes open on foam (soft surface) –(Vision & vestibular) Single leg stance - eyes closed on foam – (Vestibular system emphasis) Hold position for 30 seconds – hands on hips Tandem stance requiring initial support to stabilize tandem stance reflect meaningful deficits to balance related mobility measures 10 seconds and 30 seconds – hold Hile E. et al, Interpreting the need for initial support to perform tandem stance tests of balance Am J Phy Therapy Oct 2012
Test Failure: Opening Eyes, lifting hands from hip, touchdown of non-stance foot, step, hop, or other movement on stance foot or feet
Training the Somatosensory System Perturbation Training •
Johansson suggested by stimulation of mechanoreceptors increases gamma motor activity increasing muscle spindles sensitivity
Advance Training Jumping on to Unstable Surface
Caratta et al Knee Surg Sports Trauma Arthr 96 • • • •
600 soccer/3seasons 300 trained traditional 300 proprioceptive training 70 ACL tears trad. and 10 ACL tears balance group
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5 levels of difficulty Each phase of training 3-6 days All training sessions lasted 30 days 20 minutes per day
Balance in the Athlete The Missing Link •
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Vestibular (inner ear) CNS Vision = Three visual Oculomotor systems 1. Saccades 2. Smooth pursuit 3. Optokinetic
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VOR perception of linear and angular accelerations
Balance in the Athlete •
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Ankle strategies more dependent on somatosensory information to control posture – hip more dependent on vestibular Step strategy for center of mass control when stability limits are exceeded
http://www.thehindu.com/todays-paper/tp-sports/feng-zhereigns-supreme-on-the-bars/article3739943.ece
Ankle
Hip
Step
Vestibular System •
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Head–Hand-Eye coordination mediated by vestibular System Vestibular receptors in the inner ear can provide an exquisitely accurate representation of head motion in 3 dimensions Vestibular Ocular Reflex mechanism for GAZE stability and the perception of linear and angular accelerations of the head
Vestibulo-0cular Reflex is a system that maintains the stability of the visual field in response to acceleration of the head in a particular direction. Running velocities head acceleration up to 6000 deg/sec
Vestibular Dysfunction •
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Acute vestibular dysfunction is derived from static and dynamic disturbance in inputs from the semicircular canals and the otolithic organs
Static imbalance with the head motionless –
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Signs = nystagmus – visual vertical, horizontal, ocular tilt reaction
Dynamic disturbances impaired response during head movements –
Signs= hypo-function of the VOR – postural instabilityocular counter-rolling
Vestibular Disorders •
Dislodged Otoconia – Surgery and Head Trauma –
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Small calcium crystals embedded in the inner ear can dislodged from the otolithic organs – move to the semi-circular canals
Aging and Disuse Large amounts of Fluid Labyrinthitis- Inflammation of inner ear from infections or upper respiratory Infections
Neural Pathway of Vision •
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Cones provide color vision and are responsible for acuity (detailed) vision Fovea
Rods provide night vision, peripheral vision, an detect motion Peripheral Retina
Visual neural impulses propagate through the optic nerves to the brain centers
Visual Workspace and Motor Performance •
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The spatial environment within which objects and locations exist Gaze is the ability to bring the critical information required to perform well onto the part of the eye, the fovea, that sees with clear acuity for prolonged durations even as they move dynamically in cluttered and difficult environments
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Human retina
Quiet Eye – Final Gaze •
Since the Quiet Eye has been shown in elite athletes to be earlier and longer than that of athletes with lower skill levels Dr. Vickers
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It is trainable large increases in performance The quiet eye is an objective measure of optimal perceptual-motor coordination The Quiet Eye = Prof. golfers longer 500 msec / amateur 250-300 msec
Final Gaze Dynamic Visual Acuity •
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SVA – Ability to see detail while the head is not moving DVA - Ability to see detail while the head is in motion Test for DVA– Head is moving side to side while reading an eye chart
E HN DFN PTXZ UZDTF DFNPTH PHUNTDZ NPXTZFH
DVA Test Head Shaking – Side to Side 1200 Sec E
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Final Gaze – Quiet Eye- DVA Are we helping are athletes see better? •
Seeing the Target
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What is wrong with Andy’s eyes?
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Where is the ball?
http://online.wsj.com/news/articles/SB10001424052748704009804575308741093724362
Roger Federer Vision System •
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Watch the ball from the back of the racquet Keeps the head and eyes still longer before contact Makes it easier for you to prevent the head from jerking forward during the swing.
http://www.revolutionarytennis.com/federervisiontechnique.html
The Quiet Eye = Gaze Stability Prof. golfers longer 500-600 msec Amateur 200250 msec Dr. Vickers
Testing the Three Visual Oculomotor Systems •
Vestibular Ocular Reflex = Dynamic Visual Acuity Take into account cervical-vestibular reflex– ROM – –
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Smooth pursuit = slow movement - spins Saccades faster moving targets or move between targets. Optokinetic eye movement of equal velocity & opposite direction of head movements Nystagmus (rapid eye movement) is a normal response
Head Thrust Test for Identifying Vestibular Hypofunction
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Normal Head Thrust A-B
A- Initial starting position eyes are focused on a target cervical flexion B- Turning to the left upon stopping the head turn eyes are still on target •
Abnormal Head Thrust C-E
C- Initial starting position D- turned to right eyes are not on target Eeyes make a corrective saccade bring eyes back to target
Dynamic Visual Acuity •
Head moves
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Eyes on target
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1Hz combo VOR & COR
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3 Hz purely VOR
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Can quantify with eye chart
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Up to 2 line changes (i.e. 20/20 20/50) is WNL Herdman et al 1998 Train at higher speeds – blurry or dizzy during the exercise
Smooth Pursuit Exercise & Test for CNS Dysfunction • •
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Head still Eyes follow target through 20-40 deg/sec through narrow arc Unable to maintain image on retina over 1500 sec = 15mph Test look for over shoot and/or nystagmus of the eyes when following a target Deteriorates with age Detects spins of an object, acceleration or decreases in speed
Saccades Exercise and Test for CNS Dysfunction •
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Head Still Ballistic eye movements reach speeds excess of 900-10000/sec = 90 mph (145 kph) Important for high velocity objects such as in baseball, hockey puck, tennis ball, lacrosse, handball etc.
