The One Thing You Must Do When Evaluating for an ACL Injury

Anterior cruciate ligament (ACL) injuries are common. When evaluating the ACL, special tests like a Lachman Test or Anterior Drawer have been shown to have great reliability and validity.

However, there is one main reason why you may get a false positive for an ACL injury of the knee that is often overlooked – you actually injured your posterior cruciate ligament (PCL)!

I know, it seems backwards, but watch this quick video for my explanation!

 

Learn Exactly How I Evaluate and Treat the Knee

Want to learn even more about how I evaluate and treat the knee? My online program on the Recent Advances in the Evidence-Based Evaluation and Treatment of the Knee is now available. I’ll show you everything you need to master the knee.

The program at OnlineKneeSeminar.com is on sale until May 15th at midnight EST for $150 off! Click the button below for more information and to sign up now!

 

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3 Tips for Assessing the Patellofemoral Joint

The latest Inner Circle recording on 3 Tips for Assessing the Patellofemoral Joint is now available.

3 Tips for Assessing the Patellofemoral Joint

3 Tips for Assessing the Patellofemoral Joint

This month’s Inner Circle presentation is on 3 Tips for Assessing the Patellofemoral Joint.  In this live inservice recording, I discuss a few tips that that I follow when evaluating someone with anterior knee pain, or patellofemoral pain syndrome.  Often times the patellofemoral joint gets little attention during the examination.  But, in order to treat patellofemoral pain successfully, you need to have an accurate diagnosis that is very specific.  Not all anterior knee pain is the same!

This presentation will cover:

  • How your anatomy of your trochlea can alter your ability to statically stabilize
  • How to assess the static stabilizers of the patella
  • A detailed overview of how I palpate different soft tissue structures around the knee
  • How and why you need to look both proximally and distally as well as at the knee
  • The one simple test I do with everyone to assess how proximal and distal factors xalter the forces at the knee

To access this webinar:

The Effect of Ipsilateral and Contralateral Loading on Muscle Activity During the Lunge

One thing I talk about a lot when it comes to training and rehabilitation is the need to train the body in all three planes.  This often requires moving in one plane of motion and stabilizing in the other two.   We are often very good at moving in the sagittal plane, and poor at stabilizing in the transverse and frontal planes.  This is a big topic of discussion in my program Functional Stability Training of the Lower Body.

To enhance this triplanar stability, we often attempt to facilitate greater contraction of the gluteus medius muscle during sagittal plane exercises.  The lunge in particular is a great exercise for triplanar stability as the narrow stance challenges strength in the sagittal plane and stability in the transverse and frontal planes.

 

The Effect of Ipsilateral and Contralateral Loading on Muscle Activity During the Lunge

The Effect of Ipsilateral and Contralateral Loading on Muscle Activity During the LungeA recent study was published in the Journal of Strength and Conditioning Research that investigated the effect of holding a dumbbell in either the contralateral or ipsilateral hand during a split squat and forward lunge.  (Note: they called it a “walking lunge” but I am 99% certain it was a forward lunge, so I’m just going to say forward lunger in this article…  probably just semantics.)

The study found that:

  • Holding the dumbbell on the ipsilateral side had no effect on glute med activity.
  • Holding the dumbbell on the contralateral side resulted in a significant increase in glute med activity, but only during the forward lunge, not the split squat.

I was a bit surprised that glute med activity was not impacted during the split squat, but perhaps the static nature of the position inherently requires less transverse and frontal plane stability.

There was one other finding from this study that I thought was interesting.  Kinematic differences during the forward lunge were found between a group of trained individuals in comparison to a group without training experience.

This makes sense as the forward lunge is a complex movement pattern that requires an understanding of how to control the pattern.  It requires both mobility and stability, but also the ability to control the eccentric deceleration phase.

contralateral lungeHowever, there were no kinematic differences between training age during the split squat, meaning that both novice and experienced trainees performed the split squat in a similar fashion.  This make split squats a great exercise to incorporate in the early phases of training for those with limited training experience, eventually progressing to forward lunge as they get better at moving and stabilizing the pattern.

This helps solidify the use of split squats in our lunge regression system.

 

Implications

I like simple studies like this.  Having the rationale to make small tweaks to your program is what sets you apart.  It’s the small things that may not be obvious at first but will produce better results over time.

