[

case report

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Michael Beecher, DPT, CSCS1 • J. Craig Garrison, PT, PhD, SCS, ATC2 • Douglas Wyland, MD3

Rehabilitation Following a Minimally Invasive Procedure for the Repair of a Combined Anterior Cruciate and Posterior Cruciate Ligament Partial Rupture in a 15-Year-Old Athlete

T

he poor healing potential of injured cruciate ligaments has response to facilitate healing.3,5,34 Murray et al34 examined the histological been well documented.4,5,9,26,45 Failure to completely heal is changes seen in 23 ruptured anthought to be due to inhibitory effects of the intra-articular terior cruciate ligaments (ACLs) environment, such as a lack of cytokine stimulation and SUPPLEMENTAL and found that the healing ligaVIDEO ONLINE poor hematoma formation.3,5,34 In addition, the cruciate ligaments ment forms a layer of synovial appear to have an inherent inability to produce a significant tissue over its ruptured surface that t STUDY DESIGN: Case report.

t BACKGROUND: The healing response

procedure is a minimally invasive arthroscopic surgical technique used to stimulate healing in the treatment of partial cruciate ligament tears. The purpose of this report is to provide information on the surgical procedure, the postoperative rehabilitation, and the overall functional results in a patient who underwent such a procedure.

t CASE DESCRIPTION: A 15-year-old male,

who sustained a partial tear of both the anterior cruciate and posterior cruciate ligament while playing football, underwent arthroscopic surgical management utilizing a healing response technique. Precautions concerning range of motion and resisted activities were followed postoperatively to protect the healing cruciate ligaments. The postoperative protocol consisted of 3 phases, culminating in return-to-sport training. Treatment incorporated cardiovascular, proprioceptive, strength, power, plyometric, and sport-specific activities. Treatment was progressed based on specific criteria emphasizing proper movement patterns and eccentric control during functional activities.

t OUTCOMES: The patient attended 31 physical

therapy sessions over 17 weeks. Strength improved from 3/5 to 5/5, knee range of motion returned to normal, Lower Extremity Functional Scale scores improved from 21/80 to 80/80, and successful outcomes on functional return-to-sport testing allowed the patient to return to competitive athletics.

t DISCUSSION: Primary repair of cruciate

ligament tears has yielded poor results, and partial cruciate ligament tears may not require complete surgical reconstruction. The healing response technique offers a possible solution for the treatment of partial cruciate ligament tears. A criterion-based postoperative protocol was derived based on current evidence regarding rehabilitation following cruciate ligament reconstruction and evidence regarding lower extremity rehabilitation principles and injury prevention.

t LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(5):297-309. doi:10.2519/jospt.2010.3162

t KEY WORDS: ACL, anterior cruciate ligament,

healing response, physical therapy, PCL, posterior cruciate ligament

may impede repair and result in ligament retraction. Of note, none of the ACLs in this study demonstrated tissue bridging between the ruptured tibial and femoral remnants. Studies comparing the intrinsic properties of the injured ACL and medial collateral ligament reveal that fibroblasts of the ACL demonstrate lower proliferation, lower migration potential, and lower response to growth factors.36,48,55 Likewise, fibroblasts within cruciate ligaments synthesize nitric oxide, a free radical that has been shown to inhibit synthesis of both collagen and proteoglycan in larger amounts when compared to cells of the medial collateral ligament.10 Collectively, these results indicate a lower overall healing potential for the cruciate ligaments. Articular cartilage has similar difficulties in healing potential and exhibits limited potential for repair due to its avascular nature and the inability of chondrocytes to mount a sufficient

Sports Physical Therapist, Performance Physical Therapy, Cos Cob, CT. 2 Sports Physical Therapist and Sports Program Director, Proaxis Therapy, Greenville, SC. 3 Orthopaedic Surgeon, Steadman Hawkins Clinic of the Carolinas, Spartanburg, SC. This case was seen at Proaxis Therapy and Steadman Hawkins Clinic of the Carolinas, Spartanburg, SC. At the time of this case Dr Beecher was completing a sports physical therapy residency under the mentorship of Dr Garrison. Address correspondence to Michael Beecher, 35 River Road, Cos Cob, CT 06807. E-mail: [email protected]

1 

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[ reparative response. 32 A large body of research supports the efficacy of the microfracture procedure to stimulate healing in articular cartilage and repair chondral defects.6,13,20,21,46 This procedure involves surgically induced bleeding of subchondral bone to access mesenchymal cells and a cascade of cytokines to stimulate healing. A fibrin clot is formed around the area of the defect and mesenchymal cells eventually differentiate into fibrochondrocytes, resulting in a fibrocartilage repair.54 The “healing response”44 is an arthroscopic surgical technique that utilizes these same principles in the repair of partial proximal cruciate ligament tears. This minimally invasive, marrow-stimulating, nonreconstructive technique utilizes an arthroscopic awl to induce bleeding in and around the substance and boney attachments of the injured cruciates to stimulate healing. Preliminary research regarding the efficacy of the healing response has yielded promising results.41,44 Thirteen skeletally immature athletes with partial tears of the proximal one third of the ACL were treated with the healing response technique and displayed statistically significant improvements in average Lysholm and Tegner scores, as well as in subjective measures of patient satisfaction and activities of daily living, compared to their preoperative status.44 In addition, KT-1000 testing revealed an average decrease in anterior tibial translation of 2.6 mm. In a canine model, large partial tears of posterior cruciate ligaments (PCLs) that were treated with the healing response resulted in statistically significant improvements in the healing of the lesion, when compared to untreated PCLs.41 Histological examination of the tissue of the PCLs that underwent the healing response demonstrated an abundance of cells surrounded by a dense extracellular matrix comprised of fibroblasts and collagen bundles indicative of healing. Conversely, the PCLs that received no intervention were composed of loosely woven connective tissue with

case report

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FIGURE 1. Coronal T2-weighted magnetic resonance image shows a partial tear of the posterolateral bundle of the anterior cruciate ligament near its femoral insertion.

