Taddio Nicola ACL Rehab Suggestion The Battle 2017 Cesena (ITA)

Nicola Taddio Physical Therapist
BSc MSc ATC OMPT
Lecturer Master in “Sports Physioterapy”, University of Siena, Italy
Lecturer Master in “Sports Physiotherapy and Performing Arts”, University of Genoa, Savona pole, Italy
Lecturer International Master in “Sports Traumatology and Athlete Management” EdiErmes,MI
Member of International Advisory Board Italian Journal “Il Fisioterapista”
Faculty Member Portal www.riabilita.org
CENTRO MEDICO LA COLONNA, FLOAT THERAPY s.r.l.
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mobile ++39-345-7660602 email: nicola.taddio@gmail.com web site: www.hrrgroup.org

clinical practice not opinion based but evidence based
Evidence
Opinion
Introduction

David J. Magee William S.Quillen James E. Zachazewski
Athletic Injuries and Rehabilitation
W.B. Saunders Company, 1996
The Sports Rehab Pyramid
Knowledge skill and ability of sports medicine team

The pearl of long-term rehabilitation is
to build a small team of core people
who collaborate with other professions
Never walk alone !!!
The Sports Rehab Team
Brukner & Khan’s Clinical Sports Medicine: Injuries, Volume 1, 5e
Peter Brukner, Ben Clarsen, Jill Cook, Ann Cools, Kay Crossley, Mark Hutchinson,
Paul McCrory, Roald Bahr, Karim Khan Mc Graw Hill
Clinical Sports Medicine Collection

Injury Management
Brukner & Khan’s Clinical Sports Medicine: Injuries, Volume 1, 5e
Peter Brukner, Ben Clarsen, Jill Cook, Ann Cools, Kay Crossley, Mark Hutchinson,
Paul McCrory, Roald Bahr, Karim Khan Mc Graw Hill
Clinical Sports Medicine Collection

Problem
Clinical Reasoning
Solution
Patient
Age
Injury
Timing
Treatment Option
Wait and See
Conservative
Surgical
Outcome
Return to Sport
DECISION MAKING PROCESS
Problem solving. Treating knee pain presents challenges and options to therapists.
Jensen L, Boggs S, Ryan L.
Rehab Manag. 2004 Dec;17(10):22, 24-5, 54.

……….. we know some ACL injuries occur under circumstances that seem
innocuous doing simple maneuvres that the athlete has done hundred or
thousands of times before, such as coming down from a rebound or
making a cut.
All of us suspect complex neurologic function
like proprioception and fine neuromuscolar
control play a key role here
(foreword by Douglas W. Brown AOSSM President , 22 March 1999)
70% of ACL
injuries occur
without
contact.......

http://semrc.blogs.latrobe.edu.au/category/acl/
ACL Injury: is surgery needed to return to sport ?
Surgical versus conservative interventions for treating anterior cruciate ligament injuries.
Monk AP, Davies LJ, Hopewell S, Harris K, Beard DJ, Price AJ.
Cochrane Database Syst Rev. 2016 Apr 3;4:CD011166. doi:
10.1002/14651858.CD011166.pub2. Review.

COPERS
•  Reduce the risk of
sport activities
•  No knee abusers
NON-COPERS
ACL Recontruction
in the young active
patient and
potential knee
abusers
Conservative treatment
ACL INJURY
A systematic literature review to investigate if we identify
those patients who can cope with anterior cruciate ligament deficiency
L. Herrington, E. Fowler
The Knee, Volume 13, 2006 Aug.,Issue 4, Pages 260-265

Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the Preinjury
Level: A Review of Contextual Factors Affecting Return to Sport After Surgery.
Ardern CL.
Sports Health. 2015 May;7(3):224-30. doi: 10.1177/1941738115578131.
PMID: 26131299 Free PMC Article
ACLR not exactly a one way ticket back
2016 Consensus statement on return to sport
from the First World Congress in Sports Physical
Therapy, Bern
Clare L Ardern,1,2,3
Philip Glasgow,4,5
Anthony Schneiders,6
Erik Witvrouw,1,7
Benjamin Clarsen,8,9
Ann Cools,7
Boris Gojanovic,10,11
Steffan Griffin,12
Karim M Khan,13
Håvard Moksnes,8,9
Stephen A Mutch,14,15
Nicola Phillips,16
Gustaaf Reurink,17
Robin Sadler,18
Karin Grävare Silbernagel,19
Kristian Thorborg,20,21
Arnlaug Wangensteen,1,8
Kevin E Wilk,22
Mario Bizzini23
For numbered affiliations see
end of article.
Correspondence to
Dr Clare Ardern, Aspetar
Orthopaedic & Sports Medicine
Hospital, P.O. Box 29222,
Doha, Qatar;
c.ardern@latrobe.edu.au
Accepted 1 May 2016
To cite: Ardern CL,
Glasgow P, Schneiders A,
et al. Br J Sports Med
Published Online First:
[please include Day Month
Year] doi:10.1136/bjsports-
2016-096278
ABSTRACT
Deciding when to return to sport after injury is complex
and multifactorial—an exercise in risk management.
Return to sport decisions are made every day by
clinicians, athletes and coaches, ideally in a collaborative
way. The purpose of this consensus statement was to
present and synthesise current evidence to make
recommendations for return to sport decision-making,
clinical practice and future research directions related to
returning athletes to sport. A half day meeting was held
in Bern, Switzerland, after the First World Congress in
Sports Physical Therapy. 17 expert clinicians participated.
4 main sections were initially agreed upon, then
participants elected to join 1 of the 4 groups—each
group focused on 1 section of the consensus statement.
Participants in each group discussed and summarised the
key issues for their section before the 17-member group
met again for discussion to reach consensus on the
content of the 4 sections. Return to sport is not a
decision taken in isolation at the end of the recovery and
rehabilitation process. Instead, return to sport should be
viewed as a continuum, paralleled with recovery and
rehabilitation. Biopsychosocial models may help the
clinician make sense of individual factors that may
influence the athlete’s return to sport, and the Strategic
Assessment of Risk and Risk Tolerance framework may
help decision-makers synthesise information to make an
optimal return to sport decision. Research evidence to
support return to sport decisions in clinical practice is
scarce. Future research should focus on a standardised
approach to defining, measuring and reporting return to
sport outcomes, and identifying valuable prognostic
factors for returning to sport.
BACKGROUND
After a sports injury, the first question asked by
most athletes (and coaches) is: ‘When will I (the
athlete) be able to compete again?’ The answer to
this question is rarely straightforward and is influ-
enced by many factors. However, in most cases the
goals of the injured athlete and the treating clin-
ician (plus other stakeholders in the decision-
making team, such as coaches, parents and man-
agers) are the same—to facilitate a timely and safe
return to sport (RTS).
The Swiss Sport Physiotherapy Association along
with the International Federation of Sports Physical
Therapy and the BJSM hosted the first international
RTS congress in Bern, Switzerland (20–21
November 2015). The aim of the congress was to
present current evidence and guidelines in areas
where sports medicine clinicians (particularly phy-
siotherapists and physicians) play a major role in
helping athletes to RTS after injury or surgery. The
congress also acknowledged the important role of
practitioners including orthopaedic surgeons, phy-
siologists, coaches, and strength and conditioning
professionals in helping athletes RTS.
Consensus process
A half day consensus meeting was held following
the congress (22 November), and 17 members of
the consensus group participated. Prior to the con-
gress, members of the consensus group were
invited to write a narrative review on their topic
area. Authors were asked to focus on summarising
what is currently known and what are the future
advances needed to advance knowledge in RTS.
This information was disseminated to the group
and used as a basis for the first round-table discus-
sion, facilitated by two researchers (CLA and
KMK), where the four sections of this statement
were initially agreed on. Participants then elected to
join one of the four groups, and each group
focused on a different section of the statement.
A section leader was nominated by the members of
each group, and participants in each group dis-
cussed and summarised the key issues for their
section. Each of the groups then presented their
summary, and the 17-member group discussed the
key issues to refine each section.
Objective
This consensus builds on important formative work
published over a decade ago, regarding the team
physician’s role in the athlete’s RTS. In 2002, an
expert panel representing the most prominent
American orthopaedic, sports and family medicine
member societies placed the team physician prom-
inently as the gatekeeper of the RTS decision.1
The
field of sport and exercise medicine has progressed
considerably since then.2
Now, more than ever,
decision-making models and ways of practising that
are athlete-centred are advocated, placing the
athlete in the position of an active decision-maker
Ardern CL, et al. Br J Sports Med 2016;0:1–12. doi:10.1136/bjsports-2016-096278 1
Consensus statement
BJSM Online First, published on May 25, 2016 as 10.1136/bjsports-2016-096278
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd under licence.
group.bmj.comon June 26, 2016 - Published byhttp://bjsm.bmj.com/Downloaded from

