Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Case study: Revision ACLR rehab complicated by PFPS

823 views

Published on

This is the de-identified case study of a revision ACLR patient complicated by an episode of PFPS early during her rehabilitation when she started to increase her gym loads and running loads.
In my presentation, I take you through the initial subjective and objective findings and then take you through my clinical reasoning for her diagnosis and PFPS management. I then subsequently take you through a clinically reasoned ACLR management plan as we geared her towards an eventual return to sport.

Published in: Health & Medicine
  • Posso recomendar um site. Realmente me ayudó. Se llama ⇒ www.EddyHelp.com ⇐ Me ayudaron a escribir todos los artículos científicos en inglés y español.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD FULL BOOKS, INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y8nn3gmc } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y8nn3gmc } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y8nn3gmc } ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y8nn3gmc } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y8nn3gmc } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y8nn3gmc } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Case study: Revision ACLR rehab complicated by PFPS

  1. 1. Management of Revision ACLR with Secondary PFPS in Women’s AFL Player By Mick Hughes Pic: Google Images
  2. 2. Summary of Subjective Assessment CHx • 28 F, contracted AFLW player for inaugural 2017 season • 1 month history of worsening anterior L) knee pain whilst running (only >3km) and squatting (>60deg) • Currently 4.5 months post-op revision L) ACLR (BPTB graft)
  3. 3. Timeline of Relevant Events Past • 2010 • R) ACLR (HS graft) – Full recovery Past • Feb 2016 • L) ACLR (HS graft) – Reinjured 9 months later Now • Dec 2016 • L) ACLR (BPTB graft) – Now 4.5 months post-op
  4. 4. Summary of Subjective Assessment Past Hx & Medical Hx: - No other episodes of significant knee pain, MSK injury or MSK surgery - General health good; non-smoker, social drinker - No significant medical issues - No family history of ACL injury - No red flags Psychosocial: - Customer sales role 20-30hrs per week (on-feet) - Supportive partner, no kids - Just been de-listed from club as result of her injury // stressed & anxious as she really wants to play a role in future AFLW competition
  5. 5. Summary of Subjective Assessment AGG: - Running/squats (5-6/10 VAS) - Upstairs/sitting the next day (3/10 VAS) EASE: - Prolonged rest, ice, recovery days 24hr behaviour: - AM: mild morning stiffness (max 3- 5 mins) - PM: NAD
  6. 6. Activity Restrictions and Capabilities Restrictions Squat or Lunges >60deg knee flexion Running >3km OVERALL: Unable to build strength & CV capacity Capabilities All other lower limb gym exercises Bike/Swim/Boxing/Off- feet cardio
  7. 7. Hypotheses Most Likely Why PFPS Pain behaviour (squatting and running) consistent with PFPS BPTB graft site pain Recent surgery, immature tissue susceptible to load Less Likely Why Not Hoffa’s fat pad impingement No recent direct blow or acute hyper-extension MOI (Franklyn-Miller et al, 2011) Patella tendinopathy No reported focal pain to distal pole of patella, no recent repetitive jumping history ACL graft re-injury No recent contact or non-contact MOI Patella instability No recent contact or non-contact MOI Meniscus pathology No “clicking”, “catching”, “locking” episodes Hip referral Possible Lumbar referral Possible
  8. 8. Summary of Key Objective Findings Observations/Palpation L Quads wasted // L) 40cm R) 46cm L) Dynamic knee valgus during sit to stands and squatting Audible crepitus L) knee when rising from chair TOP lateral facet patella AROM/PROM L) Knee FAROM // crepitus through flexion L) Knee FPROM // no pain on OP flexion or extension
