1. Injury Management of The Anterior Cruciate Injury

2. Sprains Sprains Anterior cruciate Anterior cruciate Posterior cruciate Posterior cruciate Medial collateral Medial collateral Lateral collateral Lateral collateral

3. Injury Prevention

4. Knee Taping

5. Knee Evaluation

6. CHECK LIFE THREATENING SITUATIONS _____ABC'S (usually not a problem) _____check for traumatic shock CHECK LIFE THREATENING SITUATIONS _____ABC'S (usually not a problem) _____check for traumatic shock HISTORY OF THE INJURY _____where doe’s it hurts? point to the spot. _____when did it happened? _____how did it happened? _____what was the position of foot and knee before injury? _____what was the position of foot and knee after injury? _____what activity bothers you most? _____did you hear or feel a pop, snap, crack _____does your knee lock _____were you able to continue your activity after the injury HISTORY OF THE INJURY _____where doe’s it hurts? point to the spot. _____when did it happened? _____how did it happened? _____what was the position of foot and knee before injury? _____what was the position of foot and knee after injury? _____what activity bothers you most? _____did you hear or feel a pop, snap, crack _____does your knee lock _____were you able to continue your activity after the injury HISTORY OF THE INDIVIDUAL _____have you had a previous knee injuries? when? _____ -did you see a physician _____ -what was your rehab. _____have you made any training changes HISTORY OF THE INDIVIDUAL _____have you had a previous knee injuries? when? _____ -did you see a physician _____ -what was your rehab. _____have you made any training changes

7. OBSERVATION _____compare opposite sides of the body _____observe for swelling _____observe for deformity _____observe for muscle atrophy ( _____-patella alta _____-patella baja ( observe for alignment) _____-genu valgum _____-genu varum _____-Q angle OBSERVATION _____compare opposite sides of the body _____observe for swelling _____observe for deformity _____observe for muscle atrophy ( observe the position of the patella) _____-patella alta _____-patella baja ( observe for alignment) _____-genu valgum _____-genu varum _____-Q angle PALPATE _____tell athlete it will hurt and why _____palpate for pain or point tenderness _____palpate for bumps, deformity, and effusion (swelling in joint) _____start away from suspected injury _____palpate the bones (femur, tibia, fibula, patella) _____palpate ligaments (MCL, LCL, ) _____palpate joint lines _____palpate muscles/tendons (hamstring, quads, gastroc, ) _____palpate bursae PALPATE _____tell athlete it will hurt and why _____palpate for pain or point tenderness _____palpate for bumps, deformity, and effusion (swelling in joint) _____start away from suspected injury _____palpate the bones (femur, tibia, fibula, patella) _____palpate ligaments (MCL, LCL, ) _____palpate joint lines _____palpate muscles/tendons (hamstring, quads, gastroc, ) _____palpate bursae

8. TEST STRUCTURAL INTEGRITY _____sensory nerves _____motor nerves TEST STRUCTURAL INTEGRITY _____sensory nerves _____motor nerves_____circulation_____Reflexes _____ -patellar reflex (L3 and L4) _____ -medial hamstring reflex (L5) Active ROM _____ -flex, extend knee Passive ROM _____ -flex, extend knee Resistive ROM _____ sartorius _____quadriceps _____biceps femoris _____semitendinosus/ semimembranosus _____popliteus

9. Special Tests Special Tests _____ -valgus stress test (straight and 20 flex) _____ -varus stress test (straight and 20 flex) _____ -figure 4 test _____ -Lachman's test Lachman Varus stress Valgus stress

10. TEST FUNCTIONAL ACTIVITY _____**only if you suspect a mild injury** _____walk _____hop 10 times on injured leg (if walking is pain free) _____jog (if hopping is pain free) _____run and cut (if jogging is pain free) 8. DECISION AND ACTION _____if it is a mild injury--tape & play _____if it is a moderate injury--ICE & rest _____if it is a severe–refer to a physician 9. RE-EVALUATE _____after ICE, if used _____throughout rehabilitation 10. RECORD RESULTS _____ enter injury report in records TEST FUNCTIONAL ACTIVITY _____**only if you suspect a mild injury** _____walk _____hop 10 times on injured leg (if walking is pain free) _____jog (if hopping is pain free) _____run and cut (if jogging is pain free) 8. DECISION AND ACTION _____if it is a mild injury--tape & play _____if it is a moderate injury--ICE & rest _____if it is a severe–refer to a physician 9. RE-EVALUATE _____after ICE, if used _____throughout rehabilitation 10. RECORD RESULTS _____ enter injury report in records

