9 14 16 PRISM Syllabus

2016-09-14

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9/13/2016

Management of Adolescent ACL Injuries:

Treatment Outside of the Operating

Room:

Prevention

Christin Zwolski, PT, DPT, OCS

Cincinnati Children’s Hospital Medical Center

No Disclosures

Christin Zwolski, PT, DPT, OCS

Cincinnati Children’s Hospital Medical Center

How To Prevent an ACL Injury?

Neuromuscular

Training (NMT)

•Plyometric training

•Biomechanical

technique training

•Strength training

•Balance training

•Core stability training

9/13/2016

AAOS

Management of ACL Injuries CPG

AAOS

Management of ACL Injuries CPG

Studies that Favor NMT

Olsen et al. 2005 (M)

Caraffa et al. 1996 (M)

Mandelbaum et al. 2005 (L)

Overall strength of study:

M=moderate

L=low

•NMT warm-up

programs

•All demonstrate

significant reduction in

ACL injuries after

training

9/13/2016

Studies Found Not Signifigant

Gilchrist et al. 2008 (M)

Petersen et al. 2005 (M)

LaBella et al. 2011 (M)

Soderman et al. 2000 (M)

Heidt et al. 2000 (M)

Hewett et al. 1999 (H)

Overall strength of study:

M=moderate

H=high

•All suggest NMT can be

preventative

•Lack large number of

exposures

Small Effect Size (AAOS CPG)

•NNT = 109

More Recent Evidence…

•72% reduction in ACL injury rates in girls <18 years

old vs. 16% risk reduction for those ≥18 years old

(LaBella et al. 2014)

•Meta-analysis of Level 1 RCTs of soccer players:

NMT has protective effect (Grimm et al. 2014)

•Neuromuscular and proprioceptive prevention

programs reduce ACL injuries by 50.7% (Donnell-Fink et

al. 2016)

9/13/2016

Most Effective NMT Programs

•Duration: minimum of 6 weeks

•Frequency: >1x/week

•Comprehensive (with strength training)

•Combined pre- and in-season training

•Short bursts of activity

•Real-time Feedback with external-focus instructional

strategies

•Timing: Early pubertal maturation

Benjaminse et al. 2015, Ford et al. 2015, Sugimoto et al. 2015, Hewett et al. 2006

Bonus!

Participation in NMT can lead to improved sports

performance:

•LE and abdominal strength

•Vertical jump height

•Estimated maximal aerobic power

•Speed

•Agility

•Isokinetic strength

•Balance

Noyes et al. 2012, DiStefano et al. 2010

Cost-Effective Analysis

Swart et al. 2014:

On average, the implementation of a universal

training program would…

•Save $100 per player per season

•Reduce the incidence of ACL injury from 3% to 1.1%

per season

9/13/2016

What happens after one NMT

session?

Root et al. 2016:

•Landing technique improves (LESS)

•Does not impair sport performance (vertical jump,

long jump, shuttle run)

Limitations of NMT Research

•Lack of high-strength, double-blind RCTs

•Low generalizability (i.e. study populations)

•Heterogenous protocols

•Lack of compliance

Future NMT Research

•Multi-site studies using standardized NMT program

•Larger sample sizes of high-risk athletes

•Optimization of protocols

•Improved delivery

9/13/2016

Risk Assessment

•Tuck Jump (Myer et. al 2008)

•Drop Vertical Jump (DL and SL)

(Redler et al. 2016)

•Landing Error Scoring System

(LESS) (Padua et al. 2015)

ACL Injury Prevention Programs

•Prevent Injury and

Enhance Performance

(PEP)

•Knee Ligament Injury

Prevention (KLIP)

•FIFA 11+

•FIFA 11+ Kids

•Sportsmetrics

Thank You!

