What We Don't Know about ACLR: Graft Maturation

       We have talked about rehabilitation after ACL surgery. However, there are many things that are not clear to us. What we know is based on clinical trials and studies done in the past and their results are consistent. When it comes to how ACL grafts go through maturation process, it is not that clear. Once ACL graft is in place, it goes through a process of vascularization and maturation. We do not know at what point the graft is strong and mature enough to do what. All we know is that we have been successful rehabilitating those patients following protocols (to note, there are a bunch of different protocols). And time to return to sport has shortened. But we do not know whether it is safe and healthy to a graft.

       A study took a look at when ACL grafts finish their vascularization process based on MRI. It showed that it might take up to a year for the grafts to vascularize. Once again, we do not know if it is safe to return the athletes to sport before the vascularization process is finished. One thing to note is that studies done in Indianapolis using accelerated rehabilitation protocol showed that up to 20% of athletes younger than 18 years of age re-injured or tore ALC after returning to sport.

      There have been so many studies done on ACL tears and rehabilitation. However, this stays as a hot topic in sports medicine. One reason probably is that there are so many things we do not know yet.  

Rehabilitation after ACL Tear: 16 Week Post-Op and Return to Play

By week 16, agility and plyometric exercise can be initiated if the injured athlete has good proprioception, postural stability, and strength. However, those exercises should not cause any pain or other complications like swelling. Balance and proprioception are hard to measure objectively. Some may use how long they can balance on one leg and other may use BEST as a measurement. Strength may be hard to measure also if isokinetic machine or hand-held dynamometer are not available. However, before plyometric training is initiated, the athlete should have about 80% of the strength back when compared to the uninjured side.

Then, the athlete can gradually progress to sport-specific training and back to practice. The return to play criteria should include 1) full ROM, 2) no pain, 3) no swelling, 4) optimal strength (at least 85% compared to the uninjured side), especially quads, 5) good proprioception and postural stability, 6) good mechanics (risky movements such as jump-landing, cutting motion, etc.), 7) no instability. It is also important to ready the athlete psychologically.

Rehab program should also include injury prevention program for both of the knees since some studies show that athletes with history of ACL injury may be more at risk of reinjurying the same knee or the other knee. It usually takes about 6 months plus minus one month until return to sport.   

2 leg box jump (start)

finish

Rehabilitation after ACL Tear: 12 Week Post-Op

Once all of the goals from the previous phase have been achieved, athletes can advance in their rehabilitation program per physician's protocol. Once 6 week mark has passed, most surgeons will allow the athlete to advance in strengthening program more aggressively. Closed and open kinetic chain exercises both should be used. Balance and proprioceptive/neuromuscular training also play an important role. However, all of these exercises should be done pain-free. Later in this phase, the athlete will be allowed to start jogging. Isokinetic knee extension/flexion exercise can be initiated around 12 weeks post-op if it is available. However, open kinetic chain knee extension should not be done past 30 degrees of extension since it is known that open kinetic knee extension will put stress on ACL past 30 degrees (between full extension to 30 degrees).  

Main goals of this phases will be 1) maintaining full ROM, 2) continue with strengthening program and to achieve optimal strength to begin plyometrics, 3) continue with balance and proprioceptive training, 4) begin slow jogging. Again, rehabilitation program should be based on physician's protocol. Some surgeons may allow to advance earlier than others. It should also based on tissue healing and athlete's tolerance and reaction to the program.

Core Stability Exercise II

We introduced one simple core stability exercise last time. This time, we will discuss how to make it more challenging. Once draw-in exercise gets too easy and once you get used to doing this correctly, you can make it harder. One way to do it is to pick up one foot about 5 inches off the table/floor and alternate feet from the draw-in position. But it is very important to keep the back flat against the floor keeping the ab tight throughout the leg movement. You can also add arm movement to the draw-in exercise. To do this, you bring your straight arms up above your shoulders, and lower one arm at a time toward the floor while maintaining the draw-in position. Athletes should be able to do these without too much trouble, if not, they need to work on these exercises so they can do them pretty easily. 

We well try to put up some pictures either on here or on our website.

Core Stability Exercise I

Core stability is very important not only for athletic performance but also for injury prevention. Research studies have shown a link between lower extremity injury and poor core/postural stability. Core muscles are the ones that attache to the pelvis, which include abdominal muscles, hip muscles, back muscles, etc. Each muscle play an important role in providing stability, however, the muscle called transverse abdominis seem to be very important when it comes to core stability. What this muscle does is that it compresses the trunk working almost like a girdle when it contracts. When doing core exercises, this muscle should be focused on not just other '6 pack muscel' and the ones that make you look better.

