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ACL rehab questions
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ACL rehab questions - January 20, 2008 8:21:08 AM
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cowboybuboy
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How soon can we do AROM with some weights after ACL reconstruction using a graft?
Are CKC exercises advisable early on?
In terms of passive knee flexion in prone position, is this the best position to gain knee flexion ROM?
Thanks to all!
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RE: ACL rehab questions - January 20, 2008 8:24:21 AM
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cowboybuboy
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In addition to the questions, how soon can we use a stationary bike?
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RE: ACL rehab questions - January 21, 2008 3:18:59 PM
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Tom Reeves DPT ATC
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You can, and should, do range of motion immediately. exercise bike whenever heel slides are not adequate (even when they are it is ok) I would never do open kinetic chain knee extension, especially between 30 deg. and full extension. CKC is preferred immediately over open chain. Primary goals are full extension, full flexion, quad control for gait, in that order. I think the best position to regain depends upon the patient and the amount of range they are lacking, but prone is a tough position. It usually causes too much pain. I would do supine heel slides, exercise bike, or wall slides (patient is on their back with their butt against a wall and their feet straight up i.e. hips in 90 degrees of flexion. Let gravity assist them when trying to flex their knee.
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RE: ACL rehab questions - January 21, 2008 3:49:14 PM
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cowboybuboy
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Thanks Tom. I appreciate your response. Just one question, though. When you said don't do open kinetic chan in extension, does that include SLR or SLR with pillow underneath the knee? Or just don't do open chain with weights?
Thanks!
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RE: ACL rehab questions - January 21, 2008 6:14:07 PM
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Tom Reeves DPT ATC
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I don't do either but especially don't do open chain terminal knee extension with pillow or a coffee can or whatever. The last 30 degrees have the poorest mechanical advantage and so require the greatest quad force, patello-femoral compression, and create the greatest PA shear force of the tibia sliding forward on the femur. It also is the range where the patello-femoral contact is the largest, and therefore pounds per square inch is exponentially higher.
Once someone can do a SLR I stop. It is functional only to untuck the sheets at the end of the bed. There are better, safer, more functional ways to strengthen the quads/hips.
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RE: ACL rehab questions - January 21, 2008 7:41:53 PM
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cowboybuboy
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Thanks so much Tom. I asked about the SLR question since the protocol that the ortho gave me has the SLR with pillow roll underneath the knee. I thought it's strange due to the risk of anterior tibial torsion. Thanks so much Tom, you're a big help.
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RE: ACL rehab questions - January 22, 2008 11:03:24 PM
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ysumpt2006
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So, Tom, you would never do extension via OKC? I have read in quite a few texts/articles that there is only negligible difference in force exerted on the graft as well as tibial translation when comparing OKC and CKC squats (which are in every "protocol" I have ever seen/heard). Also the final few degrees of OKC extension only serves to compress the joint (simplified), correct? This information is straight from "Orthopedic Physical Therapy Secrets", also.
Just want to get some more information. I have had quite a few ACL patients and love to entertain different approaches.
< Message edited by ysumpt2006 -- January 22, 2008 11:08:51 PM >
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RE: ACL rehab questions - January 22, 2008 11:44:29 PM
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TexasOrtho
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Agree with Tom's priority list. Full extension, quad control, work toward full flexion. I get anxious when any of these are slow to progress - particularly extension. I find heel slides performed before a prolonged passive extension stretch in supine to be very effective. I will follow the extension stretch with the quadset-SLR combo.
I also agree with Tom that SLR is pretty overrated. I've found the best way to regain quad control is to normalize their gait pattern. Emphasize good heel contact and knee control during stance. ROM and quad control improve exponentially with quality gait. Early leg press can help as well.
I'm not staunchly opposed to OKC quad ex's between 30-0 degrees. I will use them if the patient tolerates it in very advanced stages. Patients with allografts and hamstring grafts are at no increased risk for patellofemoral dysfunction, so I simply monitor their tolerance.
Also, as soon as it is permissible, start hitting their hamstrings pretty hard. I've found that it can help normalize tolerance for active flexion more quickly and again facilitates better LE control during gait.
I do not let them limp. I believe it reinforces poor quad control and makes getting full extension difficult. If they need two crutches to achieve normal gait, they use it and we train for a single crutch. Once they normalize with a single crutch, we wean. I like this to happen within 2 weeks if possible, but I don't panic if it stretches to 3 weeks. Good luck and I hope that helps.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: ACL rehab questions - January 23, 2008 12:05:30 AM
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TexasOrtho
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quote:
ORIGINAL: cowboybuboy
In addition to the questions, how soon can we use a stationary bike?