Based on these results, I would recommend using the split squat with bilateral dumbbells to maximize strength gains since a unilateral load did not alter glute med activity.  The split squat is more of a basic exercise, so why not just use it to work on strength gains in the novice trainee.  As the person progresses, you can add the forward lunge variation with a contralateral load to enhance triplanar stability.

 

 

 

Can PCL Injuries Be Successfully Treated Without Surgery?

Champion Physical Therapy and Performance

My latest article is now up on the new Champion Physical Therapy and Performance blog!  I discuss a recent research study that looked at the outcomes of subjects with PCL deficient knees that were followed for up to 21 years.

Pretty interesting stuff that shows the efficacy of our programs!  However, as you’ll read, we can do as much harm as good when designing exercises for people with PCL injuries.

Read the article here and be sure to sign up to receive all the updates from the Champion blog, there is plenty more coming from the Champion team!

 

I have also announced my latest Inner Circle webinar will overview my manual therapy system.  I’ve been really trying to create systems for all aspects of what I do as we build out Champion Physical Therapy and Performance.

Last month, I talked about how I design functional rehabilitation programs.  This month is devoted to manual therapy.  In this webinar I’ll discuss my system to performing manual therapy, including the specific order and techniques that I perform.  This system can be used for any issue depending on the needs of the patient.

I like to take a systematic approach for several reasons:

  1. Assures consistency between sessions
  2. Assures consistency between therapists
  3. Creates reliable and predictable results
Join me Wednesday August 27th at 8:00 PM EST for the live webinar or be sure to catch the recorded when it is posted.

Expert Advice on Youth ACL Injuries

youth acl injuriesFor this week’s post, I wanted to share what I thought was a great video from the American Orthopedic Society for Sports Medicine (AOSSM) on youth ACL injuries.

In this video, noted orthopedic surgeons Chris Harner, Lyle Micheli, James Andrews, and Peter Indelicato share their advice on several topics regarding youth ACL injuries, return to play, female ACL injuries, and preventative programs.

Videos like this are important to education the parents and coaches on the realities of issues like youth ACL injuries.

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Do ACL Hamstring Grafts Fail More than Patellar Tendon Grafts?

This month’s issue of the American Journal of Sports Medicine included two studies comparing the revision rates of ACL reconstruction between hamstring grafts and patellar tendon grafts of over 25,000 people.  The overall number of people studied between the two groups was really compelling to me as a sample size this big is certainly worth discussing.

In recent years the graft choice for ACL reconstruction has been slowly shifting towards favoring hamstring grafts rather than patellar tendon grafts.  Recent reports have noted 84% of ACL reconstructions in Denmark and Sweden use hamstring grafts, 60% in Norway, and now are even becoming more popular in the US with 44% of ACL reconstructions using a hamstring graft compared to 42% using a patellar tendon graft.

Many research papers have been published showing that both grafts result in very good stability of the knee with excellent subjective outcome scores.  The major complaint of patellar tendon grafts is the increased risk of issues after surgery, such as patellofemoral pain and loss of motion.  Despite the reports of good stability and subjective outcomes, revision surgery is probably a more important factor to consider.

 

Do ACL Hamstring Grafts Fail More than Patellar Tendon Grafts?

The first study reviewed the nationwide Danish Knee Ligament Reconstruction Registry, which included 13,647 people undergoing ACL reconstruction between 2005 and 2011.

The revision rates for hamstring tendon grafts were 0.65% at 1 year after surgery, and 4.45% at 5 years after surgery.  The revision rates for patellar tendon grafts were 0.16% at 1 year after surgery, and 3.03% at 5 years after surgery.

Essentially, hamstring grafts had a 4x greater risk of revision in year one and 1.5x at 5 years following ACL reconstruction.

ACL reconstruction revision rates

The second study reviewed the nationwide Norwegian Cruciate Ligament Registry, which included 12,643 people undergoing ACL reconstruction between 2004 and 2012.

The revision rates for hamstring tendon grafts were 5.1% at 5 years after surgery, and 2.1% for patellar tendon grafts.  This study also looked at different age groups and found this increased rate to be consistent across all age group.s  However, the younger group (age 15-19) had a 9.5 revision rate at 5 years using the hamstring graft in comparison to 3.5% using a patellar tendon graft.

Together, there was a 2x greater risk of revision overall when using the hamstring graft, but closer to 3x greater risk for younger people.

