1. KAITLIN TORTORICH POST-ACL REPAIR ROM DEFICIENCY CASE STUDY:

2. OBJECTIVES  History  Evaluation  Diagnosis  Treatment  Procedure in Detail  Post-op Rehab and Plan  Rehab protocol weeks 1-12

3. HISTORY  This was an 18 year old female basketball player that was 8 months post ACL reconstruction hamstring graft and meniscus repair.  Athlete still had difficulty with full extension and flexion at 10-115 degrees.  She has been working with the sports medicine clinic, where they performed daily ROM measurements before and after modalities.

4. EVALUATION  Left (injured) Knee: Normal gait, 5/5 strength, incisions were all well-healed  Negative Lachman test  Negative Low-c test  Negative pivot test  Positive quad weakness  ROM 10-115 degrees

5. DIAGNOSIS  Impression: Healed ACL reconstruction with arthrofibrosis in the knee  Severe loss of ROM from scar tissue build up

6. TREATMENT  Athlete followed up with her Physician and was taken to the OR for manipulation under anesthesia, diagnostic arthroscopy, and possible debridement.  She will begin physical therapy immediately following the procedure.

7. PROCEDURE IN DETAIL  Diagnostic arthroscopy revealed scar tissue build up blocking full ROM.  Debridement of the scar tissue was performed by cauterizing the scar tissue away from the ACL.  Manipulation of full extension and flexion was performed after debridement.

8. PROCEDURE FILM: Before Debridement (Scar Tissue on ACL) After Debridement

9. POST-OP REHAB AND PLAN  Athlete will begin rehab immediately following surgery, and will continue 3-5 times per week for 2-4 weeks, then reassess.  Long Term Goal: Athlete will demonstrate full strength and ROM WNL compared to right knee allowing for full return to play.  Short Term Goals:  1.) Restore and maintain full PROM in knee extension and flexion (0-130 degrees)  2.) Restore and maintain full AROM in extension and flexion (0-130 degrees)  3.) Begin to restore quad and hamstring strength compared bilaterally

10. REHAB: WEEK 1  Modalities: Edema and Pain control with Cryotherapy and E-Stim, Ultrasound  Therapeutic Exercises: Ankle pumps, 4-way leg raises while laying, Quad sets, gait training  ROM: Wall slides for flexion, weight on knee for extension, manual therapy for PROM  Assessment of wk. 1: Full extension, 126 degrees of flexion, Normal gait restored, 5/5 strength

11. REHAB: WEEK 2-3  Modalities: Edema and Pain control with Cryotherapy and E-Stim, Ultrasound  Therapeutic Exercises: 4-way leg raises while laying, Quad sets, hamstring curls lying prone, begin balance exercises, begin light weight shuttle program  ROM: Wall slides for flexion, weight on knee for extension, manual therapy for PROM, AROM with physio-ball  Assessment of wk. 2-3: Full extension, 130 degrees of flexion, 5/5 strength

12. REHAB: WEEK 4  Modalities: Edema and Pain control with Cryotherapy and E-Stim, Ultrasound  Therapeutic Exercises: 4-way leg raises while laying, Quad sets, hamstring curls lying prone, balance pad exercises, Shuttle jump program  ROM: Wall slides for flexion, weight on knee for extension, manual therapy for PROM, AROM with physio-ball  Assessment of wk. 4: Full extension, 130 degrees of flexion, 5/5 strength

13. WEEK 4 REHAB REASSESSMENT:  Athlete has maintained full extension and can actively get to 130 degrees of flexion  Maintains 5/5 strength; Quad and hamstring strength WNL compared bilaterally  Plan: Athlete is released to limited practice for basketball with ACL brace. She will continue to work on flexion and extension at Physical Therapy.  Physical Therapy will reassess in 2 weeks  Will follow-up with Physician in 4 weeks

14. REHAB: WEEK 5-6  Modalities: Edema and Pain control with Cryotherapy and E-Stim, Ultrasound  Therapeutic Exercises: Continue to build strength with progression of previous exercises  ROM: Wall slides for flexion, weight on knee for extension, manual therapy for PROM, AROM with physio-ball  Assessment of wk 5-6: Full extension, 130 degrees of flexion, 5/5 strength, may progress in practice

15. REHAB: WEEK 6-8  Week 6 reassessment: Physical Therapy no longer recommending therapy for L knee, she is participating in all practices and games and is also attending the Sports Med clinic.  Plan: Athlete should continued ROM exercises at home and attend the Sports Med clinic PRN.  Week 8 reassessment (with Physician): Athlete is fully released to return to play.  Plan: Continue to work on full ROM. Will follow up in 10 wks. for range of motion check

16. ARTICLES  Millett, P. J., Wickiewicz, T. L., & Warren, R. F. (2001). Motion Loss after Ligament Injuries to the Knee Part I: Causes. The American journal of sports medicine, 29(5), 664-675.  Wilk, K. E., Macrina, L. C., Cain, E. L., Dugas, J. R., & Andrews, J. R. (2012). Recent advances in the rehabilitation of anterior cruciate ligament injuries. journal of orthopaedic & sports physical therapy, 42(3), 153-171.