Christy Zwolski, PT, DPT, OCS

Christin.Zwolski@cchmc.org

9/13/2016

Management of

Adolescent ACL Injuries:

Work-up

Attending Physician, Primary Care Sports Medicine

Department of Pediatric Orthopedic Surgery

The Children’s Hospital of Philadelphia

•ACL rupture is typically caused by rotation/translation of

the knee with foot planted; often non-contact

•Physical Exam:

•Effusion and decreased ROM common

•Lachman and/or anterior drawer: increased anterior translation of tibia

•Lachman is very sensitive and specific

•Pivot shift

•KT-1000

9/13/2016

•Should be done at initial assessment

•Utility: rule out fractures, evaluate physes

•Obtain 4 views: AP, lateral, tunnel, sunrise

•Associated fractures may include:

•Segond fx: lateral tibial condyle avulsion

•Lateral femoral condyle impaction

•Tibial spine avulsion

•In practice, insurance likely requires radiographs prior to

advanced imaging

Segond fracture

•Sensitivity and specificity generally 95+%

•A number of articles describe similar accuracy for

clinical evaluation

•MRI is most useful for confirming the diagnosis and

defining associated injuries

•In practice it is necessary prior to surgical

intervention

9/13/2016

•ACL may appear thick with increased intra-substance

signal on T2 images

•May see complete rupture with lack of fiber continuity, or

possible avulsion type rupture

•Bone bruise pattern: posterior lateral tibial plateau and

lateral femoral condyle

•Assess for associated injuries: menisci, articular cartilage

MRI: ACL rupture

•Starts from the time we suspect ACL tear clinically

•Discuss the importance of attaining normal knee motion

and maintaining quad strength pre-operatively

•May need pre-op physical therapy

•Protection: brace, crutches, weight bearing status?

•Consider the emotional impacts

•Know some timelines for your surgeons

9/13/2016

•Graft choice depends on several factors

•Patient age, skeletal maturity

•Surgeon experience

•In adolescents the most common options are

autograft hamstrings or cadaver graft

•Hamstrings obtained from ipsilateral knee

9/13/2016

Management of Adolescent ACL

Injuries: Treatment Outside of

the Operating Room

Post Operative Physical Therapy

Kyle Sela, PT, DPT, SCS, OCS

PT Sports Medicine Coordinator, St. Luke’s Health System

Boise, ID

Disclosures

•None to report

AAOS Guidelines

•Bottom Line Up Front

•Moderate evidence to support the following post-operative physical therapy

guidelines

•Accelerated vs non-accelerated rehab programs

•Unrestricted and immediate range of motion (ROM) vs delayed

•Immediate weight bearing vs delayed

•Early, but limited range during open kinetic chain (OKC) exercises vs delayed and full

motion

•Early closed kinetic chain (CKC) exercises vs delayed

9/13/2016

Accelerated vs Nonaccelerated

•Recommendations based off of 2 studies (Beynnon 2005, 2011)

•BTB Grafts were used for all subjects

•Non-adolescent populations: 18-50 years of age

•Randomized into 2 groups

•Accelerated program progressed subjects over 19 weeks

•Exercises thought to produce increased sheer on the graft were initiated earlier

•Nonaccelerated program lasted 32 weeks

•Followed out to 24 months

•Results

•No differences in almost all outcome measures

•Knee laxity, activity level, pain, ADLs, quality of life, articular cartilage biomarkers

•Increased quad strength in accelerated group at 3 month follow up only

•1 re-tear (6 months out, nonaccelerated group)

•Aggressive vs nonaggressive hamstring autograft (Christensen 2013)

•No difference between groups (only followed to 24 weeks)

Unrestricted and Immediate Extension ROM

•Early active extension after anterior cruciate ligament reconstruction

does not result in increased laxity of the knee. (Isberg 2006)

•22 BTB Subjects

•Randomized into 2 groups

•Full passive or active extension immediately vs delayed

•Follow up at 6 months and 2 years

•Results

•No difference between groups in any outcome measure

•Laxity

•Self reported scores

•Hop testing

Early but limited motion during OKC strengthening

•OKC in restricted range 90-45° shown to be safe (Fleming 2005, Escamilla

1998)

