Monday, May 20, 2019

RTPlay Following ACLR - How Do We Know When Is The Right Time? - Part IIX

Over the course of the last 8 weeks, we have looked at a lot of research and asking the question, how do we know when is the right time to return to play following ACLR.  Although I don't think that answer is clear, I do think it has provided us some clear direction on what we should be doing and how we should be assessing people for return to play.  Based on all the research we have reviewed and 20+ years of sports medicine clinical practice, several things have become clear.

  1. We need to test stability during single limb performance - this means controlling both magnitude of motion and speed at which that motion occurs. 
  2. We must stop relying on subjective measures and leverage technology to provide us more objective measures
  3. Measurement of limb symmetry index (LSI) is important and should be a measure of biomechanical factors versus just ability to perform
  4. We need to incorporate all segments of the lower kinetic chain that contribute to single limb stability  
  5. We need to incorporate some form of on the field testing to measure LSI in explosive activities 
Based on the research we have developed a sequence of tests (Athletic Movement Index or AMI) that has been guided by the research and which leverages the latest in 3D wearable sensor technology (DorsaVi).  The ViPerform AMI uses the DorsaVi sensor to track movement within 3% of a Vicon system during a sequence of core, bilateral and single limb tests.  Throughout this series of tests, the athlete is does not rest and goes from one test to the next.  For the single limb tests, all single limb test (SL Squat, SL Hop, SL Hop Plant, ankle lunge) are performed on the right first to completion then the sequence is repeated on the left.

Core Tests: The core tests consist of the plank and the side plank tests.  During this sequence of tests, the athlete performs the test for a set period of time.  In this example, the sensor measures the athlete's ability to maintain stability in flexion/extension and rotation for a set period of time.  The athlete is scored based on their ability to maintain this stability.



Squat Test: In this test the athlete performs a bilateral squat for a set number of repetitions.  Throughout the test, the athlete is measured on their ability to squat without a lateral shift (shifting their hips to the right or left throughout the motion) as well as measurement of their trunk flexion/extension throughout the squatting motion.


Single limb tests:  The single limb tests consist of the single leg squat, single leg hop and the single leg hop plant.  During the single leg squat, the athlete is measured on their ability to control magnitude and speed of frontal plane motion of the knee during the test.  The athlete is also scored on the whether or not they squat low enough as well as their ability to maintain balance during the course of the test.


Single leg Hop and Hop Plant - during these two tests the same factors are measured and assessed.  The only difference is that single leg hop is an explosive vertical hop on one leg and the hop plant is an explosive hop in the following sequence; forward, backward, lateral and medial.


The entire test takes ~15 minutes and a report is automatically generated at the conclusion of the test.  In most rehab scenarios, portions of the test are performed as the athlete progresses throughout rehab and as the protocol allows.  For example, an athlete who is being released to do plyometrics, we will progress them to plyos when they are able to control the frontal plane motion and speed of motion during a single leg squat.  This same philosophy is applied when progressed to sport specific training and for return to play.

For those athletes being assessed for return to play, we will perform the entire sequence of movements of the ViPerform AMI and add the acceleration deceleration test.  This on field assessment allows us to measure an athlete's limb symmetry during max acceleration and deceleration.




By being able to accurate capture the athlete's biomechanics during an athletic movement assessment and combine that with on the field assessment, we can clearly see where we need to work on from a rehabilitation/performance standpoint as well as make a more informed decision on return to play.

The best part of doing this in this fashion, with the use of technology and linking this to a master data base, is we are now able to collect over 1,000 data points for every assessment that is performed.  Since completing over 11,500 assessments since starting, we can now determine if any athlete falls within normative values or are they 1 or 2 standard deviations beyond norms.

Next week, we will discuss how data to drive what we do clinically.  It is where the rubber meets the road.   If you enjoy this blog, please share with your colleague and follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, May 13, 2019

RTPlay Following ACLR - How Do We Know When Is The Right Time? - Part VII

Throughout this series, we have been doing a deep dive into the research related to when or how do we return the ACL reconstructed athlete to play.  In the last couple of weeks, we looked at the Wren et al study and the Toole et al J Orth Sport Phy Ther 2017.  The Wren study indicated that even if an athlete has >90% LSI, that this may not be indicative of the athletes biomechanics.  In other words, even though they pass the test, they may still present with faulty mechanics that put them at risk for injury.  The Toole study indicated that when we do a battery of tests, that likelihood of an athlete passing all the test with a criteria of > or = to 90% is low. 