  9. 9. Summary of Key Objective Findings Special Tests + Swipe Test (G2 effusion) -ve Lachmans Test -ve ADT -ve Pivot Shift -ve McMurrays Test -ve Apprehension Test Function BW Squat >60deg // 5/10 VAS HHD Quads L) 30kg R) 90kg // 30% LSI HHD Hams L) 32kg R) 47kg // 68% LSI HHD Hip ABD L) 20kg R) 30kg // 66% LSI SL Sit to Stands L = R x22 reps (Culvenor et al., 2016) SL Hop L) 30cm R) 101cm // 30% LSI
  10. 10. Provisional Diagnosis Most Likely Why PFPS “Issues in the tissues” > Central Sensitisation - Recent onset of mechanical symptoms with clinical weakness of quad and hip ABD AND biomechanical features (dynamic knee valgus) - All these features consistent with PFPS (Crossley et al., 2016) - Also no chronic history of PFPS Least likely Why not Hoffa’s fat pad impingement No tenderness on palpation of fat pad tissue ACL graft reinjury Negative clinical tests Patella tendinopathy No focal tenderness to distal pole of patella Meniscus pathology Negative clinical tests Lumbar/Hip referral Negative clinical tests Patella instability Negative clinical test BPTB donor site No focal tenderness through patella tendon
  11. 11. Contributing factors PFPSWeak Quads Weak Gluteus Medius Poor NM control Poor LL power Load Management errors
  12. 12. Attitudes, Beliefs, Psychosocial Positive/realistic attitude of RTS >12months – happy to go “slower” this time around Semi-professional athlete with proven track record of exercise compliance (3rd ACLR; 2nd within 1 year) Increased anxiety from being cut from club and uncertain future in AFLW competition
  13. 13. Expectations and Goals Expectations of me: 1) Manage her current PFPS pain state to allow her to keep training as she no longer had access to club’s medical, physio and S&C staff 2) Didn’t want me as a “hands-on physio”  Had access to regular myotherapy and osteopathy 3) Wanted me to liase with her private S&C coach about what things she could and could not do throughout each stage of her rehab Goals: 1) Significantly reduce PFPS pain in ADLs, running and squats over the next 6 weeks. • Treatment based on PFPS consensus statement recommendations (Crossley et al., 2016). 2) ACL RTS goal: Return to at least VFL women level in 2018. • Treatment and progressions based on practice guidelines for ACLR rehab (van Melick et al., 2016) • ACLR RTS criteria based on research by Kyritsis et al., (2016).
  14. 14. Precautions and Contra-indications
  15. 15. Treatment PFPS pain focused > ACLR focused 1) Removed aggravating factors: • Ceased running (short term only 2-4 weeks) • Allowed to squat 0-45deg ROM due to decreased PFJ load (Powers et al, 2014) • Continue all other strength and CV exercise as L) knee pain allows (<3/10 VAS) 2) Quads deficit: • Isolated knee extensions through 45-90deg (reduced PFJ stress; as per Powers et al, 2014) 3) Hip ABD deficit • Gluteus Medius and Gluteus Maximus work 4) Neuromuscular control: • Progression of DL & SL strength and balance exercises trying to avoid DKV
  16. 16. Follow-up: 6 Weeks Later (6mths post-op) Functional Measure Left Right LSI Quads HHD 50kg (30kg) 83kg (90kg) 60% Hamstring HHD 48kg (32kg) 55kg (47kg) 87% Gmed HHD 25kg (20kg) 32kg (30kg) 78% SL Hop 76cm (30cm) 100cm (ISQ) 76% NEW TESTS Triple Hop Test 277cm 389cm 61% Triple Crossover Hop 241cm 357cm 67% • S:// Able to pain-free squat to 90deg and recommence running program (3- 5kms) in the 2 weeks leading up to review • O:// +ve Swipe Test  G1 • ACLR Rx: Gym & S/C progressions (targeting quads & glutes) to continue building strength & fitness