•Early OKC exercises in hamstring autograft may increase laxity (Heinji 2007)

•Early vs late start of OKC in both BTB and HS ACLR (4 groups)

•Early hamstring group demonstrated significantly increased AP laxity

•No other differences between groups were found (strength, pain, function)

•Best time to implement safe OKC exercises? (Fukuda 2013)

•Early start (4 weeks) vs Late start (12 weeks)

•Restricted motion at knee extension machine from 45-90

•Results

•No difference in knee joint laxity

•Earlier group had quicker return of quad strength

•No difference in function

9/13/2016

Future Research in Post-Op Therapy

•Shift focus from differences in early rehab to later rehab guidance

•Identify optimal return to play, duty or work measures and benchmarks to guide rehab

•Improve long term tracking of ACLR patients

•What is re-tear or contralateral tear rate in specific populations

•Better describe those who re-tear vs those who don’t

•Repeat functional testing in “graduates” to identify regression

•Is there sufficient evidence to support Neuromuscular Electrical Stimulation

(NMES)?

•Seems promising in ACLR and other post-op populations (Erlandson 2014)

•Rehab trends to keep an eye on in the literature

•Blood Flow Restriction Training (BFR)

•Force plates for training and evaluation

References

•Beynnon, B. D., Uh, B. S., Johnson, R. J., Abate, J. A., Nichols, C. E., Fleming, B. C., ... & Roos, H. (2005). Rehabilitation After Anterior

Cruciate Ligament Reconstruction A Prospective, Randomized, Double-Blind Comparison of Programs Administered Over 2 Different

Time Intervals. The American journal of sports medicine,33(3), 347-359.

•Beynnon, B. D., Johnson, R. J., Naud, S., Fleming, B. C., Abate, J. A., Brattbakk, B., & Nichols, C. E. (2011). Accelerated Versus

Nonaccelerated Rehabilitation After Anterior Cruciate Ligament Reconstruction A Prospective, Randomized, Double-Blind Investigation

Evaluating Knee Joint Laxity Using Roentgen Stereophotogrammetric Analysis. The American journal of sports medicine,39(12), 2536-

2548.

•Christensen, J. C., Goldfine, L. R., & West, H. S. (2013). The effects of early aggressive rehabilitation on outcomes after anterior cruciate

ligament reconstruction using autologous hamstring tendon: a randomized clinical trial. J Sport Rehabil,22(3), 191-201.

•Erlandson, A. K., & Lauber, C. A. (2014). Neuromuscular electrical stimulation compared to exercise alone for regaining strength in

patients post anterior cruciate ligament surgery: A critically appraised topic. Journal of Athletic Medicine• Volume,2(3).

•Fleming, B. C., Oksendahl, H., & Beynnon, B. D. (2005). Open-or closed-kinetic chain exercises after anterior cruciate ligament

reconstruction?.Exercise and sport sciences reviews,33(3), 134-140.

•Fukuda, T. Y., Fingerhut, D., Moreira, V. C., Camarini, P. M. F., Scodeller, N. F., Duarte, A., ... & Bryk, F. F. (2013). Open Kinetic Chain

Exercises in a Restricted Range of Motion After Anterior Cruciate Ligament Reconstruction A Randomized Controlled Clinical Trial. The

American journal of sports medicine,41(4), 788-794.

•Heijne, A., & Werner, S. (2007). Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar

tendon or hamstring grafts: a prospective randomized outcome study. Knee Surgery, Sports Traumatology, Arthroscopy,15(4), 402-

414.

•Isberg, J., Faxén, E., Brandsson, S., Eriksson, B. I., Kärrholm, J., & Karlsson, J. (2006). Early active extension after anterior cruciate

ligament reconstruction does not result in increased laxity of the knee. Knee surgery, sports traumatology, arthroscopy,14(11), 1108-

1115.