1) Draw-in

The easiest way to work this muscle is to do draw-in exercise. Sometimes, it is called pelvic tilt or ab set or iso abs. This is done by laying on the back with knees bent at around 90 degrees and trying to draw the belly button in towards the back. Or you can try to make the back flat against a table or floor. Sometimes, it is easier to do when you have a hand of someone's between the lower back and floor and try to press the hand down. You should not hold your breath or other body areas like neck and arms should be relaxed. Try to hold this position for 10 seconds and repeat 10 times to start. It may not as easy as it looks to do this exercise the right way.

Gymnast's Wrist

Gymnastics is a unique sport in that it requires weight-bearing on the hands. Because of that, injuries to the upper extremity is very common especially in elbow and wrist. Even though the most of the injuries are chronic in nature, acute injuries are also common such as ankle sprain. They start the sport really early and training can be extensive and long, which causes overuse.

Gymnast's wrist is an injury to the growth plate in the wrist. Radius is the main weight-bearing bone at the wrist and prone to injury from repetitive stress placed on it from tumbling and other weight bearing activities. Salter-Harris classification is often used to classify the severity of the injury with I being the least severe and V being the most serious. Athletes with this injury may complain of pain, swelling, loss of range of motion/strength, inability to weight-bear, etc. This condition should be treated with eliminating stress to the wrist, activity modification, rest, ice, NSAIDs, and sometimes physical therapy. She may return to sport when x-ray is normal and she is symptom-free. 

X-ray film of gymnast's wrist



Rehabilitation after ACL Tear: 4-6 Weeks Post-Op

1) ROM
It is important to regain full ROM by 4-6 weeks post-operatively. Most protocols agree with this. In some cases, ROM may be limited early depending on physician's protocol. But it is important to establish full motion especially into extension by 4-6 weeks post-operatively. ROM exercise may include heel prop, heel slide, wall slide, etc. Stretching calf and hamstring muscles will help to regain knee extension.

2) Quadriceps Straightening
Quadriceps strengthening can be initiated as soon as inflammation is controlled. Initially quad sets with or without NMES(neuromuscular electrical stimulation) is a good way to start firing quad muscle and it can be progressed to straight leg raises (only if knee extension is maintained during exercise). Strengthening exercises for other muscles can also be initiated. It is important to follow physician's protocol and to protect reconstructed graft. 

3) Gait
Normal gait should be established as the injured athlete can tolerate. If he/she can't walk normally, they should be placed on the crutches. Weight shift exercise and gait training on treadmill can help to re-establish normal gait as well as walking in a pool. 

4) Strengthening (closed kinetic chain)/balance exercise
CKC strengthening exercise can be initiated later in this phase of rehab. It includes partial squat, wall squats, leg press, single leg balance, TKE, etc. Again each physician has their own protocol, so it is important to follow it.

The goals of this phase of rehab will be 1) regain full ROM, 2) establish normal gait, 3) start strengthening exercises that include CKC exercise and balance training. Also, strengthening training should be pain-free and inflammation should be under control.

Rehabilitation after ACL Tear: Immediately Post-Op

Immediately after surgery, the knee will be swollen and inflamed. For the first 10 - 14 days after surgery, the main focus is on reducing the inflammation. Depending on the surgeon, formal rehabilitation will be held for the first 2 weeks. The injured athlete should be careful with the woulds from the portal even though they might not be large. There is still a risk of surface infection at the portal sites. The knee might be placed in a rigid knee brace to protect the reconstructed knee. Or the athlete may not even wear any type of brace depending on the surgeon's preference. CPM (continuous passive motion) and PROM (passive range of motion) exercise can be initiated immediately after surgery. However, it is dependent on surgeon's protocol. Ice and NSAIDs are used to reduce and control inflammation. Elevating the knee above the heart may also help to reduce swelling.

Rehabilitation after ACL Tear: Pre-Operative

Anterior cruciate ligament (ACL) tear can be devastating to athletes. However, with advanced surgical technique and more research based knowledge about rehabilitation, the injured athlete can return to sport relatively quickly after reconstructive surgery. Rehabilitation starts right after the injury occurs. Usually, swelling is immediate and causes pain and loss of range of motion (ROM). The athlete may not be able to walk right after injury or even bear weight. It is important to control inflammation and regain inflammation as soon as possible.

1) Reducing inflammation
Pain and swelling should be controlled with ice and/or NSAIDs. Compression wrap and elevating the limb may also help to reduce swelling. Most surgeons will not even operate until inflammation is controlled.

