Rehabilitative techniques for athletes after reconstruction of the anterior cruciate ligament

Recent advances following anterior cruciate ligament reconstruction: rehabilitation perspectives : Critical reviews in rehabilitation medicine

Injuries to the anterior cruciate ligament are common. Surgical reconstruction is more prevalent than ever. This review article discusses treatment of the patient following surgical reconstruction of the anterior cruciate ligament. Various phases of rehabilitation are discussed with emphasis on early return of passive motion, early weight bearing, bracing, kinetic chain exercises, neuromuscular electrical stimulation and accelerated rehabilitation. Although evidence exists for the treatment of the surgically reconstructed cruciate ligament, more is needed to better define specific timeframes for advancement. Evidence exists that many of these young individuals are not fully returning to unlimited high level activities. This review article presents some of the latest evidence regarding anterior cruciate ligament rehabilitation in an attempt to help the busy clinician understand and relate basic and clinical research to rehabilitation of a patient following reconstruction.

Preoperative gabapentin decreases anxiety and improves early functional recovery from knee surgery

Gabapentin has antihyperalgesic and anxiolytic properties. We thus tested the hypothesis that premedication with gabapentin would decrease preoperative anxiety and improve postoperative analgesia and early postoperative knee mobilization in patients undergoing arthroscopic anterior cruciate ligament repair under general anesthesia. Forty patients were randomly assigned to receive 1200 mg oral gabapentin or placebo 1-2 h before surgery; anesthesia was standardized. Patients received morphine, 0.1 mg/kg, 30 min before the end of surgery and postoperatively via a patient-controlled pump. Pain scores and morphine consumption were recorded over 48 h. Degrees of active and passive knee flexion and extension were recorded during physiotherapy on days 1 and 2. Preoperative anxiety scores were less in the gabapentin than control group (visual analog scale scores of 28 +/- 16 mm versus 66 +/- 15 mm, respectively; P < 0.001). The gabapentin group required less morphine than the control group (29 +/- 22 mg versus 69 +/- 40 mg, respectively; P < 0.001). Visual analog scale pain scores at rest and after mobilization were significantly reduced in the gabapentin group. First and maximal passive and active knee flexions at 24 and 48 h were significantly more extensive in the gabapentin than in the control group. In conclusion, premedication with 1200 mg gabapentin improved preoperative anxiolysis, postoperative analgesia, and early knee mobilization after arthroscopic anterior cruciate ligament repair.

Changes in weight-bearing following injury or surgical reconstruction of the ACL: relationship to quadriceps strength and function

PURPOSE

Changes in weight-bearing an average of 1.5 months after ACL injury (ACLD) and up to 3 months after surgical reconstruction (ACLR) were investigated using a force platform. Correlations between force platform test variables, quadriceps strength and functional self-report scores were also examined.

RESULTS

Each force platform test revealed impaired weight-bearing by either ACLD and/or ACLR subjects. Many variables were correlated to quadriceps strength; therefore, improved strength in ACLR subjects by 6 weeks post-operative negated any weight-bearing impairment. No single force platform variable correlated with the subjects' perception of function.

CONCLUSION

Only the step up/over test provided insight into disability in these patients. Modification of force platform analysis programs may allow for other clinical questions to be answered.

Consequences of a ligament injury on neuromuscular function and relevance to rehabilitation - using the anterior cruciate ligament-injured knee as model

The purpose of this article is to survey current knowledge concerning the consequences of a ligament injury on neuromuscular function and its relevance to rehabilitation, in relation to clinical practice. Although it deals with the ACL-injured knee, these views may also apply to other joints. The effects of a ligament injury on neuromuscular function are first considered - i.e., proprioception, postural control, muscle strength, functional performance, movement and activation pattern, central mechanisms, motor control and learning. The treatment and effects of rehabilitation on neuromuscular function are then discussed. The survey is concluded by discussing the clinical significance.

Influence of supervised and nonsupervised training on postural control after an acute anterior cruciate ligament rupture: a three-year longitudinal prospective study

STUDY DESIGN

Prospective randomized longitudinal clinical trial with matched controls.

