Acl rehabilitation.......................

Acl

1. Principles of ACL Injury Rehabilitation and its Protocols dr. Azizati Rochmania, SpKFR

2. Anterior cruciate ligament important internal stabilizer of the knee joint, restraining hyperextension . the most commonly injured ligament in the knee, with approximately 100,000 to 200,000 injuries per year in the United States alone more than half of these injuries undergo surgical reconstruction Advanceortho.org

3. most commonly occur during sports that involve sudden stops or changes in direction, jumping and landing — such as soccer, basketball, football and downhill skiing

4. Symptoms A pop sound in the knee A popping sensation in the knee Swelling and pain within few hours of injury Hemarthrosis- bleeding into the knee joint Loss of range of motion Severe pain causing hindrance in continuing the activity Tenderness and discomfort around the joint while walking

5. After ACL reconstruction, the speed and safety with which an athlete returns to sports or regains the pre-injury level of function depends largely on the rehabilitation protocol Evidence-based rehabilitation following anterior cruciate ligament reconstruction, Grinsven, Cingel, Holla, van Loon: Knee Surg Sports Traumatol Arthrosc (2010)

6. Rehabilitation protocols Progression from one phase to the next is based on readiness by achieving functional criteria rather than the time elapsed since surgery. Anterior Cruciate Ligament Reconstruction Rehabilitation: MOON Guidelines Wright, Haas, Anderson et all; SPORTS HEALTH, vol7 no 3, 2014

7. Pro bracing is used to reduce pain, immobilize the joint, and/or limit range of motion (ROM) protect the graft site by limiting varus and valgus stresses and restricting ROM recommended bracing for 1 to 3 weeks after surgery, 4 or 6 weeks, depends on surgery type Contra no study demonstrated a clinically significant or relevant improvement in safety, range of motion including extension, or other outcome measures Bracing Rehabilitation Principles to Consider for Anterior Cruciate Ligament Repair; Wu, Kator , Zarro et all, SPORTH HEALTH, vol 14 no 3, 2022 Evidence-based rehabilitation following anterior cruciate ligament reconstruction, Grinsven, Cingel, Holla, van Loon: Knee Surg Sports Traumatol Arthrosc (2010 ) Wright, Haas, Anderson et all; SPORTS HEALTH, vol7 no 3, 2014

8. Pre operative

9. . a preoperative extension deficit (lack of full extension) is a major risk factor for an extension deficit after ACLR a preoperative deficit in quadriceps strength of >20% has a significant negative consequence for the self reported outcome 2 years after ACLR prehabilitation ensures better self-reported knee function up to 2 years after ACLR. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus van Melick N, van Cingel REH, Brooijmans F, et al. Br J Sports Med 2016;50:1506–1515

10. Goals

11. Post operative

12. Weight bearing

13. ROM guidelines

14. Neuromuscular and Proprioceptive Training

15. CKC vs OKC

16. Electrical stimulation

17. Return to play

18. Post ACL Reconstruction Healing Process Differing ligamentization time frames in human grafts compared with a recent review of animal reports (Claes et al., 2011)

19. Phase 1 Recovery from surgery

20. Goals full passive extension Control post-operative pain/swelling Range of motion 0° → 90° Prevent quadriceps inhibition Early progressive weight bearing

21. Criteria to progress Knee extension ROM 0 deg • Quad contraction with superior patella glide and full active extension • Able to perform straight leg raise without lag Demonstrate ability to unilateral (involved extremity) weight bear without pain

22. Phase 2 Strength and neuromuscular control

23. Normal gait pattern ▪ Demonstrate ability to ascend 8″ step ▪ Good patella mobility Single leg balance

24. Phase 3 Running, agility, landing

25. Goals Attain excellent hopping performance Complete agility program Regain full strength and balance

26. No episodes of instability • Maintain quad strength • 10 repetitions single leg squat proper form through at least 60 deg knee flexion • Drop vertical jump with good control • KOOS-sports questionnaire >70% • Functional Assessment o Quadriceps index >80%(isokinetic testing if available) o Hamstring, glut med,glut max index ≥80%; (isokinetic testing for HS if available) o Single leg hop test ≥75% compared to contra lateral side (earliest 12 wks )

27. Phase 4 Return to sport

28. Safely progress strengthening • Safely initiate sport specific training program • Promote proper movement patterns • Avoid post exercise pain/swelling • Avoid activities that produce pain at graft donor site

29. Return to sport criteria Lack of apprehension with sport specific movements ▪ Maximize strength and flexibility as to meet demands of individual’s sport activity ▪ Isokinetic test ≥90% limb symmetry ▪ Hop test ≥90% limb symmetry ▪ Acceptable quality movement assessment Athlete is comfortable, confident, and eager to return to Sport measured by the ACL-RSI and IKDC An ACL injury prevention program is discussed, implemented, and continued whilst the athlete is participating in sport 95 + on Melbourne Return to Sport Score ACL Rehabilitation Progression: Where Are We Now?: Cavanaugh, Powers Curr Rev Musculoskelet Med (2017) 10:289–296, Melbourne ACL Rehabilitation Guide 2.0

30. Phase 5 Prevention of re-injury

31. Include :