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RETURN TO SPORT AFTER KNEE SURGERY

Justin Wilson SPT

Jennifer Cooke PT, DPT

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WHO AM I

Hometown; Elon, NC
Undergrad: B.S. in Exercise Science from Appalachian State University
Clinical Experiences

Acute: UNC Rockingham
Neuro: Duke specialty rehab services at Midtown
Ortho: Trinity Wellness Center
Interests: Sports, Ortho

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OBJECTIVES

Learners will have an understanding on the significance of tailoring a rehabilitation plan to address an athlete’s needs considering the type of surgery, preoperative fitness level and the sport specific requirements.
Learners will gain practical knowledge on integrating sport-specific guidelines into rehabilitation plans, and how to adapt rehabilitation protocols accordingly.
Learners will have an understanding on basic strength and conditioning principles that will help formulate interventions in the later stages of rehabilitation for return to sport.

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WHAT DOES RETURN TO SPORT MEAN?

Definition varies
Doege et al conducted systematic review on standardized definitions for return to sport

Doege J, Ayres JM, Mackay MJ, et al. Defining return to sport: A systematic review. Orthop J Sports Med. 2021;9(7):23259671211009588. doi:10.1177/23259671211009589

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COMMON KNEE INJURIES

Anterior cruciate ligament
Posterior cruciate ligament
Medial collateral ligament
Lateral collateral ligament
Meniscus
Patella and attaching structures

Insert Picture of Knee

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CONSIDERATIONS FOR RETURN TO SPORT

Contact vs Non-Contact
Lateral vs Linear
Jumping vs Running

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KEY COMPONENTS FOR GENERAL KNEE REHAB

Pain

Increased pain 1year post surgery correlated with lower readiness to return to sport scores
Adolescent athletes post ACL surgery reported greater pain and anxiety than adults

Motion

Normative Values

0 degrees in extension, 150 degrees in flexion

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KEY COMPONENTS FOR GENERAL KNEE REHAB

Strength

If possible obtain objective strength measures
Open Chain vs Closed Chain
Hip Hinge and Squat

Objective Strength Measure methods include dynamometry or isokinetic machine, more on this information to come

Reiterate from previous lecture that open vs closed chain is not necessarily the most important component. Appropriately loading the tissue is

- Particular consideration with knee extensor strengthening after ACLR, is minimizing patellofemoral joint (PFJ) stress, given the high prevalence of patients who go on to develop patellofemoral pain syndrome (PFPS)

n OKC exercises such as knee extensions, quadriceps muscle force and PFJ stress are greatest near full extension. As such, it is recommended to initially restrict high load OKC strengthening between 40-90 degrees of knee flexion

Hip Hinge Importance

- Necessary in order to squat properly

- Places center of gravity in position that allows us to react and move quickly

- Allows athletes to apply the most force to the ground with posterior chain muscles all engaged and ready to activate

- Hamstring flexibility can limit an athletes ability to hinge properly thus creating a more posterior pelvic tilt and could result in more knee or lower back injuries

Does anyone have any examples they used to cue the proper hip hinge??

- Ones I’ve used, dowel rod, butt close to the wall, soft knees, chin down

Squat Importance

- The back squat is widely regarded as one of the most effective exercises used to enhance athletic performance as it necessitates the coordinated interaction of numerous muscle groups and strengthens the prime movers needed to support explosive athletic movements such as jumping, running, and lifting.

-

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SQUAT VARIATIONS

Squat Form
Single Leg Squat Form

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HOW TO SQUAT

Step by Step Breakdown for Body weight squat “Squatting Absolutes”

Toes forward 5-7 degrees outward is okay
Maintain 3 points of contact “tripod foot”
Initiate hip hinge to activate posterior chain (glutes and hamstrings)
Create external rotation torque at the hips by squeezing your glutes and shoving knees out
Maintain postural integrity and maintain head in neutral

Squat University 5 Absolutes to Squatting for bodyweight squats
Point your feet as straightforward as possible. 5-7 degree toe-out angle is acceptable. This is the athletic position.

