Gabe Dimock, SPT

Background

Sports medicine was the primary area of practice that attracted me to the physical therapy profession as it combines my love of sports with my eagerness to understand human movement. Throughout my time in the UNC DPT program, I found myself choosing to work on sports medicine related cases and projects. My evidenced-based practice I (EBP) and final advanced orthopedic papers focused on throwing injuries in baseball while my EBP II critically appraised topic discussed return to sport criteria after ACL reconstruction. When our class received the list of Capstone opportunities, I jumped at the chance to work with Dr. Thoma on ACL related research along with my classmates Tanner Holden and Emma Shirley. Our initial plan was to conduct a systematic review as a team that aimed to determine normal impairment recovery (pain, strength, ROM, effusion) in early ACL reconstruction (ACLR) rehabilitation and identify whether these impairments were correlated to other knee-related outcomes. After conducting the initial literature search, we found that this project would require a much larger team of researchers than the four of us and decided to conduct three separate systematic reviews that were smaller in scope. I chose to modify the original project by focusing only on effusion recovery after ACL reconstruction. This topic was a good fit for my capstone project as it fits my clinical interests, was of appropriate scope, and allowed me to gain knowledge in an area where I had little experience or training.

Statement of Need and Purpose

Modern post-operative ACLR rehabilitation protocols typically consist of phases with specific criteria to be met before advancing to the next phase. This allows the patient to progress as quickly and safely as possible.^2,3 Resolution of knee joint effusion is one of the primary goals in the early phase of rehabilitation. Knee joint effusion is an accumulation of intracapsular fluid within the knee joint and is considered to be an indirect marker of inflammation that may contribute to quadriceps inhibition, decreased knee range of motion, difficulty with weight-bearing, altered joint kinematics, diminished proprioception, and suboptimal healing of the ligament-bone interface.^3–9  Some degree of knee joint effusion is expected post-operatively due to the inflammatory reaction induced by the surgical procedure.⁴ However, the presence of persistent effusion during rehabilitation indicates a prolonged inflammatory response in the knee joint, which may reflect an inability to meet the functional demands placed on the knee. Persistent effusion may delay recovery and is considered to be a poor outcome.⁴ While knee joint effusion assessment is considered routine practice for patients post-ACLR, there is no clear standard by which to measure effusion in clinical practice, which limits the ability to understand normal recovery.

We do not currently have a reference for the normal recovery of knee joint effusion in the first year after ACLR. Additionally, there are no known studies that seek to analyze existing associations between post-ACLR effusion recovery within one-year and knee-related outcomes such as the International Knee Documentation Committee Subjective Knee Form (IKDC), the Knee Injury and Osteoarthritis Outcome Score, or the Lysholm Knee Scoring Scale within two years post ACLR.¹⁰

Therefore, the purpose of this systematic review was to fill gaps in the literature by answering the following clinically relevant questions:

Question 1: What measurements are used to evaluate knee effusion post-ACLR in the clinic and clinical research?

Question 2: For patients up to one-year post-ACLR, what is the normal recovery timeline regarding knee effusion?

Question 3: For patients up to one-year post-ACLR, is knee effusion within the first year related to outcomes within 2 years after knee surgery?

Overview

The systematic review search was conducted in Pub Med, Sport Discus, Web of Science, Scopus, PEDro, Embase, and CINAHL databases. The search yielded 1883 potentially relevant articles, 34 of which were included in the final systematic review. The primary methods of effusion measurement used in the included studies were circumferential measurement compared to the contralateral limb and the bulge/stroke test. Combined data from the included studies that used these measurement methods demonstrated maximal effusion at approximately 1-week post-ACLR. This is likely due to the inflammatory phase of healing that typically occurs during the first week of healing to recruit an immune response.¹¹ Effusion values from the included studies demonstrated a gradual decline after the first-week post-ACLR, reaching a near-full resolution between 8- and 12- weeks. In a limited number of studies that reported associations between knee joint effusion and knee-related outcomes, effusion was found to have a strong positive association with dynamic load asymmetry during gait and a strong negative association with knee flexion ROM at 3- and 6- months post-ACLR.¹² A strong negative association was also found between effusion and return to sport rate at 1-year post-ACLR.¹³ The results stated above should be interpreted with caution due to limitations of the systematic review which include a large percentage of studies having a high risk of bias, a relatively small number of studies contributing to the average effusion recovery data, and a study population with a disproportionately large percentage of male patients (76%). Future research may help study effusion measurement by standardizing measurement methods, increasing sample sizes, and increasing methodological rigor.

