Female Adolescent Anterior Cruciate Ligament Reconstruction

Morgan Uhen, ATS Athletic Training Program, Bloomington, IN

slightly. Lachmans test was positive, but there was no indication of lateral instability. Further, posterior drawer test was negative, and the left knee revealed no abnormalities.
Table 1: Phase Specific Rehabilitation Plan Issues Phase I 1.Pain & swelling 2.Decreased range of motion 3.Decreased muscular endurance 4.Decreased neuromuscular control 1.Pain & swelling 2.Decreased range of motion 3.Decreased muscular strength 4.Decreased neuromuscular control 5.Decreased cardiovascular fitness 6.Decreased normal function 1.Decreased muscular strength 2.Decreased neuromuscular control 3.Decreased cardiovascular fitness 4.Decreased core strength 5.Decreased normal function 1. Cryotherapy, medications, stretch 2. Heel props, prone hangs, wall slides, AAROM & PROM flexion/extension* 3. 4-way SLR, quad sets, ankle pumps, calf raises, SAQ, partial lunge, wall squats, stool scoots, step ups 4. Standing weight shifts, mini squats, gait re-education, terminal knee extension, single leg balance (open/closed eyes and varying surfaces) Phase II 1. Cryotherapy, stretch 2. *same as above as needed 3. 4-way contralateral kicks, theraband monster walks, forward/backward theraband walks, form squats, forward lunge, resistance training: leg press, leg extension, hamstring curls 4. Addition of unstable surface including dynadisc to exercises 5. Stairmaster, stationary bike, elliptical 6. Lateral slides, lateral step over, double leg multi-directional jumps Phase III 1. Progress resistance exercises; incorporate leg press with athletic sport stance, squat with bar, RDL 2. Trampoline exercises, star excursion 3. Stationary bike, Stairmaster, elliptical, running progression 4. Plank multi-direction, transverse abdominus activation, med ball lunge 5. Plyometrics: jumping, bounding, quick feet and steps in multi-directions, ladder agility training, sport specific kick and dribbling exercises Rehabilitative Approach

proprioceptive and strengthening exercises10 for the quadriceps, hamstrings, and hips due to deficits (see Table 1, Phase II). Applied loads are beneficial to increase tissue alignment and growth of the ACL graft,1, 10 and resistance training improves strength and function most beneficially at low intensity initially14 focusing on form especially for adolescent athletes. 16 Mechanical joint soundness and strength are important as well as repair of nerve signals through neuromuscular exercises.17, 10, She progressed from static to dynamic exercises9 to help restore stability and functionality of the knee.3, 14 Although the core plays an important role for females10 and is the foundation for all motor skills,17 her plan did not incorporate core stability exercises until Phase III. Further cardiovascular fitness is neglected until week five, but water therapy is a safe alternative11, 18 to increase strength, flexibility, and maintain aerobic capacity as early as week three.9,18. Despite researchs support for earlier use of aquatics or a stair-stepper during this phase,9 the patient was limited by the direction of the physicians protocol. As rehabilitation continues in Phase III, the goals emphasize the role of functional activities in order to increase tissue healing without damaging any structures under appropriate stresses.10 These exercises provide a way to monitor and modify progressions by comparing her ability to meet the needed skills for returning to play.1 The program combines traditional resistance training with plyometrics that offer an improved relationship between the co-contraction of quadriceps and hamstring.16. Plyometrics also facilitate dynamic stabilization and retraining for sport, so the patient began these after 16 weeks as literature recommends.9,10 Comparison in strength gains of the quadriceps and hamstrings unilaterally and bilaterally are important to decrease the risk for reinjure.10 The sport specific progression (see Table 1, Phase III) is accomplished in a controlled atmosphere10 under supervision of an athletic trainer for the final phase of the rehabilitation five days a week. Return to non-contact soccer participation comes in stages as literature suggests moving from plyometrics to running mechanics to speed.0, 9 The patients performance and maintenance of positive results guided progressions administered by the athletic trainer.10 Returning to soccer completely unrestricted is based on regaining range of motion and strength, joint and graft stability as compared bilaterally, absence of symptoms,1, 3 10 and clearance of functional tests.3, 10, 12 These tests for symmetry are considered more reliable than a timeline3, 7 or meeting isolated strength requirements.7 The literature shows strength up to 85% and 75% in the quadriceps and ham strings respectively1 in combination with 15% strength ratio between the two9 are important markers, but the patients rehabilitation plan relied more functional scores. The patient exhibited 90%1, 9 varying hop tests at six months, but she continued in a sport specific program with the high school athletic trainer. She returned to play at ten months, and research supports safe return for adolescents up to six months1, 3 with graft maturation continuing upwards of a year1 or two.3 The patient continues to participate unlimited and is asymptomatic.

