Knee effusion and quad inhibitionThreshold   Threshold for reflex inhibition of vastus medialis 20-30 ml, rectus femoris and vastus lateralis 50-60 ml. Spencer JD et al Arch Phys Med Rehabil 1984 Knee effusion [60 cc] resulted in profound inhibition of reflexively evoked quad contraction. Kennedy JC AJSM 1982. Knee effusion and quad inhibition- Mechanism?   Most initial strength gains are neural- “Studies of early voluntary strength gains show large increases in muscle performance prior to development of hypertrophy”. Chmielewski TL et al J Ortho Res 2004 Neural factors [vs. hypertrophy] accounted for larger proportion of strength increase in 1st 3-5 wks. Moritani T Am J Phys Med 1979 Knee Effusion Assessment     Stroke Test (0 to 3+) Stroke up from Med. Jt. Line, down from suprapat. Pouch to lat jt. line Sturgill LP et al. JOSPT 2009 Effusion Grading Scale of the Knee Joint       Based on the Stroke Test Zero No wave produced on downstroke Trace Small wave on medial side with downstroke 1+ Larger bulge on medial side with downstroke 2+ Effusion spontaneously returns to medial side after upstroke (no downstroke necessary) 3+ So much fluid that it is not possible to move the effusion out of the medial aspect of the knee Limiting quad inhibition and restoring voluntary control • Compressive wrap/sleeve • Cryotherapy with elevation • Biofeedback • E-stim Compressive wrap/ sleeve• Less slippage with neoprene sleeve • Helps maintain sterile wound cover • May also have + impact on proprioception ***Must maintain sterile wound precautions with each. Wilk KE (instructional course) and Wilk KE at al Orthop Clin N Amer 2003 Cryotherapy Evidence • Assists with pain control and effusion control.  Hopkins JT J Athl Train 2006Cryotherapy ↓ quad inhibition, ↑ knee power torque versus controls  Hubbard TJ J Athl Train 2004Cryotherapy efffective in ↓ pain  Raynor MC et al J Knee Surg 2005- Cryotherapy ↓ pain but no effect on ROM Cryotherapy Devices- Assists with pain and effusion control Limiting quad inhibition and restoring voluntary control • BiofeedbackLimited research but evidence shows clinically significant benefit after 6 wk protocol to recover peak torque. Draper V Phys Ther 1991 • ↑ Sensory feedback to patient to allow increased selective muscle activation Neuromuscular Electrical Stimulation • Russian and Hi Volt Galvanic stimulation (HVGS)- HVGS and alternative wave forms with e-stim may assist with swelling and/or pain control via gate theory…..but primarily used in early rehab for quad activation………….. NMES Use After ACLR- Evidence  Snyder-Mackler L et al JBJS 1991, Snyder-Mackler L et al JBJS 1995 • High intensity e-stim produced clinically significant improvement with quad strength and gait (flx/ext excursion in stance) versus volitional exercise and low intensity e-stim groups • Problems with study- Positioning resulted in ↑ ant. Knee pain, necessitated revised protocol….. NMES Use After ACLR- A Kinder, Gentler Approach- Fitzgerald GK et al JOSPT 2003 • Revised positioning to ↓ ant. knee pain but same parameters…..produced smaller yet still clinically significant treatment effect versus control group at 12 and 16 weeks.    Performed in full passive knee ext. to ↓ patellar sx c/o Parameters used= Russian e-stim @ 10”on:50” off x 10 mins. @ 75 bursts/sec., 2 secs ramp Evidence of sup. patellar glide…full tetanic contraction NMES Use Cont’d    Hasegawa S et al J Electromyo Kinesiol 2011 Estim group showed less decline in knee extensor strength ( 4 wks p.o.) and greater knee ext. strength recovery (3 mos. P.o.) and greater vastus lateralis thickness versus control grp Kim KM et al JOSPT 2010- NMES+exer. More effective at restoring quad strength than exer. alone Portable NMES versus Plug-In Portable units versus plug-in – Empi 300 PV comparable torque production to plug-in unit. Lyons CL et al Phys Ther 2005 NMES Assisted Exercise NMES Use to Increase Extension ROM  Solomonow et al AJSM 1987demonstrated reflexive hamstring activation in case of ACL-damage. Often seen clinically with hamstring spasm and flexed knee in acute ACL tear pts. • E-stim at quads may overcome this via reciprocal inhibition and enable restoration of quad fxn and ext ROM. Knee extension ROM biomechanics Inability to extend the knee fully results in: • abnormal jt. arthrokinematics • ↑ in p-f and tib.