Play After Anterior Cruciate Ligament Reconstruction
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| Team Approach: Return to Play After Anterior Cruciate Ligament Reconstruction Dean Wang, MD Abstract » Current surgical and rehabilitation techniques have allowed for a Theresa Chiaia, PT, DPT relatively high rate of return to sports after anterior cruciate ligament John T. Cavanaugh, PT, MEd, (ACL) reconstruction. Although some patients may be expected to ATC, SCS return to sporting activities by as early as 8 months after the surgical procedure, most patients will have not achieved the appropriate Scott A. Rodeo, MD rehabilitation benchmarks by this time point and can require as long as 2 years to reach their full preoperative level. Investigation performed at the Sports » In addition to the diagnosis and surgical treatment of the ACL injury, Medicine and Shoulder Service and the the surgeon has to educate the patient about the injury, treatment, Sports Rehabilitation and Performance and rehabilitation process. Center, Hospital for Special Surgery, New York, NY » The physical therapist commonly spends the most time with the patient and therefore must foster a relationship of trust early on with the patient-athlete. Through biomechanical evaluations, factors that contributed to the ACL injury and ongoing deficits during the rehabil- itation process are identified and are addressed. » Assessment of movement quality complements the traditional quan- titative measures of performance and informs the medical and rehabil- itation team, as well as the patient, of the presence of potentially faulty movement patterns associated with an ACL injury. » Throughout the course of rehabilitation, the certified athletic trainer works closely with the physical therapist to ensure athlete compliance with the prescribed exercises. Communication between the physical therapist and the certified athletic trainer therefore plays an integral role in the patient’s rehabilitation. During the return-to-play phase of rehabilitation, the certified athletic trainer serves as the liaison between the patient, surgeon, physical therapist, and coaching staff. » This team approach to managing the athlete’s injury, rehabilitation, and expectations is key to a successful outcome. nterior cruciate ligament sports involving cutting, pivoting, and (ACL) reconstruction is com- jumping maneuvers. Recent advancements monly performed in athletes in surgical techniques and rehabilitation who sustain an ACL injury have contributed to a relatively high rate of withA the goal of returning them to preinjury return to play after ACL reconstruction1. levels of sports participation, particularly in Although some patients may be expected to Disclosure: Disclosure of Potential COPYRIGHT © 2019 BY THE There was no source of external funding for this study. The JOURNAL OF BONE AND JOINT Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/ SURGERY, INCORPORATED JBJSREV/A405). JBJS REVIEWS 2019;7(1):e1 · http://dx.doi.org/10.2106/JBJS.RVW.18.00003 1 | Team Approach: Return to Play After Anterior Cruciate Ligament Reconstruction return to sporting activities by as early as to 5 mm, grade 2 5 6 to 10 mm, and 8 to 9 months after the surgical proce- grade 3 5.10 mm increased transla- dure, most patients will not have tion compared with the uninjured side). achieved the appropriate rehabilitation The pivot-shift test was 21 in the left benchmarks by this time point and can knee and 0 in the right knee (0 5 nor- require as long as 2 years to return to mal, 115glide, 215clunk, and play2,3. Return-to-sport recommenda- 315gross). There was lateral joint line tions following ACL reconstruction are tenderness. Magnetic resonance imag- varied but are typically based on ing (MRI) demonstrated a proximal Fig. 2 assessments of knee impairment and ACL rupture with the characteristic Photograph showing low-load prolonged function, such as knee range of motion, bone edema pattern on the posterolat- stretching to facilitate extension of the left quadriceps strength,andfunctionaltest eral tibial plateau and middle of the lat- knee. performance. The clinical scenario eral femoral condyle. Additionally, there presented in this review is an example of was a peripheral tear in the posterior crutches were discontinued 5 weeks after the team approach that is required horn of the lateral meniscus without the surgical procedure upon demon- between the surgeon, athletic trainer, displacement. stration of a non-antalgic gait without and physical therapist for treating ath- Prior to the surgical procedure, deviations and control of pain and letes after ACL injury to optimize their rehabilitation was initiated to maximize swelling. She progressed well through- chances of returning safely to sport at a range of motion and function. Follow- out the ensuing course of rehabilitation, high level. ing 3 weeks of physical therapy, the achieving full symmetrical range of patient’s range of motion and gait had motion by 10 weeks postoperatively. At Clinical Scenario