limited cellularity and a lack of dense collagen bundles. Very little published data exist to support the efficacy of the healing response for the treatment of partial cruciate ligament tears. Additionally, to date, no published reports have described the surgical technique, postoperative rehabilitation, and functional outcomes for a combined ACL/PCL healing response procedure. Thus, the purpose of this case report is to provide information on the surgical procedure, the postoperative rehabilitation, and the overall functional results in a patient who underwent such a procedure. This case report should also serve to stimulate future research regarding the healing response and the optimal evidence-based postoperative rehabilitation.

CASE DESCRIPTION

T

he patient was a 15-year-old male participating in baseball and football at the varsity level. Prior to the injury, the patient was in excellent general health, with no history of significant orthopaedic injuries. The patient reported that he sustained a right knee injury during a football game while playing safety. While tackling another player he was hit from behind, resulting

FIGURE 2. Sagittal T2-weighted magnetic resonance image shows a midsubstance tear of the posterior cruciate ligament towards its tibial insertion.

in excessive flexion of his knee. A pop was not felt at the time of the incident but he was taken out of the game and noted immediate swelling. He was instructed on the use of crutches and was advised not to bear weight on his right lower extremity. Following the injury, the patient saw his primary care physician, who ordered magnetic resonance imaging of the knee, which revealed a large joint effusion, a partial tear of the posterolateral bundle of the ACL near its femoral insertion (FIGURE 1), and an indistinct PCL with a midsubstance tear towards its tibial insertion (FIGURE 2). The impression given by the radiologist, based on these results, was a partial tear of the ACL and a complete tear of the PCL. The patient was subsequently referred to an orthopaedic surgeon, whose clinical examination revealed a grade 1 Lachman test and grade 2 posterior drawer test. A pivot shift test was attempted, but an accurate assessment was not possible due to pain, effusion, and muscle guarding. The diagnosis by the orthopaedic surgeon, based on the clinical examination, was a partial tear of the ACL and a near complete tear of the PCL. Due to the patient’s age, activity level, and desire to continue to play competitive sports, operative intervention was pursued. Because the magnetic resonance imaging revealed

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partial tearing of both cruciates near the bony insertion without retraction of the ligament ends, the orthopaedic surgeon felt that the healing response technique would lead to a successful outcome. The patient was referred to physical therapy for preoperative rehabilitation immediately.



TABLE 1

Initial Examination Findings

Numeric pain rating scale

Current 4/10, worst 8/10, best 2/10

Lower extremity functional scale

21/80

Observation

Moderate joint effusion, no ecchymosis noted

Girth

Right knee 2.5 cm greater than uninvolved lower extremity, assessed 5 cm proximal to the joint line

Preoperative Intervention

Palpation

Generalized tenderness noted in a diffuse nonspecific pattern

Prior to the surgery, the patient was seen for 4 physical therapy sessions to normalize knee range of motion (ROM), reduce edema, and optimize muscle function. Subjective and objective measures from the initial evaluation are listed in TABLE 1. The patient was provided a knee brace, which was locked in full extension with a tibial buttress to prevent posterior tibial translation. Treatment consisted of passive knee ROM exercises, patellar mobilizations, straight leg raise (SLR) exercises performed in the brace for hip extension, flexion, adduction, abduction, weight shifting onto the involved limb, and basic core (trunk/hip) stabilization exercises. The patient and family were educated about the surgical procedure and postoperative rehabilitation course. The patient was provided with a home exercise program consisting of patellar mobilizations, isometric quadriceps exercises with the knee in full extension, and SLRs as performed in the clinic. The patient’s parents were instructed by the treating therapist in the performance of supine and prone passive knee ROM with tibial assistance to prevent posterior sag. Once knee ROM was equal to the uninvolved knee (0°/140°) and knee circumference for measurement of joint effusion was within 0.5 cm of the uninvolved knee, the patient underwent surgery.

