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Asymmetrical Lower extremity loading post acl reconstruction: causes and long term implications:

Asymmetrical Lower extremity loading post acl reconstruction: causes and long term implications Libby Bergman PT, DPT, MTC

History and Interview:

History and Interview R ACL tear 9/2004 non impact playing soccer, cutting. Cadaver graft 3/2011 stepping down from seawall doing plyometrics and dropped phone. Reached forward for the phone and noted severe posterior lateral knee pain 1 year rehab after reinjury ~20 episodes of giving way with stairs and noted medial lateral laxity sensation climbing stairs

History and Interview:

History and Interview 4/2012 laying on side with knee bent and knee caught and locked at ~30-45 degrees Had coworker distract her knee, consulted orthopedic surgeon MRI inconclusive Insertions appear intact but unable to evaluate midsubstance Potential arthrofibrosis identified with hypointensity of Hoffa’s fat pad Abnormality of medial meniscus ACL revision scheduled 5/23/12

Pre-Surgical Examination:

Pre-Surgical Examination Presurgical Examination R popliteal bursa effusion noted with no other signs of active inflammation A/PROM Knee Flexion: R 145˚/150˚*, L 148˚/154˚ * pain at medial incision site, swelling end feel Knee Extension: R +2˚/8˚, L +4˚/8˚ Hip PROM IR (R) 8˚* anterior hip pain Hip PROM IR (L) 16˚ Passive Accessory 2/6 Inferior patellar glide, swelling end feel 4/6 PA tibiofemoral glide, swelling end feel 2/6 AP tibiofemoral glide

Pre-Surgical Examination:

Pre-Surgical Examination MMT Glute med R: 3+/5 L: 4/5 Glute med posterior fibers R: 3+/5 L: 3+/5 Glute max R: 4-/5 L: 4/5 Hip Internal rotators 4-/5 bilateral Hip External rotators 4/5 bilateral Special Tests Positive Lachman’s Positive Anterior Drawer Palpation for tenderness Tender over medial joint line LEFS 55/80 IKDC Pain 0/10 Functional video analysis of star excursion and step down testing http://youtu.be/DRRghvV8nD8

Clinical Impression:

Clinical Impression Grade III ACL tear, tibiofemoral effusion, patellofemoral effusion Noncoper Could not return to PLOF Experienced frequent giving way upon attempting to return to PLOF 1 Prognosis: Guarded

Surgical Intervention: Medial meniscal debridement:

Surgical Intervention: Medial meniscal debridement

Surgical Intervention: Semitendinosis autograft:

Surgical Intervention: Semitendinosis autograft

Post Surgical Examination:

Post Surgical Examination Palpation for Condition Effusion, edema, ecchymosis at HS graft AROM (R) Extension -3˚ Flexion 90˚ PROM (R) Extension -2˚ Flexion 96˚ Patellar mobs hypomobile all directions swelling endfeel

Post Surgical Exam:

Post Surgical Exam Palpation for tenderness Positive between gastroc heads – reproduces anterior knee pain with quad set Gait WBAT, B axillary crutches with brace

Impairments, Functional Limitations and Goals:

Impairments, Functional Limitations and Goals Decreased ROM with effusion Patellar mobililty Gait dysfunction Quad inhibition Long term goal: Return to running, weight lifting, skiing and general overall health of her knee and kinetic chain

Intervention: Early Postoperative Goals:

Intervention: Early Postoperative Goals Restore Normal ROM Flexion AAROM as tolerated Early restoration of full passive extension Passive extension stretching: low load, long duration to 0˚ Gentle gastroc stretching in long sitting Normalize Gait B axillary crutches, brace unlocked, WBAT Normal Patellar mobility Patellar mobilization

Intervention: Early Postoperative Phase:

Intervention: Early Postoperative Phase Reduce Inflammation Retrograde massage at popliteal bursa HVPC with CP Voluntary quad control Russian NMES: quad setting to 0˚ as tolerated; SLR cues for no lag Early proprioceptive training Weight shifting AP  lateral  diagonals in parallel bars with brace

Intervention: Intermediate Postoperative Phase:

Intervention: Intermediate Postoperative Phase Patellar and Scar mobilization NMES progression 4 way SLR Focus on fatigue, no lag Passive extension stretching Progressed to 4x10-15 minutes/day. Added low load weight to passive extension stretch Gait Progression Progression to treadmill gait with cues for mobilization http://youtu.be/Efe_udPkBEc Closed chain progression: controlled loading Squats in parallel bars with heavy cues for weight bearing, core control, hip control Light resistance shuttle bilateral with cues for frontal plane knee control, foot compensation Progression to single leg eccentric lowers on the shuttle Step up progression with cues for level pelvis Progression to balance on unstable surfaces bilateral

