Saturday, 20 August 2016

ACL INJURY ASSESSMENT & REHABILITATION PROTOCOLS

HAVE YOU SUFFERED AN ANTERIOR CRUCIATE LIGAMENT INJURY? 
Arguable the most devastating injury that an athlete may encounter within their sporting career (especially soccer and skiing). Here is a blog to give you all the information you need to assess & rehab it!

ACL FUNCTION- 
Prevent anterior translation of the tibia relative to the femur. Together with the PCL It limits hyper-extension, hyper-flexion & internal rotation of the knee.

FACTS
  • ACL Accounts for only 1% of all football injuries but the long term effects can be significant to the long term health of the knee joint.
  • 30% of cases reported ACL damage in isolation
  • 50% of cases involve Meniscal damage
  • 90% of 'ELITE' players will return to play within 12 months
  • In the 'GENERAL' population a study of nearly 6000 reconstructed knees showed that only 60% returned to pre- injury fitness levels, only 44% returned to full competitive matches.
  • Those who have damaged their ACL are more at risk of OA than those who haven't.
  • Women are 3 times more likely to tear the ACL in football & 8 times more likely to suffer ACL injury than men in other sports
  • Women higher risk due to anatomical, hormonal factors and neuromuscular differences.
HISTORY
  • Associated direct trauma such as a tackle is very rarely involved.
  • ACL tears often occur via non-contact trauma.
  • Players often report uncontrolled twisted movement
  • Caused by pivoting (foot stuck), landing from a jump (on a bobble or with poor balance) or sudden deceleration
  • ACL tears occur when the knee is slightly flexed and the hip adducts (falls inward). In medical terms this is known as the 'point of no return'.
SIGNS & SYMPTOMS
  •  Popping/ snapping sensation
  •  Loss of control
  • Spasm of he quadriceps muscles around the knee
  • Rapid almost immediate swelling due to bleeding in the joint capsule
  • Feeling of something being out of place
  • Apprehension on weight bearing
  • Pain (but not in all cases)
If you are not diagnosed immediately but suffer reoccurring instability report to your GP

INVESTIGATION: If ACL damage is suspected the weapon of choice is MRI but X-Ray may be used to rule out a tibial plateau avulsion fracture.

ASSESSMENT
I have attached links (to YouTube) to provide advice on how best to assess a suspect ACL tear.
It is critical you check other structures of the knee to rule out meniscal/ cartilage damage or differential diagnosis of Patella subluxation.
Expect loss of ROM due to swelling or other joint damage.

TESTS
1- Lachmans test (most reliable) https://youtu.be/TMbSVFc-J3Q
2- Anterior draw https://youtu.be/IxyuDnRSggU
3- Lelli test https://youtu.be/44W5MER9IAA
4- Pivot Shift Test https://youtu.be/yOztSsiL2ng

It is rare for an ACL Tear to be isolated, familiarise yourself with the term 'O Donaghue's triad' which suggests likelihood of an:
1- ACL TEAR
2- MCL TEAR
3- MEDIAL MENISCUS TEAR

RECOVERY
ACL Tears do not heal, therefore once the structural integrity of the joint is lost, it either needs to be repaired by surgery or an athlete can focus on improving functional control through stability & strength training.

1- Non-operative treatment:
50% of Patients rehab without surgery but will have to change their levels of activity or are within the less physical active group. Those who are 100% confident with their stability may continue at the same level.
2- Surgery
Usually occurs after extensive prehabilitation, Swelling must be reduced, strength regained, joint range maximised, balance & control optimised before operating.
PROCEDURES- two methods are used in ACL surgery, both are considered as very good.
  1.   Hamstring graft
  2.   Bone Patella Bone

3- Graft re-rupture
Despite surgery and extensive rehabilitation re-injury is common. Interestingly there is a 7% chance of injury to the post operative limb and the uninjured limb.
Higher injury rates are likely in those under 30 who are still taking part in competitive events/ fixtures.  

LONG TERM
It is important that expectation management is given in terms of long term knee degeneration.
Ultimately there is high correlation between articulate cartilage injury and osteo-arthritis regardless of how good the management of the injury has been. There is also a link between quadriceps weakness & the development of OA within 10 years.

REHABILITATION
Recovery from ACL injury requires a comprehensive rehabilitation program.
Should surgery not be needed the athlete is likely to progress quicker. That said if an athlete tries to return before physically & psychologically ready then chances of re-injury/ instability are much higher.

PROTOCOL
the rehab protocol for ACL is broken into 4 phases.
  1. Protection & Controlled Mobilisation: Gait retraining, Reduce pain, swelling, regain optimal rand elf motion, EMS to stimulate inhibited muscles such as VMO.
  2. Controlled Training: Core stability, strengthened injured limb, balance, flexibility
  3. Intensive training: Hopping, landing, dynamic balance, endurance running, soccer specific dynamics
  4. Graduated Return to Play (RTP) & outcome testing: Consisting of the elements in phases 1-3 at higher intensity with increased difficulty
  OUTCOMES
Good Yo-Yo tests results, Triple Hop, bi-lateral leg strength, Good star excursion, slow progression into full match play.

THE AUTHOR
Based in Woking, Surrey, Gary Lewis MSTA, has an extensive history working within football & sports rehabilitation. For advice or to book an assessment contact can be made directly via the FB page.

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