Products/Health Literacy

The Capstone products (see below) consist of a manuscript for the systematic review, a clinician handout, and a patient education handout. The clinician handout is intended to guide clinicians in evidence-based measurement of effusion, provide relevant psychometric properties, and normative recovery values based on the findings of the systematic review. Additionally, video resource links are provided in the handout to further assist clinicians in knee effusion measurement. The patient education handout provides evidence-based answers to common questions about post-surgical knee swelling. The handout is written in layman’s terms and includes visuals to decrease barriers related to poor health literacy.

• Effusion Recovery After ACLR Manuscript
• Appendix I – Effusion Tables and Figures
• Appendix II-Measurement Descriptions
• Clinician Handout
• Patient Handout

Evaluation

The evaluation process for this systematic review was ongoing as our research team (Dr. Louise Thoma, Tanner Holden, Emma Shirley) met frequently throughout the semester to discuss progress and make suggestions for improvement on each other’s projects. Additionally, each section of the systematic review underwent peer review by Tanner Holden or Emma Shirley followed by a review by Dr. Thoma (project advisor). The introduction, methods, and an outline for the clinician and patient handouts were provided to my committee (Dr. Jon Hacke and Dr. Adam  McCluskey) for feedback at the mid-term review. At this time, an initial draft of the results section was submitted to Dr. Thoma for feedback. Before final submission of the capstone project products, an additional round of feedback was solicited from my committee and project advisor. The systematic review and patient/clinician handouts were improved greatly due to the input provided by my peers, Dr. Thoma, and my project committee.

Self-Reflection

Through this capstone project, I gained a much greater understanding for the rigorous process behind scientific literature and its contribution to the physical therapy profession. Early in the process, the idea of completing a manuscript for a systematic review was overwhelming and intimidating. At times, it felt like every time I took a step forward, I would have to backtrack two steps. However, I learned to remain steadfast in working diligently towards the end goal no matter how far away it seemed. I also learned to ask for help when getting stuck. There were multiple instances where I spent countless hours working on aspects of the review that I did not completely understand. In these instances, I asked Dr. Thoma or my peers for guidance which was always fruitful and provided clarity. My knowledge of ACL reconstruction, ACL rehabilitation, and knee effusion has improved exponentially and I now feel much more prepared to provide evidence-based care to this patient population despite a lack of clinical experience with patients recovering from an ACL tear.

Acknowledgments

Dr. Thoma deserves the highest praise for her patience and wisdom in coaching me through my first real research experience. She gave me ownership of the project but always provided support, clarity, and direction when I was in need. I can confidently say that I would not have been able to complete this project without the help and expertise from Dr. Thoma.

 

I also want to thank my classmates and friends, Tanner Holden and Emma Shirley. These two screened 1883 titles and abstracts for me and didn’t even complain about it. I owe both of them a debt of gratitude. They also provided encouragement and feedback that were key to a successful project.

 

Thank you to my project committee members, Dr. Jon Hacke and Dr. Adam McCluskey. During these past three years of PT school, Dr. Hacke has been a consistent voice of calm and encouragement. Whether it was teaching Modalities, MSK II, serving as my ICE instructor, or giving feedback on this project, Dr. Hacke’s genuine care for his patients and students is abundantly clear. I am lucky to have Dr. Adam McClusky as a member of my committee as he treats an active population and has a great deal of experience with musculoskeletal rehabilitation. Dr. McCluskey’s creativity with exercise prescription has greatly expanded my repertoire of exercises and his work benefits all those who follow him at The PT Initiative.

