Rehabilitation of Rehabilitation of anterior cruciate anterior cruciate

ligament ligament Dr. Ali Abd El-Monsif ThabetDr. Ali Abd El-Monsif Thabet

Operative treatmentOperative treatment

Operative treatment (either Operative treatment (either arthroscopic or open surgery): Uses a arthroscopic or open surgery): Uses a strip of tendon, usually taken from the strip of tendon, usually taken from the patient's knee (patellar tendon- BPTB) patient's knee (patellar tendon- BPTB) or hamstring muscle - STG, that is or hamstring muscle - STG, that is passed through the inside of the joint passed through the inside of the joint and secured to the thighbone and and secured to the thighbone and shinbone.shinbone.

Is followed by an exercise and Is followed by an exercise and rehabilitation program to strengthen rehabilitation program to strengthen the muscles and restore full joint the muscles and restore full joint mobility.mobility.

Pre-surgical phase Pre-surgical phase (Phase 1)(Phase 1)

Psychological preparation of Psychological preparation of patients to surgery and patients to surgery and rehabilitation is very important to rehabilitation is very important to obtain their maximum commitment. obtain their maximum commitment.

Before surgery, the patient must reach Before surgery, the patient must reach these goalsthese goals

1- Control of pain and swelling 1- Control of pain and swelling with rest, cryotherapy with rest, cryotherapy 2- Recovery of full ROM2- Recovery of full ROM3- Reestablishment of normal gait 3- Reestablishment of normal gait by walking with crutchesby walking with crutches

4- The patient must also regain 4- The patient must also regain muscle strength (quadriceps and muscle strength (quadriceps and hamstrings).hamstrings).

The goals of rehabilitation The goals of rehabilitation after ACL reconstructionafter ACL reconstruction

1- joint stability (protection of the healing 1- joint stability (protection of the healing graft)graft)

2- full ROM (including extension at levels 2- full ROM (including extension at levels of the uninvolved side), of the uninvolved side),

3- muscle strength (both concentric and 3- muscle strength (both concentric and eccentric), eccentric),

4- proprioception,4- proprioception,

5- improve cardiovascular endurance5- improve cardiovascular endurance

6- preinjury levels of activity. 6- preinjury levels of activity.

Phase 2: First and Second Phase 2: First and Second Postoperative WeeksPostoperative Weeks

GOALS GOALS

1- wound healing 1- wound healing

2- reduce swelling and pain2- reduce swelling and pain

3- regain full extension 3- regain full extension

4- regain 90°- 110° flexion4- regain 90°- 110° flexion

5- Initiate muscle control 5- Initiate muscle control

6- gradual weight bearing 6- gradual weight bearing

Phase 2: First and Second Phase 2: First and Second Postoperative WeeksPostoperative Weeks

1- Cryotherapy1- Cryotherapy

2- Active foot flexion-extension2- Active foot flexion-extension

3- Full knee extension :3- Full knee extension :

4- Static quadriceps contractions:4- Static quadriceps contractions:

Phase 2: First and Second Phase 2: First and Second Postoperative WeeksPostoperative Weeks

5- Knee flexion:5- Knee flexion:

6- Gait: partial weight bearing with two 6- Gait: partial weight bearing with two crutchescrutches

7- At the end of every exercise session, 7- At the end of every exercise session, 20min of cryotherapy must be performed.20min of cryotherapy must be performed.

8- EMS: it is possible to perform electrical 8- EMS: it is possible to perform electrical quadriceps stimulationquadriceps stimulation

9- Warning: to prevent loss of extension, the 9- Warning: to prevent loss of extension, the patient must not place supports under the patient must not place supports under the knee. knee.