11. First Aid Care Ice, Compression, Elevation Ice, Compression, Elevation Knee immobilizer Knee immobilizer Crutches Crutches

12. TRADITIONAL REHABILITATION

13. WEEKS 0-2: Non weightbearing Non weightbearing Brace locked at 30 and 60 degrees Brace locked at 30 and 60 degrees Quadricep and Hamstring isometrics Quadricep and Hamstring isometrics Electrical muscle stimulation Electrical muscle stimulation Ankle ROM and strengthening Ankle ROM and strengthening Heel slides Heel slides Patellar mobilization Patellar mobilization

14. WEEK 4: Non weightbearing Non weightbearing Brace locked at 30 and 90 degrees Brace locked at 30 and 90 degrees Quadricep and Hamstring isometrics Quadricep and Hamstring isometrics Straight leg raises Straight leg raises Electrical muscle stimulation Electrical muscle stimulation Pool exercises (hip and ankle) Pool exercises (hip and ankle)

15. WEEK 6: Non weightbearing Non weightbearing Brace locked at 0 and 90 degrees Brace locked at 0 and 90 degrees Quadricep and Hamstring isometrics Quadricep and Hamstring isometrics Straight leg raises with weight Straight leg raises with weight Hamstring curls Hamstring curls Hip progressive resistance exercises Hip progressive resistance exercises Pool ROM Pool ROM Cycling for ROM Cycling for ROM

16. WEEK 8: Begin weightbearing Begin weightbearing Derotational brace without limits Derotational brace without limits ROM should be 0 and 110 degrees ROM should be 0 and 110 degrees Cycling Cycling Hamstring curls Hamstring curls

17. 3 MONTHS: ROM 0 and 125 degrees ROM 0 and 125 degrees Treadmill walking Treadmill walking SLR with weight increase SLR with weight increase Cycling Cycling Quarter squats Quarter squats

18. 4 - 6 MONTHS: ROM 0 and l40 degrees ROM 0 and l40 degrees Treadmill walking (taster) Treadmill walking (taster) Isotonic knee extensions Isotonic knee extensions Isokinetics when 10% of body weight can be done isotonically (90-240 degrees/second) Isokinetics when 10% of body weight can be done isotonically (90-240 degrees/second) Step-ups Step-ups

19. 6 MONTHS: Test isokinetically Begin terminal knee extension Running (straight ahead)

20. ACL Rehabilitation Program Chehalem Physical Therapy, Inc., 120 - C N. Everest Rd., Newberg, Oregon 97132

21. Day 1 – 3 Range of motion with emphasis on knee extension. Range of motion with emphasis on knee extension. Cold therapy (with compression and elevation). Cold therapy (with compression and elevation). Weight bearing to comfort with crutches using long-leg brace locked at 0 degrees. Weight bearing to comfort with crutches using long-leg brace locked at 0 degrees. Patellar, scar, and soft-tissue mobilization. Patellar, scar, and soft-tissue mobilization. Exercises: Exercises: Quad/Hamstring setting. Quad/Hamstring setting. Heel slides. Heel slides. Knee extension stretch with heel pillow Knee extension stretch with heel pillow Ankle pumps. Ankle pumps. SLR (in long-leg brace; locked). SLR (in long-leg brace; locked). Patellar mobilization. Patellar mobilization.

22. Day 4 – 14 Weight bearing as tolerated with full weight bearing. Weight bearing as tolerated with full weight bearing. Continue with pain control, range of motion, and mobilization treatment. Continue with pain control, range of motion, and mobilization treatment. Begin balance and position-sense exercises (tandem stance, single stance, mini-tramp balance). Begin balance and position-sense exercises (tandem stance, single stance, mini-tramp balance). Exercises: Exercises: Quarter squats/weight shifts. Quarter squats/weight shifts. Hamstring curls. Hamstring curls. Stationary bike for range of motion and early endurance. Stationary bike for range of motion and early endurance. Lateral step-ups. Lateral step-ups. Calf raises. Calf raises.

23. Week 2 - 6 Push for full extension range of motion. Push for full extension range of motion. Exercises: Exercises: Leg press Leg press Sport cord drills Sport cord drills Swimming, cycling, functional exercises (squats, lunges) Swimming, cycling, functional exercises (squats, lunges) Fit for custom sports brace (per MD). Fit for custom sports brace (per MD).

24. Week 7 – 11 Exercise progression (intensity, resistance, and aerobic work). Exercise progression (intensity, resistance, and aerobic work). Begin lateral resistance drills (sport cord, carioca). Begin lateral resistance drills (sport cord, carioca). Straight-line jogging. Straight-line jogging.