Injury and Reinjury risk after ACLR
•  Study design: case series
•  Follow-up: 2 years
•  743 patients 760 surgical procedure
•  316 BPTB 427 QSTGR
•  Esclusion criteria: contralateral ACLR and bilateral ACLR
•  Current study: 675 knee/patients
•  612 interview by phone 5 years after (90%)
•  RE-INJURY, same knee, in 39 patients (6%)
•  CONTRALATERAL INJURY 35 pz (6%)
•  3 patients both(reinjury+contralateral injury)
•  Contact injury 3 time frequent
•  Contralateral injury risk 10 time in IKDC 1 e 2 Sports
•  Higher injury risk in the first 12 month after ACLR
•  No difference between gender (M vs F) and graft (TR vs STGR)
Incidence and risk factors for graft rupture and contralateral rupture after anterior
cruciate ligament reconstruction.
Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K.
Arthroscopy. 2005 Aug;21(8):948-57.

•  48 studies
•  5770 participants
•  Mean follow-up of 41.5 months (3,45 years)
•  82% of participants had returned to some kind of sports
•  63% had returned to their preinjury level of participation
•  44% had returned to competitive sport at final follow-up
•  90% of participants normal or nearly normal knee function when assessed
postoperatively using impairment-based outcomes such as laxity and strength
•  85% when using activity-based outcomes such as the International Knee
Documentation Committee knee evaluation form.
•  Fear of reinjury was the most common reason cited for a postoperative
reduction in or cessation of sports participation
•  The relatively low rate of return to competitive sport despite the high rates of
successful outcome in terms of knee impairment-based function suggests that other
factors such as psychological factors may be contributing to return-to-sport
outcomes.
Return to Sport after ACLR
Return to sport following anterior cruciate ligament reconstruction surgery:
a systematic review and meta-analysis of the state of play.
Ardern CL, Webster KE, Taylor NF, Feller JA.
Br J Sports Med. 2011 Jun;45(7):596-606. Epub 2011 Mar 11.
Not Elite Athletes

Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate
ligament reconstruction: a systematic review with meta-analysis of return to sport rates,
graft rupture rates and performance outcomes.
Lai CC, Ardern CL, Feller JA, Webster KE.
Br J Sports Med. 2017 Feb 21.Review.Free Article
RTS at preinjury level after ACLR
•  RTS rate was 83% in the
elite athletes cohort
•  Mean time to RTS ranged
from 6 to 13 months.
•  The graft rupture rate
was 5.2%
•  Most athletes who
returned to sport
performed comparably
with matched, uninjured
controls.

Should Return to Sport be Delayed Until 2 Years After Anterior Cruciate
Ligament Reconstruction ? Biological and Functional Considerations.
Nagelli CV Hewett TE
Sports Med. 2017 Feb;47(2):221-232.
Why ?
How ?
When ?
RTS after ACLR

Sports Med. 2017 Feb;47(2):221-232.
Why ?
How ?
When ?
RTS after ACLR
•  The active, young athlete who resumes activity follow-
ing ACLR has a greater propensity for a second ACL
injury.
•  The probability of a second injury increases three- to
sixfold when the athlete is aged <20 years
•  Injury rates in this younger cohort have been reported
to be almost as high as 30 % in the literature.
•  In addition, the increased risk in this group is apparent
immediately upon returning to sports.
•  The evidence strongly indicates that second ACL injury
risk is greatest within the first 2 years after ACLR
for young athletes returning back to high-level sports

