Guest guest Posted March 14, 2009 Report Share Posted March 14, 2009 > > > > Hi All, > > Do any members have access to any good ACL rehab articles? From a good > > journal like Med Sci or Sports med? Open v closed chain exercise. Aggressive > > rehab protocols and results. Comparisons between hamstring and patella graft > > Any good reviews of the literature. For a friend in need. Thanks for any > > and all help. *** Note the below abstracts can be found in the Supertraining archives (commentary by Dr Siff). An additional website that may be useful: http://www.ostrc.no/en/Congress/ Carruthers Wakefield, UK > The following article and a few others stresses the importance of not > relying on passive evaluation of ACL integrity, especially for evaluating > proprioceptive loss in ACL deficiency. It concludes that assessment of > failure of the injured individual to appreciate lower extremity movement is > essential. Other articles address different aspects of this very common > sporting injury, such as the prolonged time taken for proprioception to > return to the surgically treated knee. > > -------------------------- > > Detailed analysis of proprioception in normal and ACL-deficient knees > > Pap G, Machner A, Nebelung W, Awiszus F > J Bone Joint Surg Br 1999 Sep;81(5):764-8 > > We assessed proprioception using threshold levels for the perception of knee > movement at slow angular velocities (0.1 degrees/s to 0.85 degrees/s) in 20 > patients with unilateral tears of the anterior cruciate ligament (ACL) and 15 > age-related control subjects. Failure to detect movement was also analysed. > The threshold levels of detection did not differ between the damaged and > undamaged knees in the patients or between the patients and the control > group. Failure to appreciate movement, however, was significantly greater in > knees with ACL loss compared with the undamaged knees of patients and the > control group. Our findings show a proprioceptive deficit in the absence of > the ACL. Measurements of threshold levels of detection of passive movement > alone are not suitable for the evaluation of proprioceptive loss in ACL > deficiency; assessment of failure to appreciate movement is essential. > > --------------------- > > Proprioception in the nearly extended knee. Measurements of position and > movement in healthy individuals and in symptomatic anterior cruciate ligament > injured patients > > Friden T, D, Zatterstrom R, Lindstrand A, Moritz U > Knee Surg Sports Traumatol Arthrosc 1996;4(4):217-24 > > Proprioception of the knee was measured in 19 healthy individuals to evaluate > whether there were any differences between extension and flexion movements > from two different starting positions. The threshold before detecting a > passive movement, visual estimation on a protractor of a passive change in > position (30 degrees angular change) and active reproduction of the same > angular change were registered. The reference population was tested twice to > study normal variation and reproducibility, followed by the evaluation of 20 > patients with chronic, symptomatic and unilateral anterior cruciate ligament > (ACL)-deficient knees. > > In the normal population no differences were found between the right and the > left leg, men and women, or measurements made at the first and at the second > test occasion. The thresholds from a starting position of 20 degs were lower > for extension than for flexion. When comparing the thresholds for extension > between the 20 degs and the 40 degs starting position, lower values were > found in the more extended position. The thresholds for flexion were lower > from the 40 degs starting position than from the 20 degs starting position. > The active reproduction of an angular change of 30 degs was more accurate > during flexion (30 degs-60 degrees) than during extension (60 degs-30 > degrees). There were no differences in the reproduction tests or in > thresholds from the 40 degs starting position between the patients and the > normal group, but the patients had higher thresholds from the 20 degs > starting position, in movements towards both extension 1.0 deg (range 0.5 > deg-12.0 degs) and flexion 1.5 degs (range 0.5 deg-10.0 degs) than the normal > group 0.75 deg (range 0.5 deg-2.25 degs) and 1.0 degree (range 0.5 deg-3.0 > degs), respectively. > > Thus, information of passive movements in the nearly extended knee position > was more sensitive towards extension than towards flexion in threshold tests > and the sensitivity improved closer to full extension, which implies a > logical joint protective purpose. > > In this nearly extended knee position, which is the basis for most > weight-bearing activities, patients with symptomatic ACL-deficient knees had > an impaired awareness in detecting