Serial assessments to determine normalization of gait following anterior cruciate ligament reconstruction.

There is an increased emphasis to identify clinically applicable methods that quantify gait deficits following anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to perform serial gait assessments in a clinical setting to determine whether and when clinical gait parameters normalize in patients following ACLR. The hypothesis was that a clinically available gait treadmill would quantify gait deficits measured at 4 weeks post-reconstruction. The secondary hypothesis was that patients would demonstrate incremental improvements in these gait parameters measured at each interval up to 12 weeks post-reconstruction, and that the objectively measured improvements would correlate to the patient's subjective rating of function. Fifteen subjects, five male and 10 female, who had initial unilateral anterior cruciate ligament injury were selected for this study on the basis of operative data. All subjects were evaluated in a physical therapy clinic within 3 days following ACLR and were enrolled in a standardized rehabilitation program. The dependent gait variables of step length, stance time and gait velocity were measured at 4, 6, 8 and 12 weeks post-ACLR on a commercially available gait treadmill. A 2 x 4 multivariate analysis of variance (2 within factors) with measures for limb involvement (uninvolved and involved) and repeated measures for time (4, 6, 8 and 12 weeks) was used to assess the interactions and the main effects on the gait variables of stance time and step length. The results of this study supported the hypothesis that gait deficits and serial improvements can be objectively quantified in a clinical setting (P<0.001). Specifically, stance time, step length and gait velocity deficits evaluated at 4 weeks showed significant improvements at the measured intervals. Step length normalized at week 8. Stance time and gait velocity reached normal levels at the 12-week time interval. Subjective activity of daily living scores (ADLS) also improved following the 12-week rehabilitation, from 53+/-17% to a mean score of 88+/-11% (P<0.001). ADLS scores significantly correlated to step length (R=0.63) and stance time (R=0.53) in the involved limb. Self-selected gait velocity also correlated to ADLS scores and significantly predicted 49% of the variance in the subjective outcome measure. A clinically available gait treadmill can be used to quantify gait deficits and improvements following ACLR. Serial assessments of walking gait may aid clinicians to identify and target deficits in their patients during rehabilitation.

Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation.

Patellofemoral disorders are among the most common clinical conditions managed in the orthopaedic and sports medicine setting. Nonoperative intervention is typically the initial form of treatment for patellofemoral disorders; however, there is no consensus on the most effective method of treatment. Although numerous treatment options exist for patellofemoral patients, the indications and contraindications of each approach have not been well established. Additionally, there is no generally accepted classification scheme for patellofemoral disorders. In this paper, we will discuss a classification system to be used as the foundation for developing treatment strategies and interventions in the nonsurgical management of patients with patellofemoral pain and/or dysfunction. The classification system divides the patellofemoral disorders into eight groups, including: 1) patellar compression syndromes, 2) patellar instability, 3) biomechanical dysfunction, 4) direct patellar trauma, 5) soft tissue lesions, 6) overuse syndromes, 7) osteochondritis diseases, and 8) neurologic disorders. Treatment suggestions for each of the eight patellofemoral dysfunction categories will be briefly discussed.

Postoperative management of the patellofemoral patient.

Postoperative management of the patellofemoral patient requires the clinician to implement a program which reestablishes functional activities of daily living. This paper will discuss the postoperative management of the patellofemoral patient. Effective rehabilitation techniques are needed to progress the patient. Surgical procedures, such as a lateral retinacular release, proximal realignment, and distal realignments, are frequently utilized techniques; however, long-term clinical outcome studies are lacking. The postoperative protocols discussed utilize an evaluation-based treatment approach model. The model defines evaluation techniques, leading the clinician to a specific rehabilitation pathway. The crucial element of postoperative management focuses on a treatment and exercise approach similar to the nonoperative management. Inappropriate or overly aggressive exercises may lead to possible neurologic dysfunction or delayed muscle function. The clinician must recognize that patients may exhibit articular cartilage damage, and, thus, rehabilitation programs must be designed to minimize the potential risks of progressing this lesion.

Incidence of injury in indoor soccer.

