Acl Course Booklet

ACL Rehabilitation in Youth Sports
A Field to Field Examination

Clinics
Main Campus
4800 Sand Point Way NE
Seattle, WA 98105
206-987-6400
Bellevue Clinic and Surgery Center

1500 116th Ave NE
Bellevue, WA 98004
206-987-6400
South Clinic
34920 Enchanted Pkwy. S
Federal Way, WA 98003 Seattle Children’s Sports Physical Therapy
253-838-5878
All of the Sports Physical Therapists at Seattle Children’s have specialized training in
pediatric orthopedics and rehabilitation. Additional advanced training includes ankle, hip,
Mill Creek Clinic and knee injuries, ACL rehabilitation, and return to play/sport testing. Therapists perform
12800 Bothell Everett Highway biomechanical analysis for upper extremity issues such as overhead sports and throwing,
Suite 150 and for lower extremity, including video gait analysis for running and jumping. We treat
Everett, WA 98208 spine issues such as spondylolisthesis, scoliosis, non-specific back pain, and cervical pain,
206-987-6400 as well as concussion, fractures, overuse injuries, and patients with pre- and post-operative
care protocols. There are four therapists who are certified in the Schroth method for man-
agement of idiopathic scoliosis. Three therapists are licensed athletic trainers, and six are
APTA-board-certified clinical specialists in sports or orthopedics.
Speciality Clinics
ACL Class, Bellevue and South Clinics

The ACL class is designed for patients who have had an ACL reconstruction or other knee
surgery. This is a 1 hour and 20 minute session with 4-5 kids. They are taken through a pro-
gram involving warm-up, strengthening, plyometrics, functional training, endurance, core
control, and stretching. The program is based on Sportsmetrics, which is an ACL injury
prevention program. Participation in the ACL group helps kids rehabilitate their injured
leg as well as working to reduce the chance of injury on the non-operative side. Once a
patient is able to jog and do controlled jumping in their one-on-one PT sessions they can
begin the group.
Athletes with Disabilities, All Clinics

We focus on helping school-age children and adolescents with disabilities heal after sports
injuries or sports injury–related surgery. We work with athletes at any skill level who want
to return to play, prevent injuries and improve overall performance.
Schroth Method for Scoliosis, Main Campus and Bellevue Clinic

The Schroth Method uses physical therapy to treat scoliosis. The goals of the Schroth
Method are to prevent curve progression and improve posture through exercises based on
the patient’s curve. The Schroth Method is not recommended for all patients with scoliosis.
Patients must be at least 11 years old, have a cobb angle of 20 to 45 degrees, and be Risser
4 or lower.
Therapeutic Core Strengthening Class, Bellevue Clinic

The therapeutic core class is designed for patients with diagnosis of back and hip pain.
This is a 55 minute class with maximum of 5 patients that is based in the Pilates method.
The focus of this class is to improve core and glute strength and improve stability in a
group setting. This may be appropriate for patients that do require formal 1:1 physical
therapy as well as patients that are transitioning from physical therapy to the community
as a stepping stone to discharge.
Learn More
www.seattlechildrens.org/sports-physical-therapy
02
Contents
04 On the Field Injuries
Shanlyn Souza, MS, ATC, LAT
Amanda Lipke, MS, ATC, LAT
12 Pediatric Sports Medicine Provider Panel

Monique Burton, MD, FAAP
Tom Jinguji, MD
Celeste Quitiquit, MD, FAAP
ACL Rehabilitation in Youth Sports
Shelly Post, PA-C
May 7, 2014
24 Sport Psychology Principles for Rehab & Return to Play

Julie Vieselmeyer, MS, MA, CC-AASP
Venue
Wright Auditorium
Seattle Children’s Hospital
32 Surgical Intervention 4800 Sand Point Way NE
Gregory Schmale, MD, MEd Seattle, WA 98105
42 Evidence-Based Physical Therapy Following ACL Injury

Jordan Snetselaar, PT, DPT Planning Committee
Janet Morton, PT
Whitney Marois, PT, MSPT, OCS
58 Return to Play Recommendations Summer Ice-Tseng, PT, DPT
Ellie Somers, PT, MSPT, DPT Natalie Johnson, PT, DPT
Steve McKenzie, PT, MSPT
Richard Ford, Admin Assistant
66 Return to Field Following Rehabilitation
Shanlyn Souza, MS ATC, LAT
70 Appendix - Special Tests
ACL Rehabilitation in Youth Sports 03

On the Field Injuries
8:00 AM

Shanlyn Souza, MS ATC, AT/L, is a certified Athletic Trainer at Seattle Children’s Hospital. In addition
to being the Fitness Consultant for the Child Wellness Clinic, she is also the Head Athletic Trainer
for Woodinville High School.

Amanda Lipke, MS ATC, AT/L, is a certified Athletic Trainer at Seattle Children’s Hospital. She
received her Bachelor’s degree in Athletic Training and her Master’s degree in Human Performance.
She is currently the head athletic trainer at Interlake High School in Bellevue, WA.
04
• Athletic Trainers (ATs) are health care professionals
who collaborate with physicians to provide
preventative services, emergency care, clinical
diagnosis, therapeutic intervention and rehabilitation
of injuries and medical conditions.1
• ATs are described as individuals most directly • Commission on Accreditation of Athletic Training
Education (CAATE)
responsible for all phases of health care in an – 4 year Bachelor’s degree
athletic environment.2 – 2 year Master’s degree
• Includes broad roles and responsibilities • Board of Certification (BOC) Exam1.
encompassing a variety of specialties under – Individual State Department of Health requires
licensure or credentials
the sports medicine umbrella. • Moving towards Professional degree
– Injury prevention, first aid, injury management, – Baccalaureate programs may not admit, enroll, or
rehabilitation matriculate students into the athletic training program
after the start of the fall term 20221

• Evidence-based practice • Certification
• Prevention and health promotion maintenance
period = 2 years
• Clinical examination and diagnosis
• Acute care of injury and illness • 50 CEUs
• Therapeutic interventions • Minimum 10
• Psychosocial strategies and referral Evidence Based
Practice (EBP)
• Health care administration
CEUs
• Professional development and responsibility3
5 Domains of RDS
• Conducted and published by the Board of
Certification, Inc. (BOC) 1. Injury/Illness Prevention and Wellness
Protection
• Defines minimum knowledge and skills
2. Clinical Evaluation and Diagnosis
• Blueprint for developing the BOC
Examination5 3. Immediate and Emergency Care
4. Treatment and Rehabilitation
5. Organizational and Professional Health and
Well-being5
• Implementing standard evaluation techniques • Employing standard care procedures and

and formulating a clinical impression for the communicating outcomes for efficient and
determination of a course of action. appropriate care of the injured.
06
Organizational and Professional Health and Well-being
• Reconditioning participants for optimal • Understanding and adhering to approved

performance and function. organizational and professional practices and
guidelines to ensure individual and
organizational well-being.
ATs Work In:

• 9 members create the Board • Public and private secondary schools
• Colleges and universities, professional and Youth leagues
– 6 Certified ATs • Municipal and independently owned youth sports facilities
• Physician offices as physician extenders, similar to nurses, physician assistants,
– 1 Physician Director • Rural and urban hospitals, hospital emergency rooms, urgent and ambulatory care
• Clinics with specialties in sports medicine, cardiac rehab, medical fitness, wellness
– 1 Public Director • Occupational health departments in commercial settings, which include police and
fire departments
– 1 Corporate/Educational Director • Branches of the Performing arts including professional and collegiate level dance
and music
• The BOC is the only accredited athletic • Olympic sports
• Physical therapy clinic
training program for certification in the US2 • Manufacturing, distribution and offices to assist with ergonomics
• Military3
2% 2%
College/University
• 27 ATs in Puget Sound area high schools
19% Secondary Schools
• Also found in:
– Ergonomics
Clinic and Hospital
27%
– Wellness clinics
Students
– Cystic fibrosis clinic
18% Professional Sports – Outreach
Military/Occupational – Community ImPACT testing
17% Health

• Each site and
• SCH sport have own
– Provide full coverage for all practices and home events specific EAP
– Work primarily at the high school • AT, Coaches, AD
• Clinic/Hospital and site
administrator
– Work part time at the clinic all have specific
– Work home events at local high school roles
• Direct Hire • NATA position
– Hired through school or district to work only for the statement
high school(s) available on
website
• AED • At the school following classes until

• Vacuum splint kit games/practices are done.
• Crutches • In-season and post-season play includes the
• Medical kit responsibility for the daily health care of 100-
400 athletes.
• Treatment table
• Daily duties:
• Ice
– Evaluate/diagnose a wide variety of injures
– Taping and rehabilitation
Video Initial Assessment • Gold standard to treatment of athletic injury is:

– Early detection
• To avoid muscle guarding and special test false negatives,
evaluate injury right after it occurred
– The nature of the injury = mechanism
– Degree of severity
08
• Do a primary survey for life threatening • Airway/breathing
conditions • Consciousness
• Severe bleeding
• Ask yourself:
• Position of limb
– What is the level of injury
• Athlete’s response to injury
– Do I need to activate EMS • Obvious deformity
– Is the athlete able to get off field by themselves or • Watch for signs or symptoms of shock
is assistance needed • Remove athlete appropriately to the sideline for a
more thorough evaluation as needed = Secondary
Survey
Best Practices
• History: • Application of
– Chief complaint, mechanism of injury (MOI), unusual skills
sounds
• Anterior
• Observation:
Cruciate
– Immediate swelling, deformity, willingness to move
injured extremity Ligament (ACL)
Injury
• Palpation:
– Tenderness, pain
• Special Tests
– Rule out Fx before performing special tests
Predisposition and Factors

• Ruptures occur in • Q-Angle
a position of max
– Angle femur enters hip
stress socket
• Valgus stress,
lateral rotation • Different landing
with foot planted strategies
position and – Females use less knee
deceleration and hip flexion during
• Sudden landing/jump to stop
hyperextension – Causes an increase in
with rotation quad activation and
• Can be contact or decrease in hamstring
non-contact stressing the ACL

Lachman’s • Anterior Drawer
• Uniplanar – Not as sensitive as Lachman’s due to knee flexion
instability test angle
Knee in 20-30o
– Increase knee flexion pulls open capsular and
flexion (loose-
ligamentous structures taut and positions
packed
hamstrings to oppose tibial translation
position)
– May produce false negative
• Isolates ACL
– Normal translation is 4-6mm
• Lelli’s Lever Test

• Make a fist and put
Video Sideline Evaluation
underneath the athlete’s
tibia, inferior to the
tibial tuberosity. With
other hand apply a
posterior force on
quadriceps
• With intact ACL, the foot

comes up off the table
• If the ACL is not
functioning, the foot
remains on the table6
• Next 24 hours
• Patient Education
– Athlete is an active participant in evaluation and • What to expect
“game plan” • Who to call
– Answer questions • ER or no?
– Prognosis: Short and long term • R.I.C.E.
10
• Proper Referral
• Referral
1. Commission on Accreditation of Athletic Training Education. CAATE, n.d.

