Rehabilitation after ACL reconstruction

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Rehabilitation after ACL reconstruction

• Pichet Yiemsiri

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Over views

• Incidence exact incidence is unknown
• United States
• 200,000 are torn each year
• 100,000 ACL reconstructions are done each year
• associated with menisci tear in 50 of case

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Rehabilitation Considerations after ACL
Reconstruction
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Evidences base

• ACL Reconstruction Rehabilitation

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Guideline on anterior cruciate ligament injuryA
multidisciplinary review by the Dutch Orthopaedic
Association
Acta Orthopaedica 2012 83 (4) 379386
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What is the outcome of different non-operative
treatment modalities?

• Scientific evidence
• Level 1
• Balance and proprioception

Fitzgerald et al. 2000, Cooper et al. 2005,
Trees et al. 2005, 2007
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What is the outcome of different non-operative
treatment modalities?

• Scientific evidence
• Level 2
• Addition of open-chain strength training
• Supervised training

Zatterstrom et al. 2000, Perry et al. 2005,
Tagesson et al.2008
Zatterstrom et al. 1998, 2000
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What is the outcome of different non-operative
treatment modalities?

• Scientific evidence
• Level 3
• wearing a knee brace

Swirtun et al. 2005
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What is the optimal postoperative treatment ?

• Scientific evidence
• Level 1
• Wearing a knee brace has no additional treatment
  value after an ACL reconstruction
• Closed-chain exercise

Wright and Fetzer 2007, Anderson et al. 2009
Trees et al. 2005, Wrightet al. 2008, Anderson
et al. 2009
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What is the optimal postoperative treatment?

• Scientific evidence
• Level 2
• Addition of neuromuscular training
• Early open-chain exercises will lead to more
  laxity with hamstring grafts

Risberg et al. 2007
Heijne and Werner 2007
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Pain effusion management

• Cryo-therapy
• Elevation
• Compression
• Anti-inflammatory medication

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ROM exercise

• Knee extension to 0 degrees after surgery while
  avoiding hyperextension
• Prevent a flexion contracture
• Hip AROM exercise 4 planes

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Continuous Passive Motion

• CPM is not warranted to improve rehabilitation
  outcome

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Protocols after ACL reconstruction

• Time frames and guidelines after ACL
  reconstruction vary widely.
• Most protocols emphasize
• Early motion
• Developing quadriceps control early
• Obtaining full passive extension
• Controlled weight bearing
• Initiation of closed-chain exercises

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Preoperative Phase

• Goals
• Diminish inflammation, swelling, and pain.
• Restore normal ROM (especially knee extension).
• Restore voluntary muscle activation.
• Provide patient education to prepare patient for
  surgery.

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Preoperative Phase

• Exercises
• Ankle pumps.
• Passive knee extension to 0.
• Passive knee flexion to tolerance.
• SLR three-way, flexion, abduction, adduction.
• Closed-kinetic chain exercises 30-degree
  mini-squats, lunges, step-ups.

• Brace
• Elastic wrap or knee sleeve to reduce swelling.
• Weight-bearing
• As tolerated with or without crutches.

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Preoperative Phase

• Muscle Stimulation
• Electrical muscle stimulation to quadriceps
  during voluntary quadriceps exercises (4-6
  hr/day)
• Cryo-therapy/Elevation
• Apply ice 20 min of every hour, elevate leg with
  knee in full extension (knee must be above
  heart).

• Patient Education
• Review postoperative rehabilitation program.
• Review instructional video (optional).
• Select appropriate surgical date.

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Phase 1 Immediate Postoperative-Days 1-7
Day 1

• Brace
• Transitional hinged brace locked in full
  extension during ambulation (Protonics Rehab
  System as directed by physician).
• Weight-bearing
• Weight-bearing as tolerated with two crutches.

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Phase 1 Immediate Postoperative-Days 1-7
Day 1

• Exercises
• Ankle pumps.
• Overpressure into full passive knee extension
• Active and passive knee flexion (90 by day 5)
• SLR (flexion, abduction, adduction).
• Quadriceps isometric setting.
• Hamstring stretches.

