Ipsilateral or Contralateral Graft

Rehabilitation after ACL reconstruction involves two different rehabilitation efforts with different goals. First is the rehabilitation of the knee as it pertains to the placement of the ACL graft intra-articularly. Second is the rehabilitation of the graft donor site. To do both effectively in the same knee, one rehabilitation effort must take precedence over the other to prevent the main complication of arthrofibrosis in the knee. Of utmost importance for the ACL graft in the short and long term is achieving full knee range of motion, including full hyperextension and the patient’s ability to kneel and sit back on his or her heels. Repetitive stress must be applied to the patellar tendon donor site to stimulate it to regrow in size and strength. The sooner this repetitive stress can be provided, the more one can take advantage of the inflammatory response from harvesting the middle third of the patellar tendon. These two goals for the ACL graft and the graft donor site are difficult to achieve simultaneously in the same knee without causing swelling and difficulty achieving full range of motion. Therefore when a graft is harvested from the ipsilateral knee, the goal of achieving full range of motion takes precedence over rehabilitating the graft donor site.

Our choice of whether to use an ipsilateral or a contralateral patellar tendon graft is based solely on individual patient goals. The senior author used ipsilateral grafts for primary ACL surgery from 1982 to 1994, but used contralateral grafts during that time period for revision ACL reconstruction when patients had already had the patellar tendon graft used in their involved knees for primary reconstruction. We observed the ease of rehabilitation experienced by patients when the contralateral patellar tendon was used for revision surgery, especially with regard to the quick return of knee range of motion in the ACL-reconstructed knee. Patients also reported that the ACL-reconstructed knee felt normal to them very early after surgery, and they were able to return to their normal activities and sports very quickly. We initially began using the contralateral graft for primary ACL reconstruction in high-level athletes who wanted a quick return to sport. With its success and ease for achieving full symmetrical range of motion and strength, we realized that the use of the contralateral graft was appropriate for any patient. We currently use the contralateral graft source for about 75% of patients.

The rehabilitation program explained in this chapter can be followed regardless of the graft source or surgical technique used, because the principles of rehabilitation and goals for patients are the same: to obtain knee symmetry for range of motion, strength, stability, and function. If the rehabilitation program provided follows the progression shown in Fig. 109.2 , all the patient’s goals can be met.

Effective rehabilitation involves following a progression of rehabilitation goals before and after anterior cruciate ligament (ACL) reconstruction. The two conflicting goals are done sequentially for patients who receive an ipsilateral graft and simultaneously for patients who receive a contralateral graft. ROM , Range of motion.

Operative Considerations

Postoperative rehabilitation begins in the operating room after graft placement. It is critical that full range of motion, including hyperextension and flexion so that the patient’s heel touches his or her buttocks, is achieved at this point to ensure the graft has not been overtensioned, resulting in a captured joint that prevents full motion. The success of the operation is initially dependent upon correct graft placement and then subsequently dependent upon providing proper rehabilitation to the ACL graft and the graft donor site in the knee.

We perform the following activities in the operating room and recovery room area to control swelling and pain and to facilitate rehabilitation:

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  A local anesthetic is applied to the patellar tendon in the operating room.

  
  
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  An infusion of ketorolac is used preoperatively, intraoperatively, and during the first 23 hours postoperatively, which allows us to avoid the use of narcotics.

  
  
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  External drains are placed in the region of the fat pad.

  
  
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  Antiembolism stockings are placed on both lower extremities.

  
  
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  Cold/compression devices are placed on both knees.

  
  
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  The ACL-reconstructed leg is placed into a continuous passive motion (CPM) machine set to move the knee from 0 to 30 degrees of flexion to provide gentle motion and elevate the lower leg.

  
  
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  The graft donor leg is also elevated on pillows so that both knees are elevated above the level of the heart.

  
  
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  Patients are kept in 23-hour outpatient observation to prevent hemarthrosis and allow initiation of immediate rehabilitation.

