Anterior Cruciate Ligament (ACL) Rehabilitation: Difference between revisions
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'''Original Editor ''' | |||
== Clinically Relevant Anatomy<br> == | |||
<br> | |||
< | |||
== General Considerations == | |||
== | === Before surgery === | ||
RICE and electrotherapy can be applied during several weeks ahead of the surgery in order to reduce swelling and pain, to attempt full range of motion and to decrease joint effusion. This will help the patient to regain better motion and strentgh after the surgery.<ref name="Vijf">I Eitzen, H Moksnes, L Snyder-Mackler, MA Risberg. Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury. Journal of Orthopaedic and Sports Physical Therapy 2010;40(11):705-722</ref> | |||
Therapy pre-ops can encourage strengthening of the quadriceps and hamstrings. Range of motion exercises should be included if there is no pain involved.<ref name="Negen">S. van Grinsven, R. E. H. van Cingel, C. J. M. Holla, C. J. M. van Loon. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2010; 18:1128–1144</ref><ref name="Elf">Savio L-Y. Woo, Richard E. Debski, PhD, John D. Withrow, Marsie A. Janaushek. Biomechanics of Knee Ligaments. The American Journal of Sports medicine 1999;27:533</ref> | |||
[[Neuromuscular Electrical Stimulation|NMES]] combined with exercise is more effective in improving quadriceps strength than exercise alone<ref name="Kyung-Min">Kyung-Min KiM, Ted Croy, Jay HerTel, SuSan Saliba. Effects of Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction on Quadriceps Strength, Function, and Patient-Oriented Outcomes: A Systematic Review. J Orthop Sports Phys Ther 2010;40(7):383-391.</ref>. | |||
=== After surgery === | |||
*Week 1 | |||
Regular icing and elevation are used to reduce swelling. The goal is full extension and 70 degrees of flexion by the end of the first week. The use of a knee brace and crutches are imperative. | |||
Multidirectional mobilizations of the patella should be included for at least 8 weeks. Other mobilization exercises in the first 4 weeks are passive extension of the knee (no hyperextension) and passive and active mobilization towards flexion. Strenthening exercises for the calf muscle, hamstring and quadriceps (vastus medialis) can be performed. | |||
*Week 3-4 | |||
The patient must trie to genuinely increase the stance phase in an attempt to walk with one crutch. With good hamstring/quadriceps control, the use of crutches can be reduced earlier. | |||
*Week 5 | |||
== | The use of the knee brace is progessively reduced.<ref name="Vijf" /><ref name="Negen" /> Passive mobilizations should normalize motility but flexion should not yet be thorough. 9 Tonification of hamstrings and quadriceps (vastus medialis) can start in close chain exercises. The exercises should be started on light intensity (50% of maximum force) and progressively increased to 60-70%. The closed chain exercises should be built from less responsible positions (bike, leg presses, step) to more congested starting positions (ex.squad). The progress of the exercise depends on pain, swelling and quadriceps control. Proprioception and coordination exercises can start if the general strength is good. This includes balance exercises on boards and toll. | ||
*Week 10 | |||
= | Forward, backward and lateral dynamic movements can be included as well as isokinetic exercises.<ref name="Negen" /> | ||
*Month 3 | |||
= | After 3 months, patient can move on to functional exercises as running and jumping. As proprioceptive and coordination exercises become heavier, quicker changes in direction are possible. To stimulate coordination and control through afferent and efferent information processing, exercises should be enhanced by variation in visible input, surface stability (trampoline), speed of exercise performance, complexity of the task, resistance, one or two-legged performance, etc.<ref name="Negen" /> | ||
*Month 4-5 | |||
= | Final goal is to maximize endurance and strength of the knee stabilizers, optimize neuromuscular control with plyometric exercises and to add the sport-specific exercises. Acceleration and deceleration, variations in running and turning and cutting manoeuvers improve arthrokinetic reflexes to prevent new trauma during competition.<ref name="Elf">Arna Risberg, Inger Holm. The Long-term Effect of 2 Postoperative Rehabilitation Programs After Anterior Cruciate Ligament Reconstruction A Randomized Controlled Clinical Trial With 2 Years of Follow-Up. The American Journal of Sports medicine 2009; 37: 1958</ref> | ||
=== Return to sport === | |||