At the conclusion of last week's discussion, this led us to the question, are we focusing too much on biomechanics?  As rehab professionals, are we not addressing this as a part of our rehabilitation and negating any faulty biomechanics?  In a study byKing et al Am J Sport Medicine 2019, the authors attempted to investigate this.

Purpose: To identify if differences in the magnitude of asymmetry of biomechanical and performance variables exist between ACLR athletes at the end of rehabilitation and healthy cohorts.

Methods: 156 male multidirectional field sports athletes who suffered an ACL rupture and who intended to return to the same level of sports participation after surgery were recruited for this study.  Athletes were between the ages of 18 to 35 years old, underwent a primary ACLR and were tested approximately 9 months post operatively.  All of the athletes in the ACLR group had a none patellar tendon bone graft from the ipsilateral side during surgery. 

Rehabilitation Program:  All the athletes in the ACLR group underwent an accelerated rehabilitation protocol with weight-bearing as tolerated on crutches for 2 weeks, followed by progressive strengthening and neuromuscular control program.  Program progressed to include power and plyometric drills.  As competency improved the athlete was progressed to linear running and change of direction (CoD) drills. 

All athletes, cohort and ACLR athletes, underwent 3D movement (via Vicon system) analysis while the athlete performed three maximal efforts on the following tests:

  • Double leg drop jump test from 30 cm step
  • Single leg drop jump test from 20 cm step
  • Single leg hop for distance test 
  • 90 degree planned and unplanned CoD test.   

Results:  There were differences in asymmetry of biomechanical variables across all jump and CoD tests, with greater asymmetries in the ACLR group. The majority of differences between groups were in the sagittal and frontal planes with notable differences in the magnitude of motion in the frontal plane and control of speed of motion.  There were greater differences noted in the jump tests compared to the CoD tests. The single-legged drop jump demonstrated large differences in performance asymmetry. 

Discussion:  One challenge with this study is we don't know enough details related to the rehabilitation protocol.  One thing I can say from experience, is that all too often I see rehab professionals so worried about progressing the athlete to the next phase that they will let technique suffer as a result.  You train what you get and get what you train.  In other words, if they are doing plyometrics and allowing the athlete to perform the exercise while allowing the knee to fall into a valgus position with each rep, then how can we expect when we do functional or biomechanical testing that this will change?  Secondly, are we training to the testing protocol.  As easy as this sounds and as much as we think this is would skew the results, why would we not do that?  We know that if you do a single leg squat or single leg multidirectional hop that if your knee goes into a valgus position this puts you at risk.  So why would we not train to improve that.  Yes, it is a part of the testing protocol but it is a part of the testing protocol because we know if you do that during that movement, then you are at a greater risk. 

This whole series we have presented a lot of research which has lead us to some logical conclusions.

  1. In our RTPlay testing:
    • We need to do single limb testing.  Sports is single limb in nature and therefore we must measure stability in single limb performance.
    • We need to include some measure of biomechanics when assessing limb symmetry index (LSI).  Don't simply take the ability to perform the test as passing criteria but how are they controlling the magnitude of motion and speed of motion?
    • If we have the ability to look at baseline data (contralateral limb prior to sugery), we should use this to measure against for determining LSI (Rohman et al - Absolute LSI).  This helps to account for any disuse atrophy of the non-surgical leg.
  2. During our rehabilitation, we need to be measuring these factors throughout the rehab process to make sure the athlete is progressing.
  3. We need to make sure that our rehab protocols are including components of the testing protocol (training specificity).
  4. We need to make sure our rehab techniques focus on quality of movement (controlling magnitude of motion and speed of motion) throughout the rehab process.
  Obviously there are a lot of other conclusions that can be taken away from this series but the aforementioned are some key concepts we can all apply to what we do today.  Next week, we will prepare to close out this series by seeing how we are applying this knowledge to our testing and rehabilitation techniques.   If you enjoy this blog, please share with your colleague and follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  #ViPerformAMI #ACLPlayItSafe




Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, May 6, 2019

RTPlay Following ACLR - How Do We Know When Is The Right Time? - Part VI

This week, we will continue to look into considerations we should have when making return to play decisions for our ACLR athletes.  Last week, we looked at the Wren et al study, which indicated that although an athlete may have 90% LSI on this single leg hop for distance, this may not be a true representation of LSI and it does not give us an indication of what the athletes lower limb mechanics are during the performance of that test.