OBJECTIVES

To investigate the long-term effect of training on postural control and extremity function after an acute anterior cruciate ligament (ACL) injury.

BACKGROUND

ACL injuries may cause severe problems with recurrent giving way of the knee and reduced functional capacity. The effect of an acute ACL injury and the effect of various training programs on postural control, as well as the relation between postural control and extremity function after such an injury, have not been studied longitudinally.

METHODS

Sixty-three consecutive patients, 35 men and 28 women (median age 24 years, quartiles 19-33 years), with an acute nonoperated ACL injury, randomized to neuromuscular supervised or self-monitored training, were examined with stabilometry (amplitude and average speed of center of pressure movements) and a one-leg hop test for distance after 6 weeks (stabilometry only), and after 3, 12, and 36 months, and were compared to a control group.

RESULTS

Regardless of treatment, center of pressure amplitude was persistently higher in both the injured and uninjured legs during the 3-year follow-up, but average speed was less affected or unaffected compared to the control group. The one-leg hop had normalized in the neuromuscular group at the 12-month follow-up, but was shorter in both legs throughout the 3-year period in the self-monitored group. The median value (quartiles) for injured/uninjured legs at 3 months was 150 cm (120-174 cm)/177 cm (140-199 cm), at 12 months was 174 cm (140-200 cm)/180 cm (150-202 cm), and at 36 months was 172 cm (146-200 cm)/178 cm (150-200 cm) in the self-monitored group, compared to the control group (median 186 cm, quartiles 177-216 cm).

CONCLUSIONS

The higher center of pressure amplitude in both legs over the 3-year period indicate persistently impaired postural control in single-limb stance. However, functional performance, as measured with the one-leg hop test, was restored by neuromuscular training, but not by self-monitored training.

Intra-articular mechanical blocks and full extension in patients undergoing anterior cruciate ligament reconstruction

Patients with acute anterior cruciate ligament (ACL) rupture frequently present with a lack of full extension. Current literature is unclear whether arthroscopic debridement is necessary before reconstruction to achieve full extension postoperatively. This study examined the postoperative extension achieved in 153 knees that underwent ACL reconstruction within 12 weeks of index injury. All patients performed preoperative physical therapy to increase range of motion and control pain/swelling, regardless of presenting range of motion without prior aspiration or arthroscopy. Of the 153 knees, 103 had meniscal pathology, of which 73 were peripheral vertical tears; 96 of the 153 knees lacked >/=3 degrees extension preoperatively. Five of 96 knees had an intra-articular mechanical block to extension and all regained full extension after ACL reconstruction. This study documented that a true intra-articular mechanical block is unusual in primary ACL ruptures. Lack of full extension can be adequately dealt with during surgical reconstruction without a detrimental effect on knee extension postoperatively.

The Relationship between Isokinetic Open and Closed Chain Lower Extremity Strength and Functional Performance

Objectives:

To determine (1) correlations between isokinetic lower extremity strength and functional performance and (2) correlations among different modes of isokinetic testing.

Design and Setting:

A correlational design with 6 measures. A series of strength, power, and agility tests was performed at a hospital-based outpatient physical therapy clinic.

Participants:

A volunteer sample of 29 male and 31 female, college-age subjects participated.

Measurements:

All subjects were tested in the following isokinetic tests: reciprocal leg press, single-leg squat, and knee extension. Performance tests included single-leg hop and vertical jump and a speed/agility test.

Results:

Analysis showed isokinetic knee extension, leg press, and single-leg squat strength significantly correlated to all functional tests. There were significant correlations among the 3 different isokinetic strength measures, as well.

Conclusions:

These results suggest a significant relationship between lower extremity open and closed chain isokinetic strength and functional performance testing.

