This is the de-identified case study of a revision ACLR patient complicated by an episode of PFPS early during her rehabilitation when she started to increase her gym loads and running loads. In my presentation, I take you through the initial subjective and objective findings and then take you through my clinical reasoning for her diagnosis and PFPS management. I then subsequently take you through a clinically reasoned ACLR management plan as we geared her towards an eventual return to sport.

1. Management of Revision ACLR with
Secondary PFPS in Women’s AFL Player
By Mick Hughes
Pic: Google Images

2. Summary of Subjective Assessment
CHx
• 28 F, contracted AFLW player for
inaugural 2017 season
• 1 month history of worsening
anterior L) knee pain whilst
running (only >3km) and
squatting (>60deg)
• Currently 4.5 months post-op
revision L) ACLR (BPTB graft)

3. Timeline of Relevant Events
Past
• 2010
• R) ACLR (HS graft) – Full recovery
Past
• Feb 2016
• L) ACLR (HS graft) – Reinjured 9 months later
Now
• Dec 2016
• L) ACLR (BPTB graft) – Now 4.5 months post-op

4. Summary of Subjective Assessment
Past Hx & Medical Hx:
- No other episodes of significant knee pain, MSK injury or MSK surgery
- General health good; non-smoker, social drinker
- No significant medical issues
- No family history of ACL injury
- No red flags
Psychosocial:
- Customer sales role 20-30hrs per week (on-feet)
- Supportive partner, no kids
- Just been de-listed from club as result of her injury // stressed & anxious as she really
wants to play a role in future AFLW competition

5. Summary of Subjective Assessment
AGG:
- Running/squats (5-6/10 VAS)
- Upstairs/sitting the next day (3/10
VAS)
EASE:
- Prolonged rest, ice, recovery days
24hr behaviour:
- AM: mild morning stiffness (max 3-
5 mins)
- PM: NAD

6. Activity Restrictions and Capabilities
Restrictions
Squat or Lunges
>60deg knee flexion
Running >3km
OVERALL:
Unable to build
strength & CV capacity
Capabilities
All other lower limb
gym exercises
Bike/Swim/Boxing/Off-
feet cardio

7. Hypotheses
Most Likely Why
PFPS Pain behaviour (squatting and running) consistent with PFPS
BPTB graft site pain Recent surgery, immature tissue susceptible to load
Less Likely Why Not
Hoffa’s fat pad impingement No recent direct blow or acute hyper-extension MOI (Franklyn-Miller et al,
2011)
Patella tendinopathy No reported focal pain to distal pole of patella, no recent repetitive jumping
history
ACL graft re-injury No recent contact or non-contact MOI
Patella instability No recent contact or non-contact MOI
Meniscus pathology No “clicking”, “catching”, “locking” episodes
Hip referral Possible
Lumbar referral Possible

8. Summary of Key Objective Findings
Observations/Palpation
L Quads wasted // L) 40cm R)
46cm
L) Dynamic knee valgus during
sit to stands and squatting
Audible crepitus L) knee when
rising from chair
TOP lateral facet patella
AROM/PROM
L) Knee FAROM // crepitus
through flexion
L) Knee FPROM // no pain on OP
flexion or extension

9. Summary of Key Objective Findings
Special Tests
+ Swipe Test (G2 effusion)
-ve Lachmans Test
-ve ADT
-ve Pivot Shift
-ve McMurrays Test
-ve Apprehension Test
Function
BW Squat >60deg // 5/10 VAS
HHD Quads L) 30kg R) 90kg // 30% LSI
HHD Hams L) 32kg R) 47kg // 68% LSI
HHD Hip ABD L) 20kg R) 30kg // 66% LSI
SL Sit to Stands L = R x22 reps (Culvenor et
al., 2016)
SL Hop L) 30cm R) 101cm // 30% LSI

