16 I Summer 2018 www.anjc.info Legislative Update Legal Ease Chiro Assist TECHNIQUE Council REHABILITATION Council Legal Q&A S C H O L ARSHIP WI N N E R S By Dr. Donald C. DeFabio ANJC Council on Physical Rehabilitation & Performance Chairman The $64,000 question all patients ask, even on the first visit, is: “Doc, when can I return to my workouts?” From the parent of a middle school athlete to the elite level collegiate, professional or amateur athlete, everyone wants to know their return-to-play guidelines. This article will review these guidelines for the patient with knee pain. A previous article covered the assess- ment and treatment of patellofemoral pain, PFP, one of the most common causes of knee pain, and reviewed the best common exercises to address PFP. Briefly, the goal of rehabilitation when it comes to PFP is to preferentially activate the gluteal muscles while minimizing TFL activation. Since most of the research in return-to-play guidelines for the knee involves the anterior cruciate ligament, those guidelines will be the benchmark for returning to play for less serious injuries as well as PFP. First, return-to-play assessment is a clinical skill based on experience, objective findings, and the patient’s subjective complaints. While clinical skill builds with experience, it is essential to be thoughtful with your assessment. A few points to consider: •  What sport is involved? Be knowledge- able of the activity-specific kinematic demands on the knee- jumping, pivoting, lateral motion, acceleration, etc. •  What level of performance is allow- able? Light, 50 percent intensity, no pivoting... limit the allowable load. •  Special concerns to avoid reinjury? OK to run, but no sprinting; do not wear cleats on the field, only turf shoes; avoid 90 degrees knee flexion… •  Is cross training an option? Runners can maintain aerobic capacity with swimming, elliptical or perhaps a stationary bike. Give your patients guidance on activities they can do, otherwise they will engage in unrec- ommended exercise on their own, which frequently leads to re-injury. •  Slowly build intensity, duration, speed, and change of direction. Remember, speed kills! Build slowly when it comes to reintroducing change of direction, pivoting, and sprinting. •  Collaborate with other members of the athlete’s healthcare team. Competitive athletes may also be under the care of an ATC, PT, surgeon, and/or personal trainer. Be sure they all know your thought process. The objective findings to consider in return to play for knee injuries are fairly well established in the literature and include the Limb Symmetry Index, LSI, the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) and single-leg hop test LSI. The LSI includes evaluation of quadriceps and hamstring strength with a minimal goal of 90 percent compared to the uninjured side. Optimum outcomes for LSI for return to high level sport is 100 percent symmetry. However, Wellstandt, 2017, Toole, 20017, and Lepley, 2018, have all raised concern that objective findings such as LSI and the single leg hop may overestimate the athlete’s ability to return to play after ACL reconstruction. Wellstandt, 2017, further hypothesizes that the LSI needs to be determined compared to the uninvolved side before ACLR, which would delay the return to play and thus reduce the re-injury rate. In the case of PFP, the uninvolved side can be measured for girth, hamstring and quadriceps strength, as well as single leg hop and jump tuck test performance on the initial visit. Additional tests for arthrokinematics of the knee include the drop-vertical, step down and overhead squat maneuvers. During these assessments the knee is observed for the ability to maintain proper alignment and mechanics between the pelvis, hip, knee, and ankle. While the most common deficits of motion are internal rotation of the hip, knee adduction and foot eversion, any pattern can arise. While neuromuscular retraining is beneficial to correct abnormal move- ment patterns, application in a functional or sport specific manner is also needed to re-pattern normal movement patterns. Remember, as chiropractic doctors, the two most important aspects to treating the knee are our ability to assess and treat the entire kinetic chain and the thoughtful application of CMT. The combination of CMT, with neuromuscular retraining and sport specific movement training is extremely effective. In addition to the objective finding of Knee Pain: Return to Play Guidelines