ACL part3

Anterior Cruciate ligament
Reconstruction Management

for Physical Therapy

Phase III : Return to Train – Power, Agility and Landing

Nuttasith Petchruschatachart, PT.
Kayaphap Health Club

Before phase III

• Full range of motion
• No effusion/ swelling
• A “good” rating on the Single leg squat test
• No side to side different for...

o Single leg bridge test
o Single leg calf raises test
o Side bridge endurance test

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Phase 3 of Rehabilitation protocol

• Return to running, agility, jumping and hopping
• Continuation of a gym based strength and neuromuscular

program.
• Exercises and activities in Phase 3 typically include

• agility drills such as slalom running, shuttle runs, and ladder drills
• Jumping and hopping exercises usually start with drills such as scissor jumps

and single hops and progress to box jumps and single leg landings with
perturbations.

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

3 most important
goal of phase III

 Attain excellent hopping performance (technique,
distances, endurance)

 Progress successfully through an agility program and
modified game play

 Regain full strength and balance

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Outcome measures and goals

Outcome measure Goal Outcome measure Goal

Single Hop Test 1. >95% compared with Single Leg Squat Hurdle requirement
other side = >22
Triple Hop Dynamic Balance repetitions both limbs
Triple Crossover Hop 2. Equal to or greater than >95%
Test pre-operative data (Star Excursion Balance Test) compared with other side
Side hop test
(best result – affected or Dynamic Balance Pass both limb
non-affected)
(Cooper & Hughes Sports 1.8 x Body Weight
>95% Vestibular Balance Test)
compared with other side 1.8 x Body Weight
Single Leg Press
>95% Squat Supplemantary
compared with other side

>95%
compared with other side

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Hop test series

Side hop

15 1 attempt
cm

• 2 attempt
• LSI = mean distance(cm) involve side X 100

mean distance(cm) uninvolved side

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Balance test series

Star excursion balance test

anterior Posterolateral Posteromedial

LSI = mean distance(cm) involved side X 100

mean distance(cm) uninvolved side

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Strength test

Single leg squat Single leg press : 1RM Squat : 1RM

1.8 X Bodyweight

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Rehab framework

Phase 1,2 Explosive strength
Strength – static balance Power

Running jump landing

What is POWER

Ability to generate High amounts of force
in relatively Short periods of time

Important sports performance characteristics,

especially in activities that rely on jumping,
change of direction, and/or sprinting
performance

What is POWER

Speed (ex.Sprinting)
Speed-strength (ex.plyometric)
Strength-speed (ex.Olympic lift)
Maximum strength (ex.powerlifting)

Haff, G. Gregory PhD, CSCS*D, FNSCA, ASCC; Nimphius, Sophia PhD, CSCS*D Training Principles for Power, Strength and
Conditioning Journal: December 2012 - Volume 34 - Issue 6 - p 2-12

What is POWER

Haff, G. Gregory PhD, CSCS*D, FNSCA, ASCC; Nimphius, Sophia PhD, CSCS*D Training Principles for Power,
Strength and Conditioning Journal: December 2012 - Volume 34 - Issue 6 - p 2-12

What is POWER

Haff, G. Gregory PhD, CSCS*D, FNSCA, ASCC; Nimphius, Sophia PhD, CSCS*D Training Principles for Power, Strength and
Conditioning Journal: December 2012 - Volume 34 - Issue 6 - p 2-12

Rate of force development (RFD)

Haff, G. Gregory PhD, CSCS*D, FNSCA, ASCC; Nimphius, Sophia PhD, CSCS*D Training Principles for Power,
Strength and Conditioning Journal: December 2012 - Volume 34 - Issue 6 - p 2-12

Rate of force development (RFD)

Haff, G. Gregory PhD, CSCS*D, FNSCA, ASCC; Nimphius, Sophia PhD, CSCS*D Training Principles for Power,
Strength and Conditioning Journal: December 2012 - Volume 34 - Issue 6 - p 2-12

Rate of force development (RFD)

Complex understanding for simple solution : Hip & Knee, Erik Meira

Rate of force development (RFD)

Complex understanding for simple solution : Hip & Knee, Erik Meira

Programming : Power/RFD

• Mixed Methods Approach
• This is the slope of the F/T curve

2 options
 Strength = Strength Principles w/Maximum Effort
 Plyometric

Morrison & Chaconas, 2014, Cormie et al, 2011, Haff & Nimbus, 2012

Strength Principles w/Maximum Effort

• Exertion : Avoiding fatigue & maintaining velocity

• Load : <50-60% of 1RM

• Effort : Maximal - “Push as hard and fast as possible”

• Sets : 3-5

• Reps : 1-5

• Rest periods : Longer. Looking for near to complete recovery

• Frequency : 1-3 times a week

Morrison & Chaconas, 2014, Cormie et al, 2011, Haff & Nimbus, 2012

Plyometric
Stretch-Shortening cycle (SSC)

Absorption Amortization Propulsion
Eccentric Concentric
Isometric

Plyometric progression

Physio-network : A physio’s guide for plyometric, Steven Collins.