Web. 4 Apr. 2016. <http://caate.net/>.
2. Board of Certification. BOC, n.d. Web. 4 Apr. 2016.
<http://www.bocatc.org/about-us>. Path: http://www.bocatc.org/about-
us/defining-athletic-training.
3. Prentice, William E. Principle's of Athletic Training: A Competency-Based
Approach. N.p.: McGraw-Hill Higher Education, 2006. Print.
4. National Athletic Trainers' Association. NATA, n.d. Web. 4 Apr. 2016.
<https://www.nata.org/>. Path: https://www.nata.org/about/athletic-
training/education-overview; https://www.nata.org/about/code-of-
ethics.
5. Role Delineation Study. 6th ed. Omaha, NE: Board of Certification; 2009.
6. Lelli, Alessandro, Rita Paola Di Turi, David B. Spenciner, and Marcello
Dòmini. "The “Lever Sign”: a new clinical test for the diagnosis of
anterior cruciate ligament rupture." European Society of Sports
Traumatology, Knee Surgery, Arthroscopy (2014). Print.

Pediatric Sports Medicine
Provider Panel
9:00 AM
Monique Burton, MD, FAAP

Monique Burton, MD, FAAP, is a board-certified pediatrician with additional certification in Sports
Medicine. She is the Director of the Sports Medicine Program at Seattle Children’s and the Chair
of USA Track and Field’s Sports Medicine and Sports Science Committee. Dr. Burton has been a
volunteer team physician at numerous international competitions with the United States Olympic
Committee and USA Track and Field.
Tom Jinguji, MD
Tom Jinguji, MD, is a physician in the Division of Orthopedics and Sports Medicine Department
and General Pediatrics at Seattle Children’s Hospital. He is an Associate Clinical Professor of
Orthopedics and Sports Medicine at the University of Washington School of Medicine.
Celeste Quitiquit, MD, FAAP

Celeste Quitiquit, MD, FAAP, is a board-certified pediatrician with additional certification in Sports
Medicine at Seattle Children’s South Clinic. She has served as a team physician at the collegiate
level with UCLA and at the high school level both locally and regionally. She is an active member of
the American Medical Society for Sports Medicine and the American College of Sports Medicine.
Shelly Post, PA-C

Shelly Post, PA-C, is a Certified Physician Assistant in the department of Orthopedics and Sports
Medicine at Seattle Children’s Hospital. Shelly graduated from George Washington University
Physician Assistant Program in 2007 with a Master’s degree. She completed a surgical residency for
Physician Assistants at Yale University/Norwalk Hospital. Shelly has a particular interest in sports
injuries, trauma, fracture care, and orthopedic surgery.
12
Overview
The Knee:
• History
• Physical Examination
Pediatric Sports Medicine Provider • Imaging
Office Visit • Labs
• Differential Diagnosis
Monique S. Burton, MD
Tom Jinguji, MD
Shelly Post, PA-C
Celeste Quitiquit, MD
History
• What happened?
 Acute event  Insidious onset

o Duration of symptoms
History
o Mechanism of injury
o Change in activity –
o Pop?
type, frequency,
o Able to bear weight intensity
o Onset & details of o Limitations in normal
swelling/effusion physical activities
History History
• Pain • Swelling
• Constant or Intermittent  Superficial:
• Location o Contusion, sprain, bursitis
• Quality  Effusion:
o Throbbing, aching, burning o Ligamentous, meniscal, fracture, bone contusion
• Radiation
• Exacerbating Factors • Mechanical Symptoms
o With activity & types of activity  Catching or locking (not clicking)
o Positions o Meniscus, loose body
o Certain movements
• Alleviating factors • Instability v. Giving away
 Instability  internal derangement
 Giving away  Pain response

History
• Other
 Patient Age
o Remember physeal injuries in skeletally immature athlete
 Referred pain
o Hips!
 Systemic symptoms
Anatomy
o Fever, weight loss, night pain, etc
 Other joint symptoms
o Consider Rheum etiology
 Previous injury of knee pain
 Exercise Hx
 ROS, Meds, Allg, PMHx, FHx, SHx
Anatomy: Anterior Anatomy: Posterior
Anatomy: Lateral Anatomy: Medial
14
Anatomy: Transverse Cross Section
Physical Examination
Physical Exam Inspection
• Gait
• Inspection • Alignment
• Palpation • Swelling/Effusion
• Range of Motion • Discoloration
• Strength • Deformity
• Special Tests • Asymmetry
• Neurovascular • Atrophy
• Other – HIPS!
Inspection Inspection
Alignment Effusion
VALGUS
VARUS
RECURVATUM

Effusion Inspection
Atrophy
Milk fluid Tap patella
Sweep fluid from medial With lateral pressure, watch

aspect for fluid wave medially
Palpation Palpation
Anterior Knee
• Distal Quadriceps
• Quad Tendon
• Patella:
 Medial & Lateral Facets
• Patella Tendon
• Retinaculum:
 Medial & Lateral
• Tibial Plateau
• Tibial Tubercle
• Femoral Condyles
• Fibular Head
Palpation Palpation
Lateral knee Medial knee
• Lateral meniscus
• LCL • Medial meniscus
• ITB • MCL
• Distal Biceps femoris • Pes anserine bursa
16
Palpation Range of Motion
Posterior knee
• Popliteal Fossa
• Flexion: 135° to 150°
• Distal hamstring
• Proximal
gastrocnemius • Extension: -10° to 0°
Flexibility HIPS!!!
• Hamstrings • Always examine the hips!!!

 Popliteal angle  Hip pain can refer to the
o Hip flexed @ 90° knee
o Extend leg to endpoint
o Should be able to get
straight
• Quadriceps
 Standing or prone
Strength Strength
• Resisted flexion • Trendelenburg Test

• Resisted extension  Hip external rotators/abductors
• Single leg knee squat
• Hip external
rotation/abduction

Patellar Tests Patellar Tests
Patellar Glide • Grind/Compression • Apprehension

• Inhibition • Subluxation/Dislocation
Patellar Tilt
 Patellofemoral
Lateral Collateral Ligament (LCL) Medial Collateral Ligament (MCL)
• Valgus Stress Test

• Varus Stress Test
 Performed @ 0° & 30°
 Performed @ 0° & 30°
 Valgus directed force
 Varus directed force
 Assess for laxity &
 Assess for laxity & endpoint
endpoint
 Compare to opposite
 Compare to opposite side
side
Varus/Valgus Stress Test Varus/Valgus Test
• Alternative Position
18
Anterior Cruciate Ligament (ACL) Anterior Drawer
• Patient supine
• Anterior Drawer • Knee flexed to 90°
• Foot stabilized
• Lachman • Thumbs on tibial
tubercle
• Fingers on calf
• Pivot shift
• Encourage patient to
relax hamstrings
• Pull anteriorly
Anterior Drawer Lachman Test
• Patient supine
• Injured knee flexed to
~30°
• Stabilize femur w/ upper
hand
• Grasp proximal tibia w/
lower hand
• Translate tibia in anterior
direction
• Assess for endpoint &
anterior translation
Lachman Test Pivot Shift Test

Posterior Cruciate Ligaments (PCL) Posterior Drawer
• Posterior Drawer
• Posterior Sag Test
Normal Abnormal
Posterior Sag Sign Meniscus Tests
• McMurray Test
• Apley Grind Test
• Thessaly Test
McMurray Test Apley Grind Test
• Patient supine • Patient prone

• Grasp knee in one hand, • Downward force on foot
heel in other
• “Grind” foot into table
• Thumb- medial joint
  pain suggest meniscus tear
Fingers- lateral join
• Maximally flex knee • Retract foot
• Extend knee w/ varus then   pain suggest meniscus tear
valgus force in internal &
  pain suggest collateral ligament
external rotation injury
• + if click, pop, or pain
20
Thessaly Special Tests
• Patient stands flat footed

on floor
• Knee flexed 20 degrees
• Internally & externally
rotate body
Neurovascular Status
• Pulse, Capillary refill
• Sensation
 Anterior L3, L4, L5
 Posterior S1, S2 Differential Diagnosis
• Reflexes
 Patellar L2, L3, L4
Differential Diagnosis Acute
Acute Subacute/Chronic ! • Ligamentous

 +/- pop
Ligamentous Apophysitis Infection
 Effusion
Meniscus Tendinitis/Bursitis Hip pathology  Instability
 Positive ligamentous exam
Patellar dislocation Patellofemoral Tumor findings
Fractures Osteochondritis Dissecans • Meniscus

 Pain with deep knee flexion,
Traumatic bursitis Arthritis squats
 Effusion – slower onset
Tendon strain
 Mechanical symptoms
 Positive McMurrays

Acute Acute
• Patella Dislocation/Subluxation • Traumatic Bursitis

 Effusion  Fall onto knee on hard
 Positive patellar apprehension surface
• Fractures  Large swollen water balloon
like fluid collection
 Apophyseal Avulsion
o Sudden onset of pain @ tibial tuberosity, distal patellar pole • Tendon Strain
o Focal swelling  Quad/Hamstring tendons
o Pain with resisted knee extension  Sudden onset of pain @
 Tibial Spine distal tendons
o Effusion
o Pain with anterior drawer/Lachmans
• Do not repeat these tests!!!
Subacute/Chronic !
• Apophysitis • Osteochondritis • Infection

 Pain @ tibial tuberosity Dissecans  +/- fever
o Osgood Schlatter • +/- mechanical syx  Swelling, erythema, warmth
 Pain @ distal patellar pole • Most common
location • Tumor
o Sinding-Larsen-Johannson
• lateral aspect of  Lack of improvement
• Tendinitis medial femoral  Night pain
 Patellar condyle
• Hip
 Hamstring • Inflammatory
 Refers to knee
 Quad • Lack of improvement
with treatment  Consider SCFE, toxic synovitis, septic hip
• Patellofemoral methods
 + Theater sign • Erythema
 Diffuse Pain • Warmth
• Swelling without injury
Imaging
• When should you image?

 Concerning History
o Acute Injuries
o Night pain
Imaging o Unexpected course

 Positive Exam findings
o Swelling/effusion
o Point tenderness
22
Imaging: Radiographs Why we do x-rays first?
Popliteal avulsion fracture Osteochondral fracture

• Start with Radiographs
 AP, lateral, notch, sunrise
Why we do x-rays first? Imaging: MRI
Tibial eminence fracture Segond fracture • MRI: For concerning history & exam findings
ACL tear
Normal MRI
Laboratory Studies
• When are labs needed?

