Gait retraining after anterior cruciate ligament reconstruction

doi:10.1016/j.apmr.2003.07.014

Archives of Physical Medicine and Rehabilitation

Volume 85, Issue 5, May 2004, Pages 848-856

Presented in part at the International Society of Biomechanics’ 18th Annual Meeting, 2001, Zurich, Switzerland.

https://doi.org/10.1016/j.apmr.2003.07.014 Get rights and content

Abstract

Decker MJ, Torry MR, Noonan TJ, Sterett WI, Steadman JR. Gait retraining after anterior cruciate ligament reconstruction. Arch Phys Med Rehabil 2004;85:848-56.

Objectives

To examine the effects of 2 gait retraining protocols on the gait patterns of patients with bone-patellar tendon-bone anterior cruciate ligament (ACL) reconstruction.

Design

Randomized control, repeated-measures design.

Setting

Private orthopedic center and research facility.

Participants

Sixteen patients with bone-patellar tendon-bone ACL reconstruction, randomly subdivided into 2 groups (group 1, n=8; group 2, n=8), and a healthy control group of 8 subjects.

Intervention

The 16 subjects with ACL reconstruction were randomly assigned to 2 different gait retraining protocols over a 6-week training interval: (1) a protocol using a predicted stride frequency calculated from the resonant frequency of a force-driven harmonic oscillator (FDHO) model or (2) a protocol using the preferred stride frequency (PSF).

Main outcome measures

Gait analyses examining the lower-extremity kinematic, kinetic, and energetic gait patterns of each group.

Results

Gait retraining with the FDHO model showed improvements in lower-extremity positions, hip and knee extensor angular impulse, and work parameters. Gait retraining with the PSF demonstrated no statistical improvements. The FDHO training protocol facilitated a greater midstance knee range of motion (ROM) and greater rates of improvement for midstance ROM, hip extensor angular impulse, and concentric hip extensor work.

Conclusions

Gait retraining with the resonant frequency of an FDHO model facilitated a greater recovery of gait function compared with training with the PSF.

Section snippets

Participants

A total of 16 patients (mean age, 27.8±7.4y; weight, 75.5±12.5kg; height, 1.8±0.1m) who had arthroscopically assisted bone-patellar tendon-bone ACL reconstruction and 8 healthy (age, 28.3±4.3y; weight, 71.5±11.1kg; height, 1.7±0.1m) control subjects participated in this study. All subjects with ACL injuries had reconstruction by the same orthopedic surgeon, participated in an accelerated rehabilitation strength and ROM protocol,27 and were restricted from recreational and sporting activities

Group characteristics and protocol adherence

The time from injury to surgery was similar between the 2 ACL reconstruction groups (FDHO group, 120.1±104.5d; range, 5–348d; PSF group, 120.3±107.3d; range, 11–380d). Physical examination revealed all subjects to possess full passive knee extension at both test periods and that body mass did not fluctuate by more than 1kg. Review of the exercise logs demonstrated that all patients complied with the walking program, and that the training load over the 6-week protocol was equal between the 2

Discussion

Numerous studies have found that subjects with ACL reconstruction use neuromuscular adaptations during gait1, 3, 8, 9, 33, 37, 38 and functional activities.1, 10, 11, 35, 39 From these studies, it appears that the hip extensor moments and powers progressively increase during the first 6 months after surgery, whereas the knee extensor moments and powers progressively decrease. In our study, both ACL reconstruction groups showed these classical gait adaptations 6 weeks after surgery. Over the

Conclusions

Gait retraining with the FDHO model showed improvements in lower-extremity positions, hip and knee extensor angular impulse, and work parameters, whereas gait retraining with the PSF showed no statistical improvements. The FDHO mode of training was superior to the PSF protocol in promoting midstance knee ROM and facilitating normal hip extensor function. These gait performance improvements were proposed to stem from an audio signal that accessed locomotor programs and promoted a greater

Acknowledgements

We acknowledge Chris Rich and Mike Kain for their contributions to the data reduction process. We also thank Kevin Shelburne, PhD, for his critical review and contributions to the final manuscript.