  17. 17. Follow-up: 4 Weeks Later (7mths post-op) Functional Measure Left Right LSI Quads HHD 75kg (50kg) 88kg (83kg) 85% Hamstring HHD 48kg (ISQ) 55kg (ISQ) 87% Gmed HHD 30kg (25kg) 34kg (32kg) 88% SL Hop 85cm (76cm) 120cm (100cm) 70% Triple Hop Test 286cm (277cm) 390cm (ISQ) 73% Triple Crossover Hop 261cm (241cm) 381cm (357cm) 68% • S:// No increase in squatting or running pain with increased training loads • O:// No effusion • ACLR Rx: Add in a variety of plyometric drills, high-speed running drills and kicking drills • PROs: ACL-RSI (53%)
  18. 18. Follow-up: 2 months Later (9mths post-op) Functional Measure Left Right LSI Quads HHD 75kg (50kg) 88kg (83kg) 85% Hamstring HHD 48kg (ISQ) 55kg (ISQ) 87% Gmed HHD 35kg (30kg) 35kg (32kg) 100% SL Hop 85cm (76cm) 120cm (100cm) 70% Triple Hop Test 286cm (277cm) 390cm (ISQ) 73% Triple Crossover Hop 261cm (241cm) 381cm (357cm) 68% • S:// No PFJ pain; Continued improvement in strength and function. ACL and rest of knee feeling good • Rx:// Change of direction drills (anticipated/unanticipated), perturbation drills, increased sport-specific skills (no small sided games or defender yet)
  19. 19. Follow-up: 2 months later (11mths post-op) Functional Measure Left Right LSI Quads HHD 85kg (77kg) 92kg (88kg) 92% Hamstring HHD 55kg (ISQ) 55kg (ISQ) 100% Gmed HHD 35kg (ISQ) 35kg (ISQ) 100% SL Hop 140cm (76cm) 148cm (100cm) 94% Triple Hop Test 461cm (277cm) 498cm (ISQ) 92% Triple Crossover Hop 457cm (241cm) 477cm (357cm) 95% • S:// No PFJ pain & ACL still feeling good. Last visit today because she had been signed by another AFLW affiliate club! • Most likely play a role in AFLW 2019 Competition  Happy and relieved! • Re-established goal of RTS: Rd 1 VFL Women’s Comp May 5, 2018 • Handover to new treating Physiotherapist • PROs: ACL-RSI (70%)  Those that RTS >76% (Webster et al., 2009)
  20. 20. What Could I Have Done Differently? View MRI Podiatry review early for short term pain relief (Crossley et al., 2016) Allowed Athlete to Keep Running – Gait education (Esculier et al, 2017) Test Hop Tests in Fatigued State (Gokeler et al, 2014) Be Present For S&C sessions
  21. 21. Prognosis • Unclear • 3rd ACLR certainly make it hard to return to pre-injury sport • 37-55% return to pre-injury sport after ACLR revision (Grassi et al, 2015 & Anand et al, 2016) • Cases like Dan Menzel and Brent Tate (both 4x ACLRs and returned to pre-injury sport AND high levels of performance) give anyone hope • Currently on-track with excellent performance outcome measures • Big limitations to LSI! • Unable to access previous strength and hop test data; so should assess readiness to RTS against norm values • Female normative data: Single hop 149cm and triple hop 470cm (Gokeler et al., 2017) • Not too far behind: 140cm and 461cm respectively
  22. 22. Take Home Messages • Physio doesn’t always have to be hands-on • Know where your skillset ends; Don’t be afraid to refer on to exercise professionals with more time and space to work with the ACLR patient • Return to sport following ACLR needs to be criteria-driven, not time- based!
  23. 23. References • Anand, B. S., Feller, J. A., Richmond, A. K., & Webster, K. E. (2016). Return-to-Sport Outcomes After Revision Anterior Cruciate Ligament Reconstruction Surgery. Am J Sports Med, 44(3), 580-584. doi:10.1177/0363546515618381 • Barton, C. J., Lack, S., Malliaras, P., & Morrissey, D. (2013). Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med, 47(4), 207-214. doi:10.1136/bjsports-2012-090953 • Crossley, K. M., Stefanik, J. J., Selfe, J., Collins, N. J., Davis, I. S., Powers, C. M., . . . Callaghan, M. J. (2016). 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient- reported outcome measures. Br J Sports Med, 50(14), 839-843. doi:10.1136/bjsports-2016-096384 • Crossley, K. M., van Middelkoop, M., Callaghan, M. J., Collins, N. J., Rathleff, M. S., & Barton, C. J. (2016). 