Rehabilitation of anterior cruciate ligament

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Rehabilitation of anterior cruciate ligament

• Dr. Ali Abd El-Monsif Thabet

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Operative treatment

• Operative treatment (either arthroscopic or open
  surgery) Uses a strip of tendon, usually taken
  from the patient's knee (patellar tendon- BPTB)
  or hamstring muscle - STG, that is passed through
  the inside of the joint and secured to the
  thighbone and shinbone.
• Is followed by an exercise and rehabilitation
  program to strengthen the muscles and restore
  full joint mobility.

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Pre-surgical phase (Phase 1)

• Psychological preparation of patients to surgery
  and rehabilitation is very important to obtain
  their maximum commitment.

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Before surgery, the patient must reach these goals

• 1- Control of pain and swelling with rest,
  cryotherapy 2- Recovery of full ROM3-
  Reestablishment of normal gait by walking with
  crutches
• 4- The patient must also regain muscle
  strength (quadriceps and hamstrings).

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The goals of rehabilitation after ACL
reconstruction

• 1- joint stability (protection of the healing
  graft)
• 2- full ROM (including extension at levels
  of the uninvolved side),
• 3- muscle strength (both concentric and
  eccentric),
• 4- proprioception,
• 5- improve cardiovascular endurance
• 6- preinjury levels of activity.

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Phase 2 First and Second Postoperative Weeks

• GOALS
• 1- wound healing
• 2- reduce swelling and pain
• 3- regain full extension
• 4- regain 90- 110 flexion
• 5- Initiate muscle control
• 6- gradual weight bearing

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Phase 2 First and Second Postoperative Weeks

• 1- Cryotherapy
• 2- Active foot flexion-extension
• 3- Full knee extension
• 4- Static quadriceps contractions

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Phase 2 First and Second Postoperative Weeks

• 5- Knee flexion
• 6- Gait partial weight bearing with two
  crutches
• 7- At the end of every exercise session,
  20min of cryotherapy must be performed.
• 8- EMS it is possible to perform electrical
  quadriceps stimulation
• 9- Warning to prevent loss of extension, the
  patient must not place supports under the knee.

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Phase 3 Third and Fourth Postoperative Weeks

• GOALS
• 1- Increase active range of motion
• 2- Develop muscular control of quadriceps and
  hamstring
• 3- Increase weight bearing during gait
• 4- Improve cardiovascular endurance

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Phase 3 Third and Fourth Postoperative Weeks

• If there is lack of extension, a new exercise is
  added to the protocol
• Muscle exercises
• 1- Straight leg raises with weight on the thigh
  (Fig. 8)
• 2- Two-legged minisquat with up to 450 of knee
  flexion using crutches
• 3- Active extension 900 to 450 (stopping at 450)
  without resistance while sitting (Fig. 10)
• 4- Active knee flexion in standing position.

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Phase 3 Third and Fourth Postoperative Weeks

• 5- Active assisted flexion
• 6- Cocontraction simultaneous isometric (60)
  contractions of quadriceps and hamstrings
  muscles.
• 7- Gait, increase weight bearing gradually as
  tolerated with one crutch.
• 8- Swimming pool.
• 9- Stationary bicycle for 10 min two to three
  times a day slowly, without wheel resistance, and
  pedaling with the forefoot (Fig. 12)

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Phase 4 Second Postoperative Month

• Goals
• 1- Restore full ROM
• 2- Improve muscle strength
• 3- Full weight bearing

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Phase 4 Second Postoperative Month

• 1- In comparison with the contralateral knee,
• 2- Flexion must be more than 1200 and gradually
  reach the contralateral level (full ROM).
• 3- Gait the patient can walk without crutches
• 4- Stationary bicycle 15 min three times a day
  with low wheel resistance (50 W) simulating a
  slow -ride on level road, pedaling with the
  forefoot.

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Phase 4 Second Postoperative Month

• 5- Muscle strengthening exercises with elastic
  tubing are useful because they allow gradual
  resistance
• 6- Exercises to be performed in the swimming pool
  are

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Phase 5 Third Postoperative Month

• Goals
• 1- full active ROM
• 2- Increasing muscle strength
• 3- Proprioceptive training

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Phase 5 Third Postoperative Month

• 1- eccentric quadriceps strengthening
  exercises like two-legged squatting up to 900 (on
  land and in a swimming pool),
• 2- climbing and descending stairs into the
  water (20-40 cm, gradually increasing),
• 3- concentric quadriceps strengthening
  exercises (active full knee extension-flexion
  without resistance)

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Phase 5 Third Postoperative Month

• 4- one-legged proprioceptive exercises on
  unstable surfaces
• 5- Jumping on springboards is useful for
  enhancing proprioception without overloading the
  knee joint patient
• 6- Bicycling can be started for brief
  periods (10-15 mm) on a level road.
• 7- Jogging is allowed on a straight course
  for 10 min/day.

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Multidirectional rolling movement
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Single leg stand on balance board
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Phase 5 Third Postoperative Month

• Attending a gym

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Phase 6 Fourth Postoperative Month

• Goals
• 1-Increase leg strength
• 2-Advanced proprioception

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Phase 6 Fourth Postoperative Month

• 1- jogging time and distance may be increased,
  adding change of direction
• 2- uphill and downhill.
• 3- Bicycling is possible with increased
  distance and also uphill and downhill.
• 4- The swimming pool should be attended,
  performing freestyle and jumping into the water.
• 5- Proprioceptive exercises are continued.
• 6- Concentric quadriceps strengthening must
  be performed

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• "Kickers" use an elastic band fixed to the distal
  aspect of the involved or uninvolved limb. The
  athlete attempts to balance while executing short
  kicks with either knee extension or hip flexion.
  This exercise is most difficult when performed on
  unstable surfaces.

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Fifth postoperative month

• Goals
• functional training (prepare for return to
  sport and recreational lifestyle )

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Fifth postoperative month

• 1-The patient can practice running with
  acceleration, deceleration, and "stop and go"
• 2- return to sport-specific activities can begin
  including normal running, jumping, cutting,
  double and single hopping, vertical jumping.

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• Plyometrics begin with low-impact hopping,
  progressing to double-leg bounding, and finally
  single-leg hopping.

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Sixth postoperative month

• Goal
• Return to activity safely

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Sixth postoperative month

• Return to sports
• 1-Full training for 1 month prior to active
  return to competitive sport

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Criteria for return

• 1- No joint effusion
• 2- Full ROM
• 3- isokinetic testing indicates that
  strength of hamstring and quadriceps is 85- 100
  of the uninvolved leg
• 4- Satisfactory ligament stability
  testing using KT 1000 arthrometer
• 5- Successful performance during
  functional testing

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Thank you