a passive movement. There were no > differences in the more flexed position or in the reproduction tests between > the patients and the normal group, and reproduction tests in the present form > seem less appropriate to use in the evaluation of ACL injuries. > > --------------------- > > Proprioception in people with anterior cruciate ligament-deficient knees: > comparison of symptomatic and asymptomatic patients > > D, Friden T, Zatterstrom R, Lindstrand A, Moritz U > J Orthop Sports Phys Ther 1999 Oct;29(10):587-94 > > STUDY DESIGN: Nonrandomized prospective study. OBJECTIVE: To evaluate > proprioception in 2 groups of patients with anterior cruciate ligament (ACL) > deficiency who had different severity of symptoms. BACKGROUND: Defective > proprioception has previously been found in patients with ACL-deficient > knees. It has been suggested that sensory receptors of the ACL and other knee > joint ligaments contribute to proprioception and knee joint function and > stability. > > METHODS AND MEASURES: A total of 17 patients with ACL deficiency (mean [sD] > age, 28.8 ± 5.6 years; range, 22-39 years) with few, if any, symptoms were > compared with 20 patients with ACL deficiency (mean [sD] age, 26.6 ± 6.1 > years; range, 18-39 years) having instability and episodes of giving way. The > groups were compared with each other and with an age-matched reference group > of 19 nonimpaired subjects. Their mean (SD) age was 25.6 ± 3.7 years (range, > 20-37 years). Three tests of proprioception were used: threshold to detection > of passive motion from 2 starting positions (20 degs and 40 degs of knee > flexion) toward flexion and extension, active reproduction of a 30 degs > passive angle change, and visual reproduction of a 30 degs passive angle > change. The Wilcoxon rank sum test was used for between-group comparisons. > > RESULTS: Symptomatic patients had higher threshold to detection of passive > motion in their injured side in the flexion trial from 20 degs (median of 1.5 > deg vs median of 0.5 deg) and in the extension trial from 40 degs (median of > 1.0 deg vs median of 0.5 deg) than the asymptomatic patients. No differences > were found in the other threshold tests, active or visual reproduction tests. > > CONCLUSIONS: Patients with severe symptoms related to ACL deficiency were > found to have inferior proprioceptive ability in some measurements compared > with patients with a good knee function. The findings indicate that > proprioceptive deficits might influence the outcome of an ACL injury treated > nonoperatively. > > ---------------------- > > ***This article drew the disturbing conclusion that anterior cruciate > ligament reconstruction does not improve proprioception for a considerable > period after surgery (at least in the patients examined in this study). > > Proprioception in anterior cruciate ligament-deficient and reconstructed knees > > Mac PB, Hedden D, Pacin O, Sutherland K > Am J Sports Med 1996 Nov-Dec; 24(6): 774-8 > > Section of Orthopaedics, University of Manitoba, St. Boniface General > Hospital, Winnipeg, Canada > > Proprioceptive function of the knee was quantified and compared in three > groups of patients: those with anterior cruciate ligament deficiency, with > hamstring tendons-ligament augmentation device anterior cruciate ligament > reconstructions, and with bone-patellar tendon-bone anterior cruciate > ligament reconstructions. A total of 32 subjects, including 6 uninjured > control subjects, were tested for threshold to perception of passive motion > of the knee. All other sensory input was neutralized and testing occurred in > the 30 degrees to 40 degrees range of knee flexion. The noninvolved > contralateral knee served as a control for each subject. Each leg was moved > at 0.5 deg/sec into flexion or extension in a random sequence. The variables > of age, KT-1000 arthrometer scores, injury-to-surgery interval, > injury-to-followup interval, and patient satisfaction were statistically > analyzed for correlation with threshold to perception of passive motion of > the knee. > > Control subjects showed no statistically significant differences in threshold > between their two knees. The three test groups all showed significantly > higher values in the involved knee compared with the noninvolved knee. > However, no statistically significant differences were found between the > groups, including controls, with respect to mean threshold to perception of > passive motion. > > According to these results, anterior cruciate ligament reconstruction did not > improve proprioception in the patients in this study. > > ---------------------- > > *** The following study indicated that a minimum of 18 months after ACL > reconstruction may be needed for complete restoration of the proprioceptive > function in knees, although the mean position sense in all patients gradually > improved from 9 months. > > Proprioceptive improvement in knees with anterior cruciate ligament > reconstruction > > Iwasa J, Ochi M, Adachi N, Tobita M, Katsube K, Uchio Y > Clin Orthop 2000 Dec;(381):168-76 > > The correlation between the prospective course of proprioceptive improvement > and knee stability after anterior cruciate ligament reconstruction was > investigated in 38 patients. Proprioception, on the basis of the patient's > capacity to reposition the limb accurately, was evaluated at 3-month > intervals for 24 months after hamstring graft anterior cruciate ligament > surgery. Knee stability was evaluated concurrently with a KT-2000 knee > arthrometer. Thirty patients experienced improvement in postoperative > position sense in at least one of the examinations, although eight patients > had no improvement at any time. Of the 30 patients who had improvement, 28 > maintained improved position sense from 18 months to the final followup. > Thirty patients maintained significantly better knee stability for a > postoperative period of at least 24 months. > > These results indicated that a minimum of 18 months after anterior cruciate > ligament reconstruction may be needed for complete restoration of the > proprioceptive function in knees, although the mean position sense in all > patients gradually improved from 9 months. Improvement in postoperative knee > stability may have facilitated recovery of proprioception. > > ------------------- > > *** The following study also showed that patients for a prolonged time after > ACL reconstruction showed no significantly better proprioception compared > with the preoperative group. In addition, this study showed a positive > influence of a knee bandage on the proprioception of the injured knee, a > finding that may support the frequent practice of competitive lifters wearing > of knee wraps, even if not tightly worn, to protect the knees and enhance > force production. > > Knee joint proprioception in normal volunteers and patients with anterior > cruciate ligament tears, taking special account of the effect of a knee > bandage > > Jerosch J, Prymka M > Arch Orthop Trauma Surg 1996;115(3-4):162-6 > > Proprioception of the knee joint was tested in 30 healthy volunteers with > clinically inconspicuous knee joints. To examine proprioception, an angle > reproduction test was performed. We could not document any differences > between the left and the right knee joint or between men and women. At the > mid-range, proprioception was worse compared with the end range of motion. In > addition, 25 patients with an isolated rupture of the anterior cruciate > ligament were evaluated, 14 before and 11 after operative anterior cruciate > ligament (ACL) reconstruction. > > Preoperatively, there was a significant deterioration of proprioception > compared with the control group. We were able to show a positive influence of > a knee bandage on the proprioception of the injured knee. Patients after ACL > reconstruction showed no significantly better proprioception compared with > the preoperative group. > > -------------------- > > Proprioception after rehabilitation and reconstruction in knees with > deficiency of the anterior cruciate ligament: a prospective, longitudinal > study > > Fremerey RW, Lobenhoffer P, Zeichen J, Skutek M, Bosch U, Tscherne H > J Bone Joint Surg Br 2000 Aug; 82(6): 801-6 > > We assessed proprioception in the knee using the angle reproduction test in > 20 healthy volunteers, ten patients with acute anterior instability and 20 > patients with chronic anterior instability after reconstruction of the > anterior cruciate ligament (ACL). In addition, the Lysholm-knee score, > ligament laxity and patient satisfaction were determined. > > Acute trauma causes extensive damage to proprioception which is not restored > by rehabilitation alone. Three months after operation, there remained a > slight decrease in proprioception compared with the preoperative recordings, > but six months after reconstruction, restoration of proprioception was seen > near full extension and full flexion. In the mid-range position, > proprioception was not restored. At follow-up, 3.7 ± 0.3 years after > reconstruction, there was further improvement of proprioception in the > mid-range position. There was no difference between open and arthroscopic > techniques. The highest correlation was found between proprioception and > patient satisfaction. > > After reconstruction of the ACL reduced proprioception may explain the poor > functional outcome in some patients, despite restoration of mechanical > stability. > > -------------------------- > > Proprioceptive sensitivity and performance in anterior