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). Br J Sports Med, 50(14), 844-852. doi:10.1136/bjsports-2016-096268 • Culvenor, A. G., Collins, N. J., Guermazi, A., Cook, J. L., Vicenzino, B., Whitehead, T. S., . . . Crossley, K. M. (2016). Early Patellofemoral Osteoarthritis Features One Year After Anterior Cruciate Ligament Reconstruction: Symptoms and Quality of Life at Three Years. Arthritis Care Res (Hoboken), 68(6), 784-792. doi:10.1002/acr.22761 • Esculier, J. F., Bouyer, L. J., Dubois, B., Fremont, P., Moore, L., McFadyen, B., & Roy, J. S. (2017). Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain?A randomised clinical trial. Br J Sports Med. doi:10.1136/bjsports-2016-096988 • Franklyn-Miller, A., Falvey, E., McCrory, P., & Brukner, P. (2011). The Knee Triangle , Clinical Sports Anatomy (pp. 263-329). Sydney, NSW: McGraw Hill Australia Pty Ltd. • Fukuda, T. Y., Fingerhut, D., Moreira, V. C., Camarini, P. M., Scodeller, N. F., Duarte, A., Jr., . . . Bryk, F. F. (2013). Open kinetic chain exercises in a restricted range of motion after anterior cruciate ligament reconstruction: a randomized controlled clinical trial. Am J Sports Med, 41(4), 788-794. doi:10.1177/0363546513476482 • Gokeler, A., Eppinga, P., Dijkstra, P. U., Welling, W., Padua, D. A., Otten, E., & Benjaminse, A. (2014). Effect of fatigue on landing performance assessed with the landing error scoring system (less) in patients after ACL reconstruction. A pilot study. Int J Sports Phys Ther, 9(3), 302-311. • Gokeler, A., Welling, W., Benjaminse, A., Lemmink, K., Seil, R., & Zaffagnini, S. (2017). A critical analysis of limb symmetry indices of hop tests in athletes after anterior cruciate ligament reconstruction: A case control study. Orthop Traumatol Surg Res, 103(6), 947-951. doi:10.1016/j.otsr.2017.02.015 • Grassi, A., Zaffagnini, S., Marcheggiani Muccioli, G. M., Neri, M. P., Della Villa, S., & Marcacci, M. (2015). After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis. Br J Sports Med, 49(20), 1295-1304. doi:10.1136/bjsports-2014-094089
  24. 24. References • Kyritsis, P., Bahr, R., Landreau, P., Miladi, R., & Witvrouw, E. (2016). Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br J Sports Med, 50(15), 946-951. doi:10.1136/bjsports-2015-095908 • Lack, S., Barton, C., Sohan, O., Crossley, K., & Morrissey, D. (2015). Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis. Br J Sports Med, 49(21), 1365-1376. doi:10.1136/bjsports-2015-094723 • Mohan, R., Webster, K. E., Johnson, N. R., Stuart, M. J., Hewett, T. E., & Krych, A. J. (2018). Clinical Outcomes in Revision Anterior Cruciate Ligament Reconstruction: A Meta-analysis. Arthroscopy, 34(1), 289-300. doi:10.1016/j.arthro.2017.06.029 • Myer, G. D., Ford, K. R., Di Stasi, S. L., Foss, K. D., Micheli, L. J., & Hewett, T. E. (2015). High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: is PFP itself a predictor for subsequent ACL injury? Br J Sports Med, 49(2), 118-122. doi:10.1136/bjsports-2013-092536 • Powers, C. M., Ho, K. Y., Chen, Y. J., Souza, R. B., & Farrokhi, S. (2014). Patellofemoral joint stress during weight-bearing and non-weight- bearing quadriceps exercises. J Orthop Sports Phys Ther, 44(5), 320-327. doi:10.2519/jospt.2014.4936 • van der Heijden, R. A., Lankhorst, N. E., van Linschoten, R., Bierma-Zeinstra, S. M., & van Middelkoop, M. (2015). Exercise for treating patellofemoral pain syndrome. Cochrane Database Syst Rev, 1, Cd010387. doi:10.1002/14651858.CD010387.pub2 • van Melick, N., van Cingel, R. E., Brooijmans, F., Neeter, C., van Tienen, T., Hullegie, W., & Nijhuis-van der Sanden, M. W. (2016). Evidence- based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med, 50(24), 1506-1515. doi:10.1136/bjsports-2015-095898 • Webster, K. E., Feller, J. A., & Lambros, C. (2008). Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport, 9(1), 9-15. doi:10.1016/j.ptsp.2007.09.003

×