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Knee stability and movement coordination impairments: knee ligament sprain
Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ, Godges JJ [Orthopaedic Section of the American Physical Therapy Association]
The Journal of Orthopaedic and Sports Physical Therapy 2010 Sep;40(4):A1-A37
practice guideline

RECOMMENDATIONS: RISK FACTORS: Clinicians should consider the shoe-surface interaction, increased body mass index, narrow femoral notch width, increased joint laxity, preovulatory phase of the menstrual cycle in females, combined loading pattern, and strong quadriceps activation during eccentric contractions as predisposing factors for the risk of sustaining a noncontact anterior cruciate ligament (ACL) injury. (Recommendation based on moderate evidence). DIAGNOSIS/CLASSIFICATION: Passive knee instability, joint pain, joint effusion, and movement coordination impairments are useful clinical findings for classifying a patient with knee instability into the following International Statistical Classification of Diseases and Related Health Problems (ICD)categories: Sprain and strain involving collateral ligament of knee, Sprain and strain involving cruciate ligament of knee, Injury to multiple structures of knee; and the associated International Classification of Functioning, Disability, and Health (ICF impairment based category of knee instability (b7150 Stability of a single joint) and movement coordination impairments(b7601 Control of complex voluntary movements). (Recommendation based on strong evidence). DIFFERENTIAL DIAGNOSIS: Clinicians should consider diagnostic classifications associated with serious pathological conditions or psychosocial factors when the patient's reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of this guideline or when the patient's symptoms are not resolving with interventions aimed at normalization of the patient's impairments of body function. (Recommendation based on moderate evidence). EXAMINATION -- OUTCOME MEASURES: Clinicians should use a validated patient-reported outcome measure, a general health questionnaire, and a validated activity scale for patients with knee stability and movement coordination impairments. These tools are useful for identifying a patient's baseline status relative to pain, function, and disability and for monitoring changes in the patient's status throughout the course of treatment. (Recommendation based on strong evidence). EXAMINATION -- ACTIVITY LIMITATION MEASURES: Clinicians should utilize easily reproducible physical performance measures, such as single-limb hop tests, to assess activity limitation and participation restrictions associated with their patient's knee stability and movement coordination impairments,to assess the changes in the patient's level of function over the episode of care, and to classify and screen knee stability and movement coordination. (Recommendation based on weak evidence). INTERVENTIONS -- CONTINUOUS PASSIVE MOTION: Clinicians can consider using continuous passive motion in the immediate postoperative period to decrease postoperative pain. (Recommendation based on weak evidence). INTERVENTIONS -- EARLY WEIGHT BEARING: Early weight-bearing can be used for patients following ACL reconstruction without incurring detrimental effects on stability or function. (Recommendation based on weak evidence). INTERVENTIONS -- KNEE BRACING: The use of functional knee bracing appears to be more beneficial than not using a brace in patients with ACL deficiency. (Recommendation based on weak evidence). The use of immediate postoperative knee bracing appears to be no more beneficial than not using a brace in patients following ACL reconstruction. (Recommendation based on moderate evidence). Conflicting evidence exists for the use of functional knee bracing in patients following ACL reconstruction. (Recommendation based on conflicting evidence). Knee bracing can be used for patients with acute posterior cruciate ligament (PCL)injuries, severe medial collateral ligament (MCL)injuries, or posterior lateral corner (PLC) injuries. (Recommendation based on expert opinion). INTERVENTIONS -- IMMEDIATE VERSUS DELAYED MOBILIZATION: Clinicians should consider the use of immediate mobilization following ACL reconstruction to increase range of motion, reduce pain, and limit adverse changes to soft tissue structures. (Recommendation based on moderate evidence). INTERVENTIONS -- CRYOTHERAPY: Clinicians should consider the use of cryotherapy to reduce postoperative knee pain immediately post-ACL reconstruction. (Recommendation based on weak evidence). INTERVENTIONS -- SUPERVISED REHABILITATION: Clinicians should consider the use of exercises as part of the in-clinic program, supplemented by a prescribed home-based program supervised by a physical therapist in patients with knee stability and movement coordination impairments. (Recommendation based on moderate evidence). INTERVENTIONS -- THERAPEUTIC EXERCISES: Clinicians should consider the use of non-weight bearing (open chain) exercises in conjunction with weight-bearing (closed chain) exercises in patients with knee stability and movement coordination impairments. (Recommendation based on strong evidence). INTERVENTIONS -- NEUROMUSCULAR ELECTRICAL STIMULATION: Neuromuscular electrical stimulation can be used with patients following ACL reconstruction to increase quadriceps muscle strength. (Recommendation based on moderate evidence). INTERVENTIONS -- NEUROMUSCULAR REEDUCATION: Clinicians should consider the use of neuromuscular training as a supplementary program to strength training in patients with knee stability and movement coordination impairments. (Recommendation based on moderate evidence). INTERVENTIONS -- "ACCELERATED" REHABILITATION: Rehabilitation that emphasizes early restoration of knee extension and early weight bearing activity appears safe for patients with ACL reconstruction. No evidence exists to determine the efficacy or safety of early return to sports. (Recommendation based on moderate evidence). INTERVENTIONS -- ECCENTRIC STRENGTHENING: Clinicians should consider the use of an eccentric exercise ergometer in patients following ACL reconstruction to increase muscle strength and functional performance. Clinicians should consider the use of eccentric squat program in patients with PCL injury to increase muscle strength and functional performance. (Recommendation based on moderate evidence).

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