1. REHABILITATION AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
H SELCUK KUCUKOGLU
ULUDAG UNIVERSITY
SCHOOL OF MEDICINE
DEPARTMENT OF PM&R AND SPORTS MEDICINE

2. EPİDEMİOLOGY
Yearly incidence of ACL injuries has been reported to be 3/10,000 inhabitants in Denmark (Nielsen, 1991),
In Sweden, ACL injuries comprise 43% of all soccer related injuries (Roos,1995),…

3. Operation time after the injury (months) Sex
Type of graft
Age
(Year)
Weight
(kg)
Operation time after the injury (months)
Sex
Level of Sportive Activity
Injury level
Injured extremity M F Sp
Sed Ak
Sub Kr
Right
Left PT
25.66.9
75.19.4
21.732.6 53 2 36 19 9 44 29 26 SG
26.35.6
75.910.8
14.719.1 24 1 5 20 4 13 12

4. GOAL
The goal of ACL reconstruction is to improve the patients level of function, with in the hope of allowing them to return to an active life style, with minimal disability, while protecting them from further injury to the knee.

5. why treat
After an ACL lesion, knee instability is common and may produce progressive functional changes and damage to other joint structures (meniscal damage,articular cartilage damage,and degenerative arthritis) which may also affect daily life activities.

6. why TREAT
The ACL has poor potential for spontaneous healing after complete rupture,and therefore conservative treatment aims to develop joint motion patterns that help control abnormal knee motions which can arise in the absence of functional ACL.

7. why TREAT
In the years following an ACL injury additional meniscus ruptures frequently occur. 80% of ACL deficient patients were found to have a torn meniscus within 2 years of ACL injury.
Gillquist-Messner (Sports Med. March 1999)

8. why REHABILITATION
Optimal healing of an ACL graft and the knee is dependent on rehabilitation,
The strains applied to an ACL graft by body weight, muscle activity, and joint motion affect its healing response,

9. ACCELERATED REHABILITATION
Investigations of ACL grafts that have been done in animals indicate that they lose their ultimate failure strength and undergo a decrease of stiffness and the knees have an increase in anterior laxity develop during healing.

10. Accelerated rehabilitation
The exact cause of above mentioned changes and the application of this data to humans are unclear.Rougraff-Shelbourne reported that large proportion of the tendon survives and ACL graft healing in humans may not undergo the same complete necrotic stage that has been reported in animals.
Knee Surg Sports Traumatol Arthrosc 1999

11. ACLRehabilitation Preoperative Phase: Goals
Diminish inflammation,swelling, and pain
Restore normal range of motion (extension)
Restore voluntary muscle activation
Provide patient education to prepare for surgery
Brace-elastic wrap or knee sleeve to reduce swelling
Weight bearing-as tolerated with or without crutches

12. ACL Rehabilitation2 Preoperative phase Exercises Ankle pumps
Passive knee extension to zero
Passive knee flexion to tolerance
Straight leg raises (3-way, flexion, abduction, adduction
Quadriceps setting
Closed kinetic chain exercises: mini squats, lunges, step-ups

13. ACL Rehabiltation3 Preoperative Phase
Muscle stimulation-electrical muscle stimulation to quadriceps during voluntary quadriceps exercises (4-6 hours/day)
Cryotherapy/elevation-apply ice 20 minutes of every hour, elevate leg with knee in full extension
Patient education- review postoperative rehabilitation program

14. BIOMECHANICS
Isometric exercises that strain the ACL involve contraction of the dominant quadriceps muscle group with the knee between extension and 60° flexion, or involve isotonic contraction of the quadriceps between extension and 50° flexion,

15. Biomechanics2
The largest ACL strain magnitudes that have been measured and produced by isometric and isotonic contraction of the quadriceps muscles with the knee near extension.

16. Biomechanics3
Squatting, stationary bicycling,and closed kinetic chain exercises that involves body weight loading and substantial cocontraction of the muscles does not create an appreciable change in ACL strain values.

18. WEEKS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
MOTION
CPM
Intermittant passive motion
EXERCISES
Patellar mobilization
Straight leg raises (4-way)
Isometrics
Stationary bike (if ROM>110º)
Running
Closed chain
Isokinetic Quadriseps (0º-40º not permitted)
Isokinetic Quadriseps (0º-20º not permitted)
Isokinetic Hamstring
PROPRIOCEPTIVE TRAINING
Balance activities (eyes open-closedı, bilaterally)
Balance activities (eyes open-closedı,unilaterally)
Functional skill activites (low to high speed)
WEIGHT BEARING/BRACE
Rigid-hinged brace
Full weight bearing
MODALITIES
Electrical muscle stimulation
Cold (4-6 times/day)
Cold (after exercises)

