Herrington 2004
Herrington 2004
www.elsevier.com/locate/yptsp
Case Study
The rehabilitation of two patients with functionally
unstable ACL deficient knees: a case report
L. Herrington*
School of Healthcare Professionals, University of Salford, Salford, Greater Manchester M6 6PU, UK
Received 23 January 2004; revised 8 July 2004; accepted 17 August 2004
Abstract
The general consensus is that ACL reconstruction should be undertaken if the patient has functional instability. Functional instability
occurring is not just related to the mechanical insufficiency, but also to the neurophysiological role the ACL has in motion control. It may be,
possible to enhance control of the abnormal joint motion through neuromuscular training. This case presentation outlines the rehabilitation of
two patients with ACL deficient knees, who both presented with functional instability and discusses the role of conservative treatment in the
management of this type of patient.
The cases reported on indicate that with appropriate rehabilitation, some patients with functional symptomatic instability and a wish to
return to high stress sports can be successfully rehabilitated to achieve these goals. The patients achieved these outcomes despite not having a
change in joint laxity on passive testing. The significance of joint laxity tests on short term outcome would appear therefore to be not that
great, with functional outcome after a period of rehabilitation proving a more sensitive indicator of the need for surgery in the ACL deficient
patient.
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manual labour. Bollen (1998) disagreed with Daniel et al. the knee joint. Four weeks later, he had an MRI scan of the
(1994) believing that participation in any activity was knee, which revealed a full mid substance ACL tear. He was
possible and that symptomatic instability should be the then referred to physiotherapy his treatment starting 6 weeks
major criterion to carry out surgery, if functional instability after the original injury.
was not present, acceptable results would occur with
conservative treatment. 2.2. Patient 2
Functional instability is often mentioned in the literature
but rarely defined. Beard, Dodd, Trundle, Hamish, and A 45 year old male, whilst playing football attempted to
Simpson (1994) reported that it was a common manifes- cut back inside pushing of his right leg, the knee was
tation of ACLD patients and the patient presented with the abducted and externally rotated and the patient heard a pop
symptom of giving way on activity, which resulted from a was unable to weight bear and had immediate swelling of
loss of mechanical and/or neurophysiological function of the knee. Six weeks later, he had an MRI scan of the knee,
the ACL. Clinically, these patients present with giving way which revealed a full mid substance ACL tear. He was then
(or apprehension of giving way) during activities involving referred to physiotherapy his treatment starting seven and a
limb rotation and have little confidence in their affected half weeks after the original injury.
limb when weight bearing. Orthopaedic opinion would
indicate that these patients should have a surgical
reconstruction of the ligament, but within the literature
there is evidence that these patients can be rehabilitated and 3. Outcome measures
regain functional stability of the limb using a neuromuscular
(proprioceptive) training programme (Beard et al., 1994; Patient outcome from treatment was measured using a
Maitland, Ajemian, & Suter, 1999). Despite the fact that the variety of indices. A functional rating score (Lysholm &
biomechanics of the knee are significantly altered after Gillquist, 1982) was taken. Joint laxity testing was carried
injury to the ACL, Risberg, Mork, Krogstad-Jenssen, and out by means of the pivot shift, lachmans and anterior
Holm (2001) believed that neuromuscular training had the draw tests. Isokinetic strength testing of the Hamstrings
potential to enhance control of the abnormal joint and Quadriceps (concentric peak torque and time to peak
translation during functional activity. It could achieve this torque) was carried out at 60 and 1808 per second on a
by inducing compensatory alterations in muscle activity Cybex Norm isokinetic dynamometer. Wojtys and Huston
patterns. (2000) identified quadriceps and hamstring reaction time
The available literature would indicate that functionally as the best indicator of subjective functional outcome;
unstable ACLD patients should undergo reconstructive these findings may correlate with the improvements in
surgery. But within the literature, there is little unequivocal time to peak torque of the respective muscles. Functional
evidence to back the premise that the ACLR alone can testing involved single leg crossover hop for distance and
improve functional performance without appropriate reha- single leg hop for distance with performance being
bilitation. There may even be an argument to support a case measured against a limb symmetry index (Clark, 2001),
for appropriate conservative rehabilitation alone to provide Fitzgerald, Axe, and Snyder-Mackler, (2000) regarded
satisfactory functional outcomes. Appropriate randomised these hop tests as promising indicators of dynamic knee
controlled trials are currently not available to examine and stability.
resolve this question (Jones, Appleyard, Mahajan, &
Murrell, 2003).
