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					        ACL Rehab:
Traditional vs Accelerated
                   Kathryn A. Koshansky, MS, ATC
                   Athletic Training Program Chair
                               Associate Professor
       School of Health Technology & Management
                            Stony Brook University
                                      May 11, 2012
              Background

nCertified Athletic Trainer = 29 yrs
nChair of SBU Athletic Training Program
nState Education Board for Athletic Training
nNATA D2 Advanced Education Committee
nFormer SBU Assistant AD for Sports
 Medicine
               Objectives
nIdentify examples of ACL RTP that are
 shared in the media.

nDiscuss the common in ACL rehabilitation
 protocols used over the past 30 years.

nProvide insight to the concept of being
 “patient driven”.
The Injury
                   Example 1
n Former NFL wide receiver Jerry Rice famously made a
  comeback 3 ½ months after undergoing ACL
  reconstruction in 1997; In his first game back, he
  fractured his kneecap (where the ACL graft was taken
  from). This new injury ended his season.
                         Example 2
n 35-year-old forward player; isolated complete ACL tear; competitive
  2001-2002 season; contention for a position on the Italian World
  Cup Team that was to be played 135 days after his injury, only if he
  demonstrated that he could return to play at the highest level before
  the team was selected.
n ACL surgery 4 days after the injury. 8 days after surgery he began
  rehabilitation at a rate of 2 sessions a day, 5 days a week, plus 1
  session every Saturday morning. Sessions involved pool (aquatic
  exercises), gymnasium (flexibility, coordination, & strength
  exercises), and soccer field (technical and tactical skills)
n The surgical technique and the progressive rehabilitation program
  allowed the patient to play for 20 minutes in an official First Division
  soccer game 77 days after surgery and to play a full game 90 days
  after surgery. 18 months post surgery, the player had participated in
  62 First Division matches, scoring 26 times, and had received no
  further treatment for his knee.
                      Example 3
Three months removed from a torn ACL, Detroit Lions running
  back Kevin Smith says he’s on schedule in rehabbing his
  knee. But he also says that he’s not running yet and not sure
  how long it will be before he’s back to full speed: “My leg is
  feeling good and I think I’m right on schedule,” Smith wrote on
  his personal web site. “I’m just taking it day-by-day, doing my
  rehab every day and lifting. It’s time to get back into it.
  Football season is going to come back around real fast.
  There’s no timeline for my knee, I just know that I don’t want
  to waste a single day,” Smith wrote. “I rehab with a purpose,
  every day I find the focus to get myself right. My time is
  coming really soon.”                                 March 2010
             The Question

n When is it safe to Return to Play?

nIs it:
     3 months?
     6 months?
     12 months?
              The Answer?

nIf it were that easy… we all may be out of
 jobs, or have much less stress in our jobs!
nThe patient (and their family, coaches, etc)
 have all the answers
nEach patient is the perfect patient
nNot going to happen!
           We’ve Heard it All…

n “When’s the quickest I can get back to activity?”
n “I have to be back by …”
n “My friend so & so got back to activity …”
n “At xyz college so & so got back to playing …”
n “I’m committed to my rehab!”
n “You don’t know me, I’m a quick healer!”
n Etc…
       Where are we in 2012?

nSurgical techniques

nRehabilitation



We are living in a world of INSTANT GRATIFICATION!
          ACL Rehab Timeline

n“Surgical stability is easily reproducible,
 long-term patient satisfaction is difficult to
 guarantee.” Shelbourne, 2006
                The Issues
nDamaged structures in addition to ACL
nGraft choices
  nAllograft
  nAutograft
    nBPTB
    nSemitendinosus/Gracilis tendons
nPre-Injury Status
nPatient Commitment
               The Biology

nBone will have meaningful incorporation
 by 6-8 weeks

nSoft tissue healing to bone with fibrous
 tissue or scar may take up to 12 weeks
 where it's relying on the screws alone
 before the fibers start growing into bone
    Goals of ACL Rehabilitation
nReturn the patient back to activity as soon
 as possible but also as safely as possible
nReach symmetry between knees:
  nRange of Motion
  nStrength
  nStability
  nOverall Function
nSuccessfully pass RTP testing
Traditional (early 1980’s)
Accelerated (late 1980’s)
Comparison
                                                 Current




Cascade of events outlines a systematic rehabilitation program that emphasizes the return to symmetrical knee motion that
includes hyperextension. ROM, range of motion. Shelbourne & Klotz, 2006
                                                Current




Perioperative Phases of Rehabilitation. Shelbourne & Klotz, 2006
               Experience

nYou've lived it!

nWhat works for you and your patient?
          Critical input from..
n Physician (surgeon)

n Certified Athletic Trainer

n Physical Therapist

n Athlete (+/- parents)

n +/- Coach
               Bottom Line

nTo return earlier there is a higher failure
 rate

nIt's the patient's call but they have to live
 with the consequences
                Summary

nRehabilitation program is NOT going to
 follow the same timeline for each athlete

nEvery athlete is different

nRehabilitation should be “Patient Driven”!
        Take Home Message

nProtocol should be built on criteria-based
 progression rather than time-based
 progression; with the knowledge of graft
 strength timelines

nIf your athlete is not playing sports at 6
 months… stop expecting that something is
 wrong!
                                           References
n   Beynnon BD, Johnson RJ, Naud S, Fleming BC, Abate JA, Brattbakk B, Nichols CE. Accelerated versus nonaccelerated
    rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind investigation evaluating
    knee joint laxity using roentgen stereophotogrammetric analysis. Am J Sports Med. 2011 Dec;39(12):2536-48. Epub 2011
    Sep 27.

n   Decarlo MS, Shelbourne KD, McCarroll JR, Rettig AC. Traditional versus Accelerated Rehabilitation following ACL
    Reconstruction: A One-Year Follow-Up. J Orthopaedic Sports Physical Therapy. 1992;15(6):309-16.

n   Roi GS, Creta D, Nanni G, Marcacci M, Zaffagnini S, Snyder-Mackler L. Return to Official Italian First Division Soccer
    Games Within 90 Days After Anterior Cruciate Ligament Reconstruction: A Case Report. Journal of Orthopaedic & Sports
    Physical Therapy. 2005;35(2): 52-66.

n   Pezzullo, David & Fadale P. Current Controversies in Rehabilitation After Anterior Cruciate Ligament Reconstruction. Sports
    Medicine and Arthroscopy Review. 2010; 18(1); 43-47.

n   Shaw T. Accelerated rehabilitation following anterior cruciate reconstruction. Physical Therapy in Sport. 2002; 3: 19-26.

n   Shah VM, Andrews JR, Flesig, GS, McMichael CS, Lemak LJ. Return to Play After Anterior Cruciate Reconstruction in
    National Football League Athletes. American Journal of Sports Medicine. 2010; 38(11):2233-2239.

n   Shelbourne KD & Klotz C. What I have learned about the ACL: utilizing a progressive rehabilitation scheme to achieve total
    knee symmetry after anterior cruciate ligament reconstruction. Journal of Orthopaedic Science. 2006;11:318-325.


n   ACL Protocols from:     Dr. Stuart Cherney (All-Sport Orthopaedic Surgery)
                            Dr. James Paci and Dr. James Penna (SBU Department of Orthopaedics)
Thank you!

				
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