References (45)

M. Lewek et al.
The effect of insufficient quadriceps strength on gait after anterior cruciate ligament reconstruction
Clin Biomech (Bristol, Avon)
(2002)
P.K. Schot et al.
The force driven harmonic oscillator model accurately predicts the preferred stride frequency for backward walking
Hum Mov Sci
(1998)
K.G. Holt et al.
The force driven harmonic oscillator as a model for human locomotion
Hum Mov Sci
(1990)
M.H. Thaut et al.
Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation
J Neurol Sci
(1997)
P. DeVita et al.
A functional knee brace alters joint torque and power patterns during walking and running
J Biomech
(1996)
C.A. Bush-Joseph et al.
Dynamic function after anterior cruciate ligament reconstruction with autologous patellar tendon
Am J Sports Med
(2001)
F.H. Fu et al.
Current concepts for rehabilitation following anterior cruciate ligament reconstruction
J Orthop Sports Phys Ther
(1992)
H.H. Passler et al.
[Biological, biomechanical and clinical concepts of after-care following knee ligament surgery]
Orthopade
(1993)
K.D. Shelbourne et al.
Update on accelerated rehabilitation after anterior cruciate ligament reconstruction
J Orthop Sports Phys Ther
(1992)
K.D. Shelbourne et al.
Rehabilitation after autogenous bone-patellar tendon-bone ACL reconstruction
Instr Course Lect
(1996)

K.E. Wilk et al.

Current concepts in the treatment of anterior cruciate ligament disrupture

J Orthop Sports Phys Ther

(1992)

P. Devita et al.

Gait adaptations before and after anterior cruciate ligament reconstruction surgery

Med Sci Sports Exerc

(1997)

P. DeVita et al.

Gait biomechanics are not normal after anterior cruciate ligament reconstruction and accelerated rehabilitation

Med Sci Sports Exerc

(1998)

G.P. Ernst et al.

Lower extremity compensations following anterior cruciate ligament reconstruction

Phys Ther

(2000)

L. Snyder-Mackler et al.

Electrical stimulation of the thigh muscles after reconstruction of the anterior cruciate ligament. Effects of electrically elicited contraction of the quadriceps femoris and hamstring muscles on gait and on strength of the thigh muscles

J Bone Joint Surg Am

(1991)

M.S. Kocher et al.

Determinants of patient satisfaction with outcome after anterior cruciate ligament reconstruction

J Bone Joint Surg Am

(2002)

K.E. Wilk et al.

The relationship between subjective knee scores, isokinetic testing and functional testing in the ACL reconstructed knee

J Orthop Sports Phys Ther

(1994)

J.L. Seto et al.

Assessment of quadriceps/hamstring strength, knee ligament stability, functional and sports activity levels five years after anterior cruciate ligament reconstruction

Am J Sports Med

(1988)

R.A. Sachs et al.

Patellofemoral problems after anterior cruciate ligament reconstruction

Am J Sports Med

(1989)

T.D. Rosenberg et al.

Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction

Am J Sports Med

(1992)

S.F. Dye et al.

Factors contributing to function of the knee joint after injury or reconstruction of the anterior cruciate ligament

J Bone Joint Surg Am

(1998)

K.D. Shelbourne et al.

