Returning the Injured Athlete to Sports:

New Concepts in ACL Rehabilitation

Robert Donatelli, PhD, PT

Course Materials
New Concepts in ACL Rehab

Robert Donatelli PT PhD

drbob@modernathleticscience
 Rehab of ACL
• Non-contact injuries 67% Greater during competition 82.3%
• Last 15min 35%
• Strong Evidence for increased hip adduction moment – poor strength
of hip abductor/external rotation

http://pediatricsportsmed.blogspot.com/2009/05/ac
l-injury-contact-vs-non-contact.html
 Mechanism of Injury
Typically non-contact deceleration situation with
hyperextension or rotational component
***Rotational Component****
 Mechanics of ACL Tears
Hyperextension

http://extras.springer.com/2004/978-1-4757-8105-2/ACLFinal
 Forces to ACL NWBE vs WBE
• ACL loading occurs primarily between 0 – 50E
knee flexion. 50-100E knee flexion reduces ACL
strain
• Higher ACL loads between 0 and 30E peak 150N
in NWBE compared to 50N WBE
• Squatting and Lunge techniques can alter ACL
strain
• Forward trunk tilt recruits the hamstrings = reduced
anterior tibial translations compared to a erect trunk
• Anterior knee movement beyond the toes 8cm =
increase ACL loading during squat and lunge
 ACL Reconstruction
The primary goal of the reconstruction
is to restore stability to the knee and
restore its function allowing the patient
to return to normal activities, including
sports and prevent OA
Weakness of the quadriceps after reconstruction of
the anterior cruciate ligament primarily reflects a
deficit in neural activator drive from the central
nervous system rather than a pure muscle
weakness – neuromuscular rehab
 ACL Post-op Results
Rehabilitation out comes:
• 49% overall of re-injury of the • 40-90% of patients
ACL reconstruction or ACL exhibiting radiographic OA
contra lateral knee
7-12yrs following the
surgery
• Review of 48 studies – more
Barber-Westin, Noyes Objective criteria for
than 5700 patients 63% return to sport following ACL & re-injury rates
returned to pre-injury levels & a systematic review Phys SportsMed 2011
2/3’s were not back 12 months
post-op.
• 44% returned to competitive
sports
Ardern et al Br J Sports Med 2011
 Balance -
Strength/Neuromuscular
Four Systems
• Musculoskeletal
Strength of the Hip and Lower Leg = Posterior GM,
GM, and external rotators - MMT
Dynamic and Static LE testing
• Somatosensory
Star Excursion Balance Test
• Vision
• Vestibular
Factors in Females for Increased Risk
• Over powering Quad Which runner is at increased risk
strength and why?
• Hamstring less effective in
reducing anterior
translations when knee is
extended most protective
15-30 degrees flex
• Posture of the knee in
landing valgus / hyper-
extension
• Muscle Imbalances – hip
• Foot Mechanics
 Perturbation Training Improves Knee Kinematics and
Reduces Muscle Co-contraction After Complete
Unilateral ACL Rupture
Chmielewski, Hurd, Rudolph Axe, Synder-Mackler Physical Therapy 2005 Aug

Copers
• Prior to training potential copers stiffened their knees with higher
co-contraction and slightly lower peak flexion angles

• Increased compressive forces from strong co-contraction can

contribute to degeneration of articular cartilage

• The use of joint stiffening strategy = unopposed quad contraction

that can cause anterior tibial translation = increased shear forces
with over powering Quad

• Normal knee kinematics = knee flexion angles increased in copers

Dynamic and Static Movement Testing
Eccentric
• Step-Down – Step UP Test
• Jump Down Test
• Full Squat Test
• Single Leg Squat Test – Unstable knee
• Knee Flexion Angles - Hop Test unstable surface R-L – Activation
of hamstrings
Isometric
• Single Leg bridge with Dorsi-flexed Ankle
• Side Plank Test - Prone Plank
 Functional Testing

Jump Down Step up Tests

Valgus Knee

Single Leg Squat

Valgus Knee Pronated Foot Position Hyper-extended
 Step Down – Test
• Stool or step 8-inch (20.3 cm)
• Lower R/L leg, so heel touches the ground return to platform
touch top of platform
• Continue sequence for 30 seconds
• Criteria to watch
• Do not push off ground as lowering heel/touching
• Heel must make contact with slight hesitation both @ down phase & start phase
• Do not allow vaulting up with their touch leg
• Greater than 10% difference is significant
 Single Leg Hop

• Single leg hop on unstable

surface
• Straight leg position does
not bring in hamstring
protection
• 20-30 degree angle is
necessary for hamstring
activation
• Poor angle
Full & Single Leg Squat in Sports
Lateral shift Single leg squat knee over foot

