Posts tagged ACL
Quad Weakness After ACL Surgery Associated With Decreased Cartilage Health
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ACL injury is one of the most common traumatic sports medicine injuries seen in Boulder Physical Therapy practice. For patients who elect for surgical repair post operative Physical Therapy is key to facilitating a safe return to activity and sports. Common limitations for individuals returning to activity after ACL repair include: a loss of range of motion, balance and agility impairments, as well as, hip and quadricep weakness. The quadriceps are key muscles in maintaining strength and stability of the knee joint and when healthy improve weight bearing across the knee joint surfaces. Abnormal weight bearing in the knee joint leads to a decrease in joint space and increases the likelihood of knee osteoarthritis development. When undergoing surgical procedures of the knee, any effort to decrease progression of post-traumatic osteoarthritis should be taken.

Previous research has shown patients who sustain an ACL tear, treated either with PT or surgery, have an increased risk of knee arthritis. A recent study examined the cartilage and joint health of patients who had undergone ACL surgery (Pietrosimone et al. 2017). Consistent with prior research, authors found a decrease in quadricep strength in individuals 6 months after ACL repair. Concurrently, the authors found a greater T1p relaxation time within the joint which is a key marker of articular cartilage health. Thus, patients with quadricep weakness demonstrated decreased joint health compared to their stronger post operative peers. This emphasizes the importance of restoring quadricep strength after ACL surgery in order to optimize cartilage and joint health.

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Q and A with Dan Lorenz, PT, DPT, LAT, CSCS
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Photo Credit: ssorkc.com

1.  You have published a few articles on the utilization of strength and conditioning principles with Physical Therapy patients.  In my opinion, these valuable principles are under utilized in our profession.  In your experience, how can practicing clinicians improve their patient outcomes using these principles?  

Well I think one of the more basic things you can do is hang out with sports performance coaches/strength and conditioning coaches.  Spend some time in the weight room.  Talk to them about energy system development for example or long-term planning for an athlete.  A majority of PT's only see patients for a small window of time, not the whole training cycle.  Similarly, consider shadowing or spending time with PT's that are doing this everyday.  They're out there and they would be a fantastic resource to talk about this.  Additionally, I would consider joint the National Strength and Conditioning Association.   They have two journals you get as a member and lots of other newsletters.  I shutter to say social media because there's quite an array of "experts", but seeking out those experts and finding out who they trust and respect isn't a bad idea either. 

2.  At Specialists in Sports and Orthopedic Rehabilitation you have implemented a multidisciplinary journal club.  How has this journal club impacted the development of your staff and your relationships with referral sources? 

I like to think that it's helped them a lot.  I feel it helps us stay current, but also makes sure that we're always striving to be better and questioning what we're doing.   For example, we review the latest information on patellar tendinopathies to make sure we're not just doing eccentrics like we did in the 90s, but also we review things that make us squirm a little.  Dry needling articles are a good example of that.  It's a service we offer, but the literature is pretty weak right now.  I think it's important that we have resources for our patients, but also that we're not in denial about what the evidence shows. 

From a referral standpoint, we've had physicians join us at journal club which is obviously great for dialogue and for education of all of us.  I send out the articles we're reviewing to a number of physicians.  I don't know if they even review them but I think it's definitely a feather in our cap compared  to competitors because I believe we're very unique in this regard.  I think it's important they know that we're on top of things.  I will say that many reach out to us about their protocols and what they should look like.  I think they do that for two reasons - they know we take care of our folks and our outcomes are outstanding but also that they know we know what the evidence shows. 

3. The risk of a subsequent ACL injury, either in the involved or uninvolved knee, in our patients remains significant.  In your review of the literature and your experience what are some key areas Physical Therapists must focus on to reduce this risk of re injury?

Oh Gosh.  How complex a question! I think the first thing is education.  We have to educate our patients that the "6 months" return to play is frankly, a terrible idea.  We've gotten stuck on that time frame and hardly anyone is legitimately ready at that time.  Tim Hewett and Chris Nagelli published a really thought-provoking (yet probably not very practical!) article about how 2 years is more ideal for return to play.  They presented some compelling data! It will likely never happen, but the research is clearly showing that extending return to play reduces the risk of re-tear.

Along with that is a comprehensive, thorough screening and testing procedure.  Frankly, I think these are still evolving and clearly we need work on them because the re-tear rate is pretty high!  Secondly, PT's need to make sure that any movement deficits that contributed to the tear in the first place are addressed and for gosh sakes, on both sides!  It's striking to me how many re-tears I see that the patient tells me they never worked the uninvolved side in their rehab!  That's insane!  Whether it's poor knee and hip control or improper cutting techniques, we have to pin those things down during the rehab process.  

Lastly, I think we need to be better about long-term planning for their strength training.  Several papers have shown persistent deficits in strength and power in the quads as well as "unconscious loading" of the uninvolved limbs.  These athletes are being sent back out there with out these factors being addressed properly.  Making sure that their athletes are willing to load that limb and that the involved limb has appropriate strength and power is so important.  In some respects, we have to abandon having that typical "PT mindset" of being terrified to load someone for fear of swelling or pain.  It's OK people, put another plate on the bar, they'll be fine!  I would actually argue the other way - we're doing a disservice to our athletes by not making them adapt to loads! Of course I'm not advocating being foolish or progressing too fast, but 3 x 10 isn't making anyone stronger or more powerful

4.  What is your prediction for the Chiefs this season?

Ha Ha, haven't thought too much about that yet.  Andy Reid always puts a solid product on the field.  There's some questions at wide receiver after losing Jeremy Maclin.  Defensively on paper they look pretty awesome, it's just if key players produce - Justin Houston, Tamba Hall, and Dee Ford are there that come to mind.  They have a proven leader and veteran QB in Alex Smith.  I think they'll definitely content for if not win the AFC West.  Of course the x factor every year is always what happens with that pesky injury bug.