-fem. contact pressure • inability to contract quads • muscular fatigue Wilk KE et al. Ortho Clin N. Amer 2003 Obtaining full knee extension ROM  Active  Static  Restoration of patellar mobility  Scar mobilization  Low load long duration stretching for HEP Obtaining full knee ext. ROM  Active- use of Russian NMES to facilitate, prefer active vs. passive to improve voluntary neuromuscular control Obtaining full knee extension ROM Static stretchesSave static stretches until mid/end of rehab session when tissue viscoelasticity is better Restoration of Patellar Mobility- Avoid Infrapatellar Contracture Syndrome Paulos LE, Rosenberg TD, Drawbert J, Manning J, Abbott P. Am J Sports Med. 1987 Jul-Aug;15(4):331-41 Who’s highest Risk Category????? PATELLAR TENDON GRAFT Restoration of Patellar Mobility 4 Way Patellar Mobs beginning @ initial eval with care to avoid incision Obtaining full knee extension ROM- Scar Mobilization Scar mobilization- prevent adhesions to underlying tissue Total End Range Time (TERT) Principle  Phys Ther. 1994 Dec;74(12):1101-7. The use of splints in the treatment of joint stiffness: biologic rationale and an algorithm for making clinical decisions. McClure PW, Blackburn LG, Dusold C  TERT (total end range time)- to cause permanent elastic deformation tissue changes- must be in end range position total of 60 mins./day Low Load Long Duration (LLLD) stretching for HEP prn with ≤ 10 lbs. overpressure- long sitting (heel propped with towel), supine, or prone Risks of Inadequate/Incomplete ROM restoration   Knee OA risk was 2x greater in ACLR pts. with abnormal ROM (ext. ROM not within 2° opp. Knee and flx ROM not within 5° opp. Knee) at min. 5 yr. f/u Shelbourne KD et al AJSM 2012 Jan. Risks of Inadequate/Incomplete ROM restoration   Shelbourne KD et al AJSM 2009 Loss of 3-5° ext. adversely affected SUBJECTIVE and OBJECTIVE post-op results, especially when coupled with meniscectomy or articular cartilage damage Hyperextension- How much should we strive to regain in hyperflexible athletes? Restore only 5° hyperextension, if athlete demonstrates more ext. ROM on contralateral knee, allow to gradually regain Wilk KE et al J Athl Train 1999- ROM Exercises- precautions? Safe to begin as soon as ROM and pain allows post-op • Wright RW et al J Knee Surg 2008 (review)- Early motion is safe and may help avoid problems with later arthrofibrosis • Cascio BM et al Clin Sports Med 2004 (review)- Early joint motion after ACLR can ↓ pain, lessen adverse changes in articular cartilage, and prevent capsular contraction. ROM Exercises- precautions? Fleming B et al AJSM 1998- Stationary bicycling at increased resistance levels did not significantly ↑ ACL strain Meyers et al Clin J Sport Med 2002Stairmaster is viable and safe alternative to cycle use for post-op ACLR rehab ROM Exercises-When to begin? Biking, Elliptical Trainer, and Stairmaster are acceptable when: • ROM sufficient (generally ≥ 90° knee flexion) • Pain and effusion are controlled • Weight bearing and gait are normalized and symmetrical for Elliptical and Stairmaster Post-op WB- When to begin WB and how much???? Post-op WB- Evidence • Beynnon B et al Clin Ortho Related Res. 2002, Beynnon BD et al AJSM Dec. 2011- “Findings indicate that WB IMMEDIATELY after ACLR does NOT seem to produce excessive loads across a healing graft that permanently deform the graft or its fixation AND is beneficial because it lowers incidence of patellofemoral pain” • Tyler T et al Clin Orthop Relat Res. 1998- Immediate WB after ACLR did not compromise jt. stability and resulted in better outcome with ↓ incidence of ant. knee pain. Post-op WB Progression Guidelines • Ideally both crutches 7-10 days • Progress to 