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K
nee ligament sprain is one of the most common or- ommendations from clinical practice guidelines (CPGs), such
thopaedic and sports injuries. Knee stability and as the revised guidelines on knee ligament sprains published in
movement coordination impairments can be im- the November 2017 issue of JOSPT,1 can help to reduce unwar-
proved by physical therapists during nonoperative ranted variation in clinical physical therapy practice, support
and operative management. Implementation rec- evidence-informed practice, and add value at the point of care.
WHAT WE KNEW
The original knee ligament sprain CPG was BOTTOM LINE FOR PRACTICE
published in 20102 and made evidence-informed
recommendations on diagnosis and classification, The resulting recommendations for the diagnosis/classification, examination, and
examination, and interventions for impairments treatment of knee ligament sprains are as follows:
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
observational studies to update the CPG on clinical A flow chart summarizing key elements of the proposed model for examination,
course, risk factors for primary and secondary
diagnosis, and treatment planning for patients with knee ligament sprains is pro-
knee injuries, and treatment interventions for knee
ligament sprains. vided on the next page.
WHAT WE FOUND This JOSPT Perspectives for Practice is based on the guidelines by Logerstedt et al1 and was produced by a team of
We screened nearly 14 000 articles. Of these, we JOSPT’s Special Features Editorial Board, Alexander Scott, PhD, BSc(PT) and Kathryn Sibley, PhD, and staff, led by
assessed 1617 articles for eligibility and appraised Editor-in-Chief J. Haxby Abbott, DPT, PhD, FNZCP, using material contributed by the authors of the 2017 guidelines.1
250 relevant articles for quality, which contributed The flow chart on the next page was produced by Kate Minick, DPT, OCS and Gerard P. Brennan, PT, PhD, FAPTA of
to the strength of the recommendations. Forty- Intermountain Healthcare, Rehabilitation Services, Salt Lake City, UT.
one articles were included in the Examination For this and more topics, visit JOSPT Perspectives for Practice online at www.jospt.org.
recommendations and 9 were included in the
Intervention recommendations. We were able to
make specific recommendations on the use of
self-reported measures and performance-based
tests, and on the timing and duration of specific
interventions.
REFERENCES
1. Logerstedt DS, Scalzitti D, Risberg MA, et al. Knee stability and movement coordination impairments: knee ligament sprain revision 2017. J Orthop Sports Phys Ther.
2017;47:A1-A47. https://doi.org/10.2519/jospt.2017.0303
2. Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ, Godges JJ. Knee stability and movement coordination impairments: knee ligament sprain. J Orthop Sports Phys
Ther. 2010;40:A1-A37. https://doi.org/10.2519/jospt.2010.0303
JOSPT PERSPECTIVES FOR PRACTICE is a service of the Journal of Orthopaedic & Sports Physical Therapy®. The information and recommendations
summarize the impact for practice of the referenced research article. For a full discussion of the findings, please see the article itself. The official journal
of the Orthopaedic Section and the Sports Physical Therapy Section of the American Physical Therapy Association (APTA) and a recognized journal with
35 international partners, JOSPT strives to offer high-quality research, immediately applicable clinical material, and useful supplemental information on
musculoskeletal and sports-related health, injury, and rehabilitation. Copyright ©2017 Journal of Orthopaedic & Sports Physical Therapy ®
822 | november 2017 | volume 47 | number 11 | journal of orthopaedic & sports physical therapy
Anterior Cruciate Ligament (ACL) Posterior Cruciate Ligament (PCL) Medial Collateral Ligament (MCL) Lateral Collateral Ligament (LCL)
Downloaded from www.jospt.org at University of Auckland on November 11, 2017. For personal use only. No other uses without permission.
• Mechanism of injury: deceleration • Mechanism of injury: posterior- • Mechanism of injury: valgus trauma • Mechanism of injury: varus trauma
and acceleration motions with directed force on proximal tibia, fall • Rotational trauma • Localized swelling over LCL
noncontact valgus load near full on the flexed knee, or sudden violent • Medial knee pain with valgus stress • Lateral knee pain with varus stress
knee extension knee hyperextension test (sensitivity, 78%; specificity, test
• “Pop” at time of injury • Localized posterior knee pain with 67%) • Laxity with varus stress test
• Hemarthrosis within 0 to 12 hours of kneeling or decelerating • Laxity with valgus stress test • Tenderness over LCL reproduces
injury • Positive posterior drawer test at 90° (sensitivity, 91%; specificity, 49%) familiar pain
• Reported history of giving way with with a nondiscrete end feel or an • Tenderness over the MCL
activities of daily living (ADLs) increased posterior tibial translation reproduces familiar pain
• Positive Lachman test with “soft” (sensitivity, 90%; specificity, 99%)
end feel or increased anterior tibial • Posterior sag of the proximal tibia
translation (sensitivity, 85%; relative to the anterior aspect of
specificity, 94%) femoral condyles (sensitivity, 79%;
• Positive pivot shift test (sensitivity, specificity, 100%)
24%; specificity, 98%)
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Assessment Grade B
• Patient-reported outcome measures to assess • Physical performance measures, such as • Physical impairment measures to assess
Journal of Orthopaedic & Sports Physical Therapy®
– Knee symptoms and function: IKDC 2000, KOOS, single-limb hop tests, to – Knee laxity/stability: Lachman or pivot shift tests
or Lysholm Knee Scoring Scale – Identify baseline pain, function, disability – Lower-limb movement coordination
– Activity level: Tegner scale or Marx Activity Rating – Detect side-to-side asymmetries – Thigh muscle strength: dynamometry
Scale – Assess global knee function – Knee effusion: modified stroke test
– Psychological factors that may hinder return to – Determine readiness to return to activities – Knee joint range of motion: goniometry
sports: ACL-RSI – Monitor status changes throughout care
Intervention Strategies
• Weight-bearing and non–weight-bearing concentric and eccentric exercises should be implemented within 4 to 6 weeks, 2 to 3 times per week for 6 to 10 months, to increase
thigh muscle strength and functional performance after ACL reconstruction – A
• Neuromuscular electrical stimulation should be used for 6 to 8 weeks after ACL reconstruction to augment muscle strengthening exercises to increase quadriceps muscle
strength and enhance short-term functional outcomes – A
• Neuromuscular re-education training should be incorporated with muscle strengthening exercises in patients with knee stability and movement coordination impairments – A
• Immediate mobilization (within 1 week) after ACL reconstruction should be used to increase joint range of motion, reduce joint pain, and reduce risk of adverse responses of
surrounding soft tissue – B
• Cryotherapy should be used immediately after ACL reconstruction to reduce postoperative knee pain – B
• Supervised rehabilitation programs following ACL reconstruction should include exercise and a home-based exercise program with education to ensure independence – B
• Functional knee bracing may be used in patients with ACL deficiency – C
• Continuous passive motion may be used in the immediate postoperative period to decrease pain after ACL reconstruction – C
• Early weight bearing as tolerated may be implemented within 1 week after ACL reconstruction – C
• Elicit patient preferences in the decision to use functional knee bracing after ACL reconstruction, as evidence exists for and against its use – D
Based on the guidelines, the grades in this flow chart may be translated as follows: A = strong evidence, B = moderate evidence, C = weak evidence, and D = conflicting
evidence. Figure produced for JOSPT by Kate Minick, DPT, OCS and Gerard P. Brennan, PT, PhD, FAPTA of Intermountain Healthcare, Rehabilitation Services, Salt Lake City, UT.
journal of orthopaedic & sports physical therapy | volume 47 | number 11 | november 2017 | 823