The Rohman et al study had suggested a series or battery of tests, not just a single test, should be considered when assessing an athlete for RTPlay following ACLR.  During our last discussion, this also raised the question that if we have a battery of tests, what is the likelihood that the athlete will pass this whole battery?

The purpose of a study by Toole et al J Orth Sport Phy Ther 2017 was to determine if athletes who met the recommended cutoffs for sports participation post op ACLR were able maintain the same level of sports participation when compared to those who did not meet the criteria.

Methods:
115 young athletes (88 female, 27 male, mean age 17.2 y/o) were included in the study.  Each subject filled out an IKDC (International Knee Documentation Committee) subjective knee evaluation form and went through the following battery of tests:

  • Quadricep and hamstring testing - isokinetic test via Biodex test
  • Single leg hop for distance 
  • Triple hop for distance 
  • Cross over hop for distance  
  • 6 meter timed hop
For each of the single limb hop tests, the subject completed a practice trial and then performed 2 measured trials on each limb.  The average for the two trials was determined and LSI was calculated (univolved score/involved score X `100%).  

Results:
Of the 27 males, the average age was 18.8 y/o with the average time from surgery to return to play of 8.1 months post op.  Of the males, 51.9% were patellar tendon autografts, 40.7% hamstring tendon autograft and 7.4% were allograft.  The average score on the IKDC for men was 87.3.  Of the 88 women, the average age was 16.6 y/o with the average time from surgery to return to play of 8.2 months post op.  Of the females, 40.9 % were patellar tendon autografts, 52.3% were hamstring autografts, and 6.8% were allografts.  The average score on the IKDC for women was 87.7. The portions of athletes that met cutoffs for the individual tests ranged from 43.5% to 78.3%.  The portion of athletes that met cut offs for all hop tests was 53%, for all strength tests was 27.8% and all combined tests was 13.9%.  A higher portion of athletes who met cutoffs maintained same level of sports participation over the 1 year follow up compared to those who did not meet.


Based on these results, it makes us question if we are making the passing criteria too tough to pass.  It would be interesting to take an ACLR group and compare that to norms and see what the pass rate would be.  Although that has not been done, I would suspect we might see some interesting results and pass rates might not be what we would think they should be.  If we consider the Wren et al study we discussed last week, then even if an athlete does pass, it does not necessarily mean they had good mechanics or did not represent pathokinematics that would put them at risk for future injury. 

Are we being overly concerned about faulty biomechanics in the end stages of rehabilitation?  As rehab professionals (PTs, PTAs, ATCs, Strength Coaches) aren't we addressing this in the rehab process?  That is exactly what our next study looked at.  Next week, we will look at study by King et al Am J Sports Med 2019 where we get some insight into what athletes' biomechanics look like at the end phases or physical therapy.  If you enjoy this blog, please share with your colleague and follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, April 29, 2019

RTPlay Following ACLR - How Do We Know When Is The Right Time? - Part V

Throughout this blog, we have been discussing the need to have a more standardized and objective measures for returning athletes to play (RTPlay) following anterior cruciate ligament reconstruction (ACLR).  Current standard of practice is often reliant on time based criteria and/or some somewhat subjective measures taken at the end point of rehabilitation.  One test that is often used in making this determination on RTPlay or not is the bilateral vertical drop jump (VDJ) test.  Last week, we discussed two recent studies (Krosshaug et al Am J Sport Med 2016Noehren et al Orthoo J Sport Med 17) that highlighted the challenges with this test and the predictability for risk. 


We also looked at the Rohman et al Am J Sport Med 15 which laid out which single limb tests we should use to determine RTPlay.  These were:
  • Single leg squat
  • Single leg hop
  • Cross over hop
  • Timed hop.
However, the majority of these single limb tests are scored visually and hence still lend themselves to some subjectivity.  Some have gone to the use of video based technology where the practitioner will film the athlete performing these tests then try to score based on the video review.  Although this is often provides more information than what we might see in visual observation, it is still somewhat of a subject measure of movement. 