Sports Med. 2017 Feb;47(2):221-232.
RTS after ACLR
•  A young athlete who returns to sport within 1
year is 15 times more likely to suffer a second
ACL injury than a healthy athlete with no medical
history of a knee injury
•  This elevated risk remains evident within 2 years
of returning to activity, when an athlete is
approximately six times more likely to sustain a
second injury than an uninjured counterpart
•  These athletes are at a disproportionately
higher risk of second ACL injury within the first
2 years after ACLR. Therefore, waiting to
reintegrate into high-level sports activity will
significantly benefit the ACLR athlete.
Why ?
How ?
When ?

Evidence
Opinion
Clinical Case

MEDICAL HISTORY
Age: 25 y/o
Gender: male
Knee: left
Sport: soccer
Role: midfielder
Level: professional
Season: ???
PATIENT
Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament
rehabilitation based on a systematic review and multidisciplinary consensus.
van Melick N, van Cingel RE, Brooijmans F, Neeter C, van Tienen T, Hullegie W,
Nijhuis-van der Sanden MW.
Br J Sports Med. 2016 Dec;50(24):1506-1515. Epub 2016 Aug 18. Review.

MEDICAL DIAGNOSIS
1.  ACL tear
2.  Ramp lesion
3.  Horizontal tear of medial meniscus
4.  Posterior superior meniscal popliteus tear
INJURY
Rehabilitation and return to play after anatomic anterior cruciate ligament
reconstruction.
Yabroudi MA, Irrgang JJ.
Clin Sports Med. 2013 Jan;32(1):165-75. Epub 2012 Oct 13. Review.

In a 25 y/o
professional
soccer player
TREATMENT ???
MISSION IMPOSSIBLE
CONSERVATIVE ???
Who needs ACL surgery ? An open question.
Snyder-Mackler L, Risberg MA.
J Orthop Sports Phys Ther. 2011 Oct;41(10):706-7.Epub 2011 Sep 30.

1) forms a layer of synovial tissue
over the ruptured surface, which may impede repair of the ligament. Moreover, a large number of
cells in this synovial layer and in the epiligamentous tissue
2) express the gene for a contractile
actin isoform, a-smooth muscle actin, thus differentiating into myofibroblasts.
These events may play a role in the
A) retraction and B) lack of healing
of the ruptured anterior cruciate ligament……”
Histological changes in the human anterior cruciate ligament after rupture.
Murray MM, Martin SD, Martin TL, Spector M.
J Bone Joint Surg Am. 2000 Oct;82-A(10):1387-97.
Unlike extra-articular
ligaments that heal after
injury, the human
intra-articular anterior
cruciate ligament
Injury 1: ACL TEAR

•  The ACL disruption never heal
•  The outcome of ACL injury is
a ACL deficient knee
•  ACL insufficiency = ACL instability
•  ACL instability = pathological joint kinematics
•  Alteration of rolling-gliding knee mechanism =
•  Shear forces friction wear
The ACL cascade
Prospective trial of a treatment algorithm for the management of the anterior cruciate
ligament-injured knee.
Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, Daniel DM.
Am J Sports Med. 2005 Mar;33(3):335-46.

•  Pathologycal biomechanics
•  Secondary damage
•  Medial meniscus
•  Articular cartilage
•  Release the secondary restraints
•  Joint involvement = OA ???
•  The crucial role of meniscus = save the meniscus
The ACL cascade
Natural history of partial anterior cruciate ligament tears: a systematic literature review.
Pujol N, Colombet P, Cucurulo T, Graveleau N, Hulet C, Panisset JC, Potel JF, Servien E, Sonnery-
Cottet B, Trojani C, Djian P; French Arthroscopy Society (SFA)..
Orthop Traumatol Surg Res. 2012 Dec;98(8 Suppl):S160-4. doi: 10.1016/j.otsr.2012.09.013.
Review.PMID: 23153663 Free Article