Range of motion

0/80° with empty end feel; uninvolved, 0/140°

Surgical Procedure The patient was placed in the supine position, and examination under general anesthesia was performed by the orthopaedic surgeon. The Lachman test revealed a grade 1 ACL sprain with

Strength Involved knee

Uninvolved knee

Knee extension, 3/5; knee flexion, not tested; hip flexion (in brace), 3/5; hip extension (in brace), 3+/5; hip abduction (in brace), 3+/5; hip adduction (in brace), 3+/5 Knee extension, 5/5; knee flexion, 5/5; hip flexion, 5/5; hip extension, 5/5; hip abduction, 4+/5; hip adduction, 4+/5

Special tests

Not tested due to severe muscle guarding

Gait

Antalgic gait noted in brace with decreased stance time on right lower extremity

a 3-mm side-to-side difference. The posterior drawer test revealed a grade 2 sprain of the PCL with a 7- to 8-mm side-to-side difference. Pivot shift on the involved knee was graded as nearly normal (+, glide). The dial test was symmetric at 30° and 90°, and varus and valgus testing were negative. Diagnostic arthroscopy revealed an area of hemorrhage near the tibial insertion of the ACL with intact fibers. Near the femoral insertion of the ACL a small partial tear involving the posterolateral bundle was noted. The femoral insertion of the PCL was intact, but the ligament was 75% torn near its tibial insertion. All meniscal and chondral surfaces were examined, probed, and considered normal. The healing response procedure was first performed on the PCL. A 90° arthroscopic microfracture awl was used to perforate the midsubstance of the PCL to stimulate a bleeding response. A mallet was then used to perforate the back of the tibial slope at the insertion of the PCL to create 6 to 10 punctured bleeding holes approximately 2 to 3 mm in diameter and 3 to 4 mm in depth, consistent with the published description of the technique.41,44 Bleeding commenced immediately, and the presence of fat droplets in the blood indicated the awl penetrated

sufficiently into the marrow space. A clot formed in situ within minutes. A probe was used to manipulate the disrupted fibers of the PCL back to the tibial insertion area. The ACL was addressed in the same manner. The cortical bone at the femoral and tibial attachments and the tissue of the posterolateral bundle were perforated several times. Again bleeding and fat droplet response were visualized immediately. The disrupted tissue of the ACL was manipulated into the area of the origin of the posterolateral bundle. The knee was brought into full extension and a brace was placed and locked in full extension with a buttress behind the proximal tibia to maintain the tibia anteriorly.

Postoperative Findings The patient presented to physical therapy 1 day postsurgery in the brace and using crutches with partial weight bearing. He was alert, oriented, and in no apparent distress. The patient’s pain was assessed using the numeric pain rating scale (NPRS) and was rated as 8/10, where 0 is no pain and 10 is the worst pain imaginable. Function was rated as 21/80 on the Lower Extremity Functional Scale (LEFS), where 80 represents full function and 0 represents complete functional

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[ loss. ROM, strength, and functional tests were not performed secondary to the surgical precautions. The surgeon stipulated the need for partial weight-bearing restrictions with the use of crutches for 6 weeks and ROM restrictions allowing no ROM for the first week to protect the integrity of the clot created surgically. The patient was to wear the brace locked in full extension for 6 weeks at all times except for bathing, performance of his home exercise program, and during his therapy sessions. At the beginning of week 2, passive knee flexion to 45° was allowed in either the prone or supine position, while maintaining the tibia anteriorly. ROM was advanced to 90° at 4 weeks and was progressed as tolerated thereafter. Wall slides were strictly avoided to prevent posterior tibial translation. A wall slide is a gravity-assisted knee ROM exercise where the patient lies supine, with his involved limb placed on a wall and supported by his uninvolved limb. The patient is then asked to lower the involved limb slowly until the desired knee flexion angle is achieved.

Physical Therapy Intervention The physical therapy protocol (APPENDIX) for this case was developed in collaboration with the orthopaedic surgeon and was criterion-based. Therefore, the progression of exercises was dictated by objective measures of functional performance rather than time alone. However, for the purpose of this case report, time frames for progressing between phases have been established in the protocol as phase 1 (0 to 8 weeks), phase 2 (8 to 12 weeks), and phase 3 (12 weeks to return to sport) to reflect postsurgical restrictions and the patient’s progression through the specific markers of functional performance. The nature of the healing response surgery is less invasive than a complete reconstruction. The healing response does not involve removal of the damaged ligament, drilling of bone tunnels, or acquisition and fixation of a graft,

case report

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as may be required in a complete reconstruction. Due to the less-invasive nature of the healing response surgery, the overall rehabilitative program may be accelerated with the potential for a faster return to sport and previous level of activity. Although the surgery is less invasive than surgical reconstruction, the initial stage of rehabilitation is more conservative in an effort to protect the surgically created blood clot and to allow for maturation of the mesenchymal cells. The initial management of a patient after a healing response procedure also differs from a nonoperative case, where progression of rehabilitation in the early stages can be more aggressive. Secondary to the absence of guidance from the professional literature regarding rehabilitation following a combined ACL/PCL healing response procedure, the protocol for this case was based on the authors’ prior experience and adapted from research available for isolated ACL and PCL surgical reconstructions. Phase 1  Goals to be accomplished in phase 1 included restoring ROM, reducing edema and pain, normalizing gait, facilitating quadriceps contraction, maintaining patellar mobility, and establishing hip and core strength. Patellar mobilizations were performed throughout this phase to prevent the development of adhesions in the anterior interval (the space between the infrapatellar fat pad and patellar tendon anteriorly, and the anterior border of the tibia and the transverse meniscal ligament posteriorly). Ahmad et al2 examined the effects of patellar tendon adhesion to the anterior tibia and found altered tibiofemoral and patellar femoral arthrokinematics, joint contact forces, and a decreased moment arm of the quadriceps when comparing knees with adhesion to controls. Quadriceps weakness following ACL injury is well documented and is related to poor functional outcomes. 14,28,39,50 For this reason, isometric quadriceps contractions with the knee in full extension were performed immediately and were

