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ARTS

ACL Return To Sports

City Baths Spinal and Sports Medicine Clinic Ground Floor, 420 Swanston Street

Melbourne 3000 T: 03 9639 2286

Melbourne Sports and Aquatic Centre Level 1, Melbourne Sports & Aquatic Centre

Aughtie Drive, Albert Park 3206 T: 0417 371 657

Victoria Harbour Medical Centre 2/3, 850 Collins Street

Docklands 3008 T: 03 9629 1414

W: www.trewrehab.com

Facebook: www.facebook.com/trewrehab YouTube: https://www.youtube.com/channel/UC-‐NKm1ayqWYiPmKttK8IpyQ

Trew Rehab, in conjunction with The Knee Clinic (The City Baths Spinal and Sports Medicine Clinic) has developed this evidence based ACL Reconstruction Rehabilitation Program. Timeframes are soft tissue healing dependent and individual’s progress based on function, allowing a safer return to vocational and sports related activities as soon as the patient is ready. The following is a criteria based 4 phase rehabilitation program. In order to progress to the next phase, the patient must achieve the goals outlined at the end of each phase. The patient will be encouraged towards self-‐managing their rehabilitation with regular reviews with their therapist to ensure they are progressing accordingly and performing the set exercises with correct technique. It will be possible to complete most of the exercise programs at home; however access to gym facilities may facilitate and improve compliance. Individual variations will occur depending on surgical technique, age, pre-‐injury health status, rehab compliance, tissue quality and injury severity. The following factors will be taken into consideration:

• Teenage patients may be progressed more slowly due to their physiological immaturity and an apparent higher risk of re-‐injury (Lind, Menhert & Pederson, 2012)

• If a meniscus repair is performed in conjunction with the ACL reconstruction, other restrictions including the use of a post op brace may be required and a slower progression initially is often necessary

• Secondary complications of patello-‐femoral pain, hamstring strain, neural pain, persisting swelling, etc.

Broad goals of the program are:

• Controlled loading of graft/joint • Addressing deficits of muscle activation and strength throughout rehabilitation • Reduce biomechanical risk factors such as:

o Dynamic valgus during impact on landing, walking, squatting o Leg strength imbalance o Lumbo-‐pelvic control o Quadriceps/hamstring imbalance

• Ensure dynamic stability of the trunk, pelvis, hips, knees and ankles • Build the patients confidence in their ability to safely return to their chosen activity/sport

We will achieve these goals through:

• Targeted individual muscle activation and strengthening • Regular testing and progression of functional exercises • Neuromuscular and proprioceptive training • Training and education regarding proper landing and cutting techniques

There are a total of four phases of rehabilitation to complete before a return to competition can be considered. Estimated time frames are not outlined as not all patients will progress equally as there may be complicating factors that may hinder or accelerate rehabilitation. Progression will be based on the achievement of functional goals. Below are the criteria for progression through the various phases of our protocol.

Prehab

Aim: • Decrease swelling with use of Rest Ice Compression Elevation • Achieve full knee extension with heel strike with every step when walking • Achieve an excellent quad set. A good quad set is achieved when you can see the kneecap move

up and down when the quad is contracted and relaxed. • Achieve good kneecap mobility. A kneecap that becomes stiff will limit your ability to bend and

straighten your knee as much as you would like • Progress off crutches once good quadriceps/knee control is achieved • Educate the athlete about what is expected of them from their rehabilitation program with or

without surgery

As the inflammation, swelling, and knee ROM are improved, neuromuscular re-‐training is initiated. Patients are taught leg control activities like quad sets and leg raises, and instructed how to walk with a normal gait pattern. Patients may resume low impact activities and weight training if they desire, but these activities are not required pre-‐operatively. Both single leg hop and unilateral leg press are measured preoperatively and used as post-‐operative strength goals as well. The strength measures obtained on the uninjured knee are utilised as a post-‐operative goal for both knees. Knee function is measured with the International Knee Documentation Committee (IKDC), Tegner activity grading scale, and the Tampa scale for kinesiophobia subjective outcome instruments. Each patient is given these instruments pre-‐operatively and at regular intervals post-‐operatively. The IKDC is used as a hurdle requirement for progression to the following phase, while the Tegner and Tampa are collected for research into the ability of athletes to return to sport following ACL rehabilitation.