A great example of this is a recent study by Wren et al Orth Sport Phy Ther 2018.  In this study the authors looked at 46 athletes that were 5-12 months post op ACLR.  The authors used the single leg hop for distance test to assess the athlete's limb symmetry index (LSI) at the time of testing.  In this test the subject would stand on one foot with their toes behind a line marked on the floor. The subject would hop forward as far as possible, landing on the same foot from which you took off.  The distance for each jump was measured and recorded in centimeters (cm).  In addition, each subject also performed the test while capturing their lower limb mechanics via a Vicon motion capture system.


The authors compared the distance in meters of the involved to the uninvolved side looking for an LSI of 90% symmetry.  In addition, they also compared data captured via the Vicon system for each subject.  The authors found some interested results:


  • Both the groups that had LSI >90% and those that did not tended to offload the non-operative knee.  Meaning they would subconsciously or consciously perform worse on the non-operative side in order to achieve 90% LSI.
  • Although subjects had 90% LSI on the single leg hop for distance, this was not indicative of whether or not there was faulty biomechanics in achieving those results. 
Looking at both of these results makes realize that the way we are measuring this today is still not sufficient.  If a subject can perform the tests that are determined to be a part of the standard of practice and still pass those tests by under performing on the non-operative side and with faulty mechanics, then is this sufficient.  In other words, whatever we use we have to have a way of measure the mechanics during these tests.  If we know that it is the amount of frontal plane motion that occurs at the knee and the speed at which this occurs during these tests that puts the athlete at risk, then we must somehow find a way to measure this.  

Although the Wren et al study only looked at one test in isolation, we can assume we would get similar results when looking at other tests or a battery of tests.  As Rohman et al suggested, when testing an athlete for return to play, this should include a series or battery of tests.  If the criteria is that the athlete achieve 90% or > LSI on this battery of tests, what is the likelihood the athlete will pass?

That is exactly what our next study looked at.  Next week, we will look at study by Toole et al 2017 where we get some insight into how many athletes pass a single functional test or battery of tests.  If you enjoy this blog, please share with your colleague and follow us on instagrm @ bjjpt_acl_guy and twitter @acl_prevention.  #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, April 22, 2019

RTPlay Following ACLR - How Do We Know When Is The Right Time

Last week in our discussion we looked at the study by Rohman et al Am J Sports Med 2015 where the authors discussed the topic of absolute LSI or Limb Symmetry Index.  The authors introduced the concept of absolute LSI which is a comparison of the pre-operative non-involved limb to the post operative involved limb.  This is a better measure due to the disuse atrophy and weakness that will occur in the non-involved limb during the surgical and rehabilitation process.  Absolute LSI accounts for this variance.  Whether using absolute LSI or not, measurement of limb symmetry is important.

Since sports are primarily single limb in nature, it makes sense that the majority of the measures we do to determine if someone is ready to return to play should be single limb in nature as well.  Although, one of the gold standards in testing is the bilateral vertical drop jump (VDJ) test.  In this test, the subject stands on a 31 cm step, steps off thus dropping to the floor.  Upon contact with the floor, they immediately jump in the air.  The VDJ test is intended to give some indication of the athlete's biomechanics during explosive movements.  Traditionally, this has been used as a screening tool for injury.  However, Krosshaug et al Am J Sport Med 2016 did a study looking at the use of the VDJ test for predicting injury risk in 782 elite soccer and handball players.  In this study, the authors were looking for valgus at landing, peak knee abduction moment, peak knee medial displacement and peak ground reaction force.  Although peak knee medial displacement was the #1 risk factor identified, none of the VDJ test variables were associated with risk in these athletes.

If you think about it, that does not seem logical.  Seems like we should be able to look at this movement and identify those that are at risk.  Would make sense that those at risk would have frontal plane motion of the knee during the explosive phase of this test.  Why are we not able see that or use this test to asses that?  We don't necessarily know the answer to that question but we do know that athletes are good at compensating.  The better the athlete is, the better they are at compensating.  If you look at the study by Noehren et al Orthoo J Sport Med 17, the authors of this study looked at VDJ test in collegiate athletes who had been cleared to start sport specific training following ACLR.  The authors were using this test to identify those athletes at risk for injury.  What the authors of this study found was that athletes who had high levels of kinesiophobia (fear of movement as identified via TSK-11) had significantly less loading of the involved leg during the drop than did non-injured athletes.   In other words, these athletes were not demonstrating any of the risk factors commonly assessed on this test but at the same time were significantly off loading the involved side to compensate for the weakness.