FIGURE 3. Wood chops and lifts seated on physioball exercise. Patient sits on a physioball and grasps the handle of a resistance cord. For chops (top), the patient rotates the trunk diagonally from a superiorto-inferior direction with arms extended. For lifts (bottom), the patient rotates the trunk diagonally from an inferior-to-superior direction, with arms extended. The patient is instructed to maintain a neutral spine (avoiding excessive flexion or extension) and to rotate using the trunk musculature.

progressed to SLRs when appropriate. Strengthening of the quadriceps for the uninvolved limb in a weight-bearing

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TABLE 2

Criteria to Progress to Phase 2

No swelling Range of motion to within normal limits 25 repetitions of straight leg raises with knee in full extension Normal gait Patellar mobility equal to uninvolved knee Ability to demonstrate proper form in a side plank exercise for 30 s No pain with therapeutic exercise

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Ability to maintain single-limb stance with neutral pelvis for 1 min

position was initiated within the first week postoperatively due to mounting evidence suggesting bilateral quadriceps weakness following unilateral ACL injury.49,51,52 Multiplanar SLRs were performed in the brace to prevent hip weakness that has been found in patients following knee surgery.25 Hip extension was avoided, as resisted hamstring exercises were contraindicated until 8 weeks postoperatively in an effort to protect the healing PCL, due to research indicating that hamstring contraction results in strain of the PCL.16 Initial core stabilization exercises included supine bracing with upper and lower extremity movements, front and side planks, and diagonal functional movements such as wood chops and lifts (FIGURE 3). Establishing core (hip/trunk) stability early in the rehabilitation process was emphasized due to evidence that factors related to decreased core stability have been shown to predict ACL injuries in athletes.56 The side plank exercise was chosen due to evidence that electromyographic (EMG) signal amplitude of the gluteus medius, gluteus maximus, and external oblique was highest during this activity as compared to 8 other exercises targeting the core musculature.18 Weight-shifting onto the injured lower extremity was performed in the brace at week 5 and was progressed to gait training with decreasing assistance from crutches in week 6. Because the patient was a football quarterback and

FIGURE 4. Single-limb Romanian dead lifts. The patient stands in unilateral stance and flexes forward at the hip, while keeping the knee in approximately 20° of flexion and the spine in neutral. Once the patient reaches a point where he/she is parallel to the ground, the patient is instructed to extend the hip to raise the patient’s trunk back to the beginning position.

a baseball pitcher, a large emphasis was also placed on strengthening the scapulothoracic and rotator cuff musculature throughout this phase. Criteria for progression to phase 2 are listed in TABLE 2. Weaning from the crutches began at week 6 postoperatively, and the patient’s gait was normalized by week 7. ROM measured 0°/140° by week 6 postoperatively and was equal to the uninvolved limb at that time. The patient attended a total of 16 physical therapy sessions during phase 1 and met the criteria for progression to phase 2 at week 8 postoperatively. Phase 2  The emphasis of phase 2 was to develop strength and neuromuscular control in a weight-bearing position in all planes of motion under various proprioceptive conditions. Exercises in this phase became more functional, progressing along a continuum from double-limb to single-limb activities.

FIGURE 5. Posteromedial and posterolateral reaches in single-limb stance. The patient stands in unilateral stance and reaches with the nonstance limb in the posteromedial and posterolateral directions as far as the patient can, without flexing the trunk forward. The patient is instructed not to touch down with the reaching foot and to return back to the neutral position.

Exercises were progressed by decreasing surface stability, increasing the demands of the task, and adding external resistance. Quadriceps strengthening remained a key emphasis in this phase and included double-limb squatting, multiplanar lunging, single-limb minisquats, step-downs in various directions, and single-limb squatting against resistance.

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TABLE 3

Criteria to Progress to Phase 3

Maintain all criteria from phase 1 Repeated single-limb squat for 1 min with black sport cord (depth 0°-60°) Lateral agility for 30 s with black sport cord Forward/backward jogging for 1 min with black sport cord

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Ability to perform multiplanar lunges with at least 60° of knee flexion and eccentric control, avoiding dynamic valgus angulation and/or buckling of the knee

FIGURE 6. Tall kneeling falls. The patient is positioned in tall kneeling with both limbs stabilized and is instructed to slowly lower the body towards the floor while maintaining the hips in neutral.

Non–weight-bearing isotonic quadriceps strengthening was initiated at 10 weeks postoperatively. Research suggests that the combination of weight-bearing and non–weight-bearing exercises may lead to greater quadriceps strength and better functional outcomes than weightbearing exercises alone, without resulting in increased laxity.33,47 Isotonic knee extension was performed from 90° flexion to full extension, beginning with approximately 5 kg of resistance and increasing it by 5 kg per week thereafter, as long as the patient had no pain or increased edema. Isotonic knee extension with approximately 5 kg has been found to result in a peak strain of the ACL in an amount nearly equal to that of the Lachman test.7 Because this test is performed early in the postoperative period and is not thought to result in any residual laxity, we felt this resistance was an appropriate starting point. Resisted hamstring strengthening began at week 12, with the emphasis on eccentric strength, as is necessary for most functional activities and sport. Hamstring