The benefits of intraoperative small-dose ketamine on postoperative pain after anterior cruciate ligament repair

In a randomized, double-blinded study with three parallel groups, we assessed the analgesic effect of intraoperative ketamine administration in 45 ASA physical status I or II patients undergoing elective arthroscopic anterior ligament repair under general anesthesia. The patients received either IV ketamine 0.15 mg/kg after the induction of anesthesia and before surgical incision and normal saline at the end of surgery (PRE group); normal saline after the induction of anesthesia and before surgical incision and IV ketamine at the end of surgery (POST group); or normal saline at the beginning and the end of surgery (CONT group). Anesthesia was performed with propofol (2 mg/kg for induction, 60-200 microg x kg(-1) x min(-1) for maintenance), sufentanil (0.2 microg/kg 10 min after surgical incision, followed by an infusion of 0.25 microg x kg(-1) x h(-1) stopped 30 min before skinclosure), vecuronium (0.1 mg/kg), and 60% N2O in O2 via a laryngeal mask airway. Postoperative analgesia was initially provided with IV morphine in the postanesthesia care unit, then with IV patient-controlled analgesia started before discharge from the postanesthesia care unit. Pain scores, morphine consumption, side effects, and degree of knee flexion were recorded over 48 h and during the first and second physiotherapy periods, performed on Days 1 and 2. Patients in the ketamine groups required significantly less morphine than those in the CONT group over 48 h postoperatively (CONT group 67.7+/-38.3 mg versus PRE group 34.3+/-23.2 mg and POST group 29.5+/-21.5 mg; P < 0.01). Better first knee flexion (CONT group 35+/-10 degrees versus PRE group 46+/-12 degrees and POST group 47+/-13 degrees; P < 0.05) and lower morphine consumption (CONT group 3.8+/-1.7 mg versus PRE group 1.2+/-0.4 mg and POST group 1.4+/-0.4 mg; P < 0.05) were noted at first knee mobilization. No differences were seen between the PRE and POST groups, except for an increase in morphine demand in the PRE versus the POST group (P < 0.05) in the second hour postoperatively.

IMPLICATIONS

We found that intraoperative small-dose ketamine reduced postoperative morphine requirements and improved mobilization 24 h after arthroscopic anterior ligament repair. No differences were observed in the timing of administration. Intraoperative small-dose ketamine may therefore be a useful adjuvant to perioperative analgesic management.

The test-retest reliability of an inclined squat strength test protocol

Functional testing of the lower extremity is supported as a good predictor for successful return to premorbid activity. However, current reliable functional tests may be too strenuous for a patient in the acute stage of recovery. A functional testing protocol utilizing an inclined sliding board apparatus was evaluated for test-retest reliability. Thirty-five subjects (ages = 18-25, mean = 20.49 +/- 1.71) with no known knee pathologies were tested. Subjects performed a 20-second test for squat repetitions and a 50-squat repetition test for time, executing a single leg squat in an inclined position on the sliding board apparatus. The test was repeated 1 week later. The intraclass correlation coefficient equaled 0.80 for the 50-repetition timed test and 0.89 for the 20-second repetition test. The results indicate an acceptable test-retest reliability for the inclined sliding board apparatus protocol. We advocate the use of this testing protocol for the purpose of evaluating functional ability during the early stages of rehabilitation of lower extremity conditions.

Electromyographic analysis of the squat performed in self-selected lower extremity neutral rotation and 30 degrees of lower extremity turn-out from the self-selected neutral position

Little research is available on the muscle activity patterns of the lower extremity muscles during dynamic closed chain squatting activities. The purpose of this study was to examine the effect of lower extremity position during an Olympic squat on the muscle activity patterns of the vastus medialis, vastus lateralis, semimembranosus/semitendinosus, and biceps femoris. Twenty-five healthy, untrained subjects, 18-35 years old, were randomly assigned initial squatting positions of either self-selected neutral or 30 degrees of lower extremity turn-out from the self-selected neutral position. Surface electromyography and motion analysis data were collected simultaneously in 10 degrees intervals and analyzed from 10-60 degrees of knee flexion in both the ascending and descending phases of the squat. A four-way analysis of variance indicated that the main effect of lower extremity position and the interaction of extremity position and knee joint angles were not found to cause significant changes in muscle activity patterns. Significant changes in muscle activity did occur with changes in knee flexion angles in the vastus medialis and vastus lateralis but not in the semimembranosus/semitendinosus or biceps femoris.