Phase I: Early Postoperative Period

Phase I rehabilitation continues on arrival to the outpatient hospital unit. We start with exercises for assisted flexion in a CPM machine for the ACL-reconstructed leg. The patient is instructed to maximally flex the CPM to 125 degrees and hold this position for 3 minutes. The CPM is progressed to maximum flexion slowly and as tolerated. Heel-slide exercises are performed for both the ACL-reconstructed leg and the contralateral donor site leg. A yardstick is positioned next to the leg, with the zero end aligned with the end of the heel ( Fig. 109.3 ). The yardstick provides a visual cue for patients to easily monitor the progress of knee flexion. Next, the patient flexes the knee with the help of a towel looped under the thigh until further flexion becomes difficult. The number of centimeters the heel has traveled is recorded. This number makes it easy for the patient and physical therapist to communicate changes in range of motion when the patient is at home. Flexion in the ACL-reconstructed leg should be approximately 110–120 degrees immediately postoperatively. When a contralateral graft is used, flexion in the donor knee should be full and equal to preoperative measurements, because harvesting the graft alone does not cause swelling and the patellar tendon has been stretched to maximal length while still in the operating room.

A yardstick is positioned next to the leg with the zero end aligned with the end of the heel. With heel-slide exercises (A) , the patient can easily monitor the amount of flexion as it corresponds to the number of centimeters on the yardstick (B) .

Patients prop both legs into extension with their heels resting on the ice water canister, allowing for any hyperextension. A small 2.5-pound weight is placed just distal to the incision on the ACL-reconstructed leg. This exercise is maintained for 10 minutes. Following the heel-prop exercise, the patient performs three to five knee thunk exercises on each knee, in which the patient flexes the knee to a height of several inches and then allows the leg to relax and “thunk” into hyperextension. Thunk exercises can be difficult for patients to perform on the ACL-reconstructed leg at first for fear of damaging the ACL reconstruction. Typically, therefore, thunk exercises are performed first on the noninvolved or graft donor leg so that the patient understands how hyperextension feels.

Towel stretches are performed as a passive self-mobilization technique using a towel looped around the midfoot. The towel ends are held in one hand while the other hand is used to press and hold the thigh to the table. The towel is used to lift the heel of the affected lower extremity to end-range hyperextension by pulling the end of the towel upward toward the shoulder, where it is held for a count of 5 seconds, and then the heel is lowered back to the table ( Fig. 109.4 ). Five to 10 towel stretch exercises are performed for each leg. Active heel-lift exercises are combined with the towel stretch to achieve good quadriceps control.

Towel stretch exercise.

The towel is used to lift the heel of the affected lower extremity to end-range hyperextension by pulling the end of the towel upward toward the shoulder.

Straight leg raise exercises for leg control are performed on both legs by having the patient first initiate a quadriceps muscle contraction and then focus on maintaining the knee in a locked-out position while lifting the leg so that the heel is 2–3 feet in the air. When the contralateral graft is used, high repetition stress to the graft donor site is accomplished while the patient remains in bed with using the Shuttle (Contemporary Design, Glacier, Washington). The Shuttle is a light-weight, low-resistance portable leg press machine. Resistance is provided by the placement of weighted rubber cords, each adding additional resistance. This weight is applied during both the concentric and eccentric movements. Twenty-five repetitions with one cord (7 pounds) are then completed with the emphasis on slow, controlled motion.

Following these exercises, the cold/compression devices are applied to the ACL-reconstructed knee and graft donor knee, and the ACL-reconstructed leg is placed back into the CPM set from 0 to 30 degrees, with the graft donor leg again propped up on pillows. The drains are removed from both knees the following morning, and an identical set of exercises is performed. At the end of this session, the patient stands and ambulates for the first time. The patient is instructed to stand and shift his or her weight over to the ACL-reconstructed leg and lock that leg into hyperextension with a quadriceps muscle contraction ( Fig. 109.5 ). The patient then ambulates to the door of the room and back using small steps. Patients are allowed to ambulate with full weight bearing as tolerated; however, the use of crutches or a walker is allowed for patients who are unsteady on their feet and are at risk of falling.

Standing habit.

The patient is instructed to stand on the anterior cruciate ligament-reconstructed leg so that the leg is extended into full hyperextension.

Patients are released home from the hospital the day after surgery. Patients are advised that flexion may decrease from the previous day in the ACL-reconstructed knee, but the flexion obtained initially after surgery should return gradually by 3 to 5 days after surgery. In general, patients are counseled against pushing flexion too hard in this period, as maintaining full extension is more important. Flexion in the contralateral graft donor knee should remain full.