 Concern for
o Infection Thank You!
o Inflammatory condition
o Other
• What labs do you start with?
 CBC with differential, ESR, CRP
 Blood cultures when appropriate
• Refer to appropriate provider for more detailed labs

Sport Psychology Principles for
Rehab & Return to Play
10:45 AM
Julie Vieselmeyer, MS, MA, CC-AASP

Julie Vieselmeyer, MS, MA, CC-AASP, is a sport and performance psychology consultant based in
Seattle. She has served as the sport psychology consultant for high school and collegiate teams.
She is an active member of the American Psychological Association and Association for Applied
Sport Psychology. Julie is an instructor at Western Washington University.
24
Agenda
 Psychological impact of ACL injury
 Psychological response & reactions to injury
SPORT PSYCHOLOGY  Role of sport psychology
PRINCIPLES FOR REHAB  A biopsychosocial model
& RETURN TO PLAY
 Protective & risk factors
Julie Vieselmeyer, MS, MA
Sport & Performance Psychology Consultant  Cognitive-behavioral interventions
Seattle Pacific University
 A Case Study
Psychology of ACL Rehabilitation Psychology of Injury
 Despite being physically recovered

from ACL reconstruction 30-60% of
athletes may not return to pre-injury
participation level (Ardern, Osterberg,
Tagesson, Gauffin, Webster, & Kvist, 2014)
 ACL surgery has been found to have

many ramifications for psychological
functioning (Brewer et al., 2007) The study of personal and situational factors, as well as
cognitive, emotional, and behavioral responses of
athletes to athletic injuries.
Psychological Response to Injury Psychological Reactions: After Injury
 Injury-relevant information processing

 Immediate negative consequences  Disappointment  Performance decrements
 Attempts to understand how and why injury occurred  Relief  Fear of treatment
 Emotional upheaval and reactive behavior  Hopelessness  Loss of motivation
 Increased emotionality
 Denial  Dreams shattered  Lack of confidence
 Greatest need for social support  Isolation  Fear of re-injury
 Positive outlook and coping
 Losing fitness  Identity loss
 Acceptance
 Adherence to treatment  Pain  Grief
 Feelings of hopefulness

Psychological Reactions: After Injury Treatment Goals for ACL Injury
 Reconstruction & Rehab  Sport Psychology
 All of the previous responses listed including  Physical restoration  Mental restoration and
anxiety and depression are actually NORMAL  Rehabilitation
wellbeing
reactions to injury.  Return to play
 To increase adherence to
rehabilitation
 Increased strength & health
 Psychological readiness to
 IF psychological reactions persist: return to play
 Ability to participate in
 TWO weeks or more lifelong sport  Increased resilience for
 Interferes with life recovery and to prevent
future injury
 THEN a referral to a sport psychologist or mental  Ability to participate in
health professional is needed. lifelong sport is a source
of enjoyment and
satisfaction
Sport Psychology Utilizes a Cognitive-

What is Sport Psychology? Behavioral (CBT) Approach
 A cognitive-behavioral approach considers how an

individual’s thoughts, feelings, and behaviors
interact to cause and maintain problems
 A tool for helping athletes see their sport from a different

perspective with the goal of helping them reach their potential
 Addresses clinical issues, performance enhancement, and life
concerns in athletes
Biopsychosocial Model of Post-Sport

Sport Psychology for Injured Athletes Injury Response and Recovery
 Recent survey of 800 sports medicine docs indicated that 80%
often discuss psychological/ emotional factors related to injury
 Research with high risk athletes shows fewer injuries in those

who complete stress management training (Weinberg & Gould, 2011) Cognition Affect
 Help athletes return to sport more quickly

Outcome Behavior
 Educate athlete about themselves and performance – provide
tools to take attention away from maladaptive thoughts,
emotions, and behaviors
 Improves future performance
(Weise-Bjornstal, 2010; Wierike et al., 2013)
26
Cognition Affect
 Interpretations  Emotions
 Appraisals  Feelings
 Beliefs  Moods
Behavior Protective Factors for ACL Rehab

 Cognition
 High health & sport locus of control
 High self-efficacy
 Athletic identity
 Efforts
 Affect
 Adaptive emotion regulation
 Actions  Self efficacy of knee function
 Behavior
 Activities  Moderate avoidance coping
 Rehabilitation adherence
 Use of mental skills
 Relational (Brewer et al., 2007; Tripp, Stanish,

 High social support
Ebel-Lam, Brewer, & Birchard, 2011)
Risk Factors for ACL Rehab Goals of Sport Psychology

Cognitive
Sport psychology strives to understand personal and

 Low health & sport locus of control

 Low self-efficacy situational factors, as well as cognitive, emotional, and
 Catastrophizing
behavioral responses of athletes to athletic injuries. The
 Affective sport psychologist strives to select interventions and
 Fear of reinjury
 Negative mood
provide support to:
 Pain
 High optimism
 Increase protective factors
 Behavioral  Decrease risk factors
 Poor knee function
 Avoidance coping
 Relational Wierike, van der Sluis, van den Akker-

 Low social support Scheek, Elferink-Gemser, & Visscher, 2013)

Cognitive-Behavioral Interventions Motivational Interviewing (MI)
 Coping skills training  When injury occurs something has to CHANGE!
 Mindfulness-based stress reduction  Typically injury is not a welcome change but that’s
 Motivational Interviewing (MI) not always the case
 Acceptance-based interventions
 MI is an intervention or a “way of
 Emotion regulation
being with people” to facilitate change
 Mental skills training
 Fundamental tenets:
 Goal setting
 Relaxation  Collaboration
 Self-talk  Evocation
 Imagery  Autonomy
 Routines
Motivational Interviewing (MI) Goal Setting

Build a strategic plan to achieve a desired result.
 How does MI look in practice?
(1) Empathy LAW OF THE LADDER
(2) Develop Discrepancy
(3) Roll with Resistance
(4) Support Self-Efficacy

LAW OF THE HARVEST
Goal Setting Self-talk

Refers to our internal dialogue. Many benefits to positive talk!
 Builds motivation
 Being goal oriented promotes a positive attitude
 Promotes adherence to rehabilitation plan  Enhances concentration
 Ensures athlete and treatment team have matching expectations:
 Set date for return to play  Improves confidence
 Establish concrete plan for home program
 Determine other areas for improvement: sleep, nutrition,

 Builds self-efficacy
mental skills
 Reinforces success
Note: Treatment team should emphasize the importance of sticking
to the plan and not doing more even when athlete feels stronger
28
Self-talk Relaxation
Being relaxed is an important state for body and mind to function
THOUGHTS  FEELINGS  BEHAVIOR
optimally. Many benefits of relaxation for rehab and sport.
 Decreases body tension

Use cue words to trigger effectiveness  Improves coordination
Ex: “breathe” or “engage core - lift”
 Improves body awareness
Use affirmations to improve self-efficacy
“I am doing everything possible to get better.”
 Increased energy management
“I have a great team supporting me.”  Improves ability to focus
“I can do this!”
 Increases composure
 Facilitates rest and recovery
Relaxation Imagery
Creating or re-creating an experience in one’s mind. Building an
 Deep breathing optimal image works to program our bodies and minds to engage
the best response at critical moments.
 Progression Muscle Relaxation (PMR)
 Autogenic Training  Improves concentration
 Meditation  Reduces anxiety

 Stretching  Increases motivation
 Other: Listening to music, reading, etc.
 Builds confidence
Imagery Routines
Develop complementary physical and mental routines to
 Rehearse specific sport skills
facilitate goal achievement.
 Recall past successful performances
 Master rehabilitation exercises  Increases adherence
 Healing imagery  Builds concentration
 Increases motivation
 Maintains composure
 Builds confidence
Tips for Effective Imagery
Polysensory  Cultivates purpose
Controllability  Enhances commitment to goals
Vividness

Routines A Case Study: Hannah
Why routines work?  Hannah is 21 year old collegiate soccer player
 Presenting problem
 Right ACL reconstruction during her senior year of
high school
 Left ACL reconstruction during the first game of her
sophomore year of college
 Physical and psychological challenges in her sport,
school, and relationships as well as in changes in self-
esteem and identity as a result of her injuries
 Focus is on “doing”
 Hannah wants to regain her past level of play for her
 Routine behavior aids in minimizing negative thoughts or emotions
senior year of college and regain enjoyment in her
 Effective routines incorporate physical and mental skills sport.
A Case Study: Hannah Treatment & Prognosis

 Cognition
 “Am I ever going to play  Behavior
 Counseling
again?”  Sleep difficulties  Journaling
 “What if I can’t achieve my  Change in appetite
goals?”  Modeling
 Avoidance of team
 “What do others think of me?” activities  Mental Skills
 Affect  Relationally  Goal setting
 Symptoms of anxiety and  Problems with teammates  Relaxation
depression and coach
 Fear of reinjury  Problems with friends and
 Imagery
 Decrease in self-efficacy significant others  Self-talk
 Reduced motivation
Key Take-Aways Resources

 Following injury there is a typical pattern of response and
psychological reactions but how athletes progress through these
stages can vary widely Association for Applied Sport Psychology
Identify coping problems early in rehabilitation and assess for

psychological difficulties even after physical healing has occurred
http://www.appliedsportpsych.org/
 Psychological functioning during rehabilitation predicts return to
play and may impact future health and fitness
American Psychological Association
 Utilize a biopsychosocial model to develop interventions such as
motivational interviewing (MI), mindfulness based stress Division 47 – Sport & Exercise Psychology
reduction, and mental skills training http://www.apa.org/about/division/div47.aspx
 Sport psychology interventions can help athletes return to sport,
increase speed of recovery, reduce susceptibility to future injury as
well as face adversity in future situations
30
References
Ardern, C., Osterberg, A, Tagesson, S., Guaffine, H, Webster, K, Kvist, J., (2014). The impact of psychological readiness to
Thank You!
return to sport and recreational activities after anterior cruciate ligament reconstruction. British Journal of Sports Medicine,
48(22), 1613-U50. http://dx.doi.org/10.1136/bjsports-2014-093842
Brewer, B. W., Cornelius, A. E., Sklar, J. H., Van Raalte, J. L., Tennen, H., Armeli, S., & ... Brickner, J. C. (2007). Pain and
negative mood during rehabilitation after anterior cruciate ligament reconstruction: A daily process analysis. Scandinavian
Journal Of Medicine & Science In Sports, 17(5), 520-529.
Brewer, B. W., Van Raalte, J. L., Cornelius, A. E., Petitpas, A. J., Sklar, J. H., Pohlman, M. H., & ... Ditmar, T. D. (2000).
Psychological factors, rehabilitation adherence, and rehabilitation outcome after anterior cruciate ligament
reconstruction. Rehabilitation Psychology, 45(1), 20-37. doi:10.1037/0090-5550.45.1.20
Miller, W. R. & Rollnick S. (2002). Motivational Interviewing (2nd ed). The Guilford Press: New York.
te Wierike, S. M., van der Sluis, A., van den Akker-Scheek, I., Elferink Gemser, M. T., & Visscher, C. (2013). Psychosocial
factors influencing the recovery of athletes with anterior cruciate ligament injury: A systematic review. Scandinavian
Journal Of Medicine & Science In Sports, 23(5), 527-540.
Julie Vieselmeyer, MS, MA Tripp, D. A., Stanish, W., Ebel-Lam, A., Brewer, B. W., & Birchard, J. (2011). Fear of reinjury, negative affect, and
catastrophizing predicting return to sport in recreational athletes with anterior cruciate ligament injuries at 1 year
Seattle Pacific University postsurgery. Sport, Exercise, And Performance Psychology,1(S), 38-48. doi:10.1037/2157-3905.1.S.38
jvieselmeyer@spu.edu Weinberg, R. & Gould, D. (2011). Foundations of Sport & Exercise Psychology (5th ed). Human Kinetics: Champaign, IL.
206.859.9881
Williams, J. M. (2010). Applied Sport Psychology (6th ed). McGraw Hill: New York.