Restricted mobility Full squat Full Range

Restoring Neuromuscular Control
Balance in the Athlete
Somatosensory- Vestibular – Vision
The muscle must be set on a higher state of
readiness to prevent injury by protecting joints from
perturbation forces and be able to perform
exceptionally skilled activities performed at high
velocities. This higher state of readiness of the
neural control of the musculoskeletal system can be
achieved through neuromuscular training such as
perturbation, plyometrics and vestibular exercises.
 Neuromuscular Control
Defined: Subconscious integration of sensory information
that is processed by the CNS resulting in controlled,
coordinated muscular activity
Quadriceps

Spinal Sensory
Motor Cord Neurons
neuron
Sensory
stimulating Patellar tendond
hamstrings Neuron

Motor
Motor
neuron Neurons
stimulating
quadriceps
 Neuromuscular
Three Systems to Maintain Balance
Conscious Sense of Orientation

• Somatosensory – mechanoreceptors
• Two reflex arcs
• Myototic ( GTO – Spindle) Stretch Reflex
• Functional Stretch response – provides coordinated limb and trunk
movements across joints

• Vestibular apparatus
Two Groups of sensory receptors
• Semicircular canals 6 total = 3 in each ear
• Otolithic organs

• Vision – Eyes aid in maintenance in upright posture

and orientation
• Three Visual Reflex Arcs
• Optokinetic
• Saccades
• Smooth Pursuit
 Theory of neuro-muscular mechanisms in
perturbation training: “Readiness”
Johansson and Sjolander

 Neuromuscular training results in more efficient

processing of sensory input as well as faster
selection of the correct motor program resulting in
relatively fast but more appropriate movement

 Results in a higher state of readiness of muscles

and joints to respond to perturbing forces applied
to the joints.
 Somatosensory Testing
Star Excursion Balance Test/Y Reach Test to Predict LE Injures in
Basketball Players
Plisky et al. J Orthop Sports Phys Ther 2006;36(12):911-919
• Results: The reliability of the SEBT excellent
• Athletes with anterior right/left reach distance
difference greater than 4 cm were 2.5 times more likely
to sustain

Posterolateral Posteromedial

Anterior
Classic Test for Sensory Integration and Balance CTSIB
Somatosensory – Vestibular – Vision

Test Positions:
1. Single leg stance – eye open – all three systems (SL stress to Hip
Abduction)
2. Single leg stance - eyes closed on firm surface (Somatosensory –
Vestibular)
3. Single leg stance – eyes open on foam (soft surface) –(Vision & vestibular)
4. Single leg stance - eyes closed on foam – (Vestibular system emphasis)
5. Hold position for 30 seconds – hands on hips
Tandem stance requiring initial support to stabilize tandem stance reflect
meaningful deficits to balance related mobility measures 10 seconds and 30
seconds – hold
Hile E. et al, Interpreting the need for initial support to perform tandem stance tests of balance
Am J Phy Therapy Oct 2012
Test Failure:
Opening Eyes, lifting hands from hip, touchdown of non-stance foot, step, hop,
or other movement on stance foot or feet
 Training the Somatosensory System
Perturbation Training
• Johansson suggested
by stimulation of
mechanoreceptors
increases gamma
motor activity
increasing muscle
spindles sensitivity
Advance Training Jumping on to Unstable
Surface

Caratta et al Knee Surg Sports Trauma Arthr 96

• 600 soccer/3seasons
• 300 trained traditional
• 300 proprioceptive training
• 70 ACL tears trad. and 10 ACL tears
balance group
• 5 levels of difficulty
• Each phase of training 3-6 days
• All training sessions lasted 30 days
• 20 minutes per day
 Balance in the Athlete
The Missing Link

• Vestibular (inner ear) CNS

• Vision = Three visual Oculomotor systems

1. Saccades
2. Smooth pursuit
3. Optokinetic
• VOR perception of linear and angular
accelerations
 Balance in the Athlete
• Ankle strategies more dependent on somatosensory
information to control posture – hip more dependent on
vestibular
• Step strategy for center of mass control when stability limits
are exceeded