strengthening was initiated in full knee extension due to data indicating that increasing strain is placed on the PCL with hamstring contraction at knee flexion angles of 70° to 110°.16 Examples of eccentric hamstring strengthening include single-limb Romanian dead lifts (FIGURE 4), and posteromedial and posterolateral reaches in single-limb stance (FIGURE 5). Tall kneeling falls (FIGURE 6) were performed in the later stages of phase 2, as this exercise requires the hamstrings to contract in a greater range of knee flexion and has the potential to strain the PCL to a higher extent. Initial core stabilization exercises were progressed to exercises that provided less external stability and required greater neuromuscular control, such as front planks with hip extension, side planks with hip abduction, and chops and lifts on an unstable surface. Gastrocnemius muscle strengthening was initiated in this phase to prevent further atrophy and improve the strength of this muscle, as it is important for gait and running mechanics. Durselen et al16 found that activation of the gastrocnemius at knee flexion angles greater than 40° significantly strained the PCL. Consequently, gastrocnemius strengthening was performed in weight bearing, with the patient’s knees fully extended. Heel raise exercises were progressed from double- to single-limb strengthening and from stable to unstable surfaces. Perturbation training was initiated in this phase, as it has been shown to normalize quadriceps-hamstring muscle balance and improve knee kinematics

in individuals following ACL injury. Perturbation training consisted of various techniques and performance on unstable surfaces such as roller boards, tilt boards, and bosu balls.12,24 An example of a specific technique that was utilized is an activity in which the athlete stood with the surgical limb on a roller board while the therapist provided perturbations to the roller board in various directions. Initial plyometric training was initiated in a reduced weight-bearing environment on the Shuttle MVP (Contemporary Design Company, Glacier, WA) towards the end of this phase. We felt it was important to initiate plyometric training as soon as possible to facilitate cocontraction around the joint, increase power, and improve landing mechanics. Participants who engaged in plyometric training have displayed increased knee flexion and decreased hip adduction during drop-landing tasks, when compared to participants who underwent dynamic stabilization training only. 35 Plyometric training was advanced to full weight-bearing activities when the patient displayed excellent eccentric control and a short amortization phase with single-limb plyometric jumps on the shuttle. Plyometric activities with resistance from the sport cord in both the sagittal and frontal planes were emphasized toward the end of this phase and were utilized as criteria for progression. Criteria for progression to phase 3 are listed in TABLE 3. The patient attended a total of 7 physical therapy sessions during this phase and met criteria for progression to phase 3 at week 12 postoperatively.

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TABLE 4

Criteria to Return to Sport

Maintain all criteria from phase 1 and 2 Pass SportCord test (18/21) Demonstrate symmetry of both lower extremities within 4 cm during the star excursion balance test Demonstrate the ability of the knee to absorb body weight, quickly change directions, and produce force during sprinting, agility, and plyometric activities, while avoiding excessive hip adduction, internal rotation, and valgus angulation of the knee

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Demonstrate the ability of the knee to absorb body weight during a battery of sport-specific tasks and movements, while avoiding excessive hip adduction, internal rotation, and valgus angulation of the knee

FIGURE 7. SportCord forward jogging. With a cord attached around the waist, the patient faces away from the resistance band and forcefully bounds from one limb to the other, while maintaining good neuromuscular control during landing. The patient is told to transition from eccentric control during landing to a powerful concentric bound onto the other limb in a timely fashion.

Phase 3  The emphasis of this phase was sport-specific training, ensuring power and lower extremity neuromuscular control during dynamic, multiplanar, sports-specific movements. Goals for this phase were to improve neuromuscular control in multiple planes of motion at varying velocities, improve

power, maximally challenge proprioception through sport-specific tasks, and to ensure proper landing mechanics. The ultimate goal was to ensure that the patient could handle all physical demands of his sport. Exercises in this phase were more dynamic in nature, including plyometric jumps in multiple planes of motion and at varying heights, progressing from bilateral to unilateral jumps. Proper form was ensured prior to progression of the demands of the task. The athlete was instructed to land with knees flexed, avoiding excessive hip adduction and internal rotation positions that could jeopardize the integrity of his ACL. Core activities emphasized in this phase included medicine ball throws into a wall, emphasizing maximum power. Cocontraction around the knee joint during sport-specific movements was facilitated by having the athlete sprint from cone to cone, with rapid deceleration on the injured limb, immediately followed by backwards sprinting. Multiplanar agility was targeted through agility ladder and speed drills. One such agility drill required the athlete to stand in the center of 4 cones spaced 10 m apart and sprint to each cone in a random order provided by the treating therapist. The purpose of this drill was to mimic the unpredictable nature of sport and ensure that the athlete could decelerate and quickly accelerate without difficulty. Once the athlete displayed adequate form and endurance during agility drills, the drills were advanced to be task specific to the patient’s primary sports of

baseball and football. Form was deemed adequate, based on a qualitative assessment of movement strategies. Adequate form was observed if the patient could decelerate and change directions with sufficient knee flexion, indicating an ability to eccentrically control his body weight on the surgical lower extremity, while also avoiding any dynamic valgus angulation of the knee. Comparison was made to the contralateral extremity. Endurance was deemed adequate when the patient could perform these drills consistently with adequate form for a 30-second interval. This time frame was chosen based on the principle of specificity of training, as it simulates the amount of time the patient will be engaged in such tasks during football or baseball games. Examples of the sport-specific tasks performed included baseball ground ball drills and a simulated scramble, as if under pressure while playing quarterback. Prior to completion of this phase, the patient was required to pass the SportCord test.29 The SportCord test is a returnto-sport assessment that incorporates a series of dynamic multiplanar functional activities against resistance from a SportCord. Components of the test include single-limb squats for 3 minutes, lateral bounding for 80 seconds, and forward/ backward jogging for 2 minutes each (FIGURE 7, ONLINE VIDEO). The patient was graded on the ability to demonstrate good neuromuscular control of the lower extremity during multiplanar movements that simulate athletic activities. A pass-