Surgical Intervention
12:45 PM
Gregory Schmale, MD, MEd

Gregory Schmale, MD, MEd, is a pediatric orthopedic surgeon with specialty certification in sports
medicine. He is an Associate Professor in the Department of Orthopedics and Sports Medicine at
the University of Washington School of Medicine. He serves as Clinic Chief for Sports Medicine
and is the Program Director for Orthopedic Medical Education at Seattle Children’s Hospital. His
specialty interests include knee injuries in the adolescent athlete and pediatric orthopedic trauma.
32
Youth ACL Injuries are on the rise
Youth ACL injuries • Increasing awareness
– Increased reporting
– Increased incidence
Gregory A. Schmale, MD
Seattle Children’s Hospital
Seattle, Washington
Treatment philosophies Observation

 Protect the physis  Woods, 2004: “No evidence that intentionally delayed
anterior cruciate ligament reconstruction increased the
 No surgery until mature rate of additional knee injuries.”
 Reconstruct, but avoid the physis

 intra/extra-articular procedure  Risk of further injury –
 all epiphyseal reconstruction • Graf,1992: 8/12 skeletally immature patients with ACL tears returned
to sports with a brace after quad and HS rehabilitation.
• After return to sports, all braced patients developed instability with
multiple episodes of "giving way,” by a mean of 7 months.
 Risk the physis and reconstruct • 7 patients sustained further meniscal damage an average of 15 months
 More anatomic reconstruction (range 7-27 months) after initial injury.
 Protect the knee • Brace management did not prevent instability or new
meniscal tears.
Observation Physeal Sparing

 Mizuta, 1995
 Conservative treatment for complete tears of the ACL in 18
Techniques
skeletally immature patients, min 36 months f/u
 Lysholm knee mean score of 64.3.
 Only one patient had returned to her pre-injury level of athletics.  Over-the-top ITBand
 Secondary meniscal tears in 6 patients, and 3 more had the clinical reconstruction
signs of a tear at follow-up. Radiological evidence of degenerative
changes was found in 11 of the 18 patients.  Kocher and Micheli
 The results of non-operative treatment for ACL injuries in
this age group are poor and not acceptable.
- Lawrence, 2011: Patients < 14 yo who underwent surgical
reconstruction of an acute ACL tear >12 weeks after the injury:  All Epiphyseal
• Had a significant increase in irreparable medial meniscal tears and reconstruction
lateral compartment chondral injuries at the time of reconstruction.
• When a subjective sense of knee instability was present, this
 Anderson
association was even stronger.

Kocher-Micheli extraphyseal ACL Kocher-Micheli extraphyseal ACL
reconstruction reconstruction
� �
Kocher and Micheli results
 Mean IKDC 97, mean Lysholm 96at 5.3 yrs mean f/u
 Mean growth over 20 cm
 2/44 failures
 All patients Tanner 1 or 2
 No identified growth abnormalities
OR?
Risks of Extra-physeal Anderson's all-epiphyseal

procedures ACL reconstruction - 1
 Non-anatomic reconstruction
 A trough has to be made to encourage "ingrowth" since
no tunnel is drilled
 This trough on the anterior tibia for "graft-ingrowth" is

near the apophysis of the proximal tibia
34
Anderson's all-epiphyseal ACL Anderson's all-epiphyseal
reconstruction - 2 ACL reconstruction - 3
Anderson's all-epiphyseal ACL

reconstruction - 3 Anderson results
 12 patients, 4 yrs mean f/u

 Mean IKDC objective score = 97
 All patients Tanner 1, 2, or 3
 No identified growth abnormalities
Risks of all epiphyseal Transphyseal reconstruction

reconstructions
 UW and SCH:
 Proximity of the femoral tunnel to the germinal cell layer
 Soft-tissue grafts
of the femoral physis  Hamstring autograft
 Tibialis anterior allograft
 Proximity of the tibial tunnel to the germinal cell layer  Single incision technique
tibial physis  “Centrally” located tunnels
 No fixation across physes
 Oblique nature of the tunnels risks compromising large  Endobutton femoral fixation
surface area of joint surfaces  Screw and washer tibia
Technically Demanding Procedure

Questions Retrospective Review
 Do growth abnormalities occur with transphyseal (Schmale, Kweon, Bompadre, Larson, CORR, 2014)
reconstructions?
50 patients skeletally immature at surgery
 What is the reinjury rate and rate of further surgery after invited for interviews, exams, and radiographs
ACL reconstruction in youth undergoing a transphyseal  Pre-injury & current Tegner activity
ACL reconstruction?  Current Lysholm functional score
 Height, weight, KT-1000 arthrometry
 IKDC guided physical exam
 How do satisfaction and function correlate with return to  Radiographs
prior level of sports after ACL reconstruction in youth?
All 29 living locally returned for interviews, exams, and
radiographs
 What factors contribute to failure to return to pre-injury
activity levels?
Demographics Results
Age at
Number of surgery Increase in height post-
n Range
Sex
patients (yrs + stnd surgery*
dev) Mean Satisfaction score 9 4-10
< 3 cm >3cm
Mean Lysholm score 91 61-100

Female 23 14 + 1 10 8
(mean 6 cm)
Re-ruptures 4/29 (14%)
Male 6 14 + 1 2 4
(mean 8 cm)
Overall re-operations (index knee) 11/29 (38%)
Contralateral ACL ruptures 8/29 (28%)

*5 patients without pre-op heights
IKDC scores Results

 Tegner activity scores dropped from 7.6 to 6.8
A B C D (p=0.003)
Subjective 9 12 4
 Only 12/29 (41%) returned to prior level of
Symptom 14 6 4 1 sports
 High satisfaction correlated with return to sports
Physical Exam 5 15 5
 Ipsilateral re-operation or contralateral ACL
Radiographic Imaging 17 7 1 disruption not associated with changes in return
to prior level of sports
Overall IKDC 3 129 1  No relationship between function and activity
 Most who were less active indicated a change
in interest with increasing age
36
Male: 13 yo at reconstruction
Tegner Activity Scores
• 2 yr f/u, physes open, 15 cm increase in
height since surgery
 No clinically obvious malalignment
4 yrs post-op 7 yo, unstable knee, wouldn't wear a brace,

recurrent giving way.
• Physes closed
• 26 cm growth overall
 No malalignment
 No leg-length difference
1 wk post-op films
Pre-op (age 7) & 3 yrs p-op

2 and 3 years post-op

Age 15, 8 yrs post-op Study Conclusions
ACL reconstruction in the skeletally immature using soft tissue
grafts across open physes:
 No angular malalignments, no early physeal closures
 High satisfaction correlated with return to sports

But, less than 50% return to prior activities
 Re-rupture rates high, contralateral rupture rates higher

Repeat or contralateral knee injuries not associated with changes in
return to prior level of sports
Fresh-frozen tibialis anterior allograft may fail at higher rates than
quadruple stranded hamstring autograft
(odds ratio, 7.3; exact nonparametric 95% CI, 0.7–73; p = 0.13
 No relationship between function and activity

Patients who were less active indicated a change in interest with
advancing age
Summary Teenage boy, unstable knee
 History – c/w ACL tear

 ACL tears are common in youth.
 Exam – c/w ACL tear
 Rehab and bracing programs may not prevent further
injury in patients with an ACL deficient knee.  Imaging
 Radiographs
 Rehab after surgery may not return the athlete to their  Assess the physis – still open?
pre-injury activity level.  Look for fx – Segond fx is pathognomonic for ACL tear
 MR
 Assess menisci, collateral and cruciate ligaments
 Assess the articular cartilage
Imaging Advanced Imaging
38
Advanced Imaging Advanced Imaging
ACL Reconstruction Exam under anesthesia - ACL is deficient

 Arthroscopically assisted procedure
 Typically using hamstring autograft
 Similar techniques: transphyseal or with closed physes
 Exam under anesthesia
 Harvest the semitendinosus and gracilis
 Diagnostic arthroscopy
 Preparation of notch
 clear soft tissues
 mark for femoral tunnel
Diagnostic Arthroscopy Set-up for harvest

Hamstring harvest approach
Hamstring Harvest for ACL reconstruction Graft preparation onto button
ACL Reconstruction Technique Tunnel locations
 Femoral tunnel
 Knee flexed, using accessory medial portal
 Guide pin followed by 4.5mm drilling
 Drilling socket
 Passing suture
 Tibial tunnel
 Knee flexed 90㼻
 Tip aiming guide
 Check guide pin position
 Overdrill
 Rasp tunnel edges
40
Passing the graft Passing the ACL graft
 Thru tibial then femoral tunnel

 Flipping the button
 Cycling the graft, checking isometry
 Fixing in full extension
Fixation Summary
 Button on femur, screw and washer tibia
 Hamstring autograft is our go-to ACL graft.
 Transphyseal reconstructions deserve careful
monitoring of post-op growth.
 The surgery is straightforward;

the rehab, challenging.
Controversies References
 Aichroth P.M, Patel D.V and Zorrilla P., The natural history and treatment of rupture of the anterior cruciate ligament in children and
adolescents. A prospective review, J Bone Joint Surg Br 84 (2002), pp. 618–619.
With regards to bracing, there are few facts:  Anderson A.F, Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. A preliminary report. J
Bone Joint Surg Am. 85 (2003), pp. 1255-63
 No known study shows a knee with a torn ACL does better with
a brace than without, with regards to further activity.  Ballal, M.S, Bruce, C.E, Nayagam, S. Correction genu varum and genu valgum in children by guided growth. J Bone Joint Surg Br.
(2010); 92:273-276
 No known study shows post-op bracing after ACL  Castaneda, P., Urquhard, B. Sullivan, E. Haynes, R. Hemiepiphysiodesis for the correction of Angular Deformity About the Knee.
JPediatr Orthop (2008); 28: 188-191
reconstruction is advantageous and prevents re-tear. Repeated  Gorman, T.M, Vanderwerff, R., Pond, M., MacWilliams, B. and Santora, S.D, Mechanical Axis Following Staple Epiphysiodesis for
studies have shown that there is no advantage to post-op bracing. Limb-Length Inequality. J Bone Joint Surg Am. (2009); 91:2430-2439
 Kocher M.S, Garg S, Micheli L.J. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent
children and adolescents. J Bone Joint Surg Am. (2005);87:2371-9.
However, hyperflexible patients are
 Kocher M.S, Micheli J.S and Zurakowski D., et al., Partial tears of the anterior cruciate ligament in children and adolescents, Am J
1) more likely to tear their ACL’s in the first place, and Sports Med 30 (2002), pp. 697–703.
2) are more likely to re-tear after a reconstruction.  Koman J.D, Sanders J.O. Valgus deformity after reconstruction of the anterior cruciate ligament in a skeletally immature patient. A
case report. J Bone Joint Surg Am. (1999) ;81:711-5.
 Lipscomb A.B and Anderson A.F, Tears of the anterior cruciate ligament in adolescents, J Bone Joint Surg Am 68 (1986), pp. 19–28.
Hence, I brace these patients to avoid the position of  Wijdicks C.A, Griffith C.J et al. Injuries to the medial collateral ligament and associated medial structures of the knee, J Bone Joint
hyperextension, a position that might put them at risk for further Surg Am 92 (2010), pp. 1266-80.
injury.