cruciate > ligament-deficient knee joints > > Fischer-Rasmussen T, Jensen PE > Scand J Med Sci Sports 2000 Apr; 10(2): 85-9 > > We studied the performance and proprioception of the knee joint in a group of > non-reconstructed anterior cruciate ligament (ACL)-deficient (n=20) patients > and compared them with a group of ACL-reconstructed patients (n=18) and a > group of healthy controls (n=20). Each patient was scored according to > Lysholm and Tegner and was then asked to subjectively evaluate the > performance of the injured knee and the degree of retropatellar discomfort. > The knee joint laxity was measured. The performance was assessed based on the > performance in a triple jump test and a one-leg one-step leap test. The > proprioception in the knee was measured as the threshold when passive > movement was detected and as the ability to reproduce a flexion angle from a > start position of 60 degrees of flexion or from full extension of the knee. > All tests were performed on both legs. The scoring systems and the subjective > evaluation showed significant differences between the reconstructed and the > non-reconstructed patients. > > No significant difference in knee joint laxity was found between the two > groups. In the triple jump test and the one-step leap test, both groups > performed significantly worse on the leg with the injured knee joint than on > the non-injured leg. The proprioceptive tests showed decreased ability to > recognize and reproduce a prior angle from a start position of 60 degrees. > The threshold to detection of passive movement with the injured knee was > significantly increased in both groups of patients. No difference was found > between the dominant and non-dominant knee in the control group. When > reproduction of the same angles started from full extension, the groups did > not differ. > > These data show that decreased performance and changes in the proprioception > of the knee joint accompany ACL rupture. > > -------------------------- > > *** The following article addresses the important issue of the effects of > lateral stability in the ACL deficient knee. > > Analysis of the significance of the measurement of acceleration with respect > to lateral laxity of the anterior cruciate ligament insufficient knee > > Yoshimura I, Naito M, Hara M, Zhang J Int Orthop 2000;24(5):276-8 > > The purpose of this study was to assess dynamically the lateral thrust of > anterior cruciate ligament (ACL) insufficient knees, and from the findings > determine any relationship between ACL insufficiency and the later > development of osteoarthritis (OA). > > We investigated 80 knees in 40 patients awaiting ACL reconstruction and 25 > knees of 25 patients, which had undergone ACL reconstruction. An acceleration > sensor was fixed to the anterior tibial tubercle and this 'acted' in two > directions--medial lateral and perpendicular. The peak value of the lateral > acceleration immediately after heel strike was significantly greater in the > ACL insufficient knees when compared to their opposite normal knees. When the > periods from injury were compared, the lateral thrust of the injured side > after 3 years or more was significantly greater than in the first 3 years. > There was no significant difference between the normal knees and the ACL > reconstructed knees. > > The results indicated that the lateral acceleration peak value was > significantly greater in the ACL insufficient knees than in their opposite > normal knees. > > ----------------------- > > Different patterns of meniscal tears in acute anterior cruciate ligament > (ACL) ruptures and in chronic ACL-deficient knees. Classification, staging > and timing of treatment. > > Cipolla M, Scala A, Gianni E, Puddu G > Knee Surg Sports Traumatol Arthrosc 1995;3(3):130-4 > > Through the retrospective study of 1103 reconstructions of the anterior > cruciate ligament (ACL) performed between 1984 and 1993, we try to outline > the natural history of meniscal tears in acute lesions and in chronic > insufficiency of the ACL. According to a more accurate evaluation of the > clinical evolution, ACL-deficient knees can be classified into four different > stages: acute, subacute, subchronic and properly chronic laxities. While > acute injuries show a higher rate of lateral meniscus tears, chronic laxities > are very frequently associated with severe medial meniscus lesions. Subacute > and subchronic stages seem therefore to be the most favourable phases for ACL > reconstruction, because of the lower percentage of severe associated meniscus > tears and the minor risk of arthrofibrosis. > > ==================== > Carruthers > Wakefield, UK > Quote Link to comment Share on other sites More sharing options...
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