Introduction
As a relatively familiar and costly expense affecting thousands of individuals in the United States every year, complete rupture of the anterior cruciate ligament (ACL) is not as uncommon to adolescents as it was one viewed.1-4 Adolescent females are more than twice as likely to tear their ACL compared to their male counterparts, 5-6 and this risk doubles for female soccer

Differential Diagnosis
Meniscal tear, collateral ligament sprain, subluxated patella, hamstring strain, ACL sprain.

Uniqueness
Diagnostic tests revealed that the patient is still skeletally immature. The risks for surgical or rehabilitative complications can become problematic to an individual even after release due to inherent causes. Despite the overwhelming research on the adult population reconstruction procedures, there remains uncertainty in the approaches and outcomes for an adolescent.

athletes or other multidirectional sports. Accounting for thirty-seven percent of all knee injuries for females age 11-18, this gender discrepancy coincides with the onset of puberty beginning at age 11 12.6 Non-contact mechanisms like quick transitions in acceleration or direction and pivotal motion account for a majority of injuries in adolescents. Typical observations at the time of injury indicate a notable valgus angle with inertia or load from the body.3 However,
2

predisposition of injury to the ACL includes individual factors like hormones, anatomy, and biomechanics (see Figure 1) in combination with the training intensity and circumstance.3-4,6 As a primary passive restrictor of knee displacement, the ACL and surrounding ligaments, soft tissue, muscle, and boney contour contribute significantly to lower leg stability and function. 6

Treatment
The athlete discontinued soccer participation with home treatment of ice and rest before and after physician referral. Subsequent X-rays returned normal , but her plates were not completely closed (see figure 2). An ordered Magnetic Resonant Image (MRI) revealed a third degree sprain of the ACL but no other surrounding ligaments. Reports also exposed slight injury to the posterior lateral tibial plateau and lateral femoral condyle from the impact. In order to have optimal strength, range of motion, and knee kinematics, the patient began a four week preoperative rehabilitation program in the clinic. Reconstructive surgery was scheduled six weeks after initial diagnosis. A four strand autograft of the semitendinosis from the same leg replaced the ruptured ACL without complications. The physicians protocol followed a six month agenda that was implemented immediately post operation with a home exercise program and structured office visits. The patient was educated on exercises prior to the addition of new ones. The main goals throughout the rehabilitation program addressed pain, decreased range of motion, decreased strength, potential for decreased cardiovascular fitness, inhibited neuromuscular control, core activation, and decreased functional ability for sport specific tasks (see table 1). Then end of Phase I and progression to Phase II came with decreased inflammatory signs and removal of staples as well as quadriceps control and cessation of assistive device use. In Phase II, re-acquired range of motion, strength, and proprioception allowed for the continuum of activities incorporating cardiovascular, increased load through planes or resistance, and advancing progressions as indicated by the patients function. By Phase III, the patient had consistent motion, comparable

Commonly, this injury is combined with surgery and rehabilitation to reach full estimated graft maturation after a tendon or year.2 Grafts available are autologous such as the hamstring and patellar

allografts.1

However, a skeletally immature patient is at risk for growth plate injury predictable. 4 The goals of rehabilitation are

inflammation through cryotherapy and range of motion exercises.9,10 With limited rehabilitation appointments, her motivation and dedication toward the rehabilitation process are notable and contribute to the success of the home exercise program as literature supports.8,11 As found in other research, extension, gradual flexion, weight bearing and some proprioceptive and strengthening exercises were emphasized early in this phase9-12 (see Table 1, Phase I), but she ambulated with crutches and bracing according to protocol. Literature supports an increase in function10 and decrease in adverse complications13 when a supportive brace is worn for two weeks,10, 13 yet recent research questions any added benefit.8 While quadriceps strength is an important goal throughout the rehabilitation process,14 the patient discontinued assistive device use completely after two weeks having achieved adequate quadriceps control.10 In Phase I, varying isometric and isotonic motion exercises are used (see Table 1, Phase I) to reestablish early strength gains9 along with electrical stimulation of the quadriceps after the staples are removed.3,10-11,15 Although isokinetic exercises can benefit ACL rehabilitation,9 the patient did not have access to the equipment. Return of extension remained crucial to favorable outcomes,3,10 so the patient participated in several passive exercises (see Table 1, Phase 1) to obtain maximal extension by week 2 in line with literature.1 Despite the post-operative efforts, literature1 suggests the loss of motion pre surgically determines potential throughout rehabilitation. The patient did not achieve her symmetrical five degree hyperextension. The Phase II rehabilitation plan more explicitly addresses knee flexion as she steadily achieved it in week nine1, and she was able to maintain all range of motion measurements in order to progress her strength and functional exercises.1, 9 For this phase strength and range of motion

