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Rehabilitation

Strategies Specific to

ACL Reconstruction in

the Female Athlete Jerry Latimer ATC,PT

Associate Director of Sports Medicine

The Florida State University

Functional Testing Algorithm Davies & Zillmer, 2000

Sport Specific Testing

Lower Extremity Functional Testing (LEFT)

Functional Hop Test

Functional Jump Test

Open Kinetic Chain Isokinetic Testing

Kinesthetic/Proprioceptive/Balance Testing

Basic Measurements

Basic

Measurements

Strength & Power

Functional Tests

Following maturation female athletes landed with significantly more medial knee motion and greater lower extremity valgus compared to males. (Hewett et al, 2009)2.

Ligament Dominance. The supporting musculature supporting the knee struggles to appropriately absorb ground reaction forces thereby placing more force through the static stabilizers of the knee in females. (Hewett et al, 2010)3.

Females land with more valgus and less LE control. Females struggle with maintaining proper landing LE alignment due to compromised hip abduction strength and trunk control. (Myer et al, 2013)4

Never lose an opportunity to

help correct what science has

taught us.

Never lose an opportunity to help

correct what science has taught

us.

Females with ACL injuries present with greater trunk displacement in all directions compared to non-ACL

injured females. The greatest predictor of ACL injury risk

was lateral trunk displacement. (Zazulak, 2007)5.

Trunk Dominance Inability to adequately control the trunk during dynamic activity. Therefore larger moments

about the LE exist. (Hewett et al, 2010)3

Females have demonstrated improper recruitment of the gluteal, hamstring, and gastrocnemius muscles during

landing leading to greater abduction moments. (Chappell

et al, 2007, Hewett et al, 1996, Myer et al 2006)6-8

Functional Testing Algorithm Davies & Zillmer 20001

Sport Specific Testing

Lower Extremity Functional Testing (LEFT)

Functional Hop Test

Functional Jump Test

Open Kinetic Chain Isokinetic Testing

Kinesthetic/Proprioceptive/Balance Testing

Basic Measurements

Basic

Measurements

Strength & Power

Functional Tests

Functional Testing Algorithm

Basic Measurements: quantity vs quality

Time since surgery

VAS: < 3 on the 0-10 analogue scale

AROM (

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Star Excursion FMS Hurdle Step

Functional Testing Algorithm

Basic Measurements:

Core strength (Selective functional movement assessment)

Lateral flexor (side bridge). Prone bridge, Supine bridge, Endurance of extensors. (Reiman & Manske- Functional Testing in Human Performance, 2009)9.

Selective Functional Movement Assessment: Overhead Deep Squat. May reveal functional weakness within the core (pelvis, hips and lumbar spine) to adequately stabilize the trunk during dynamic activity. (Rose &Cook, 2009, Course manual).

Strength and Power:

Manual muscle testing

Digital dynamometer testing

Isokinetic testing: FSU- 12-16 weeks. ( Wilk et al10, JOSPT 1994, Correlation of concentric quadriceps peak

torque to single leg hop test. r=0.41-0.62.)

< 25% bilateral comparison for sport related activities.

QPT/BW ratio: Males: 60-65%, Females 50-55%. H/Q ratio: Males: 66-77%, Females: 75%. (Davies et al, 2013)11.

No mans land. Where do we go from here?

Functional Testing Algorithm

Proprioception Upgrade

Nature vs Nurture: We know what the research says about what females have, how can we influence that?

How do we re-program? Help facilitate the athlete to develop new engrams for proper movement.

Sportsmetrics TM (Cincinnati Sports Medicine Research and Education Foundation: Course certification manual).

6 week program including dynamic warm up, jump training, strength training and agility progression.

Findings of research: Corrected muscular imbalances, decreased landing forces and increased power, strength, jump and height. (Hewitt et al, 1996)7.

Proprioception Upgrade

Jump training: Wall jumps, tuck jumps, squat jumps, barrier jumps (f/b, s/s). 180 degree jumps, broad jumps, bounding in place. SportsmetricsTM (Cincinnati Sports Medicine Research and Education Foundation: Course certification Manual).

Agility drill progression: Dot Drills progression, T-drill, square drill, serpentine run, shuttle sprints. Continuing to progress speed while maintaining quality of movement pattern. SportsmetricsTM (Cincinnati Sports Medicine Research and Education Foundation: Course certification Manual).