All injuries occurring over a 7-week period at a local indoor soccer arena were documented for analysis of incidence rates. All injury rates were calculated per 100 player-hours. The overall injury rates for male and female players were similar, 5.04 and 5.03, respectively. The lowest injury rate was found among the 19- to 24-year-old athletes and the highest injury rate was found among the oldest age group (> or = 25 years). Collision with another player was the most common activity at the time of injury, accounting for 31% of all injuries. The most common injury types were sprains and muscle contusions, both occurring at a rate of 1.1 injuries per 100 player-hours. Male players suffered a significantly higher rate of ankle ligament injuries compared with female players (1.24 versus 0.43, P < 0.05), while female players suffered a significantly higher rate of knee ligament injuries (0.87 versus 0.29, P < 0.01). Goalkeepers had injury rates (4.2) similar to players in nongoalkeeper positions (4.5).

The early treatment of motion complications after reconstruction of the anterior cruciate ligament.

The use of active and passive knee motion in the immediate postoperative period and a treatment plan for early postoperative limitations in knee motion has proven highly effective in restoring motion after anterior cruciate ligament (ACL) reconstruction. Of 207 knees, 189 (91%) regained a full range of motion of 0 degrees-135 degrees. The remaining 18 knees (9%) did not regain motion as rapidly as the others and were placed in an early postoperative phased treatment program. Six knees had serial extension casts, nine had early gentle manipulation under anesthesia, and three had arthroscopic lysis of intraarticular adhesions and scar tissue. Fourteen of these 18 knees regained a full range of knee motion. Two of the remaining four knees lacked 5 degrees of full extension, whereas the other two, in patients who had failed to follow medical advice and the rehabilitation program, had permanent and significant limitation of motion. The incidence of postoperative motion problems was related to the extent of the surgical procedure. The incidence was 4% in patients who had only ACL reconstruction, 10% in cases in which added lateral extraarticular procedure had been done, 12% where a meniscus repair had been done, and 23% where a medial collateral ligament repair was done.

Rehabilitation of the allograft reconstruction.

A series of prospective studies have been performed using allograft tissue for anterior cruciate ligament (ACL) reconstruction. This type of procedure has been shown to effectively control joint displacement and increase overall patient function in a specific patient population. In considering the use of allograft tissue, the surgeon must take into account the indications and contraindications as well as graft preparation and possible immune response. The current clinical trend is utilization of allograft tissue for patients who have previously failed autograft surgery, have patellofemoral arthrosis, or have a long-standing chronic ACL deficiency. The rehabilitation process for these types of patients is very similar to our approach in the autograft patient. It is important for the clinician to facilitate an early motion program after surgery, early exercise protocols, and early weight bearing. However, as in any protocol, careful evaluation is critical. Three different studies reported by our group have shown the allograft to be successful in controlling joint displacement. On testing with the KT-1000 arthrometer, 69 percent of acute repairs had less than 3 mm of anterior posterior displacement; 26 percent of these patients had only 3-5 mm of anterior displacement compared to the contralateral knee. A second study of chronic anterior cruciate ligament patients showed 54 percent had under 2.5 mm of anterior displacement and 34 percent had 3-5 mm of anterior displacement when compared to the contralateral knee. With effective implementation of a rehabilitation program, only 5 percent of our acute and chronic patients developed a motion complication, and only 9 percent had patellofemoral complaints. Using a strict rating system, the overall rating of these patients showed that 89 percent were in the excellent to good range, which allowed them to once again participate in recreational or competitive sports. Only 11 percent had a fair to poor result; 50 percent of that group chose not to return to sporting activity for nonknee related causes. These studies have shown that allograft ligament reconstructive techniques are effective and improve functional ability in the chronic anterior cruciate ligament patient. Use of these tissues should, however, be on a selective basis. Caution must be used by the physician when using these tissues, and the physical therapist must recognize that the protocol for postoperative management is essentially the same as for the autograft techniques. J Orthop Sports Phys Ther 1992;15(6):294-302.

Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture.

