ARTHROSCOPIC ACL REHABILITATION UPDATES

1. RECENT ADVANCES IN ACL REHAB
journal review
B.KANNABIRAN .P.T(PhD)

2. summing up
A Criterion-Based Rehabilitation Progression
• Original ACLR rehab guideline
• Post operative phases early through –transitional
phase
• Soreness rules
• Running progression
• Return to sport
• Weight bearing vs non weight bearing exercises
• proprioception ,NM Control Exercise update
• Associated lesion in Acl rehab

3. Current Concepts for Anterior Cruciate
Ligament Reconstruction: A Criterion-
Based Rehabilitation Progression
• journal of orthopaedic & sports physical therapy
volume 42 | number 7 | july 2012 | 601

4. Journal of orthopaedic & sports physical therapy | volume 42 | number 7 | july 2012 |

5. Early Postoperative Phase
The milestones of the early postoperative phase (week 2 post surgery)
• knee flexion greater than 110°,
• walking without crutches,
• the use of a cycle/stair climber without difficulty,
• walking with full knee extension,
• reciprocal stair climbing, straight leg raise without an extension
lag,
In this phase, treatments incorporate weight-bearing (closed-chain)
activities
• such as wall slides and step-ups in pain-free ranges
(typically 0°-60°), which have been shown to be safe and effective, to
possibly place less stress on the healing graft, and to cause less
patellofemoral pain.

6. Neuromuscular electrical stimulation
(NMES). & Wall squats

7. Intermediate Postoperative Phase
The milestones for the
intermediate postoperative phase
• knee flexion within 10° of the uninvolved
side
• a quadriceps index greater than 60%.
• Balance and neuromuscular re-education
exercises begin in this time frame

8. Single-leg balance. & Single-leg cone
pick-up.

9. Late Postoperative Phase
The milestones are
• quadriceps index greater than 80%,
• a normal gait pattern,
• full knee ROM,
• knee joint effusion equal to a grade of trace
or less.

10. Transitional Phase
• Once a patient is 8 weeks
post surgery and has met
the criteria of 80%
quadriceps index, effusion
of trace or less, and
demonstrated an
understanding of the
soreness rules
• a running progression
may commence

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12. Running progression
journal of orthopaedic & sports physical therapy | volume 42 | number 7 | july 2012 |

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14. RETURN TO SPORT
Fitzgerald GK, Axe MJ, Snyder-Mackler L. Proposed practice guidelines for
nonoperative anterior cruciate ligament rehabilitation of physically active individuals.
J Orthop Sports Phys Ther. 2000;30:194-203.

15. Anterior Cruciate Ligament
Strain and Tensile Forces for
Weight-Bearing
and
Non–Weight-Bearing Exercises:
A Guide to Exercise Selection
• journal of orthopaedic & sports physical therapy
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| 211sport

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23. Evidence to suggest that individuals who
perform predominantly WB exercises,
compared to NWB exercises, in their
rehabilitation tend to have less knee pain
and more stable knees, are generally
more satisfied with the end result, and
return to their sport sooner.
Heijne A, Werner S. Early versus late start of open kinetic chain quadriceps exercises
after ACL reconstruction with patellar tendon or hamstring grafts: a prospective
randomized outcome study. Knee Surg Sports Traumatol Arthrosc. 2007;15:402-414.
http://dx.doi.org/10.1007/s00167-006-0246-z

24. •The exercises chosen in early, intermediate, and advanced
phases of ACL rehabilitation must therefore be carefully
selected based on the stages of incorporation and maturation
of the graft and with consideration of the differences in the
nature of the graft fixation and source of the graft.
•Another approach of reducing ACL loading while performing
lower extremity exercises is to facilitate a greater hamstring
contraction during squatting, lunges, and balance activities.
•It is generally accepted that the incorporation and maturation
process of allografts takes longer than that of autografts,
potentially indicating a need for slower progression in
rehabilitation and return to sport in these individuals

25. Current rehabilitation programs focus not only
on strengthening exercises but also on
proprioceptive and
neuromuscular control
drills to provide a neurological stimulus so
that the athlete can regain the dynamic
stability that is needed in athletic competition.

26. EXERCISES FOR ACLR
• Lateral step-down with resistance bands.
• Lateral stepping with resistance bands
• Front step-down movement:
• Progressive loading treadmill
• Double-leg polymetric jumping drills in the
lateral direction
• Single-leg stance on foam
• Lateral lunges performed using a sport cord
• Single-leg stance (knee flexed at 30°)
• Squats performed on a tilt board

27. Lateral step-down with resistance bands.
A resistance band is applied around the inner knee to provide resistance and to
control the valgus moment at the knee by recruiting hip abductors and rotators.

