Optimal management of ACL injury in 2007 - Part 1

[physiobob]

by Mr Andy Williams, FRCS (Orth)

Abstract
Anterior cruciate ligament (ACL) injury is relatively common. The incidence is increasing, partly due to the growing competitive nature of sport and participation of individuals in sport, and particularly involvement among women who have a significantly higher instance of ACL rupture compared to males. Despite the increase in profile of this injury the diagnosis is often missed on first presentation and even correctly diagnosed, management is not neccisarily as good as one would expect.

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[vickyr]

Thanks for this. Any chance of seeing part 2?

[sharileedahl]

Let see if I can get the ball rolling with some discussion about this article...
First, with an interest in prevention, I have read some articles about high school girls and ACL tears and the effect of proprioceptive training....looks like it is beneficial. What I really wanted to ask others about is their thoughts on some of the points in this article. Maybe my assessment and problem-solving is stuck in a rut with ACL injuries but...
1. I have only seen a hand full of ACL tears in the last couple years (due to place of work) however in the past, I do not recall commonly seeing lateral meniscus tears &/or "posterolateral corner" injuries with ACL ruptures. Is this a common finding with any of you reading this as noted in the article (p.7). If so, what are your typical findings (i.e. subjective / objective)?
Thanks.....

[WrightDPT]

Any thoughts on the use of open versus closed kinetic chain exercises following ACL repair. Closed chain exercises certainly have the added benefit of being more functional, utilizing proprioceptive principles, and strenghtening mutliple muscle groups. In my experience, it is common place to limit open chain knee extension from 30* to 90* for several months. It is my understanding that these limitations serve to decrease sheer stress on the graft. Any thoughts on this. I have always been curious as to how much stress is actually occuring with an unresisted open chain knee extension. In comparison to sheer stresses with typical walking activities I would think stress a long arc quad would be relatively minimal. This exercise would certainly be beneficial for increasing quad strength and VMO activity. Especially considering the post surgical inhibition of quad and VMO.

[Canuck Physio]

There;s a physio club here!

Sign me up

[sharileedahl]

Regarding open vs closed chain exercise....I have always gone with the same thoughts as you (WrightDPT) but I'm having a vague memory of reading an article recently regarding the minimal stress to the graft with open-chain exercise which would support the more recent support of quicker ACL rehab protocols.
I'll do a search for those papers and get back to you......

[sharileedahl]

Originally Posted by sharileedahl

Regarding open vs closed chain exercise....I have always gone with the same thoughts as you (WrightDPT) but I'm having a vague memory of reading an article recently regarding the minimal stress to the graft with open-chain exercise which would support the more recent support of quicker ACL rehab protocols.
I'll do a search for those papers and get back to you......

OK....looked through the journals that I have read at home and done a search of abstracts that I may have reviewed recently and can't find anything about shear stresses with open-chain knee extension.
So... either I'm not looking in the right spot or I made an assumption....
The most recent article re. ACL rehab that I have read goes through a progression for return-to-sport (RTS). Based on functional criteria, the athlete can be progressed much more quickly than with the traditional ACL rehab protocol with successful, early RTS as early as 2-3 months. My assumption may have been that because RTS (in some sports) could include running backward, pivoting, kicking.... then open-chain knee extension must not produce a significant enough amount of shear stress to the ACL to contraindicate the activity. (Again, this is my assumption only.)
There is a contact email address for one of the authors. I am going to send off an email to him to see what their group's thought is on this. I'll get back to you re. what I hear.

The article is....
Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Rehabilitation after Anterior Cruciate Ligament Reconstruction: Criteria-Based Progression Through the Return-to-Sport Phase. J Orthop Sports Phys Ther, 2006; 36(6): 385-402.

[jesspt]

Shari,

Here's an editorial by Kevin Wilk, PT, a US physical therapist who has contributed a lot to the releevant ACL rehab literature. He comments specifically on how fast should we be rehabbing these patients.

[sharileedahl]

Thanks for that "jesspt". It will be interesting to see long-term results of these accelerated program....I'm sure the research is coming.....

One of the points in the attached editorial made me wonder if the amount / timing of revascularization matters. The point that revascularization may not happen for many months. Yet I don't think the failure rates are that high with a traditional rehab protocol.....So - can the graft have enough strength even without being fully revascularized??????