ACL rehab

[awilson12]

Information overload… sorry in advance.

I have 5 post-op ACL-R patients on my case load right now spanning from about 2 weeks to 8 weeks out. I personally have no experience with taking someone through rehab start to finish, so I have been doing a lot of research and discussing this with colleagues. I have attached the articles different people have sent me that I have been working through for reference and also my notes with some nuggets that I took from each article. If anyone has any other good articles on this topic send them my way. Hope this is helpful!

Also some questions for those of you that have experience with this population-
1) What objective measures do you use throughout to track progress?
2) What are your go-to techniques to gain terminal knee extension and get the patient to utilize it during exercise and gait?
3) What does your HEP look like early on and as rehab progresses?
4) How often are you seeing these patients early on and as they progress through each stage of rehab?
5) Thoughts on open chain kinetic exercises?

ps- wouldn’t let me attach all of the articles so just put links to them in the PDF; let me know if you can’t access any of them and I’ll send them your way!

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[Eric Magrum]

Another question to help facilitate this discussion.

What criterion help you with decision making to “accelerate” ACLR rehab; what criterion help you with decision making to “delay” rehab – from the protocol guidelines from your specific surgeon?

Thanks for starting this discussion Anna

[awilson12]

From just comparing the folks I have now, I feel like I have a few characteristics that moving forward I can use to help gauge accelerating or delaying rehab:
– involvement of other ligament or meniscus repairs usually come with range of motion limitations and weight bearing precautions for a certain period of time, so respecting the surgeons protocol is one indication for delaying rehab; also from a clinical reasoning standpoint need to have an idea of what stresses these structures and may have to delay progression because of healing timeframe and the tissue’s ability to handle increased stress
– pre-surgery strength and range of motion: I have a guy in his 30s who has been a “coper” for years now until another injury mountain biking led him down the surgical pathway; I have found I am able to progress him much quicker because he had full return of strength and function prior to surgery, and was a highly active and strong dude all the way leading up to surgery; post-op day 1 he had the best quad contraction I had seen in this circumstance and I have been to progress him much quicker than any of my other post-op ACL-R patients
– patient affect: again going back to a specific patient example I have a teenager who on paper seems to be a good candidate for “accelerated” rehab (ACL-R only, good range of motion, good quad contraction early on, good overall fitness), but in some instances haven’t been able to progress as quickly because of his fear and lack of confidence in his abilities
– post-op “complications”: one of my patients had a meniscal repair as well as ACL-R so was limited from that standpoint, but even after the period of precautions she is an example of “delayed” rehab; gaining extension back has been a struggle for sure (likely part my inexperience but also HEP compliance) and this has in turn delayed strengthening, which is likely going to affect the overall time frame of return to higher level activities
– goals: if a patient is in no rush to get back to high level activities, then there might not be a need for progressing as quickly

Would love to hear others thoughts on this!

[helenrshep]

Information overload for sure but good for you for doing all this research! I couldn’t access the first article or the “rehab principles – 12 steps for success” article just fyi.

1) What objective measures do you use throughout to track progress?
Obviously range of motion, pain scale, and girth… I try to also use quad strength but without actually testing it early on – i.e. knee extension lag for SLR

2) What are your go-to techniques to gain terminal knee extension and get the patient to utilize it during exercise and gait?
All closed chain stuff – mini squats, TKE with band, step ups, light leg press

3) What does your HEP look like early on and as rehab progresses?
Depends on the MD protocol and my conversation with the doctor. Per Eric’s question, I base those decisions on the op report (complications, repairs other than just the ACL, graft site/type, etc), the patient presentation (high pain levels, psychosocial factors), and obviously objective measures and my clinical reasoning based on how I’m seeing them move in the clinic. I think quad sets and SLR are great but if they’re able to weight bear I prefer more functional closed chain exercises. I also try to integrate things that are specific to their goals – do they play a sport, lift, run, etc – helps with keeping their spirits up and prepares them early for return to sport. I also try to keep the whole kinetic chain in mind. Just like we were talking about with do a forward reach with a row for the shoulder instead of just an isolated row, I try to do that for the knee too. If we can keep their trunk engaged and make activities functional, even though they’re lower intensity for the actual knee, I think it helps return to sport faster.

4) How often are you seeing these patients early on and as they progress through each stage of rehab?
Depends on the patient! Those that I feel are pretty self sufficient, I don’t feel the need to have them come in and more basic exercises if they can do them at home. Depends on if I feel that I can add something new each time I see them (provide a different type of stimulus).

5) Thoughts on open chain kinetic exercises?
Meh… I don’t place a ton of value in them because they’re not very functional.

Final thought: I teach everyone lymphatic drainage techniques post op! There’s some good research on it actually making a difference.

[awilson12]

Kind of going off the lymphatic drainage point… Swelling is definitely something I have kind of neglected placing an importance on managing, but more recently have realized how much it makes a difference (especially for ext ROM and strength). I am not sure from an evidence based standpoint what the recommendation is for frequency of elevation, but I have been trying to do a better job at telling my patients they should try and elevate as much as possible immediately post-op and for 10-15 minutes every couple of hours if possible once they are a little further out. Thoughts or suggestions on this?

