Modalities

In the immediate postoperative period (1–3 days), knee effusion must be controlled to avoid the quadriceps inhibition phenomenon. Electrogalvanic stimulation or high-voltage electrical muscle stimulation (EMS) may be used to augment the ice, compression, and elevation program to control swelling. This treatment uses the concept of like charges repelling. The effusion or swelling has a negative electrical charge, so using the negative electrodes at the knee and the positive (dispersive) electrode on either the low back or the opposite thigh will assist the body in removing the fluid from the joint to be reabsorbed. The treatment duration is approximately 30 minutes, the intensity is set to patient tolerance, and the treatment frequency is three to six times per day. Once the joint effusion is controlled, functional EMS is begun for muscle reeducation and quadriceps facilitation (Table 13-2).

TABLE 13-2 Cincinnati Sportsmedicine and Orthopaedic Center Rehabilitation Protocol for Primary Anterior Cruciate Ligament Reconstruction: Early Return to Strenuous Activities

The use of EMS to facilitate and enhance an adequate quadriceps contraction is based on the evaluation of quadriceps and vastus medialis oblique (VMO) muscle tone. One electrode is placed over the VMO and the second electrode is placed on the central to lateral aspect of the upper third of the quadriceps muscle belly (Fig. 13-1). The treatment duration is 20 minutes. The patient actively contracts the quadriceps muscle simultaneously with the machine’s stimulation. A portable EMS machine for home use may be required in individuals whose muscle rating is poor. EMS is continued until the muscle grade is rated as good.

FIGURE 13-1 Electrical muscle stimulation is used to facilitate and enhance an adequate quadriceps contraction early postoperatively.

Biofeedback therapy also has an important role in facilitating an adequate quadriceps muscle contraction early postoperatively. The surface electrode is placed over the selected muscle component to provide positive feedback to the patient and clinician regarding the quality of active or voluntary quadriceps contraction (Fig. 13-2). Biofeedback is also useful in enhancing hamstring relaxation if the patient experiences difficulty achieving full knee extension secondary to knee pain or muscle spasm. The electrode is placed over the belly of the hamstring muscle while the patient performs range of motion (ROM) exercises.

FIGURE 13-2 Biofeedback therapy is implemented to facilitate an adequate quadriceps muscle contraction early postoperatively.

The most widely used modality after ACL reconstruction is cryotherapy, which is begun in the recovery room after surgery. Cost of various cryotherapy options and patient compliance are two major factors in the successful control of postoperative pain and swelling. The standard method of cold therapy is an ice bag or commercial cold pack, which is kept in the freezer until required. Empirically, patients prefer motorized cooler units (Fig. 13-3). These units maintain a constant temperature and circulation of ice water through a pad, which provides excellent pain control. Gravity flow units are also effective; however, temperature maintenance is more difficult with these devices than with the motorized cooler units. The temperature can be controlled by using gravity to backflow and drain the water, refilling the cuff with fresh ice water as required. Cryotherapy is used for 20 minutes at a time from three times a day to every waking hour depending upon the extent of pain and swelling. In some cases, the treatment time is extended owing to the thickness of the buffer used between the skin and the device. The motorized units contain a thermostat, which is helpful when cold therapy is used for an extended treatment time. Vasopneumatic devices offer another option for cold therapy. The Game Ready device (Game Ready, Berkeley, CA) allows the clinician to set the temperature and, as well, one of four different compression levels depending on patient tolerance. Although this is primarily a clinical treatment tool, it may be used at home as well. Cryotherapy is typically done after exercise or when required for pain and swelling control and is maintained throughout the entire postoperative rehabilitation protocol.

FIGURE 13-3 A motorized cooler unit used to provide cryotherapy.