Post 1 year ACL recon

[jennifer]

Hi all...

I need your help with this patient...

He a 40 y/o gentleman who is very active in sports. Had ACL recon on left knee in 2000. Rehab done well not with me definately.

In 2005, Rt Knee AcL recon done...in Kuala Lumpur. Rehab went for 5/52 weeks in the hospital. after that continue rehab by himself...till now after one year came to me.

Seen large effusion the knee...went to KL to extract the fluid on and off.
Quads wasting...marked wasting.
Hamstring strengh good 5/5.Other muscles gluts, abds. add, rotators 4/5. Quads is bad...
Pt able to play football, fully squat, running in figure of 8.
Balance : fair in dynamic std
I think is the control of both quads and hamcstring is affected...How do i help him???

Pt problem now...
1. pain after sports...
2. quads wasting...
3. Pain when climbing down stairs...

when i give exs...
lateral step up & std one leg pick object on floor....pt reported pain!!

Pls help me with this patient.


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[karen.hankey]

Hi Jennifer,

During his squats, is his aligment correct? Also is this bilat or unilat squat you said was full. Also, does he still have the effusion he mentioned?

I may have some tests/treatment that may help, but the info is at home, so will get back to you.

Karen

[jennifer]

Thanks karen...

Yup...the effusion gets worse after exercise.after exercise after resting at home and IFT done...effusion subside a little.
Bilateral squat is..more weight shifted on the good side during midrange to full squat.
Please help me....thanks.
now...im juz doing ulytarsound and IFT only.

[karen.hankey]

OK, well firstly on what you've said I would do a full knee re-assessment to check for any other structures injured. Just to rule out any other cause.

The bilat squat need to be better quality. If he can only bilat squat to mid range with correct biomechanics and full weight on both legs evenly I would stop there. When he is going down further his biomechanics and technique will suffer due to compensation.

My initial suggestions are taht you need to also assess the hip and the ankle as they play a vital role in knee stability.

[physiobob]

Was this recent reconstruction via a patella tendon graft? or hamstring. If the former sounds like a possible tendinosis issue? As for the effusion well that could be anything really - I am assuming no blood in the effusion of course.

[jennifer]

Hi all...

when i did the re assessment of knee...it seems like the ACL graft is alittle lax compared to the good side. When pt went to consult different surgeon, he too mention the same with a help from an MRI. But..when pt went back to see the surgeon who conduct the operation...he says its ok!!!the graft is still intact.

This guy Hip and Ankle...is rule out also.it no problem with that.

Yup..its patella graft. No blood in the effusion jus yellowish fluid.

Now he report pain aon both side of the patella bone...lateral and medial.Juz at one spot.

according to the dr. His patella glide is stiff...but i dun think so!!its mobile in all direction.

The thing is i dun get y the quads is wasted...coz this guy is along distance runner, swimmer, football playeer.

Thanks for your concern.

[alophysio]

What about his back?? You say the hip and ankle are cleared but what about his SIJ and L/S joints?

What is the status of his ITB?

How is his glut med strength?

[karen.hankey]

Agree with Alophysio, I would check ITB, but also TFL for tightness and alos his Glut Med stability.

What I meant by checking the hip and ankle was not so much looking for injuries, but assessing tightness and lack of strength which may affect the pull on the patella. e.g. He may have weak hip abductors which would cause internal rotation of the femur leading to a tight ITB causing altered pressure of the patella in its groove and therefore contributing to his problem. (hope I explained that ok)

[uranfeman]

Agree with the above. Patellofemoral dysfunction is common after patella tendon graft ACL recon's. This would need a total approach to his biomechanics. I would get the stability and mobility of the ankle and hip/pelvis right first, otherwise anything you achieve for the knee will be short term.

If you aren't confident with assessing functional biomechanics I would suggest checking out Gary Gray's functional movement screen - www.functionalmovement.com

Kevin