Current concepts in anterior cruciate ligament rehabilitation

Orthop Rev

(1990)

Cited by (35)

Environmental Risk Factors for Osteoarthritis: The Impact on Individuals with Knee Joint Injury
2022, Rheumatic Disease Clinics of North America
Subtle alterations in whole body mechanics during gait following anterior cruciate ligament reconstruction
2019, Gait and Posture
Citation Excerpt :
Self-reported IKDC scores and knee pain during testing suggest that participants were progressing typically [25]. Altered knee mechanics observed in this study are consistent with previous studies [3–7,14]. Participants walked without observable gait alterations, which was supported by an absence of differences in COM position.
Clinically, normalization of gait following anterior cruciate ligament reconstruction (ACLr) is defined as the absence of observable deviations. However, biomechanical studies report altered knee mechanics during loading response (LR); a time of double limb support and weight transfer between limbs. It is conceivable that subtle adjustments in whole body mechanics, including center of mass (COM) velocity and ground reaction force (GRF) peaks and timing, are present.
The purpose was to compare limb and whole body mechanics during LR of gait in the surgical and non-surgical limbs post-ACLr.
Anterior and vertical COM velocity at initial contact; knee flexion range of motion, peak knee extensor moment, peak vertical and posterior GRF, minimum vertical COM position and maximum anterior and vertical COM velocity during LR were identified for twenty individuals 112 ± 17 days post-ACLr without observable gait deficits. To assess differences in timing of COM variables, coupling angles (vector coding) were calculated for multidirectional coordination of vertical and anteroposterior COM velocities and GRFs and categorized as in-phase, anti-phase, vertical phase, or anteroposterior phase coordination. Paired t-tests compared peaks between limbs; non-parametric Wilcoxon signed-rank tests compared coordination pattern frequency.
Less knee range of motion (5.6 °), 30% smaller knee extensor moment, 11% smaller posterior GRF, and slower anterior COM velocity at initial contact (2%) and peak during LR (1.3%; all p < 0.05) were observed in the surgical compared to the non-surgical limb. For COM velocity coordination, lesser anti-phase (7.38%) and greater in-phase coordination (2.88%) were observed in the surgical limb. For GRF coordination, less in-phase coordination (1.94%) was observed in the surgical limb.
Differences in coordination patterns, suggest that individuals post-ACLr make subtle adjustments in timing of whole body mechanics; particularly in COM velocity during gait. These adjustments are consistent with reduced sagittal plane loading in the surgical knee.
Contributors to knee loading deficits during gait in individuals following anterior cruciate ligament reconstruction
2018, Gait and Posture
Altered gait mechanics following anterior cruciate ligament reconstruction (ACLr) are commonly reported in the surgical limb 2–3 months post-surgery when normalization of gait is expected clinically. Specifically, deficits in knee extensor moment during loading response of gait are found to persist long-term; however, the mechanisms by which individuals reduce sagittal plane knee loading during gait are not well understood.
Research question: This study investigated between limb asymmetries in knee flexion range of motion, shank angular velocity, and ground reaction forces to determine the strongest predictor of knee extensor moment asymmetries during gait.
Thirty individuals 108 ± 17 days post-ACLr performed walking gait at a self-selected speed and peak knee extensor moment, peak vertical and posterior ground reaction force, and peak anterior shank angular velocity were identified during loading response. Paired t-tests compared limbs; Pearson's correlations determined associations between variables in surgical and non-surgical limbs; and stepwise linear regression determined the best predictor of knee extensor moment asymmetries during gait.
Reduced vertical and posterior ground reaction forces and shank angular velocity were strongly associated with reduced knee extensor moment in both limbs (r = 0.499-0.917, p < 0.005). Less knee flexion range of motion was associated with reduced knee moment in the surgical limb (r = 0.358, p < 0.05). Additionally, asymmetries in posterior ground reaction force and knee flexion range of motion predicted asymmetries in knee extensor moment (R2 = 0.473, p < 0.001).
Modulation of kinetics and kinematics contribute to decreases in knee extensor moments during gait and provide direction for targeted interventions to restore gait mechanics.
Curve analyses reveal altered knee, hip, and trunk kinematics during drop–jumps long after anterior cruciate ligament rupture
2018, Knee
Citation Excerpt :
A meta-analysis of gait data has also highlighted altered long-term sagittal plane knee mechanics in patients with ACL reconstruction, which might contribute to the early onset or progression of osteoarthritis [45]. Previously, movement retraining programs have been successfully employed to reduce impact forces and increase lower-limb sagittal plane motion during dynamic tasks [44,46], as well as improving knee-specific outcome scores 16 years post-ACLR [47]. Movement retraining should be considered as a valuable tool able to improve knee-specific outcomes and address compensatory movement patterns in ACLR and ACLPT individuals who exhibit long-term alterations in lower extremity mechanics even several decades after an intervention.
