Thread by @czuppons

On to topic #2 from @ACLStudyDay home study session:

Return to run post-ACLR with @rwilly2003 ! Notes to follow in this thread...

@ACLStudyDay @rwilly2003 Resolving basic fundamentals is impt prior to running - edema, ROM, strength, etc - or these impairments may persist/be magnified once pt returns to running

@ACLStudyDay @rwilly2003 Recreational running may become exercise of choice for some athletes who choose NOT to return to pre-injury sport

@ACLStudyDay @rwilly2003 Little evidence supporting that running is harmful to those with knee OA!

**Caution: we don't know long-term data on running post-ACLR.

@ACLStudyDay @rwilly2003 Post-op impairments that must be addressed:
- pain
- psych
- ROM
- muscle force production
- effusion
- altered coordination

@ACLStudyDay @rwilly2003 Running:
- 2.5x BW on impact
- 5-6BW's of TFJ and PFJ contact force
- rapid energy storage/release, cumulative loads + these peak loads
- avg 10k run, runner takes 7000 foot strikes

***Consider how these loads increasein other running sports (jumping, sprinting)

@ACLStudyDay @rwilly2003 "Heavy, slow resistance training is the absolute foundation for recovery for all our athletes for return to sport and return to daily activities."

@ACLStudyDay @rwilly2003 Load progression:

Heavy, slow resistance training --> plyometrics --> graded return to running

@ACLStudyDay @rwilly2003 Impaired running biomechanics do NOT seem to "smooth out" as post-ACLR pts continue to run. Need to address during rehab.

@ACLStudyDay @rwilly2003 Post-ACLR running biomechanics:
- Peak VGRF not different between limbs
- impact forces (loading rates) not different between limbs
- BUT individ w/ quad weakness have LOWER peak VGRF (can't control load as well, but this doesn't allow efficient storage/release of energy)

@ACLStudyDay @rwilly2003 Post-ACLR running biomechanics:

- At footstrike: land in greater knee flexion
- At midstance: Decr peak knee flex, decr knee flex excursion, & decr knee extensor moment. Incr PFJ contact force/stress due to knee angle.

@ACLStudyDay @rwilly2003 Load shifts off knee & onto hip after partial meniscectomy (Willy 2017 KSSTA) - similar mechanics seen post-ACLR.

KOOS QOL predicted these load shifts. As knee confidence decr, load to knee decr, load to hip incr.

@ACLStudyDay @rwilly2003 Individ scoring >=85% LSI hop tests and Cincinnati Knee Pain Score assoc w/ higher peak knee external movement & peak VGRF than those <85% (Perraton 2018 KSSTA).

Hopping and running intricately related.

@ACLStudyDay @rwilly2003 Post-ACLR, 30% of pts will experience PFP, REGARDLESS OF GRAFT TYPE.

Peak PFJ stresses during running 23% greater in ACLR than opp limb, 25% greater than healthy matched controls.

(Herrington AJSM 2017, Culvenor JSMS 2016)

@ACLStudyDay @rwilly2003 Quad function is a predictor of knee biomechanics during running post-ACLR! (Kline 2016 MSSE)

@ACLStudyDay @rwilly2003 Return to run post ACLR review Rambaud BJSM 2018: bjsm.bmj.com/content/52/22/…
In lit,
- Avg @ 12 wks post-op
- only 1/5 studies used add'l criteria!

Recs for RTRun:
- full ext ROM
- flex within 5% opp limb
- pain <=2/10 VAS
- absent/trace effusion
- HS&Quad LSI >70%
- Hop tests >70%

@ACLStudyDay @rwilly2003 Rich's recs (modified Rambaud):
- full ext ROM
- flex within 5% opp limb
- min/absent pain w/ repetitive hops
- absent/trace effusion
- HS&Quad LSI >=80%
- Iso quad torge 3.0 Nm/kg
- Hop test >70% LSI
- Walk 7000 steps/day, 4000/bout
- IKDC >=70%
- min 12 wks post ACLR