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ing score was considered to be 18 out of 21 points. The patient in the current report received a passing score at week 16 postoperatively. Criteria for progression to discharge from formal therapy and return to sports are listed in TABLE 4. The patient attended a total of 6 physical therapy sessions during the final phase of rehabilitation and was discharged from physical therapy at week 16 postoperatively.

case report

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OUTCOMES

T

he patient’s outcome data at specific time frames throughout the treatment are listed in TABLE 5. Pain was assessed using the NPRS. The NPRS has been shown to have adequate reliability and validity in populations with musculoskeletal disorders and requires a 2-point change to be clinically meaningful.11,19 The patient was asked to rate his average pain over the previous 24 hours

at the start of each treatment session. He reported a pain level of 4/10 at the initial preoperative assessment and a complete resolution of pain at 7 weeks and thereafter. The LEFS was used to assess the patient’s functional progress. Test-retest reliability has been shown to be excellent in a patient population with lower extremity musculoskeletal disorders.8,53 The LEFS has also been shown to be strongly correlated to the score on the



TABLE 5

Measurements Throughout the Course of Treatment

Time Postsurgery/Measures Outcomes

Time Postsurgery/Measures Outcomes

4 wk

Strength

NPRS

3/10

Hip flexion

5/5

LEFS

35/80

Hip abduction

5/5

Knee ROM

0°-90°

Hip adduction

5/5

Hip extension

4/5

Strength Hip flexion

3+/5

Knee extension

5/5

Hip abduction

3+/5

Knee flexion

4/5

Hip adduction

3-/5

Functional Strength

Hip extension

NT

SEBT

Knee extension

NT

Ant (involved/uninvolved)

80/86 cm

Knee flexion

NT

PM (involved/uninvolved)

93/99 cm

PL (involved/uninvolved)

100/104 cm 15/21

Functional Strength SEBT

NT

SportCord test

SportCord test

NT

16 wk

8 wk

NPRS

0/10

NPRS

0/10

LEFS

80/80

LEFS

61/80

Knee ROM

0°-140°

Knee ROM

0°-140°

Strength

Strength

Hip flexion

5/5

Hip flexion

5/5

Hip abduction

5/5

Hip abduction

5/5

Hip adduction

5/5

Hip adduction

4/5

Hip extension

5/5

Hip extension

NT

Knee extension

5/5

Knee extension

3/5

Knee flexion

5/5

Knee flexion

3/5

Functional Strength

Functional Strength

SEBT

SEBT

NT

Ant (involved/uninvolved)

87/88 cm

SportCord test

NT

PM (involved/uninvolved)

98/99 cm

PL (involved/uninvolved)

105/104 cm

SportCord test

18/21

12 wk NPRS

0/10

LEFS

75/80

Knee ROM

0°-140°

Abbreviations: Ant, anterior; LEFS, Lower Extremity Functional Scale; NPRS, numeric pain rating scale; NT, not tested; PL, posterolateral; PM, posteromedial; ROM, range of motion; SEBT, star excursion balance test.

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SF-36 physical function scale and is responsive to change in patients with lower extremity disorders.8 The patient in the current report received a score of 21 at the preoperative assessment and progressed to a maximum score of 80 at 15 weeks. Dynamic balance was measured using a simplified version of the star excursion balance test (SEBT), in which individuals are required to stand in single-limb stance while reaching with the free limb in the anterior, posteromedial, and posterolateral directions in relation to the stance limb. Reliability of this test has been shown to be good with intraclass correlation coefficients (ICCs) of 0.84 to 0.87 and 0.89 to 0.93 for intrarater and test-retest reliability, respectively.40 At the initial SEBT assessment, the patient displayed an anterior reach deficit of 6 cm on his involved side. At 16 weeks, the patient’s anterior reach on his involved limb was equal to that of his uninvolved limb. The patient’s ability to return-to-sport was first assessed using the SportCord test at 14 weeks. At this time the patient did not pass the test and received a score of 15/21 due to inadequate knee excursion and excessive trunk flexion during the test components. The patient was again tested at 16 weeks, at which time he received a passing score of 18/21. At this time the patient’s home exercise program was reviewed and he was discharged from formal therapy and allowed to return to sports. At 20 weeks the patient was contacted over the phone and reported no pain or dysfunction and an ability to participate in competitive athletics at a varsity level. At 40 weeks the patient was again contacted and reported successful completion of his baseball season, with reintegration into his role as a starting pitcher. At that time he was fully participating in preseason football activities, including running, cutting, sprinting, and all demands of his sport, without reports of instability, pain, or limitation.