This is similar to what we see with the squatting motion.  Athletes who lack confidence or ROM or strength or a multitude of other reasons will end up shifting their weight over to the non-involved leg.  Unlike the athlete pictured above, most of the time this is not as obvious and as easy to see with the naked eye.  During high explosive activities, this is even harder to see.  So, how do we test in a way that we are addressing the movement patterns that we know put athletes at risk and at the same time mitigates the athletes ability to compensate.

Knowing that sports are primarily single limb in nature, the results of these studies further indicate the importance of doing single limb testing.  So then the question becomes which tests should we do?  If we look at the Rohman et al Am J Sport Med 15 study, the authors concluded the best measures of single limb performance were the single leg squat, single leg hop, cross over hop and timed hop.  The authors further suggest that core testing should also be a component that should be considered in assessing an athlete's ability to return to play.

If we do single limb testing and we compare the involved leg to the non-involved leg (pre-operatively or post-operatively), does this mean that the athlete is safe for return to play.  Knowing that the majority of these tests are measured by the ability to perform, the ability to do in the same amount of time or with the same distance, does symmetry on the test alone determine whether someone is at risk or not.  Can an athlete have 100% symmetry and still be at risk?

This is the question we will dive into next week as we look at the study by Toole et al 2017 and Wren et al 2018.   If you enjoy this blog, please share with your colleagues and follow us on instagram @ bjjpt_acl_guy and twitter at @acl_prevention.  #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, April 15, 2019

RTPlay Following ACLR - How Do We Know When Is The Right Time? - Part III

Last week, we concluded our discussion talking about Melick et alBr J Sport Med 2016 systematic review that provided guidelines for RTPlay based on the most current evidence.  Specifically, we dove into the topic of LSI or limb symmetry index.  The systematic review suggest that looking for an LSI of >90% of the non-involved limb was a criteria we should consider.  This led to Rohman et al Am JSport Med study which showed that 93% of non-injured norms had an LSI of 85% or greater.  This may make us question whether or not we might be setting the criteria to high.  Is 90% realistic if 93% of non-injured norms are 85% or greater?

We also brought up the concept of what happens to the non-involved limb during the rehab process?  We all know those athletes are less active during rehab than they are during their sports participation.  So, are we comparing the injured side to a deconditioned side?  If we are, is this a good measure of LSI for determining someone’s ability to safely return to play?  In the Rohman et al Am J Sports Med 2015 they looked at 122 ACLR athletes.  In this study they performed single limb testing on the involved leg and non-involved leg pre-operatively and post operatively. 

To measure LSI, based on literature review, the authors choose several tests.

1.     Balance – single leg anterolateral reach, single leg anteromedial reach, stork stance eyes open and stork stance eyes closed.
2.     Strength – retro step up and single leg squat
3.     Functional testing – single leg hop, single leg triple hop, cross over triple hop and timed hop
4.     Core – plank and single leg bridge

Based on the results, the authors found that the best measures for determining LSI are the single leg squat, single leg hop, retro step up, cross over triple hop and the timed hop.  This is one key take home for all of us.  Inclusion of these tests or portion thereof should be considered when we are looking to put together our RTPlay assessment.  The other finding that  was very telling was the measure of post-operative LSI.  The results of this study indicate the LSI measures performed on the non-involved leg showed there was significant deterioration of the non-involved extremity from pre-operative measures to post-operative measures.  This means if we are using the post-operative non-involved leg to compare to, then we are comparing this to a deconditioned limb and may not be truly assessing the risk that is associated with RTPlay. 

Based on this information, this led the authors to suggest the use of absolute LSI.  Absolute LSI is defined as:

Absolute LSI % = Post-operative leg LSI measures / Pre-operative non-involved leg x 100

As we discussed last week, as clear cut as the Melick et al study appeared to be, we can now see that may not have been the case.  Based on these two Rohman studies we now know some tests that we should consider for measuring LSI and what we should compare the involved limb to for determining the absolute LSI.  However, this still does not answer another fundamental question we may have with these tests.

