April Journal Club

[Justin Pretlow]

Pt case details:
Subjective: 19 yo female 10 months s/p R ACL-R hamstring autograft returning for Re-eval/continued PT for clearance for full participation in ROTC physical training. Pt last visit was December 2017 w plan to resume PT in Jan. At time of last visit she had progressed to running 1.5-2 miles on even surfaces without symptoms. Currently participating in all aspects of ROTC training except for running on uneven terrain – allowed to run on treadmill or indoor track instead. Performing DL and SL hopping drills w ROTC at slower speeds, no symptoms. Has not attempted any running outside on uneven ground over last 4 months. Not confident that she can handle trails, and is particularly worried about downhill running.
LEFS: 65/80
Pain NPRS: 0/10 current, 5/10 at worst
Location: 1. lateral right knee. 2. medial mid/distal hamstring
Aggs: 1: mild lateral knee pain occurs only when rounding curves on indoor track clockwise(tighter curves, no camber to track). 2. HS pain is brief, sharp, occurs inconsistently when stepping over obstacles(eg high step over a backpack in auditorium seating classroom).
Goals: Find out if she is cleared for running on uneven terrain(sidewalks and trails) during ROTC training.
Objective:
Functional Tests: DL squat: good form.
SL Stance: mild trunk sway Bilat
SL squat: dynamic valgus, trendelenberg bilat.
SL stepdown: dynamic valgus bilat, loss of balance.
DL/SL hop WNL nonpainful
Hip Swing test: limited hip ext bilat.

AROM/PROM: knee flex/ext symmetrical – nonpainful crepitus right knee endrange flexion
Joint mobility: patella mobility normal Bilat, Tib/fem med/lat/ant/post glide normal
Palp: No TTP
MMT: hip abduction 4/5 bilat. Prone Hamstring Right 4/5 at 90/60/30 deg. Mild medial HS pain inconsistently with resisted testing.
Flexibility: + Thomas test bilat
SL hop test:
SL triple hop:
SL crossover 3 hop:

My main concern and the patient’s only goal – can she handle running on uneven terrain without injuring herself.
PICO question: In a patient 10 months s/p ACL-R, which return to sport criteria are most important to meet in order to minimize risk of re-injury.

[Justin Pretlow]

Discussion questions:

Time was an issue during this patient visit. What other info would you like to have in considering if she can safely return to full participation?

I intentionally omitted the SL hopping numbers. Based on other objective findings, what would you expect to see with the 3 selected SL hop tests?

Pt compliance has been an ongoing issue over the course of treatment. Which exercises for hamstring strengthening might you prescribe or re-prescribe to address her hamstring weakness? Basically – which might give you the most bang for your buck if you needed to limit the number of HS exercises given?

[Justin Pretlow]

Article attached.

Hypothetically, if you were going to clear this patient for return to full participation in ROTC training, what criteria would be most important to you? What objective measurements do you weigh more heavily?
How do you present those to the patient as clear well-defined benchmarks required for “clearance” to full participation?

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[Justin Pretlow]

After sleeping on it, I think the article attached below is more appropriate for the journal club presentation. The JOSPT article I attached in previous post is interesting, but I will be presenting on the A. Gokeler, et al article attached below.

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[Tyler France]

Hey Justin,

What did her L hamstring strength and bilateral quad strength look like? The article showed better rates of returning to previous level of sports participation in those with higher leg symmetry index values, so I think it is important to compare the two sides before making a decision. I would want to see how she responds to single leg dynamic balance tasks with some speed component like she may encounter when running on uneven terrain (maybe small hops onto airex, etc). It would be hard to make a guess about her SL hop test performance without quad or hip extensor strength numbers. Based on the results of her functional screen, I’d imagine that she may experience some dynamic valgus and trendelenberg upon landing. I’d say a single leg exercise that emphasizes the hamstrings, but also requires hip abductor strengthening, such as an RDL, could be beneficial for the patient. However, that would be dissimilar and out of context with her primary functional goal, so you would have to decide whether she lacks the strength for the activity and may require something out of task before progressing into something more functional.

