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This site developed by Jim Nespor PT/ATC and Dabney Larson PT/ATC.
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[ACL Injuries] [ACL Protocols] [Functional
ACL Braces] [Shoulder Anatomy] [Shoulder
Injuries] [Shoulder Protocols] [Shoulder
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ANTERIOR CRUCIATE LIGAMENT (ACL) INJURIES
The anterior cruciate ligament (ACL) is the most important ligament for proper functioning of your knee. Its purpose is to maintain stability of the knee joint. As you can see from the anatomy picture below, it runs from the shin bone (tibia) up to the thigh bone (femur).
The ACL is often injured in active individuals. People that are in high intensity sports or have jobs that require a significant amount of activity are prone to tearing (rupturing) this ligament. Unfortunately, there are rarely varying degrees of injury to the ACL. In general, the ACL either withstands the trauma or is completely torn.
To view an animation of an ACL rupture, Click here .
How do I know if I've hurt my ACL?
You may be able to predict if you have injured your ACL based on the background and/or history of your injury. If you have any of the following signs or symptoms, you may be highly suspicious that you have injured your ACL:
At this point, your knee should probably be evaluated by an athletic trainer, physical therapist, and/or orthopedic surgeon. The primary diagnostic test that is used to determine the extent of injury to the ACL is called the Lachman's test.
If there is increased movement with this test and a feeling that there is no "stopping point", then you may assume that you have torn your ACL.
You may be sent for a Magnetic Resonance Imaging (MRI) test of your knee, which may or may not be necessary. Below is a photo of an MRI scan with a torn ACL.
This picture is provided courtesy of
Medical Multimedia Group.
Surgery
If you wish to remain active in sports, recreation, or have an active occupation, then it is recommended that the ACL be surgically repaired. Without an intact ACL, the knee may be unstable and repeated "giving way" episodes may cause injury to the surrounding structures (i.e. ligaments, cartilage, etc.)
We recommend the following physical therapy goals be met before preceeding with surgery:
Types of Surgeries
There are basically two types of ACL reconstruction surgeries. The first type is the patellar tendon-bone autograft, which means that the surgeon takes a piece of your patellar tendon and uses it as your new ACL. The second type of surgery uses "quadrupled" hamstring tendon autografts or allografts (semitendinosus and gracilis). In the second type of surgery, the physician uses two tendons on the backside of your knee and doubles them up to become your new ACL. There are advantages and disadvantages to either type of surgery and which one you choose will be based on your activity level and your surgeon's experience.
Studies on the two Surgery Types
"A Prospective Randomized Comparison of Patellar Tendon vs. Semitendonosus and Gracilis Tendon Autografts for Anterior Cruciate Ligament Reconstruction": Shaieb, et al.: American Journal of Sports Medicine, Vol. 30, No.2, pp.214-220, 2002. This article concluded that both methods worked well.
"A Five-Year Comparison of Patellar Tendon Versus Four-Strand Hamstring Tendon Autograph for Arthroscopic Reconstruction of the Anterior Cruciate Ligament": Pinczewski, et al.: American Journal of Sports Medicine Vol. 30, No. 4, pp. 523-536, 2002. This study confirmed the clinical impression that surgical reconstruction with either patellar or hamstring tendon graft reliably restores knee stability, allowing for return to a high level of functional activity. There was no significant difference in the clinical outcome of these two groups of patients.
"Arthroscopic Anterior Cruciate Ligament Reconstruction: A Metaanalysis Comparing Patellar Tendon and Hamstring Tendon Autografts": Freedman, et al.: American Journal of Sports Medicine Vol. 31, No. 1, 2003. Patellar tendon autografts had a significantly lower rate of graft failure and resulted in better static knee stability and increased patient satisfaction compared with hamstring tendon autografts. However, patellar tendon autograft reconstructions resulted in an increased rate of anterior knee pain.
"A Prospective Randomized Study of Patellar versus Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction": Jansson, et al.: American Journal of Sports Medicine Vol. 31, No. 1, 2003. Equal results were seen for patellar and hamstring tendon autograft anterior cruciate ligament reconstructions at two years after surgery. Both techniques seem to improve patients' performance.
"Patellar Tendon or Semitendinosus Tendon Autografts for Anterior Cruciate Ligament Reconstruction?": Ejerhed, et al.: American Journal of Sports Medicine Vol. 31, No. 1, 2003. The hamstring tendon graft is at least an equivalent option to the bone-patellar tendon-bone graft for anterior cruciate ligament reconstruction, and we recommend its use.