The meniscus in the cruciate-deficient knee.
Thompson WO, Fu FH.
Clin Sports Med. 1993 Oct;12(4):771-96. Review.
Meniscus in ACLD knee
Evidence clearly implicates meniscectomy as a primary factor in the premature development of OA of the knee joint.
Although data demonstrate the ability of the menisci to transmit load, they do not contribute to the primary stability
of the knee. In the absence of the ACL, the menisci have been shown to enhance the knee's stability in the AP, varus-
valgus, and internal-external directions in vitro. Clinically, the argument that the menisci are
important secondary stabilizers is less clear. The restraining
capacity of the menisci to AP translation is much smaller than the forces the knee is subjected to in vivo during
activities of daily living. Additionally, these forces can increase as much as threefold during strenuous athletics. It
becomes apparent, on review of the literature, that the menisci clearly are not designed to participate as a significant
restraining mechanism for the ACL-deficient knee. The incidence of acute
meniscal tear is 52% and increases to 83%
in the long run. It is important to realize that although the menisci contribute in part to the
stability of the ACL-deficient knee, such a role places them at risk for injury. When meniscal lesions are noted in the
ACL-deficient knee, it is important to bear in mind the patient's goals, including his or her willingness to have an ACL
reconstructive procedure and desire to return to sports. Also, the tear's configuration and location dictate its the
ability to heal. One final area of interest relates to the fate of an ACL reconstruction in the meniscus-deficient knee.
Although the meniscus is not a participant
in primary stability, the subtle alteration in knee joint kinematics may create
unfavorable conditions for the ACL graft. It is possible that the menisci may provide some protection to an ACL-
reconstructed knee by restoring normal knee joint kinematics. Such a situation may
explain why some ACL reconstructions in the
meniscectomized knee fail over time.Prosthetic meniscal
substitution or allograft meniscal transplantation are techniques on the horizon and may prove useful in the future
when the remaining meniscus cannot be repaired

RAMP LESION
Injury 2: RAMP LESION
Meniscal Ramp Lesions: Anatomy, Incidence, Diagnosis, and Treatment.
Chahla J, Dean CS, Moatshe G, Mitchell JJ, Cram TR, Yacuzzi C, LaPrade RF.
Orthop J Sports Med. 2016 Jul 26;4(7):2325967116657815.
Tear or disruption of the peripheral
meniscocapsular attachments of the posterior
horn of the medial meniscus

RAMP LESION
Hidden lesions of the posterior horn of the medial meniscus: a systematic arthroscopic
exploration of the concealed portion of the knee.
Sonnery-Cottet B, Conteduca J, Thaunat M, Gunepin FX, Seil R.
Am J Sports Med. 2014 Apr;42(4):921-6. Epub 2014 Feb 24.

Classification and Surgical Repair of Ramp Lesions of the Medial Meniscus.
Thaunat M, Fayard JM, Guimaraes TM, Jan N, Murphy CG, Sonnery-Cottet B.
Arthrosc Tech. 2016 Aug 8;5(4):e871-e875. eCollection 2016 Aug.
The ACL is the guardian of
posterior horn of medial meniscus

Menisco-Capsular Separation
Medial meniscocapsular separation: MR imaging criteria and diagnostic pitfalls.
De Maeseneer M, Shahabpour M, Vanderdood K, Van Roy F, Osteaux M.
Eur J Radiol. 2002 Mar;41(3):242-52.

Injury 3: Horizontal Medial
Meniscus Tear
Treatment of meniscus tears during anterior cruciate ligament reconstruction.
Noyes FR, Barber-Westin SD.
Arthroscopy. 2012 Jan;28(1):123-30. doi: 10.1016/j.arthro.2011.08.292.
Epub 2011 Nov 9. Review.
Longitudinal
Bucket-handle
Displaced bucket handle
Root detachments
Parrot beak
Radial
Horizontal
Displaced flap
Degenerative

POSTERIOR SUPERIOR
MENISCAL POPLITEUS
TEAR
Popliteomeniscal fascicle tears causing symptomatic lateral compartment knee
pain: diagnosis by the figure-4 test and treatment by open repair.
LaPrade RF, Konowalchuk BK.
Am J Sports Med. 2005 Aug;33(8):1231-6. Epub 2005 Jul 6.
Can create lateral meniscus
instability, knee lateral pain,
snapping, clicking,.....
Injury 4: PSMPT