Do not use the bike to force flexion. Once the range is there, go nuts with light to medium resistance.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: ACL rehab questions - January 23, 2008 8:26:47 AM
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PTupdate.com
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Personally, I will continue multi-plane SLR until symmetry with the opposite side occurs. If a 16 year old athlete, who has never done SLR in his life, still has a hip flexor and/or abductor and/or extensor strength that takes "X" pounds of force to break during MMT on his NON involved side, I expect to gain that back on the involved side. But, because the non-involved side is so strong, we have to recognize that something he has been doing functionally in his life created that strength. It may have taken years, and we can't necessarily assume that some of the more "functional" exercises we propose will regain that strength. So, I work on the leg in both combination functional patterns, and also isolate each area as well.
In other words, if it took that kid 6 years of running around his back yard to develop the gluteal or psoas strength he had prior to injury and surgery, is it smart to launch him back onto the playing field with a deficit? If it took that many years to gain the strength doing functional tasks, there is even the chance his surgical intervention has changed his motor patterns and the process could even take longer.
When I was in PT school, we discussed the adductor musculature. These groups are huge, and quite strong, yet nobody had good research as to where in our lives we used them so much that they developed the way they had. But, we still recognized that something was occurring to cause this, and therefore that strength and mass were considered normal and needed.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: ACL rehab questions - January 23, 2008 8:45:11 AM
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Tom Reeves DPT ATC
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ysumpt,
go back to physics. True, in a quad set the extensor mechanism applies almost exclusively compressive forces, but in the few degrees before that, say 20-5, in order for the quads to exert an anterior force on the tibia i.e. extend it the rest of the way, there has to be a massive compressive force to get any extension, the component vector is extremely small. Like trying to close a door from the hinge side. I find it not functional and there are better ways.
Tex,
I agree with the no limping. Proper gait is essential for so many things from timing of contractions, to ROM maintenance.
Another goal I failed to mention, which is not really an immediate goal, but certainly an essential long term goal is knee stability. Yack and Washco published a study, I forget what journal in the mid 90s about the importance of weight bearing, the actual structure of the joint in knee stability. Further, OKC ex do nothing to retrain the proprioception of the joint. The cues encountered in weight bearing for quad/ham/butt/adductor contraction are simply not there when the foot is in the air. No ACL gets injured or re-injured when the foot is in the air. For this reason, I eschew almost all OKC exercises, that way I can train both strength and proprioception.
Duffy,
We will probably start up our rant and re rant thing here about function vs exercise for exercise sake, but once my patients can do SLR, I stop encouraging them. I prefer to spend the time on propriocetion and functional strength as you know. I DO agree with you that if they cannot perform SLR that they need to do them, however, I find it hard to believe that with an ACL tear and reconstruction their hips got weak all of a sudden. I associate it more with inhibition because of the post op effusion.
BTW, the adductors work more in the transverse plane than people give them credit for. Further, their job is to decelerate abduction more than accelerate adduction so there is no appropriate trigger to tell them to contract when the foot is in the air. (I know,same story different day) I think the only way we really disagree is that you do both functional and isolated and I don't do the isolated. My reasoning is that the patient has a limited time that they will assign for their home ex program, and I have limited time for rehab in my clinic so I go to the exercises that give me the biggest bang for my time. Therefore, bye bye isolation.
My two cents.
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RE: ACL rehab questions - January 23, 2008 9:02:22 AM
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PTupdate.com
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As long as the strength of the limb is where it should be, it does not matter to me how that goal was achieved. I do believe we should still assess to make sure. I started a D1 player with ACLR durng Thanksgiving, and then he returned after Xmas for continuation while home for the break. Hip flexors, abductors, and extensors all weak in isolation (compared to other side. By themselves, many would have graded him 5/5), and he was way past the inhibition phase. As SLR were not part of what he was doing at school, I threw them into the mix.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: ACL rehab questions - January 25, 2008 2:50:19 PM
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buckeye
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Great comments from everyone. I also tend to lean more toward closed kinetic chain and functional exercises. I assign the multi-plane SLR as home exercise early in the program and only re-visit them in the clinic rarely.
Although I am not entirely in the Shelbourne house for ACL rehab, I do use some of his ideas - especially the early goals of controlling pain and swelling, restoring full terminal extension/hyperextension early, and restore early neuromuscular control (especially the quads). I agree early normal gait pattern is important. Also, the bike is not the best bet for regaining flexion - I think heel slide supine or heel slide with foot on wall are great.
At a seminar for ACL rehab (I think from Kevin Wilk), several rules and guidelines were discussed with regards to exercise and activity for ACL post-op patients within limitations of any protocol used.