== | Strength and power deficits after surgery may be a risk factor for future injuries and may set athletes up for failure when they try to return to their prior performance levels. Researchers suggest that the surgically repaired leg should perform at least 90% as well as the uninjured leg before you return to sport<ref name="Myer" />. Three hopping tests can be used as part of a comprehensive physical and functional examination to help ensure not just a speedy, but a safe return to sport after ACL reconstruction. These 3 tests are sensitive enough to measure side-to-side differences and can be used during more advanced recovery phases after surgery to help ensure that the athlete’s exercise program is successful in returning the injured leg at least to the level of the uninjured leg<ref name="Myer">Gregory D. Myer, Laura C. Schmitt, Jensen L. Brent, Kevin R. Ford, Kim D. Barber Foss, Bradley J. Scherer, Robert S. Heidt Jr., Jon G. Divine, Timothy E. Hewett.[http://www.jospt.org/issues/articleID.2585/article_detail.asp Utilization of Modified NFL Combine Testing to Identify Functional Deficits in Athletes Following ACL Reconstruction]. J Orthop Sports Phys Ther 2011;41(6):377-387.</ref>. | ||
[http://thejacksonclinics.com/wp-content/uploads/2012/01/20110531_June2011PerspectivesforPatients.pdf When Should an Athlete Return to Sport After an ACL Surgery?] | |||
== | == Rehab Protocols == | ||
[http://drmillett.com/downloads/rehab-protocols/acl-rehab-protocol.pdf Steadman Protocol] | |||
[http://www.fowlerkennedy.com/wordPress/wp-content/uploads/2010/12/ACL-Protocol-Fowler-Kennedy-revised-Mar-2009.pdf Fowler-Kennedy Protocol] | |||
[http://www.kneeclinic.info/rehab_markdecarlo.php Chester Knee Clinic] | |||
== Sport Specific Considerations == | |||
= | [https://www.jospt.org/issues/articleID.2738,type.1/article_detail.asp Suggestions From the Field for Return-to-Sport Rehabilitation Following Anterior Cruciate Ligament Reconstruction: Alpine Skiing]<ref name="Kokmeyer">Kokmeyer, D., Wahoff M., Myhern M. [https://www.jospt.org/issues/articleID.2738,type.1/article_detail.asp Suggestions From the Field for Return-to-Sport Rehabilitation Following Anterior Cruciate Ligament Reconstruction: Alpine Skiing]. Journal of Orthopaedic &amp;amp; Sports Physical Therapy, April 2012, 42(4):313-325.</ref> | ||
== | == Considerations for Female Athletes == | ||
[http://blog.brianschiff.com/?tag=acl-rehab Late stage rehab ideas with specifics for the female athlete] | |||
== Adjuncts == | |||
- | NMES - Neurotech's Kneehab XP Quadriceps Therapy System has been shown to significantly improve rehab following ACL reconstruction<ref name="Kneehab">Sven Feil, John Newell, Conor Minogue and Hans H. Paessler. [http://ajs.sagepub.com/content/early/2011/02/20/0363546510396180.full.pdf+html?ijkey=28W1kfCXExivc&amp;amp;amp;amp;amp;amp;amp;amp;amp;keytype=ref&amp;amp;amp;amp;amp;amp;amp;amp;amp;siteid=amjsports The Effectiveness of Supplementing a Standard Rehabilitation Program With Superimposed Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized, Single-Blind Study]. Am J Sports Med February 22, 2011</ref>. | ||
== | |||
The | |||
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | ||
<div class="researchbox"> | <div class="researchbox"> | ||
<rss> | <rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1h3SAs98aPqnd6UdzcSka13Q2QC0xPe6Uxyj13qIjh7-m7FgTo|charset=UTF-8|short|max=10</rss> | ||
</div> | </div> | ||
== References == | == References == | ||
<references /> | |||
<references /> | |||
Revision as of 19:04, 21 June 2013
This article requires improvement to meet Physiopedia's quality standards. The reasons have been specified in the page's Discussion. Please help improve this page if you can. #qualityalert
Original Editor
Clinically Relevant Anatomy
[edit | edit source]
General Considerations[edit | edit source]
Before surgery[edit | edit source]
RICE and electrotherapy can be applied during several weeks ahead of the surgery in order to reduce swelling and pain, to attempt full range of motion and to decrease joint effusion. This will help the patient to regain better motion and strentgh after the surgery.[1]
Therapy pre-ops can encourage strengthening of the quadriceps and hamstrings. Range of motion exercises should be included if there is no pain involved.[2][3]
NMES combined with exercise is more effective in improving quadriceps strength than exercise alone[4].
After surgery[edit | edit source]
- Week 1
Regular icing and elevation are used to reduce swelling. The goal is full extension and 70 degrees of flexion by the end of the first week. The use of a knee brace and crutches are imperative.
Multidirectional mobilizations of the patella should be included for at least 8 weeks. Other mobilization exercises in the first 4 weeks are passive extension of the knee (no hyperextension) and passive and active mobilization towards flexion. Strenthening exercises for the calf muscle, hamstring and quadriceps (vastus medialis) can be performed.