Phase 1: Acute Post-‐Operative Care

After the operation The main aim of the initial period following surgery is to keep swelling and pain to a minimum and to maintain some muscle tone and flexibility. This can be achieved in the following ways:

-‐ Apply ice to the knee for 10 to 15 minutes after each set of exercises, i.e. 3-‐4 times per day. When applying ice, keep the leg in elevation. Sitting with your leg up on a stool is not adequate; you need to have the whole leg above the level of your heart. For example, lie on floor/bed with foot up on chair/pillows etc.

-‐ You will be advised to wear a compression bandage during the day -‐ The amount and level of exercise will be determined by swelling and pain

Frequency of Exercises 3-‐4 times per day, unless otherwise indicated. Aim:

• Effusion/swelling control • Muscle activation • Restore range of movement • Gait re-‐education • Quadriceps control • Progressive limb loading

Full extension is obtained by doing the following exercises: 1) Passive knee extension

• Sit in a chair and place your heel on the edge of a stool or chair • Relax the thigh muscles • Let the knee sag under its own weight until maximum extension is achieved • Then contract quads to accentuate stretch

2) Heel Props • Place the heel on a rolled towel making sure the heel is propped high enough to lift the thigh

off the table • Allow the leg to relax into extension • 3 -‐ 4 times a day for 10 -‐ 15 minutes at a time

3) Prone hang exercise • Lie face down on a table with the legs hanging off the edge of the table • Allow the legs to sag into full extension

Bending (Flexion) is obtained by doing the following exercises: 1) Passive knee bend

• Sit on the edge of a table and let the knee bend under the influence of gravity • You may support with your other leg

2) Wall slides are used to further increase bending • Lie on the back with the involved foot on the wall and allow the foot to slide down the wall by

bending the knee. Use other leg to apply pressure downward if you feel comfortable 3) Heel slides are used to gain final degrees of flexion

• Pull the heel toward the buttocks, flexing the knee. Hold for 5 seconds • Straighten the leg by sliding the heel downward and hold for 5 seconds. In later stages of

rehabilitation, do heel slides by grasping the leg with both hands and pulling the heel toward the buttocks

Outcome Measures and Goals for Progression to Phase 2:

Measure Test description & Reference Goal -‐> Purpose/ reasoning

Knee Flexion Athlete is supine, goniometer used on the following landmarks: greater trochanter, lateral femoral condyle, and the lateral malleolus (Norkin & White 1995)

>90˚ To enable cycling

Effusion Stroke test (Sturgill et al, 2009). Zero: No wave produced on downstroke Trace: Small wave on medial side with downstroke 1+: Large bulge on medial side with downstroke 2+: Effusion spontaneously returns to medial side after upstroke 3+: So much fluid that it is not possible to move the effusion out of the medial aspect of the knee

Zero to 1+ To minimise quadriceps inhibition

Knee Extension Athlete is supine, goniometer used on the following landmarks: greater trochanter, lateral femoral condyle, and the lateral malleolus (Norkin & White 1995)

0˚ To restore full ROM

Quadriceps Lag Test

With the athlete seated, the examiner lifts the heel until the relaxed knee is in full extension. The subject is required to maintain full extension for 5 seconds once the examiner removes support (Stillman, BC. 2004).

0˚ lag To monitor quadriceps control and knee stability

Functional Score IKDC Subjective Knee Evaluation Form (Irrgang et al, 2001)

Score >40

Bilateral Squat to Parallel

Subject stands on 2 floor scales, squats to 60-‐90˚ knee flexion 5 times (Nietzel et al, 2002)

>95% equal limb loading Even symmetrical weight bearing

Standing Hamstring Activation

Subject flexes the knee in standing to 90˚ (Seto et al. 1988) Prone knee bend without resistance

>20 reps Encourage knee flexion range and hamstring activation

Short Lever Bridge Subject raises pelvis off ground 10 times while lying supine with knees bent to 90˚

No knee valgus Dynamic hip stability

Calf Raises Standing on the edge of a step, the subject performs full range unilateral heel raises to fatigue. 1 repetition every 2 seconds. (Schlumberger et al, 2002)

20+, no greater than 5 rep difference between limbs Maintain calf strength

Unipedal Stance Test

Subject stands on one leg with other leg raised and arms crossed over the chest. The assessor uses a stopwatch to time how long stance is maintained on one leg with a) eyes open, and b) eyes closed. Time ends when; -‐ Arms are used (uncrossed) -‐ Use of the raised foot (touches down or other leg) -‐ Movement of the stance foot -‐ 45 secs has elapsed (maximum time) -‐ Eyes opened on eyes closed trials (Springer et al, 2007)