Evidence-Based Physical
Therapy Following ACL Injury
1:45 PM
Jordan Snetselaar, PT, DPT

jordan.snetselaar@seattlechildrens.org
Jordan Snetselaar, PT, DPT, is a Seattle Children’s Sports Physical Therapist. He specializes
in functional treatment and acute management of sports orthopedic injuries with a focus on
biomechanical analysis. He helped develop the injury prevention screen program and return to
sports program.
42
Objectives
• Determine ACL injury risk factors

• Understand principles of ACL injury prevention
• Identify and understand copers vs noncopers
• Understand principles of ACL reconstruction (ACLR)
“prehabilitation”
• Understand principles of ACLR rehabilitation (early,
Evidence-Based Physical Therapy intermediate, and late phases)
• Identify special considerations based on surgical
Following Anterior Cruciate procedure and concomitant injuries
Ligament (ACL) Injury
Jordan Snetselaar, PT, DPT
May 7, 2016 2
Non-Modifiable Factors
• Gender
• Females have two to six times greater ACL injury rate1
• No gender differences in ACL injury rates before onset of
puberty2
• Anatomy
• Height3
• Femoral notch width3,4
• Q-angle3,4
ACL Injury Risk Factors
• Joint laxity5 – Knee hyperextension increases the odds of an
ACL injury fivefold in young female athletes6
3 4
Modifiable Factors Modifiable Factors (cont.)
• ACL injury occurs within 30-100 ms of initial contact • Neuromuscular deficits leading to ACL injury
during landing, deceleration, and/or lateral pivoting • Female athletes often lack “Neuromuscular spurt” 12,13
maneuvers7,8
• Decreased lower extremity force attenuation during landing 14
• Biomechanical impairments leading to ACL injury:
• Decreased hamstrings to quadriceps torque ratios 15
• Decreased knee, hip, and trunk flexion8,9,10
• Knee valgus8,9,11
• Altered hip musculature recruitment16
• Hip and knee internal rotation8,9,10,11
• Anterior tibial shear10,11 • Proprioception deficits in trunk control 17
5 6

Neuromuscular imbalances associated with Neuromuscular imbalances associated with
ACL injury mechanisms18 ACL injury mechanisms18 (cont.)
Figure 818
Figure 818
7 8
Neuromuscular imbalances associated with Neuromuscular imbalances associated with

ACL injury mechanisms18 (cont.) ACL injury mechanisms18 (cont.)
Figure 818 Figure 818
9 10
Prediction Algorithm for Female Athletes at

High Risk for ACL Injury
• Measurements of knee valgus and knee flexion ROM

during drop vertical jump, as well as body mass, tibia
length, and quadriceps-to-hamstrings strength ratio
predict high knee abduction moment in female athletes
which has been linked to increased risk of ACL injuries19
• Predicts high knee abduction moment with 84% sensitivity and

67% specificity in female athletes19
Predicting Potential ACL

Injuries
11 12
44
Figure 919
Figure 919
13 14
The Landing Error Scoring System (LESS) Drop Vertical Jump Predicts ACL Injuries
• The LESS utilizes video analysis of a drop vertical jump • Increased knee abduction
task. Shown to be valid and reliable for identifying high during landing of drop
risk movement patterns10 vertical jump predict ACL
injury with 78% sensitivity
• No relationship between risk of ACL injury and LESS score in and 73% specificity for
male and female high school and collegiate athletes 20 teenage female athletes21
Figure 425
• Physical therapists can identify high knee valgus angles

during a drop vertical jump using real time
observation22
Figure 110
15 16
Trunk Control Predicts Potential Knee Tuck Jump Assessment

Injuries
• Tuck jump assessment tool may be useful in assessing
and training high risk movements23
• Deficits in active trunk repositioning predict knee injury
status with 90% sensitivity and 56% specificity in
collegiate female athletes17
Appendix 118
17 18

Predicting Potential ACL Injuries Predicting Potential ACL Injuries (cont.)
• Females with low hamstrings strength and similar • Isometric hip abduction and external rotation (ER)
quadriceps strength relative to male controls may be at strength measures are able to predict noncontact ACL
increased risk for ACL injury24 injury in male and female athletes26
• Decreased hamstrings strength correlated to increased • Cutoff for athletes at high injury risk: hip ER ≤ 20.3% of
knee valgus during double and single leg leap landing in body weight, hip abduction ≤ 35.4% of body weight26
adolescent females resulting in increased loading at
ACL25
19 20
Training Strategies for ACL Injury Prevention
• Meta-analysis suggests that neuromuscular training and

education interventions decrease the incidence rate of
ACL injury by approximately 50%27
• Plyometric training with biomechanical analysis and

training appears to be key in reducing ACL injury
rates28
Principles of ACL Injury
Prevention
21 22

(cont.)
• Neuromuscular training programs that include

biomechanical, proprioceptive, and strength training
have shown:
• Positive performance enhancements – improved strength and

power28,29,30,31,32
• Improved biomechanics and coordination leading to decreased

ACL injury risk28,29,30
23 Table 118 24
46
(cont.) Feedback with External Focus of Attention
• Feedback with external focus of attention (focus on

movement effect not the movements themselves) may
be more suitable for acquiring complex motor skills33
• Improved movement patterns found when using external

focus of attention:
• Greater knee flexion angles34
• Lower peak vertical ground reaction force 35
• Improved neuromuscular coordination36
Figure 1 and 237
25 26
Timing of ACL Injury Prevention Timing of ACL Injury Prevention (cont.)
• Systematic review of ACL injury prevention programs38 • Preadolescence or early puberty seems to be a critical
showed success with: phase related to increase ACL injury risk in female
• At least 6 weeks of preseason training 2-3 times per week athletes39
• In-season training 1-2 times per week
• focus on strength, plyometrics, balance, proprioception, and
• Neuromuscular training programs may help to decrease
education/feedback on proper technique
the gender differences in biomechanical control and
decrease adolescent female athlete ACL injury risk1
• Both high intensity preseason neuromuscular training
and medium intensity (warm up) in-season training have
demonstrated decreased ACL injury risks28
27 28
ACL Injury Prevention Programs ACL Injury Prevention Programs (cont.)
• Sportsmeterics • Knee Injury Prevention Program (KIPP)

• Training program including flexibility, plyometric, and strength • Coach-led 20 minute neuromuscular warm up focusing on
training shows significant decrease in non-contact knee injuries strength, balance, plyometrics, agility, and education to avoid
for high school female athletes29 dynamic knee valgus showed significant reduction in noncontact
lower extremity injuries for girls high school basketball and
soccer42
• Santa Monica Prevent Injury and Enhance Performance
(PEP) Program
• Training program including education, strengthening, stretching,
• FIFA 11+
plyometrics, and agility training showed decreased ACL injuries • Warm up including strengthening, education, and neuromuscular
in female division I soccer players40,41 training showed a trend toward lower extremity injury risk
reduction in youth female soccer players, although not
significant43
29 30

ACL Injury Prevention Programs (cont.)
• A systematic review44 found that the only programs to

significantly reduce ACL injuries in adolescent female
athletes were:
• Sportsmetrics
• Prevent Injury and Enhance Performance (PEP) Program
• Knee Injury Prevention Program (KIPP)
After ACL Injury

31
http://www.newsday.com/sports/football/acl-injuries-no-longer-spelling-doom-for-football-careers-1.5335284
Copers vs. Noncopers
• Copers:
• Able to resume all preinjury activities without episodes of giving
way and do not require surgery
• Perform significantly better than noncopers on all four single leg
hop tests45
• Noncopers
• Unable to return to previous level of activity or experience
Copers and Noncopers episodes of giving way
• Demonstrate worse gait kinematics and time-distance variables
Following ACL Injury when compared to copers at 4 months post injury, noncopers
utilize a joint stiffening strategy46
33 34
Copers vs. Noncopers (cont.) Copers vs. Noncopers (cont.)
• Hurd et al 200847
• 832 highly active individuals with subacute ACL tears were
• Ramski et al 201348
followed over 10 years
• Meta analysis of operative vs nonoperative treatment of child
• Screening exam around 6 weeks after injury determined
and adolescent ACL tears favors early surgical stabilization over
potential copers (146/345) and noncopers (199/345)
nonoperative or delayed treatment
• 6 meter timed hop at least 80%
• Knee Outcome Survey ADL scale at least 80% • Nonoperative or delayed treatment patients were 33.7 times more
• Global rating of knee function of at least 60 likely to have clinical instability or pathological laxity
• No more than one episode of giving way
• Risk of meniscal tear after operative treatment was 4%, risk after
• 25 out of 63 (39%) of the individuals who passed all components nonoperative treatment was 67%
of rehabilitation and the return to sports test did not undergo
ACLR • Significantly greater rate of return to activity, 92% with operative
• 89% (308/345) of the initial group eventually had surgery, only treatment, 43.75% with nonoperative treatment
7% (25/345) did not
35 36
48
Copers vs. Noncopers (cont.) Principles of “Prehabilitation”
• Reduce inflammation
• Surgical repair appears to be the preferred treatment for
individuals who choose to return to high level pivoting
sports49 • Restore normal range of motion – decreased risk of
post-op arthrofibrosis with normalized AROM prior to
• Early onset knee osteoarthritis (OA) is a risk after ACL injury with surgery54
or without surgical intervention50,51
• Restore neuromuscular control – normalize gait pattern
• 70% reduction in high risk sports participation for those treated
conservatively, only 44% reduction for those treated surgically at
10-13 year follow up52 • Prepare patient for surgery
37 38
Principles of “Prehabilitation” (cont.)

• Prevent muscle weakness
• Pre-op quadriceps strength has significant impact on long term
knee functional outcomes following ACLR55,56
• Quadriceps strength within 20% of uninvolved leg recommended
prior to surgery55
• A progressive 5 week exercise therapy program has

shown significant improvement in knee function following
ACL injury57
Anatomy and Physiology of
ACL Reconstruction (ACLR)
39 40
• Incorporation of graft at insertion site: Ligamentization

• Bone autograft (patellar tendon) between 6-8 weeks58
• Soft tissue autograft (hamstring or quad tendon) between 8-12 • Graft weakens during first 2-4 weeks, then begins
weeks59 progressive revascularization and maturation62,63
• Allografts between 4-6 months60 • Resembles a native ACL by 1 year62
• Graft strength:
Figure 264
Table 361
41 42

Principles of Early ACLR Rehabilitation
• Goals of immediate post-op phase (~0-3 weeks)

• Restore full passive knee extension
• Progress knee flexion ROM
• Reduce post-op inflammation and pain
• Progress toward ambulation without assistive device
• Re-establish voluntary quadriceps control
• Protect reconstructed ACL and donor site
Rehabilitation following ACL

Reconstruction (ACLR)
43 44
Early ACLR Rehabilitation (cont.) Early ACLR Rehabilitation (cont.)
• Restore full passive knee extension ROM • Reduce post-op inflammation and pain
• Patients who get and maintain full knee motion show decreased • Reduced effusion leads to increased ROM, decreased pain, and
prevalence of OA long term after ACLR65 improved function53
• Loss of 3-5° knee extension compared to uninvolved knee had • Pain may play a role in quadriceps inhibition69
worse subjective and objective outcomes a mean of 14.1 years • Debate exists on joint effusions role in quadriceps inhibition56,70,71
post ACLR66
• Progress toward ambulation without assistive device
• Progress knee flexion ROM • Weight-bearing as tolerated
• Immediate motion is critical to avoid ROM complications 67 • No significant benefits of bracing72
• No significant difference for continuous passive motion and • Possible benefit of locked brace immediately post-op due to
standard treatment vs standard treatment alone on knee ROM quadriceps inhibition
and joint laxity68
45 46
Quadriceps Inhibition 1 Week Post-Op Early ACLR Rehabilitation (cont.)
• Re-establish voluntary quadriceps control

• Inhibition of quadriceps is common initially after ACLR and can
persist long term74
• Weakness due to arthrogenic muscle inhibition and muscle
atrophy53
• Neuromuscular electrical stimulation (NMES) combined with
exercise was more efficient than exercise alone at increasing
quadriceps strength75
• Open and closed chain exercises are as effective as each other
for knee laxity, pain and function in short term after ACLR 68
47 48
50
Straight Leg Raise with Mild Quadriceps Lag Early ACLR Rehabilitation (cont.)
• Protect reconstructed ACL
• Seated knee extension between 10°-50° knee flexion loads the
ACL significantly more than weight bearing exercises 73
• Facilitate hamstrings co-contraction: forward trunk tilt (30-40°),
heels on ground, knees over feet (sagittal plane), knees not
moving more than 8-10 cm anterior to toes73,76,77
• Protect donor site