- Week 3-4
The patient must trie to genuinely increase the stance phase in an attempt to walk with one crutch. With good hamstring/quadriceps control, the use of crutches can be reduced earlier.
- Week 5
The use of the knee brace is progessively reduced.[1][2] Passive mobilizations should normalize motility but flexion should not yet be thorough. 9 Tonification of hamstrings and quadriceps (vastus medialis) can start in close chain exercises. The exercises should be started on light intensity (50% of maximum force) and progressively increased to 60-70%. The closed chain exercises should be built from less responsible positions (bike, leg presses, step) to more congested starting positions (ex.squad). The progress of the exercise depends on pain, swelling and quadriceps control. Proprioception and coordination exercises can start if the general strength is good. This includes balance exercises on boards and toll.
- Week 10
Forward, backward and lateral dynamic movements can be included as well as isokinetic exercises.[2]
- Month 3
After 3 months, patient can move on to functional exercises as running and jumping. As proprioceptive and coordination exercises become heavier, quicker changes in direction are possible. To stimulate coordination and control through afferent and efferent information processing, exercises should be enhanced by variation in visible input, surface stability (trampoline), speed of exercise performance, complexity of the task, resistance, one or two-legged performance, etc.[2]
- Month 4-5
Final goal is to maximize endurance and strength of the knee stabilizers, optimize neuromuscular control with plyometric exercises and to add the sport-specific exercises. Acceleration and deceleration, variations in running and turning and cutting manoeuvers improve arthrokinetic reflexes to prevent new trauma during competition.[3]
Return to sport[edit | edit source]
Strength and power deficits after surgery may be a risk factor for future injuries and may set athletes up for failure when they try to return to their prior performance levels. Researchers suggest that the surgically repaired leg should perform at least 90% as well as the uninjured leg before you return to sport[5]. Three hopping tests can be used as part of a comprehensive physical and functional examination to help ensure not just a speedy, but a safe return to sport after ACL reconstruction. These 3 tests are sensitive enough to measure side-to-side differences and can be used during more advanced recovery phases after surgery to help ensure that the athlete’s exercise program is successful in returning the injured leg at least to the level of the uninjured leg[5].
When Should an Athlete Return to Sport After an ACL Surgery?
Rehab Protocols[edit | edit source]
Sport Specific Considerations[edit | edit source]
Suggestions From the Field for Return-to-Sport Rehabilitation Following Anterior Cruciate Ligament Reconstruction: Alpine Skiing[6]
Considerations for Female Athletes[edit | edit source]
Late stage rehab ideas with specifics for the female athlete
Adjuncts[edit | edit source]
NMES - Neurotech's Kneehab XP Quadriceps Therapy System has been shown to significantly improve rehab following ACL reconstruction[7].
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
- ↑ 1.0 1.1 I Eitzen, H Moksnes, L Snyder-Mackler, MA Risberg. Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury. Journal of Orthopaedic and Sports Physical Therapy 2010;40(11):705-722
- ↑ 2.0 2.1 2.2 2.3 S. van Grinsven, R. E. H. van Cingel, C. J. M. Holla, C. J. M. van Loon. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2010; 18:1128–1144
- ↑ 3.0 3.1 Savio L-Y. Woo, Richard E. Debski, PhD, John D. Withrow, Marsie A. Janaushek. Biomechanics of Knee Ligaments. The American Journal of Sports medicine 1999;27:533 Cite error: Invalid
<ref>tag; name "Elf" defined multiple times with different content - ↑ Kyung-Min KiM, Ted Croy, Jay HerTel, SuSan Saliba. Effects of Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction on Quadriceps Strength, Function, and Patient-Oriented Outcomes: A Systematic Review. J Orthop Sports Phys Ther 2010;40(7):383-391.
- ↑ 5.0 5.1 Gregory D. Myer, Laura C. Schmitt, Jensen L. Brent, Kevin R. Ford, Kim D. Barber Foss, Bradley J. Scherer, Robert S. Heidt Jr., Jon G. Divine, Timothy E. Hewett.Utilization of Modified NFL Combine Testing to Identify Functional Deficits in Athletes Following ACL Reconstruction. J Orthop Sports Phys Ther 2011;41(6):377-387.
- ↑ Kokmeyer, D., Wahoff M., Myhern M. Suggestions From the Field for Return-to-Sport Rehabilitation Following Anterior Cruciate Ligament Reconstruction: Alpine Skiing. Journal of Orthopaedic &amp; Sports Physical Therapy, April 2012, 42(4):313-325.
- ↑ Sven Feil, John Newell, Conor Minogue and Hans H. Paessler. The Effectiveness of Supplementing a Standard Rehabilitation Program With Superimposed Neuromuscular Electrical Stimulation After Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized, Single-Blind Study. Am J Sports Med February 22, 2011
