Accelerated ACL Rehabilitation

Hu gh West, Jr., MD K. Donald Shelbourne, MD

Purpose
20 minute overview of one accelerated ACL rehabilitation technique u Not intended to create a debate over theories or practices D Due to time constraints Will challenge current models and practices

O Objectives

Background on Dr. Shelbourne Shelbouneb based rehabilitation protocol Rehabilitation considerations

Dr. Shelbourne
Practicing since 1982 with a knee only focus Currently limits practice to ACL repair, simple scopes, and realignments. Reports a patient profile of >50% young athletes Over 80 publications as primary author (knee related) Holds patent on the cryo-cuff

Dr. Shel

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Claims that most ph sicians tend to focus on the sur ical techni ue
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States rehabilitation is an afterthou ht left to the ph sical therapist/athletic trainer to f i ure out u
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Demands a lon term follow up of patients Emplo s ~4 FTE researchers s Performs all rehabilitation in-house
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Emplo s 5 PTs and/or ATCs

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What Ive Learned About the ACL , KDS, 2003

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What I've Learned About the ACL" , KDS, 2003

ShelbourneSur ical Tech

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Mini-Arthrotomy
For optimal raft placement
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Has alwa s used this techni ue, to maintain comparabilit of data

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Has allow rehabilitation to be the dependent variable in outcome

Button fixation
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04

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What I've Learned About the ACL", KDS, 2003

v e n t s o v e r t e n s i o n i n
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l l o w s t i
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h t b o n e f i t

Utilizes a contralateral donor raft, exclusively

Stron raft, allows B2B healin Claims it allows for earl return to
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sports

Wh at Ive Lear ned Abo ut the ACL , KDS , 200 3

Reach s mmetr between knees

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Ran e of Motion
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Stren th
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Stabilit

O Overall Function

Would rather have two knees @ 90% of preop levels than a 100%/70% split of preop levels

S mmetr
y

S mmetr is also necessar for all patients to be able to do normal ever day activities comfortabl (stairs, s uattin ) Man patients have a stable knee but never achieve knee s mmetr , and yet the are told the have a ood result
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All these issues are a problem in some wa , re ardless of the raft source
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What Ive Learned About the ACL , KDS, 2003

Lack ext/normal flex fter surgery IKDC valuesNormal ext/flex Normal ext/lack flexion Lack ext/lack flexon

Emphasize Full Extension/Hyperextension

Normal extension is defined by the normal knee preop levels Aggressive use of extension exercises to return normal extension values

What Ive Learned About the ACL, KDS, 2003

"

What I've Learned About the ACL", KDS, 2003

Rehabili

Protocol Rehabilitation Protocol

Calls into question the notion of graft strength timelines
Idea that graft is strong/weaker depending on point in time; related to vascularization p

Protocol is built on criteria based progression rather than time based progression.

Shelbourne claims it now models many things he told his patients not to do, they did anyways, and still got better s Results in 1wk, 2wk, 4wk, 8wk, 12wk, PRN f follow up visits / rehabilitation sessions Relies on patients to follow guidelines and perform exercises at home Allows patients to make decisions regarding what they can and cannot do; with advisement

Rehabilitation Cascade of Ev

Pre-o rehab: No sweling, f u l ROM, good leg control

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Surgery: F u l ROM after graft lacement and fixation

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Post-o - F u l ROM and no sweling C onf l i c t i ng

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Increase leg strength g oa l s Pro rioce tion and agility drils

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S ort-s ecific drils Com etition

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What Ive

Learned About the ACL , KDS, 2003

P Pre-Op Education Heel Slides Towel-Toe Pull/Hyperextension Quad Sets S t r a i ght Leg Raises h
P Patient

Compression & Cold to prevent h hemarthrosis

CPM provides elevation & ently maintains available ROM

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Patients kept for a 23hr stay

G Good terminal extension, actively

Flexion measured by patient using a yardstick Excellent self-assessment tool

Helps when patients call w/ ?

