FRAMEWORK FOR OPTIMIZING ACL REHABILITATION UTILIZING A GLOBAL SYSTEMS APPROACH

Abstract

Knee injuries such as ACL tears commonly occur and there is a high re-injury rate after primary ACL reconstruction with figures estimated at 25%-33%. Clinicians often use hip strengthening as a key component of knee rehabilitation. Evidence suggests that adopting a "regional" or "proximal" approach to rehabilitation can increase hip strength, but motor control often remains unchanged, particularly during more complex tasks such as running and jumping. It has been previously suggested that the current approach to "regional/proximal" rehabilitation is too basic and is constrained by a reductionist philosophy. This clinical commentary provides the clinician a framework for optimizing knee rehabilitation, underpinned by a more global approach. Although this approach remains hip-focused, it can be easily adapted to modify exercise complexity and key loading variables (speed, direction, flight), which will help the clinician to better replicate the sport specific demands on the knee.

Level of evidence: 5.

Keywords: ACL; dynamic knee valgus; hip exercise; movement system; proximal rehabilitation.

Figure 1.

Dynamic knee valgus control exercise utilizing a bottom-up approach. The band tethered around the knee restricts the athlete's ability to leave the ground and delivers the resistance in one specific plane only.

Figure 2.

Schematic representation of acetabulo-femoral movements in red (“socket over ball”) whereas the pelvis is moving on a fixed femur and femoral-acetabular movements in yellow (“ball under socket”) illustrating how the femur is moving under a fixed or stable pelvis.

Figure 3.

Single leg squat progression utilizing the trunk as the lever for triaxial resistance. The resistance is on a downward angle moving across three planes of motion specifically targeting the hip.

Figure 4.

ingle leg jumps with triaxial resistance at the proximal trunk. The resistance is moved proximally allowing the trunk to become the lever for the exercise. The resistance induces a spin about the longitudinal z-axis which makes the athlete accommodate for these spiraling forces as she lands.

Figure 5.

Venn Diagram: Multifactorial representation of the modifiable components of a hip focused therapeutic exercise program.