Popliteomeniscal fasciculi and lateral meniscal stability.
Simonian PT, Sussmann PS, van Trommel M, Wickiewicz TL, Warren RF.
Am J Sports Med. 1997 Nov-Dec;25(6):849-53.
Injury 4: PSMPT

Evidence
Opinion
Post Op Rehab

Knee Rehab = variables
Is physical therapy more beneficial than unsupervised home exercise in treatment of post
surgical knee disorders ? A systematic review.
Coppola SM, Collins SM.
Knee. 2009 Jun;16(3):171-5. Epub 2008 Oct 11. Review.
•  Patient: coper vs non coper
•  Age: children vs adolescent vs adults
•  Sports: professionel vs amatorial vs sedentary
•  Injury: isolated vs associated (men. cart. lig/per.)
•  Timing: acute vs sub-acute vs chronic
•  Reconstruction: primary vs revision
•  Graft: biological vs artificial ACI, MACI, YALOGRAFT
•  autograft vs allograft bptb vs dstg vs quad
•  Fixation: rigid vs not rigid (bone vs soft-tissue)
•  Concomitant surgery: meniscus, cartilage, bone, other ligaments
•  Preview pathology: OCD, Osgood-Shlatter, ecc.
•  Preview surgery: meniscus, cartilage vs osteotomy
•  Surgeon: learning curve vs espertise
•  Physiotherapist: learning curve vs espertise
•  Rehabilitation: accelerated vs delayed vs accomodating

PHYSIOTHERAPIST GOALS
1.  Prevent the complication
2.  Educate the patient an active
approach
3.  Help to get through surgical trauma
minimizing the joint reactivity
4.  Remove the symptoms (pain,
sweeling, oedema, hemathoma,
stiffness, arthrogenic muscle
inibition ….…)
5.  Normal gait and function of ADL
6.  Safe and fast return of ADL, work
and sports
7.  Restore Biologic Homeostasis
8.  No recurrence of functional
instability
9.  The result don’ t deteriorate in time
Arthrofibrosis
Loss of motion
Hemarthrosis
Septic arthritis Cartilage injuries
Associate Tears
Predicting physical therapy visits needed to achieve minimal functional goals after arthroscopic knee surgery.
O'Connor DP, Jackson AS.
J Orthop Sports Phys Ther. 2001 Jul;31(7):340-52;

Post-op Knee Bracing
A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament
Michael J. Anderson, William M. Browning, III, Christopher E. Urband,
Melissa A. Kluczynski, Leslie J. Bisson
Orthop J Sports Med. 2016 Mar; 4(3): Published online 2016 Mar 15. Free PMC Article
Multiple systematic reviews have
evaluated whether there is any benefit to
routine brace treatment in the
postoperative period after ACL
reconstruction. In 2007, Wright and
Fetzer performed a systematic review of
12 level 1 randomized controlled trials and
found no evidence that braces contribute
to pain control, graft stability, ROM, or
protection from additional injury. The
remaining authors also concluded in their
respective reviews that the literature
shows no added benefit from bracing in
the postoperative period.

Continuous Passive Motion
Several systematic reviews have
examined the effectiveness of
routine continuous passive motion
(CPM) for increasing ROM after
ACL reconstruction; however,
moderate evidence was found,
suggesting no added benefit of
CPM compared with standard
treatment.

Cryotherapy
Raynor et al and Martimbianco et al performed
meta-analyses that investigated the
effectiveness and safety of cryotherapy after
ACL reconstruction. Compared with placebo,
Raynor et al found that cryotherapy was
statistically significantly associated with
reduced pain but was not significantly associated
with ROM or postoperative drainage output.
Martimbianco et al compared outcomes for a
cryotherapy device versus ice pack, no
treatment, and placebo. Pain scores at 48 hours
after ACL reconstruction were significantly
reduced for cryotherapy versus no therapy,
suggesting that cryotherapy is safe and
effective during this short-term postoperative
period. However there were no other significant
results.

