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A 17-year-old competitive female soccer player presents to physical therapy with a diagnosis of a right acute anterior cruciate ligament (ACL) tear. She reports injuring her knee while participating in a soccer game 1 week ago. At that time, she was running down the field and attempted to execute a cutting maneuver when an opponent collided slightly with her trunk and threw her off balance. She felt a "pop" in her knee and an immediate sensation of her knee "giving way." She was unable to continue playing and sought immediate medical attention. The MRI of her right knee obtained at her medical follow-up demonstrated a complete acute ACL tear with no concomitant meniscal or articular cartilage damage. She is a senior in high school and this injury occurred in the first game of her season.

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Based on the patient's diagnosis, what factors would be appropriate to consider before choosing a nonoperative treatment plan?

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What are the most appropriate physical therapy interventions if a nonoperative treatment plan is implemented?

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What are possible complications that may limit the effectiveness of physical therapy?

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COPER: Person with ACL deficiency who is able to resume all preinjury levels of activity without any episodes of the knee giving-way for at least one year1

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NONCOPER: Person with ACL deficiency who experiences knee instability upon return to activity1

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PERTURBATION TRAINING: Nonoperative treatment intervention for ACL-deficient individuals; training includes progressive application of disruptions to the individual's balance on unstable surfaces in an attempt to enhance dynamic neuromuscular stability in the affected knee prior to return to activity2

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  1. Describe a decision-making algorithm to determine if an ACL-deficient individual is a candidate to pursue nonsurgical management of ACL injury.

  2. Identify appropriate interventions to utilize with an individual pursuing nonsurgical management of an ACL injury.

  3. Identify appropriate return-to-sport criteria for individuals pursuing conservative management of ACL injury.

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PT considerations during nonoperative management of the individual with a diagnosis of acute anterior cruciate ligament tear:

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  • General physical therapy plan of care/goals: Decrease acute pain and effusion; increase muscular strength; increase lower quadrant strength; improve functional stability; prevent or minimize loss of aerobic fitness capacity
  • Physical therapy interventions: Patient education regarding functional anatomy and injury pathomechanics; modalities and manual therapy to decrease pain and effusion; muscular flexibility exercises; resistance exercises to increase muscular strength, activation, and endurance capacity with a focus on the lower extremity and core musculature; balance and proprioceptive interventions; perturbation training
  • Precautions during physical therapy: Monitor all activity to ensure no episodes of knee giving-way; address precautions or contraindications for exercise, based on patient's mechanical instability (e.g., limit open kinetic chain knee extension in the range from 30° to full extension to decrease anterior shear forces at tibiofemoral joint)
  • Complications interfering with physical therapy:...

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