1 crutch then FWB without crutch by 10-14 days • Goal is to assume full body weight on involved LE during 2nd wk post-op. ******* Modify given concomitant pathology/procedures (i.e. articular cartilage, meniscal repair, etc.) • Wilk KE et al. Ortho Clin N. Amer 2003 Proprioception and Gait  Adverse effects of ACL rupture and invasive reconstruction on proprioception and throughout gait cycle, but effects vary in each individual! Quad wknss and Effect on Gait    Lewek M et al Clin Biomech 2002 Quad wknss (< 80% uninvolved) led to significant gait alterations in early stance with walking and jogging “Quad avoidance gait”Timoney JM et al AJSM 1993 Proprioception and Gait  Zatterstrom et al. AJSM 1994- found balance disturbance/deficiencies at BOTH LE’s after ACL rupture versus controls •****Underlies the importance of early closed chain exercise to facilitate return of proprioception at BOTH LE’s. Gait and Proprioceptive Training Principles    Begins at initial eval-don’t allow continued reinforcement of abnormal inefficient gait- will be more difficult to break later in rehab Progress out of brace/immobilizer ASAP to facilitate normal gait and ROM Early WB will enhance proprioception restoration. Normalizing Gait    Early weight shifts- multi-planar Cup Drill/Hurdle Walking Balance/Perturbation beginning bilaterally on tilt board/variable surface and progressing to single LE. Begin @ 30° knee flx (most quad/hams cocontraction on EMG = SAFER FOR GRAFT INITIALLY!!!). Wilk KE et al Orthop Clin N Amer 2003. Normalized Gait Assessment ? BREAK Essential Components of PostOperative S & C Programs        OKC vs. CKC? Isolated vs. Multi-Joint Exercises? Eccentric and Concentric Loading Anterior Chain Strength Posterior Chain Strength Core Strengthening Plyometrics Eccentric Exercise Considerations for Max. Strength Return    Gerber JP et al JBJS Am. 2007 Gerber JP et al Phys Ther 2009 Eccentric training beginning 3 wks s/p ACLR induced greater gains in glute and quad volume and strength without deleterious effects (i.e. graft laxity, etc.) up to 1 yr post-op Strength Exercise Selection    Escamilla R et al. JOSPT 2012 NWB exercises gen. load ACL more than WB exercises For NWB and WB exer. ACL is loaded more between 10-50° versus 50-100° knee flx ROM OKC vs. CKC Exercise Selection Considerations Open Kinetic Chain (OKC) vs. Closed Kinetic Chain (CKC)- Impact on ACL Beynnon B et al Clin Ortho Related Res. 2002 (review)  • Largest ACL strain values produced by isometric and isotonic contraction of the quads with the knee near full extension • ↑ resist. during active knee ext motion and OKC exer. that does not involve body weight loading and appreciable cocontraction generates ↑ in ACL strain. • Rehab with CKC program (vs. OKC) results in:   a-p knee laxity values that are closer to normal earlier return to normal daily activities Surprising ACL Strain Values CKC- Squat/ Leg Press/ Lunge Considerations      Escamilla RF et al. JOSPT 2012 No change in ACL strain with squat no resistance vs. up to 30 lbs. resist. Grtr. ACL load with single LE vs. double LE squat Forward trunk tilt dec. ACL load by inc. hams activation Leg Press at higher knee flx angles when ROM is available to dec. ACL strain Closed Kinetic Chain (CKC) Functional Exercise Considerations    Asymmetrical loading differences @ involved vs. uninvolved LE with parallel squat were greatest in s/p ACLR group @ 1.4-4 mos. post-op Did not equalize until 12-15 mos. Post-op Neitzel JA et al. Clin. Biomechanics 2002 Squat/wall slide- Mirror and/or bathroom scale under each foot to assist selfcorrection of asymmetry with weight bearing. Closed Kinetic Chain (CKC) Functional Exercise Progressions Step Downs (front and lateral)- Strong correlation between fxnl scores and front step down performance. Chmielewski TL et al Gait Posture 2002 Closed Kinetic Chain (CKC) Functional Exercise Progressions  Variables • Surface: AIREX pads, Dynadisks, BOSUstimulate proprioceptive feedback • Planes: Don’t forget frontal and oblique