STUDY DESIGN: Case report. BACKGROUND: The healing response procedure is a minimally invasive arthroscopic surgical technique used to stimulate healing in the treatment of partial cruciate ligament tears. The purpose of this report is to provide information on the surgical procedure, the postoperative rehabilitation, and the overall functional results in a patient who underwent such a procedure. CASE DESCRIPTION: A 15-year-old male, who sustained a partial tear of both the anterior cruciate and posterior cruciate ligament while playing football, underwent arthroscopic surgical management utilizing a healing response technique. Precautions concerning range of motion and resisted activities were followed postoperatively to protect the healing cruciate ligaments. The postoperative protocol consisted of 3 phases, culminating in return-to-sport training. Treatment incorporated cardiovascular, proprioceptive, strength, power, plyometric, and sport-specific activities. Treatment was progressed based on specific criteria emphasizing proper movement patterns and eccentric control during functional activities. OUTCOMES: The patient attended 31 physical therapy sessions over 17 weeks. Strength improved from 3/5 to 5/5, knee range of motion returned to normal, Lower Extremity Functional Scale scores improved from 21/80 to 80/80, and successful outcomes on functional return-to-sport testing allowed the patient to return to competitive athletics. DISCUSSION: Primary repair of cruciate ligament tears has yielded poor results, and partial cruciate ligament tears may not require complete surgical reconstruction. The healing response technique offers a possible solution for the treatment of partial cruciate ligament tears. A criterion-based postoperative protocol was derived based on current evidence regarding rehabilitation following cruciate ligament reconstruction and evidence regarding lower extremity rehabilitation principles and injury prevention. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(5):297-309, Epub 12 March 2010. doi:10.2519/jospt.2010.3162

KEY WORDS: ACL, anterior cruciate ligament, healing response, physical therapy, PCL, posterior cruciate ligament

STUDY DESIGN: Case report. BACKGROUND: After 2 attempts at conservative care for a diagnosis of hamstring strain, the patient had a surgical hamstring allograft reconstruction. The purpose of this report is to describe the physical therapy approach to postoperative management of a hamstring reconstruction. CASE DESCRIPTION: A 24-year-old female coach who sustained a complete avulsion of the proximal hamstring tendon while playing softball had a surgical hamstring reconstruction using an Achilles tendon allograft. Precautions concerning range of motion and stretching, weight-bearing status, and brace were followed to protect the surgical graft. Treatment incorporated cardiovascular, strength and proprioception exercises, and progressed with the focus on correct movement patterns and eccentric muscle control during functional movements. OUTCOMES: The patient attended 25 physical therapy sessions over 7 months. Muscle strength improved from 4/5 to 5/5. Straight-leg raise range of motion decreased from 145° to 90°. Lower Extremity Functional Scale (LEFS) scores improved from 15/80 to 70/80. DISCUSSION: A complete avulsion of the proximal insertion is rare. Conservative management of hamstring tears has traditionally focused on end-range passive stretching, modalities, and direct hamstring strengthening. New evidence recommends a program that is more protective of the injured tissue and includes exercises such as core stabilization; indirect hamstring strengthening may be beneficial in the treatment of hamstring injuries. This concept was taken into account when considering the rehabilitation protocol and progression for this patient. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther. 2008;38(12):754-760. doi:10.2519/jospt.2008.2845

KEY WORDS: Achilles allograft, hamstring reconstruction, physical therapy

STUDY DESIGN: Case report. BACKGROUND: Decreased quadriceps activation has been shown to be present following anterior cruciate ligament (ACL) injury, but its presence prior to ACL injury is unknown. The purpose of this case report was to describe the level of quadriceps activation measured hours before a noncontact ACL injury in an individual who previously demonstrated known biomechanical risk factors for ACL injury. CASE DESCRIPTION: A 23-year-old female (height, 176.9 cm; mass, 72.4 kg), sustained a left noncontact ACL injury while landing from a jump stop during a recreational basketball game. This case was unique because data regarding landing biomechanics and quadriceps force and activation were gathered in 2 separate, unrelated studies prior to injury. OUTCOMES: Peak external knee abduction moment (-65.3 Nm) during a drop jump landing 8 months prior to injury indicated elevated risk for ACL injury. Involved quadriceps central activation ratios (CAR) were obtained 1 week (CAR, 0.81) and 4 hours (CAR, 0.77) prior to injury. Strength and CAR (0.76) measurements changed very little within 36 hours of injury and both strength, and activation (CAR, 0.90) improved following surgical reconstruction and formal rehabilitation. DISCUSSION: An individual with known biomechanical risk factors for ACL injury may compound risk for noncontact ACL injury if decreased quadriceps activation is also present. LEVEL OF EVIDENCE: Prognosis, level 4.

J Orthop Sports Phys Ther. 2008;38(8):502-507, published online 25 April 2008. doi:10.2519/jospt.2008.2761

KEY WORDS: ACL, biomechanics, knee, muscle inhibition