This study assessed the sensitivity of four different types of one-legged hop tests. The goal was to determine alterations in lower limb function in ACL deficient knees. Regression analyses were conducted between limb symmetry as measured by the hop tests and muscle strength, symptoms, and self-assessed function. In 67 patients, 50% had abnormal limb symmetry scores on a single hop test. When the results of two hop tests were calculated, the percent of abnormal scores increased to 62%. The percentage of normal scores indicated that these hop tests had a low sensitivity rate. However, the high specificity and low false-positive rates allow the tests to be used to confirm suspected defects in lower limb function. Statistical trends were noted between abnormal limb symmetry on the hop tests and low velocity quadriceps isokinetic test results.

Bone-patellar ligament-bone and fascia lata allografts for reconstruction of the anterior cruciate ligament.

A prospective study was performed of the first forty-seven consecutive patients who had repair of a ruptured anterior cruciate ligament and replacement with an allograft. Patients who had a rupture of another ligament were excluded, to provide a homogeneous group. Twenty-two patients received a fascia lata allograft and twenty-five patients received a bone-patellar ligament-bone allograft. All patients were enrolled in an exercise program to facilitate motion of the knee immediately after the operation, and all patients returned for postoperative evaluation (mean, forty months; range, twenty-five to sixty-seven months). The results were based on a comprehensive subjective and objective rating system, which assessed twenty factors. On testing with the KT-1000 arthrometer, 69 per cent of the patients had less than three millimeters of increased anterior-posterior displacement of the knee that had been operated on compared with the contralateral knee, 26 per cent had three to five millimeters, and 5 per cent had more than five millimeters. The knees that had a bone-patellar ligament-bone allograft had significantly lower values for anterior-posterior displacement than did those that had a fascia lata allograft (p less than 0.05). Just one patient, the only one in whom the fascia lata graft failed, had giving-way. There were no infections, and there was no evidence of rejection of the allograft or documented transmission of disease at the time of writing. A strict rating system was used. Eighteen patients (38 per cent) had an excellent result, twenty-four (51 per cent) had a good result, and five (11 per cent) had a fair or poor result. Motion of the knee immediately postoperatively was not deleterious to the allograft, and, because limitations of motion were identified and treated in the early postoperative period, full motion (0 to 135 degrees) was restored in all knees.

Quantitative assessment of functional limitations in normal and anterior cruciate ligament-deficient knees.

The purpose of this study was to evaluate the effectiveness of five hopping, jumping, and cutting-type (shuttle run) tests in determining lower extremity functional limitations in anterior cruciate ligament- (ACL) deficient knees. Ninety-three normal subjects were tested. No statistical significance was found between right and left lower limb scores (limb symmetry index) as related to sports activity level, gender, or dominant side. This allowed an overall symmetry index score to be established for the population as a whole. An 85% symmetry index score was found in more than 90% of the normal population for the one-legged hop for distance test and the one-legged timed hop test. Thirty-five patients with ACL-deficient knees were tested. The patients also had KT-1000 and Cybex testing and completed questionnaires rating symptoms, sports activity levels, and sports functional limitations. The cutting-type tests and the vertical jump test did not detect functional limitations in a reliable manner. In the one-legged hop tests, 50% of the patients performed normally, however, all reported giving-way episodes with sports, indicating a lack of sensitivity of these tests in defining functional limitations. Patients with abnormal one-legged hop test scores were considered at serious risk for giving way and limitations during sports activities. Statistically significant relationships were found among abnormal scores on the one-legged hop-type tests and (1) self-assessed difficulty with pivoting, cutting, and twisting, (2) quadriceps weakness (Cybex), and (3) patellofemoral compression pain.

A physiological profile of the elite soccer athlete.