planes with lunges, etc. • Speed • Resistance- can increase safely without risk to ACL graft • Height • Incorporation of UE involvement/external challenges OKC considerations OKC exer. not typically fxnl (unless soccer player or martial artist), but may better isolate indvdl muscle grp • ACL injuries usually in WB/CKC • OKC P-F jt. rxn forces > CKC • BREAK Importance of Core Stability “The Butt and The Gut” Gluteus Maximus Transverse Abdominus Gluteus Medius Gluteus Minimus Quadratus Lumborum Deep Rotators Multifidi External and Internal Oblique Importance of Core/Hip Stability   Markolf KL et al JBJS 1978Muscular contraction can ↓ valgus/varus laxity of knee threefold. Help with control of ↑ tibial ER in WB (already discussed), by limiting femoral IR via increased strength at glutes and hip ext. rotators Powers CM JOSPT 2003 and Powers CM APTA ACP Course 2008. Gold Standard for Core Stability Assessment    No current consensus about best method Multiple definitions of core stability exist May evaluate power, proprioception, postural stability, etc. Weir et al. Clin J Sport Med 2010  Found INSUFFICIENT reliability of 6 tests for core stability including: • Single LE squat • Lat. Step down • Bridging • Prone plank • Observation of standing dynamic trunk control in sagittal, frontal, and transverse planes Core Stability Evaluation • Assessment:      Step Down Test (Watch for Femoral IR/Knee Valgus, lateral trunk flexion) Bridges and progressions- look for ability to maintain ASIS level in single LE hold Planks/Side planks- decrease support via hip ext. or punch with plank and hip abd with side plank. Can they perform? MMT/Strength of hip abductors, extensors and external rotators Knee and trunk deviations with lunging progressions Step Down Test Ant View Step Down Test Lat. View Traveling Lunge Assessment Core Progressions Sagittal Plane Frontal Plane Transverse Plane Combined Planes Core Stability- Ant. Pelvic Tilt     Delp SL et al. J Biomech 1999 Shultz SJ (2007) Understanding and Preventing non-contact ACL injuries Human Kinetics pp. 239-258 Ant. Pelvic Tilt places hip in ↑ Fem. IR, anteversion and ↑ flx= lengthened and weaker hamstrings and altered moment arm at glutes Ant .pelvic tilt increases genu valgus and subtalar pronation Anterior Progressions Abdominal Bracing Plank Push Up Plank with UE/LE Challenges Roll Outs Roll Outs Lateral Core Progressions Side Support Side Plank Side Bridge Side Plank with Star Suitcase Carries Side Plank and Star Rotational Stability Maintain a stable foundation while creating rotational power Essential Skill for Sport -Baseball -Soccer -Hockey -Golf Progressions Pallof Press Chop/Lift Side Plank with Row Rotational Plank Medicine Ball Shot Putt Medicine Ball Rotational Throw Pallof Press Cable Chop Side Plank with Row Rotational Plank Gluteus Medius Essential in Pelvic Alignment Major Player in Dynamic LE Alignment Key Stabilizing Muscle For the knee and ankle Research Powers et al. JOSPT 2011, 2012 Davis et al. JOSPT 2010, 2011 Ireland et al. Med Sci Sports Exerc. 2006, J Am Acad Orthop. Surg 2005 More Research…. Bolga LA, Uhl TL. Electromyographic Analysis of Hip Rehabilitation Exercises in a Group of Healthy Subjects. JOSPT 2005 Ekstrom RA, Donatelli RA, Carp KC. EMG Analysis of Core Trunk, Hip, and Thigh Musculature During Common Therapeutic Exercises. JOSPT 2007 Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal Muscle Activation During Common Therapeutic Exercises. JOSPT 2009 Take Home Message Gluteus Maximus: Single Limb Squat Gluteus Medius: Sidelying Hip Abduction Hamstrings: Unilateral Bridge External Oblique/Rectus Abdominus: Plank Multifidi: Unilateral Bridge CKC Gluteus Maximus Progressions Bridge Bridge with March Hip Lift Thrust Hinge Pull Through Rack Pull to Deadlift Progressions SL Deadlift Bridge Progressions Hip Thrust Hip Hinge Pull Through Single Leg Deadlift SLDL with rotation OKC Gluteus Maximus Progressions Bird Dog (Knee Flexed) Hydrant Hyper Hyper off Table OKC Gluteus Medius Progressions