Anterior cruciate ligament (ACL) ruptures may lead to knee dysfunctions later in life. Single-leg tasks are often evaluated, but bilateral movements may also be compromised. Our aim was to use curve analyses to examine double-leg drop–jump kinematics in ACL-reconstructed, ACL-deficient, and healthy-knee cohorts.
Subjects with unilateral ACL ruptures treated more than two decades ago (17–28 years) conservatively with physiotherapy (ACL_PT, n = 26) or in combination with reconstructive surgery (ACL_R, n = 28) and healthy-knee controls (n = 25) performed 40-cm drop–jumps. Three-dimensional knee, hip, and trunk kinematics were analyzed during Rebound, Flight, and Landing phases. Curves were time-normalized and compared between groups (injured and non-injured legs of ACL_PT and ACL_R vs. non-dominant and dominant legs of controls) and within groups (between legs) using functional analysis of variance methods.
Compared to controls, ACL groups exhibited less knee and hip flexion on both legs during Rebound and greater knee external rotation on their injured leg at the start of Rebound and Landing. ACL_R also showed less trunk flexion during Rebound. Between-leg differences were observed in ACL_R only, with the injured leg more internally rotated at the hip. Overall, kinematic curves were similar between ACL_R and ACL_PT. However, compared to controls, deviations spanned a greater proportion of the drop–jump movement at the hip in ACL_R and at the knee in ACL_PT.
Trunk and bilateral leg kinematics during double-leg drop–jumps are still compromised long after ACL-rupture care, independent of treatment. Curve analyses indicate the presence of distinct compensatory mechanisms in ACL_PT and ACL_R compared to controls.
Knee loading asymmetries during gait and running in early rehabilitation following anterior cruciate ligament reconstruction: A longitudinal study
2016, Clinical Biomechanics
Normalization of gait is expected 8–12 weeks after anterior cruciate ligament reconstruction and is a criterion for progression to running. Long-term persistence of sagittal knee loading deficits suggests that early goals are not met. Magnitude and progression of deficits in gait during this time and their relationship to deficits in running are not known.
12 individuals status-post reconstruction (5 males) underwent 3-dimensional motion analysis of gait after surgery: one (T1) and three (T2) months and at initiation of running (T3); and running T3. Repeated measures ANOVAs (limb × time) assessed differences in knee flexion, extensor moment impulse and negative work in gait; paired t-tests compared limbs during running; and Pearson's correlations determined associations between limb ratios (moment and work) in gait and running.
Less flexion (− 4.4 (0.63) degrees; mean (SE)), 35% smaller extensor moment (− 0.15 (0.006) Nm ∗ s/kg) and 47% less work (− 0.03 (0.008) J/kg) were observed in the surgical knee during gait across time. Moment and work were 1.7 (− 0.1 (0.03) Nm ∗ s/kg) and 1.6 times greater (− 0.23 (0.047) J/kg) in non-surgical knee during running. Moment and work limb asymmetries correlated across time during gait (r = 0.778–0.929, P < 0.001) and to asymmetries during running.
Limb asymmetries in knee loading present one month after reconstruction persist 4 months post-reconstruction. Correlations between limb asymmetries during gait across time and to running suggest that early gait behaviors relate to longer-term loading. Greater attention should be placed on early gait training.
Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: A clinical commentary
2013, Physical Therapy in Sport
Citation Excerpt :
Seto, Orofino, Morrissey, Medeiros, and Mason (1988) found increased hamstring muscle activation and strength to be associated with superior outcomes (functional scores and return to sport). Abnormal gait patterns have been associated with quadriceps weakness (Bush-Joseph et al., 2001), low patient satisfaction with outcome after ACLR (Kocher et al., 2002), decreased functional performance (Decker, Torry, Noonan, Sterett, & Steadman, 2004), post-operative complications including osteoarthritis (Dye, Staubli, Biedert, & Vaupel, 1999). Patients following ACLR have been shown to have significantly different gait patterns 12 months post-operation (Hall, Stevermer, & Gillette, 2012) with these changes being associated with articular cartilage matrix degeneration (Haughom et al., 2012) and so osteoarthritis risk.
Anterior Cruciate ligament (ACL) injuries are one of the most common and devastating knee injuries sustained whilst participating in sport. ACL reconstruction (ACLR) remains the standard approach for athletes who aim to return to high level sporting activities but the outcome from surgery is not assured. Secondary morbidities and an inability to return to the same competitive level are common following ACLR. One factor which might be linked to these sub-optimal outcomes may be a failure to have clearly defined performance criteria for return to activity and sport. This paper presents a commentary describing a structured return to sport rehabilitation protocol for athletes following ACLR. The protocol was developed from synthesis of the available literature and consensus of physiotherapists and strength and conditioning coaches based in the home country Institute of Sports within the United Kingdom.

