Rehabilitation after ACL reconstruction
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Transcript Rehabilitation after ACL reconstruction
Rehabilitation
after ACL reconstruction
Pichet Yiemsiri
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
Rehabilitation Considerations
after ACL Reconstruction
Evidences base
ACL Reconstruction
Rehabilitation
Guideline on anterior cruciate ligament injury
A multidisciplinary review by the Dutch Orthopaedic
Association
Acta Orthopaedica 2012; 83 (4): 379–386
What is the outcome of different nonoperative treatment modalities?
Scientific evidence
Level 1:
Balance and proprioception
Fitzgerald et al. 2000,
Cooper et al. 2005,
Trees et al. 2005, 2007
What is the outcome of different nonoperative treatment modalities?
Scientific evidence
Level 2:
Addition of open-chain strength training
Zatterstrom et al. 2000,
Perry et al. 2005,
Tagesson et al.2008
Supervised training
Zatterstrom et al. 1998, 2000
What is the outcome of different nonoperative treatment modalities?
Scientific evidence
Level 3:
wearing a knee brace
Swirtun et al. 2005
What is the optimal postoperative treatment ?
Scientific evidence
Level 1:
Wearing a knee brace has no additional
treatment value after an ACL reconstruction
Wright and Fetzer 2007,
Anderson et al. 2009
Closed-chain exercise
Trees et al. 2005,
Wrightet al. 2008,
Anderson et al. 2009
What is the optimal postoperative treatment?
Scientific evidence
Level 2:
Addition of neuromuscular training
Risberg et al. 2007
Early open-chain exercises will lead to more laxity
with hamstring grafts
Heijne and Werner 2007
Pain & effusion management
Cryo-therapy
Elevation
Compression
Anti-inflammatory medication
ROM exercise
Knee extension to 0 degrees after surgery while
avoiding hyperextension
Prevent a flexion contracture
Hip AROM exercise 4 planes
Continuous Passive Motion
CPM is not warranted to improve rehabilitation
outcome
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
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.
Preoperative Phase
Exercises
Ankle pumps.
Elastic wrap or knee
Passive knee extension to 0°.
sleeve to reduce swelling.
Passive knee flexion to
Weight-bearing
tolerance.
SLR: three-way, flexion,
As tolerated with or
abduction, adduction.
without crutches.
Closed-kinetic chain
exercises: 30-degree minisquats, lunges, step-ups.
Brace
Preoperative Phase
Muscle Stimulation
Patient Education
Review postoperative
Electrical muscle
stimulation to quadriceps
rehabilitation program.
during voluntary quadriceps
Review instructional
exercises (4-6 hr/day)
video (optional).
Cryo-therapy/Elevation
Select appropriate
surgical date.
Apply ice 20 min of every
hour, elevate leg with knee
in full extension (knee must
be above heart).
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.
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.
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).
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.
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.
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.
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.
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.
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.
Phase 2: Early Rehabilitation-Weeks 2-4
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
Week 2
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.
Phase 2: Early Rehabilitation-Weeks 2-4
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.
Week 3
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.
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.
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.
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.
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).
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.
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
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.
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.
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.
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.
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.
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.
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.
Thank you