25. Week 12 – 16 Advanced closed kinetic chain functional exercises. Advanced closed kinetic chain functional exercises. Sport-specific exercises. Sport-specific exercises. Isokinetic knee evaluation 90 - 40 degrees. Isokinetic knee evaluation 90 - 40 degrees.

26. Week 16 + Progressive cutting/pivoting. Progressive cutting/pivoting. Progressive running. Progressive running. Progressive plyometrics. Progressive plyometrics.

27. Criteria for return to competition: Full range of motion. Full range of motion. Normal balance and proprioception. Normal balance and proprioception. 90% or better functional strength. 90% or better functional strength.

28. University of Oregon Athletic Medicine Anterior Cruciate Ligament Rehabilitation Protocol Purpose: The purpose of having a written protocol for the rehabilitation of knees after ACL reconstructive surgery is not to create a "cook book" formula, but to have an outline that can be followed as a consistent guideline for progression of the athlete. The time frames may change depending on the goals of each athlete and the philosophy of the surgeon. Ideally, surgery would be delayed until knee motion and quadriceps control are restored and effusion is minimal. Purpose: The purpose of having a written protocol for the rehabilitation of knees after ACL reconstructive surgery is not to create a "cook book" formula, but to have an outline that can be followed as a consistent guideline for progression of the athlete. The time frames may change depending on the goals of each athlete and the philosophy of the surgeon. Ideally, surgery would be delayed until knee motion and quadriceps control are restored and effusion is minimal.

29. Weeks 1-4 Goals: Goals: Decrease pain and swelling Decrease pain and swelling Increase ROM Increase ROM Progress from partial to full weight bearing with proper gait Progress from partial to full weight bearing with proper gait Increase quadriceps and Increase quadriceps and hamstring strength hamstring strength Promote proper patellofemoral function Promote proper patellofemoral function Initiate restoration of proprioception Initiate restoration of proprioception Promote crossover effect by exercising uninvolved knee Promote crossover effect by exercising uninvolved knee Specific Rehabilitation Techniques: Specific Rehabilitation Techniques: Ice/electrical modalities Ice/electrical modalities Quadriceps/hamstring sets (single & co-contraction) Quadriceps/hamstring sets (single & co-contraction) Biodex PROM (Pain-Free) Biodex PROM (Pain-Free) Patellar mobilization Patellar mobilization Prone hangs (Progress to ankle weights) Prone hangs (Progress to ankle weights) Supine passive terminal extension stretch Supine passive terminal extension stretch VMO training (starting w/QS & Russian EMS) VMO training (starting w/QS & Russian EMS) Lateral complex stretching & McConnell taping (If necessary) Lateral complex stretching & McConnell taping (If necessary) Ankle pumps & PNF Ankle pumps & PNF AROM leg extension (No resistance) AROM leg extension (No resistance) MRE for hip (Ext., ab., ad., flex. (bent knee) MRE for hip (Ext., ab., ad., flex. (bent knee) Note: Adduction is contraindicated during this time for athletes who also injured their MCL Note: Adduction is contraindicated during this time for athletes who also injured their MCL Non-weight bearing to weight bearing step-up progression Non-weight bearing to weight bearing step-up progression Bike for ROM Bike for ROM ¼ Squats ¼ Squats Carpet Drags Carpet Drags Step-ups w/Russian EMS Step-ups w/Russian EMS Shuttle w/Russian EMS Shuttle w/Russian EMS Sport cord 1/3 squats (double & single leg) Sport cord 1/3 squats (double & single leg) Shuttle leg presses (double and single leg) Shuttle leg presses (double and single leg) Leg curls (single) Leg curls (single) Bridging with and without a physioball (Can be initiated after athlete has 45 degrees of flexion) Bridging with and without a physioball (Can be initiated after athlete has 45 degrees of flexion) Single leg balance (Begin on floor, progress to foam and then to trampoline) Single leg balance (Begin on floor, progress to foam and then to trampoline) UBE UBE Calf exercises (Seated machine, leg press, shuttle, standing) Calf exercises (Seated machine, leg press, shuttle, standing)