[Katie Long]

Hi Justin, good case, certainly relevant following the Running Medicine conference from last month. I agree with Tyler about wanting more information on her L hamstring and bilateral quad strength for consideration in a limb symmetry index. I also agree with Tyler on liking a single-limb RDL for this patient or a resisted runner’s ready at the pulleys or with a band.

As for her hop testing, I am willing to bet she still has lingering impairments in her hop testing. However, something that was emphasized quite heavily in the VCU return to sport course was the endurance component. I am a little more interested in what her hop testing would look like after she has been fatigued, as she would be at the end of an ROTC run over uneven ground. I am wondering if maybe assessing something like the VAIL Sport Test might be valuable, as it objectively assesses power, endurance, strength and movement quality? This article addresses the question of 90% being the cut off, from what I gathered from the VCU course, some are recommending 100% LSI in those participating in pivoting/cutting/competitive sports.

I have not yet had to make the “return to sport” decision in a patient s/p ACLr yet, but I think I would consider what LSI I would aim for and why (>90% in recreational athletes, 100% in competitive/cutting/pivoting sports). I would also consider the demands of their sport and consider the fatigue/endurance component when performing my objective assessments, as that is when their deficits are going to be the most pronounced.

Lastly, with patient compliance, I wonder about getting her more involved in her specific rehab goals. For example: when you can perform x-number of reps of this weight, you can progress to this functional task. Or when you can perform this hop testing distance, then you can return to running this milage. It might help her motivate herself to keep up with her exercises and take some of the decision making off of you.

[Justin Pretlow]

Thanks for the input –
My bad for omitting some of the objective measures that were WNL. MMT Quads 5/5 bilat at multiple angles. Left hamstring prone MMT 5/5 at 90/60/30 deg.
I had her demonstrate DL and SL line hops, 20 reps, fwd and lateral as a quick assessment before the single leg tests – slightly less precision with landing foot placement on right, but otherwise similar quality of movement.
Single Leg Hop for Distance (SLH) : Limb symmetry index(LSI) of 90%.
Triple Hop for Distance (TLH): LSI of 93%
Triple Hop Crossover for Distance: LSI of 93%
Quality of movement and control were not great – similar to SL squat, but the numbers surprised me. I thought her limb symmetry index might be much lower across those tests.

[Justin Pretlow]

Thanks Tyler – RDL’s are a good call – that was part of her HEP at some point but I don’t think she is still performing that specific exercise. Hopping to landing on airex or uneven surface is a good idea as well.

Katie- your point about testing when fatigued is a great reminder. Maybe I can have her run to the clinic before her next appointment so that I can retest her when fatigued.

As for the idea of aiming for 100% limb symmetry index scores for return to cutting/pivoting sports – this sounds like a very good idea to me. After reading the posted article and considering how LSI’s may overestimate a patient’s performance, it makes sense to me to elevate the bar.

I agree that I need to get her more involved in setting subgoals, or at least framing them as a positive challenge to be met, much like discussed at the conference on Thursday.

[Katie Long]

I can’t gain access to the article that references 100% LSI for cutting/pivoting sports, but its “Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward” by Dingenen et al., Sports Medicine, August 2017. It was an article cited in the VCU course for good return to sport criteria.

[Jennifer Boyle]

Without being repetitive I’d like to agree with a lot of the discussion going on. After the running med course I had major changes in the way I looked at return to run protocols for post op ACLs in how much time and effort goes into getting them back. I feel that for cases like this it is very important to give her all of the tools that she needs to be able to have a successful RTS, however, her compliance may be a hurdle – especially when getting her to commit to her rehab outside of the clinic. In this case I think having a discussion on more specific short term goals that lead up to her ultimate goal is worth while. If she feels like she is progressing and hitting smaller more achievable goals this may increase pt buy-in and increase her motivation. I also agree with the group with starting her hs strengthening out of context (RDL, Bridge walk out or Nordic hs curl) and progressing to something more meaningful once her strength increases. Maybe even go over the warm up and cool down activities we were shown at running med during the lab portion once she has met the appropriate goals.
As for her hop tests I’d anticipate decrease in hop distance as well as specific mechanical deficits such as what Tyler suggested.