Test look for over shoot and/or nystagmus of the eyes when moving from targets
Abnormal Optokinetic and Perceptual Span Parameters in Cerebellar-Vestibular Dysfunction and Related Anxiety Disorders Harold N. Levinson – New York University Medical Center
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Optokinetic Tracking Capacity blurring speed end point b, c, d Subjects experienced themselves or the back ground moving or blurring = perceptual instability
Balance & Vestibular Testing Peripheral 1.
Classic Test for Sensory Integration and Balance CTSIB –
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Feet – Tandem, extend head – close eyes – then to single leg 60 sec hold times except single leg (10sec)
Fukuda Test/March Test : –
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Patient stands feet together arms crossed with the eyes closed to see if the patient can maintain balance for 60 seconds It tests vestibular (primarily otolith organs) and proprioceptive balance pathways. The vestibulospinal pathway canbe isolated by having the patient stand on a foam surface to minimize proprioceptive input.
Sharpened- Advanced Rhomberg : –
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Eyes open / Eyes closed/ Firm surface / Soft foam - R-L single leg
Rhomberg:
The patient steps in place with the eyes closed for one minute. The patient may turn towards the side of the lesion. It is important to note though that right handed people often drift to the left somewhat with this test.
Past Pointing : –
The past-pointing test is primarily (though not completely) a test of proprioception, and it involves having the patient repeatedly bring his finger to a remembered position withhis eyes closed. Patients with vestibular pathology may point more to the side with the lesion.
Vestibular Dysfunction = Physical Limitations in the Athlete • • •
Unable to focus with quick head movements Poor hand-eye coordination Poor balance compensations hip and step strategies –
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Make compensations that reduce the athletes agility, speed, and performance May cause injury
Maintenance of GAZE and Posture interaction of inputs from – – –
Vestibular Visual Somatosensory
Patient Case - Dancer •
Post-op ACL reconstruction
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4 weeks post-op
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Weakness of the Quads and Hamstrings
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Poor balance – history of inner ear infections and minor concussions Weak posterior hip muscles
Hip Strengthening External Rotation
Perturbation Training Shuttle Balance
Balance Positions
Balance & Vestibular Training •
Dynamic Edge – Quad strengthening and endurance training & balance training
Advanced Perturbation Training Place Kicker Football Torn Rectus
ACL Rehab Based on Healing Ligament Week 1-2 – – – – – –
No aggressive passive movement – grade II mob ilization large amplitude Russian current and Isometric exercises Hip strengthening exercises – posterior-lateral Trunk endurance exercises Low Load Prolonged Stretch into extension Active Flexion exercises - bicycle
Week 2-6 –
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CKC exercises for strengthening–single leg squat- leg press, Dyn Edge, Lunges, Eccentric loading Perturbation exercises – balance training - vestibular Passive stretch – joint mobs into extension and flexion – Grade III end of range
Week 7-16 – –
Complex surfaces – perturbation and vestibular exercises Hopping one foot to next – 30 E flexion angle, Balance complex surfaces
Week 16 –
OKC strengthening Quads
Week 17-24 – –
Plyometric exercises (jump training) – Agg ressive weight training Sport specific exercises
New Con cepts in ACL Rehab Restoring Balance in the Athlete •
Strength training to reduce Muscle Imbalances
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Perturbation training
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Training the Vestibular system VOR Plyometrics –
Agility training combination of all the above
New Concepts in ACL Rehabilitation
Bibliography MedBridge Education Returning the Injured Athlete to Sports: New Concepts in ACL Rehabilitation Robert Donatelli, PhD, PT 1. Arden, Clare L., Kate E. Webster, Nicholas F. Taylor, and Julian A. Feller. "Return to Sport following Anterior Cruciate Ligament Reconstruction Surgery: A Systematic Review and Metaanalysis of the State of Play." Return to Sport following Anterior Cruciate Ligament
Reconstruction Surgery: A Systematic Review and Meta-analysis of the State of Play. British Journal of Sports Medicine, 11 Mar. 2011. Web. 04 Apr. 2014. 2. Caratta. "Knee Surgery,Sports Traumatology,Arthroscopy-incl. Option to Publish Open Access." Springer.com. Springer, n.d. Web. 04 Apr. 2014. 3. Chmielewski, T., W. Hurd, K. Rudolph, M. Axe, and L. Snyder-Mackler. "Result Filters." National Center for Biotechnology Information. U.S. National Library of Medicine, Aug. 2005. Web. 04 Apr. 2014. 4. Plisky, Philip. "The Reliability of an Instrumented Device for Measuring Components of the Star Excursion Balance Test." Http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953327/. North American Journal of Sports Physical Therapy, May 2009. Web. 04 Apr. 2014. 5. Westin, Barbara, and Noyes FR. "Result Filters." National Center for Biotechnology
Information. U.S. National Library of Medicine, Sept. 2011. Web. 04 Apr. 2014.
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