ACL rehabilitation after ACL reconstruction

Rehabilitation after ACL reconstruction

Physical Examination

• History
• Chief complaints
• Pain assessment
• Observation
• Palpation
• Examination
• Special test

REHABILITATION CONSIDERATIONS

• Pain and Effusion
• Motion loss
• Continuous Passive Motion
• Weight-bearing status
• Muscle training
• Electrical muscle stimulation & Biofeedback
• Proprioception
• ACL bracing
• Gender issues

Preoperative Phase

Goals:

• Diminish inflammation
• Restore normal ROM
• Restore voluntary muscle activation
• Provide patient education to prepare for surgery

Brace:

• Elastic wrap or knee sleeve to reduce swelling

Weight bearing:

• As tolerated with or without crutches

Exercises:

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

Muscle Stimulation:

• Electrical muscle stimulation to quadriceps during voluntary quadriceps exercises(4-6 hr/day)

 Cryotherapy/ Elevation:

• Apply ice 20 min of every hour, elevate leg with knee in full extension (Knee must be above heart)

Patient Education

• Review post operative rehabilitation program
• Review instructional video (optional)
• Select appropriate surgical date

Phase 1: Immediate postoperative – Days 1 – 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

Day 1

Brace

• Transitional hinged brace locked in full extension during ambulation

Weight bearing:

• Weight bearing as tolerated with two crutches

Exercises:

• Ankle pumps
• Overpressure into full passive knee extension
• Active and passive knee flexion(90 degrees by day 5)
• SLR (flexion, abduction, adduction)
• Quadriceps isometric setting
• Hamstring stretches
• Closed – kinetic chain exercises, 30 degree mini-squats, weight shifts

Muscle stimulation:

• Used during active muscle exercises(4-6 hr/day)

 CPM:

• 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)

Day 2- 3

Brace:

• Brace locked at 0-degrees extension for ambulation and unlocked for sitting

Weight-bearing:

• As tolerated with two crutches

Range of motion:

• Brace removed for ROM exercises for 4-6 times a day

Exercises:

• Multiangle isometrics and 90 degrees and 60 degrees (knee extension)
• Knee extension 90-40 degrees
• Overpressure into extension
• Ankle pumps
• SLR (three-way)
• Minisquats and weight shifts
• Standing hamstring curls
• Quadriceps isometric setting
• Proprioception and balance activities

Muscle stimulation:

• 6 hr/day

CPM:

• 0-90 degrees as needed

Ice and elevation:

• Ice 20 min of every hour and elevate leg with full knee extension

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

Goals:

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

Week 2

Brace:

• Discontinue at 2-3 week

Weight-bearing:

• As tolerated (goal is to discontinue crutches 10 days after surgery)

ROM:

• Self-ROM stretching exercises 4-5 times daily, emphasis is on maintaining full passive ROM

Exercises:

• Isometrics quadriceps sets
• SLR four planes)
• Leg press
• Knee extension 90-40 degrees
• Half squats(0-40 degrees)
• Weight shifts
• Front and side lunges
• Hamstring curls
• Bicycling
• Proprioception training
• Overpressure into extension
• Passive ROM 0-50 degrees
• Patellar mobilization
• Well-leg exercises
• PRE: start with 1 pound & progress 1 pound/week

Swelling control:

• Ice
• Compression
• elevation

Week 3

Brace:

• Discontinue

ROM:

• Continue ROM stretching and overpressure into extension

Exercises:

• Continue all exercises as in week 2
• Passive ROM 0-115 degrees
• Bicycling for ROM stimulus and endurance
• Pool walking program (if incision is closed)
• Eccentric quadriceps program 40-100 degrees (isotonic only)
• Lateral lunges
• Lateral step ups
• Front step ups
• Lateral step-overs (cones)
• Stair-stepper machine/elliptical trainer
• Progress proprioception drills, neuromuscular control drills

Phase 3: Controlled Ambulation – Weeks 4-10

Criteria for progression to Phase 3:

• Active ROM 0-115 degrees
• Quadriceps strength 60% of contralateral side (isometric test at 60 degrees knee flexion)
• Minimal or full no joint effusion
• No joint line or patellofemoral pain

Goals:

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

Brace:

• No immobilizer or brace

ROM:

• Self-ROM (4-5 times daily using the other leg to provide ROM), emphasis on maintaining 0 degrees passive extension

Week 4

Exercises:

• Progress isometric strengthening program
• Leg press
• Knee extension 90-40 degrees
• 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 & leg exercises
• Continue all exercises
• Poor running (forward), agility drills
• Balance on tilt boards
• Progress to balance and board throws

Week 5

Exercises:

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

Week 6

Exercises:

• Continue all exercises
• Plyometric leg press
• Pertubation training
• Isokinetic exercises (90-40 degrees) (120-240 degrees/sec)
• Walking program
• Bicycling and stair stepper for endurance

Week 7

Exercises:

• Continue all exercises
• Plyometric training drills
• Continue stretching drills

Phase 4: Advanced Activity – Weeks 10-16

Criteria for progression to Phase 4:

• Active ROM 0-125 degrees or greater
• Quadriceps strength 79% of  contralateral side
• Knee extension flexor : extensor ratio 70-75%
• No pain or effusion
• Satisfactory clinical examination
• Satisfactory isokinetic tests (values at 180 degrees)
• Quadriceps bilateral comparision 75%
• Hamstring equal bilateral
• Hop test 80% of contralateral leg
• Subjective knee scoring (modified noyes system) 80 points or better

Goals:

• Normalize lower extremity strength
• Enhance muscular power and endurance
• Improve neuromuscular control
• Perform selected sport-specific drills

Exercises:

• Continue all exercises

Phase 5: Return to Activity – Months 16-22

Criteria for progression to Phase 5:

• Full ROM
• Satisfactory clinical examination
• Subjective knee scoring (modified noyes system) >/= 90 points

Goals:

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

Exercises:

• Continue strengthening exercises
• Continue neuromuscular control drills
• Continue plyometrics drills
• Progress running and agility program
• Progress sport-specific training

Criteria for return to sports

• Quadriceps strength 85% or more of  contralateral side
• Hamstring strength 100% of  contralateral side

o   No pain/ effusion/or other symptoms

• Functional test battery 85% or greater compared to contralateral side:

o   single-leg hop

o   timed leg hop for 20 ft

o   vertical jump

Complications

• Loss of motion
• Anterior knee pain