ACL Repair and Return To Play

By Peter Batz, SPT

ACL TEARS AND SPORTS 1,2

The occurrence of injury to the Anterior Cruciate Ligament (ACL) is reported to be as high as 46% of all knee ligament injuries in sports

Most anterior cruciate ligament (ACL) injuries occur by noncontact mechanisms

Anterior cruciate ligament injuries often occur during landing from a jump, decelerating, or pivoting on one foot while running.

MALE VS FEMALE ATHLETES 2

Female athletes who participate in jumping and pivoting sports are 4 to 6 times more likely to sustain an ACL injury than male athletes.

When women land, decelerate, and pivot, increased knee instability-due to four neuromuscular imbalances commonly observed in female athletes-contribute to the ACL injury mechanism:o 1. Ligament dominance (decreased dynamic neuromuscular control of the joint,

which is related to the knee abduction component of the injury mechanism)o 2. Quadriceps dominance (increased quadriceps recruitment and decreased

hamstring strength and recruitment, which is related to the extended knee position component of the injury mechanism)

o 3. Leg dominance (side-to-side differences in strength, flexibility, and coordination, which is related to the asymmetrical foot weighting component of the injury mechanism)

o 4. Core instability (increased trunk motion, which is related to the foot displaced away from the body center of mass component of the injury mechanism).

These imbalances cause female athletes to treat their knee joints as a ball and socket joint while male athletes knees behave more like a hinge joint.

TYPES OF ACL GRAFTS Autografts

o Patellar Tendono Hamstring Tendon

Allografts

PATELLAR TENDON GRAFTS 3

When selected, the central 1/3 of the patellar tendon is removed (~9-10mm long) with a block of bone at the sites of attachment on the kneecap and tibia.

Advantageso Length of the patellar tendon is about the same as the

ACLo Bone ends of the graft can be placed into the bone

where the ACL attaches• This allows for “bone to bone” healing

Disadvantages o Risk of patellar fracture or tendon tear following surgeryo Anterior knee pain is commonly reported post surgery

HAMSTRING TENDON GRAFTS 3

When used in ACL surgery, two of the tendons of the hamstring muscles are removed and bundled together to create new ACL

Advantageso Anterior knee pain is not present as it is commonly with

a patellar grafto Smaller incision to obtain the graft

Disadvantageso Fixation of this graft can be difficult as there are no bone

ends with this grafto Longer period of healing time is necessary (longer

recovery time)

ALLOGRAFTS (DONOR TISSUE) 3

Allografts come from a donor tissue, such as a cadaver.

More commonly used in recreational athletes than in competitive athletes.

Advantageso Using allografts allows for decreased operative timeo No need for multiple incisions to obtain the graft, leading to

decreased risk of infections Disadvantages

o Previously there was a risk of disease transmission when cadavers were not screened properly. • Still a risk today but much less likely

o Decreased strength of tissue compared to autografts

RETURN TO SOCCER 4

Rehab can be divided into 4 phaseso Protection and controlled ambulationo Controlled trainingo Intensive trainingo Return to play

PHASE 1 4

Usually last from 4-6 weeks Goals during this phase:

o Control pain/swellingo Improve ROMo Quadriceps activationo ADL activities

Functional Trainingo Strengthening noninvolved limbo Trunk and hip basic core stability exerciseso Cardiovascular (upper-body ergometer)

Aquatic Therapyo Gait trainingo Simple exercises (ROM, balance)

PHASE 2 4

Begins from 4-6 to 8-12 weeks Criteria for this phase:

o Minimal pain/swellingo Near full ROMo Good patellar mobilityo Sufficient quadriceps controlo Normal gait pattern

Goals for this phase:o Prepare basic soccer neuromuscular controlo Prepare the player for the more intense phase 3

Functional training to include:o Core stabilityo Balance trainingo Strengthening involved limb (open/closed chain), use of thera-bands for resistance.o Plyometricso Cardiovascular training (bike)o Flexibility

Aquatic Therapyo Progression toward water runningo Flexibility/ROMo Simulated basic soccer drills (heading the ball)

PHASE 2 4

PHASE 3 4

Begins at 8-12 to 16-24 weeks Criteria to enter this phase:

o No pain/swellingo Full ROMo Good neuromuscular control at knee, hip, and trunko Quadriceps and hamstring strength >75% of noninvolved limbo Good hop/jump and landing techniques

Goals for this phase:o Optimize soccer-specific neuromuscular controlo Prepare the player for return to team practice

Functional training should include:o Core stability/strengtheningo Strength training (body-machine exercise)o Cardiovascular soccer specific training (interval, bike)o Flexibilityo Water running: endurance training

PHASE 3 4

PHASE 3 4

PHASE 3 4

PHASE 4 4

Phase 4 consists of two partso Return to reduced soccer practiceo Return to full soccer practice

RETURN TO REDUCED SOCCER PRACTICE 4

Can begin at 16-24 weeks or later Criteria to start this phase:

o No pain/swellingo Symmetrical ROMo Optimal soccer-specific neuromuscular controlo Quadriceps and hamstring strength >85% of noninvolved limbo Hop index >80% of noninvolved limb

Goal for this phaseo Bring the player back to unrestricted team practice, with full

possession of his/her soccer skills and conditioning Functional training to be done:

o Core stability/strengtheningo Strength training (body machine exercises) focused on addressing

remaining deficitso Flexibility

RETURN TO FULL SOCCER PRACTICE 4

Same time frame Criteria for this phase:

o No pain/swellingo Symmetrical ROMo Optimal soccer-specific neuromuscular controlo Quadriceps and hamstring strength >95% of

noninvolved limbo Hop index >90% of noninvolved limbo Final preparation of the player for the needs and

demands of competitive soccer. Functional Training to include:

o Continuation of additional training in the form of soccer specific warm-ups.