2) Regaining range of motion (ROM)
The athlete will lose knee ROM due to swelling and muscle guarding after the injury. Regaining lost ROM is very important especially in extension. Again, surgery may be delayed until optimal ROM is regained.

3) Regaining quadriceps strength
Swelling/effusion in the knee shuts down quad activity and the muscle gets weak after knee injury. The stronger the quad muscle is before surgery, the easier post-operative rehabilitation will be, because regaining the quad strength is one of the focus during the rehab period.

4) Gait
The injured athlete may not be able to put weight on the injured limb after surgery or walk. Being able to ambulate with or without crutches is important. If the athlete can't walk normally or without symptoms such as pain or knee giving out, crutches should be used. A knee brace may or may not be worn.

Pre-op rehab after ACL tear should focus on controlling inflammation, regaining ROM, and regaining quad strength. However, when treating an athlete, they can stay active while protecting the injured limb using upper arm stationary bike or even walking in the pool.

Asymptomatic Loss of Range of Motion in Junior Athletes

Loss of range of motion (ROM) after acute injury is very common primarily due to swelling and pain. And it usually returns back to normal when inflammation is relieved. For instance, an athlete with acute ankle sprain may display swelling and loss of immediate ROM and it will be to where it was before injury when swelling and pain are gone. However, loss of ROM due to chronic conditions such as frozen shoulder may be more difficult to relieve. One of the reason is that it is developed over a long time and there may be some changes in structure and properties of sift tissue.

But some athletes may display loss of ROM and may not have any symptoms. So, it this bad?? It is not necessarily bad if they do not complain any symptoms which may include pain, decreased performance level, stiffness, etc. However, some research has shown that loss of ROM in certain joint may be linked to possible risk of injury. In overhead athletes such as baseball, softball, and tennis, it is very common to have loss of range of shoulder internal rotation in the dominant shoulder. Instead, usually those athletes will have increased shoulder external rotation compared to the other shoulder. Looking at the total ROM from internal to external rotation end range, if one side has more than 15 degrees less motion than the other side, it is called GIRD (glenohumeral internal rotation deficit) and some research has shown that those athletes may be more prone to an shoulder injury.

Overhead athletes and some athletes like gymnasts may also display loss range of elbow extension compared to the other side. Elbow extension in the dominant arm in overhead athletes may be less than that of non-dominant arm. This may be due to joint capsule tightness and/or forearm muscle tightness (pronator-flexor mass) as a result of repetitive use of the elbow, which can be relieved by stretching exercise. At the same time, it could be as result of early stage of OCD, Panner's disease, bone spur in the olecranon (back of the elbow) which could develop from repetitive stress placed in the joint during overhead motion. Some gymnasts may display loss of elbow ROM without any symptoms probably from repetitive weight-bearing, which puts compressive stress on the outside of the elbow, distraction forces on the inside of the elbow, and overloads between olecranon and humerus. Loss of ROM without any symptoms may not mean that they will need an immediate medical attention but it may be something that needs an eye kept on especially loss of motion is significantly less than the other side. When it is symptomatic in young athletes or elbow does not fully extend (extension is less than 0), they should be seen by a health care provider to find out what is causing it and correct it. Symptomatic loss motion likely indicate some type of injury or condition that needs an attention.

Asymptomatic loss ROM is often ignored until it becomes symptomatic. This may not need an immediate attention as long as it is asymptomatic, however, some literature shows that ROM loss in certain joint may be linked to risk of injury. Loss of ROM in young athletes is certainly something that we need to keep an eye on even when it is asymptomatic.  

NSAIDs

NSAIDs (non-steroidal anti-inflammatory drugs) are commonly-used pain-reliever and fever-reducer. Ibuprophen (Motrin, Advil) and Naproxen (Aleve) are examples of NSAIDs. They act by inhibiting the actions of cyclooxygenase-1 and -2 (cox-1, cox-2), which inhibits the formation of prostaglandins. However, inhibition of prostaglandin synthesis in stomach increases secretion of gastric acid and reduces mucus secretion. Thus, one of the adverse effects of NSAIDs is stomach irritation or ulcers. Selective cox-2 inhibitors are thought to reduce side-effects on GI (gastrointestinal) tract because only cox-1 produces prostaglandins that protect the stomach. Other side-effects of NSAIDs include prolonged bleeding time, increased risk of myocardial infarction (MI) , altered renal function, etc. Asprin, also an NSAID, is rarely used in a sports medicine setting.