Rehabilitation following ACL reconstruction focuses on treatment of impairments and functional limitations. Clinical pathways that have been developed for rehabilitation of the knee are useful for identifying and classifying impairments and functional limitations following ACL reconstruction. Application of these clinical pathways will enable the physical therapist or athletic trainer to select the most appropriate treatment for an individual. Knowledge of secondary pathology and concomitant surgery allows the clinician to modify application of the clinical pathway. The purpose of this manuscript is to describe modifications for rehabilitation of individuals following ACL reconstruction, based on knowledge of secondary pathology and/or concomitant surgery.
James J. Irrgang and Christopher D. Harner
Matthew D. Pepe and Christopher D. Harner
Christopher D. Harner, Tracy M. Vogrin and Savio L-Y. Woo
This article discusses the anatomy and biomechanics of the posterior cruciate ligament (PCL) and PCL reconstructions and their implications for clinical management of PCL injuries. The PCL consists of two functional components, the anterolateral and posteromedial, based on their reciprocal tensioning patterns. The anterolateral has been the focus of single-bundle PCL reconstructions. Recent biomechanical studies have indicated that the posteromedial bundle also plays an important role, and double-bundle PCL reconstructions have also been proposed. The PCL works closely with the posterolateral structures in providing posterior knee stability. The effects of several surgical variables, including graft fixation, associated injuries, and tunnel placement, that can significantly affect the outcome of PCL reconstruction are discussed. With improved knowledge of the PCL, new reconstructive techniques are being developed, offering the potential of more closely replicating the anatomy and biomechanics of the normal PCL and improving clinical outcomes of PCL injuries.
James J. Irrgang, Susan L. Whitney and Christopher D. Harner
Shoulder pain in throwing athletes is reviewed. The anatomy and function of the rotator cuff and the biomechanics of the throwing mechanism are described. Physical examination for rotator cuff injuries, treatment considerations, and a protocol are presented. Failure to recognize glenohumeral instability may limit the success of nonoperative management of rotator cuff injuries in throwing athletes. This article provides a comprehensive review of some of the underlying causes of rotator cuff pathology in throwing athletes. Rotator cuff injuries in throwing athletes are closely associated with glenohumeral instability. The role of glenohumeral instability in the pathogenesis of rotator cuff injuries is described.
James J. Irrgang, Christopher D. Harner, Freddie H. Fu, Mark B. Silbey and Robbie DiGiacomo
The purpose of this study was to determine the effects of preoperative, intraoperative, and postoperative intervention on the incidence of loss of motion (LOM) following ACL reconstruction. A retrospective review of patients undergoing ACL reconstruction between 1990 and 1991 was conducted to identify those with LOM. Factors potentially related to loss of motion were recorded. The results were compared to the findings of a similar group of patients who underwent ACL reconstruction between 1987 and 1989. In 1990 to 1991, less concomitant ligament surgery was performed, the incidence of loss of extension was significantly reduced, and the incidence of loss of flexion was significantly increased. It appears the risk for loss of extension can be minimized by delaying surgery following acute injury, performing less concomitant ligament surgery, paying meticulous attention to notchplasty and anatomic placement of the graft, and placing early emphasis on restoration of full extension following surgery.
Scott M. Lephart, Mininder S. Kocher, Freddie H. Fu, Paul A. Borsa and Christopher D. Harner
Injury to the anterior cruciate ligament (ACL) is thought to disrupt joint afferent sensation and result in proprioceptive deficits. This investigation examined proprioception following ACL reconstruction. Using a proprioceptive testing device designed for this study, kinesthetic awareness was assessed by measuring the threshold to detect passive motion in 12 active patients, who were 11 to 26 months post-ACL reconstruction, using arthroscopic patellar tendon autograft (n=6) or allograft (n=6) techniques. Results revealed significantly decreased kinesthetic awareness in the ACL reconstructed knee versus the uninvolved knee at the near-terminal range of motion and enhanced kinesthetic awareness in the ACL reconstructed knee with the use of a neoprene orthotic. Kinesthesia was enhanced in the near-terminal range of motion for both the ACL reconstructed knee and the contralateral uninvolved knee. No significant between-group differences were observed with autograft and allograft techniques.
Marc R. Safran, Christopher D. Harner, Jorge L. Giraldo, Scott M. Lephart, Paul A. Borsa and Freddie H. Fu
Proprioceptive deficits have been demonstrated following anterior cruciate ligament (ACL) disruption, but little research exists evaluating proprioception in the posterior cruciate ligament (PCL)-deficient and/or -reconstructed knee. We have studied proprioception in PCL-deficient and PCL-reconstructed knees. The following summarizes our protocol and results of proprioceptive testing of kinesthesia and joint position sense in participants with isolated PCL injuries and those who underwent PCL reconstruction. We studied 18 participants with isolated raptures of the PCL and 10 participants who underwent PCL reconstruction. Proprioception was evaluated by two tests: the threshold to detect passive motion (TTDPM) and the ability to passively reproduce passive positioning (RPP). These assess kinesthesia and joint position sense, respectively. We have shown that isolated PCL deficiency in the human knee does result in reduced kinesthesia and enhanced joint position sense. Thus, the proprioceptive mechanoreceptors in the PCL do appear to have some function. We further found that PCL reconstruction significantly improved kinesthesia at 45° of knee flexion, while 110° was not significantly different between the involved and uninvolved knee in both studies.