Following discharge from the hospital, physical therapists call patients at home daily for the first week to monitor progress and answer questions that might arise. The previous list of exercises is carried out 3 times daily. If any loss of knee flexion in the contralateral donor leg occurs, patients stop performing leg press exercises with the Shuttle machine until full flexion returns. Daily flexion measurements are made using the yardstick, measuring the distance the heel travels on both knees. Patients are allowed to increase the number of repetitions performed during each session on a daily basis, up to 10 additional repetitions per day. When 100 repetitions become easy for the patient, an additional cord can be added for progressive resistance, but the number of repetitions is decreased to 50 per session. The patient is allowed to then begin progressing up to 100 repetitions again with the increased weight. In the ACL-reconstructed leg, knee extension is emphasized more than flexion during this phase. If the amount of knee extension plateaus or decreases, exercise to increase flexion should be deceased accordingly. Patients are warned that exercises will become more difficult at day 2 or 3 after surgery, before gradually improving as a result of the body metabolizing the ketorolac medication. During the first week after surgery, patients are allowed out of bed only 2 to 3 times daily for bathroom needs.

Postoperative Rehabilitation Phase II

The first postoperative visit is at 1 week after surgery. Rehabilitation remains unique to each leg. The patient continues to work on maintaining full extension of the ACL-reconstructed knee while concentrating on patellar tendon remodeling and regrowth in the graft donor knee through the use of strengthening exercises and maintaining full flexion.

The primary goal is full extension of the ACL-reconstructed leg; 110 degrees of knee flexion is a secondary goal and represents the average flexion in this period. No patients should have less than 90 degrees of flexion. Full flexion is expected in the graft donor knee.

Next, quadriceps muscle control is assessed. Each patient should be able to perform a straight leg raise without a lag and perform an active heel lift, contracting the quadriceps muscle with the knee in a hyperextended position. The patient should also have sufficient quadriceps muscle control to ambulate stairs using only the handrail for balance. Stance and gait training includes using a mirror to help the patient visualize and understand the correct position of a hyperextended knee in stance, as well as working on gait using a decreased step length and focusing on terminal extension during initial contact with overemphasized heel contact.

Whenever sitting, the patient should be performing a heel prop to work on passive extension on the ACL-reconstructed leg. Whenever standing, weight should be shifted to the ACL-reconstructed leg locking the knee into hyperextension. Towel stretches are continued through this phase, as the importance of full symmetrical hyperextension cannot be overemphasized. Knee flexion exercises are also implemented for the ACL-reconstructed knee. The goal for the end of week 2 is 120 degrees. Exercises including heel slides and wall slides are routinely given. All range-of-motion exercises are performed 2 to 4 times a day during the intermediate phase.

During week 2, the CPM is discontinued while cold/compression therapy continues. Shuttle exercises for the contralateral graft donor leg are progressed as described previously, as long as the patient retains full flexion. Front step-down exercises are initiated at this point, and patients start with 25 repetitions 2 to 3 times per day on the 2-inch step. This is progressed until the patient is performing 100 repetitions on the 2-inch step. The patient independently advances this progression based on the amount of donor site soreness. The step box, a hinged, foldable device, allows step exercises from heights up to 8 inches. Patients are instructed to perform front step-down exercises, focusing on quality of form and technique rather than quantity performed. Balancing on the graft donor leg with the hands placed on the hips, the patient lowers the heel of the opposite leg to the floor in front of the step box until it touches the floor. It is important for the patient to keep the pelvis in a neutral position during the descent phase to prevent compensation from the hip musculature.

The second postoperative visit takes place 2 weeks after surgery. By this time, patients should report that they are back to performing their full normal activities of daily living independently. In the ACL-reconstructed knee, 120 degrees of flexion is expected in addition to full extension. Effusion should be well controlled. Excessive effusion is indicative of an overly intense activity level and should be addressed immediately. Patients should be instructed to return to a decreased level of activity, with the leg elevated on pillows and continuous usage of the cold/compression device until the swelling has returned to an expected baseline amount. During this time, full flexion and extension in the graft donor knee should be maintained. Normal gait should be demonstrated, and patients should be able to ambulate up and down stairs without holding onto the handrail.

When a graft from the contralateral knee is used, the goal of rehabilitation for the graft donor site between weeks 2 and 4 is remodeling and regrowth of the donor patellar tendon through high-repetition, low-resistance exercise carried out several times daily. These exercises are essential to avoid long-term donor site pain. Patients are instructed in leg press and knee extension exercises, as well as continuation of the step-down exercises. These exercises should not be performed on the ACL-reconstructed leg until full knee range of motion is obtained. Typically patients are asked to start with half their body weight or less for the leg press and 2–5 pounds with the knee extension exercise. These exercises can be performed every other day to ensure that the graft donor site does not become overly sore. Three to five sets of 10–12 repetitions of each exercise are usually sufficient. The weight used for both exercises can be progressed slowly as the patient improves in strength.