9/12/2016

Management of Adolescent

ACL Injuries: Bracing

Opal Griffin, LAT, ATC

St. Luke’s Health System, Boise ID

Sports Medicine: Outreach Athletic Training

Disclosers:

Presenter: Opal Griffin, LAT, ATC

With respect to the following presentation, there has been no relevant (direct

or indirect) financial relationship between the party listed above (and/or

spouse/partner) and any for-profit company in the past 24 months which

could be considered a conflict of interest.

All images that are included are for clarification purposes only, not a

suggestion of the “best brace” or the type that was specifically tested.

Prophylactic Bracing:

Ortho Guidelines from the AAOS (5, 6)

Limited evidence supports Preventative braces might not be prescribed

Studies showed no reductions in ACL injuries with Bracing

Only tested American HS and Collegiate FB players.

Future Research

Would this be different in other papulations?

Female Soccer has the highest rate of ACL injury per the AAOS

Greater population size?

Younger population?

9/12/2016

Postoperative Functional Bracing:

Ortho Guidelines from the AAOS (1, 2, 3)

Moderate evidence does not support routine use

not proven effective when compared to neoprene knee sleeve and no

bracing.

Routine use cannot be supported

There was lack of efficacy following ACL reconstruction..

Types of Braces Studied (examples)

Functional Bracing Neoprene sleeve

Postoperative Functional Bracing:

2015 Review published in Sports Health (4)

Anterior Cruciate Ligament Reconstruction Rehabilitation: MOON Guidelines

Postoperative bracing did NOT improve: pain, swelling, range of

motion or safety

“Eleven studies… no study demonstrated a clinically significant or

relevant improvement in safety, range of motion including

extension, or other outcome measures.7,15,19,25,27,31,36,43,47,50,57,67”

Supported by 17 studies that the MOON group considered to be level 1

or 2 evidence

9/12/2016

Postoperative Bracing: Exception

Meniscal Injury with about half of

all ACL injuries. Per the AAOS.

Meniscal repair requires support

post surgically.

References:

Functional knee braces after ACLR

1. Birmingham TB, Bryant DM, Giffin JR et al. A randomized controlled trial

comparing the effectiveness of functional knee brace and neoprene sleeve use

after anterior cruciate ligament reconstruction. Am J Sports Med 2008;36:648-

655.

2. McDevitt ER, Taylor DC, Miller MD et al. Functional bracing after anterior

cruciate ligament reconstruction: a prospective, randomized, multicenter study.

Am J Sports Med 2004;32:1887-1892.

3. Risberg MA, Holm I, Steen H, Eriksson J, Ekeland A. The effect of knee bracing

after anterior cruciate ligament reconstruction. A prospective, randomized

study with two years' follow-up. Am J Sports Med 1999;27:76-83.

4. Wright R, Haas, A, Anderson, J et al. and MOON Group. Anterior Cruciate

Ligament Reconstruction Rehabilitation: MOON Guidelines. Sports Health

2015;7:239-243.

Prophylactic knee bracing

5. Sitler M, Ryan J, Hopkinson W et al. The efficacy of a prophylactic knee brace

to reduce knee injuries in football. A prospective, randomized study at West

Point. Am J Sports Med 1990;18:310-315.

6. Deppen RJ, Landfried MJ. Efficacy of prophylactic knee bracing in high school

football players. J Orthop Sports Phys Ther 1994;20:243-246.

Questions…

Thank you for joini ng us!

9/13/2016

Return to Sport after ACL

Reconstruction: How

Objective is your Decision?

Mark V. Paterno PT, PhD, MBA, SCS

Coordinator of Orthopaedic and Sports Physical Therapy

Acting Scientific Director

Division of Occupational Therapy and Physical Therapy

Associate Professor, Division of Sports Medicine

Cincinnati Children’s

Cincinnati, OH

Objectives

1. Review current evidence regarding RTS after ACL

reconstruction

2. Discuss current criteria used to determine

readiness to RTS.