From the Cincinnati Sportsmedicine and Orthopaedic Center and The Deaconess Hospital, Cincinnati, OH. Research Funded by the Cincinnati Sportsmedicine Research and Education Foundation and the United States Olympic Committee. The purpose of this study was to develop a physiological profile of the elite soccer athlete. Protocols were developed to assess flexibility, knee ligament translation, body composition, anaerobic power, lower extremity functional performance, and muscle strength. Eighty-three male U.S. National Team players provided data for this study. Different protocols were used over the years the data was gathered. Each area was tested, using a subset of the total group. The physiological profile of the elite soccer player was compiled from results in each area tested. The players were flexible, on the whole, although 17% of the players demonstrated hamstring tightness. All but one player tested had less than 2.5 mm anterior/posterior (A/P) knee ligament translation. The average body fat was 9.5%, and all athletes performed normally on the function tests. The mean power output on Wingate testing was 8.1 Watts per kilogram body weight. The average hamstring-to-quadricep torque ratio (H/Q) at 60 degrees /sec was 56% (right) and 56.6% (left), and at 450 degrees /sec, was 67.1% and 70.1 %. Identification and measurement of these key physiological qualities for the elite soccer athlete will provide standards and a baseline for trainers, coaches, players, and future investigators. J Orthop Sports Phys Ther 1990;12(4):147-152.

Early knee motion after open and arthroscopic anterior cruciate ligament reconstruction.

The hypothesis proposed in this study was that the initiation of active and passive knee motion within 48 hours of major intraarticular knee ligament surgery would not have the deleterious effects of increasing knee effusion, hemarthrosis, periarticular soft tissue edema, and swelling. We conducted a prospective study with randomized assignment of 18 patients into two groups: 9 patients in the "motion" group began 10 hours of daily continuous passive motion (CPM) on the 2nd postoperative day, while the remaining 9 in the "delayed motion" group used a soft hinged knee brace with knee hinges locked at 10 degrees of flexion and entered into the motion program on the 7th postoperative day. All knees were allowed full 0 degrees to 90 degrees of motion except for a total of seven knees with concomitant mensicus repairs and extraarticular reconstructions where 20 degrees to 90 degrees of motion was allowed, limiting the last 20 degrees of knee extension for the first 4 postoperative weeks to protect the repair. In all other respects, the rehabilitation program after surgery was the same for the two groups, including postoperative compression dressings, exercises, and weight-bearing status. Ten of the eighteen patients had acute ACL disruptions and 8 had chronic ACL insufficiencies. There was an even distribution of acute and chronic knee cases and of open and arthroscopic ligament procedures in the early and delayed motion groups. Associated surgery included four meniscus repairs, three medial collateral ligament repairs, and one lateral collateral ligament repair. Special suturing and fixation techniques were used at surgery to maintain the integrity of ligament and meniscus structures, allowing the surgeon to feel safe in subjecting the joint to early postoperative motion. The objective parameters measured were KT-1000 arthrometer measurements, Cybex isokinetic testing, girth measurements at four lower limb locations, range of motion goniometer measurements, postoperative pain medications, and days of hospitalization. Starting intermittent passive motion on the 2nd postoperative day did not increase joint effusion, hemarthrosis, or soft tissue swelling. In both motion groups, postoperative joint effusions were absent after the 14th postoperative day. There was no statistically significant difference in knee extension or flexion limits, pain medication used, or hospital stay in comparing the two knee motion programs. An important finding of this study was the significant decreases in thigh circumference that occurred within the first few weeks of surgery, which progressed despite a closely supervised inpatient and outpatient rehabilitation program.(ABSTRACT TRUNCATED AT 400 WORDS)

The use of thermography for the diagnosis and management of patellar tendinitis.

Computerized thermography was used to evaluate 17 patients diagnosed with patellar tendinitis. The intent of this study was to determine if a specific patellar tendinitis thermal pattern could be distinguished using infrared thermography. A specific thermal abnormality was found over the patellar tendon in 14 subjects (78%). Twelve subjects showed focal "hot" spots, while two showed focal "cold" spots. The thermal abnormalities appeared as specific focal areas directly overlaying the patellar tendon, without disruption to the thermal pattern of the remaining peripatellar regions. The thermal gradient slope over the patellar tendon was greater in symptomatic knees. Five subjects returned 2-4 weeks later for follow-up thermographic examination. Among the follow-up subject group, changes in thermal asymmetry correlated with changes in symptoms 80% of the time. Computerized thermography appears useful as a noninvasive, objective method of detecting inflammation of the soft tissues about the patellar tendon, and also helps to differentiate this disorder from other knee pathologies. J Orthop Sports Phys Ther 1987;9(4):132-140.