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Risk Factors
Hamstring/Quadriceps imbalance
Poor hamstring strength
Hamstrings protect ACL
Quads stretch/stress ACL
RESEARCH RESULTS
(Huston et al. 24 )
Female athletes and controls demonstrated more anterior tibial laxity than
their male counterparts and significantly less muscle strength and
endurance
Compared with the male athletes the female athletes took significantly
longer to generate maximum hamstring muscle torque during isokinetic
testing
Female athletes relied more on their quadriceps muscles in response to
anterior tibial translation; the three other test groups relied more on their
hamstring muscles for initial knee stabilization
So what does this mean?
Repetitions or time
TECHNIQUE
WEEK 1
WEEK 2
Fundamentals
Week 3
Week 4
Performance
Week 5
Week 6
WALL JUMPS
20 sec
25 sec
Wall Jumps
30 sec
30 sec
Wall Jumps
30 sec
30 sec
TUCK JUMPS
20 sec
25 sec
Tuck Jumps
30 sec
30 sec
10 reps
5 reps
10 reps
5 reps
8 reps
Mattress Jumps
30 sec/ 30 sec
SQUAT JUMPS
10 sec
5 reps
Squat Jumps
20 sec
20 sec
5 reps/leg
5 reps/leg
1 run
2 runs
Squat Jumps
25 sec
25 sec
Scissor Jump
30 sec
30 sec
3 runs
4 runs
et al, 1996
Hop,Hewett
Hop, Stick
5 reps/ leg
5 reps/ leg
5 reps/leg
5 reps/ leg
15 sec
180 JUMPS
25 sec
20 sec
BOUNDING IN PLACE
20 sec
25 sec
Introduction/Subjective/Clinical Impression:
18-year old female athlete, who sustained an injury while playing soccer 1 week ago. She was evaluated
by a physical therapist 1 day status post R ACL allograft and meniscal repair. Patient also presents with
Grade II MCL sprain. Surgeon has indicated NWB status for first two weeks postoperative, the second
two weeks PWB, and then WBAT from five weeks on. Prior to surgery, patient was PWB. There is
swelling at the right knee and surrounding areas causing discomfort and limitation of range of motion.
Patient is currently ambulating on crutches with no WB on RLE. Prognosis for recovery is excellent.
Patient is a National Team soccer athlete, has excellent cardiovascular health, no other medical issues
and is eager to return to sports as soon as possible. Patient reports severe right knee pain of 8/10 and
stiffness after surgery one day ago.
Impairments/Objective Measures:
-Edema and joint effusion of the R knee, with atrophy to R quads and calf muscles:
-Decreased A/PROM: -10/-15 degrees R knee extension and 90/100 degrees R knee flexion
with swelling end-feel. Left knee A/PROM extension 5/5 degrees and flexion 140/140 degrees
with normal end-feel.
-Hypomobile tibiofemoral and patellofemoral joints of R knee in all directions with swelling endfeel. L=WNL
-Abnormal gait pattern: decreased weight bearing on R LE.
-Incomplete MMT /MLT exam due to pain and swelling at the right knee.
LTG: In four weeks the patient will achieve the following goals to
increase range of motion, decrease swelling, stabilize muscle
atrophy, and decrease pain in the right knee in order to return to
sport in six months.
Decrease edema/effusion at R knee joint line
Increase A/PROM of right knee flexion to 100/105 degrees and right
knee extension to -5/-5 degrees.
Increase R patellar accessory mobility by 1 grade in all directions
and decrease swelling end-feel.
Normalize gait: teach patient modified 3-point gait pattern with PWB
on R LE; normal stride length with proper heel strike to toe off with
no VC for 500 feet.
Complete MMT exam when tolerated by patient.
STG: In two weeks the patient will achieve the following to achieve LTGs
listed above.
Decrease edema/effusion of R knee joint
Increase A/PROM of R knee flexion to 80/90 degrees and R knee
extension -5/-2.5 degrees.
Increase right patellar accessory mobility by grade in all directions and
decrease swelling end-feel.
Normalize gait: heel strike to toe off SL RLE on treadmill for 5 minutes at
1.0 mph, no incline.
Complete MMT exam when tolerated by patient.
Clinical Impression/Subjective: Patient is now partial weight bearing with crutches but can be full
weight bearing standing in place, as per doctor protocol. Patient reports a decrease in pain to a 4/10 on
the visual analog scale. Her AROM and PROM have increased in both extension and flexion of right
knee with a abnormal muscular endfeel. Her right tibiofemoral and patellofemoral joints are still
hypomobile in all directions due to pain, swelling, and muscle guarding. Some MMTs are performed and
patient shows decreased strength and muscle atrophy in right knee musculature. MMT of quad and
gastroc not performed due to nature of ACL graft. Patient prognosis is excellent due to her motivation to
return to soccer, her young age and athleticism, and the positive progression of her healing.