19. ACL Rehabilitation Immediate postoperative Phase (1-7 days) Goals
Restore full passive knee extension
Diminish joint swelling and pain
Restore patellar mobility
Gradually improve knee flexion
Reestablish quadriceps control
Restore independent ambulation

20. ACL Rehabilitation Early Rehabilitation Phase (2-4 weeks)
Criteria to progress to phase 2
Quad control (ability to perform good quad set and straight leg raises
Full passive knee extension
Passive ROM 0° -90°
Good patellar mobility
Minimal joint inflammation
Independent ambulation

21. ACL Rehabilitation Early Rehabilitation Phase Goals
Maintain full passive knee extension
Gradually increase knee flexion
Diminish swelling and pain
Muscle training
Restore proprioception
Patellar mobility

22. ACL Rehabilitation Controlled ambulation Phase (weeks 4-10)
Criteria to enter phase 3
Active ROM 0° to 115°
Quadriceps strength 60%>contralateral side (isometric test at 60° knee flexion)
Minimal to no joint inflammation
No joint line or patellofemoral pain

23. ACL Rehabilitation Controlled Ambulation Phase(2) Goals
Restore full knee ROM (0° -125°)
Improve lower extremity strength
Enhance proprioception,balance and neuromuscular control
Improve muscular endurance
Restore limb confidence and function
No brace or immobilizer, may use knee sleeve

24. ACL Rehabilitation Advanced Activity Phase (10-16 weeks)
Criteria to enter Phase 4
Active ROM 0°-125°
Quad strength 80% of contralateral side
Knee flexor:extensor ratio 70%-75%
No pain or effusion
*Satisfactory clinical exam
*Satisfactory isokinetic test
(values at 60°/sec, 180°/sec
and 300°/sec)
*Hop Test (80% of contralateral
leg) (4test)
*Subjective knee scoring 80 points
or better (Noyes)

25. ACL Rehabilitation Advanced activity phase (2) Goals
Normalize lower extremity strength
Enhance muscular power and endurance
Improve neuromuscular control
Perform selected sport-specific drills

27. ACL Rehabilitation Return to activity phase Criteria to enter phase 5
Full ROM
Isokinetic test that fulfills criteria
Quad bil comparison (80% or greater)
Hams Bil comparison (110% or greater)
Proprioceptive test (100% of contralateral leg)
Hamstring/quadriceps ratio (70% or greater)
Functional test(85%or greater of contralateral side)
Satisfactory clinical exam
Subjective knee scoring (Noyes) 90 points or better

28. ACL Rehabilitation Return to activity phase (2) Goals
Gradual return to full unrestricted sports
Achieve maximal strength and endurance
Normalize neuromuscular control
Progress skill training

29. Complications Hemarthrosis; Operative trauma and repeated operations
Pretension of the substitute ligament
Septic arthritis
Postoperative arthrofibrosis
Patellafemoral pain
All may lead to gonarthrosis in the long run

30. ROLE of PMR
Check for the goals and the criterias to upgrade the patient
Evaluate the results of isometric and isokinetic tests
Evaluate the results of four HOP tests
Examine the patient when appropriate for the stability
Examine the patient for the complications and progress

31. PROPRIOCEPTION AND BALANCE AFTER ACL RECONSTRUCTION
Ufuk Şekir , Bedrettin Akova , Hakan Gür
Medical School of Uludag University,
Department of Sports Medicine , BURSA

32. THE AIM OF THE STUDY
To observe the changes in the proprioception and balance after ACL reconstruction.

33. PATIENTS AND METHODS 31 patients, mean age 24±7 (17-44)
Patellar tendon autograft
Time period between injury and the operation: 12 months ( 1-96)
Follow-up : At 1th, 2nd, 3rd, 4th, 6th, and 12th months after operation
Accelerated rehabilitation program, includes proprioceptive exercises (which began in the first month):
Single-leg stance on hard surface (eyes open-closed)
Single-leg stance on soft surface (eyes open-closed )
Balance board exercises (eyes open-closed )

34. Joint Position Sense (JPS)
Eyes closed
Index angles: 200,450 and 700
Angular velocity: 10/s
Before matching an index angle, the examiner extends the knee passively to the index angle for 3 s.
Three repetitions for each index angle was made.
The mean of absolute error score (AES) for each index angle was calculated
Mean AES= Sum of means of index angles /3
JPS active
JPS passive
Cybex 6000

35. Single-limb Balance On a soft surface. Eyes open-closed.
First on the uninjured and then on the injured side.
Arms crossed, contralateral leg flexed.
The subjects were required to stand 60s.
Two repetition were made.
Mean number of touchdowns and mean time to first touchdown were recorded.