30. Weeks 5-12 Weeks 5-12 Goals: Goals: Continue to strengthen the quadriceps muscles with closed chain exercises ONLY Continue to strengthen the quadriceps muscles with closed chain exercises ONLY Continue to strengthen the hamstring muscles Continue to strengthen the hamstring muscles Facilitate proper gait patterns and joint mechanics Facilitate proper gait patterns and joint mechanics Continue to facilitate proprioception Continue to facilitate proprioception Initiate restoration of cardiorespiratory function Initiate restoration of cardiorespiratory function Specific Rehabilitation Techniques: Specific Rehabilitation Techniques: WWP (AROM) WWP (AROM) Leg curls (single) Leg curls (single) Hip & thigh machine Hip & thigh machine Step-downs w/Russian EMS Step-downs w/Russian EMS Backward walking on treadmill (Progress to 2.0 MPH at 12x % grade for 5 minutes) Backward walking on treadmill (Progress to 2.0 MPH at 12x % grade for 5 minutes) Shuttle leg presses (Double & single leg) Shuttle leg presses (Double & single leg) Leg press Leg press Tubing squats Tubing squats Biodex (Hamstrings only) Biodex (Hamstrings only) Eccentric hamstrings on Biodex Eccentric hamstrings on Biodex Squats (Back & overhead) Squats (Back & overhead) Pool Pool Bike Bike Form walking routine Form walking routine Balance squats Balance squats Single leg balance (Progress to trampoline: eyes open/closed w/wo body blade) Single leg balance (Progress to trampoline: eyes open/closed w/wo body blade) Stairmaster Stairmaster Slideboard Slideboard Treadmill walking Treadmill walking Treadmill walk/jog Treadmill walk/jog Treadmill jogging Treadmill jogging Treadmill walking/running Treadmill walking/running Seated calf raises Seated calf raises Ball toss Ball toss Chair scoots Chair scoots Calf exercises (seated machine, leg press, shuttle, standing) Calf exercises (seated machine, leg press, shuttle, standing)

31. Weeks 13-24 Weeks 13-24 Goals: Goals: Continue increasing strength, power, muscular endurance Continue increasing strength, power, muscular endurance Restoration of cardiorespiratory function Restoration of cardiorespiratory function Further development of normal gait patterns Further development of normal gait patterns Progress from general sport movements to sport and position specific drills Progress from general sport movements to sport and position specific drills Specific Rehabilitation Techniques: Specific Rehabilitation Techniques: Stairmaster Stairmaster Bike Bike Treadmill Jogging Treadmill Jogging Leg curls (Single) Leg curls (Single) Biodex (Hamstrings only) Biodex (Hamstrings only) Eccentric hamstrings on Eccentric hamstrings on Biodex Biodex Ball toss (Foam & trampoline) Ball toss (Foam & trampoline) Strides Strides Figure 8’s Figure 8’s Zig-zags Zig-zags Stadiums Stadiums Form walking/running routine Form walking/running routine Slideboard Slideboard Sport cord jogging Sport cord jogging Leg press Leg press Shuttle leg presses (Double & single leg) Shuttle leg presses (Double & single leg) Shuttle jumps (Double & single leg) Shuttle jumps (Double & single leg) Fitter Fitter Calf exercises (Seated machine, leg press, shuttle, standing) Calf exercises (Seated machine, leg press, shuttle, standing)

32. 6-9 Months Goals: Goals: Increase strength, power, muscular endurance to 90%+ of uninvolved leg Increase strength, power, muscular endurance to 90%+ of uninvolved leg Increase running and cutting to meet demands of individual sport Increase running and cutting to meet demands of individual sport Increase cardiorespiratory function to levels needed for particular sport participation Increase cardiorespiratory function to levels needed for particular sport participation Progress to partial of full sport activities Progress to partial of full sport activities Specific Rehabilitation Techniques: Specific Rehabilitation Techniques: Biodex testing (180 degrees – 10 reps, 300 degrees – 15 reps) Biodex testing (180 degrees – 10 reps, 300 degrees – 15 reps) Return to activity drills Agilities Return to activity drills Agilities Plyometric program Plyometric program Calf exercises Calf exercises Squats Squats Shuttle jumps (Double & single leg) Shuttle jumps (Double & single leg) Leg curls (Double) Leg curls (Double) Sprint Progression Sprint Progression Integrate into normal lifting and conditioning activities with appropriate limitations Integrate into normal lifting and conditioning activities with appropriate limitations

33. 9-12 Months Goals: Goals: Continue rehabilitation of any deficient areas of involved extremity (i.e. strength, power, muscular endurance, or cardiorespiratory function) Continue rehabilitation of any deficient areas of involved extremity (i.e. strength, power, muscular endurance, or cardiorespiratory function) Maintenance program for non-deficient areas Maintenance program for non-deficient areas Specific Rehabilitation Techniques: Specific Rehabilitation Techniques: Appropriate exercises from previous techniques Appropriate exercises from previous techniques Biodex Testing (If necessary) Biodex Testing (If necessary)