"Reconstruction of the Anterior Cruciate Ligament: Meta-analysis of Patellar Tendon versus Hamstring Tendon Autograft". Goldblatt et al.;Arthroscopy July 2005;21(7):791-803. This article suggests that the incidence of instability is not significantly different between the two types of surgery. The patellar tendon graft was more likely to result in normal stability tests and less flexion ROM loss. The hamstring graft had a reduced incidence of patellar crepitus (grinding), kneeling pain and extension ROM loss. The choice of graft by the patient and surgeon must be individualized.
Patellar Tendon (Bone-Tendon-Bone) Technique
This surgical technique for reconstruction of the ACL involves five basic steps. (The following information will include links to animated photos of the ACL surgery. Please allow a few moments for the link to bring the photo to your screen. After the photo appears, you may have to perform a left click on your mouse, or push play in Real Player, to begin the animation. These animations are provided courtesy of Medical Multimedia Group.
Hamstring Tendon Technique
One incision is made on the front of the knee, and two tendons (semitendinosus and gracilis) are harvested from behind the patient's knee.
The two harvested tendons are "doubled" and serve as the "new ACL" The minimum accepted length for the "new ACL" is 7cm. Two bone tunnels are drilled and this new ACL is fixed on both ends.
The fixation of this graft differs as compared to the patellar tendon graft because there is no bone to use. Several types of fixation exist for this surgical procedure resulting in challenges for the surgeon.
After Surgery
After surgery, you will have a dressing applied to your knee and you will return to your room. Your knee will be placed in a continuous passive motion (CPM) machine (see picture below).
Orthologic
Lite Lift CPM Machine
This device will move your knee back and forth in a very slow, controlled manner to aid with your range of motion, swelling and pain.
You will also be issued a cold therapy unit that will circulate chilled water through an appliance placed on the top and around the sides of your knee (see picture below).
Donjoy
Iceman Cold Therapy Unit
The cold therapy will help with your pain and swelling.
The usual hospital stay is approximately 24 hours. Before you leave the hospital, a physical therapist will show you how to walk with crutches and you will be required to wear a post-operative brace (see picture below).
Donjoy ELS Post-Operative Brace
The brace will be locked so that your knee will be fully straight. Your supervised rehabilitation will begin 48 hours after surgery.
Rehabilitation
Supervised rehabilitation usually involves following an ACL protocol agreed upon by the surgeon and physical therapist/athletic trainer. We recommend the use of either one of the following two protocols listed below:
ACL PROTOCOLS
1. Standard Protocol
Bone-Tendon-Bone Patellar Tendon Autograft with Screw Fixation
The following protocol has been developed in conjunction with Peter Buck, M.D. and Tom Greenwald, M.D., who are both orthopedic surgeons at McFarland Clinic, P.C. in Ames, Iowa.
Dr.
Peter Buck M.D.
Dr. Tom Greenwald M.D.
This protocol is Criteria/Evaluation based. Time basis is included. (Time based protocols apply to approximately 70% of the patient population, another 15% may heal faster and the remaining 15% may heal slower). We are suggesting approximately 20 physical therapy treatments, TIW (three times per week) for 3 weeks, BIW (two times per week) for 2 weeks and QW (one time per week) for the last 7 weeks. The patient will be expected to perform some therapy independently.
2. Accelerated Protocol
Bone-Tendon-Bone Patellar Tendon Autograft
This protocol is Criteria/Evaluation based. Time basis is included. (Time based protocols apply to approximately 70% of the patient population, another 15% may heal faster and the remaining 15% may heal slower).
REFERENCES
FUNCTIONAL BRACES
A functional ACL brace may be prescribed by your orthopedic surgeon. As a general rule, the surgeon recommends this type of brace as the demand and level of activity increase. We recommend that this brace be fitted at approximately 12 weeks post-operatively, or when the size of the thigh is nearly equal to the size of the opposite leg.
Our Center uses the Air Townsend functional ACL brace, seen below.
The
Air Townsend Functional ACL Brace
CLICK HERE to view other Townsend Design knee braces and products!
Shoulder Anatomy
Although the "shoulder" is typically thought to include only the glenohumeral joint (the ball and socket), the shoulder complex actually consists of three joints (sternoclavicular, acromioclavicular, and the glenohumeral). The shoulder complex also includes the junction of the scapula (shoulder blade) on the posterior (back) body wall.