In terms of HEP- early on I feel like its a given that these lower level exercises need to be performed every day. Where I am unsure of frequency is later on when you are really able to challenge strength and stability to a greater degree. I guess my concern is that every day may be a bit much and lead to potential overuse injuries, so I have been experimenting with A day and B day type routines with off days to add some variability in focus. I just struggle between not wanting to under dose or over dose. Thoughts on this? What is your education like on what to do, how often, soreness, etc. during the mid to later stages?

[Eric Magrum]

“Final thought: I teach everyone lymphatic drainage techniques post op! There’s some good research on it actually making a difference.”

Please post that research, and describe what you mean by Post op lymphatic drainage techniques.

Thanks

[helenrshep]

Alright so… thanks for challenging my practice, Eric :) Several things have happened in the past week. I’ve spent a ridiculous amount of time trying to find the articles I thought I was remembering and asking a bunch of people to assist in the search but.. there’s not much on it. What I was remembering was a student presentation on manual lymph drainage, and my mentor saying she uses it and thought there was research to support it. What I meant by “techniques” is the “pet the cat” method of gently stroking the skin (distal to proximal) to encourage lymphatic circulation and blood flow. Most research I found was on it being helpful for breast cancer/managing lymphedema but not on general post op for other things. Also, most of the articles that I found that were supporting it, supported it more based on reduced pain and improved knee ROM rather than decreased swelling. I attached a systematic review that basically says we need more research. In conclusion, I still don’t really know what the answer is but I’m thinking this technique is no longer going to be one I implement…

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[Steven Lagasse]

Helen, thanks for this post. I appreciate your transparency. I have also struggled with this. In DPT school, we have three condensed years of learning, where we are exposed to an abundance of literature and ideas. Misconstruing certain evidence and/or remembering an idea incorrectly inevitably happens. I find posts like these worthwhile, as they work to keep us humble and in-tune with the information we say to our patients and colleagues. Thanks!

[awilson12]

Agreed with Eric. It seems like there may be some sort of lower level evidence to support this, and I would argue pain and range of motion are definitely desirable outcomes and potentially easier and more reliable to measure in the clinic vs swelling specifically. One of my CI’s used this on occasion for post-op TKA when swelling was really limiting progression of range of motion and strength, and he had some good success with post-treatment range of motion improvements.

[pbarrettcoleman]

I have never treated an ACL pt to date, so I would be in the same boat. I’m interested to see what other people’s ideas are. The one question I am willing to throw out a suggestion for is:

2) What are your go-to techniques to gain terminal knee extension and get the patient to utilize it during exercise and gait?

As far as manual therapy, I really like doing a posterior glide on the tibia (at about the tuberosity) while pulling upwards underneath their foot. While not matching the biomechanical rules (PA on tibia/AP on femur) to get knee extension, I have found it to be more tolerable for lots of populations and shows improvement post assess-treat-reassess. I remember someone also pointing out (probably Aaron) that since it isn’t stressing the anterior translation of the tibia, it may be something you could do earlier as it shouldn’t endanger the graft.

As far as return to gait, at my Brooks Rehab rotation in outpatient neuro there were a lot of nifty things we did to get people as within context as possible to retrain things.

We actually talked about this exercise before and how I need to show you in person. Where you need that TKE is middle midstance into beginning terminal stance. I get them in that position by putting their unaffected LE on a step to force weightbear them on the affected LE behind them. From this position, you can have the pt work on TKE resisted, calf raises while preventing that knee from bending, and more to have it as within context of the phase of gait where it needs to happen while providing them enough balance for them to focus on the motor control aspect.

Treadmill pushes, where the patient works on just pushing back on a treadmill that is off, is another way to facilitate what you want during the gait cycle. In that particular instance, you can be off to the side and facilitating what you want through hand placement.

If we ever remember, I’ll show you at the next VOMPTI course.

[awilson12]

Yes, for sure need to go over this! Thanks for the input. I definitely struggle with variation in my manual techniques from patient to patient and as one technique is no longer giving me the same benefit, so a posterior tibial mob with facilitation of extension distally is something new to give a shot.

[awilson12]

Some follow up on another resource- listened to a really awesome and interesting podcast today on my run that really challenges a lot of common PT practice with ACL rehab (or just in general) and provided some cool ideas of things to try in the clinic.
Complete Football Health Podcast: Neuroscience and Knee Injuries with Dustin Grooms

[Eric Magrum]

Great discussion guys.

Helen – great example of something that you do in the clinic daily assuming it has evidence behind it until forming a clinical question to actually look at the evidence.

That all being said – why would you throw it out as a treatment tool? Maybe understand the limitations of the evidence, but continue to assess the value as a treatment tool understanding which specific patient presentations, and your previous clinical successes/failure to make decisions about who, and when you use that technique.

That’s EBP…So don’t chuck it out because it doesn’t have level 1 evidence behind it; but critically reason through what/why/who understanding the limitations of the evidence.

Maybe write up a case with that clinical question you were unable to answer through a literature review.