Rules: 1) Avoid swelling, 2) Avoid pain (this is tough one to explain because early it is expected to have some pain/discomfort with regaining motion, the rule is meant for the strengthening phases)
Guidelines: 1) Carriage (proper performance of an exercise or activity, carrying the body in the correct manner) 2) Control (Can the knee control me and can I control the knee?), 3) Confidence (Do I feel safe with my knee for this exercise/activity?)
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RE: ACL rehab questions - January 26, 2008 12:00:52 AM
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dscouras
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Ok guys then here is a question that may be pertinent here.
Agreed with most above but I have a question about odd situations here.
What are your tricks for a client who has a decrease in Extension? Client had full ROM and was feeling quite good when she fell on some ice and re tweaked the knee. We have been stuck at approximatley 3 degrees of extension and 120 degrees of flexion at 8 weeks post op now.
I have tried some flexion mobs etc. We had a breakthrough in knee extension this past week however the flexion is still late.
Thanks
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RE: ACL rehab questions - January 26, 2008 9:33:06 AM
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jma
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There may be some swelling going on inside even though it might not be so apparent visually on the outside. I hope that the patient had a followup to make sure the knee was okay.
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RE: ACL rehab questions - January 26, 2008 9:49:06 AM
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dscouras
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Thx JMA,
The ACL is still intact and the knee is ok however my question remains because of my experiences over the last few years with ACL's. I have a relatively aggressive approach with clients yet cautious at the same time. On a couple of the reconstructions there has been a lag in ROM improvement.
1 lady came in 8 weeks post with 90 degrees max ROM and we could not mobilise or stretch the ROM in etc. She ended up getting better ROM but only to about 110-120 degrees if memory serves me right, when she decided to go water skiing - fell and snapped her knee and since has full painfree ROM and awesome stability, movement etc.
Another was complaining of a general stiff feeling in the knee although had full ROM, he walked up the stairs decided to rotate his knee (shank relatively ext. rot'd) got a crack and know feels awesome again.
So it leads me to conclude that these clients were likely a little keloidy and were were are getting some increased scar resorption on the ACL. My young athlete here that fell on ice definatley increased the swelling in her knee but did she increase her scarring at the same time? So my question becomes is there a sure fire way of manipulating the knee to remove that crap? Has anybody else had this experience?
Thanks guys
dscouras
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RE: ACL rehab questions - January 26, 2008 11:02:09 AM
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dscouras
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JMA,
I will try that technique. I am assuming that it is only a traction force and not a small manip he used. The arthroscopic technique is valuable and will reduce the fibrotic tissue on the ACL, but it takes months to schedule one up here in the great white north. So that leaves us looking for other techniques to resolve these issues. I will get back and let everyone know how this one works.
Thx
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RE: ACL rehab questions - January 26, 2008 1:38:55 PM
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PTupdate.com
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I would have to be forced at gunpoint to put a strap around someones tibia and pull fowards with my body weight when they are only 8 weeks s/p ACLR. I hope you are reading this dscouras!!!!!!!!!!
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: ACL rehab questions - January 26, 2008 1:44:02 PM
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TexasOrtho
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quote:
assuming that it is only a traction force and not a small manip he used. The arthroscopic technique is valuable and will reduce the fibrotic tissue on the ACL, but it takes months to schedule one up here in the great white north. So that
Slow progression of ROM can be a nightmare sometimes. From what I've experienced, not many doctors like to manipulate the knee unless the ranges are worse than 10-125. To me, a 5-10 degree passive extension defecit is functionally significant for most athletes, so I'm not sure what the med/surg managment would be in these marginal cases.
Unfortunately if they are less than 100 degrees at four weeks or beyond, I think that is a grim prognosis for conservative management. I haven't found many folks who can tolerate the necessary force to remodel a fibrotic knee. Not to mention that I believe aggressive stretching the way it is often performed by therapists causes even more harm than good in the form of local inflammation and proliferation of more fibrotic tissue.
If their ROM cannot progress with mobilization or standard postoperative techniques, I think manipulation by the therapist could be potentially harmful and even expose the therapist to legal risk. It may sound overly protective, but that's my approach. I do everything I can to increase their ROM in a reasonable manner.
I believe postoperative motion loss is multifactoral. If you read some of the surgical journals, they will often site surgical technique as a predictor of motion loss. My take home there is that even if you do everything right, patient compliance, poor surgical technique, or even bad luck can conspire to create a bad outcome. Thank goodness it doesn't happen too often.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: ACL rehab questions - January 26, 2008 1:47:46 PM
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TexasOrtho
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quote:
ORIGINAL: PTupdate.com
I would have to be forced at gunpoint to put a strap around someones tibia and pull fowards with my body weight when they are only 8 weeks s/p ACLR. I hope you are reading this dscouras!!!!!!!!!!
Amen to this my friend. High risk with a dubious outcome = Beware.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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