• Potential for hamstring tendon regrowth following ACLR 78,
consider delaying resistive hamstrings exercises 8 weeks 61
• Donor site morbidity can occur with patellar tendon graft 79, be
aware of patellar tendon pain
49 50
Squat Facilitating Hamstrings

Protect Reconstructed ACL
Co-Contraction
Table 160
51 52
Principles of Intermediate ACLR

Intermediate ACLR Rehabilitation (cont.)
Rehabilitation
• Restore full ROM – full knee ROM compared to
• Goals of intermediate post-op phase (~3-12 weeks) uninvolved limb results in decreased risk of OA long
• Restore full ROM term65
• Progress quadriceps strength and control
• Restore neuromuscular control and balance
• Progress quadriceps strength and control
• Gradually increase loading at knee
• Initial focus on closed chain terminal knee extension control
• Squat80 and lunge81 show minimal to no ACL loading, LAQ
against resistance increases ACL load82 (still less than walking83)
• Progress eccentric loading84
53 54

Intermediate ACLR Rehabilitation (cont.) Intermediate ACLR Rehabilitation (cont.)
• Soreness rules to guide progressive strengthening
• Restore neuromuscular control and
balance
• Address core and hip strength and

stability impairments
• Hip and core weakness may be

predictive of second ACL injury86,87
• Target hip extensors, abductors, and

external rotators early in order to
decrease second ACL injury risk86,88
Dynamic knee valgus

during single leg hip hinge
Table 385
55 56
Intermediate ACLR Rehabilitation (cont.) Altered Motor Control with Lateral Heel Tap
• Restore neuromuscular control and balance (cont.)
• Address motor patterns that led to initial injury and decrease

second injury risk
• Multi-planar neuromuscular impairments in both ACLR and

uninjured limbs combined to predict second ACL injury risk86
• Poor neuromuscular control of trunk position may increase the risk

of ACL injury17,89
• Improved self-reported knee function after ACLR with

neuromuscular rehab program over strength training alone90
57 Operative Leg 58
Altered Motor Control with Single Leg Hip

Intermediate ACLR Rehabilitation (cont.)
Hinge
• Gradually increase loading at knee
• Protect graft  gradual increase in stress to knee

• Davis’s law: soft tissue heals according to how it is mechanically
stressed
• Peak ACL force:76,81,82,91,92,93

• Leg press and barbell squat with max resistance = 0 N
• Forward and lateral lunge = 0 N
• Single leg squat = 124 N
• Seated knee extension with max resistance = 248 N
Operative Leg • Double-foot drop landing off 60 cm step = 253 N
Non-Operative Leg • Single leg landing from running to a stop = 1294 N
59 60
52
Intermediate ACLR Rehabilitation (cont.) Hamstrings Deficits Following ACLR
• Gradually increase loading at knee (cont.)

• Progress from sagittal plane to multi-planar movements
• Persistent swelling or pain indicate over aggressive treatment 61
• Introduce jogging in pool at 2 months
• Progress hamstrings strength following hamstring autograft
• Hamstring tendons have the ability to regenerate following
autograft78
• The use of hamstring autograft does not limit recovery of hamstrings
strength94
• Prepare for late phase plyometrics – practice good

habits!
61 62
Principles of Late ACLR Rehabilitation Late ACLR Rehabilitation (cont.)
• Progress neuromuscular control

• Goals of Late post-op phase (~3-9 months)
• Progress neuromuscular control • Biomechanical factors predict second ACL injury risk, 92%
• Normalize quadriceps and hamstrings strength sensitivity, 88% specificity86:
• Introduce plyometric activities • A net internal rotation moment of the uninvolved hip with landing
drop vertical jump
• Progress to sport specific training
• Increased frontal plane knee motion during landing drop vertical
• Prepare for return to sport jump
• Seattle Children’s ACL group class • Sagittal plane knee moment asymmetries at initial contact on drop
vertical jump
• Deficits in single leg postural stability
• Neuromuscular control deficiencies are the only known

modifiable factors predictive of second ACL injury risk 86
63 64
Neuromuscular Impairments Leading to

Late ACLR Rehabilitation (cont.)
Secondary ACL Injury Risk
• Normalize quadriceps and hamstrings strength
• Recommended that prior to return to sports:
• quadriceps strength at least 85% of uninvolved leg30
• hamstrings:quadriceps strength ratio >66% for males, >75% for
females61
• Deficits in neuromuscular coordination of hamstrings and quads
following ACLR may manifest as excessive landing contact
noise95
Figure 586
Soft single leg
hop landings
65 66

Late ACLR Rehabilitation (cont.) Biomechanical Flaws with Jumps
• Introduce plyometric activities
• Recommended that prior to initiating late phase rehab: 85

• Full pain free AROM
• Minimal to no joint effusion
• At least 70% strength symmetry
• Neuromuscular training including plyometric and strength

training can improve speed, strength, and power while
decreasing injury risk in teenage females96
• Control of dynamic knee valgus improves with plyometric

training30
67 68
Late ACLR Rehabilitation (cont.) Lunge Jumps
• Introduce plyometric activities (cont.)
• Alterations in force-attenuation and generation as well as multi-

planar asymmetries at hips and knees noted up to 2 years after
ACLR in males and females97,98
• Altered hip and knee biomechanics found on the involved limb

following ACLR even though single leg hop test distance was
within 93% of uninvolved limb99
• Altered trunk control during running found in females post-ACLR

compared to matched controls100
69 70
Late ACLR Rehabilitation (cont.) Late ACLR Rehabilitation (cont.)
• Progress sport specific training • Prepare for return to sport
• Return to running program initiated at 3 months at our clinics • Return to sport assessment – 6 months post-ACLR at our clinics
• Debate exists on when to return to running85,61 followed by gradual return to sports
• Keep in mind graft incorporation time frames
• Single leg hop tests at 6 months post-ACLR demonstrate
• Addition of on field rehabilitation may help to address deficits in excellent accuracy for prediction of athletes with normal knee
return to sport101,102 function at 1 year post-op104
• Female athletes who had returned to sport following ACLR • Within the first year post-ACLR 2/3 of athletes had not returned to
showed significantly higher knee valgus during 45° cutting task their competitive sport105
compared to uninjured controls103
• Individuals with very high preinjury activity level have a higher
probability of not returning, due in part to fear of reinjury106
71 72
54
Seattle Children’s ACL Group Class Seattle Children’s ACL Group Class (cont.)
• Dynamic warm up
• Jump training
• Group treatment session • Focus on proper biomechanics and correcting “high risk”
• 80 minute weekly sessions with intensive plyometric, movements
strength, endurance, and agility training • Progress from DL  SL, stationary  multi-planar, increasing
speed
• Patients eligible once they are at least 3.5 months post- • Strength and stability training
op and: • Focus on quadriceps, hips, and hamstrings strengthening
• Perform single leg squat to at least 60 degrees with good form • Focus on proper biomechanics
• Able to jog for 5 minutes with proper gait • Agility training
• No reported feelings of instability • Progressing from sagittal plane  multi-planar
• Sport specific agility activities
• Progressing toward return to sports assessment at 6
months • Cardiovascular endurance training
• Core strengthening
• Flexibility training
73 74
ACLR Using Allograft
• Morphology, maturation, and ligamentization of autograft

is favorable to allograft at 3 and 6 months post-op107
• Meta-analysis of patellar tendon autograft vs allograft

showed increased graft failure and decreased
performance on single leg hop test for allograft108
• A slower progression to athletic activities is advised.61

Special Considerations for Due to delayed graft incorporation (4-6 months)
ACLR
75 76
ACLR With Meniscal Pathology ACLR With Collateral Ligament Injury
• Meniscal repairs performed at the time of ACLR have • Medial Collateral Ligament (MCL) Injury
superior healing rates and better outcomes than isolated • Grade I and II MCL sprains may not require surgical intervention
repairs109 • ACL with concomitant MCL injuries often present with excessive
scar tissue formation and may require an accelerated
• Immediate weight bearing and mobilization progression for ROM110
recommended84
• Lateral Collateral Ligament (LCL) Injury
• Limit deep knee flexion in weight bearing (specific • Combined ACL and LCL injuries are relatively rare, 1%
guidelines based on location and extent of repair), no incidence111
squatting past 60° for 8-12 weeks61 • Avoid excessive varus stress at knee, as well as, isolated
hamstrings strengthening up to 6-8 weeks61
77 78

ACLR With Articular Cartilage Lesions
• Occur in approximately 71%-85% of traumatic ACL
injuries112,113, most commonly on lateral femoral condyle
and lateral tibial plateau114
• Progress partial to full weight bearing and gentle ROM to

assist articular cartilage healing61
• Avoid excessive compressive force early in rehab115
• Full unloading and immobilization may be harmful to healing
articular cartilage115
Take Home Messages
• Surgical articular cartilage repair will impact rehabilitation
progression depending on size and location of repair
79 80
Take Home Messages Take Home Messages (cont.)
• Look for modifiable ACL injury risk factors in all patients • Adolescent athletes who desire to return to a high level
• Decreased hip and knee flexion, knee valgus, heavy landings
of sport participation have the best success with surgical
with jumping tasks, and poor trunk control
ACLR
• Neuromuscular training may help decrease the risk of • “Prehabilitation” to normalize knee ROM and quad
ACL injuries and enhance athletic performance if: strength has significant benefit for post-op outcomes
• Comprehensive training programs include plyometric, balance,
strengthening exercises, and education/feedback on technique • Incorporation times of ACL graft:
• They are performed 2-3 times per week for at least 6 weeks at • Bone autograft (patellar tendon) between 6-8 weeks
high intensity
• Soft tissue autograft (hamstring or quad tendon) between 8-12
weeks
• Allografts between 4-6 months
81 82
Take Home Messages (cont.) References

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13.
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16.
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• In late post-op phase:

