Tina Postrel, SPT

University of Central Florida

Spring 2015 Inservice

Incidence: re-injury & return to sport

Risk factors

Key concepts of rehab

Early phase

Late phase

Return to sport outcome measures

Objective measures

Subjective/psychosocial

Biomechanical screens

Time vs. functional tests

Return to practice

Clinical Recommendation

Summary

@ 2 yrs:

Study overview:

return to pivoting/cutting sport

N=78

C=47

LOE=2 cohort study

Overall: 30% of athletes sustained 2nd ACL injury

21% contralateral

9% ipsilateral

Females: 2x more likely for contralateral injury

vs ipsilateral

@ 10 yrs:

Study overview:

systematic review

N=2682

LOE=2

Overall: 20.5%

8% ipsilateral, 12.5% contralateral

contralateral tear 1.63x greater

20113 2014 4 20115

Achieve successful knee function 90% ----- ------

Return to ANY sport 82% 81% 67%

Return to PRE injury level 63% 65% ------

Return to COMPETITVE sport 44% 55% 33%

Study size N=5,770 N=7,556 N=503

(athletes)

Study design MA & SR MA & SR Case

series

Mean F/U time 3.5 yrs N/A 12 mo

Effusion

Extension

Proprioception

Stability

Hip & glut strength

control medial collapse

Power

Contralateral limb training too!

Running Progression

Trace or less effusion, >80% strength, >8-16wks

Quad Strength

MVIC: Max Voluntary Isometric Contraction

>90% contralateral strength

similar hop test scores compared to uninjured athletes

<85% = ↓ self reported fxn, impaired performance (hop tests)

Hamstring/Quad Ratio

>60% H:Q ratio

Clinical Application:

Biodex Isokinetic machine OR Dynamometer @ 60° Flex

Hop Testing >16-22 weeks

Test dynamic knee stability, agility

≥ 90% limb symmetry index

Instructions: 2 practice trials ea LE→2 measured trials →avg & compare involved to

uninvolved

Subjective /psychosocial

IKDC

International Knee Documentation Subjective Knee Form

High Specificity (SP= 84.8% @ 6mo, 91.9% @ 12mo)

Athlete low score = indicative of failing fxnal tests

Low Sensitivity (SN= 62% @ 6mo, 37% @ 12mo)

High/normal score = better symmetry on hop test, but

doesn’t correlate w/passing

IKDC > KOOS

Knee Injury & OA Outcome Score

TSK

Tampa Scale for Kinesiophobia

good to ID fear of reinjury

Biomechanical Screens

Drop Vertical Jump

Tuck Jump

Y balance Test

Quality of Movement SL

step down

Rate of Force Development (RFD)

Way to compare neuromuscular control vs max strength

RFD: Measures quick accelerations & power

RFD vs MVIC: Max Voluntary Isometric Contraction (@ 60° Flex)

• MVIC 97% pre-injury level

@ 6 mo

• RFD≥ 90% pre-injury level

@ 12 mo

• Subjects required +20wks

rehab c power focus

Time vs Functional Measures?

Most recommendations ≥ 6 months

However… time does not correlate c functional abilities

20149 201011

Pass Fxnal outcomes @ 6 mo 30% 48%

Pass Fxnal outcomes @ 12 mo 52% 78%

Fxnal outcomes tested: Quadriceps

index, hop tests

Quadriceps index, hop

tests, KOS-ADLS,

Global Rating Scale of

Overall Knee Function

Study design Prospective

Cohort

RCT

cohort N=141 N=40

Objective Tests: Absence of knee effusion and pain

Full knee AROM/PROM

Quad Strength ≥ 90% contralateral quad strength

Subjective: Athlete Perception via IKDC

Functional & Biomechanical Screens: ≥ 90% bilat symmetry c SL hop tests

Quality test: Vertical drop jump test (consider contralateral too)

Overall Time:≥ 12 mo 0-6 mo: strength, balance, proprioception

6-12 mo: power/explosive strength, sport specific, return to practice

*risk of re-injury is significant and return to sport % is low so multiple measures needed. Single measures may be inadequate to ID deficiencies.

Incidence of Re-injury Contralateral ACL tear 1.6x > ipsilateral

Athletic population > general

Women > men

Incidence of Return to Sport Only ½ return to competitive sport

Comprehensive testing needed before clearance for return to sport Subjective, objective, functional & biomechanical screens

Don’t forget about power!

“Gold Standard” for return to sport No effusion

>90% quad MVIC

SL hop test

IKDC

Quality of Movement: Vertical Drop Jump

Functional Milestones > Time Milestones

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sport. The American Journal Of Sports Medicine. 2014;(7):1567.

2. Magnussen R, Meschbach N, Kaeding C, Wright R, Spindler K. ACL graft and contralateral ACL tear risk within ten years following

reconstruction: a systematic review. JBJS Reviews. 2015; 3(1):e3.

3. Ardern C, Webster K, Taylor N, Feller J. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and

meta-analysis of the state of play. British Journal Of Sports Medicine. 2011;45(7):596-606.

4. Ardern C, Taylor N, Feller J, Webster K. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction

surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British Journal Of

Sports Medicine. November 2014;48(21):1543-1553.

5. Ardern C, Webster K, Taylor N, Feller J. Return to the Preinjury Level of Competitive Sport After Anterior Cruciate Ligament Reconstruction

Surgery. American Journal Of Sports Medicine. March 2011;39(3):538-543.

6. Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a

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7. Schmitt L, Paterno M, Hewett T. The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following

ACL recostruction. JOPST. 2012; 42(9):750-759.

8. Reid A, Birmingham B, Stratford P, Alcock G, Giffin R. Hop testing provides a reliable and valid outcome measure during rehabilitation after

anterior cruciate ligament reconstruction. Phys Ther. 2007; 87:337-349.

9. LOGERSTEDT D, Dl STASI S, SNYDER-MACKLER L, et al. Self-Reported Knee Function Can Identify Athletes Who Fail Return-to-Activity Criteria

up to 1 Year After Anterior Cruciate Ligament Reconstruction: A Delaware-Oslo ACL Cohort Study. Journal Of Orthopaedic & Sports Physical

Therapy. December 2014;44(12):914-923.

10. Angelozzi M, Madama M, Cacchio A, et al. Rate of Force Development as an Adjunctive Outcome Measure for Return-to-Sport Decisions After

Anterior Cruciate Ligament Reconstruction. Journal Of Orthopaedic & Sports Physical Therapy. Sept 2012 ;42(9):772-780.

11. Hartigan E, Axe M, Snyder-Mackler L. Time Line for Noncopers to Pass Return-to-Sports Criteria After Anterior Cruciate Ligament

Reconstruction. JOSPT. 2010;40(3):141-154.

12. Hu F, Chmieleski T, Spindler K, Wilk K, Swiontkowski M, Marx R. Return to Sport after ACL Reconstruction. JOSPT & JBJS Webinar. Nov 2014.

13. Mueller L, Bloomer B, Durall C. Which Outcome Measures Should Be Used to Determine Readiness to Play After ACL Reconstruction?. Journal

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