http://www.thehindu.com/todays-paper/tp-sports/feng-zhe-
Ankle Hip Step
reigns-supreme-on-the-bars/article3739943.ece
 Vestibular System
• Head–Hand-Eye
coordination mediated
by vestibular System
• Vestibular receptors in
the inner ear can provide
an exquisitely accurate
representation of head
motion in 3 dimensions
• Vestibular Ocular Reflex
mechanism for GAZE
stability and the Vestibulo-0cular Reflex is a system that
perception of linear and maintains the stability of the visual field in
response to acceleration of the head in a
angular accelerations of particular direction. Running velocities head
the head acceleration up to 6000 deg/sec
 Vestibular Dysfunction
• Acute vestibular dysfunction is derived from static
and dynamic disturbance in inputs from the
semicircular canals and the otolithic organs
• Static imbalance with the head motionless
– Signs = nystagmus – visual vertical, horizontal, ocular tilt
reaction
• Dynamic disturbances impaired response during
head movements
– Signs= hypo-function of the VOR – postural instability-
ocular counter-rolling
 Vestibular Disorders
• Dislodged Otoconia –
Surgery and Head Trauma
– Small calcium crystals
embedded in the inner ear
can dislodged from the
otolithic organs – move to the
semi-circular canals
• Aging and Disuse
• Large amounts of Fluid
• Labyrinthitis- Inflammation
of inner ear from infections
or upper respiratory
Infections
 Neural Pathway of Vision
• Cones provide color vision and are responsible for
acuity (detailed) vision

• Fovea

• Rods provide night vision, peripheral vision, an

detect motion

• Peripheral Retina

• Visual neural impulses propagate through the optic

nerves to the brain centers
 Visual Workspace and Motor
Performance
• The spatial environment • Human retina
within which objects and
locations exist
• Gaze is the ability to bring
the critical information
required to perform well
onto the part of the eye,
the fovea, that sees with
clear acuity for prolonged
durations even as they
move dynamically in
cluttered and difficult
environments
 Quiet Eye – Final Gaze
• Since the Quiet Eye has been
shown in elite athletes to be
earlier and longer than that of
athletes with lower skill levels -
Dr. Vickers

• It is trainable large increases in

performance
• The quiet eye is an objective
measure of optimal
perceptual-motor coordination
The Quiet Eye = Prof. golfers longer 500
msec / amateur 250-300 msec
 Final Gaze
Dynamic Visual Acuity
• SVA – Ability to see detail
while the head is not
E
moving
• DVA - Ability to see detail
HN
while the head is in DFN
motion
PTXZ
• Test for DVA – Head is
UZDTF
moving side to side while DFNPTH
reading an eye chart PHUNTDZ
NPXTZFH
 DVA Test
0
Head Shaking – Side to Side 120 Sec

E E E E

E E E E
 Final Gaze – Quiet Eye- DVA
Are we helping are athletes see better?
• Seeing the Target
• What is wrong with Andy’s eyes?
• Where is the ball?

http://online.wsj.com/news/articles/SB10001424052748704009804575308741093724362
 Roger Federer Vision System

• Watch the ball from the back

of the racquet Keeps the
head and eyes still longer
before contact
• Makes it easier for you to
prevent the head from
jerking forward during the
swing.

http://www.revolutionarytennis.com/federervisiontechnique.html
The Quiet Eye =
Gaze Stability
Prof. golfers
longer 500-600
msec
Amateur 200-
250 msec
Dr. Vickers
 Testing the Three Visual Oculomotor
Systems
• Vestibular Ocular Reflex = Dynamic Visual Acuity
Take into account cervical-vestibular reflex – ROM

– Smooth pursuit = slow movement - spins

– Saccades faster moving targets or move between
targets.
– Optokinetic eye movement of equal velocity &
opposite direction of head movements
Nystagmus (rapid eye movement) is a normal response
Head Thrust Test for Identifying Vestibular
Hypofunction

• Normal Head Thrust A-B

A- Initial starting position eyes are focused on a target cervical flexion
B- Turning to the left upon stopping the head turn eyes are still on
target
• Abnormal Head Thrust C-E
C- Initial starting position D- turned to right eyes are not on target E-
eyes make a corrective saccade bring eyes back to target
 Dynamic Visual Acuity
• Head moves
• Eyes on target
• 1Hz combo VOR & COR
• 3 Hz purely VOR
• Can quantify with eye chart
• Up to 2 line changes (i.e.
20/20 20/50) is WNL
• Herdman et al 1998
• Train at higher speeds –
blurry or dizzy during the
exercise
 Smooth Pursuit
Exercise & Test for CNS Dysfunction

• Head still
• Eyes follow target through 20-40
deg/sec through narrow arc
• Unable to maintain image on
retina over 1500 sec = 15mph
• Test look for over shoot and/or
nystagmus of the eyes when
following a target
• Deteriorates with age
• Detects spins of an object,
acceleration or decreases in speed
 Saccades Exercise and Test for CNS
Dysfunction
• Head Still

• Ballistic eye movements reach

speeds excess of 900-10000/sec
= 90 mph (145 kph)
• Important for high velocity
objects such as in baseball,
hockey puck, tennis ball,
lacrosse, handball etc.

