Motion• Passive• Passive assist• ROM re-education• Active assist• Active• Stretch• ROM limits?
Maximum anterior translation ofthe tibia occurs at 15-25 deg of flexion Limit knee extension
Strengthening• Isometrics• Multiple angle isometrics• Short arc isotonics• Full arc isotonics• Isokinetrics• Speed• ROM
Close Kinetic exercises in ACL rehab1. Enhance functional performance activities2. Less strain on the ACL3. Less harmful on the patellofemoral joint
Q/H Ratio• exercisers are told that there should be a certain ratio between the strength of their hamstring and quadriceps muscles.• Called the H/Q ratio and reported to be anywhere from .50 to .75 with a normative value of .60, the strength ratio of this important agonist/antagonist pairing is considered essential to the stability of the knee joint and to prevent ACL and other injuries.
Q/H Ratio• The balance of quadriceps to hamstring strength is not 1:1; but closer to 3:2. In general healthy hamstrings can lift 60 - 80% of what healthy quads can do.
Isokinetic exercises• are performed at a dynamic preset fixed speed (ranging from 1 degree per second to approximately 1000 degrees per second) with resistance that is accommodating throughout the range of motion (ROM).• Accommodating resistance means that Isokinetic exercise is the only way to dynamically load a muscle to its maximum capability throughout every point in the ROM.• Therefore, the resistance varies to exactly match the force applied by the athlete at every point in the ROM.
Isokinetic machines have the ability to objectively measure muscle strength• The Isokinetic device is attached to a computer, that assesses the torque output of the muscles being testing.• The torque output is converted to a foot-pound measurement. Isokinetic testing allows for a variety of testing protocols ranging from strength, strength ratios between two muscle groups, power, and endurance.
Quadricep avoidance gait• quadriceps avoidance gait: - most patients will alter their gait in order to avoid anterior displacement of the tibia which occurs with quadriceps contraction;• - between 0 to 45 deg of flexion, contraction of the quadriceps will cause anterior translation of the quadriceps (which is normally resisted by the ACL);• - maximum anterior translation of the tibia occurs at 15-25 deg of flexion;
Quadricep avoidance gait• that is characterized by increased hip and knee flexion, reduced knee extensor torque, power, and loss of the biphasic knee joint torque pattern•• EMG studies support these findings with increased hamstrings and reduced quadriceps activity
Summary• Early weight bearing is beneficial and may decrease PF pain• Early motion is safe and help avoid arthofibrosis• CPM is not warranted• CKE should be used in the first 6 weeks• Bracing has no advantage• Neuromuscular stimulation electric stimulation high enough intensity• Accelerated rehab program safe in the 5 to 6 month period• Water base activities, stair climber, slide board exercise are safe and add variety• Gait proprioception and psychological training may be of some benefit• Creatine offers no benefit