-‐ A (eyes open) 43 seconds

-‐ B (eyes closed) 9 seconds

Normative data for 18-‐39 year olds Test for balance

Phase 2: Strength and Neuromuscular Control

Aim:

• Muscle strengthening • Work capacity training • Cardiovascular training • Single leg balance • Prevent secondary injury PFPS/patella tendonitis/hamstring injury • Maintain upper extremity and core conditioning • Promote proper movement mechanics and symmetrical movement • Improve confidence • Eccentric and concentric control • Gait re-‐education • Dynamic movement control

ACL reconstruction patients at 2 years following surgery demonstrate significantly weaker quadriceps strength, but more resistance to fatigue compared to their unaffected limb (Snyder at al, 1993). In spite of an apparent resistance to fatigue, ACL-‐R patients demonstrate significant declines in stability and power after fatiguing exercise (Augustsson et al, 2006; Gustavsson et al, 2006). One possible explanation according to Kuenze et al (2013), is that patients with a decreased ability to generate knee-‐extension torque begin to develop poor or dysfunctional movement and muscle activation patterns. To prevent these long-‐term strength deficits from occurring, we emphasise progressive limb loading to develop muscular strength and prevent compensation patterns from developing through carefully monitoring technique and prescribing neuromuscular and specific muscle activation exercises.

Sample Exercise Session Phase 2 Home Program

Exercise Sets/duration Resistance Reps Recovery WARM UP Cross-‐trainer/ Treadmill/ Bike 5 mins 90 secs Walking lunges progression 60m total 10 30 secs Mini-‐tramp jog 3 mins 90 secs SUPER STRENGTH SET (see appendix A)

Single Leg (SL) VMO squeeze and hold 1 30 90 secs SL arabesque 3 15 SL lateral step down 3 20 90 secs SL hamstring Fit Ball (FB) hip extension 3 15 90 secs SL wall slides 3 15 90 secs SL Spanish squats 3 10 Bosu/FB side ups 3 15 Supine fit ball twists 3 15 Bilateral jump onto box (30 cm) 2 -‐ 6 120 secs Lateral mini-‐hurdle hops (both legs) 15 secs -‐ 4 120 secs Mini-‐tramp bounce and hold (5 secs) 2 -‐ 6/leg 60 secs Single-‐leg balance (dura disc/mini tramp/bosu)

10 secs -‐ 10 120 secs

COOL DOWN Stationary cycle 10 mins


Measure Test Description & Reference Goal -‐> Purpose/ reasoning Single Leg Squat Maintain single leg stance on deformable

pad at 5, 45 and 90˚ (Herrington et al. 2013)

10 second hold at each angle of knee flexion. No postural sway. Test for static stability of kinetic chain

Eccentric Step Test

The subject stands on a 20 cm step on one leg and has 30 seconds to reach forward and touch the ground lightly with their heel and return to full knee extension. Each limb is tested (Loudon et al, 2002)

No knee valgus <5 difference in scores Tests eccentric quad control and dynamic hip control

Modified Bilateral Drop Jump Test

The subject drops off a 10 cm box then performs a controlled jump after landing (Kristianslund & Krosshaug, 2013)

Landing even weight distribution, knee flexion >30˚, no knee valgus. Screens for dynamic knee valgus, hip stability and eccentric quads control during landing

Star Excursion Balance Test (SEBT)

The subject must maintain a base of support on one leg, while using the other leg to reach as far as possible in 3 different directions. A composite score is obtained for each leg from which the limb symmetry index (LSI) is then calculated (Herrington et al, 2009)

-‐ Symmetrical anterior and posterior reach directions

-‐ Medial and lateral reach distance less than 10% difference in LSI

-‐ Composite score (total anterior, posterior, medial and lateral) has less than 10% difference in LSI

Multi-‐directional balance Prone Hang Test Subject lies prone on the treatment table

with the lower legs off the end of the bed allowing passive extension. Heel height difference is measured (Sachs et al, 1989)

Equal to opposite side Limb symmetry, full extension maintained

Knee Flexion Athlete is supine, goniometer used on the following landmarks: greater trochanter, lateral femoral condyle, and the lateral malleolus (Norkin & White 1995)