@ACLStudyDay @rwilly2003 Quad strength testing: Isometric dynamometry best.
- 5 sec hold make test
- Torque = force x moment arm length.
- Force (kg) x 9.81 to get N
- Moment arm length = dynamometer to lat fem condyle
- Divide by body mass to get N*m/kg
- Avg values post-ACLR quad torque 3.0-3.2 N*m/kg

@ACLStudyDay @rwilly2003 Base resistance training based on 1RM (ACSM position statement, MSSE 2009):

Use 1RM calculator app (free) which estimates your 1RM based on weight and reps you can do

Goal: train at least >=75% 1RM to gain strength

@ACLStudyDay @rwilly2003 Quad program example: DAPRE protocol (Herrington & Al-Sherhi JOSPT 2007):
1) determine 6 RM
2) set 1 = 10 reps 50% 6RM
3) set 2 = 6 reps 75% 6RM
4) set 3 = max reps 6RM
5) set 4 = adjusted based on set 3 (Table 3)

jospt.org/doi/10.2519/jo…

@ACLStudyDay @rwilly2003 OPEN CHAIN EXERCISE DOES NOT STRETCH OUT THE ACL GRAFT

- need to isolate quads

ACL strain
Resisted squatting = 4%
OKC knee ext to 30 deg = 4%
Walking = 13%

Graft was a tendon - needs loading to mature!

@ACLStudyDay @rwilly2003 Add plyometrics when effusion <= 1+, full ROM, quad index >60%

Start:
- stationary hop unilateral
- forward hop unilateral

Suggested pgm:
Mon 3x10
Wed 3x15
Fri 3x20
Next week progress

@ACLStudyDay @rwilly2003 Return to run programs - graded exposure!

"Hard days" with running, "easy days" cross-training every other day. Perform resistance training on (before) running days.

@ACLStudyDay @rwilly2003 Consider having athletes use objective app to help with timing:

Example: "Interval Timer - HIIT Training" (for Android and iPhone):
- can program warmup, interval and cool-down
- alarm will sound over music when it's time to switch

@ACLStudyDay @rwilly2003 Soreness rules! (pain >=2/10 VAS)

Continue w/training pgm IF:
- no pain during/after warmup
- pain during warmup but goes away

GO BACK 1 STEP, add x-training day:
- pain or effusion>trace next day

STOP, GO BACK:
- recurrent pain during warmup or session persists/worsens

@ACLStudyDay @rwilly2003 Stroke test (Sturgill 2009) for effusion

jospt.org/doi/10.2519/jo…

@ACLStudyDay @rwilly2003 Treadmill and overground running very similar in terms of:
- TFJ loads, both for total peak TFJ & medial compartment
- PFJ loads

(Willy JOSPT 2016)

@ACLStudyDay @rwilly2003 Change shoewear?
NOT WORTH INJURY RISK.

- Sure, minimalist shoes reduce PFJ loads, but they increase Achilles tendon loads (might not be a great tradeoff)

@ACLStudyDay @rwilly2003 For athlete w/persistent knee pain and/or effusion with running:

- avoid downhills (due to higher ecc loads)
- do more uphill running (incr pf & hip loads), ideally on treadmill @3-5% grade
- slow jogging tends to worsen sx (longer ground contact time) - speedwork reduces loads

@ACLStudyDay @rwilly2003 @3 Can increase cadence/step rate 5-10% as well:

- decr PFJ loads by 15-20%
- decr TF contact forces by 7.5-11%

@ACLStudyDay @rwilly2003 @3 How to address asymmetrical loading pattern:
- can't just increase cadence (asymmetry persists)
- use metronome for external pacing

@ACLStudyDay @rwilly2003 @3 SUMMARY KEY POINTS:
- Quad strength critical
- hopping as bridge to running
- time and performance-based criteria to clear to run
- address biomechanical changes early
- use an app to guide dosage

/end

@ACLStudyDay @rwilly2003 @rwilly2003 We've talked hopping before/after running. You think someone needs unilateral hop (R to R) >70% such as in Noyes hop tests before doing a contralateral unilateral hop (R to L) such as w/ running necessary to begin to run? This is my main struggle w/ this criteria.