Comparison of intersegmental tibiofemoral joint forces and muscle activity during various closed kinetic chain exercises

The purpose of this study was to analyze intersegmental forces at the tibiofemoral joint and muscle activity during three commonly prescribed closed kinetic chain exercises: the power squat, the front squat, and the lunge. Subjects with anterior cruciate ligament-intact knees performed repetitions of each of the three exercises using a 223-N (50-pound) barbell. The results showed that the mean tibiofemoral shear force was posterior (tibial force on femur) throughout the cycle of all three exercises. The magnitude of the posterior shear forces increased with knee flexion during the descent phase of each exercise. Joint compression forces remained constant throughout the descent and ascent phases of the power squat and the front squat. A net offset in extension for the moment about the knee was present for all three exercises. Increased quadriceps muscle activity and the decreased hamstring muscle activity are required to perform the lunge as compared with the power squat and the front squat. A posterior tibiofemoral shear force throughout the entire cycle of all three exercises in these subjects with anterior cruciate ligament-intact knees indicates that the potential loading on the injured or reconstructed anterior cruciate ligament is not significant. The magnitude of the posterior tibiofemoral shear force is not likely to be detrimental to the injured or reconstructed posterior cruciate ligament. These conclusions assume that the resultant anteroposterior shear force corresponds to the anterior and posterior cruciate ligament forces.

Backward walking at three levels of treadmill inclination: an electromyographic and kinematic analysis

Backward walking on a treadmill is a common tool for lower extremity rehabilitation in the clinical setting. The purpose of this study was to evaluate the adaptations in the gait cycle produced by walking backward on a treadmill at 0, 5, and 10% inclination. Sixteen healthy adult subjects (14 females, two males), mean age of 23.19 +/- 3.02, participated. Joint positions for hip, knee, and ankle were measured during a complete gait cycle. Values were time matched with average electromyographic (EMG) activity (surface electrode) of the rectus femoris, hamstrings, gastrocnemius, and anterior tibialis during each subphase of gait (initial contact, midstance, heel-off, and midswing). Values of joint position and average EMG were compared over the three treadmill conditions. Subjects walked for approximately 1 minute at 4.0 km/h. A simple repeated measures analysis of variance (p < .05) with a Duncan post hoc test was used to analyze for changes. Significant changes occurred in the joint positions of the knee and ankle at initial contact (ankle increased from 9.81 +/- 5.06 degrees to 13.08 +/- 3.68 degrees; knee increased from 30.94 +/- 5.25 degrees to 42.42 +/- 4.08 degrees) as the treadmill was raised from 0 to 10%. Significant changes occurred for average EMG activity for each muscle studied over the three treadmill conditions. The greatest changes occurred in the gastrocnemius at initial contact (increase from 189.76 +/- 44.29% to 293.09 +/- 79.16%) between the 0 and 10% conditions. The results of this investigation confirm that backward walking up an incline may place additional muscular demands on an individual.(ABSTRACT TRUNCATED AT 250 WORDS)

Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study

We conducted a prospective, randomized study of open and closed kinetic chain exercises during accelerated rehabilitation after anterior cruciate ligament reconstruction to determine if closed kinetic chain exercises are safe and if they offer any advantages over conventional rehabilitation. The closed kinetic chain group used a length of elastic tubing, the Sport Cord, to perform weightbearing exercises and the open kinetic chain group used conventional physical therapy equipment. Results are reported with a minimum 1-year followup (mean, 19 months). Pre- and postoperative evaluation included the Lysholm knee function scoring scale, Tegner activity rating scale and KT-1000 arthrometer measurements. Overall, stability was restored in over 90% of the knees. Preoperative patellofemoral pain was reduced significantly; 95% of the patients had a full range of motion. The closed kinetic chain group had lower mean KT-1000 arthrometer side-to-side differences, less patellofemoral pain, was generally more satisfied with the end result, and more often thought they returned to normal daily activities and sports sooner than expected. We concluded that closed kinetic chain exercises are safe and effective and offer some important advantages over open kinetic chain exercises. As a result of this study, we now use the closed kinetic chain protocol exclusively after anterior cruciate ligament reconstruction.