Within 10˚ to opposite side To enable successful landing strategies

Modified Single Leg Bridges

Subject supine with one foot on 30cm box, hip flexed to 90˚, raising pelvis to neutral until fatigue (Zazulak et al, 2007)

20+, no greater than 5 rep difference between limbs Ensures gluteal activation, strength and endurance

Calf Raises Standing on the edge of a step, the subject performs full range unilateral heel raises to fatigue. 1 repetition every 2 seconds. (Schlumberger et al, 2002)

25+, no greater than 5 rep difference between limbs To enable running

1RM Single Leg Press

Incline leg press machine, hip flexed to 90˚. A valid repetition 10 repetitions, 0-‐90˚ knee flexion (Cleather et al, 2013)

1.5x body weight To ensure sufficient strength and stability for plyometrics

Swelling/Effusion Knee circumference (Jakobsen et al. 2010). Measured 1cm proximal to the base of the patella with knee in full extension.

<1 cm change in circumference To ensure exercises are not being progressed beyond tolerance

ROM (as required) ITB foam roller 20 up and back Alternate

Phase 3: Running, Agility, and Landings

Aim:

• Strength and neuromuscular progressions • Dynamic postural stability • Initiate agility, change of direction and crossover drills • Deceleration control • Challenge symmetry and provide bench marks to progress and monitor

As with primary ACL injuries, the majority of secondary ACL injuries occur through non-‐contact mechanisms (Wright et al, 2010). This strongly suggests that there are underlying intrinsic, neuromuscular factors contributing to the injury risk. Multiple studies have demonstrated the effectiveness of neuromuscular retraining in the prevention of secondary ACL injuries (Hewett et al, 1996; Hewett et al, 1999; Myer et al, 2007). This is believed to be related to enhancing athletes function and movement behaviours early after the injury, as well as improving function and movement behaviours following ACLR (Chmielewski et al, 2005; Risberg et al, 2007; Di Stasi et al, 2012).

To facilitate the athlete’s progression through the challenging running, agility, and landings phase, we have developed the Learning Tool for Athletes with Knee injuries (LTAKI) as a means of providing internal and external feedback and encouraging the athlete to assess their own technique.

The LTAKI consists of five different functional activities evaluating the athlete’s knee function during the rehabilitation period. Both the patient and the therapist independently and simultaneously evaluate the athlete’s ability to perform functional tasks. The LTAKI is incorporated to educate the athlete about correct landing, cutting, running, hopping, and jumping techniques, neuromuscular control, and correct muscle activation; allowing them to assess their own functional performance. The LTAKI will be conducted by the therapist at monthly intervals during phase 3 to provide feedback on technique and areas to develop.

Phase 3 LTAKI Test Description (see videos at

Trewrehab.com) Therapist Points

Athlete Points

Eccentric step downs

The subject stands on a 20 cm step on one leg and has 30 seconds to reach forward and touch the ground lightly with their heel and return to full knee extension.

Single leg squat

Stand on one leg with arms crossed. Squat down to 60˚, then return to start position

Running man with calf raise

Stand on one leg, hands by side. Bend forward from hips while simultaneously bending knee. Reach arms forward with torso parallel with the ground and other leg stretched behind you. Return to start position, finishing with a calf raise.

Bounding in place

Jump from one leg to the other straight up and down, progressively increasing rhythm and height

Cone jumps Double leg jump with feet together. Jump side to side over cones quickly. Repeat forward and backward.

Phase 4 LTAKI Test Description (see videos at Trewrehab.com) Athlete

Points For scores <10 please give a reason

Eccentric step downs on foam

The subject stands on a pillow or cushion on a 20 cm step on one leg and has 30 seconds to reach forward and touch the ground lightly with their heel and return to full knee extension.

Single leg squat

Stand on one leg with arms crossed. Squat down to 90˚, then return to start position.

Running man with calf raise on mini tramp

Stand on mini tramp on one leg, hands by side. Bend forward from hips while simultaneously bending knee. Move arms in running pattern coordinated with legs. Return to start position, finishing with a calf raise.

Bound and hold

Jump from one leg to the other forwards and backwards, holding the landing for 3 seconds each time. Repeat side to side.

Cone jumps

Single leg hop side to side over cones quickly. Repeat forward and backward.