37. To compare injured-uninjured leg results; Wilcoxon test
STATISTICS
To compare injured-uninjured leg results;
Wilcoxon test

38. The results at the follow-up of the Single-limb Balance Test (Mean number of touchdowns)
** p<0,01, *p<0,05

39. The results at the follow-up of the Single-limb Balance Test (Mean time to first touchdown)
** p<0,01, *p<0,05

40. Joint Position Sense at 200 of Flexion

41. Joint Position Sense at 450 of Flexion
** p<0,01, *p<0,05

42. Joint Position Sense at 700 of Flexion

43. Joint Position Sense (Mean)

44. CONCLUSION
The results of this study indicates that the proprioceptive capabilities of the ACL reconstructed knee can improved to the same level of the uninjured knee at 2 months after operation, with a rehabilitation program including proprioceptive exercises in early phase.

45. FUNCTIONAL CAPACITY AFTER ACL RECONSTRUCTION: RELATIONSHIPS WITH KNEE EXTENSOR AND FLEXOR MUSCLE STRENGTH
1 Bedrettin Akova ,1 Hakan Gür, 1 Ufuk Şekir, 2 Sefa Müezzinoğlu
1Medical School of Uludag University,Department of Sports Medicine , BURSA
2 Medical School of Kocaeli University, Department of Orthopaedic Surgery, KOCAELİ

46. THE AIM OF THIS STUDY;
To determine 1) the functional capacity and 2) the relationships between the functional capacity and knee extensor, and flexor peak torque after ACL reconstruction.

47. PATIENTS AND METHODS Between January, 2000 and June, 2002
21 male patients, mean age 24±7 (17-44)
Patellar tendon autograft
Time period between injury and the surgery: 7 months ( 1-48)
The follow-up was performed at 2nd, 3rd, 4th, 6th, and 12th months after operation

48. FUNCTIONAL TESTS 6 meters Total distance Single Hop For Distance
Triple Hop For Distance
Cross-over Hop For Distance
Timed Hop

49. ISOKINETIC TEST
Cybex 6000
Concentric test for knee flexors and extensors at the angular velocity of 600 and 1800/seconds
Peak torques (Pt)
Both legs

50. STATISTICS To compare injured-uninjured leg results;
Wilcoxon test
Relationships between functional capacity and isokinetic test results;
Pearson correlation coefficient test

51. The results of the Single Hop test
*** p<0.001,** p<0.01 compared with uninjured leg at same month p<0.01 compared with uninjured leg at 2nd month

52. The results of the Timed Hop test
*** p<0.001,** p<0.01, *p<0.05 compared with uninjured leg at same month p<0.01 compared with uninjured leg at 2nd month

53. The results of the Triple Hop test
*** p<0.001,** p<0.01 compared with uninjured leg at same month p<0.001, ++ p<0.01 compared with uninjured leg at 2nd month

54. The results of Cross-over Hop test
*** p<0.001,** p<0.01 compared with uninjured leg at same month p<0.001, + p<0.05 compared with uninjured leg at 2nd month

55. Results

56. RESULTS

57. CONCLUSION
It is concluded that, the functional capacity can improve with a rehabilitation program used in this study up to four months after ACL surgery, and this improvement is significantly correlated by knee strength.

58. Outcome Measures – Patellar Tendon
TIME
2nd week
1st month
2nd month
3rd month
4th month
6th month
12th month
TOTAL SCORE
2,81,2
3,6 1,1
5,4 1,6
6,8 1,3
7,7 1,4
8,7 1,1
8,9 1,1
DAILY ACTIVITY
14,1 9,1
22,7 7,5
32,0 6,6
36,0 3,7
38,3 2,5
38,9 2,6
38,6 2,6
SPORTS ACTIVITY
40,4 2,0
41,5 4,0
52,5 10,8
63,3 11,2
71,7 12,3
83,3 10,4
88,6 9,1

59. Outcome Measures – SG TIME 2nd week 1st month 2nd month 3rd month
4th month
6th month
12th month
TOTAL SCORE
3,21,2
3,9 1,0
5,1 1,2
6,0 1,3
7,2 1,3
7,5 0,8
8,7 0,9
DAILY ACTIVITY
14,7 11,2
22,8 6,8
33,2 4,6
35,8 3,7
37,8 3,5
38,7 2,9
38,7 1,8
SPORTS ACTIVITY
41,4 5,6
41,7 5,7
49,2 10,0
55,1 9,1
64,5 13,9
74,9 9,9
85,3 15,2

60. IKDC - Final Score (Patellar Tendon) % POINT A B C D TIME 2nd week - 496
1st month 2 27 71
2nd month 13 65 22
3rd month 51 43 6
4th month 29
6th month 23 56 21
12th month 54 17

61. IKDC - Final Score (SG) % POINT A B C D TIME 2nd week - 29 71
1st month 12 38 50
2nd month 33 46 21
3rd month 32 58 10
4th month 6 76 18
6th month 8 92
12th month 20 80

62. THANK YOU FOR YOUR
KIND ATTENTION