CLINICAL CONCEPTS

The two anterior cruciate ligament (ACL) postoperative rehabilitation protocols described in this chapter consist of a careful incorporation of exercise concepts supported by the scientific data presented in Chapter 12, Scientific Basis of Rehabilitation after Anterior Cruciate Ligament Autogenous Reconstruction. The protocols are evaluation-based; that is, progression through the program is based on continual evaluation using the principles of anatomy, physiology, biomechanics, and surgery 2–5,7,14–17 and understanding that the overall goals of the reconstruction and rehabilitation are to

Regain normal knee stability (<3 mm of increased anteroposterior [AP] displacement on knee arthrometer testing, negative or trace pivot shift).

Control joint pain, swelling, and hemarthrosis.

Regain a normal range of knee motion.

Restore a normal gait pattern and neuromuscular stability for ambulation.

Recover normal lower limb muscle strength.

Regain normal proprioception, balance, coordination, and neuromuscular control for desired activities.

Achieve optimal functional outcome based on orthopaedic and patient goals.

Each patient is taken through the appropriate program at a rate that takes into account sports and occupational goals; the condition of the articular surfaces, menisci, and other knee ligaments; concomitant operative procedures performed with the ACL reconstruction; the type of graft used; postoperative healing and response to surgery; and biologic principles of graft healing and remodeling. The protocols are divided into seven phases according to the time period postoperatively (e.g., phase I comprises postoperative wk 1–2). Each phase has four main categories that describe the factors evaluated by the therapist and exercises performed by the patient:

General observation of the patient’s condition.

Evaluation and measurement of specific variables, with goals identified for each variable.

Treatment and exercise program according to frequency and duration.

Rehabilitation goals that must be achieved to enter the next phase.

The first protocol is designed for patients who undergo primary ACL bone–patellar tendon–bone (B-PT-B) autogenous reconstruction and desire to return to strenuous sports or work activities as soon as possible after surgery. All patients are warned that the return to strenuous activities early postoperatively carries a risk of either a reinjury to the ACL-reconstructed knee or a new injury to the contralateral knee. These risks cannot be scientifically predicted and patients are cautioned to return to strenuous activities carefully and avoid any activity in which pain, swelling, or a feeling of instability develops. Patients who enter this protocol who develop postoperative problems such as knee motion complications, chronic effusion, patellofemoral pain, or patellar tendinitis are advised to slow the rate of progression until the problems are resolved. The following criteria exclude a patient from this protocol:

Concomitant major operative procedures including meniscal repair, ligament reconstruction, patellofemoral realignment, articular cartilage restorative procedure, and osteotomy.

Prior ACL reconstruction that has failed.

Residual muscular atrophy with chronic instability.

Magnetic resonance imaging (MRI) or arthroscopic evidence of major bone bruising or articular cartilage damage.

Critical Points CLINICAL CONCEPTS

Protocols are evaluation-based: progression is based on continual evaluation using the principles of anatomy, physiology, biomechanics, and surgery.

Goals

• Regain normal knee stability.

• Control joint pain, swelling, hemarthrosis.

• Regain normal range of knee motion.

• Restore normal gait pattern.

• Recover normal lower limb muscle strength.

• Regain normal proprioception, balance, coordination, and neuromuscular control.

• Achieve optimal functional outcome based on orthopaedic and patient goals.

The protocols are divided into seven phases according to the time period postoperatively. Each phase has four categories:

• General observation of the patient’s condition.

• Evaluation and measurement of specific variables, with goals identified for each variable.

• Treatment and exercise program according to frequency and duration.

• Rehabilitation goals that must be achieved to enter into the next phase.

One protocol for patients who undergo primary anterior cruciate ligament (ACL) bone–patellar tendon–bone (B-PT-B) autogenous reconstruction and desire to return to strenuous sports or work activities as soon as possible after surgery.

Second protocol for ACL revision reconstruction, primary ACL allograft or semitendinosus-gracilis autograft reconstruction, complex reconstruction in which major concomitant operative procedures were performed or in whom significant articular cartilage lesions were found during the operation.

Both protocols incorporate home self-management program.

Neuromuscular-retraining program (Sportsmetrics) advocated for all patients returning to high-risk activities.

First postoperative week critical for all patients: control pain and swelling, demonstrate adequate quadriceps muscle contraction, immediate knee motion, and adequate limb elevation.

A second protocol, designed to delay or diminish knee joint and graft loading, is used for patients who undergo ACL revision reconstruction (with either allogeneic or autogenic tissue), primary ACL allograft or semitendinosus-gracilis autograft reconstruction, or complex B-PT-B autogenous reconstruction in which major concomitant operative procedures were performed or in whom significant articular cartilage lesions were found during the operation. Delays in return of full weight-bearing, initiation of certain strengthening and conditioning exercises, initiation of running and agility drills, and return to full sports activities are incorporated. This protocol is designed to protect healing concomitant meniscal or ligament repairs or allograft tissues and avoid exacerbating articular cartilage deterioration or symptoms.