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Phase 1 Immediate Postoperative-Days 1-7
Day 1

• Muscle Stimulation
• Used during active muscle exercises (4-6 hr/day).
• Continuous Passive Motion
• As needed, 0-45/50 degrees (as tolerated by
  patient and directed by physician).
• Ice and Elevation
• Ice 20 min out of every hour and elevate with
  knee in full extension (elevated above the heart
  with pillows below the ankle, not the knee).

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Phase 1 Immediate Postoperative-Days 1-7
Days 2-7

• Goals
• Restore full passive knee extension.
• Diminish joint swelling and pain.
• Restore patellar mobility.
• Gradually improve knee flexion.
• Reestablish quadriceps control.
• Restore independent ambulation.

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Phase 1 Immediate Postoperative-Days 1-7
Days 2-7

• Brace
• EZ Wrap brace/immobilizer, locked at O-degrees
  extension for ambulation and unlocked for sitting
  (or Protonics Rehab System as directed by
  physician).
• Weight-bearing
• As tolerated with two crutches.

• Range of Motion
• Brace removed during ROM exercises 4-6 times a
  day.

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Phase 1 Immediate Postoperative-Days 1-7
Days 2-7

• Exercises
• Multi-angle isometrics and 90 and 60 (knee
  extension).
• Knee extension 90-40 degrees.
• Overpressure into extension.
• Ankle pumps.
• SLR (three-way).
• Mini-squats and weight shifts.
• Standing hamstring curls.
• Quadriceps isometric setting.
• Proprioception and balance activities.

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Phase 1 Immediate Postoperative-Days 1-7
Days 2-7

• Muscle Stimulation
• Continue electrical muscle stimulation 6 hr/day.
• Continuous Passive Motion
• 0 - 90 as needed.
• Ice and Elevation
• Ice 20 min of every hour and elevate leg with
  full knee extension.

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Phase 2 Early Rehabilitation-Weeks 2-4

• Criteria for Progression to Phase 2
• Quadriceps control (ability to perform good quad
  set and SLR).
• Full passive knee extension.
• Passive ROM 0-90 degrees.
• Good patellar mobility.
• Minimal joint effusion.
• Independent ambulation.

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Phase 2 Early Rehabilitation-Weeks 2-4

• Goals
• Maintain full passive knee extension.
• Gradually increase knee flexion.
• Decrease swelling and pain.
• Muscle training.
• Restore proprioception.
• Patellar mobility.

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Phase 2 Early Rehabilitation-Weeks 2-4
Week 2

• Brace
• Discontinue at 2-3 wk.
• Weight-bearing
• As tolerated (goal is to discontinue crutches 10
  days after surgery).
• Range of Motion
• Self-ROM stretching exercises four to five times
  daily, emphasis on maintaining full passive ROM.

• Swelling Control
• Ice, compression, elevation

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Phase 2 Early Rehabilitation-Weeks 2-4
Week 2

• Exercises
• Muscle stimulation to quadriceps exercises.
• Isometric quadriceps sets.
• SLR (four planes).
• Leg press.
• Knee extension 90-40
• Half squats (0-40).
• Weight shifts.
• Front and side lunges.
• Hamstring curls

• Bicycling.
• Proprioception training.
• Overpressure into extension.
• Passive ROM 0-50 degrees.
• Patellar mobilization.
• Well-leg exercises.
• Progressive resistance program start with 1
  pound and progress I pound per week.

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Phase 2 Early Rehabilitation-Weeks 2-4
Week 3

• Range of Motion
• Continue ROM stretching and overpressure into
  extension.
• Exercises
• Continue all exercises as in week 2.
• Passive ROM 0-115.
• Bicycling for ROM stimulus and endurance.

• Pool walking program
• Eccentric quadriceps program 40-100 (isotonic
  only).
• Lateral lunges.
• Lateral step-ups.
• Front step-ups.
• Lateral step-overs (cones).
• Stair-stepper machine or elliptical trainer.
• Progress proprioception drills, neuromuscular
  control drills.

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Phase 3 Controlled Ambulation-Weeks 4-10

• Criteria for Progression to Phase 3
• Active ROM 0-115.
• Quadriceps strength 60 of contralateral side
  (isometric test at 60 degrees knee flexion).
• Unchanged KT test bilateral values ( 1 or less).
• Minimal or no full joint effusion.
• No joint line or patellofemoral pain.