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29.
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56. Lynch AD, Logerstedt DS, Axe MJ, Snyder-Mackler L. Quadriceps activation failure after anterior cruciate ligament rupture is not mediated by knee joint effusion. J Orthop Sports Phys Ther. 2012 Jun;42(6):502-10. 95. Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. Am J Sports Med. 2013 Jan;41(1):216-24.
57. Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA. A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2010 96. Myer GD, Brunner HI, Melson PG, Paterno MV, Ford KR, Hewett TE. Specialized neuromuscular training to improve neuromuscular function and biomechanics in a patient with quiescent juvenile rheumatoid arthritis. Phys Ther.
Nov;40(11):705-21. 2005 Aug;85(8):791-802.
58. Walton M. Absorbable and metal interference screws: comparison of graft security during healing. Arthroscopy. 1999 Nov-Dec;15(8):818-26. 97. Castanharo R, da Luz BS, Bitar AC, D'Elia CO, Castropil W, Duarte M. Males still have limb asymmetries in multijoint movement tasks more than 2 years following anterior cruciate ligament reconstruction. J Orthop Sci. 2011
59. Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF. Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am. 1993 Dec;75(12):1795-803. Sep;16(5):531-5.
60. Jackson DW, Grood ES, Goldstein JD, Rosen MA, Kurzweil PR, Cummings JF, Simon TM. A comparison of patellar tendon autograft and allograft used for anterior cruciate ligament reconstruction in the goat model. Am J Sports 98. Delahunt E, Prendiville A, Sweeney L, Chawke M, Kelleher J, Patterson M, Murphy K. Hip and knee joint kinematics during a diagonal jump landing in anterior cruciate ligament reconstructed females. J Electromyogr Kinesiol.
Med. 1993 Mar-Apr;21(2):176-85. 2012 Aug;22(4):598-606.
61. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Recent advances in the rehabilitation of anterior cruciate ligament injuries. J Orthop Sports Phys Ther. 2012 Mar;42(3):153-71. 99. Orishimo KF, Kremenic IJ, Mullaney MJ, McHugh MP, Nicholas SJ. Adaptations in single-leg hop biomechanics following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010 Nov;18(11):1587-
62. Marumo K, Saito M, Yamagishi T, Fujii K. The "ligamentization" process in human anterior cruciate ligament reconstruction with autogenous patellar and hamstring tendons: a biochemical study. Am J Sports Med. 2005 93.
Aug;33(8):1166-73. 100. Noehren B, Abraham A, Curry M, Johnson D, Ireland ML. Evaluation of proximal joint kinematics and muscle strength following ACL reconstruction surgery in female athletes. J Orthop Res. 2014 Oct;32(10):1305-10.
63. Claes S, Verdonk P, Forsyth R, Bellemans J. The "ligamentization" process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med. 2011 101. Bizzini M, Hancock D, Impellizzeri F. Suggestions from the field for return to sports participation following anterior cruciate ligament reconstruction: soccer. J Orthop Sports Phys Ther. 2012 Apr;42(4):304-12.
Nov;39(11):2476-83. 102. Waters E. Suggestions from the field for return to sports participation following anterior cruciate ligament reconstruction: basketball. J Orthop Sports Phys Ther. 2012 Apr;42(4):326-36.
64. Pauzenberger L, Syré S, Schurz M. "Ligamentization" in hamstring tendon grafts after anterior cruciate ligament reconstruction: a systematic review of the literature and a glimpse into the future. Arthroscopy. 2013 103. Stearns KM, Pollard CD. Abnormal frontal plane knee mechanics during sidestep cutting in female soccer athletes after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med. 2013 Apr;41(4):918-23.
Oct;29(10):1712-21.
104. Logerstedt D, Lynch A, Axe MJ, Snyder-Mackler L. Symmetry restoration and functional recovery before and after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2013 Apr;21(4):859-68.
65. Shelbourne KD, Freeman H, Gray T. Osteoarthritis after anterior cruciate ligament reconstruction: the importance of regaining and maintaining full range of motion. Sports Health. 2012 Jan;4(1):79-85.
105. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery. Am J
66. Shelbourne KD, Gray T. Minimum 10-year results after anterior cruciate ligament reconstruction: how the loss of normal knee motion compounds other factors related to the development of osteoarthritis after surgery. Am J Sports Med. 2011 Mar;39(3):538-43.
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67. Millett PJ, Wickiewicz TL, Warren RF. Motion loss after ligament injuries to the knee. Part II: prevention and treatment. Am J Sports Med. 2001 Nov-Dec;29(6):822-8.
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69. Young A, Stokes M, Shakespeare DT, Sherman KP. The effect of intra-articular bupivicaine on quadriceps inhibition after meniscectomy. Med Sci Sports Exerc. 1983;15:154.
109. Pyne SW. Current progress in meniscal repair and postoperative rehabilitation. Curr Sports Med Rep. 2002 Oct;1(5):265-71.
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72. Kruse LM, Gray B, Wright RW. Rehabilitation after anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am. 2012 Oct 3;94(19):1737-48. 111. Hirshman HP, Daniel DM, Miyasaka K. The fate of unoperated knee ligament injuries. In: Daniel DL, Akeson WH, O’Connor JJ eds. Knee Ligaments: Sturcture, Function, Injury and Repair. New York, NY: Raven Press;
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112. Graf BK, Cook DA, De Smet AA, Keene JS. "Bone bruises" on magnetic resonance imaging evaluation of anterior cruciate ligament injuries. Am J Sports Med. 1993 Mar-Apr;21(2):220-3.
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85 115. Vanwanseele B, Lucchinetti E, Stüssi E. The effects of immobilization on the characteristics of articular cartilage: current concepts and future directions. Osteoarthritis Cartilage. 2002 May;10(5):408-19. 86

Return to Play Recommendations
3:00 PM
Ellie Somers, PT, MSPT, DPT

elissa.somers@seattlechildrens.org
Ellie Somers, PT, MSPT, DPT, is a Seattle Children’s Sports Physical Therapist. As a certified
Sportsmetrics provider, she specializes in ACL injury prevention, as well as in the treatment of ACL
repairs. She has helped to update our ACL protocol and was integral in updating our return to
sports hop test.
58
Objectives
• Demonstrate understanding of the evidence on return to

sport testing and assessment
• Understand the importance of managing patients as

individuals
• Demonstrate proficiency in administering functional

Return to Sport Assessment Following return to sport testing
Anterior Cruciate Ligament Repair
Dr. Ellie Somers
Physical Therapist
Meeting my idol…. Take Away Points
1. Treat the Individual
2. Cluster your exam
3. Get the WHOLE picture
When to return to sport? Assess Risk
?  Less than 25yrs old = 30-40X

SURGERY 3 MONTHS 6 MONTHS 7 MONTHS 9 MONTHS 12 MONTHS 24 MONTHS
greater risk of sustaining
secondary ACL injury
Wiggins et al 2016

Assess Risk
Return to Sport Goals
Cutting
FEAR Range of motion
Strength Pivoting
Excessive Frontal Swelling Speed
Hip Rotational Control
Plane Knee Pain
Functional Stability
Deficits
Mechanics Pivot shift testing
Biomechanics
Graft choice
Time from surgery
Asymmetries Sport
Function
Proprioception
Power
Postural Control Muscle girth
Knee flexor Deficits Stability of the knee
Deficits Neuromuscular control
Motor control
Loading control
Psychological Readiness
Force generation
Endurance
Etc...
Coordination
Hewett et al 2013, Ardern et al 2014, Tjong et al 2014, Paterno et al 2010
Evidence-Based Return to Sport Testing Evidence-Based Return to Sport Testing
1. Functional Performance Functional testing:

• Hop testing
2. Strength • Star Excursion/Y-balance
• Drop landing vertical jump
3. Psychological Readiness • Agility testing
Contraindications to RTS Functional Testing Hop Testing
• Marked knee effusion

• Poor dynamic stability
• Pain
• Significant quadriceps weakness
• ACL graft rupture
• Any instability of the knee
• Pregnancy
60
Hop Testing Hop Testing
Purposes: • Passing score =

• Determine limb symmetry • LSI >/= 85%
• Assess symmetry in all 4 risk factors • 4 factors on secondary risk schematic look good!
• Determine power
Hip rotational control
• Coordination
• Speed Knee flexor control
• Force generation Postural stability
Frontal plane knee mechanics
• Fluid hopping
Reid et al, 2007
Hop Testing Brandon’s Hop Test
• Video
Percentage
5. HOP TEST Trial 1 Trial 2 Average Right Left
Single HOP Right 5.10 4.90 5.00 105.26%
Single HOP Left 4.90 4.60 4.75 95.00%
Triple HOP Right 17.80 17.80 17.80 113.74%
Triple HOP Left 16.40 14.90 15.65 87.92%
Cross over Right 14.00 13.20 13.60 110.57%
Cross over Left 12.60 12.00 12.30 90.44%
Timed HOP Right 2.22 2.25 2.24 92.93%
Timed HOP Left 2.47 2.34 2.41 107.61%
Modified Star-Excursion/Y-Balance Modified Star-Excursion/Y-Balance
Purposes:
• Determine limb symmetry
• Assess all 4 predictive factors
• Determine balance
• Strength assessment
Anterior Posterolateral Posteromedial
Gribble et al 2012, Plisky et al, Clagg et al 2015 Plisky et al, 2009, Garrison et al 2015

Modified Star-Excursion/Y-Balance Modified Star-Excursion/Y-Balance
• Passing score = • Video

• Composite reach = 90% or better
• Anterior reach distance <4cm side to side
• No loss of balance
• Stable trunk
• Good knee alignment
• Heel remains in contact with floor
Plisky et al 2006
Brandon’s Y-Balance Drop Landing Vertical Jump
Redler et al 2016
Drop Landing Vertical Jump Drop Landing Vertical Jump
Purposes: • Passing score =

• Determine RISK for ACL
injury : primary or • Knee separation distance >80%
secondary! • 60% and below considered HIGH RISK
• Assess loading control • 60%-80% is better but still MOD risk
• Determine movement
symmetry • Minimal asymmetry in sagittal plane, frontal
• Asses valgus plane and transverse plane
Paterno et al 2010
62
Drop Landing Vertical Jump Drop Landing Vertical Jump
“There’s an app for that”

• Video
Javascript is required to show this page properly.

Drag image to reposition. Double click to magnify further.
Agility Testing Agility Testing
Quality of Movement is Key
Modified Pro Shuttle Modified agility T-Test
Stearns et al, 2013 Myer et al, 2011
Agility Testing Strength Testing
• Purposes:
• Assess QUALITY of dynamic sport movement:
• Cutting
• Pivoting
• Speed
• Power
• Stability
• Agility
• Coordination
• Loading control

Strength Testing Strength Testing
Purposes: • Picture/video
• Determine strength symmetry
• Determine quad/ham ratio
• Determine hip strength
Strength Testing Brandon’s Strength Testing
• Passing = 1. DYNAMETRIC STRENGTH TESTING
• >85% strength symmetry of quads, hams, hip Trial 1 Trial 2 Average Right Left HS:Quad Ratio
abd Right Knee Extension 96.6 95.3 95.95 114.98% 42.78269932
• Quad/ham ratio = 50% males, 60% females Knee Flexion 42.4 39.7 41.05 96.82%
(ideally even higher) Hip Abduction 31.6 29.6 30.6 91.89%
Left Knee Extension 83.7 83.2 83.45 86.97% 50.80886759
Knee Flexion 41.8 43 42.4 103.29%
Hip Abduction 32.8 33.8 33.3 108.82%
Schmitt et al 2015
Psychological Readiness Psychological Readiness
• Strongly associated with returning to preinjury • Recognize Problematic Characteristics

activity • Threatened athletic identity – particularly true for young athletes!
• Low self efficacy or self esteem
• FEAR • Pessimism
• Associated with not returning to preinjury levels up to 7yrs after • Anxiety
ACLR
• Catastrophizing
• Commonly cited by athletes
• Lack of motivation
• Associated with altered movement patterns!!
Ardern et al 2014, Tjong et al 2013, Czuppon et al 2014 Christino et al 2015
64
Psychological Readiness Psychological Readiness
• Treatment options: • Knee Self-Efficacy Scale (K-SES)