TEST FOR ACL STABILITY

Hop Tests (4)o Single hop for distanceo 6-m timed hopo Triple hop for distanceo Crossover hop for distance

Y-Balance Test Star excursion test

SINGLE HOP FOR DISTANCE 5

For single leg hopping, stand on one foot with your toes behind a marked line on the floor.

Hop forward as far as possible, landing on the same foot from which you took off

Measure and record the distance you hopped in centimeterso Must maintain landing for a minimum of 2 seconds

Repeat the test a total of three times for both legs, recording the distance hopped each time

Results:o The expected values for the injured leg in the single hop test are

137cm for males and 121cm for females at 4 months post surger. At the 6 month mark, norms for the single hop test are 149 cm and 133 cm for males and females.

6-METER TIMED HOP 5 For single leg distance hopping, stand on one foot

with your 6 meter line extending out in front of you

Hop as quickly as you can on one foot until you reach the end of the 6 meters

Record the time it takes for you to hop 6 meters on one foot.

Results:o Expected times 4 months after surgery are 2.7 seconds

for males and 3.0 seconds for females. Six months post ACL surgery, the expected times are 2.4 seconds for males and 2.8 seconds for females.

TRIPLE HOP FOR DISTANCE 5

For straight line triple hopping, stand on one foot with your toes behind a marked line on the floor

Hop forward as far as possible for three consecutive hops

Measure and record the distance hopped in centimeters

Repeat the test three times for both legs, recording distance hopped each time

Results:o The norms at the 4 month post-op mark are 401cm for

males and 343cm for females. The expected norms at the 6-month point after surgery are 420cm for males and 363cm for females.

CROSSOVER HOP FOR DISTANCE 5

Mark a line on the floor about 6 meters long Stand on one foot and hop forward and over the

line Continue hopping in a zig-zag pattern over the

line for three hops Record the distance hopped in centimeters for the

injured and uninjured leg. Results:

o Expected values at 4 months post-op are 358cm for males and 305cm for females. At the 6 month point it is 377cm for males and 337cm for females.

LIMB SYMMETRY INDEX 6

Used to determine abnormality between surgical and non surgical leg post ACL repair.

Distance hops:o (mean involved leg/mean uninvolved leg) x 100% = LSI

Timed hops:o (mean uninvolved leg/mean involved leg) x 100% = LSI

Abnormal LSI = < 85%

HOP TESTS IN ACTION https://www.youtube.com/watch?v=iNzGCet0Ll0

Y-BALANCE TEST 7 Study of Y-balance test was performed on 184

collegiate athletes It was determined that an anterior reach

asymmetry of > 4cm between legs was the optimal cut-point for predicting injuryo (Sensitivity=59%; Specificity=72%)

This study suggested that the composite score was not related to injury risko It was suggested that this was due to their needing to be

cut off scores for athletes need to be based on the sport which they play

Y-BALANCE TEST

STAR EXCURSION TEST 1

Used to assess dynamic postural control Test is shown to have high inter and intra-rater

reliability. Study by Herington et al. found that in ACL

deficient patients both their injured and uninjured legs showed deficits when compared to the control group.

It was thought that this may be due to a postural control deficit which may make ACL deficient patients more predisposed to ACL injury or re-injury.

STAR EXCURSION TEST

QUESTIONS?

References 1. Herrington L, Hatcher J, Hatcher A, McNicholas M. A comparison of star excursion balance test

reach distances between ACL deficient patients and asymptomatic controls. The Knee. 2009;16(2):149-52. http://search.proquest.com/docview/1034985361?accountid=12846. doi: http://dx.doi.org/10.1016/j.knee.2008.10.004.

2. Hewett TE, PhD. Predisposition to ACL injuries in female athletes versus male athletes. Orthopedics (Online). 2008;31(1):26-8. Http://search.proquest.com/docview/220381547?accountid=12846.

3. ACL Surgery Graft Options. Available at: http://orthopedics.about.com/cs/aclrepain/a/aclgrafts.htm. Accessed April 25, 2015.

4. Bizzini, Mario, Hancock D, Impellizzeri F. Suggestions From the Field for Return to Sports Participation Following Anterior Cruciate Ligament Reconstruction: Soccer. J Orthop Sports Phys Ther. 2012: 42(4): 304-312. http://www.jospt.org/doi/pdf/10.2519/jospt.2012.4005

5. Sears B. Single Leg Hop Testing. Available at: http://physicaltherapy.about.com/od/postoperativeexercises/a/The-Single-Leg-Hop-Test.htm. Accessed April 20, 2015.

6. Braegelmann B, Corbo J, and Himmerick R. Lower Extremity Functional Testing: Is my Athlete Ready to Return to Sport? Available at: http://c.ymcdn.com/sites/www.mnapta.org/resource/resmgr/imported/Athlete 1. Accessed April 20, 2015.

7. Smith CA, Chimera NJ, Warren M. Association of Y Balance Test Reach Asymmetry and Injury in Division I Athletes. Med Sci Sports Exerc. 2014. http://www.ybalancetest.com/y-balance-test-anterior-reach-asymmetry-predicts-injury-collegiate-athletes/