Specific criteria are evaluated throughout both rehabilitation programs to determine whether the patient is ready to progress from one phase to the next. Both protocols incorporate a home self- management program, along with an estimated number of formal physical therapy visits (Table 13-1). For most patients, 11 to 21 postoperative visits are expected to produce a desirable result. A few more supervised sessions may be required between the 6th and the 12th postoperative month for patients who undergo advanced training to return to strenuous activities. A specific neuromuscular-retraining program (Sportsmetrics) is advocated for all patients returning to high-risk activities, discussed in Chapter 19, Decreasing the Risk of Anterior Cruciate Ligament Injuries in Female Athletes. For all patients, the following signs are continually monitored postoperatively: joint swelling, pain, gait pattern, knee moion, patellar mobility, muscle strength, flexibility, and AP displacement. Any individual who experiences difficulty progressing through the protocol or who develops a complication is expected to require additional supervision in the formal clinic setting.

TABLE 13-1 Estimated Supervised Physical Therapy Visits after Anterior Cruciate Ligament Reconstruction

The 1st postoperative week represents a critical time period for all patients in regard to control of knee joint pain and swelling, demonstration of adequate quadriceps muscle contraction, initiation of immediate knee motion exercises, and maintenance of adequate limb elevation. A bulky compression dressing is used for 48 hours and then converted to compression stockings with an additional Ace bandage if necessary. Patients are encouraged to stay in bed and elevate the limb above their heart for the first 5 to 7 days, rising only to perform exercises and attend to personal bathing issues. Prophylaxis against deep venous thrombosis includes one aspirin a day for 10 days, ambulation (with crutch support) six to eight times a day for short periods of time, ankle pumping every hour that the patient is awake, and close observation of the lower limb by the therapist and surgeon. Knee joint hemarthroses require aspiration. Nonsteroidal anti-inflammatories are used for at least 5 days postoperative. Appropriate pain medication is prescribed to provide relief and allow the immediate exercise protocol described later to be performed.

REHABILITATION PROTOCOL FOR PRIMARY ACL B-PT-B AUTOGENOUS RECONSTRUCTION: EARLY RETURN TO STRENUOUS ACTIVITIES

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

Critical Points REHABILITATION PROTOCOL FOR PRIMARY ANTERIOR CRUCIATE LIGAMENT BONE–PATELLAR TENDON–BONE AUTOGENOUS RECONSTRUCTION: EARLY RETURN TO ACTIVITIES

Modalities

• EMS, ice, compression, elevation, cryotherapy to control swelling.

• EMS, biofeedback for quadriceps muscle reeducation.

Postoperative Bracing

• Primary indication is protection during weight-bearing in the event of a fall and to initiate early, more comfortable weight-bearing during the first few postoperative weeks.

• Rigid brace, knee at 0°.

Range of Knee Motion

• Goal in 1st postoperative wk: 0°–90°.

• Passive and active range of motion exercises done for 10 min/session, four to six times per day.

• Extension overpressure program (0° not achieved by 7th postoperative day): hanging weights, extension board, drop-out cast.

• Flexion overpressure program (90° not achieved by 7th postoperative day): rolling stool, wall-slides, overpressure devices.

• Gentle manipulation under anesthesia wk 4 if 90° not easily achieved.

Patellar mobilization: all four planes, done with motion exercises.

Partial weight-bearing immediately, full by 3–4 wk.

Flexibility: Hamstring, gastrocnemius-soleus, quadriceps, iliotibial band.

Strengthening

• 1st day postoperative: quadriceps isometrics, straight leg raises.

• Mini-squats, wall-sits, toe-raises, lateral step-ups when tolerated.

• Hamstring curls, hip abductors, hip adductors, hip flexors, and hip extensors with weight machines per protocol.

• Core, upper extremity as required.

Balance, Proprioception

• Weight-shifting, cup-walking, double- and single-leg balance on stable then unstable platform initially.

• Perturbation training, walking on half foam rolls, balance board 7–8 wk postoperative.

Conditioning

• Upper extremity ergometer when tolerated.

• Stationary bicycling 3rd wk.

• Cross-country ski and stair-climbing machines, aquatic program 5–6 wk.

Running, Agility

Indications

• ≤30% deficit average torque quadriceps and hamstrings on isokinetic testing.

• ≤3 mm increased AP displacement on arthrometer testing.

• ≥9 wk postoperative.

Majority begin 16–20 wk postoperative.

Running program designed based on the patient’s athletic goals; 3 x/wk.

• First level: straight-ahead walk/run combinations.

• Second level: lateral running, crossover maneuvers.

• Third level: figure-eight running drills.

• Fourth level: cutting patterns.

Plyometric Training

• Begun after completion of running program.

• Patient instructed to keep body weight on the balls of the feet, to jump and land with the knees flexed and shoulder-width apart to avoid knee hyperextension and an overall valgus lower limb position.

• First level: level surface box hopping using both legs, front-to-back, side-to-side.

• Second level: longer sequences.

• Third level: diagonal hops.

• Fourth level: surface box hopping using single leg.

• Fifth level: vertical box hops.

• Final level: Sportsmetrics training.

AP, anteroposterior; EMS, electrical muscle stimulation.

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.

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