Intervention Weeks 4-9: Late Postoperative Phase :

Intervention Weeks 4-9: Late Postoperative Phase GOALS: Restoring full flexion and extension ROM 11 Addressing entire kinetic chain with functional movement core, hip, knee, foot/ankle Heavy visual, verbal and tactile feedback Movement symmetry without compensation Quad hypertrophy Frontal plane control Perturbation training 11

Intervention Weeks 4-9: Late Postoperative Phase :

Intervention Weeks 4-9: Late Postoperative Phase Asymmetrical movement: Compensatory Strategies of Unloading 4 Shift weight to uninvolved lower extremity Shift force to hip and ankle 10 Altered movement strategies decrease stimulus for quad hypertrophy, perpetuate movement dysfunction which caused the injury http://youtu.be/sbiGuI-3r2g http://youtu.be/DRRghvV8nD8

Discussion:

Discussion Asymmetrical loading strategies lead to 4,12 : Risk of reinjury of surgical limb Risk of injury to contralateral limb Posttraumatic OA Asymmetrical loading in early phases that is unrecognized sets up risk for further cartilage degeneration with higher forces in advanced phases of ACL rehabilitation

Discussion:

Discussion Mechanisms of Asymmetrical Loading: Quad inhibition Arthrogenic inhibition 9 Effusion- Amount does not correlate to level of inhibition Inflammatory biomarkers Loss of proprioception from native ACL 5 History of laxity leading to learned neuromuscular dysfunction 5,8

Discussion:

Discussion Long Term Asymmetrical Loading Post ACLR: Side to side differences in vertical ground reaction force and loading rate persist up to 2 years 5 Knee extensor isokinetic limb symmetry 90% at 24-49 months 5 Load uninvolved side significantly more during squatting12-15 months post op 5 Decrease knee extensor torque, greater hip and ankle extensor torque with squat up to one year 6

Discussion:

Discussion Recurrence Rate 7 12% recurrence 5 years post op 27% in 10 years Predictive Variables of Reinjury (drop vertical jump) 5 1. Transverse plane moment impulse at the hip 2. Frontal plane knee ROM during landing 3. Side-to-side differences in sagittal plane knee moment at initial contact 4. Deficits in postural stability Collectively high sensitivity and specificity (0.92/0.88) Hip Rotation moment impulse (0.78 sensitivity and 0.81 specificity)

Thank you:

Thank you Dr. Eric Chaconas PT, DPT, MTC, FAAOMPT Summer Price SPT

References:

References 1. Kaplan, Y. Identifying individuals with an anterior cruciate ligament-deficient knee as copers and non- copers : a narrative literature review. J Orthop Sports Phys Ther . 2011;41:758-766. 2. Kvist , J. Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Med 2004;34(4):269-280. 3. Adam D, Logerstedt D, Hunter-Giordano A, Axe M, Snyder- Mackler L. Current Concepts for Anterior Cruciate Ligament Reconstruction: A Criterion Based Rehabilitation Progression. J Orthop Sports Phys Ther . 2012;42(7): 601-614. 4. Chmielewski TL, Wilk KE, Snyder- Mackler L. Changes in weight-bearing following injury or surgical reconstruction of the ACL: relationship to quadriceps strength and function. Gait and Posture. 2002;16:87-95. 5. Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, Hewett TE. Biomechanical Measures During Landing and Postural Stability Predict Second Anterior Cruciate Ligament Injury After Anterior Cruciate Ligament Reconstruction and Return to Sport. Am J Sports Med. 2010; 38(10):1968-1978. 6. Salem GJ, Salinas R, Harding V. Bilateral Kinematic and Kinetic Analysis of the Squat Exercise After Anterior Cruciate Ligament Reconstruction. Arch Phys Med Rehabil . 2003; 84:1211-1216. 7. Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy . 2005;21(8):948-957. 8. Snyder- Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. J Bone and Joint Surg . 1995; 77-A(8): 1166-1173. 9. Lynch AD, Logerstedt DS, Axe MJ, Snyder- Mackler L. Quadriceps activation failure after anterior cruciate ligament rupture is not mediated by knee joint effusion. J Orthop Sports Phys Ther . 2012; 42(6):502-510. 10. Ernst GP, Saliba E., Diduch DR, Hurwitz SR, Ball DW. Lower-Extremity Compensations Following Anterior Cruciate Ligament Reconstruction. Phys Ther . 2000;80(3):251-260. 11. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Recent advances in the rehabilitation of anterior cruciate ligament injuries. J Orthop Sports Phys Ther . 2012;42(3):153-171. 12. Chmielewski TL. Asymmertical lower extremity loading after ACL reconstruction: more than meets the eye. J orthop Sports Phys Ther . 2011;41(6):374-376.

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