Qualitative analysis of single leg squat

QASLS Closed Kinetic Chain Exercises Left Right Arm strategy Excessive arm movement to balance Trunk alignment Leaning in any direction Pelvic plane Loss of horizontal plane Excessive tilt or rotation Thigh motion WB thigh moves into hip adduction NWB thigh not held in neutral Knee position Patella pointing towards 2nd toe (noticeable valgus) Patella pointing past inside of foot (significant valgus) Steady stance Touches down with NWB foot Stance leg wobbles noticeably Total Modified from “Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary” Herrington et al, 2013

Qualitative analysis of single leg squat

QASLS Plyometric Exercises Left Right Arm strategy Excessive arm movement to balance Trunk alignment Leaning in any direction Pelvic plane Loss of horizontal plane Excessive tilt or rotation Thigh motion WB thigh moves into hip adduction NWB thigh not held in neutral Knee position Patella pointing towards 2nd toe (noticeable valgus) Patella pointing past inside of foot (significant valgus) Landing stance Touches down with NWB foot Noticeably wobbly during landing Total

Modified from “Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary” Herrington et al, 2013

Sample Exercise Session Phase 3

Sample Training Program Phase 3 TYPE VENUE MON TUE WED THU FRI SAT SUN

Prescribed

program

Home /

Gym

60 mins 60 mins 60 mins LTAKI

20

mins

Cardio Pool/

Bike/Run

45

mins

45

mins

45

mins


Measure Test description & Reference Goal -‐> Purpose/ reasoning

Star Excursion Balance Test (SEBT)

The athlete must maintain a base of support on one leg, while using the other leg to reach as far as possible in 3 different directions. A composite score is obtained for each leg from which the limb symmetry index (LSI) is then calculated (Herrington et al, 2009)

Symmetrical reach in all directions , >95% compared with other side Test for balance in multiple planes

Single Leg The athlete stands on one leg and hops as far forward as >90% compared

Exercise Sets/duration Resistance Reps Recovery WARM UP Cross-‐trainer/ Treadmill/ Rower/ Bike 5 mins 90 secs PEP style dynamic warm up (see appendix B)

10 mins 30 secs

STRENGTH/PROPRIOCEPTION (see appendix A)

Kettlebell swings 30 secs 4 90 secs Power leg press 3 10 90 secs Single leg running man progression 2 20 90 secs Bulgarian lunges 3 10 90 secs Nordic hamstrings 3 10 90 secs Bosu trunk extensions 3 20 90 secs Single leg Romanian deadlifts 3 10 90 secs Bosu v-‐sit crunches 3 20 90 secs Lunge jumps 2 20 20 secs Scissor jumps 2 20 20 secs Depth jumps 2 20 20 secs Zig zag running 2 6 20 secs 3 point lateral bound and hold 2 6 20 secs COOL DOWN Mini tramp jog 10 mins ROM (as required) ITB foam roller 20 up and back Alternate

Hop for Distance

possible, landing on the same leg. The landing is maintained for a minimum of 2 seconds (Noyes et al, 1991).

with other side

Triple Cross-‐Over Hop Test

The athlete performs three hops as far as possible crossing over a 15cm wide strip, holding the final landing for 2 seconds (Noyes et al, 1991)

>90% compared with side

Landing Error Scoring System

The subject jumps forward from a 30cm high box with both feet a distance equal to half their body height. Upon landing the athlete immediately jumps vertically as high as possible. The task is repeated until the following has been assessed (Padua et al, 2009): Sagittal (Side) View • Hip flexion angle at contact -‐ hips are flexed

Yes=0, No=1 • Trunk flexion angle at contact -‐ trunk in front of hips

Yes=0, No=1 • Knee flexion angle at contact -‐ greater than 30

degrees Yes=0, No=1

• Ankle plantar flexion angle at contact -‐ toe to heel Yes=0, No=1

• Hip flexion at max knee flexion angle -‐ greater than at contact Yes=0, No=1

• Trunk flexion at max knee flexion -‐ trunk in front of the hips Yes=0, No=1

• Knee flexion displacement -‐ greater than 30 degrees Yes=0, No=1

• Sagittal plane joint displacement Large motion (soft)=0, Average=1, Small motion(loud/stiff)=2

Coronal (Frontal) View • Lateral (side) trunk flexion at contact -‐ trunk is flexed