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Phase 3 Controlled Ambulation-Weeks 4-10

• Goals
• Restore full knee ROM (0-125).
• Improve lower extremity strength.
• Enhance proprioception, balance, and
  neuromuscular control.
• Restore limb confidence and function.

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Phase 3 Controlled Ambulation-Weeks 4-10
Week 4

• Range of Motion
• Self-ROM (four to five times daily using the
  other leg to provide ROM), emphasis on
  maintaining 0 passive extension.

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Phase 3 Controlled Ambulation-Weeks 4-10
Week 4

• Exercises
• Progress isometric strengthening program.
• Leg press.
• Knee extension 90-40.
• Hamstring curls.
• Hip abduction and adduction.
• Hip flexion and extension.
• Lateral step-overs.
• Lateral lunges.

• Lateral step-ups.
• Front step-downs.
• Wall squats.
• Vertical squats.
• Toe calf raises.
• Biodex Stability System (e.g., balance, squats).
• Proprioception drills.
• Bicycling.
• Stair-stepper machine.
• Pool program (backward running, hip and leg
  exercises).

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Phase 3 Controlled Ambulation-Weeks 4-10
Week 6

• Exercises
• Continue all exercises.
• Poor running (forward), agility drills.
• Balance on tilt boards.
• Progress to balance and board throws.

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Phase 3 Controlled Ambulation-Weeks 4-10
Week 8

• Exercises
• Continue all exercises.
• Plyometric leg press.
• Perturbation training.
• lsokinetic exercises (90-40).
• Walking program.
• Bicycling for endurance.
• Stair-stepper machine for endurance

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Phase 3 Controlled Ambulation-Weeks 4-10
Week 10

• Isokinetic Test
• Concentric knee extension-flexion at 180 and
  300/sec
• Exercises
• Continue all exercises.
• Plyometric training drills.
• Continue stretching drills.

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Phase 4 Advanced Activity-Weeks 10-16
Criteria for Progression to Phase4

• Active ROM 0-125 degrees or greater.
• Quadriceps strength 79 of contralateral side.
• Knee extension flexor extensor ratio 70- 75.
• No change in KT values (comparable with
  contralateral side, within 2 mm).
• No pain or effusion.
• Satisfactory clinical examination.

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Phase 4 Advanced Activity-Weeks 10-16
Criteria for Progression to Phase4

• Satisfactory isokinetic test (values at 180
  degrees)
• Quadriceps bilateral comparison 75.
• Hamstrings equal bilateral.
• Quadriceps peak torque-to-body weight ratio.
• Hamstrings quadriceps ratio 66- 75.
• Hop test 80 of contralateral leg.
• Subjective knee scoring (modified Noyes system)
  80 points or better.

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Phase 4 Advanced Activity-Weeks 10-16

• Goals
• Normalize lower extremity strength.
• Enhance muscular power and endurance.
• Improve neuromuscular control.
• Perform selected sport-specific drills.
• Exercises
• Continue all exercises.

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Phase 5 Return to Activity-Months 16-22

• Criteria for Progression to Phase 5
• Full ROM.
• Unchanged KT 2000 test (within 2.5 mm of opposite
  side).
• Isokinetic test that fulfills criteria.
• Quadriceps bilateral comparison 80.
• Hamstring bilateral comparison 110.
• Quadriceps torque body weight ratio 70.
• Proprioceptive test 100 of contralateral leg.
• Functional test 85 of contralateral side.
• Satisfactory clinical examination.

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Phase 5 Return to Activity-Months 16-22

• Goals
• Gradual return to full unrestricted sports.
• Achieve maximal strength and endurance.
• Normalize neuromuscular control.
• Progress skill training.

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Phase 5 Return to Activity-Months 16-22

• Exercises
• Continue strengthening exercises.
• Continue neuromuscular control drills.
• Continue plyometrics drills.
• Progress running and agility program.
• Progress sport-specific training.
• 6- and 12-Month Follow-up
• Isokinetic test.
• Functional test.

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Thank you