Barbell squat may require more outward toeing for form and stability
Maintain three points of contact with your feet in relation to the floor establishing the ‘tripod’ foot.
Hip Hinge to engage the posterior chain (glutes & hamstrings) by pushing your hips backwards slightly and bringing your chest forward. Your bodyweight should be balanced over the middle of your feet.
Create external rotational torque at the hips by squeezing your glutes and shoving the knees out to the side while maintaining the ‘tripod’ foot.
Solidify our postural integrity by holding our arms out in front (parallel to the floor) while looking straight ahead.

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SINGLE LEG SQUAT VARIATIONS

Things to watch for

Contralateral hip drop
Dynamic Knee Valgus
Heel elevation
Failure to reach terminal knee extension

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KEY COMPONENTS FOR GENERAL KNEE REHAB

Control and Muscular Endurance

Implementation of motor learning principles important for balance, symmetry, control and reducing risk of re-injury
Muscular endurance is important for return to sport considerations due to demands of participating to in game situations

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CONTROL AND ENDURANCE

EXTERNAL FOCUS OF ATTENTION

30,15,15,15 rep range at 20-40% of 1RM

BLOOD FLOW RESTRICTION

”Keep the bars as steady as possible”

External Focus of Attention

- Patients received an instruction with either an internal focus or an external focus before performing a single-leg hop jump. The instructions for the internal focus group were “Jump as far as you can. While you are jumping, I want you to think about extending your knees as rapidly as possible” and for the external focus group “Jump as far as you can. While you are jumping, I want you to think about pushing yourself off as hard as possible from the floor.” During landing, the external focus group had significantly larger knee flexion angles at initial contact, peak knee flexion, total range of motion, and time to peak knee flexion

BFR

- Important to first assess whether this is appropriate for athlete. Could be risk of DVT or Venous thromboembolism

-In the load compromised patient (early after surgery) or in those patients who experience PFP and subsequent quadriceps inhibition and as such, cannot achieve the required load and activation to bring about the necessary stimulus for adaptation, blood flow restriction (BFR) training may be an effective therapy. Low-intensity resistance training with BFR can result in in greater strength and muscle hypertrophy when compared to resistance training with the same intensity under normal flow

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KEY COMPONENTS FOR GENERAL KNEE REHAB

Return to Sport
Dynamic Movements

Speed
Balance
Jump and Landing mechanics

Squat jump

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JUMP AND LANDING MECHANICS

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JUMP AND LANDING MECHANICS

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OUTCOME MEASURES

Performance Test

Y Balance test

Report used to assess risk of injury

Hop Test

Vertical assessment more important to Horizontal

Counter movement jump

Usage of Force Plates
Measure of lower body power
Kinematics and quality of jump

Subjective Patient Reports

KOOS-QOL, VAS score, Cincinnati Knee Rating System, ACL-RSI

Objective Strength Measures

Hand-held Dynamometry
Isokinetic Testing
Limb Symmetry Index

Y Balance Test

- <4 cm difference for anterior reach

- < 6 cm difference for posterior medial and lateral reach

Hop Test

-Horizontal jump can allow for more compensations. Vertical jump is better assessment

Counter movement Jump

- Measuring force and jump height

-May not have access to force plates so assessing the quality of the jump is important

Patient Report

- KOOS-QOL, VAS score, Cincinnati Knee Rating System-cut

- ACL-RSI scores have been shown to correlate with readiness to return to sport

Objective Strength Measures

-Important to have baselines and continuous measures

-Need to get to 100% stop settling for 90% in order to allow athletes to get to preinjury

- Isokinetic

- Peak Torque – want to see 100% equal force

- Peak Torque to BW – Important to assess deceleration, must produce enough force to stop body

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SPORT SPECIFIC TRAINING PROGRESSIONS

Jumping

Vertical to Horizontal

Sprinting

Acceleration and Deceleration

Change of Direction

Varying degrees of direction change
Pre-planned progression to Reactionary

Power Generation

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FACTORS THAT COULD IMPACT RETURN TO SPORT TIMELINE

Psychological
Severity of injury
Age, overall health
Collaboration of Team (SC’s, Team Doctors, etc.)
Insurance Coverage

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QUESTIONS??