DISCUSSION

F

ollowing a healing response procedure for a combined partial tear of the ACL and PCL, this patient was able to return to competitive sports after 4 months of physical therapy that consisted of 29 total sessions. This time frame is shorter than that which has typically been reported following cruciate reconstruction.15,31,38 The more expedient recovery in the current report may be due to several factors. The preoperative intervention to avoid quadriceps atrophy and decreased ROM might have led to fewer impairments after surgery. Likewise, the less-invasive nature of the healing response procedure, as compared to that of complete reconstruction, might have resulted in lesssevere postoperative sequelae such as pain, effusion, and arthrogenic muscle inhibition. The criterion-based postoperative protocol used functional indicators of the patient’s ability to progress and might have ultimately allowed the patient to return to sport in a timely manner. It is interesting to note the minimal level of pain (3/10) reported by this patient 4 weeks after surgery and the resolution of pain (0/10) by 8 weeks after surgery. ROM was limited in the early phase of rehabilitation due to restrictions given by the surgeon to protect the healing ligaments and was fully recovered by 8 weeks. Anterior knee pain has frequently been reported following ACL reconstruction1,42 and primary repair,27,43 and has been linked to anterior interval scarring and patellar tendon adhesion.1,37 For this reason, patellar mobilizations were initiated immediately postoperatively and were an integral component of treatment throughout the initial phases of treatment. Ligamentous testing of the knee was performed by the orthopaedic surgeon at 8 and 12 weeks postoperatively. The integrity of the ACL was assessed using the Lachman and pivot shift tests. Both tests were determined to be negative at

both the 8- and 12-week assessments. The examiner felt a solid end point during the Lachman test, with less than 3 mm of anterior tibial translation noted, as compared to the uninvolved knee. The integrity of the PCL was determined using the posterior drawer test. A mild increase in posterior tibial translation was felt during this test, as compared to the uninvolved side, and was determined to approximately 3 to 5 mm. Thus, although the preoperative laxity noted in the PCL was not completely eliminated, it was decreased. The patient did not report any patellofemoral pain throughout treatment or when he was contacted for follow-up. Impaired strength, neuromuscular control, and balance were the patient’s primary impairments leading to functional limitations. Knee and hip strength was assessed through manual muscle testing and was judged equal to the uninvolved side at 12 weeks. The patient displayed a side-toside asymmetry in each of the 3 reach directions during the initial SEBT assessment. High school basketball players with an anterior right/left reach difference of greater than 4 cm have been shown to be 2.5 times more likely to sustain a lower extremity injury.40 At initial assessment of the SEBT, our patient displayed an anterior asymmetry of 6 cm, thus placing him at an increased risk for reinjury. Earl and Hertel17 analyzed EMG signal amplitude during the various reaching directions of the SEBT and found that the anterior reach direction was a quadriceps-dominant activity. Our patient displayed a deficit in this reach direction due to the quadriceps weakness he displayed, which is consistent with other previous reports of weakness following ACL injury. 14,28,39,50 Previous authors have found that individuals with ACL deficiency displayed lower reaching distances during the SEBT, as compared to matched controls.23 In a randomized control trial, subjects with chronic ankle instability significantly improved their

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[ scores on the SEBT following 4 weeks of rehabilitation emphasizing dynamic balance and proprioceptive training, as compared to controls who received no intervention.22 Following training of the quadriceps musculature and dynamic balance through various weight-bearing activities, the patient in the current report was able to normalize his anterior reach distance on the involved limb at 16 weeks postoperatively.

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CONCLUSION

T

he postoperative rehabilitative protocol described in this report was based on evidence regarding rehabilitation following ACL reconstruction, as well as evidence pertaining to lower extremity neuromuscular strengthening and injury prevention. The patient in this report had a successful outcome, with subjective reports of full lower extremity function and an ability to return to his previous level of sport competition. There are some limitations to the current report that must be noted. Strength was assessed using manual muscle testing only and no assessment of isokinetic strength was performed. Data from isokinetic strength testing would have provided valuable information regarding the patient’s strength and readiness to return to sport. However, the authors feel the criteria described in this case report for the assessment of functional strength and readiness to return to sport were sufficient and appropriately simulated the demands of sport. A further limitation to the current report is the lack of ligament stability testing using a KT-1000 arthrometer. Stability testing using a KT-1000 arthrometer would have allowed for a more objective assessment of anterior tibial translation, providing an indication of the ability of the ACL to resist this motion. However, ligamentous laxity in the current report was assessed using the Lachman test, which has been shown to be as accurate

case report

]

as KT-1000 testing, if an assessment of a solid end point is made. 30 The results of this case report should be interpreted with caution, as the results cannot be generalized to other patients and no cause-and-effect relationship can be inferred between the surgery, rehabilitation protocol, and the outcomes experienced by this patient. The outcomes of this case report, however, are consistent with previous research regarding successful outcomes following the healing response technique. This case report is the first description of a successful outcome following a combined cruciate ligaments healing response procedure. There is a need for future research with larger sample sizes and longer followup to assess the efficacy of the healing response procedure and the described postoperative rehabilitation in the treatment of combined partial cruciate ligament injury. t