Accelerated Rehabilitation,
Early Weightbearing and A/P ROM
Three systematic reviews
found that accelerated
rehabilitation, early
weightbearing, and early
ROM are likely safe and
possibly beneficial to
patient outcomes

Home- Versus Clinic-Based
Physical Therapy
Four systematic reviews have examined the
effectiveness of home- versus clinic-based
physical therapy after ACL reconstruction,
and overall the findings are inconclusive.
Kruse et al and Wright et al found some
support for the effectiveness of home-
based therapy. However, Lobb et al found
no difference in the effectiveness of
home- versus clinic-based therapy, and
Coppola and Collins concluded that not
enough evidence exists to determine the
effectiveness of a home-based program
after ACL reconstruction.

Open Chain Rehabilitation
Exercises
Glass et al reviewed 6 randomized controlled studies that
compared open chain with closed chain exercises and
found no differences in laxity, pain, and function between
these types of rehabilitation in patients with ACL
deficiency or reconstruction. Additionally, the most
appropriate timing of implementation of open chain
exercises is uncertain. A systematic review by Lobb et al
also found no differences in pain, function, and laxity for
open versus closed chain exercises for ACL
reconstruction rehabilitation. Grodski and Marks
concluded that carefully planned rehabilitation programs
help reduce muscle atrophy and regulate graft strain, and
thus, open chain exercises in ranges where the extensors
can work without harming the joint are advisable.

Resistance Training
Augustsson systematically reviewed 6 studies
that documented strength training protocols
after ACL reconstruction, and it was found that
only 2 studies clearly documented the
postoperative strength training protocol used in
their study, suggesting a need for more accurate
reporting of strength training protocols.
Kristensen and Franklyn-Miller reviewed the
efficacy of resistance training for various
musculoskeletal conditions, including ACL
reconstruction. Low to moderate resistance
training after ACL reconstruction resulted in
significant increases in strength and functional
ability; however, there was little to gain from
high-intensity resistance training in the
immediate postoperative period.

Cooper et al reviewed the effect of proprioceptive and balance training on outcomes in
both ACL-deficient and ACL-reconstructed knees. Proprioceptive and balance training
were associated with improvements in knee joint position sense, muscle strength,
perceived knee function, and hop testing in ACL-deficient knees. Only 1 study
examined ACL-reconstructed knees and found improvements in quadriceps and
hamstring strength as well as proprioception. Also, there were no differences in laxity
and strength for proprioceptive and balance training versus standard rehabilitation in
ACL-deficient or -reconstructed knees. Zech et al reviewed the effects of
neuromuscular and proprioceptive training for treating various musculoskeletal
conditions, including ACL injuries. ACL-deficient knees showed significant
improvements in knee function, function for activities of daily living, and single-leg hop
testing and decreased instability after neuromuscular and proprioceptive training.
Alternatively, training did not have a significant effect on outcome scores, ROM, and
single-leg hop testing.
Neuromuscular and
Proprioceptive Training

full weightbearing
and
early range of
motion.
Meniscus Repair:
weightbearing vs non-weightbearing
ACCELERATED REHABILITATION
Weightbearing Versus Nonweightbearing After Meniscus Repair.
VanderHave KL, Perkins C, Le M.
Sports Health. 2015 Sep-Oct;7(5):399-402. Epub 2015 Mar 10. Review.
Successful clinical outcomes
ranged from 70% to 94% in the
studies reviewed here. More
recent studies have trended
toward an accelerated
rehabilitation protocol with full
weightbearing and early range
of motion. Reported outcomes in
the studies reviewed are
comparable (64% to 96% good
results) to the more
conservative protocols.