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REFERENCES

1. Betsch M, Hoit G, Dwyer T, et al. Postoperative Pain Is Associated With Psychological and Physical Readiness to Return to Sports One-Year After Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil. 2021;3(6):e1737-e1743. doi:10.1016/j.asmr.2021.08.001

�2. Buckthorpe M, La Rosa G, Villa FD. RESTORING KNEE EXTENSOR STRENGTH AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A CLINICAL COMMENTARY. Int J Sports Phys Ther. 2019;14(1):159-172. doi:10.26603/ijspt20190159

�3. Doege J, Ayres JM, Mackay MJ, et al. Defining return to sport: A systematic review. Orthop J Sports Med. 2021;9(7):23259671211009588. doi:10.1177/23259671211009589

�4. Gokeler A, Neuhaus D, Benjaminse A, Grooms DR, Baumeister J. Principles of motor learning to support neuroplasticity after ACL injury: implications for optimizing performance and reducing risk of second ACL injury. Sports Med. 2019;49(6):853-865. doi:10.1007/s40279-019-01058-0

�5. How To Return Back To Sport After An Injury (ACL, Meniscus, MCL, Ankle Sprain). Youtube. Accessed November 29, 2023. https://youtu.be/sKZcTjlxk-Q?si=Mi4jnjJMZTLdNh-z

�6. Kim Y, Kubota M, Sato T, Inui T, Ohno R, Ishijima M. Psychological Patient-reported outcome measure after anterior cruciate ligament reconstruction: Evaluation of subcategory in ACL-Return to Sport after Injury (ACL-RSI) scale. Orthop Traumatol Surg Res. 2022;108(3):103141. doi:10.1016/j.otsr.2021.103141

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REFERENCES

7. Majewski M, Susanne H, Klaus S. Epidemiology of athletic knee injuries: A 10-year study. Knee. 2006;13(3):184-188. doi:10.1016/j.knee.2006.01.005

�8. Mike Reinold. Return to Sport Testing After ACL Reconstruction. Youtube. Accessed November 29, 2023. https://youtu.be/V6hUtjwoWLQ?si=u0gMXkQYpT9nHe7K

�9. My Return-to-Sport Criteria for Knee Injuries: Thinking Aloud – Articles and resources for enhanced sports medicine rehab and career development. Accessed November 27, 2023. https://vienvudpt.com/2019/02/02/my-return-to-sport-criteria-for-knee-injuries-thinking-aloud/

�10. Myer GD, Kushner AM, Brent JL, et al. The back squat: A proposed assessment of functional deficits and technical factors that limit performance. Strength Cond J. 2014;36(6):4-27. doi:10.1519/SSC.0000000000000103

�11. Patterson SD, Hughes L, Warmington S, et al. Blood flow restriction exercise: considerations of methodology, application, and safety. Front Physiol. 2019;10:533. doi:10.3389/fphys.2019.00533

�12. Saavedra MÁ, Navarro-Zarza JE, Villaseñor-Ovies P, et al. Clinical anatomy of the knee. Reumatol Clin. 2012;8 Suppl 2:39-45. doi:10.1016/j.reuma.2012.10.002

�13. Tripp DA, Stanish WD, Reardon G, Coady C, Sullivan MJL. Comparing postoperative pain experiences of the adolescent and adult athlete after anterior cruciate ligament surgery. J Athl Train. 2003;38(2):154-157.

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