A comparison of outpatient and inpatient anterior cruciate ligament reconstruction surgery

The feasibility of outpatient anterior cruciate ligament (ACL) surgery has not been reported in the literature. We evaluated outpatient ACL surgery by comparing outpatient versus inpatient pain control, narcotic consumption, postoperative complications, recovery time, and cost analysis. Thirty-seven ACL reconstructions were performed in 37 patients over a 16-month period. Twenty-five of the patients had surgery performed as outpatients and 12 as inpatients. One of the outpatients required hospitalization because of excessive nausea and vomiting and another for urinary retention. Only 2 of the 25 outpatients (8%) believed that they should have been hospitalized for pain control. Based on a visual analog scale, pain severity, pain frequency, and pain relief were measured, and no statistically significant difference (P < .05) was noted between the groups, although the data suggested that the inpatients were slightly more comfortable. There were no differences in rehabilitation or in regaining full range of motion of the operated knee. Also, the only postoperative complication in both groups occurred in an inpatient who developed arthrofibrosis. Cost analysis showed that outpatient ACL reconstruction was cost effective. The average inpatient cost was $9,220 (2.4 hospital days) compared with the average outpatient cost of $3,905. This reflected a savings of 58%. These results show that outpatient ACL reconstruction surgery is possible in the appropriate patient without harm to the patient and with a significant cost savings.

Comparability of Work Output Measures as Determined by Isokinetic Dynamometry and a Closed Kinetic Chain Exercise

The purpose of this study was to determine if a relationship existed between work output as measured by the Lateral Step-Up Test (LSUT) and work output as measured by a Kin-Com isokinetic dynamometer test (KCT). Forty subjects were randomly assigned to one of two different testing orders. Subjects performed each test with their dominant leg only. Group 1 performed the LSUT followed by the KCT. The second group performed the same two exercises in reverse order. A multiple linear regression analysis was performed (Kin-Com work = Constant + Age + Gender + Lateral step-up work) and was found to provide a good fit to the data. Gender, age, and lateral step-up work were each subsequently analyzed, with the other independent variables held constant. A significant relationship existed (r= .74,p< .01) between the calculated work performed on the LSUT and Kin-Com work. This preliminary finding suggests that clinicians may consider employing standardized closed kinetic chain exercise tests as an objective measure of musculoskeletal performance.

Knee injuries and Alpine skiing. Treatment and rehabilitation

Alpine skiing is an increasingly popular recreational sport worldwide. While the overall injury rate has declined and the pattern of injury changed over the years, the incidence of knee injuries has not changed substantially and accounts for 20 to 30% of all alpine skiing injuries. Medial collateral ligament (MCL) injuries are the most common in skiing, accounting for 15 to 20% of all skiing injuries and 60% of knee injuries in skiers. Tears are commonly isolated, but may occur in association with other ligamentous injuries. Associated meniscal pathology is rare. Isolated MCL injuries are treated nonoperatively with a programme of initial immobilisation, early range-of-motion, and isometric quadriceps strengthening exercises. When full range of motion is achieved, a programme of progressive resistance exercises, isokinetic and closed chain exercises, and functional rehabilitation is instituted. Good results with return to skiing can be expected in most cases. Isolated lateral collateral ligament (LCL) injuries are rare in skiers. There is usually associated cruciate or arcuate ligament complex. Careful physical examination is essential to rule out associated ligament injuries and more complex instability patterns. In the rare case of isolated LCL injury, a similar approach to isolated MCL injury should be instituted. Anterior cruciate ligament (ACL) injuries have become increasingly common in skiers. This may reflect a true increase in the incidence or an improved awareness and ability to diagnose ACL injury. Physical examination and arthrometric analysis are important in assessing the integrity of the ACL. Radiographic and magnetic resonance imaging (MRI) evaluation may be helpful in assessing associated meniscal pathology. Treatment of the ACL-deficient knee is usually surgical. However, prior to reconstruction, a programme aimed at reducing effusion and regaining a full, pain-free range of motion is recommended. Surgical reconstruction is usually with the central third of the patella tendon using a bone-tendon-bone autograft. Postoperative rehabilitation employs a functional staged approach, requiring vigilant supervision by the surgeon. Isolated posterior cruciate ligament (PCL) injury is rare in skiing, constituting less than 1% of all knee injuries in most series. Careful physical examination must be employed to rule out associated arcuate ligament complex injury and more complex patterns of instability. Most isolated PCL injuries are treated nonoperatively with a programme of initial immobilisation in extension, ice, protected weight-bearing, early range-of-motion exercises and progressive isometric strengthening.(ABSTRACT TRUNCATED AT 400 WORDS)

