ACL Rehab (Full Version)

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pwrandall -> ACL Rehab (May 15, 2004 4:43:00 AM)

Hi All,
I've been reading your posts for months, but finally found myself in need of participating in the dialogue. I'm a new grad, working in out-patient ortho (~4 months). Recently, I turned a patellar tendon ACL surgery over to one of our PTA's with instructions to avoid open chain TKE or short arc quads to prevent excessive anterior sheer forces. Today, my boss (a 20 yr. veteran) chewed my ass out for taking away a tool the PTA's need to get decent quad contraction. Admittantly, this patient is still not performing a good quad set and has quad lag at 4 weeks into her treatment, but I was instructed both in school and during interships not to allow open chain knee extension in low flexion ranges in this type of patient. My suggestions were to pursue a program of isometics at 90 and 60 degrees, or knee extension from 90 to 45, but the boss says open chain TKE's and Short Arc Quads are appropriate and that I have done our patient a disservice. While I agree with the fact that this patient is not progressing as I would have liked, my training tells me that my approach is safer and appropriate. I'm frustrated and could use some help. Any suggestions out there? Thanks.

nari -> Re: ACL Rehab (May 15, 2004 8:25:00 AM)

PT Pete-

Eeeek - open chain quads on a post-surgical P/T repair? How long since surgery?
I would think your precautions are quite justified and I think closed chain exs are more effective and safer.
I would be interested in what the others think.


Bill Egan -> Re: ACL Rehab (May 15, 2004 11:42:00 AM)


High intensity e-stim to the quad has some good research to supports its use in post op ACL reconstruction. I utilize this until they achieve an independent quad set, and 0 lag with the SLR.

I believe there are some biomechanical studies that demonstrate the shear forces with the open chain TKE. Try to locate these through pubmed or ovid and discuss your findings with your boss.
Good luck


jma -> Re: ACL Rehab (May 15, 2004 4:00:00 PM)

E-stem with quad sets are good to use. If they have a brace, hopefully, without an extensor lag, they can do SLR's until they demonstrate good quad strength without it. Why? With the brace or with quad sets, the knee is practically at zero and will not harm the graft.


pwrandall -> Re: ACL Rehab (May 15, 2004 8:15:00 PM)

Thanks everyone...your suggestions are on track with the direction I would prefer to take with this patient. I suggested using e-stim with this patient last week, however, the supervising PT didn't feel that our equipment was appropriate for the job.

jma -> Re: ACL Rehab (May 15, 2004 9:16:00 PM)

Even if your supervisor says that there isn't a good e-stem machine around to use, you can still teach the patient to do quad sets effectively.

While an e-stem machine may have a ramp time and time for contraction and relaxation (5 sec and 10 seconds respectively). You can easily teach the patient to do this at home with an extended knee. Have them watch their quads contract and hold for the stated times for a certain number of sets/reps. The body can be trained to work like a machine and with just as good results. Its all in the training you teach them.

JMA -> Re: ACL Rehab (May 15, 2004 10:53:00 PM)

Tough situation, but you did the best thing. In the early phases, SAQ with heavier weight will indeed strain the graft, and probably irritate the PF joint as well!

I once had an ortho surgeon put SAQ on his protocol, and even told the patient to do these. Another ortho, who is a friend and well seasoned, told me just to do it with low weight and high reps, which won't bother the graft, and the physician won't know anything but the fact that we are doing SAQ.

Some physicians don't want ANY open chain quad exercises, even in the safer ranges of higher flexion. This becomes frustrating, as the closed chain program just does not isolate the quad like the open chain.

John Duffy, PT OCS

coloradojulie -> Re: ACL Rehab (May 16, 2004 1:25:00 AM)

There actually is a study that looked at graft strain using a variety of exercises. It would be great if you could find it...I'll see if I can dig it up in our files...the worst activity for increased graft strain was downhill or ramp walking. Open chain extension was the next worst...they were the worst by a considerable margin. These activities should be avoided. Period. Your superior is showing his age....and lack of literature review and updating...

We see alot of ACLS in the mountains...quad return can be a problem. Inhibition secondary to joint effusion is a possibility....make sure swelling is gone. I get people to do quad sets in two ways. One as the standard contract and hold, the other as a rapid on/off contraction...contract your muscle as quickly as you can (in extension, or less than 25 degrees of flexion)and release it quickly. This can create an almost subconcious contraction that can be built into stronger contractions. SLR should not be performed with a quads lag against gravity as that is adversely stressing the graft.

Priorities post op are first swelling, second extension range of motion and third quad function. The order shifts as you progress through rehab. I rarely stretch ACLs and almost never use e-stim.

I think that most patient's recovery is delayed by their feeling of fear and over protection of the knee. Helping your clients overcome the fear and moving forward can reduce the rehab time and allow them to advance more quickly. I recently told one of my ACLs clients to pretend he didn't just have knee surgery...I reminded him to be careful with certain activities, but suggested he could enhance his recovery by moving forward.

As a side note...our clinic just got a new ACL client from Steadman and he did a "healing response repair". It seems that if the tear occurs in either the proximal or distal 1/3 (I have to double check this...) that they can use microfracture to initiate an inflammatory reaction, and the marrow will grab the ligament and create an anchor. Apparently it has a 92% success rate. No graft. Any one heard of this? It is our first. The patient in non-weightbearing for 4 weeks and I haven't reviewed the surgeons protocols yet to see what the rest is.

