Clinical Experience 23rd September 2019 – 2 Hours

Shadowing graduate intern Danny Watts
Overview of Patient:
ACL Rupture follow up after complete rupture of ACL. MOI not recorded, no meniscus damage shown from MRI.
Patient is 3months post injury.
This patient was 3 months into ACL Rupture conservative treatment which was recommended by the surgeon with whom he discussed initial diagnostic imaging and treatment options.
I have found that studies on the outcome of rehabilitation following reconstructive surgery are in abundance, however those on conservative treatment options are limited. In a study conducted on 143 patients with ACL injury, Grindem, Eitzen, Engebretsen, Snyder-Mackler and Risberg (2014) found there to be limited differences between the two treatment outcomes and recommends further research. This conclusion was reiterated in a systematic review by Smith et al. (2014) however this did find there to be limited evidence in favour of the non-operative approach. With this in mind, a non-operative treatment plan could therefore be a more cost effective, less risky option for the patient, especially if the outcome is the same.

The therapist was able to give me a brief history of the treatment that this patient has undergone in this clinic. It was made clear that once the initial inflammatory response had been managed, early rehabilitation focused predominantly on regaining pain free range of movement and that this was an indicative marker for progression through treatment phases. A study by Eitzen et al. (2010) also followed these indicative markers and further suggested that the next phase of rehabilitation should include the restoration of muscular strength and good neuromuscular response. In early stage two of the rehabilitation, the patient therefore worked to regain good hyper extension and flexion by way of a progressive exercise program performed in the clinic with the therapist and at home working on hamstring and quadricep muscle strength.
It was clear, however that this program of rehabilitation did not necessarily continually improve week by week due to occupational limitations of the patient and therefore progression at this particular appointment was limited to maintaining last week’s level of fitness and strength. The aforementioned study by Eitzen et al. (2010) whereby a 5 week intensive exercise program for patients with complete uni-lateral ACL ruptures was found to improve knee function after ACL injuries gradually and appropriately incorporated plyometric exercises, however on a case by case basis and by using individual markers of progression, this patient was not yet progressed onto explosive plyometric motions.

During this session, the patient focused on hamstring and quadriceps muscle strength, which I have since found to be supported in a review by Gokeler et al. (2013), which found evidence in support of eccentric training being the most beneficial method, particularly quadriceps muscles strength.
I also read other studies and articles to understand the effects and benefits of eccentric exercises in rehabilitation to support its popular usage in clinic and found a number of relevant articles.
From reading these articles I have furthered my understanding of what eccentric exercises are and how they are used within a rehabilitation setting.
A review by Lorenz and Reiman (2011) highlighted the benefits of eccentric training and specifically identified the mechanisms behind this; muscle and tendon physiology, but did emphasise the importance of the variables involved and understanding behind this, for example the load, volume, frequency and intensity of the exercises).

In support of eccentric exercise programs being a useful intervention for increasing muscle strength, LaStayo et al. (2014) further highlights the importance of a gradual progression of eccentric exercises over a set period of time by way of gradual increase in loads for prolonged periods of time. Furthermore, a report by Gerber (2009) found a 50% improvement in the quadriceps volume 1 year after a 12 week progressive eccentric exercise program was introduced just 3 weeks post ACL reconstructive surgery compared with a control group with non-eccentric exercises. It would therefore be interesting to know if this data could be extrapolated to patients post ACL rupture, but those who do not undergo surgery and opt for the conservative treatment option.

From watching this session, I was also able to learn the correct technique and start to build on my repertoire of rehabilitation exercises; I therefore intend to use this blog as one means of documenting these for future reference.
The following exercises were performed to improve hamstring and quadricep strength. Through experience, the therapist was able to explain how the order of exercises can affect the intensity of the session. For example, alternating more specific hamstrings and quadriceps exercises allowed the muscle groups some rest periods between exercises, whereas completing all exercises for muscle group at a time would not allow for that same rest; this could be determined on an individual patient basis and in particular, their ability to cope with intensity and their progression within the program. In this case, the muscle groups were worked altogether to increase the intensity of the session and due to the agonist/antagonist nature of these two muscle groups, most of these exercises worked both groups by some means simultaneously.
Interestingly, when reading articles to further understand this, I found there to be supporting evidence to suggest that throughout ACL injury rehabilitation sessions, it could be beneficial to perform hamstrings exercises at the end, as the are in a fatigued state, which is usually when they are at highest risk of injury (Lorenz and Reiman, 2011).

Squat variations until full ROM:
1. Shallow step heel drops
2. squat split
3. Squat with leg behind
4. Squat with leg behind on box
5. Single leg squat with leg held out in front

Particular hamstring exercises:
Bridge, deadlifts to single leg lifts (these were introduced to this patient only recently. If they are performed too early in the program, too much force is applied to the tibia, which could prove detrimental in progress and could cause reinjury).
Leg curl with instability (eg. using a ball while lying supine on floor or tea towel across the floor while seated to add instability).

At the end of the session, the therapist and I had a discussion on how to distract the patient if they perceive exercises to be too difficult and on the importance of being able to adapt exercises and tailor them for the patient and for their current circumstance. For example, one method could be to ask them to hold a dumbbell over their chest with both hands and pushing this weight up while also performing a bridge simultaneously; this will ensure that they perform the ‘bridge’ but without any apprehension or predisposition, as it may shift their focus on the other task. This can also be made functional and specific to the patient, for example, they might enjoy pushing weights or the use of a ball could reproduce their sporting function.