normalized, and she demonstrated the approximately 3 to 4 months, quality of A 16-year-old female high school soccer ability to actively contract the quadri- movement became the focus during player sustained a non-contact left knee ceps. The patient then underwent an body-weight exercises. The patient injury during a game while attempting ACL reconstruction with bone-patellar demonstrated a pain-free, 8-inch (20- to kick the ball out of bounds on defense. tendon-bone autograft and all-inside cm) forward step-down without devia- She recalled her knee buckling when she lateral meniscal repair. Postoperatively, a tions, and, thus, progressive plyometric planted her left leg. There was no history commercial cold and compression training and running programs were of knee injury. She presented to the device (Fig. 1) was prescribed for home initiated. Controlled soccer-specific office 6 days after the injury and reported use to control postoperative inflamma- agility programs were introduced. mild pain and residual swelling in the tion and pain. Her weight-bearing was At 6 months, the patient under- knee. The physical examination dem- protected for the first week and was then went a quality-of-movement assess- onstrated normal alignment; however, transitioned to weight-bearing as toler- ment. Her first quality-of-movement she was walking with a bent knee gait. ated with her postoperative brace locked assessment revealed that she had a very The left knee had a 21 effusion. The at 0° of extension. The patient was in- good movement strategy on 2 legs as she range of motion was 5° to 120° of flexion structed by a physical therapist to begin a initiated and continued to drive move- in the left knee and 22° to 135° of home exercise program consisting of ment with the hips. However, she was flexion in the right knee. The Lachman low-load prolonged stretching to pro- asymmetrical, shifting to her right (non- test was 2B in the left knee (A 5 firm end mote full passive extension (Fig. 2); injured) side with take-off and landing point and B 5 no end point; grade 1 5 3 quadriceps setting in a supine or seated during the double-leg squat and jump in position, active-assisted range-of- place. Additionally, during the single-leg motion (knee flexion and extension) squat, she initiated movement with the exercise; and active range-of-motion knees, and the left knee collapsed into ankle exercises. Formal physical therapy valgus because of insufficient use of the was initiated 1 week after the surgical posterior chain (gluteals and ham- procedure and focused on restoring strings) (Fig. 3). This strategy placed range of motion and gait, patellar increased strain on her graft. Therefore, mobilization, and minimizing knee it was recommended that she work on effusion. At 3 weeks, the patient dem- single-leg gluteal and eccentric quadri- onstrated full passive extension range of ceps strength as well as single-leg motion and good quadriceps control. movement strategy. The broad jump Fig. 1 The postoperative brace was then and forward hop from 1 leg to the Photograph showing Game Ready, a com- mercial cold and compression device used to opened to 60° to assist in restoring a opposite leg (hop to opposite side) as- control postoperative inflammation and pain. normal gait pattern. The brace and sessed her ability to control shear forces. 2 JANUARY 2019 · VOLUME 7, ISSUE 1 · e1 Team Approach: Return to Play After Anterior Cruciate Ligament Reconstruction | Fig. 3 Photographs showing a single-leg squat on the left knee at 6 and 10 months after ACL reconstruction. Left: At 6 months, the patient demonstrated poor alignment and balance. Right: At 10 months, the patient demonstrated improved movement strategy, alignment, and balance, with loading of the knee in a safer position. At 8 months, the patient returned she was upright and lacked control turn to full play at that time. She con- for the second quality-of-movement during single-leg landings and cutting, tinued to work with her certified athletic assessment and she was anxious to return with valgus noted. Gluteal and quadri- trainer on single-leg strengthening, to soccer. In addition to her weekly ceps weakness persisted, which contrib- agility with resistance, and deceleration physical therapy sessions, she had been uted to her lack of ability to decelerate. training, and on her own for isolated working on sprinting, agility, and speed She continued to move through the strengthening of the quadriceps, glu- with her athletic trainer twice weekly. knees on 1 leg (Fig. 4). Because of these teals, and hamstrings. At 10 months, During landings from horizontal jumps, deficiencies, she was not cleared to re- she returned for the third quality-of- Fig. 4 Photographs showing a cutting movement on the left knee at 8 and 10 months after ACL reconstruction. Left and middle: At 8 months, the patient demonstrated poor alignment with the cutting movement on the left, surgically treated knee compared with good alignment (and safe loading) on the right, uninvolved knee.