Core Stabilization Exercise III

In our past post, we discussed basic core strengthening exercises such as pelvic tilt or draw-in exercise. This is the fundamental of core exercises because that position has to be maintained during any core exercises. Click here to read the post. There are numerous things you can do to make it harder once draw-in exercise can be achieved easily. One way to do it is to add arm and leg movements. From that draw-in position, you can slide one led down straightening the leg and  slide it back up and alternate legs. Once again, the draw-in position must be maintained during leg movement. Dead-bug exercise is more advanced core exercise. Plank is also a good core stability and endurance exercise. It can also be made more difficult by using an unstable surface (see picture).  Burdock, lower trunk rotation, multifidus walk, etc. also are a good core exercises. However, theses exercises only mean a little if the fundamental of core exercise is not established.

What We Don't Know about ACLR: Grafts' Health

Athletes can return to sports successfully after ACLR even though there are chances of re-injury. Rehabilitation process has been shortened and they may return as soon as 4 months post-operatively. However, it is unclear that what is healthy and what is unhealthy to do in a rehabilitation process. We do know what puts stress on the graft and mechanisms of injury. So, we need to avoid things that stress it. For example, during the last 30 degrees of open kinetic knee extension, ACL is under stress from quadriceps muscle contraction force. But we can only assume that things such as walking, weight-bearing, not using a knee brace or crutches are safe to do. But we do not know for sure that it is safe in a long run. We just know that athletes do well either way and it does not appear to affect rehabilitation process or re-injury rate. It is difficult to know how safe and what is safe without knowing graft maturation process and when they are ready to do what. To our knowledge, there are no studies that show when it is too early to do what in terms of graft safety and re-injury rate. We just know the most athletes do well with current ACLR rehabilitation protocols. We feel like there are a lot more studies to be done on this topic especially some studies suggest that ACL grafts elongate after surgery as much as 3mm compared to graft length at the time of reconstruction. Some studies show that re-injury rate after ACLR in active people may be up to 18%. There are many things we know about ACL compared to 10 years ago, but, at the same time, there are many things we do not know yet.   

Soft Tissue/Bony Adaptation in Throwing Elbow

It is known that our body has an ability to adapt in response to stress placed on it. Muscles get bigger and stronger after weight lifting. Endurance improves after prolonged exercise. In similar way, properties of joints and soft tissues changes as a result of stress placed on them. For example, in overhead athletes, they will lose the amount of internal rotation range of motion (ROM) and gain external rotation ROM, commonly known as GIRD (glenohumeral internal rotation deficits). In throwing elbow, as a result of repetitive throwing motion, soft tissue and bony adaptation about the elbow joint occurs. During throwing motion, distractive force is placed on the medial side (inside) of the elbow, where ulnar collateral ligament is. Compressive force exists on the lateral side (outside) of the joint. Also, stress is placed between trochlea and olecranon on the back of the elbow joint. After repetitive stress placed on the joint, it is shown that properties of UCL may change without any symptoms. In a study conducted on non-injured high school-aged baseball pitchers, MRI's were taken on their throwing elbows and non-throwing elbows and those images were compared. They found out that more than 60% of pitchers had thickening of the ligament in throwing elbow. Also, they found sclerosis in ulnar-throchlea joint without symptoms. Sclerosis means hardening of a bone mainly as a result of repetitive direct contact between two bones. We do not know it this will be a risk factor for future injuries or this may indicate anything significant. However, even in healthy pitchers, these changes do occur. When evaluating throwing athletes, it is important to know that these changes in MRI may not indicate an actual injuries if it is not consistent with objective and subjective evaluation. Other findings in the study was edema around UCL attachment, bone spur, etc. Further studies will be needed to investigate whether this soft tissue and bony adaptation may indicate risks of future injuries.  

MRI image of UCL tear

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.