 This picture is provided courtesy of
Medical Multimedia Group.
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 This picture is provided courtesy of
Medical Multimedia Group.
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The glenohumeral joint is a ball and socket joint similar to the hip. However, unlike the hip, it does not receive much stability from its bony structure. Instead, the shoulder has several soft tissue modifications that help improve its stability, including ligaments (connecting bone to bone), cartilage, and muscle.
The ligaments of the shoulder are the thickest on the front and undersurface of the shoulder, the direction in which most dislocations occur. A rim of cartilage, the labrum, surrounds and serves to deepen the socket. Finally, the rotator cuff is a group of four small muscles that originate from different positions on the scapula, but insert through a common tendon onto the head of the humerus. These muscles help improve the stability of the joint by "steering" the ball on the socket. Shoulder injury/instability results from an inability of the rotator cuff and ligaments of the shoulder to maintain the ball firmly within the socket. Because the rotator cuff muscles originate on the shoulder blade, it should be apparent that shoulder stability is largely dependent upon the scapular muscles (trapezius, rhomboids, serratus anterior). If these muscles were deficient, the rotator cuff would not have a stable platform from which to pull.
 This picture is provided courtesy of
Medical Multimedia Group.
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 This picture is provided courtesy of
Medical Multimedia Group.
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Shoulder Injuries
Shoulder problems in a young, athletic population often include one of two diagnoses: shoulder instability or shoulder impingement.
Shoulder Instability
Shoulder instability includes either a dislocation or subluxation. Dislocation of a joint means that the two surfaces completely separate. In a subluxation, the joint surfaces come only partially apart. Often an accident or traumatic force is the cause of shoulder instability. However, there is a group of people with generalized "loose shoulders" who may feel their shoulder "come out" with relatively simple daily activities, such as reaching for a seatbelt or sleeping with their arms overhead. In general, these individuals often experience instability in both shoulders in contrast to the one sided instability experienced by those who have suffered a traumatic accident.
 This picture is provided courtesy of
Medical Multimedia Group.
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 This picture is provided courtesy of
Medical Multimedia Group.
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Regardless of whether one's instability is traumatic or atraumatic, in approximately 90% of cases the instability is in an antero-inferior direction, i.e. the humeral head (ball) slips forward and down out of the glenoid (socket). When someone suffers their first dislocation, they experience significant pain, they will typically hold their arm down by their side unable to move their shoulder, and the deltoid area may appear flatter when compared to the opposite shoulder. In general, with each subsequent episode of instability, less trauma is required to separate the joint surfaces. Subsequent dislocations typically produce less pain, less disability, and a faster recovery time. However, the unfortunate consequence is a shoulder that may have once required significant trauma to dislocate can now become unstable with simple daily tasks.
After an episode of instability, the ligaments of the shoulder rarely return to their pre-injury length. Therefore, the hallmark of treatment for instability lies in strengthening exercises for the rotator cuff. For if the rotator cuff is strong, it can successfully steer the ball on the socket decreasing the reliance of ligamentous stability. Rotator cuff strengthening exercises would include both internal and external rotation exercises as well as resisted elevation exercises.
Historically, individuals with atraumatic shoulder instability have done very well with rehabilitation alone. When one suffers a traumatic dislocation, often there is an associated tearing of the ligaments or the labrum that cannot be overcome by a strengthening program. This may account for the high recurrence rate of instability in adolescents- 60-90% of those who suffer their first dislocation under the age of 20 will have subsequent episodes of instability. If instability persists after a 4-6 week trial of strengthening, surgery is often necessary to either repair the cartilage tear (Bankart repair) or to tighten the ligaments of the shoulder (Capsular Shift). The rehabilitation program after either of those two procedures is very similar.
 This picture is provided courtesy of
Medical Multimedia Group.
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 This picture is provided courtesy of
Medical Multimedia Group.
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Shoulder Tendonitis/Impingement
Another common athletic shoulder injury is rotator cuff tendonitis or impingement. As stated earlier, the rotator cuff is a group of four muscles that surround the humeral head (ball). In general, these muscles are not strengthened with a typical weight lifting routine and so they are often weaker than the primary movers of the shoulder. This muscle imbalance may eventually lead to inflammation of the rotator cuff (rotator cuff tendonitis). Once the tendon becomes inflamed, it may swell and become pinched between the humeral head (ball) and the acromion process of the shoulder blade. Whether the rotator cuff tendon is merely inflamed or being impinged, the signs and symptoms are relatively similar. Individuals typically complain of pain with overhead or repetitive motions or with heavy lifting. In general, they have little pain with simple daily tasks with the arm down by the side, although their symptoms may progress to this point if left untreated.
