"Releasing" a pt after ACL rehab? (Full Version)

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ysumpt2006 -> "Releasing" a pt after ACL rehab? (May 22, 2007 8:21:00 AM)

I have an ACL patient who informed me that the surgeon has told him that he is leaving the decision of returning to sport up to his therapist.

Is this common-place? Do you do this?

This patient is 20 weeks out and has progressed very well. The surgeon did not have a protocol, but wanted him progressed at an accelerated rate.

I feel he could return to sport, but is it my place to say that?

I will be completing functional testing at next session (single leg hop for distance) to compare involved vs. uninvolved.

Opinions?



SJBird55 -> Re: "Releasing" a pt after ACL rehab? (May 22, 2007 10:07:00 AM)

Depends on the surgeon in this area. Yes, leaving the decision to the therapist occurs in this area - athletic trainers are sometimes allowed to make the decision, especially in the collegiate setting.

If you did a search, there are current articles out there that indicate the sensitivity and specificity of functional tests. There are published guidelines for return to sport based on functional testing.



ragempt -> Re: "Releasing" a pt after ACL rehab? (May 29, 2007 9:51:00 AM)

I feel it should be our responsibility to determine when patients return to a sports. Of course returning to soccer and retuning to ball room dancing are 2 different activities. Maybe we can give you some specifics. What is the sport? What is the position? How old? What level (example travel soccer). Does the doctor want a brace worn?



treybien -> Re: "Releasing" a pt after ACL rehab? (May 29, 2007 10:47:00 AM)

Interesting topic. Tough to fully evaluate. A certain Colts running back a few years back came back in about 10 months and probably was not ready. Passed functional tests nicely. Cybex score for quad at 60 and 180 degrees per second was around 61% of uninvolved leg. Ended up with multiple problems including hamstring and achilles in season. Knee was fine.



ragempt -> Re: "Releasing" a pt after ACL rehab? (May 30, 2007 9:58:00 AM)

Ryan, have you seen the JOSPT articals on functional performance after Cybex testing. its not good dude or sir what ever you want. we threw our cybex machine out about 12 years ago. it was great throwing this in the dumpster. it took about 4 PTs. you should try it some day. was your athlete using machines to rehab?



treybien -> Re: "Releasing" a pt after ACL rehab? (May 30, 2007 4:21:00 PM)

My point is not really about Cybex or rehabing with machines, or throwing machines out in the dumpster, or what rehab protocol is right or wrong. My point is that a 1600 yard per season rushing pro football player passed his "functional test" as we normally test people after an ACl. His straight line speed was good. He had no swelling. He could cut and turn. Yet other signs may have pointed that he was not ready. A poor Cybex score was one of those sings. My point is be careful in how you evaluate functional tests and make sure you take a lot of factors into consideration depending on what activity you are returning them to.



orthotherapist -> Re: "Releasing" a pt after ACL rehab? (May 31, 2007 4:23:00 AM)

Ryan,

I understand your point about carefully evaluating functional tests yet your inclusion of the cybex into "functional" is far from the truth -

There is nothing functional about isolating the quads in an open chain manner.

What functional tests did he pass nicely because a 40% deficit is substantial and dispite not being tested from a functional perspective would indicate that the knee was not "fine".



treybien -> Re: "Releasing" a pt after ACL rehab? (May 31, 2007 6:55:00 AM)

I never really meant to imply the functionality of Cybex I did not mean my post to imply this. I do not think my post said that Cybex is a functional test. I apolagize if this is what it sounded like. What I said was he passed functional progression and had a very poor comparitive Cybex score. I think we all know what the studies have shown about Cybex. What I was trying to imply is that I think you have to treat these situations sort of like SIJ tests. Some tests in and of themselves are not useful, but when added into a body of knowledge and with results of other tests a certain test can give us info that may be important. Maybe a poor Cybex score makes you think more critically about how the patient performed in functional testing.
Ultimately use all the information you have plus functional testing to make a decision. I would be sure though that the coach and the athlete understand that the athlete is probably not ready in terms of overall endurance and stregth to fully participate at 20 weeks. An overall progression of return to game status may take another 20 weeks or more depending on the sport.



orthotherapist -> Re: "Releasing" a pt after ACL rehab? (May 31, 2007 7:35:00 AM)

I agree with what you say - it just hit a nerve to see function and Cybex in the same sentance as my last job required 80% of patients to use the Cybex because it was a "good measure of fucntion" - I quickly exited that job stage left

As you state use all pieces of the puzzle to determine when an athlete is able to return to competition.