Walkin g for bathroom privile ges

First 5 da ys at hom s 5 da ys of bed rest

1d-5d s/p ALC-r

Bed rest except for bathroom privileges e Heel prop extension exercises 10 min y 6x/day Flexion exercises 6x/day SLR Quad Sets CPM & Cryo/Cuff worn continually except during exercises

Knee needs a period of rest, elevation, and c cold/compression to prevent a hemarthrosis Without a hemarthrosis
Obtaining full ROM is easier when the knee does not have an effusion Knee is less painful Quad control can be obtained easier

week post-op
If patient has been compliant, Minimal effusion will be present, ROM will be excellent, and NM control is a acceptable Transition Exercises were possible
Heel slides wall slides QS/SLR Step Downs/SAQ

1 week post-op
Can return to dail y activities Use of cr y o/cuff after exercises o Emphasis of a normal g ait a Monitor swellin g
Adjust activities where needed to prevent g swelling

Return of normal flexion/extension values emphasized

2 2

weeks

Instructions:
Maintain full hyperextension Increase flexion Emphasize a normal gait pattern H i gh repetition exercise for graft-donor site Use Cryo/Cuff after exercise Can return to daily activities Monitor swelling and adjust activities to keep swelling to a minimum

weeks Post-op
If >125, no lon ger a primar y emphasis

ROM should exceed 125 degrees Progress strength

Increase step h e i ght Lon g Arc Quads Bench Hamstrin gs s

Increase proprioceptive challen ges

4 weeks post-op
By 4 weeks, ROM should be normal or nearnormal
Patient must be able to sit on heels to pro gress Sittin g on heels will remain a test prior to activit y

4weekspost-op
ADLs should pose no challenge e Patient has prerequisite strength to begin g formal strength training Patients who advance quickly may be able to begiin basic sport-specific drills Rules for new activity: No pain during or after activity, No increase in swelling, No altering of gait

Possible Exercises
All h i gh rep, low weight, initially Commonly include:
Leg press HS Curl 4-Way hip SL S Proprioception (i.e. Stork)

May Include:
Slow/Light plyometrics Basic sports skills (i.e., soccer = dribble, short kick)

y 4 8 weeks after sur ger y Patient instructions for next 4 weeks

Additional strengthening with w e i ghts single leg exercises Begin functional agility program Sport-specific agility drills L i gh controlled sport-specific drills ht

If an athlete, may utilize ATC at home y facility If no on-site ATC, support provided via email and phone

8 weeks post-op
If strength is around 70 to 80% (of normal knee pre-op), then begin more intense functional work i E Every other day to allow period of rest Specific functional activity to increase strength Example controlled jumping drills in basketball (rebounding, jump shot) May need to do every other day, dependin g in soreness in tendon g Continue with w e i ght training Keep it specific to the patient!

"W h a t

I've Learned About the ACL

",

KDS, 2003

2-4 months fter sur ger y Continue to progress strength Continually adapt sport-specific drills to more closely resemble actual sport When able to perform drills in a controlled environment, reintroduce to actual p practices When able to practice without difficulty, reintroduce to game situations a Remember, No pain, swelling, or altered gait

Important Note
Use Objective Feedback
Isometric Leg Press w/ tensiometer
1,2,4,8,12

Biodex when capable

4,8,12

3PQ; Leg Press Force Place

4,8,12

Consideratio
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Consideratio
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If you try to do a ressive stren thenin immediatel after ACL reconstruction, the knee will become swollen, stiff, and painful So it is best to wait until full ROM has been obtained before the patient be ins a ressive stren thenin
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What Ive Learned About the ACL, KDS, 2003

Even then, when doin stren thenin exercises, ROM must be monitored dail to make sure the knee is not losin motion Patients h i hest function will be at the level of the worst knee/leg Must obtain s mmetr with ROM and stren th for function to be totall normal
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What Ive Learned About the ACL, KDS, 2003

y Summar y Re g ardless of g raft source, proper and complete pre-op and post-op rehabilitation y is necessar y Patient must go throu g h a pro g ression of s steps to achieve an optimum result Full s y mmetrical ROM is re q uired to obtain the best lon g -term result Obtainin g full s y mmetrical ROM, stren g th, and function is possible
W h a t
Ive Learned About the ACL , KDS, 2003

This presentation was created based on oral & written communications with Dr. K Donald Shelborne. It also incorporate much information found on a powerpoint authored by Dr. Shelbourne, entitled What Ive Learned About the ACL, 2003 version. For more information re g ardin g Dr. Shelbournes techni q ues or practice, please visit: www.aclmd.com