Phase 3: Third and Fourth Phase 3: Third and Fourth Postoperative WeeksPostoperative Weeks

GOALS GOALS

1- Increase active range of motion1- Increase active range of motion

2- Develop muscular control of 2- Develop muscular control of quadriceps and hamstringquadriceps and hamstring

3- Increase weight bearing during gait3- Increase weight bearing during gait

4- Improve cardiovascular endurance4- Improve cardiovascular endurance

Phase 3: Third and Fourth Phase 3: Third and Fourth Postoperative WeeksPostoperative Weeks

If there is lack of extension, a new If there is lack of extension, a new exercise is added to the protocolexercise is added to the protocol

Muscle exercises:Muscle exercises:

1- Straight leg raises with weight on the 1- Straight leg raises with weight on the thigh (Fig. 8)thigh (Fig. 8)

2- Two-legged minisquat with up to 452- Two-legged minisquat with up to 4500 of of knee flexion using crutchesknee flexion using crutches

3- Active extension 903- Active extension 9000 to 45 to 4500 (stopping at (stopping at 454500) without resistance while sitting (Fig. ) without resistance while sitting (Fig. 10)10)

4- Active knee flexion in standing position.4- Active knee flexion in standing position.

Phase 3: Third and Fourth Phase 3: Third and Fourth Postoperative WeeksPostoperative Weeks

5- Active assisted flexion5- Active assisted flexion

6- Cocontraction: simultaneous 6- Cocontraction: simultaneous isometric (60°) contractions of isometric (60°) contractions of quadriceps and hamstrings muscles. quadriceps and hamstrings muscles.

7- Gait, increase weight bearing 7- Gait, increase weight bearing gradually as tolerated with one crutch. gradually as tolerated with one crutch.

8- Swimming pool. 8- Swimming pool.

9- Stationary bicycle for 10 min two to 9- Stationary bicycle for 10 min two to three times a day slowly, without wheel three times a day slowly, without wheel resistance, and pedaling with the resistance, and pedaling with the forefoot (Fig. 12)forefoot (Fig. 12)

Phase 4: Second Phase 4: Second Postoperative MonthPostoperative Month

Goals Goals

1- Restore full ROM1- Restore full ROM

2- Improve muscle strength2- Improve muscle strength

3- Full weight bearing 3- Full weight bearing

Phase 4: Second Postoperative Phase 4: Second Postoperative MonthMonth

1- In comparison with the contralateral 1- In comparison with the contralateral knee, knee,

2- Flexion must be more than 1202- Flexion must be more than 12000 and and gradually reach the contralateral level gradually reach the contralateral level (full ROM).(full ROM).

3- Gait the patient can walk without 3- Gait the patient can walk without crutchescrutches

4- Stationary bicycle; 15 min three times 4- Stationary bicycle; 15 min three times a day with low wheel resistance (50 W) a day with low wheel resistance (50 W) simulating a slow -ride on level road, simulating a slow -ride on level road, pedaling with the forefoot.pedaling with the forefoot.

Phase 4: Second Phase 4: Second Postoperative MonthPostoperative Month

5- Muscle strengthening exercises with 5- Muscle strengthening exercises with elastic tubing are useful because they elastic tubing are useful because they allow gradual resistance: allow gradual resistance:

6- Exercises to be performed in the 6- Exercises to be performed in the swimming pool areswimming pool are

Phase 5: Third Phase 5: Third Postoperative MonthPostoperative Month

Goals Goals

1- full active ROM1- full active ROM

2- Increasing muscle strength2- Increasing muscle strength

3- Proprioceptive training3- Proprioceptive training

Phase 5: Third Phase 5: Third Postoperative MonthPostoperative Month

1- eccentric quadriceps strengthening 1- eccentric quadriceps strengthening exercises like two-legged squatting up to exercises like two-legged squatting up to 909000 (on land and in a swimming pool), (on land and in a swimming pool),

2- climbing and descending stairs into 2- climbing and descending stairs into the water (20-40 cm, gradually the water (20-40 cm, gradually increasing),increasing),

3- concentric quadriceps strengthening 3- concentric quadriceps strengthening exercises (active full knee extension-exercises (active full knee extension-flexion without resistance)flexion without resistance)