Standing Abduction with IR Clam Shell Concentric/Eccentric Clam Shell Band or Cable Resisted Abduction Sidelying Abduction (Against Wall) Side Plank Star Clam Shells Manually Resisted Clam Shells CKC Gluteus Medius Progressions Band Walk at Knees Band Walk at Ankles Band Walk at Toes Step Down Single Leg Squat Pistol Squat Band Walk Pistol Squat Hamstring function and training     Core muscle via attachment at ischial tuberosity Backup stabilizer to ACL to prevent ant. tibial translation Assist with tibiofemoral rot. Control Must receive appropriate attention (i.e. concentric and eccentric training). Often functions eccentrically during sport Posterior Chain Progressions Hinge with Staff Pull Through Deadlift Single Leg Dead Lift Physioball DKTC Slide Board Eccentric Hamstring Russian Hamstring Slide Board Eccentric Hamstring Eccentric Hamstring- Russian/ Nordic Leg Curl Physioball DKTC/Theraball Leg Curl Multi-Joint Progressions Split Squat Rear Foot Elevated Split Squat Reverse Lunge Lunge Lateral Lunge Transverse Lunge Multi Joint Progressions Gastroc-Soleus Function    Gastrocnemius contraction results in ↑ ACL strain- results in ant. tib. translation by pulling femur posteriorly. Kvist J Sports Med 2004 Soleus acts as ACL agonist by stabilizing tibia posteriorly in closed chain. Cascio BM Clin Sports Med 2004 ****Importance of including gastrocsoleus exercises in rehab program, specifically with knee flexed to increase soleus focus Retro Training   Functionally critical for some sports (backpedal and change of directioni.e. soccer, basketball, tennis, football, etc.) Vary and diversify recruitment of quadricepsimprove neuromuscular activation Retro Training  Cipriani DJ et al. JOSPT 1995- Retro walking on inclined treadmill produces: • ↑ knee flx ROM • ↑ challenge to rectus femoris during propulsion phase • normal eccentric contraction of rectus femoris is replaced by concentric contraction= less potential for ant. knee pain  Flynn TW et al. JOSPT 1995- Backward running at self-selected speed may: • reduce p-f compressive forces • ↑ quad strength and power • Quads active longer during stance phase than during forward running. Retro Training Examples • Retrowalk on inclined treadmill • Retrowalk with superband with progression to Retrorunning when appropriate • Retro StairMaster and Elliptical Band Resisted Retrowalking Band Resisted Retrorunning Incorporate Rotational Activties        Single leg dead lift with rotation Multi-Planar Lunges with rotation 90°/180° jumps (double LE→single) Carioca agility Figure 8 running 45° angle cuts and hops ****Rotation will significantly stress graft. Delay these activities until 14-16 wks. post-op to allow graft maturation and stability. Dynamic Rotational ExercisesWarmup Perturbation Training- Operational Definition    Chmielewski TL et al Phys. Ther. 2005 Pts. are exposed to carefully controlled forces that destabilize knee joint- allows motor learning and skill acquisition “Provides stimulus for reorganizing muscle responses that may ultimately lead to improved fxn” Why Perturbation Training…..Unexpected Challenges ? Perturbation Training Evidence  Fitzgerald GK et al Phys. Ther. 2000, Chmielewski TL et al Phys. Ther. 2005 • Improved long-term maintenance of fxnl and proprioceptive rehab gains in ACL-deficient pts. (versus control group without perturbation training) and higher scores on fxnl tests • ↓ co-contraction “stiffening” pattern, allows pt. to ↑ selective muscle activity and movements, normalized kinematics . • ↑ carryover of protective response to fxnl situations improves patient safety with return to sport and unpredictable demands and/or unstable positions Perturbations Implementation Alter: • Predictability • Speed • Amplitude • Direction • Intensity Perturbation Training- Proximally Proximal Challenges Perturbation Training- Distally Perturbation TrainingCoordinated with UE Perturbation Training Perturbation Training- High Speed Perturbation Training- Sport-specific Return to Running Progression