 

I’d like to thank my wife, Anna, who has shown unwavering love and support for me through the stress of PT school and completing a rigorous research project. It has been a joy to watch her thrive as a mother during this season. I owe thanks to my 6-month old son, Drew, who reminds me about the important things in life and lights up a room with his smile. I can’t forget to thank my dog, Randall, as well. He convinces me to exercise daily despite feeling like I have too much work to do.

 

Lastly, I’d like to thank the entire UNC DPT faculty and class of 2020 as they have provided a family atmosphere and relationships that I will forever treasure.

References

1. Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol. 2019;33(1):33-47. doi:10.1016/j.berh.2019.01.018
2. van Grinsven S, van Cingel REH, Holla CJM, van Loon CJM. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010;18(8):1128-1144. doi:10.1007/s00167-009-1027-2
3. Lynch AD, Logerstedt DS, Grindem H, et al. Consensus criteria for defining “successful outcome” after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation. Br J Sports Med. 2015;49(5):335-342. doi:10.1136/bjsports-2013-092299
4. Coughlan GF, McLoughlin R, McCarthy Persson U, Caulfield BM. An investigation into the effects of a simulated effusion in healthy subjects on knee kinematics during jogging and running. Clin Biomech (Bristol, Avon). 2008;23(8):1038-1043. doi:10.1016/j.clinbiomech.2008.04.010
5. Palmieri-Smith RM, Kreinbrink J, Ashton-Miller JA, Wojtys EM. Quadriceps inhibition induced by an experimental knee joint effusion affects knee joint mechanics during a single-legged drop landing. Am J Sports Med. 2007;35(8):1269-1275. doi:10.1177/0363546506296417
6. Cho YR, Hong BY, Lim SH, et al. Effects of joint effusion on proprioception in patients with knee osteoarthritis: a single-blind, randomized controlled clinical trial. Osteoarthr Cartil. 2011;19(1):22-28. doi:10.1016/j.joca.2010.10.013
7. Dagher E, Hays PL, Kawamura S, Godin J, Deng X, Rodeo SA. Immobilization modulates macrophage accumulation in tendon-bone healing. Clin Orthop Relat Res. 2009;467(1):281-287. doi:10.1007/s11999-008-0512-0
8. Sturgill LP, Snyder-Mackler L, Manal TJ, Axe MJ. Interrater reliability of a clinical scale to assess knee joint effusion. J Orthop Sports Phys Ther. 2009;39(12):845-849. doi:10.2519/jospt.2009.3143
9. Gagnier JJ, Shen Y, Huang H. Psychometric Properties of Patient-Reported Outcome Measures for Use in Patients with Anterior Cruciate Ligament Injuries: A Systematic Review. JBJS Reviews. 2018;6(4):e5. doi:10.2106/JBJS.RVW.17.00114
10. Landén NX, Li D, Ståhle M. Transition from inflammation to proliferation: a critical step during wound healing. Cell Mol Life Sci. 2016;73(20):3861-3885. doi:10.1007/s00018-016-2268-0
11. Cappellino F, Paolucci T, Zangrando F, et al. Neurocognitive rehabilitative approach effectiveness after anterior cruciate ligament reconstruction with patellar tendon. A randomized controlled trial. Eur J Phys Rehabil Med. 2012;48(1):17-30.
12. Lentz TA, Zeppieri G, Tillman SM, et al. Return to preinjury sports participation following anterior cruciate ligament reconstruction: contributions of demographic, knee impairment, and self-report measures. J Orthop Sports Phys Ther. 2012;42(11):893-901. doi:10.2519/jospt.2012.4077

Image Reference

1. Partial Anterior Cruciate Ligament – ACL – Tears. https://www.howardluksmd.com/sports-medicine/partial-anterior-cruciate-ligament-acl-tears/. Accessed April 17, 2020.