10. Provisional Diagnosis
Most Likely Why
PFPS “Issues in the tissues” > Central Sensitisation
- Recent onset of mechanical symptoms with clinical weakness of quad
and hip ABD AND biomechanical features (dynamic knee valgus)
- All these features consistent with PFPS (Crossley et al., 2016)
- Also no chronic history of PFPS
Least likely Why not
Hoffa’s fat pad impingement No tenderness on palpation of fat pad tissue
ACL graft reinjury Negative clinical tests
Patella tendinopathy No focal tenderness to distal pole of patella
Meniscus pathology Negative clinical tests
Lumbar/Hip referral Negative clinical tests
Patella instability Negative clinical test
BPTB donor site No focal tenderness through patella tendon

11. Contributing factors
PFPSWeak Quads
Weak Gluteus
Medius
Poor NM
control
Poor LL
power
Load
Management
errors

12. Attitudes, Beliefs, Psychosocial
Positive/realistic attitude of RTS >12months – happy to go
“slower” this time around
Semi-professional athlete with proven track record of
exercise compliance (3rd ACLR; 2nd within 1 year)
Increased anxiety from being cut from club and uncertain
future in AFLW competition

13. Expectations and Goals
Expectations of me:
1) Manage her current PFPS pain state to allow her to keep training as she no longer had access to
club’s medical, physio and S&C staff
2) Didn’t want me as a “hands-on physio”  Had access to regular myotherapy and osteopathy
3) Wanted me to liase with her private S&C coach about what things she could and could not do
throughout each stage of her rehab
Goals:
1) Significantly reduce PFPS pain in ADLs, running and squats over the next 6 weeks.
• Treatment based on PFPS consensus statement recommendations (Crossley et al., 2016).
2) ACL RTS goal: Return to at least VFL women level in 2018.
• Treatment and progressions based on practice guidelines for ACLR rehab (van Melick et al., 2016)
• ACLR RTS criteria based on research by Kyritsis et al., (2016).

14. Precautions and Contra-indications

15. Treatment
PFPS pain focused > ACLR focused
1) Removed aggravating factors:
• Ceased running (short term only 2-4 weeks)
• Allowed to squat 0-45deg ROM due to decreased PFJ load (Powers et al, 2014)
• Continue all other strength and CV exercise as L) knee pain allows (<3/10 VAS)
2) Quads deficit:
• Isolated knee extensions through 45-90deg (reduced PFJ stress; as per Powers et al,
2014)
3) Hip ABD deficit
• Gluteus Medius and Gluteus Maximus work
4) Neuromuscular control:
• Progression of DL & SL strength and balance exercises trying to avoid DKV

16. Follow-up: 6 Weeks Later (6mths post-op)
Functional Measure Left Right LSI
Quads HHD 50kg (30kg) 83kg (90kg) 60%
Hamstring HHD 48kg (32kg) 55kg (47kg) 87%
Gmed HHD 25kg (20kg) 32kg (30kg) 78%
SL Hop 76cm (30cm) 100cm (ISQ) 76%
NEW TESTS
Triple Hop Test 277cm 389cm 61%
Triple Crossover Hop 241cm 357cm 67%
• S:// Able to pain-free squat to 90deg and recommence running program (3-
5kms) in the 2 weeks leading up to review
• O:// +ve Swipe Test  G1
• ACLR Rx: Gym & S/C progressions (targeting quads & glutes) to continue building
strength & fitness

17. Follow-up: 4 Weeks Later (7mths post-op)
Functional Measure Left Right LSI
Quads HHD 75kg (50kg) 88kg (83kg) 85%
Hamstring HHD 48kg (ISQ) 55kg (ISQ) 87%
Gmed HHD 30kg (25kg) 34kg (32kg) 88%
SL Hop 85cm (76cm) 120cm (100cm) 70%
Triple Hop Test 286cm (277cm) 390cm (ISQ) 73%
Triple Crossover Hop 261cm (241cm) 381cm (357cm) 68%
• S:// No increase in squatting or running pain with increased training
loads
• O:// No effusion
• ACLR Rx: Add in a variety of plyometric drills, high-speed running
drills and kicking drills
• PROs: ACL-RSI (53%)