View all citing articles on Scopus

^☆: Supported in part by the NFL Charities and the Steadman-Hawkins Sports Medicine Foundation.

¹: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

View full text

Gait retraining after anterior cruciate ligament reconstruction 1☆,

Abstract

Objectives

Design

Setting

Participants

Intervention

Main outcome measures

Results

Conclusions

Section snippets

Participants

Group characteristics and protocol adherence

Discussion

Conclusions

Acknowledgements

Clin Biomech (Bristol, Avon)

Hum Mov Sci

Hum Mov Sci

J Neurol Sci

J Biomech

Dynamic function after anterior cruciate ligament reconstruction with autologous patellar tendon

Am J Sports Med

Current concepts for rehabilitation following anterior cruciate ligament reconstruction

J Orthop Sports Phys Ther

[Biological, biomechanical and clinical concepts of after-care following knee ligament surgery]

Orthopade

Update on accelerated rehabilitation after anterior cruciate ligament reconstruction

J Orthop Sports Phys Ther

Rehabilitation after autogenous bone-patellar tendon-bone ACL reconstruction

Instr Course Lect

Current concepts in the treatment of anterior cruciate ligament disrupture

J Orthop Sports Phys Ther

Gait adaptations before and after anterior cruciate ligament reconstruction surgery

Med Sci Sports Exerc

Gait biomechanics are not normal after anterior cruciate ligament reconstruction and accelerated rehabilitation

Med Sci Sports Exerc

Lower extremity compensations following anterior cruciate ligament reconstruction

Phys Ther

Electrical stimulation of the thigh muscles after reconstruction of the anterior cruciate ligament. Effects of electrically elicited contraction of the quadriceps femoris and hamstring muscles on gait and on strength of the thigh muscles

J Bone Joint Surg Am

Determinants of patient satisfaction with outcome after anterior cruciate ligament reconstruction

J Bone Joint Surg Am

The relationship between subjective knee scores, isokinetic testing and functional testing in the ACL reconstructed knee

J Orthop Sports Phys Ther

Assessment of quadriceps/hamstring strength, knee ligament stability, functional and sports activity levels five years after anterior cruciate ligament reconstruction

Am J Sports Med

Patellofemoral problems after anterior cruciate ligament reconstruction

Am J Sports Med

Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction

Am J Sports Med

Factors contributing to function of the knee joint after injury or reconstruction of the anterior cruciate ligament

J Bone Joint Surg Am

Current concepts in anterior cruciate ligament rehabilitation

Orthop Rev

Gait retraining after anterior cruciate ligament reconstruction ¹☆,