• Positive self talk • ACL-Return to Sport after Injury Scale (ACL-RSI)
• Guided imagery
• Tampa Scale for Kinesiophobia (TSK)
• Relaxation
• ACL-Quality of Life Scale (ACL-QoL)
• Goal setting
• Counseling
Christino et al 2015
Assess Risk Summary
FEAR
1. Treat patients as individuals
Excessive Frontal 2. Use a cluster of tests
Hip Rotational Control  Functional testing
Plane Knee
Deficits Hop testing
Mechanics
Y-balance
Asymmetries Drop down vertical jump
Agility testing
Postural Control  Strength testing
Knee flexor Deficits
Deficits 3. Don’t forget the WHOLE patient
 Patient’s first!
 Psychological readiness assessment
Hewett et al 2013, Ardern et al 2014, Tjong et al 2014, Paterno et al 2010
References
1. Fitzgerald GK, Lephart SM, Hwang JH, Wainner MF. Hop tests as predictors of dynamic knee stability. J Orthop Sports Phys Ther.
2001;31:588-597
2. Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure during
rehabilitation after anterior cruciate ligament reconstruction. Phys Ther. 2007; 87:337-349.
3. Bandy W, Rusche K, Tekulve F. Reliability and limb symmetry for five unilateral functional tests of the lower extremity. Isokinet Exerc
Sci. 1994;4:108-111.
4. Bolgla LA, Keskula DR. Reliability of lower extremity functional performance tests. J Orthop Sports Phys Ther. 1997;26:138-142.
5. Logerstedt D, Lynch A, Risberg MA, Snyder-Mackler L. Single-legged hop tests as predictors of self-reported knee function after
anterior cruciate ligament reconstruction. Am J Sports Med. 2012 40: 2348.
6. Ericsson YB, Roos EM, Frobell RB. Lower extremity performance following ACL rehabilitation in the KANON-trial: impact of
reconstruction and predictive value at 2 and 5 years. Br J Sports Med. 2013;47:980-985.
7. Noyes
8. Paterno MV, Schmitt LC, Ford KR, Rauh MJ, Myer GD, Huang B, Hewett TE. Biomechanical measures during landing and postural
stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports
Med. 2010;38:1968-1978.
9. Paterno MV, Fod KR, Myer GD, Heyl R, Hewett TE. Limb asymmetries in landing and jumping 2 years following anterior cruciate
Thank you!! 10.

ligament reconstruction. Clin J Sport Med. 2007;17:258-262.
Hewett TE, Myer GD, Ford KR, Heidt RS, Colosimo AJ, McLean SG, van den Bogert AJ, Materno MV, Succop P. Biomechanical
measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes. Am J
Sports Med. 2005;33:492-501.
11. Gribble PA, Hertel J, Plisky P. Using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower
extremity injury: a literature and systematic review. J Athl Train. 2012;47(3):339-357
12. Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. Recent advances in the rehabilitation of anterior cruciate ligament injuries. J
Orthop Sport Phys Ther. 2012;42(3). 153-171.
13. Ardern CL, Wbster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: A systematic
review and meta analysis of the state of play. Br J Sports Med 2011;45(7):596-606
14. Ellman MB, Sherman SL, Forsythe B, LaPrade RF, Cole BJ, Back BR. Return to play following anterior cruciate ligament
reconstruction. J Am Acad Orthop Surg 2015;23:283-296.
15. Ithburn MP, Paterno MV, Ford KR, Hewett TE, Schmitt LC. Young athletes with quadriceps femoris strength asymmetry return to sport
after anterior cruciate ligament reconstruction demonstrate asymmetric single-leg drop-landing mechanics. Am J Sports Med 2015
43:2727-2737.
16. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury
after primary ACL reconstruction and return to sport. Clin J Sport MEd. 2012:22(2):116-121

Return to Field Following
Rehabilitation
4:00 PM

Shanlyn Souza, MS ATC, AT/L, is a certified Athletic Trainer at Seattle Children’s Hospital. In addition
to being the Fitness Consultant for the Child Wellness Clinic, she is also the Head Athletic Trainer
for Woodinville High School.

Amanda Lipke, MS ATC, AT/L, is a certified Athletic Trainer at Seattle Children’s Hospital. She
received her Bachelor’s degree in Athletic Training and her Master’s degree in Human Performance.
She is currently the head athletic trainer at Interlake High School in Bellevue, WA.
66
• Now What?
• Clearance note/restrictions
Now what? • Insurance only covers 12-18 PT visits
– Partnership PT with the ATC
– Work together to create a cohesive plan
• Athlete + PT + AT = Maximized Results
• Normal motion • Specific instruction on desired performance

• Multiplanar motion and integration • Perform activity slowly progressing with resistance
• Stabilization and acceleration changes • Add complexity once skill mastered
• Proprioceptive stimulation • Increase intensity once performance improves
• Agility and power • Repetition of correct pattern is key
• Activity specific skill development

• Plyos before sport specific • Patient is 100% to pre-injury
• Consider pre-disposing factors and strengthening the
deficits as part of RTP • Has confidence in ability and previously
• Difficulty can be increased by injured knee
– Distance – No barriers in psychological or physical
– Multiple jumps
performance
– Speed
– Height
– Double leg vs single leg
• Running and jumping should mimic sport specific
movements
• Designed to decrease the likelihood and severity of

an athletic injury
– FIFA
– Dynamic sport specific warm-up
– 3 planar warm-up
68
1. Prentice, William E. Principle's of Athletic Training: A
• Sport specific functionality Competency-Based Approach. N.p.: McGraw-Hill Higher
• Confident in abilities Education, 2006. Print.
• Be a part of a cohesive sports medicine team 2. Mensch, James M., and Gary M. Miller. The Athletic
Trainer's Guide to Psychosocial Intervention and
– Surgeon
Referral. N.p.: SLACK Incorporated, 2008. Print.
– Physical therapists 3. Houglum, Peggy A. Therapeutic Exercise for
– Athletic trainer Musculoskeletal Injuries. Third ed. N.p.: Human Kinetics,
– Parents 2010. Print.
– Coaches 4. F-MARC. (2013) Fifa 11+ - a complete warm-up
– Athlete programme. Available from URL: http://f-marc.com

Appendix - Special Tests
70
Special Test Purpose Positive Test Technique Sensitivity Specificity
Anterior Integrity of the ACL Increased tibial displacement With patient in supine, knee is flexed to 60-90 degrees with foot 0.20-0.78 0.86-1.00
Drawer Test compared to uninjured side resting on table. PT places both hands behind tibia and attempts to
glide tibia anteriorly.
Lachman's Test Integrity of the ACL Anterior subluxation of tibia With patient in supine, knee is flexed to 20-30 degrees. PT stabilizes 0.82-0.96 0.91-1.00
compared to uninjured knee the femur with one hand and anteriorly glides the tibia with the
other.
Pivot Shift Test Anterior-lateral Anterior subluxation of the lateral With patient in supine, knee is flexed 20-30 degrees. PT rotates the 0.24-0.93 0.83-1.00
rotatory instability, tibial plateau underneath the femoral tibia laterally while applying a valgus stress. Knee is flexed and
possibly due to ACL condyle extended to feel for subluxation and reduction.
or meniscus injury
Posterior Sag Integrity of the PCL Tibia sags on the femur or the medial With patient in supine, hip is flexed to 45 degrees and knee is flexed 0.79 1
Sign Test tibial plateau does not extends 1cm to 90 degrees.
anteriorly beyond the femoral condyle
Posterior Integrity of the PCL Increased posterior tibial With patient in supine, knee is flexed 60-90 degrees with foot 0.9 0.99
Drawer Test displacement compared to uninjured resting on table. PT puts hands behind the tibia and thumbs
side anteriorly on the tibial plateau. PT applies a posterior force to tibia.
Posterolateral Posterolateral Increased posterolateral motion of the With patient in supine, the hip is flexed to 45 degrees and the knee n/a n/a
Drawer Test rotatory instability lateral tibial condyle compared to the flexed at 80 degrees with the foot placed on the table. The posterior
medial tibial condyle drawer test is performed with the tibia in neutral, internal rotation
and external rotation.
Thessaly Test Integrity of the Joint line pain, catching or locking Patient stands on one leg with hands supported by examiner. 0.66-0.90 0.87-0.98
meniscus Patient rotates his body and knee internally and externally three
times with 5 degrees knee flexion. Performed again with knee in 20
degrees flexion.
McMurray's Integrity of the Clicking, patient reports similar With patient in supine, knee is fully flexed. The leg is internally 0.16-0.70 0.71-0.98
Test meniscus sensation to when knee gives way rotated on the thigh and the knee is extended to a right angle. The
test is repeated with the tibia externally rotated.
Valgus Stress Integrity of the MCL Medial joint line laxity or gapping With patient in supine, knee is flexed to 30 degrees. PT grasps lateral 0.86 0.93
Test compared to uninvolved side knee with one hand and ankle with the other then applies a valgus
stress to the knee. The test is repeated in full extension.
Varus Stress Integrity of the LCL Lateral joint line laxity or gapping With patient in supine, knee is flexed to 30 degrees. PT grasps 0.25 0.99
Test compared to uninvolved side medial knee with one hand and ankle with the other then applies a
varus stress to the knee. The test is repeated in full extension.

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ACL Rehabilitation in Youth Sports

A Field to Field Examination

Bellevue Clinic and Surgery Center

ACL Class, Bellevue and South Clinics

Athletes with Disabilities, All Clinics

Schroth Method for Scoliosis, Main Campus and Bellevue Clinic

Therapeutic Core Strengthening Class, Bellevue Clinic

12 Pediatric Sports Medicine Provider Panel

24 Sport Psychology Principles for Rehab & Return to Play

42 Evidence-Based Physical Therapy Following ACL Injury

70 Appendix - Special Tests

ACL Rehabilitation in Youth Sports 03

Shanlyn Souza, MS, ATC, LAT

Amanda Lipke, MS, ATC, LAT

ACL Rehabilitation in Youth Sports 05

• Implementing standard evaluation techniques • Employing standard care procedures and

• Reconditioning participants for optimal • Understanding and adhering to approved

ATs Work In:

ACL Rehabilitation in Youth Sports 07

• AED • At the school following classes until

Video Initial Assessment • Gold standard to treatment of athletic injury is:

Predisposition and Factors

ACL Rehabilitation in Youth Sports 09

• Lelli’s Lever Test

• With intact ACL, the foot

1. Commission on Accreditation of Athletic Training Education. CAATE, n.d.

ACL Rehabilitation in Youth Sports 11

Monique Burton, MD, FAAP

Celeste Quitiquit, MD, FAAP

Shelly Post, PA-C

 Acute event  Insidious onset

ACL Rehabilitation in Youth Sports 13

Anatomy: Anterior Anatomy: Posterior

Anatomy: Lateral Anatomy: Medial

Physical Exam Inspection

ACL Rehabilitation in Youth Sports 15

Milk fluid Tap patella

Sweep fluid from medial With lateral pressure, watch

• Hamstrings • Always examine the hips!!!

• Resisted flexion • Trendelenburg Test

ACL Rehabilitation in Youth Sports 17

Patellar Glide • Grind/Compression • Apprehension

Lateral Collateral Ligament (LCL) Medial Collateral Ligament (MCL)

• Valgus Stress Test

Varus/Valgus Stress Test Varus/Valgus Test

Anterior Drawer Lachman Test

Lachman Test Pivot Shift Test

ACL Rehabilitation in Youth Sports 19

• Posterior Sag Test

Posterior Sag Sign Meniscus Tests

• Apley Grind Test

McMurray Test Apley Grind Test

• Patient supine • Patient prone

• Patient stands flat footed

• Pulse, Capillary refill

Differential Diagnosis Acute

Acute Subacute/Chronic ! • Ligamentous

Fractures Osteochondritis Dissecans • Meniscus

ACL Rehabilitation in Youth Sports 21

• Patella Dislocation/Subluxation • Traumatic Bursitis

• Apophysitis • Osteochondritis • Infection

• When should you image?

Imaging o Unexpected course

Popliteal avulsion fracture Osteochondral fracture