Another couple of things to think about – what about graft selection? and graft healing rates? as a few more points to think about/discuss when to “accelerate/delay” rehab.

One more thing – We discuss motor learning principles throughout (isn’t that what we do – teach people how to move more efficiency), in the framework of some of the principles brought up by Anna.

Have a read – discuss some key take homes for this population, and everyone else who walks in your door…

Morning and caffeinated

Happy Turkey Day

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[awilson12]

Learning about motor learning in neuro class was interesting but always something I have struggled to find how to implement- it’s easier to just tell someone what to do than figure out a different way to get them to change their motor pattern for the desired outcome. Had actually just read this article earlier this week, and found it helpful as a reminder of these principles and to give some more specific examples of clinical application in this population that can also be used for every other patient to some degree.

Take home points:
– external cuing, meaningful and patient specific exercises and verbal cues/analogies, variability in practice order and environment/situation may further increase adaptation of movement patterns with improved carryover
– self-controlled learning is something I haven’t really thought about outside of the pediatric setting; makes sense to increase engagement and motivation for positive experiences to potentially enhance motor learning
– I need to challenge myself more to 1) implement these strategies and 2) identify appropriate times to progress feedback in this manor

[pbarrettcoleman]

I could talk all day about external cueing.

[Michael McMurray]

1) What objective measures do you use throughout to track progress?
-Quad strength (SLR – extensor lag/no lag), isometric strength (at end stages) and isokinetic (I don’t have the equipment though)
-gait kinematics (I think normalizing gait and monitoring it throughout, especially at the start of weightbearing is important)
-Functional: Squat (symmetry, depth, quality). I also read somewhere about being able to lunge with adding 1/2 body weight is a good indicator to begin running protocol. Other tests such as hop testing (single leg hop for distance, triple hop for distance, crossover hop for distance and 6-meter time hop. The general rule is to obtain an LSI ≥ 90% compared to the reference limb.)

Below is a nice article by Mike Reinold which discusses this and has some good references added in.

Return to Play Testing After ACL Reconstruction

2) What are your go-to techniques to gain terminal knee extension and get the patient to utilize it during exercise and gait?
I tend to perform manual techniques (anterior tibiofemoral glides, superior patellar glides, etc.) first.

Passive: The exercises I go to are heel/calf props, sitting in a chair with leg propped on another chair with a gap between and using either a weight or self-applied force (LLLD has worked well for my patients). More ac

Active: SLR(can do active assist with PT, use NMES, or even march up/ecc SLR), retrowalking, sled push/pull, TKE (standing/prone), SLS, Marching.

There was an Instagram post regarding knee extension posted by prehabguys that have videos and explanations on some of these.

3) What does your HEP look like early on and as rehab progresses?

Early – Understanding of weightbearing status, proper use of crutche(s) then get rid of them as early and safe as possible. Large emphasis on knee extension (more time the better, as long as they are doing it safely and to tolerance), quad strength, and gait kinematics. I also through some heel slides in to promote knee flexion. Scar mobilization, proper wrapping and cleaning of surgical site is also taught.

*One really cool external cue that I use during squats to help equal weight shifting is to have them perform a mini-squat while standing on a wobble board with a box under the affected side. If they are weightshfiting properly the wobble board should remain relatively fixed. If they are placing more weight on the uninvolved side, the wobbleboard will..well..wobble and they will be able to see and feel the difference. A mirror works well but is not as effective through my experience.

Mid – Same as early but focusing largely on functional strengthening (wall sits, squats, continued gait, glute strengthening, hamstring strengthening, etc.) Incorporating proprioception and kinesthetics into treatment by adding in some external perturbations and changing surfaces. I tend to try and make this phase a little more fun as the first phase is kind of boring for them. During wall sits or lateral walking I’ll give them a basketball or something to dribble (more so if they are a basketball player)

Late – I make it more functional : if they are an athlete or are trying to get back into running and are ready, I may give them hopping drills, running intervals, resisted lunges, squats, etc. For other patients I may give a faster walking exercise, stairs, squats, etc.

4) How often are you seeing these patients early on and as they progress through each stage of rehab?

I think the first 2-3 weeks are crucial and if able, I like to see them 3x a week to help get the ball rolling and then drop them down to 2x a week. Once they are late enough into the game to perform activities safely in the gym (if an athlete), I may do once a week to focus on higher level activities to make sure they can perform them safely outside of the clinic.

5) Thoughts on open chain kinetic exercises?

I think they are okay for isolated strengthening when safe to perform but I think they aren’t the most functional and should be used as an adjunct more so than a main intervention.

Graft selection

I think this is very important to go over with your patient to help educate them on the graft that was utilized. I observed an ACLR and was able to watch the surgeon create the hamstring graft and talk me through the steps. One of the golden nuggets that the surgeon told me was that patients who have a hamstring graft will often describe discomfort in the medial aspect of their affected leg which may be related to the hamstring harvesting process (they really have to go up high in the leg in order to get a good amount of tendon). Knowing that has really helped me when patients have told me about their inner thigh pain and I am able to explain to them that it may be related to the graft and that it is a normal sensation to feel post-op.

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