Shadowing Graduate Intern Alfie Jones
Overview of patient:
follow up for patient presenting with hip pain

Lateral hip pain during adduction
+ve OBERS test indicative of weak lateral structures incl. TFL, GMeds
Less pain since last week after doing exercises

Reassessed ROM and performed gait analysis which showed “too many toes sign” and slight int.rot of hip on contralateral side to pain.
SCOWER TEST/quadrant test to test integrity and feel of labrum in hip; pain during which could be indicative of degenerative changes.
Good ROM, no pain. -ve OBERS test performed to retest effectiveness of Tx and exercises prescribed.
At present, no clinical diagnosis has been formally made due to lack of positive testing and indicative markers. As pain has decreased, good ROM and -ve OBERS, therapist has advised to continue Rx and increase intensity and frequency of this.

The following exercises were prescribed for Rx to strengthen lateral structures, strengthen tibialis post. to improve arch strength:
Side plank, progress to straight leg with resistance, weight or hand on hip.
Glute bridges with TheraBand around lower leg to encourage abduction.
Heel raise with ball between feet, squeeze heels in slowly and controlled movements (keep squeezing on downwards movements).

During the session, a gait analysis was performed in order to assess the patients running mechanics in an attempt to find out what may be causing the hip pain. It was important to do this on a treadmill running, instead of walking as this is when symptoms were reproduced and this was her chosen sport.
To further my learning and to help understand the mechanics of this patient’s injury, I read articles explaining Gait analysis and in particular, Dugan and Bhat (2005), an explanation of running gait analysis and biomechanics.
Interestingly, it was reported that 10% of sports injury clinic patients experience hip pain and this could be commonly due to a number of changeable factors such as (and more relevantly to this patient due to lack of indicating tests and a gait analysis performed), poor technique and running errors (Paluska, 2005).

While visually trying to identifying any obvious abnormalities, muscle weaknesses or differences between any element of the patient’s running gait on a contralateral basis, it is really important to know the mechanisms of normal running mechanics. The therapist was able to identify two potential issues that could increase risk of pain or injury; slight right knee valgus during the terminal swing phase which is indicative of internal hip rotation and therefore weakness in the lateral hip structures or tightness of adductors. The too many toes sign was also identified on the left foot while planted on the floor. From my research, I now understand the role of the adductors in the terminal swing stage and as such the importance of their continued activation in order to stabilise the lower leg. However, it was noticed that it was the patients right knee with the valgus but the pain was present in the left knee, which can be due to compensatory mechanics and as a result, this malalignment could well have contributed to the pain on the contralateral side (Dugan & Bhat, 2005).

Although we videoed the patient running and used slow motion as a means to analysis and discuss the biomechanics (motion and observational analysis), there are other potentially more accurate methods to do this which involve identifying markers to measure more precise angles, as well as but not limited to, dynamic electromyography which use electrodes with EMG to measure muscle activation and forces plates which measure ground reaction forces during the landing phases (Dugan & Bhat, 2005).

References – 

Dugan, S. A., & Bhat, K. P. (2005). Biomechanics and analysis of running gait. Physical Medicine and Rehabilitation Clinics of North America, 16(3), 603–621. https://doi.org/10.1016/j.pmr.2005.02.007

Eitzen, I., Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2010). A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury. Journal of Orthopaedic and Sports Physical Therapy, 40(11), 705–721. https://doi.org/10.2519/jospt.2010.3345

Gerber, J. P., Marcus, R. L., Dibble, L. E., Greis, P. E., Burks, R. T., & LaStayo, P. C. (2009). Effects of Early Progressive Eccentric Exercise on Muscle Size and Function After Anterior Cruciate Ligament Reconstruction: A 1-Year Follow-up Study of a Randomized Clinical Trial. Physical Therapy, 89(1), 51–59. https://doi.org/10.2522/ptj.20070189

Gokeler, A., Bisschop, M., Benjaminse, A., Myer, G., Eppinga, P., & Otten, E. (2014). Quadriceps function following ACL reconstruction and rehabilitation: implications for optimisation of current practices. Knee Surgery, Sports Traumatology, Arthroscopy, 22(5), 1163-1174.

Grindem, H., Eitzen, I., Engebretsen, L., Snyder-Mackler, L., & Risberg, M. A. (2014). Nonsurgical or surgical treatment of ACL injuries: Knee function, sports participation, and knee reinjury: The Delaware-Oslo ACL cohort study. Journal of Bone and Joint Surgery – American Volume, 96(15), 1233–1241. https://doi.org/10.2106/JBJS.M.01054

LaStayo, P., Marcus, R., Dibble, L., Frajacomo, F., & Lindstedt, S. (2014). Eccentric exercise in rehabilitation: Safety feasibility, and application. Journal of Applied Physiology, 116(11), 1426–1434. https://doi.org/10.1152/japplphysiol.00008.2013

Lorenz D, and M Reiman. 2011. The role and implementation of eccentric training in athletic rehabilitation: tendinopathy, hamstring strains, and ACL reconstruction. International Journal of Sports Physical Therapy. 6(1), 27-44.

Paluska, S. A. (2005). An overview of hip injuries in running. Sports Medicine, 35(11), 991–1014. https://doi.org/10.2165/00007256-200535110-00005

Smith, T. O., Postle, K., Penny, F., McNamara, I., & Mann, C. J. V. (2014). Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment. Knee, 21(2), 462–470. https://doi.org/10.1016/j.knee.2013.10.009

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