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@

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appendix

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Postoperative Protocol for Combined Anterior Cruciate Ligament/Posterior Cruciate Ligament Healing Response Technique Phase 1 Precautions/Restrictions Partial weight bearing, with use of crutches for 6 wk Range of motion (ROM): • No ROM for the first week • Passive knee flexion to 45° in prone or supine position maintaining tibia anteriorly beginning week 2; advance to 90° at 4 wk and progress as tolerated thereafter • Wall slides strictly avoided to prevent posterior tibial translation • Active assisted ROM initiated in prone at week 4 (prone only until week 8) • Active ROM initiated in prone at week 6 Brace: • Locked at 0° for 6 wk with posterior tibial buttress • Worn at all times except during physical therapy sessions and performance of home exercise program (HEP) • Opened to 0°-90° after 6 wk and discontinued once quadriceps control is adequate Resisted exercise: • No resisted hamstring activities for 8 wk Interventions Manual therapy: • Patellar mobilizations: medial-lateral, superior-inferior • Soft-tissue mobilizations - Patellar tendon/retropatellar fat pad: medial-lateral - Quadriceps tendon/suprapatellar pouch: medial-lateral Lower extremity (LE) strengthening/neuromuscular re-education: • Involved lower extremity - Quadriceps isometrics in full extension - Multiplanar straight leg raise (SLR) in brace: hip flexion, abduction, adduction, no extension until week 8 - Clamshells - Weight shifting onto involved limb, progressed to single-limb stance after week 6 • Uninvolved lower extremity - Unilateral leg press on Shuttle MVP (Contemporary Design Company, Glacier, WA) - Single-limb step-downs in multiple directions - Single-limb stance with involved LE reaching in various directions - Unilateral supine bridges involved LE held in slight flexion • Bilateral - Mini-squats in double-limb stance after week 6 - Lateral band walks (once full weight bearing) - Bilateral stance on unstable surfaces progressing to unilateral Core stabilization: • Supine abdominal bracing, progressed with addition of upper extremity (UE) and LE movements • Front and side planks (pillar bridges) • Wood chops and lifts seated on physioball

• T runk rotations seated and supine on physioball, progressed with addition of medicine ball UE strengthening: • Shoulder external rotation (ER) against resistance at 90°/90° • Push-ups, progressed to push-ups on unstable surface • Seated rows against resistance; standing rows on uninvolved LE against resistance Cardiovascular: • Upper body ergometer • Stationary bike beginning week 6 (utilizing interval training principles) Phase 2 Interventions LE Strengthening/neuromuscular re-education: • Bilateral deep squats with dowel overhead, progressed by performing on unstable surface or adding external resistance • Single-limb squats, progressed by performing on unstable surface or adding external resistance • Single-limb squats with UE reach in various directions • Bilateral leg press on shuttle, progressed to unilateral with progressive increase of resistance • Unilateral step-downs, progressed by increasing height and adding external resistance • Posterior and anterior band walks (monster walks) • Single-limb stance with opposite LE reaching in various directions, also performed on unstable surface • Multiplanar lunges, progressed by adding external resistance and lunging onto unstable surfaces • Multiplanar lunges with trunk flexion and trunk extension • Tall kneeling falls • Single-limb Romanian dead lifts (RDLs), progressed by adding external resistance or using unstable surface LE plyometrics: • Bilateral and unilateral shuttle jumps • Forward and backward jogging in place, progressed by adding SportCord resistance • Lateral agility, progressed by adding sport cord resistance Core stabilization: • Prone planks with hip extension • Prone planks with shoulder flexion • Prone planks with shoulder flexion and opposite hip extension • Side planks with hip abduction • Side planks with trunk rotation • Prone walk-outs on physioball • Bridging with abdominal brace, progressed by adding knee extension • Cook hip lift, single-limb bridge holds • Proprioceptive neuromuscular facilitation (PNF) diagonals seated on physioball with weighted ball toss into rebounder

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appendix (continued)

Postoperative Protocol for Combined Anterior Cruciate Ligament/Posterior Cruciate Ligament Healing Response Technique

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• S  tanding chops and lifts with band resistance and with medicine ball resistance, progressed by performing on unstable surface Cardiovascular: • Stationary bike (utilizing interval training principles) • Treadmill running towards end of phase (utilizing interval training principles) Phase 3 Interventions LE strengthening/neuromuscular re-education: • Continue with phase 2 activities, progressed as tolerated • Sportcord test components, progressed time and increased band resistance LE plyometrics: • Bilateral squat jumps • Unilateral squat jumps

• • • • • •

Multiplanar bilateral hops Multiplanar unilateral hops Multiplanar hops over barrier Split squat jumps Tuck jumps Multiplanar box jumps, progressed by increasing box height and performing unilaterally Speed/agility: • Sprinting with rapid reacceleration and involved LE stabilization hold • Sprinting with rapid reacceleration and direction change • Cone drills • Agility ladder drills Core stabilization: • Medicine ball catches and throws during dynamic movements • Medicine ball throws into wall, stable and unstable surfaces

BROWSE Collections of Articles on JOSPT’s Website The Journal’s website (www.jospt.org) sorts published articles into more than 50 distinct clinical collections, which can be used as convenient entry points to clinical content by region of the body, sport, and other categories such as differential diagnosis and exercise or muscle physiology. In each collection, articles are cited in reverse chronological order, with the most recent first. In addition, JOSPT offers easy online access to special issues and features, including a series on clinical practice guidelines that are linked to the International Classification of Functioning, Disability and Health. Please see “Special Issues & Features” in the right-hand column of the Journal website’s home page.

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