By the 1-month visit, the goal is for patients to be able to comfortably sit on their heels with their ankles in maximal plantarflexion, indicative of full knee flexion. Motion exercises for the ACL-reconstructed knee remain the same as weeks 1 and 2. Extension habits are again reviewed and reinforced, because some patients have trouble integrating them into their daily routine.

Postoperative Rehabilitation Phase III: Advanced Strengthening

Four weeks after surgery, the patient returns for strength testing. When an ipsilateral graft is used, patients can begin strengthening the ACL-reconstructed leg if the knee has full range of motion and very little swelling. The exercises and progression for strengthening the ACL-reconstructed leg are the same as those prescribed for the graft donor leg, with the concentration on single leg strengthening exercises as described previously. The patient adjusts the amount and intensity of the strengthening exercises based on whether he or she experiences any decrease in range of motion or an increase in knee swelling. Typically patients have about 60% quadriceps muscle strength in the ACL-reconstructed leg compared with the normal leg. Patients should perform single leg strengthening until they achieve 90% strength in the ACL-reconstructed leg; then they can continue with bilateral leg strengthening exercises.

When a contralateral graft is used, the recovery of strength to preoperative normal levels is not as important as symmetry between the ACL-reconstructed leg and the graft donor leg. For a patient doing well, isokinetic strength in the graft donor leg should be within 10% of the ACL-reconstructed knee.

The ability to return to activities depends on the strength of the graft donor knee, the presence of full motion in both knees, and the lack of an effusion in the ACL-reconstructed knee. If symmetrical quadriceps muscle strength (differences of less than 10% on testing) is achieved, the patient begins bilateral strengthening and conditioning exercises. Leg press, knee extension, and step-down exercises are now performed on both legs, with the patient doing the exercises with each leg independently and continuing to progress the intensity by adding weight as possible. If the quadriceps muscle strength is not within 10% between legs, the patient continues with strengthening the graft donor leg only.

Low-impact conditioning, including stationary bike, stair-stepping machine, or elliptical trainer, is added. These activities need to be started very slowly and cautiously as the amount of swelling in the ACL-reconstructed knee is monitored. Typically most patients’ tolerance starts with 10 minutes every other day and increases to 20–30 minutes over the course of the next 4 weeks. Patients who have had an ipsilateral graft need to know that these low-impact conditioning exercises will not help strengthen the leg. Given that both legs are involved, it is difficult for patients to use both legs equally when there is more than a 10% discrepancy in strength between legs. Therefore these exercises should not replace the specific single leg exercises prescribed.

Straight-line forward and backward jogging, lateral slides, and crossover agility steps can be introduced. Shooting baskets or other individual noncompetitive sport-specific drills are performed as tolerated. These agility activities are done in a controlled situation and do much to keep athletes motivated toward their goals, but again these activities should not replace specific strengthening exercises. No competitive situations are allowed at this time.

Postoperative Rehabilitation Phase IV: Return to Competition

There are no strict guidelines as to when a patient may return to sports. Patients return to the clinic for follow-up testing and adjustment to their home exercise programs and activity level regularly at 2-, 4-, and 6-month visits. Symmetry, in the form of equal strength, full range of motion, and joint effusion, is evaluated at each visit. Once symmetry is achieved between both knees, the level of activity can be increased slowly to include return to sports activities.

During the return to full activities, the patient must monitor swelling and range of motion daily. If swelling occurs or the knee loses any extension or flexion, the patient must back off on activities, ice the knee, and perform range-of-motion exercises.

When the patient first returns to athletic practice or competition, it should be done on an every-other-day basis. The initial return to activities is similar to that of a weight-lifting program. The athlete, while doing the activity, may feel and perform normally but may become quite sore afterward. Thus the athlete can practice as usual one day but then needs to take a day off to allow the knee (or knees) to recover. We have found that coaches sometimes do not understand this process and put pressure on the athlete to practice and compete every day. It is important for the physician and physical therapist to communicate directly with the coach to explain that having athletes practice every other day will allow them to do the sport with better quality when they are practicing, and to eventually return to full competition faster instead of having long-term problems with knee soreness that are difficult to resolve with everyday activity.