ACL hamstring patellar tendon graft

 

Both Grafts are Great Options for ACL Reconstruction

When we really assess the numbers, it is clear that both graft options are great choices with low revision rates.  Even though we are comparing the two, realistically the revision rates after ACL reconstruction are low for both hamstring grafts and patellar tendon grafts.  There are many factors that go into deciding which graft to use.  Also realize this does not apply to skeletally immature patients.  This revision information is just a piece of the puzzle.

The patellar tendon graft has less failure rate and has been reported to heal faster in animal models due to the bone-to-tendon interface.  While this is true there are also reports of increased anterior knee pain and loss of motion.  I have discussed this in the past, but I really do believe that many of the issues with patellar tendon grafts after surgery are minimized or eliminated with proper physical therapy (in addition to excellent patient compliance).  This is especially true if these factors are the primary emphasis of the early phases of ACL rehabilitation.

SEE ALSO: 6 Keys to the Early Phases of Rehabilitation Following ACL Reconstruction Surgery

That all being said, hamstring grafts have also been shown to result in less strength of the hamstrings after surgery.  Considering the role of the hamstring to assist the ACL in control anterior tibial translation, this has to be considered when reviewing the higher ACL reconstruction revision rate when using hamstring grafts.  Perhaps it really has nothing to do with the graft itself and more to do with the hamstring strength.

Regardless, the revision rate following ACL reconstruction is higher when using a hamstring graft than when using a patellar tendon graft.

 

 

Did We Really Discover a New Ligament in the Knee?

This week’s Stuff You Should Read is about the “new” discovery of the anterolateral ligament of the knee.

 

Inner Circle and RehabWebinars.com Updates

My next live Inner Circle will be an evening live Q&A which is always fun, ask me anything!  This was a big hit last year so I expect it to be even better this year.  It will be Monday December 16th at 8:30 PM EST.  Looking forward to this one.

RehabWebinars.com has a bunch of awesome new webinars coming up over the next few months.  Michael Mullin had part 1 of a webinar on Integrating Postural Restoration Institute Concepts into Training, part is coming in January.  This was a great webinar and a great intro into the PRI concepts!  This month, David Weinstock, the developer of Neurokinetic Therapy, discusses some of the principles of NKT.

 

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The Discovery of the “New” Knee Ligament – The Anterolateral Knee Ligament

anterolateral knee ligamentFor this week’s stuff you should read, I thought I would piece together a few articles that go over the press received over the “discovery” of the “new” anterolateral ligament of the knee.  Notice all my “quotes!”  Here is a link to one of the many sensationalized articles from the media on this new ligament:

Pretty exciting title, right?!  The media cracks me up.  Sensationalizing everything.  The news report is in reference to a paper published in the Journal of Anatomy regarding the anterolateral ligament.  Here is the abstract of the paper, which ironically, starts with the phrase “In 1879, the French surgeon Segond described the existence of a ‘pearly, resistant, fibrous band’ at the anterolateral aspect of the human knee.”

The website io9 did a good job highlighting these facts in their article:

But Dr. LaPrade from the Steadman Clinic did an even better job talking about everything you want to know about this “new” ligament!

Here is a video of the ligament:

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So, nice articles and video, but no, not a new ligament.

 

 

A Simple Dynamic Stability Exercise for the Leg [Video Demo]

This week’s post is a video demonstration of a simple way to integrate reactive neuromuscular training (RNT) into your programming to enhance dynamic stabilization of the lower extremity.

Reactive Neuromuscular Training for Dynamic Stabilization of the Lower ExtremityIn this video, I show a client that has an ankle sprain.  While going through her rehabilitation, it became clear that she also needed balance training to really work her ankle, knee, and hip to stabilize during functional tasks.

To perform this exercise, you simple need a large resistance band (which are great from many stretching, strengthening, and stability exercises – here are the ones I use).  Loop the band around a rack or other object and step within the loop.  Place the band just above your knee.

I show a few exercise ideas in the video, progressing from simple balance, to unstable surfaces, to incorporating functional movements.  By using the band, you can emphasize training the bodu’s ability to stabilize in the frontal and transverse planes while performing a sagittal plane exercise.  This is essential to optimal function and a big key to my Functional Stability Training program.

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5 Things You Need to Understand to Master Functional Rehab and Performance

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