Accelerated rehabilitation after arthroscopic meniscal repair: a clinical and magnetic
resonance imaging evaluation.
Mariani PP, Santori N, Adriani E, Mastantuono M.
Arthroscopy. 1996 Dec;12(6):680-6.
In a study by Mariani et al, 22 patients
underwent meniscal repair using an outside-in
technique and an accelerated rehabilitation
protocol that included immediate weightbearing
and full range of motion. They were evaluated
postoperatively with clinical examination and MRI
at an average 28-month follow-up (range, 17-38
months). Three of 22 patients showed clinical
signs of retear and had evidence of a rim gap
>1 mm from the meniscal wall on MRI. They
concluded that the low failure rate in this
cohort suggests that an aggressive rehabilitation
regimen may be prescribed without compromising
results.
Meniscus Repair

All-inside meniscal repair using the FasT-Fix meniscal repair system: is still needed to avoid weight
bearing ? A systematic review.
Vascellari A, Rebuzzi E, Schiavetti S, Coletti N.
Musculoskelet Surg. 2012 Dec;96(3):149-54.. Epub 2012 Jul 7. Review.
Vascellari et al published a systematic review of
the clinical outcomes of meniscal repair using
only the all-inside Fast-Fix device comparing a
standard rehabilitation program with an
accelerated rehabilitation protocol. Eight studies
were identified for inclusion. The failure rate
was 13% for patients who followed an
accelerated rehabilitation regimen and 10% for
standard protocol. On the basis of the clinical
outcomes of these studies, there was no
difference between an accelerated rehabilitation
regimen and a standard postoperative
rehabilitation program for this device and type
of tear.
Meniscus Repair

Wierike et al systematically reviewed
psychological factors and outcomes after ACL
reconstruction in athletes. A greater internal
locus of control and increased self-efficacy
before ACL reconstruction were associated with
improvements in postoperative outcomes.
Athletes with low levels of fear of reinjury had
better postoperative outcomes, and athletes who
returned to sport had less fear of reinjury.
Everhart et al also found patient self-confidence,
optimism, self-motivation, stress, social support,
and athletic self-identity to be predictive of
clinical outcomes, including return to sport,
rehabilitation compliance, knee pain, and knee
function after ACL reconstruction
Psychological Factors
Athletes with internal locus of
control, increased self-
efficacy, with low levels of fear
of reinjury, self-confidence,
optimism, self-motivation,
stress, social support, and
athletic self-identity to be
predictive had better
postoperative outcomes,

Limb Symmetry Index (LSI), improved with increasing time, with nearly all
results greater than 90% at 1 year following primary ACL reconstruction.
Functional Performance Testing After Anterior Cruciate Ligament Reconstruction:
A Systematic Review.
Abrams GD, Harris JD, Gupta AK, McCormick FM, Bush-Joseph CA, Verma NN, Cole BJ, Bach BR Jr.
Orthop J Sports Med. 2014 Jan 21;2(1):2325967113518305. doi: 10.1177/2325967113518305. eCollection 2014
Jan. Review.PMID: 26535266 Free PMC Article
Functional and Performance Tests for RTS after ACLR
THE HOP TEST

Evidence
Opinion
Take home message

•  Immediate passive/active motion
•  Early weight bearing and correct gait patterns
•  No postoperative bracing
•  Home-based rehabilitation
•  Open versus closed kinetic chain exercises
•  Neuromuscular electrical stimulation
•  Accelerated rehabilitation in isolate ACLR
•  Delayed rehabilitation in the complex or revision ACLR
•  Preventive bracing if necessary
•  Prevent the post-operative complication
•  Safe (no only fast) return to activities
and sports
•  Prevention of failure and re-injury
•  Prevention of degenerative changes
My 2017 Rehabilitation Goals
Past &
Present
Rehabilitation
Goals
Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament
rehabilitation based on a systematic review and multidisciplinary consensus.
van Melick N, van Cingel RE, Brooijmans F, Neeter C, van Tienen T, Hullegie W, Nijhuis-van der Sanden MW.
Br J Sports Med. 2016 Dec;50(24):1506-1515. doi: 10.1136/bjsports-2015-095898. Epub 2016 Aug 18. Review.

When Can I Drive After Orthopaedic Surgery ? A Systematic Review.
DiSilvestro KJ, Santoro AJ, Tjoumakaris FP, Levicoff EA, Freedman KB.
Clin Orthop Relat Res. 2016 Dec;474(12):2557-2570. Review
Not all people are created equal ....!!!
Doc when I can drive after surgery...???

Thank you very much for your kind attention

Taddio Nicola ACL Rehab Suggestion The Battle 2017 Cesena (ITA)

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