Cranial cruciate ligament rupture. Pathogenesis, diagnosis, and postoperative rehabilitation

Rupture of the cranial cruciate ligament is the most common cause of stifle lameness in the adult dog. An understanding of the pathogenesis of cranial cruciate ligament rupture and the resulting degenerative joint disease is crucial in establishing an accurate diagnosis and implementing appropriate treatment. Early diagnosis of the cruciate-deficient stifle with appropriate therapeutic intervention may minimize degenerative joint disease but does not prevent it in all cases. Rehabilitation of the surgically corrected cruciate-deficient stifle may influence the success of the surgical outcome.

Comparison of tibiofemoral joint forces during open-kinetic-chain and closed-kinetic-chain exercises

The purpose of this study was to analyze forces at the tibiofemoral joint during open and closed-kinetic-chain exercises. Five healthy subjects performed maximum isometric contractions at 30, 60, and 90 degrees of knee flexion during open-kinetic-chain extension, open-kinetic-chain flexion, and closed-kinetic-chain exercises. Electromyographic activity of the quadriceps and hamstrings, as well as load and torque-cell data, were recorded. Tibiofemoral shear and compression forces were calculated with use of a two-dimensional biomechanical model. The results showed that, during the open-kinetic-chain extension exercise, maximum posterior shear forces (the resisting forces to anterior drawer) of 285 +/- 120 newtons (mean and standard deviation) occurred at 30 degrees of knee flexion and maximum anterior shear forces (the resisting forces to posterior drawer) of 1780 +/- 699 newtons occurred at 90 degrees of knee flexion. The closed-kinetic-chain exercise produced significantly less posterior shear force at all angles when compared with the open-kinetic-chain extension exercise. In addition, the closed-kinetic-chain exercise produced significantly less anterior shear force at all angles except 30 degrees when compared with the open-kinetic-chain flexion exercise (p < 0.05). Analysis of tibiofemoral compression forces and electromyographic recruitment patterns revealed that the closed-kinetic-chain exercise produced significantly greater compression forces and increased muscular co-contraction at the same angles at which the open-kinetic-chain exercises produced maximum shear forces and minimum muscular co-contraction.(ABSTRACT TRUNCATED AT 250 WORDS)

Rehabilitation following reconstruction of the anterior cruciate ligament

A closely supervised rehabilitation program is mandatory if maximum benefit is to be derived from anterior cruciate ligament (ACL) reconstruction. The author describes a postoperative rehabilitation protocol based on kinesiologic, histologic, and biomechanical factors affecting the ACL.

EMG Comparison of Lateral Step-up and Stepping Machine Exercise

The availability and use of stairstepping machines in both the rehabilitation and fitness industries have seen a significant increase in the last several years. The primary purpose of this study was to evaluate the electromyographic (EMG) activity levels of the rectus femoris (R), vastus medialis (V), biceps femoris (B), gastrocnemius (G), and semimembranosus/semitendonosus (S) muscles during exercise on a stepping machine and during performance of an 8-in lateral step-up. Eighteen subjects, without prior knee pathology, participated in the study. The root mean square EMG activity was obtained using surface electromyography and normalized to percent of maximum voluntary isometric contraction. Each exercise was broken down into knee flexion and knee extension phases for descriptive purposes. Analysis of variance (p < .05) was used for between exercise comparisons. Mean R and V activity were significantly greater during the lateral step-up exercise. Mean G activity was significantly greater for stepping machine exercise. Both B and S showed no significant mean differences between exercises. The stepping machine, in general, showed decreased activity during the knee extension phase and very little activity during the knee flexion phase when compared to the lateral step-up. The results indicate that exercise on the stepping machine would result in a more conservative rehabilitation approach for strengthening the quadriceps and hamstrings. J Orthop Sports Phys Ther 1992;16(3):108-113.