 This picture is provided courtesy of
Medical Multimedia Group.
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Because rotator cuff tendonitis and shoulder impingement lie on a continuum, the treatment for these two conditions is similar. The primary goals of a rehabilitation program are to reduce pain and then to slowly improve the pain-free range of motion. Pain reduction may be accomplished with the use of superficial modalities such as heat or ice or with medications. If the individual is involved in a supervised rehabilitation program, physical modalities such as ultrasound or electrical stimulation may also be used. Once pain has begun to resolve, stretching exercises are used to improve the overall range of motion and specifically target the posterior (back) aspect of the shoulder. Once range of motion has been restored, the goal becomes strengthening of the rotator cuff to correct any strength imbalances and prevent re-injury.
Rotator Cuff Tears
A true tear in the rotator cuff typically affects only those over 40 years of age. Certainly, there are well publicized rotator cuff tears in the shoulders of professional baseball pitchers, but the amount of force and number of repetitions that they expose their shoulders to is obviously greater than the population at large. A typical rotator cuff tear is one that begins without incident as a result of minor trauma throughout an individual's life. This process is often hastened by a traumatic injury to the shoulder-fall on the outstretched arm, overexertion, heavy lifting, etc.
 This picture is provided courtesy of
Medical Multimedia Group.
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Depending on the size of the rotator cuff tear, the symptoms may range from pain with overhead activities (mimicking impingement) or may render the individual unable to actively lift even the weight of their arm. Depending upon the amount of pain and disability the rotator cuff tear causes, the treatment of choice may be simple rehabilitation exercises or may involve surgical reattachment of the rotator cuff.
 This picture is provided courtesy of
Medical Multimedia Group.
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Surgical Rehabilitation Protocols
Rehabilitation Exercises
As with any other joint, the goal of rehabilitation of the shoulder falls into 5 phases
1. Control inflammation (Swelling,Pain)
2. Restore range of motion
3. Restore strength
4. Improve function
5. Return to activity
Inflammation is typically controlled through a varitey of means including-medication, rest, ice, elevation, and compression. Typically shoulder injuries do not cause a great deal of swelling, but they can be quite painful, particularly at night. The use of medication, rest, and regular icing can help decrease pain as can the use of a pillow for support of the shoulder at night.
Once the pain has been controlled, range of motion exercises are begun. Typically these are performed with the use of an exercise wand or towel to allow the uninjured shoulder to guide the injured shoulder through its available range of motion
Stretching Exercises
Cross Body Adduction Stretch |
Wand Exercise- External Rotation |
Wand Exercise- Flexion |
Towel Stretch |
During supervised rehabilitation, devices such as the overhead pulleys or finger ladder can also be used to improve overhead range of motion.
Finger Ladder |
Pulleys |
Strengthening Exercises
Strengthening can be performed with light dumbbells or an elastic band. The elastic band provides portability and convenience, but is limited to only 5-6 resistance levels. Dumbbells offer a wider variety of resistance levels, but are not easily portable and a wide range of weights will be needed to challenge the shoulder appropriately through all of its various motions.
The important factor is not which mode of exercises one chooses, but that the exercises are done properly and consistently. It should be obvious by now, the importance of a strong rotator cuff and these muscles are not well addressed during a typical circuit-training regimen.
Theraband- External Rotation |
Theraband- Internal Rotation |
Theraband- Full Can |
Dumbbells- External Rotation |
Dumbbells- Internal Rotation |
Finally, the rotator cuff can only function appropriately if these muscles have a firm base to pull from- once again highlighting the importance of the scapular muscles to stabilize the shoulder blade.
Scapular Retraction |
Punches |
Dumbbells- Rows |
Theraband- Rows |
As range of motion and strength are returning, it is important to address any remaining functional deficits and to begin to focus the rehabilitation on tasks to which the individual would like to return. If athletic participation is desired, devices such as the body blade or Plyoballs will be helpful for enhancing neuromuscular control and dynamic, explosive strength about the shoulder.
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Plyoballs- Catching |
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Plyoballs- Push |
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Plyoballs- Throwing |
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Body Blade |
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Body Blade |
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Body Blade |
The final stage of rehabilitation involves the successful return of the patient/athlete to their desired activities.
Please feel free to contact us with questions or comments.
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