Phase 2: Strength and Neuromuscular Control

Aim:

  • Muscle strengthening
  • Work capacity training
  • Cardiovascular training
  • Single leg balance
  • Prevent secondary injury PFPS/patella tendonitis/hamstring injury
  • Maintain upper extremity and core conditioning
  • Promote proper movement mechanics and symmetrical movement
  • Improve confidence
  • Eccentric and concentric control
  • Gait re-education
  • Dynamic movement control
  • ACL reconstruction patients at 2 years following surgery demonstrate significantly weaker quadriceps strength, but more resistance to fatigue compared to their unaffected limb (Snyder at al, 1993). In spite of an apparent resistance to fatigue, ACL-R patients demonstrate significant declines in stability and power after fatiguing exercise (Augustsson et al, 2006; Gustavsson et al, 2006). One possible explanation according to Kuenze et al (2013), is that patients with a decreased ability to generate knee-extension torque begin to develop poor or dysfunctional movement and muscle activation patterns. To prevent these long-term strength deficits from occurring, we emphasise progressive limb loading to develop muscular strength and prevent compensation patterns from developing through carefully monitoring technique and prescribing neuromuscular and specific muscle activation exercises.

    ne-hab-program

    Sample Exercise Session Phase 2 Home Program

    Exercise Sets / Duration
    Reps Recovery
    WARM UP
         
    Cross-trainer/ Treadmill/ Bike      
    Walking lunges progression      
    Mini-tramp jog      
    SUPER STRENGTH SET
         
    Single Leg (SL) VMO squeeze and hold      
    SL arabesque      
    SUPER STRENGTH SET      
    SL lateral step down      
    SL hamstring Fit Ball (FB) hip extension      
    SL wall slides      
    SL Spanish squats      
    Bosu/FB side ups      
    Supine fit ball twists      
    Bilateral jump onto box (30 cm)      
    Lateral mini-hurdle hops (both legs)      
    Mini-tramp bounce and hold (5 secs)      
    Single-leg balance (dura disc/mini tramp/bosu)      
    COOL DOWN
         
    Stationary cycle      
    ROM (as required)
         
    ITB foam roller      

    Outcome Measures and Goals for Progression to Phase 3:

    Measure Test Description & Reference Goal -> Purpose/ reasoning
    Single Leg Squat Maintain single leg stance on deformable pad at 5, 45 and 90˚ (Herrington et al. 2013) 10 second hold at each angle of knee flexion. No postural sway. Test for static stability of kinetic chain
    Eccentric Step Test The subject stands on a 20 cm step on one leg and has 30 seconds to reach forward and touch the ground lightly with their heel and return to full knee extension. Each limb is tested (Loudon et al, 2002) No knee valgus

    <5 difference in scores

    Tests eccentric quad control and dynamic hip control

    Modified Bilateral Drop Jump Test The subject drops off a 10 cm box then performs a controlled jump after landing (Kristianslund & Krosshaug, 2013) Landing even weight distribution, knee flexion >30˚, no knee valgus. Screens for dynamic knee valgus, hip stability and eccentric quads control during landing
    Star Excursion Balance Test (SEBT) The subject must maintain a base of support on one leg, while using the other leg to reach as far as possible in 3 different directions. A composite score is obtained for each leg from which the limb symmetry index (LSI) is then calculated (Herrington et al, 2009) - Symmetrical anterior and posterior reach directions
    - Medial and lateral reach distance less than 10% difference in LSI
    - Composite score (total anterior, posterior, medial and lateral) has less than 10% difference in LSI
    Multi-directional balance
    Prone Hang Test Subject lies prone on the treatment table with the lower legs off the end of the bed allowing passive extension. Heel height difference is measured (Sachs et al, 1989) Equal to opposite side Limb symmetry, full extension maintained
    Knee Flexion Athlete is supine, goniometer used on the following landmarks: greater trochanter, lateral femoral condyle, and the lateral malleolus (Norkin & White 1995) Within 10˚ to opposite side To enable successful landing strategies
    Modified Single Leg Bridges Subject supine with one foot on 30cm box, hip flexed to 90˚, raising pelvis to neutral until fatigue (Zazulak et al, 2007) 20+, no greater than 5 rep difference between limbs Ensures gluteal activation, strength and endurance
    Calf Raises Standing on the edge of a step, the subject performs full range unilateral heel raises to fatigue. 1 repetition every 2 seconds. (Schlumberger et al, 2002) 25+, no greater than 5 rep difference between limbs To enable running
    1RM Single Leg Press Incline leg press machine, hip flexed to 90˚. A valid repetition 10 repetitions, 0-90˚ knee flexion (Cleather et al, 2013) 1.5x body weight To ensure sufficient strength and stability for plyometrics
    Swelling/Effusion Knee circumference (Jakobsen et al. 2010). Measured 1cm proximal to the base of the patella with knee in full extension. <1 cm change in circumference

    To ensure exercises are not being progressed beyond tolerance