• Test look for over shoot and/or

nystagmus of the eyes when
moving from targets
Abnormal Optokinetic and Perceptual Span Parameters
in Cerebellar-Vestibular Dysfunction and Related
Anxiety Disorders
Harold N. Levinson – New York University Medical Center

• Optokinetic Tracking
Capacity blurring
speed end point b, c, d

• Subjects experienced
themselves or the
back ground moving
or blurring =
perceptual instability
 Balance & Vestibular Testing Peripheral
1. Classic Test for Sensory Integration and Balance CTSIB
– Eyes open / Eyes closed/ Firm surface / Soft foam - R-L single leg
2. Rhomberg:
– Patient stands feet together arms crossed with the eyes closed to see if the
patient can maintain balance for 60 seconds
– It tests vestibular (primarily otolith organs) and proprioceptive balance
pathways. The vestibulospinal pathway can be isolated by having the patient
stand on a foam surface to minimize proprioceptive input.
3. Sharpened- Advanced Rhomberg:
– Feet – Tandem, extend head – close eyes – then to single leg
– 60 sec hold times except single leg (10sec)
4. Fukuda Test/March Test:
– The patient steps in place with the eyes closed for one minute. The patient may
turn towards the side of the lesion. It is important to note though that right
handed people often drift to the left somewhat with this test.
5. Past Pointing:
– The past-pointing test is primarily (though not completely) a test of
proprioception, and it involves having the patient repeatedly bring his finger to a
remembered position with his eyes closed. Patients with vestibular pathology
may point more to the side with the lesion.
 Vestibular Dysfunction =
Physical Limitations in the Athlete
• Unable to focus with quick head movements
• Poor hand-eye coordination
• Poor balance compensations hip and step strategies
– Make compensations that reduce the athletes agility,
speed, and performance
– May cause injury
• Maintenance of GAZE and Posture interaction of
inputs from
– Vestibular
– Visual
– Somatosensory
 Patient Case - Dancer
• Post-op ACL reconstruction
• 4 weeks post-op
• Weakness of the Quads and Hamstrings
• Poor balance – history of inner ear infections
and minor concussions
• Weak posterior hip muscles
Hip Strengthening External Rotation
Perturbation Training Shuttle Balance
Balance Positions
 Balance & Vestibular Training
• Dynamic Edge – Quad strengthening and
endurance training & balance training
Advanced Perturbation Training
Place Kicker Football Torn Rectus
 ACL Rehab Based on Healing Ligament
Week 1-2
– No aggressive passive movement – grade II mobilization large amplitude
– Russian current and Isometric exercises
– Hip strengthening exercises – posterior-lateral
– Trunk endurance exercises
– Low Load Prolonged Stretch into extension
– Active Flexion exercises - bicycle
Week 2-6
– CKC exercises for strengthening –single leg squat- leg press, Dyn Edge, Lunges,
Eccentric loading
– Perturbation exercises – balance training - vestibular
– Passive stretch – joint mobs into extension and flexion – Grade III end of range
Week 7-16
– Complex surfaces – perturbation and vestibular exercises
– Hopping one foot to next – 30 E flexion angle, Balance complex surfaces
Week 16
– OKC strengthening Quads
Week 17-24
– Plyometric exercises (jump training) – Aggressive weight training
– Sport specific exercises
 New Concepts in ACL Rehab
Restoring Balance in the Athlete
• Strength training to reduce Muscle Imbalances
• Perturbation training
• Training the Vestibular system VOR
• Plyometrics
– Agility training combination of all the above
 New Concepts in ACL Rehabilitation

Bibliography
MedBridge Education
Returning the Injured Athlete to Sports: New Concepts in ACL Rehabilitation
Robert Donatelli, PhD, PT

1. Arden, Clare L., Kate E. Webster, Nicholas F. Taylor, and Julian A. Feller. "Return to Sport

following Anterior Cruciate Ligament Reconstruction Surgery: A Systematic Review and Meta-

analysis of the State of Play." Return to Sport following Anterior Cruciate Ligament

Reconstruction Surgery: A Systematic Review and Meta-analysis of the State of Play. British

Journal of Sports Medicine, 11 Mar. 2011. Web. 04 Apr. 2014.

2. Caratta. "Knee Surgery,Sports Traumatology,Arthroscopy-incl. Option to Publish Open

Access." Springer.com. Springer, n.d. Web. 04 Apr. 2014.

3. Chmielewski, T., W. Hurd, K. Rudolph, M. Axe, and L. Snyder-Mackler. "Result

Filters." National Center for Biotechnology Information. U.S. National Library of Medicine,

Aug. 2005. Web. 04 Apr. 2014.

4. Plisky, Philip. "The Reliability of an Instrumented Device for Measuring Components of the Star

Excursion Balance Test." Http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953327/. North

American Journal of Sports Physical Therapy, May 2009. Web. 04 Apr. 2014.

5. Westin, Barbara, and Noyes FR. "Result Filters." National Center for Biotechnology
Information. U.S. National Library of Medicine, Sept. 2011. Web. 04 Apr. 2014.