making surgery and rehabilitation outcomes less

complete range of motion, strength, proprioception, and sport specific tasks. Adolescents are 20% more likely to injure themselves upon return to sport,7 so prevention plans and aggressive literature.3,8 The purpose of this

versus conservative techniques for rehabilitation are debated in

report is to present the rehabilitative regimen for a 14 year old female, middle school yearround soccer player.

Figure 1. 19 Biomechanics demonstrated by female athletes such as soccer players predispose them to mechanisms of injury. The increased valgus angle is evident in untrained individuals.

Figure The growth plate is often open in most adolescents as pictured and labeled above. This can be viewed through a diagnostic image including, but not limited to, an X-ray .

2.19

Figure This scanned version of the patients X-ray image shows an anterior view of her right knee. The growth plates are almost closed in comparison to Figure 2; however, they are not completely closed.

3.19

proprioceptive ability, and began to improve transferrable skills for of plyometric exercise, agility training, running progression and soccer related drills. The patient was released to return to non-contact soccer practice at just over six months, but she was not allowed to return to unrestricted play until the ten month mark.

Discussion
Due to such prevalence, there is no distinct leading rehabilitation program for a complete rupture of the anterior cruciate ligament (ACL) postoperatively.8, 9 Modern successful rehabilitation programs are becoming increasingly more aggressive 9,10, compounding the effects of the adolescent populations urgency to return.1 Immediate motion and weight bearing with progression through functional exercise incorporating muscular strength, endurance, proprioception, and neuromuscular control are common goals established. 3,9,10 Preferably,

Background
This case deals with a well-developed and well-nourished 14-year-old female soccer player complaining of posterior pain in her right knee and no history of orthopedic injury. After planting her right foot on an artificial turf field during indoor practice, she felt a pop. The patient was unable to continue activities immediately after, but her first formal evaluation by a medical professional occurred three days after incident as symptoms including notable swelling

Conclusion
This case shows that adolescents have the potential to return to play successfully by adhering to protocols and rehabilitation goals designed similarly to an adults. There was little variation presented to the patient despite the physiologic differences between the populations. Regardless, the patient may have benefited from earlier inclusion of core exercises considering the role it plays in females10, 17 and the nature of the mechanism of injury. Special considerations for adolescent females including knee alignment education and landing techniques should be more directly addressed, especially for a sport such as soccer involving constant transfer of weight. This could improve the therapy plan and outcome, but also a preventative program implemented for adolescent sports incorporating these components may be necessary.

remain major goals with the addition of increased neuromuscular control and improved gait. 1, 9 Cryotherapy is continued to increase overall rehabilitative effects, and it is particularly important to limit inflammation and pain at this stage due to the significance of normal quadriceps function and control. 9 Patella mobilization as a preventative measure can further limit dysfunction at the knee joint there was an issue. The closed kinetic chain activities selected enhanced neuromuscular control, safety, 1,10 and replication of functional movements1, 5, 8 for the patient; however, recent reviews suggest structured open kinetic chain exercises may have also been effective.8 Hamstring open kinetic chain exercises are reserved for 8 weeks post operatively for safety of the graft.1 Progressive loading occurs several ways such as multi-planar exercises or by using both limbs for
9,10

including gait

reeducation,1 but

the patient only used these if

remained. Upon examination, fairly large effusion and pain inhibited full knee flexion. There was rehabilitation begins pre-operatively to decrease negative effects including atrophy and no pain around the patella or medial joint line, and the apprehension, McMurrays , and Lachmans test were equal when compared bilaterally. The patient demonstrated innate joint laxity, so she went for a second evaluation by an orthopedic surgeon the following day. The patient had irregular gait mechanics with effusion remaining, but range of motion increased permanent loss of range of motion that are critical to enhancing post-operative outcomes.1,10 As a female adolescent athlete, special considerations for biomechanics,10 equipment size adaptations, and motivation4 must also be considered for successful outcomes. Early goals of rehabilitation for this patient included decreasing pain, swelling, and

References
Please see supplemental reference page..