Yes=0, No=1 • Knee valgus angle at contact -‐ knees over the midfoot

Yes=0, No=1 • Knee valgus displacement -‐ knees inside of large toe

Yes=1, No=0 • Foot position at contact -‐ toes pointing out greater

than 30 degrees Yes=1, No=0

• Foot position at contact -‐ toes pointing out less than 30 degrees Yes=1, No=0

• Stance width at contact -‐ less than shoulder width Yes=1, No=0

• Stance width at contact -‐ greater than shoulder width Yes=1, No=0

• Initial foot contact -‐ symmetric Yes=0, No=1

• Overall impression Excellent=0, Average=1, Poor=2

A score of ‘Excellent’ is required. Excellent (0-‐3) Good (4-‐5) Moderate (6) Poor (7 or greater) Test for stability and range through trunk and lower extremity during landing

Single Leg Press

1RM as tested on an incline leg press. Starting with knee fully extended, the weight is lowered until approximately

2 x body weight Ensure adequate

90˚ of knee flexion, then returned to full extension (ACSM testing protocol, 2013)

strength for injury prevention

Prone Leg Curl

Athlete lying prone with knee in full extension. A valid test is when the athlete can control the weight through full range of flexion and return to start position (Kraemer & Fry, 1995).

HS/Quad ratio >70% Test for quads dominance

Functional Score

IKDC Subjective Knee Evaluation Form (Irrgang et al, 2001) Sore > 70

Phase 4: Return to Sport; Injury Prevention

Aim:

During this phase the emphasis is on quality, not quantity. To reflect this the training load has been reduced, and team training has been introduced. Team training will be a gradual re-‐introduction beginning with straight line running and ball handling drills before progressing to complex cutting drills and sudden changes of direction.

Cross-‐training has been incorporated to prevent overtraining and secondary injuries. Gym sessions are still performed 3 days per week and will be used primarily for sport-‐specific drills, to address imbalances and weaknesses, and to further develop strength.

Introducing sport-‐specific neuromuscular and proprioceptive based training into a warm up has been consistently shown to reduce the likelihood of injury from contact and non-‐contact mechanisms (Pollard et al, 2006; Mandelbaum et al, 2005; Gilchrist et al, 2008; Silvers et al, 2007). Adherence is important to ensure the effectiveness of these programs, therefore we introduce injury prevention exercises as part of the training during phase 4, to be carried on once athletes are discharged.

Sample Exercise Session Phase 4

Exercise Sets/duration Resistance Reps Recovery WARM UP Mini tramp jog 5 mins 90 secs PEP sport-‐specific dynamic warm up (see Trewrehab.com)

10 mins 30 secs

SPORT-‐SPECIFIC STRENGTH & NEUROMUSCULAR CONTROL (see appendix A)

Eccentric step downs with foam 1 min 2 90 secs Single leg Romanian deadlift 2 10 90 secs Lateral step downs with foam 1 min 2 90 secs Forward hurdle hops – over and back 30 secs 2 90 secs Jump into bounding for distance 3 6 90 secs Single leg ricochets – fwd/bwd 30 secs 2 90 secs Triple hop and hold 3 6 90 secs Single leg lateral bound onto foam 3 6 90 secs Compound functional movement 1 (sport specific)

Compound functional movement 2 (sport specific)

Compound functional movement 3 (sport specific)

COOL DOWN Deep water running 10 mins

Sample Training Program Phase 4

TYPE VENUE MON TUE WED THU FRI SAT SUN

Prescribed

Exercise

Home /

Gym

60

mins

60 mins 60 mins

Cardio Pool/

Bike/Run

45 mins

Team

Club

Grounds

90 mins 90

mins

Cross Outdoors 4pm

45 mins

Explanation of training types: Cardio = Deep-‐water running and swimming, spin bike, treadmill Strength = Strength, proprioception and sport-‐specific plyometric exercises Team = Team training (gradually progressed) Cross = Cross –training activities such as running and cycling

Testing battery recommended by the European Board of Sports Rehab (EBSR):

Recommended criteria for strength and hop performance prior to a return to sport after ACL reconstruction

Type of sport

LSI strength LSI hop performance

Pivoting Contact Competitive

100% on knee extensor as well as knee flexor strength

90% on two maximumᵃ as well as one endurableᵇ

Non-‐pivoting Non-‐contact Recreational

90% on knee extensor as well as knee flexor strength

90% on one maximumᵃ or one endurableᵇ

ᵃ For example, a vertical jump and a hop for distance ᵇ For example, the triple jump, stair hop or side hop test Reprinted from Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction (Thomee et al, 2011)