[Sarah Bosserman]

Sounds like there are still some motor control issues. I think you said that you have watched her run before on even surfaces, but I would be interested to see if she had any issues (compliance, bounce, overstriding) that we can see and potentially show her on video. As for RTS, the quad and hamstring weakness would be a big part of the patient education I would give (maybe even show her how she looks with the hop tests) to emphasize the importance of her HEP. She also is still having pain when stepping over a backpack slowly so I would also want to talk with her about the potential difficulty with navigating uneven terrain (and risk of tripping) during trail runs once fatigued.

[Eric Magrum]

Where do biopsychosocial factors fit in here; especially with LSI > 90%.

How do you address?

Lots of evidence here to be aware of and clinically asses/address.

– Physiother Theory Pract. 2017 Feb;33(2):103-114.
Factors informing fear of reinjury after anterior cruciate ligament reconstruction.
Ross CA1, Clifford A2, Louw QA.

– Decision to Return to Sport After Anterior Cruciate Ligament Reconstruction, Part I: A Qualitative Investigation of Psychosocial Factors.
Burland JP, Toonstra J, Werner JL, Mattacola CG, Howell DM, Howard JS.
J Athl Train. 2018

– The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction.
Ardern CL, Österberg A, Tagesson S, Gauffin H, Webster KE, Kvist J.
Br J Sports Med. 2014 Dec;48(22):1613-9

[Justin Pretlow]

Per Sarah – Agreed that she still has some motor control deficits that become very evident during single leg testing. At previous visits, she has been able to improve her frontal plane knee motion with use of a mirror and extra cuing/education. I often used regressions of exercise with the mirror to show her how much better her control was if the exercise was more appropriate. I just didn’t succeed with getting much carry over. It often seemed like we had to review and teach the same concepts at each follow up.
I do think showing her ipad footage of some of the functional tests may be helpful to make sure she understands the significance of the deficits.

[Justin Pretlow]

Per Sarah – Agreed that she still has some motor control deficits that become very evident during single leg testing. At previous visits, she has been able to improve her frontal plane knee motion with use of a mirror and extra cuing/education. I often used regressions of exercise with the mirror to show her how much better her control was if the exercise was more appropriate. I just didn’t succeed with getting much carry over. It often seemed like we had to review and teach the same concepts at each follow up.
I do think showing her ipad footage of some of the functional tests may be helpful to make sure she understands the significance of the deficits.

[Justin Pretlow]

Considering biopsychosocial-
With this particular patient, I think confidence level and fear are playing a significant role. Evidenced by – she expressed that the running down hill during ROTC runs was the most concerning to her because she didn’t know if she was ready. Also evidenced by her dramatic pauses before SL hop testing as if she was about to jump off a high dive.
Ideally, I’d like to address this by providing her exercises and drills that build her confidence slowly over time.
I also think her maturity level has been an issue – meaning, we’ve had some good conversations about the rehab progress, timeline, appropriate progressions, quality over quantity. Afterwards – I’d think- that went well, maybe she finally gets it. Then at the next visit, she has done the exact opposite of what we discussed.

[Eric Magrum]

Kevin Wilke was and always has been big on perturbation training for all injuries – especially ACL (unexpected perturbation training especially).

Here’s a good resource from him.

Page 4 starts to talk about Kinesiophobia and return to sport, and proceeds into perturbation training.

Sorry videos not included.

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[Justin Pretlow]

Here are some additional details about the case that may help paint a better picture.
Initial Eval was mid Sept 2017 when patient came to UVA as a first year. She had surgery June 2017 followed by 2 months of PT at home – had progressed to some hopping drills with previous PT.
MOI: playing football and collided with another student – SEPT 2016
Ortho consult/MRI NOV 2016.
Pt opted to delay surgery until after her senior year of high school was over to not interfere with busy schedule/academics.
I treated her for 7 total visits from mid Sept to mid Dec. Able to run 2 mile timed run test for ROTC by mid November.

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