Plyometric progression

Force absorption phase

This phase is centred around the eccentric
portion, teaching the patient how to
decelerate the systems mass in the most
safe and efficient manner

Example : Tall to short landing, altitude
landing, fall start catch

Plyometric progression

Force creation phase

This phase is the beginning of assessing
and coaching the concentric portion of
a plyometric movement, as well as the
use of a single amortization phase

Example : seated vertical jump, box jump,
broad jump, single leg hop, loaded jump

Plyometric progression

Stretch-Shortening cycle phase

This phase involves the real assessment and
progression of the musculotendinous unit
towards the movements specific to athlete’s
goals. This is where we put multiple contacts
together of some of the previous movements in
a single rep. Here we are testing the efficiency of
the stretch-shortening cycle to store and release
energy through multiple controlled contacts.

Example : skips, bounds, multiple jump/hops ,
skater hops, barbell squat jumps

Plyometric progression

Maximal demands phase

This phase is where we want to bulletproof
the patient for returning to their goal activity.
Here we should be assessing and training
towards the capacity to handle higher than
task-specific plyometric intensities.

Example : depth jumps +/- subsequent jump,
sports specific jumping / landing, multidirectional
multiple hops

Plyometric dosage

Plyometric load Total foot contact Ground contact time

Sloptimal loading : realistic exrx in rehab, Scot Morrison.

Plyometric programming

Plyometrics only programming

• Beginner 80-100 contacts per session

• Intermediate 100-120 contacts per session

• Advanced 120-140 contacts per session

• Split across 2-3 sessions per week, with minimum 48 hours

between sessions

Mixed model programming (plyometrics + other training)
• Per session: 2-5 sets, 1-6 contacts per set
• 2-3 x per week, with minimum 48 hours between sessions

Muscle power matter

Hop technique, distance, endurance
Running & jumping ability

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
MANAGEMENT FOR PHYSICAL THERAPY

Phase 4

Return to Sport

Teerapat Laddawong, CKTP, MSc.
Department of Physical Therapy, Faculty of Allied Health Science,
Thammasat University. Email: [email protected]

Phase 4

Return to Sport

Physical factors

- Highly individualized
- Specific skills

Focus on knee stability

- Muscular strength
- Optimal neuromuscular control pattern
- Optimal biomechanics

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Phase 4

Return to Sport

Psychological factors

“repetition of successful training and
match play situations”

Self confident
Mental Readiness

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

Muscular Strength Essential

Gluteus, Quadriceps, Hamstring, and Calf 4
muscles
Basic Skills
Balance

Static and Dynamic single leg balance and
core body control

Jumping and Landing

Muscular power and Neuromuscular control

Agility

Ability to move quickly and easily

3 KEY CRITERIA

RETURN TO SPORT

95+ the Melbourne Return Athletes is comfortable, ACL injury
to Sport Score confident, and eager to prevention program
return to sport implemented

Cooper & Hughes, Melbourne ACL Rehabilitation Guide 2.0

RISK FACTORS OF SPORT INJURIES

Brukner and Khan’s, 2012

INTEGRATED MODEL OF
PSYCHOLOGICAL RESPONSE

TO SPORT INJURY AND
REHABILITATION

WieseBjornstal et al. 1998 Brukner and Khan’s, 2012





6 COMPONENTS OF THE
MRSS 2.0

A: Clinical examination (10 points)

B: IKDC Subjective Knee Evaluation and ACL-RSI (20 points)
C: Tempa Scale of Kinesiophobia (hurdle criteria)
D: Functional Testing (50 points)
E: Assessment of General Fitness (hurdle criteria)
F: Functional Testing in a Fatigued State (20 points)

TESTING SESSION 1 TESTING SESSION 2

Part A At least 3 days apart Part E

Clinical examination Assessment of General Fitness

Part B Part F

IKDC and ACL-RSI Functional Testing in a
Fatigued State
Part C

Tempa Scale of Kinesiophobia

Part D

Functional Testing

The Melbourne Return to Sport
Scoring Sheet

Download

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART A: STABILITY, SWELLING, AND RANGE

Stroke Test (Sturgill et al, 2009)

Item Outcome Points Awarded
Effusion Absent 5 Points
Present 0 Points

Stroke Test

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART A: STABILITY, SWELLING, AND RANGE

Stability (Pivot Shift Test)

Item Outcome Points Awarded
Stability Nil 5 Points
Grade I 3 Points
Grade II 1 Points
Grade III-IV 0 Points

Pivot Shift Test

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART A: STABILITY, SWELLING, AND RANGE

Passive Knee Flexion

Item Outcome Points Awarded
Flexion 0-5 degrees deficit
5-20 degrees deficit 5 Points
20+ degrees deficit 3 Points
0 Points

Test Description & Reference
Passive Knee Flexion
- Supine with a long arm goniometer (Norkin & White, 1995).
- Bony landmarks: greater trochanter, the lateral femoral condyle, and the lateral mallelous.

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART A: STABILITY, SWELLING, AND RANGE

Passive Knee Extension (Prone Hang Test)

Item Outcome Points Awarded
Extension 0-1 cm deficit 5 Points
(Prone Hang 1-5 cm deficit 3 Points
Test)
5 cm+ deficit 0 Points

Test Description & Reference
Prone hang test (Sachs et al, 1989)
- Subjects lie prone on a treatment bed with the lower legs off the end allowing full passive knee

extension.
- The heel height difference is measured (approx. 1 cm = 1°)

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART B: ACL-RSI

ACL-RSI

CRITERIA, QUESTIONNAIRES AND TESTING SHEETS

PART B: IKDC

IKDC Thai IKDC auto calculation