ROM (as required) ITB foam roller 20 up and back Alternate

Return to Sport Discharge Criteria Functional Testing Protocol

Category Tests Required Outcome Special Tests for Swelling, Stability, and Range of Motion

Lachman’s Pivot Shift

-‐ve -‐ve

Sport Specific Movements (warm up)

Functional movements as part of a dynamic warm up

Excellent technique rating during all movements

Single Leg Power, Stability, Balance

Star Excursion Balance Test Single leg hop for distance Triple cross over hop test Triple hop for distance

< 5% to other side < 5% to other side < 5% to other side < 5% to other side

Bilateral Landing, Power

Tuck jump test 100% score

Single Leg Strength 3RM Single Leg Incline Press 3RM Single Leg Hamstring Curl

Equal to other side Equal to other side

Subjective Evaluation IKDC subjective knee evaluation form 95% + Special Tests

Measure Outcome Pass Criteria

Lachmans Nil: No laxity, equal to other side Mild: 0 to 5 mm laxity (greater than the uninvolved side) Moderate: 6 to 10 mm laxity (greater than the uninvolved side) Severe: 11 to 15 mm laxity (greater than the uninvolved side)

Nil

Pivot Shift

1 : Gentle twisting slide with tibia twisting internally maximally 2 : Clunk with tibia neutral, negative when tibia externally rotated 3: Painless glide for examiner and patient; 4 : Jamming and plowing, impingement;

1

Sport Specific Movements (included as part of warm up) Quality Quality

Forward/Backpedaling: P • A • G • E Bounding: P • A • G • E Side Shuttles: P • A • G • E Shuttle Run: P • A • G • E Carioca: P • A • G • E High Knees: P • A • G • E Gluteal Kicks: P • A • G • E Other: _______ P • A • G • E Star Excursion Balance Test

Right Left Anterior Posteriomedial Posteriolateral Total

Single Hop for Distance

R #1 R #2 R #3 L #1 L #2 L #3 Total R

Total L

LSI Quality

% P • A • G • E Triple Cross Over Hop Test

R #1 R #2 R #3 L #1 L #2 L #3 Total R

Total L

LSI Quality

% P • A • G • E

Single Hop for Distance

R #1 R #2 R #3 L #1 L #2 L #3 Total R

Total L

LSI Quality

% P • A • G • E

Subjective Evaluation

Measure Outcome IKDC (Total score / 87) x 100

Limb Symmetry Index: A limb symmetry index will be calculated from the average of 3 trials as the involved limb hop distance divided by the involved limb hop distance, multiplied by 100. Tuck Jump Assessment: Athletes perform repeated tuck jumps for 10 seconds while the clinician scores the performance for each category from frontal and sagittal planes (Myer et al, 2006).

Tuck Jump Assessment

TUCK JUMP ASSESSMENT Yes No Comments

Knee and Thigh Motion

-‐ Lower extremity valgus at landing

-‐ Thighs do not reach parallel (peak of jump)

-‐ Thighs do not equal side to side (during flight)

Foot Position During Landing

-‐ Foot placement not shoulder width apart

-‐ Foot placement not parallel (front to back)

-‐ Foot contact timing not equal

-‐ Excessive landing contact noise

Plyometric Technique

-‐ Pause between jumps

-‐ Technique declines prior to 10 seconds

-‐ Does not land in same footprint (excessive in flight motion)

Table reprinted from “Tuck jump assessment for reducing anterior cruciate ligament injury risk”. Myer et al, 2008

Single Leg Strength Tests

Test Left Right Single Leg Incline Leg Press Single Leg Hamstring Curl

Subjective Evaluation: Patient reported outcome measures will be completed after all objective clinical measures have been collected Follow up measures To assist with the long term validity of the ARTS program, three subjective assessments will be conducted intermittently at the initial consult; testing for progression; and 12 months; 2 years; and 5 years following injury. IKDC Subjective Knee Evaluation Form: The IKDC was selected due to the strong focus on patient reported outcomes which reflect the concerns of athletes (Hambly & Konstandina, 2010) Tegner activity grading scale: Quantifies activity levels related to both work and sports in patients with ACL ruptures. A reliable tool to determine whether athletes return to previous levels of physical activity (Briggs et al, 2009). Tampa Scale for Kinesiophobia (TSK-‐11): Measures the pain-‐related fear associated with movement and re-‐injury. Increased levels of function have been associated with reduced levels of fear avoidance during ACL rehabilitation (Chmielewski et al, 2008).

References

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