Phase 5: Third Phase 5: Third Postoperative MonthPostoperative Month

4- one-legged proprioceptive exercises 4- one-legged proprioceptive exercises on unstable surfaceson unstable surfaces

5- Jumping on springboards is useful 5- Jumping on springboards is useful for enhancing proprioception without for enhancing proprioception without overloading the knee joint patientoverloading the knee joint patient

6- Bicycling can be started for brief 6- Bicycling can be started for brief periods (10-15 mm) on a level road. periods (10-15 mm) on a level road.

7- Jogging is allowed on a straight 7- Jogging is allowed on a straight course for 10 min/day. course for 10 min/day.

Multidirectional rolling movement

Single leg stand on balance board

Phase 5: Third Phase 5: Third Postoperative MonthPostoperative Month

Attending a gymAttending a gym

Phase 6: Fourth Phase 6: Fourth Postoperative MonthPostoperative Month

Goals Goals

1-Increase leg strength 1-Increase leg strength

2-Advanced proprioception 2-Advanced proprioception

Phase 6: Fourth Phase 6: Fourth Postoperative MonthPostoperative Month

1- jogging time and distance may be 1- jogging time and distance may be increased, adding change of directionincreased, adding change of direction

2- uphill and downhill. 2- uphill and downhill.

3- Bicycling is possible with increased 3- Bicycling is possible with increased distance and also uphill and downhill. distance and also uphill and downhill.

4- The swimming pool should be 4- The swimming pool should be attended, performing freestyle and attended, performing freestyle and jumping into the water. jumping into the water.

5- Proprioceptive exercises are 5- Proprioceptive exercises are continued. continued.

6- Concentric quadriceps strengthening 6- Concentric quadriceps strengthening must be performedmust be performed

"Kickers" use an elastic band fixed to the distal aspect of the involved or "Kickers" use an elastic band fixed to the distal aspect of the involved or uninvolved limb. The athlete attempts to balance while executing short kicks uninvolved limb. The athlete attempts to balance while executing short kicks with either knee extension or hip flexion. This exercise is most difficult when with either knee extension or hip flexion. This exercise is most difficult when performed on unstable surfaces.performed on unstable surfaces.

Fifth postoperative Fifth postoperative monthmonth

Goals Goals

functional training (prepare for functional training (prepare for return to sport and recreational return to sport and recreational lifestyle )lifestyle )

Fifth postoperative Fifth postoperative monthmonth

1-The patient can practice running 1-The patient can practice running with acceleration, deceleration, and with acceleration, deceleration, and "stop and go" "stop and go"

2- return to sport-specific activities 2- return to sport-specific activities can begin including normal running, can begin including normal running, jumping, cutting, double and single jumping, cutting, double and single hopping, vertical jumping.hopping, vertical jumping.

Plyometrics begin with low-impact hopping, progressing Plyometrics begin with low-impact hopping, progressing to double-leg bounding, and finally single-leg hopping.to double-leg bounding, and finally single-leg hopping.

Sixth post operative Sixth post operative monthmonth

GoalGoal

Return to activity safely Return to activity safely

Sixth post operative Sixth post operative monthmonth

Return to sports Return to sports

1-Full training for 1 month prior to 1-Full training for 1 month prior to active return to competitive sport active return to competitive sport

Criteria for returnCriteria for return 1- No joint effusion1- No joint effusion 2- Full ROM2- Full ROM 3- isokinetic testing indicates that 3- isokinetic testing indicates that

strength of hamstring and quadriceps strength of hamstring and quadriceps is 85- 100° of the uninvolved legis 85- 100° of the uninvolved leg

4- Satisfactory ligament stability 4- Satisfactory ligament stability testing using KT 1000 arthrometertesting using KT 1000 arthrometer

5- Successful performance during 5- Successful performance during functional testingfunctional testing

Thank you