18. Follow-up: 2 months Later (9mths post-op)
Functional Measure Left Right LSI
Quads HHD 75kg (50kg) 88kg (83kg) 85%
Hamstring HHD 48kg (ISQ) 55kg (ISQ) 87%
Gmed HHD 35kg (30kg) 35kg (32kg) 100%
SL Hop 85cm (76cm) 120cm (100cm) 70%
Triple Hop Test 286cm (277cm) 390cm (ISQ) 73%
Triple Crossover Hop 261cm (241cm) 381cm (357cm) 68%
• S:// No PFJ pain; Continued improvement in strength and function.
ACL and rest of knee feeling good
• Rx:// Change of direction drills (anticipated/unanticipated),
perturbation drills, increased sport-specific skills (no small sided
games or defender yet)

19. Follow-up: 2 months later (11mths post-op)
Functional Measure Left Right LSI
Quads HHD 85kg (77kg) 92kg (88kg) 92%
Hamstring HHD 55kg (ISQ) 55kg (ISQ) 100%
Gmed HHD 35kg (ISQ) 35kg (ISQ) 100%
SL Hop 140cm (76cm) 148cm (100cm) 94%
Triple Hop Test 461cm (277cm) 498cm (ISQ) 92%
Triple Crossover Hop 457cm (241cm) 477cm (357cm) 95%
• S:// No PFJ pain & ACL still feeling good. Last visit today because she had been
signed by another AFLW affiliate club!
• Most likely play a role in AFLW 2019 Competition  Happy and relieved!
• Re-established goal of RTS: Rd 1 VFL Women’s Comp May 5, 2018
• Handover to new treating Physiotherapist
• PROs: ACL-RSI (70%)  Those that RTS >76% (Webster et al., 2009)

20. What Could I
Have Done
Differently?
View MRI
Podiatry review early for
short term pain relief
(Crossley et al., 2016)
Allowed Athlete to Keep
Running – Gait education
(Esculier et al, 2017)
Test Hop Tests in Fatigued
State
(Gokeler et al, 2014)
Be Present For S&C
sessions

21. Prognosis
• Unclear
• 3rd ACLR certainly make it hard to return to pre-injury sport
• 37-55% return to pre-injury sport after ACLR revision (Grassi et al, 2015 & Anand et
al, 2016)
• Cases like Dan Menzel and Brent Tate (both 4x ACLRs and returned to pre-injury
sport AND high levels of performance) give anyone hope
• Currently on-track with excellent performance outcome measures
• Big limitations to LSI!
• Unable to access previous strength and hop test data; so should assess readiness to
RTS against norm values
• Female normative data: Single hop 149cm and triple hop 470cm (Gokeler et al.,
2017)
• Not too far behind: 140cm and 461cm respectively

22. Take Home Messages
• Physio doesn’t always have to be hands-on
• Know where your skillset ends; Don’t be afraid to refer on to exercise
professionals with more time and space to work with the ACLR
patient
• Return to sport following ACLR needs to be criteria-driven, not time-
based!

23. References
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doi:10.1136/bjsports-2012-090953
• Crossley, K. M., Stefanik, J. J., Selfe, J., Collins, N. J., Davis, I. S., Powers, C. M., . . . Callaghan, M. J. (2016). 2016 Patellofemoral pain consensus statement from the 4th
International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-
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24. References
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discharge criteria before return to sport is associated with a four times greater risk of rupture. Br J Sports Med, 50(15), 946-951.
doi:10.1136/bjsports-2015-095908
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systematic review with meta-analysis. Br J Sports Med, 49(21), 1365-1376. doi:10.1136/bjsports-2015-094723
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Ligament Reconstruction: A Meta-analysis. Arthroscopy, 34(1), 289-300. doi:10.1016/j.arthro.2017.06.029
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for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: is PFP itself a predictor for subsequent ACL injury? Br J
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