Impairments/Objective Measures:
Edema and joint effusion of the R knee, with atrophy to R quads and calf muscles
Decreased A/PROM of right knee: flexion 120/125 and extension -5/-5 with abnormal muscle end-feel.
L=WNL
Hypomobile tibiofemoral and patellofemoral joints of R knee in all directions with abnormal capsule endfeel. L=WNL
Decreased strength and muscle atrophy of the following muscles:
Hip Adductors/ Hip Flexors/ Hamstrings / Glut Max/ Glut Med
Incomplete MMT of quad, gatroc, and soleus muscles due to unsafe application of force across knee.
Abnormal gait pattern with decreased knee extension, stride length, and decreased weight bearing of
right LE.
The main goals for the acute phase are to protect the repair of the
right knee, reduce inflammation, prevent further atrophy of knee
muscles, reduce pain, increase range of motion of the joint, and
maintain the conditioning of all of the other muscles. Once these
goals have been accomplished, we can begin to strengthen the
muscles surrounding the knee and have the patient weight bear to
facilitate functional activities.
ACUTE HEP
LTG: By week 12, the patient will achieve the following goals to increase
range of motion, decrease swelling, reduce atrophy, and increase strength
in the right knee in order to return to soccer in six months.
Reduce edema of right knee to R=L.
Increase A/PROM of right knee to 135/140 degrees of flexion and 0/0
degrees of extension and reduce abnormal muscle end-feel. L=R
Increase joint accessory mobility of right knee in all directions by 1 grade
and decrease abnormal capsule end-feel so the L=R
Increase strength/reduce atrophy of all of the muscles listed above by 1
grade.
Complete MMT of right quad, gastroc, and soleus and treat accordingly.
Normalize Gait: Pt. will be able to walk with a symmetrical gait pattern and
equal WB with no assistive device for 30 minutes at 3.5 mph on treadmill;
15 minutes with 10% incline.
STG: By week 8, the patient will achieve the following short term goals to
achieve the above LTG.
Reduce edema of right knee
Increase A/PROM of right knee to 115/120 degrees of flexion and 3/3
degrees of extension and reduce abnormal muscle end-feel.
Increase joint accessory mobility of right knee by grade in all directions
and decrease abnormal muscle end-feel.
Increase strength/reduce atrophy of all muscles listed previously by
grade.
Complete MMT of right quad, gastroc, and soleus and treat accordingly.
Normalize Gait: Pt. will be able to walk with a symmetrical gait pattern and
equal WB with no assistive devices for 15 minutes at 3.5 mph on treadmill;
no incline
Rationale Summary:
Settled Phase
12-19 weeks
SETTLED PHASE
12-19 weeks post-op
Settled Phase
12-19 weeks
Impairments:
Decreased strength of R hamstrings and gluteus medius, both a
4+/5. R quads/calf muscles 4/5. L=WNL
Atrophy of R knee musculature:
Decreased length of R rectus femoris at 75 degrees of knee flexion,
and R hamstrings at 75 degrees. L rectus femoris 90 degrees of
knee flexion and L hamstrings 90 degrees hip flexion.
Hypomobile tibiofemoral and patellofemoral joints of R knee in all
directions with abnormal capsule end-feel. L=WNL
Decreased R SL balance with eyes closed to 20 seconds.
Decreased functional ability: decreased power, endurance, agility,
speed
SETTLED PHASE
Rationale Summary:
In the settled phase of healing, fibroblasts remodel previously laid
down collagen fibers making the connective tissue more functionally
efficient. The collagen becomes stronger, thicker, and realigned to
orient the fibers along the lines of mechanical stress. Rehabilitation
should be sports specific, utilizing the SAID principle to
progressively overload the tissues in ways specific to the
movements needed to play high level soccer. Rehab should also
focus on recruiting both fast twitch muscle fibers to enhance speed,
power, and agility and slow twitch muscle fibers to increase
endurance and dynamic stability. Finally, the patient should be
taught proper techniques in both plyometric and change of direction
drills to recruit muscle fibers in the proper sequence to avoid further
injury and enhance overall sports performance.
RETURN TO SPORT
20-24 weeks post-op
RETURN TO SPORT
20-24 weeks
Mobility Needs
Impairments:
Decreased functional ability: decreased power, endurance, agility,
speed
LTG: By week 24, pt will be able to run a 40 yard sprint under 5.4
seconds, perform vertical jump of 22 inches, score a level 10 on the
Beep Test, and perform 5/10/5 in under 4 seconds.
STG: By week 22, pt will be able to run a 40 yard sprint under 5.8
seconds, perform vertical jump of 20 inches, score a level 8 on the
Beep Test, and perform the 5/10/5 in 5 seconds.
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