Alex Brenner PT MPT OCS -> Re: ACL Rehab (May 16, 2004 7:10:00 AM)

[QUOTE]a new ACL client from Steadman and he did a "healing response repair". It seems that if the tear occurs in either the proximal or distal 1/3 (I have to double check this...) that they can use microfracture to initiate an inflammatory reaction, and the marrow will grab the ligament and create an anchor. Apparently it has a 92% success rate.[/QUOTE]Wow, I haven't read about this. I think if it were my knee I would go with the Bone Tendon Bone. I see good success with it and have seen many soldiers go back to jumping out of airplanes with this procedure with no problems. I guess it would have to depend on the patient and what level they want to return to.


Jon Newman -> Re: ACL Rehab (May 16, 2004 9:49:00 AM)

Hi Pete, a stategy I haven't seen offered yet is to have a conversation with the MD who did the surgery. I agree with Bill, do a thourough lit search to make sure you aren't missing something. Then give the MD a call, then talk to your boss. I think your quickly finding that there are few conditions in which everyone is on the same page. Good luck.


colores11 -> Re: ACL Rehab (May 16, 2004 11:32:00 AM)

Hi. The times to the ACL depends on the surgeon who operates the knee. I works with, for me, the best in Argentina. He doesnīt put a brace after the operation so the patient goes outside the hospital walking. This, for our job, is great,
Itīs accelerate a lot the times specially for knee ROM. Then we start the exercises in knee isometric extension (in all hip planes) and close chain. This for us is very important, we works a lot in close chain in differents plane and surfaces. And the most important thing is the PROPIOCEPTION. Itīs very importat to work this since the first stage of the treatment. Then the progression is normal, tha patient starts open chain cuad in the last 25° of extension.
We works strengthening at the same time we works propioception. Because the most important thing is the stability of the knee.
With this surgeon and this agressive tratment the patient is playning his/her sport in the 3-4 month.


rodgere -> Re: ACL Rehab (June 29, 2004 12:32:00 AM)

Effects of open versus closed kinetic chain training on knee laxity in the early period after anterior cruciate ligament reconstruction
Morrissey MC, Hudson ZL, Drechsler WI, Coutts FJ, Knight PR, King JB
Knee Surg Sports Traumatol Arthrosc 2000; 8(6): 343-348

here you go

Geert Jeuring -> Re: ACL Rehab (June 29, 2004 1:30:00 AM)

Apart from the question if the strain on the ACL is bigger in open chain exercise (it is as far as I know),there is also the question if hypertrophy is the same as funktional strength. Training is specific and the transfer from open chain exercise to close chain activitys of daily living seems rather far fetched. To train muscles seperate or isolated is stuff for body - builders and I gather we all know what kind of Body controll they have.



ericdmb -> Re: ACL Rehab (June 30, 2004 10:47:00 AM)

I just took Kevin Wilk's Complicated patient course and we talked about this issue, what the literature shows is that with no external resistance (SAQ with no ankle weight or bodyweight squat) the strain on the ACL is essentially equal. As we add resistance the strain goes up considerably in the OKC and more slowly in the CKC. Take home message is OKC is fine early on to establish quad control, but as the patient progresses and requires increased resistance it would be wise to proceed with CKC exercises. Most of the strain with the OKC quad execises is in terminal ext hence the use of 90-40 degree knee extensions. I believe the article he quoted was this one

KE Wilk, RF Escamilla, GS Fleisig, SW Barrentine, JR Andrews, and ML Boyd
A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises
Am. J. Sports Med., Jul 1996; 24: 518 - 527.

ZEAL -> Re: ACL Rehab (August 4, 2004 7:43:00 PM)

HI pete,
as far i know it right to avoid okc quad. ex.but SAQ's with 40 to 0 degree rom with simultaneous hams contraction can be started anywhere b/w 4 to 6 week.with careful emphasis on slow lowering of the wt.Also there is no harm in starting SLR's early as it reduces q atrophy.


FLAOrthoPT -> Re: ACL Rehab (August 4, 2004 10:39:00 PM)

forces on the tib/fem joint or the ACL, isn't that more like apples and oranges?

CarolinaPT -> Re: ACL Rehab (August 9, 2004 10:57:00 PM)

FLAOrthoPT, in the study, Wilk actually looked at translation of the tibia on the femur with the different types of exs.

spfister -> Re: ACL Rehab (August 12, 2004 12:39:00 PM)

Why is the debate always whether to do OKC OR CKC exercises? I think we need to come to the realization that both are needed. Research shows that OKC exercises are the only way to work a muscle at high percentages of the maximum isolated contraction. Specificity of training research tells us that CKC exercises must be included to replicate function. Estim literature tells us that it is effective in speeding the recovery of muscle strength. Why wouldn't you include all of these things in your rehab? Interestingly enough, the research quoted does not support the avoidance of OKC exercises. From the abstract of the Morrisey article "These results indicate that the great concern about the safety of OKC knee extensor training in the early period after ACLR surgery may not be well founded." And from the Wilk article "Perhaps this risk (ACL stress)occurs only during th early phases of rehabilitation, when graft strength is diminishing and fixation is a concern."
My two-cents.

Shill -> Re: ACL Rehab (August 12, 2004 2:03:00 PM)

Good Job. Well said.

FLAOrthoPT -> Re: ACL Rehab (August 12, 2004 4:04:00 PM)

go back to Nova!
ben galin, mpt, ocs

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