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Functional Testing Algorithm Davies & Zillmer 20001

Sport Specific Testing

Lower Extremity Functional Testing (LEFT)

Functional Hop Test

Functional Jump Test

Open Kinetic Chain Isokinetic Testing

Kinesthetic/Proprioceptive/Balance Testing

Basic Measurements

Basic

Measurements

Strength & Power

Functional Tests

Functional Testing Algorithm (Davies et al, 2013)

Functional Testing: (Quantitative & Qualitative LE assessment)

2-legged jump test: 80-90% distance of height. (Davies et al, 2013)11.

Return to Sport Functional Testing

1-legged hop test: 70-80% distance of body height. (Davies et al, 2013)11

The Lower Extremity

Functional Test Davies & Zillmer 20001

Functional Testing Algorithm

Lower Extremity Functional Test (LEFT): 100 seconds for females. (Davies & Zillmer, 2000)1.

Return to Sport Functional Testing

Other tests (Functional Testing in human Performance) Reiman & Manske, 2009.9

Soligard et al, 200812 concluded that a structured warm up program for young female soccer players can prevent injuries.

Several warm up programs out there. Warm-up for Injury Prevention and performance (WIPPTM from certification

manual presented by Sportsmetrics TM) A program designed

to provide training and conditioning during an athletes

existing practice time.

SL march, Hand walk, leg cradle, hip rotation walk, tuck and squat jump

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References 1) Davies, GJ, Zillmer, DA. Functional Progression of a Patient Through a Rehabilitation Program. Orthopaedic Physical

Therapy Clinics of North America, 9:103-118, 2000.

2) Hewett, TE, Torg, JS, Boden, BP. Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined componenets of the injury mechanism. Br J Sports Med. 2009 Jun; 43 (6): 417-22.

3) Hewett, TE, Ford, KR, Hoogenboom, BJ, Myer, GD. Understanding and preventing ACL injuries: current biomechanical and epidemiologic considerations- update 2010. N Am J Sports Phys Ther. 2010 Dec; 5 (4): 234-51. Epub 2013.

4) Myer, GD, Sugimoto, D, Thomas, S, Hewett, TE, The influence of Age on the Effectiveness of Neuromuscular Training to Reduce Anterior Cruciate Ligament Injury in Female Athletes. The American Journal of Sports Medicine. 2013; 41,(1): 203-213.

5). Zazulak, BT, Hewett, TE, Reeves, NP, Goldber, B, Cholewicki, J. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical epidemiologic study. Am J Sports Med. 2007 Jul; 35(7): 1123-30. Epub 2013.

6) Chappell, JD, Creighton, RA, Giuliani, C, Yu, B, Garrett, WE. Kinematics and electromyography of landing preparation in vertical stop-jump: risks for noncontact anterior cruciate ligament injury. Am J Sports Med. 2007 Feb;35(2): 235-41. Epub 2013.

7) Hewett, TE, Stroupe, AL, Nance, TA, Noyes, FR. Plyometric training in femalte athletes. Decreased impact forces and increased hamstring torques. Am J Sports Med. 1996 Nov-Dec; 24(6): 765-73. Epub December 2013.

8)Myer, GD, Ford, KR, Brent, JL, Hewett, TE. The effects of plyometric vs. dynamic stabilization and balance training on power, balance, and landing force in female athletes. J Strength Cond Res. 2006. May;20(2): 345-53.

9). Reiman, MP, and Manske, RC. Functional Testing in Human Performance. Human Kinetics. LD Robertson ED. Sheridan Books. 2009.

10) Wilk, KE, Romaniello, WT, Soscia, SM, Arrigo, CA, Andrews, FR. The Relationship Between Subjective Knee Scores, Isokinetic testing, and Functional Testin in the ACL-Reconstructed Knee. Journal of Orthopedic & Sports Physical Therapy; 20(2) Aug, 1994.

11). Davies, GJ, Ellenbecker, T, Irrgang, J, Manske, R, Wilk, K. Functional Testing Algorithm and Clinical Decision Making for Return to Play Criteria for the Lower Extremity. APTA-CSM Orthopedic Section course notes. 2013. Epub Dec 2013.

12).Soligard, T, Nilstad, A, Steffen, K, Myklebust, G, Holme, I, Dvorak, J, Bahr, R, Andersen, TE. Compliance with a comprehensive warm-up program to prevent injuries in youth footbal. Br J Sports Med (2010).

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