This case study presents the cases of two ACLD patients, 4. Examination findings
with reported functional instability who returned to full
unlimited functional activity following a rehabilitation Both patients reported the knee feeling unstable and not
programme in attempt to show conservative rehabilitation trusting it during functional activities, neither patient could
could bring about favourable functional outcomes in run because of the feeling of instability. Both patients
functionally unstable ACLD patients. presented with mild effusion in the knee, this effusion
limited both squat and knee flexion at the end of range. They
had inhibited and slightly atrophied quadriceps but normal
2. Patients patella gliding. Ligament testing revealed a positive pivot
shift test for both patients and excessive joint laxity on
2.1. Patient 1 Lachmans test (greater than 5 mm difference bilaterally)
and anterior draw test (greater than 10 mm difference
A 52-year-old male, whilst skiing the right ski became bilaterally). Other ligament tests proved negative. Both
fixed and he pivoted around the right knee causing an patients completed a functional rating scale, based on
external rotation and valgus stress to be applied to the knee Lysholm and Gilquist (1982), patient 1 scored 59 and
whilst in a flexed position, there was immediate swelling of patient 2 scoring 62.
L. Herrington / Physical Therapy in Sport 5 (2004) 175178 177
Table 2
Isokinetic testing results for patients one and two (% deficits)
and swelling were not a major complaint in their ACLD Clark, N. (2001). Functional knee performance testing following knee
patient cohort, with 46% of patients having no pain during ligament injury. Physical Therapy in Sport, 2, 91105.
Daniel, D., Stone, M., Dobson, B., Fithian, D., Rossman, D., & Kaufman,
any activities and 68% any swelling. Shelbourne and Gray K. (1994). Fate of the ACL injured patient. A prospective outcome
(2000) reported the status of the articular surface and study. American Journal of Sports Medicine, 22, 632644.
menisci at the time of ACLR had a significant bearing on the Fitzgerald, K., Axe, M., & Snyder-Mackler, L. (2000). The efficacy of
level of joint degeneration at 515 year follow up. This perturbation training in nonoperative anterior cruciate ligament
would appear to indicate that the reconstruction alone is not rehabilitation for the physically active individual. Physical Therapy,
80, 128140.
capable of preventing joint degeneration, whereas ACLD
Friden, T., Roberts, D., Ageberg, E., Walden, M., & Zatterstrom, R. (2001).
would not appear to necessarily generate those clinical Review of knee proprioception and the relation to extremity function
markers of joint degeneration, namely, swelling and pain. after anterior cruciate rupture stability. Journal of Orthopaedic and
This point is significant in the older ACLD patient, where Sports Physical Therapy, 31, 567576.
degenerative joint changes may already be present and Hawkins, R., Misamore, G., & Merritt, T. (1986). Follow up of acute non-
operated isolated anterior cruciate tear. American Journal of Sports
surgery may increase the risk of further degenerative
Medicine, 14, 205210.
changes not lessen them (Shelbourne & Gray, 2000), whilst Irrgang, J., Safran, M., & Fu, F. (1996). The knee ligamentous and meniscal
an appropriate exercise programme could lessen the risk of injuries Chp 30. In S. Zachazewski (Ed.), Athletic injuries and
degenerative disease progression (Buckwalter, 2003). rehabilitation. New York, NY: Sauders.
The cases reported indicate that with appropriate Jones, H., Appleyard, R., Mahajan, S., & Murrell, G. (2003). Meniscal and
rehabilitation, patients with functional symptomatic chondral loss in the anterior cruciate ligament injured knee. Sports
Medicine, 33, 10751089.
instability and a wish to return to high stress sports can be Lysholm, J., & Gilquist, J. (1982). Evaluation of knee ligament surgery
successfully rehabilitated to achieve these goals, whilst not results with special emphasis on the use of a scoring scale. American
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degeneration. The patients achieved these outcomes despite Maitland, M., Ajemian, S., & Suter, E. (1999). Quadriceps Femoris and
not having a change in joint laxity on passive testing. The hamstring muscle function in a person with an unstable knee. Physical
Therapy, 79, 6675.
significance of joint laxity tests on outcome would appear
Noyes, F., Matthews, D., Mooar, P., & Grood, E. (1983). The symptomatic
therefore to be not that great, with these cases indicating anterior cruciate deficient knee. Journal of Bone and Joint Surgery, 65-
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proving a more sensitive indicator of the need for surgery in Risberg, M., Mork, M., Krogstad-Jenssen, H., & Holm, I. (2001). Design
the ACLD patient. and implementation of a neuromuscular training program following
anterior cruciate ligament reconstruction. Journal of Orthopaedic and
Sports Physical Therapy, 31, 620631.
Shelbourne, D., & Gray, T. (2000). Results of anterior cruciate ligament
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