If someone’s ability to do a single leg squat, single leg hop or a cross over hop and they are able to do this within 90% or 95% of their absolute LSI, does this mean they are not at risk?  Does simply having the ability to perform 10 single leg squats bilateral, or perform 10 hops or 10 cross over hops all within 90% or > of their non-involved limb tell me they are not at risk?  Is risk associated with just the ability to do alone?  Can you perform this movement and be 100% of the non-involved leg and still have horrible movement that would put you at risk?  I think we all intuitively know that answer and yet the tests we use do not typically account for that.  

Next week, we will start to dig into just this concept by looking at what should we assess and what does the studies tell us about functional testing.  If you enjoy this blog, please share with your colleagues and follow us on instagram @ bjjpt_acl_guy and twitter at @acl_prevention.  #ViPerformAMI #ACLPlayItSafe


Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years. 

Monday, April 8, 2019

RTPlay Following ACLR - How Do We Know When Is The Right Time? - Part II

Last week we started our discussion regarding returning an athlete to play following an anterior cruciate ligament reconstruction (ACLR).  This is a hot topic in sports medicine and one without a really clear answer.  To start our discussion we looked at several studies which indicate athletes are at greater risk for reinjury following a primary ACL injury and ACLR.  For those that do return to play following the primary ACLR, the Faltstrom et al Am J Sport Med 2019, study showed that athletes who suffered a second ACL injury were not only at greater risk for another knee or ACL injury but were also more likely to discontinue their sport all together.   We concluded our discussion talking about the impact that a primary ACLR has on athletic performance.  Specifically the Mai et al Am J Sports Med 2017, which showed that NFL players not only reduced their performance up to 2 years following a primary ACLR but also reduced their professional career by 2 years. 

So, obviously we need to prevent the primary ACL injury.  However, what we also need to do is get better at determining when the athlete is ready for return to play.  Unfortunately there is not a concesus in the literature or in the standard of practice on what should be assessed.  Melick et al Br J Sports Med 2016 performed a systematic review of the literature from 1990 to 2015.  The aim of this study was to develop an evidence based statement for rehabilitation after ACLR.  This literature review included studies that addressed the following clinical topics:

1.     Pre-operative predictors of post-operative outcomes
2.     Effectiveness of physical therapy
3.     Open and closed chain quadriceps exercises
4.     Strength and neuromuscular training
5.     Electrostimulation and electromyographic feedback
6.     Cryotherapy
7.     Measurements of functional performance
8.     Return to play
9.     Risk for reinjury


Overall, 90 studies were included in the systematic review for the basis of the authors evidence statement.  For the purposes of our discussion, we are going to look at the recommendations for RTPlay.

Based on the systematic review, the studies suggest that the following criteria should be included as a part of the RTPlay decision making process.

1.     Psychological measures – the two most commonly referenced are the TSK-11 (Paterno et al Sport Health 2018) and the ACL-RSI (Webster et al Am J Sport Med 2018, Webster et al Am J Sport Med 2019).
2.     Battery of tests for determining the quantity and quality of movement
3.     Tests which measure single limb performance
4.     A measurement of limb symmetry index
5.     A measurement of and obtaining a minimum of 90% limb symmetry index

This comprehensive approach, based on the literature, should provide us data to make a much more informed decision.  End of the day, it should allow us to make sure we are providing our athlete with the most informed decision to make a safe return to play.

Based on this systematic review, this seems pretty clear.  We add this to our return to play assessments and we should be good.  Sadly, it is not that clear cut.  For example, let’s just take a look at LSI (limb symmetry index).  This is simply a measure of the variance between the right leg and the left leg.  Seems very clear that setting the standard at 90% of the non-involved limb would be reasonable. 

However, a review of the literature shows us this is not so clear.  Rohman et al Am J Sports Med 2015 looked at this issue and looked at LSI in the ACLR athlete and compared that to healthy norms.  Couple of key findings from this study was that 93% of non-injured healthy norms had an LSI of 85% or >.  They also found that athletes that underwent an ACLR had some degradation of the non-involved leg.  This makes sense to those of us that have been involved in the rehab of these athletes since we know these athletes are not near as physically active during rehab as they are during sport.  As such, it makes sense there is some muscle atrophy, associated weakness and degradation of proprioceptive awareness that occurs in the non-involved leg during rehab. 

This led the authors to look at this further in which Rohman et alAm J Sports Med 2015 performed a retrospective case series of 122 athletes who had an ACLR to see what the impact is on the non-involved extremity.  Next week, we will dive into this study and continue our discussion on the results of the Melick et al study.

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Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years.