Didn't Jerry Rice also hurry back from ACL only to be injured in his first game back - I think it was a fractured patella if my memory serves me correctly.



ragempt -> Re: "Releasing" a pt after ACL rehab? (June 1, 2007 6:36:00 AM)

im glad were all on the same page. i dont think we helped ken at all though



orthotherapist -> Re: "Releasing" a pt after ACL rehab? (June 1, 2007 8:11:00 AM)

Ken,

What were the reults of the functional tests? What tests did you do?



garyd -> Re: "Releasing" a pt after ACL rehab? (June 1, 2007 9:19:00 AM)

I would check with the surgeon to see if that is the case. I do not think that is unrealistic at all. PT's generally spend more time with these patients after surgery and are likely as good or better able to determine how the individual is tolerating various sport like movements (both quality and quantity). The 5 minutes that the surgeon spend at follow-up is usually focused on the stability of the graft, any other issues pertaining to patellar tendon (harvest site) meniscus type issues among others.

Best way to proceed in my opinion is to contact the MD and give a good detailed report of ROM strength and functional movement tests (% of difference vs. contralateral side) quality of deceleration mechanics both double leg and single leg in multiplane. TOlerance with pivoting, twisting, cutting at various speeds. Following this report, you can then provide your opinion as to return to sport. Likely the MD will say that it is your call or will want to see the patient to make that call.

As for my setting, it is generally left up to the PT's and based on a variety of factors. ROM, post activity swelling, functional scores as compared to opposite side, sometimes isokinetic test scores, qualtiy of deceleration mechanics, cutting twisting. I will usually "release" them to short portions of practice, scheduled rest breaks every 5-10 minutes so the athlete can assess the knees response to activities and prevent fatigue related risks. Each week, increasing as based on tolerance of previous.

Gary



Rwantz -> Re: "Releasing" a pt after ACL rehab? (June 1, 2007 7:44:00 PM)

Athletic trainers routinely make the decision to return to sport. It requires a clear understanding of the sport and it's demands, as well as the biomechanics. Is the ACL strong? Is the hamstring stong and is the quad back? Do they have appropriate proprioception? Are they safe? This is best determined by observing the athlete doing functional activities.
Granted a single leg hop for distance is fine, but is it going to give information how they are cutting and running?



jma -> Re: "Releasing" a pt after ACL rehab? (June 3, 2007 7:19:00 AM)

Here's a nice read on an article from JOSPT. Perhaps it can guide you in the right direction:

"J Orthop Sports Phys Ther. 2006 Jun;36(6):385-402.

Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase.Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE.
Cincinnati Children's Hospital Research Foundation, Sports Medicine Biodynamics Center and Human Performance Laboratory, Cincinnati, OH 45229, USA. greg.myer@chmcc.org

Rehabilitation following anterior cruciate ligament (ACL) reconstruction has undergone a relatively rapid and global evolution over the past 25 years. However, there is an absence of standardized, objective criteria to accurately assess an athlete's ability to progress through the end stages of rehabilitation and safe return to sport. Return-to-sport rehabilitation, progressed by quantitatively measured functional goals, may improve the athlete's integration back into sport participation. The purpose of the following clinical commentary is to introduce an example of a criteria-driven algorithm for progression through return-to-sport rehabilitation following ACL reconstruction. Our criteria-based protocol incorporates a dynamic assessment of baseline limb strength, patient-reported outcomes, functional knee stability, bilateral limb symmetry with functional tasks, postural control, power, endurance, agility, and technique with sport-specific tasks. Although this algorithm has limitations, it serves as a foundation to expand future evidence-based evaluation and to foster critical investigation into the development of objective measures to accurately determine readiness to safely return to sport following injury.

PMID: 16776488 [PubMed - indexed for MEDLINE]"



Gator PT -> Re: "Releasing" a pt after ACL rehab? (June 20, 2007 1:43:00 PM)

I work with a group of ortho MDs that perform ACLs on D1 athletes. We have a criteria-based protocol that we follow as well as the convenience of walking upstairs into their office to give updates and ask advice. As a general rule, all of our athletes are told that it will be 6 months before returning to sport. We rehab for 12 weeks and then do KT arthometry and Biodex testing to give a profile of where they are at. If they have less than a 40 percent quad deficit then they begin a 4-6 week form running program (linear, no cutting or agilities). After that time, they begin a progressive agility program that takes them up to the 6 month mark. Hope that gives a different perspective.



ragempt -> Re: "Releasing" a pt after ACL rehab? (June 22, 2007 11:07:00 AM)

Gator whats your test for transverse movements? such as pivoting or quick rotations. You spoke of sagg. but not transverse movment preperation.



jwb -> RE: Re: "Releasing" a pt after ACL rehab? (July 7, 2007 1:46:31 AM)

As for our rehab department, we do a basic functional assessment usually at 6-8 weeks post-op.  If the patient passes that test, then we progress the rehab (including plyometrics and running) to pass an advanced functional assessement at 4-5 months post-op, then it's on to our acceleration program (if the patient participates in competitive athletics).  The testing time (basic) depends on whether or not they are a patellar tendon graft or hamstring graft and physician preference. If anything, the referring physician makes the decision. I don't much concern myself with isokinetic testing. It's a waste of time IMO!  I'm much more concerned if my patients can walk, run, or jump without compensation than some % score on an isokinetic machine. Conclusion, take into account the healing of the graft (hamstring slower than BTB), functional requirements of the patient and physician.  



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