3. Identify potential opportunities to improve RTS

decision making in this population

9/13/2016

CLINICAL QUESTION:

When is it safe to return to sports (RTS)

after ACL Reconstruction?

1. What is “safe”?

2. What are the functional demands of the sport?

RTS: When is it safe?

1. Incidence of 2nd ACL injury after ACLR and RTS

Ipsilateral Graft Re-tear (Wright et al JBJS 2011)

Contralateral ACL Injury (Wright et al JBJS 2011)

2. Incidence of Secondary Injury after ACLR and RTS

3. Incidence of Osteoarthritis after ACLR and RTS

50-100% of patients develop OA after ACL injury

Lohmander et al 2004

9/13/2016

RTS: When are you able to return

to your prior level of function?

What factors are necessary to insure success:

•Strength

•Balance/Postural Stability

•Mechanical Stability/Functional Stability

•Power

•Endurance

•Agility

•Etc….

ACL Return to Sport: Systematic

Review

Kvist J. “Rehabilitation Following Anterior Cruciate

Ligament Injury: Current Recommendations for

Sports Participation.” Sports Med 2004: 34(4): 269-

280.

34 articles between 1998-2003

ACL Return to Sport: Systematic

Review- Kvist Sports Med 2004

Outline of criteria reported:

•13/34 assessed isokinetic strength

•25/34 used jump testing

•14/34 reported some clinical criteria (i.e.

ROM, knee stability etc.)

•4/34 had no assessment of strength or

performance

9/13/2016

ACL Return to Sport: Systematic

Review- Barber-Westin et al 2011

Systematic Review (n=264)

•40% : no criteria

•13% : objective criteria

Current Return to Sport Measures

1. Time from surgery

2. Strength

3. Knee Laxity

4. Functional Performance

Testing

Single Hop X-Hop Triple Hop Timed Hop

Current Return to Sport Measures

“…low correlations between various hop test scores

and self-reported measures of function may

indicate that neither of these methods can stand

alone as an adequate assessment of knee

function.”

Fitzgerald GK et al

“Hop Tests as Predictors of Dynamic Knee Stability”

JOSPT 2001

9/13/2016

Return to Sport Assessment:

What are we missing?

1. Patient reported outcomes

2. Assessment of movement quality

3. Patient readiness to return to activity

RTS: Patient Reported Outcomes

1. Patient Reported Quality of Life Measure

2. Region Specific Assessment

•IKDC: Zwolski et al AJSM 2015

•KOOS: Wasserstein et al Osteo Cart 2015 (MOON Data)

•Others

RTS: Assessment of Movement

Quality

9/13/2016

RTS: Assessment of Movement

Quality

“Biomechanical Measures during Landing and

Postural Stability Predict Second Anterior Cruciate

Ligament Injury after ACL Reconstruction and

Return to Sport”

Paterno et al AJSM 2010

RTS: Predictors of 2nd ACL Injury

Paterno et al AJSM 2010

RTS: Patient Readiness to RTS

1. Fear of Reinjury/Lack of Confidence

•Lentz et al JOSPT 2012: Athletes who RTS had lower level

of kinesiophobia

•Lentz et al AJSM 2015: Athletes who did not RTS due to

fear of reinjury was older, lower quad strength and

lower IKDC

2. Other Factors

9/13/2016

Summary

1. Limited evidence exists regarding RTS decision

making after ACLR

2. Current criteria used to determine readiness to

RTS may not identify those at high risk for injury

or likely to maintain pre-injury level of function

3. Future work needs to better identify critical

factors to use to determine readiness to safely

return to sport

Thank you!!

Mark V. Paterno PT, PhD, MBA, SCS

Cincinnati Children’s

mark.Paterno@cchmc.org

@mvpaternopt

9 14 16 PRISM Syllabus

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