28. Lateral stepping with resistance bands around the distal femur
to further recruit hip musculature.

29. Front step-down movement:
during the eccentric or lowering phase, the patient is instructed to maintain proper
alignment of the lower extremity to prevent the knee from moving into a valgus moment.

30. Progressive loading treadmill (AlterG -Anti-Gravity Treadmill ;
AlterG, Fremont, CA)
utilized to initiate a walking or running program to minimize impact loading on the knee joint.

31. Double-leg plyometric jumping drills in the lateral direction,
In which the patient is instructed to land on the box and flat ground with the knee in a
flexed position. These activities are initiated to allow the quadriceps musculature to
create and dissipate forces at a higher level prior to returning to sport.

32. Single-leg stance on foam
while performing upper extremity movements using a 3.2-kg medicine ball. The clinician can
perform a perturbation by striking the ball to cause a postural disturbance.

33. Lateral lunges performed using a sport cord
for resistance while landing on a foam pad and catching a ball. The patient is
instructed to land and maintain a knee flexion angle of 30° during the drill.

34. Single-leg stance (knee flexed at 30°)
performed on a tilt board while throwing and catching a 3.2-kg plyo ball. Manual
perturbations are performed by tapping the tilt board with the clinician’s foot to
create a postural disturbance.

35. Squats performed on a tilt board
to improve neuromuscular control, utilizing a Monitored Rehab Systems MR Cube
(CDM Sport, Ft Worth, TX).

36. (A) A low-load, long-duration stretch to restore the patient’s full passive knee
extension. A 4.5-kg weight is used for 10 to 15 minutes, with a bolster placed under
the ankle to create a stretch.
(B) Commercial device (Extensionater; ERMI, Inc, Atlanta, GA) to improve extension
range of motion and prevent compensatory hip external rotation.

37. COMMERCIAL COLD WRAP

38. The Challenge of Return to Sports
for Patients Post–ACL
Reconstruction
GUY G. SIMONEAU & KEVIN E. WILK, When
read in combination, the 4 featured articles
reveal that a one-size-fits-all solution is unlikely,
and that optimal rehabilitation and design of
return-to-sports criteria should include sports-
specific considerations.
journal of orthopaedic & sports physical therapy | volume 42 | number 4 | april 2012 | 301

39. Graft selection is an important
consideration for the rehabilitation
specialist.
• With a bone-patellar tendon-bone autograft, donor-
site morbidity can occur, and the rehabilitation
specialist should be aware of patellar tendon pain
during quadriceps strengthening
• If a hamstring autograft is used, resisted hamstring
activities are not performed for 12 weeks after
surgery
• After 12 weeks, the patient can begin a resisted
hamstring-strengthening progression and activities
according to the soreness rules.

40. Graft selection is an important
consideration for the rehabilitation
specialist.
• Double-bundle grafts have shown some
advantage in decreasing anterior and rotational
laxity after surgery, but no modifications to the
rehabilitation guidelines are warranted when
compared with single-bundle grafts.
• Therefore, all individuals, despite graft selection,
should be required to meet the criteria at each
phase before being able to progress to the next
phase of the rehabilitation.

41. Meniscal injury
• Typically, when a partial arthroscopic meniscectomy is
performed concurrently with an ACL reconstruction, no
modifications to rehabilitation are necessary unless
specified by the surgeon.
• The clinical practice guidelines, “Knee Pain and Mobility
Impairments: Meniscal and Articular Cartilage Lesions,”
published by the Orthopaedic Section of the American
Physical Therapy Association, suggest that clinicians
consider early weight bearing and mobilization.
• If a meniscal repair is performed concurrently with ACL
reconstruction, modifications include no weight-bearing
activities at knee angles greater than 45° of flexion for 4
weeks, with no restrictions on weight bearing in full
extension.

42. Chondral defects
• A patient who undergoes a chondral debridement may be
weight bearing as tolerated with crutches for 3 to 5 days
after surgery, with no other modification of the post–ACL
reconstruction rehabilitation guidelines
• Microfracture procedures are performed arthroscopically,
usually in conjunction with ACL reconstruction, with the
cartilage surgical site requiring additional protection.
Patients are non–weight bearing with crutches from 2 to 8
weeks, depending on knee pain, effusion, the surgeon’s
preference, and the location and size of the lesion.
• ACI procedures are typically surgeon specific, due to the
nature of the technique, larger lesion size, and length of
healing time and rehabilitation.64 However, soreness and
effusion guidelines are still used to direct the rehabilitation
process and readiness for return-to-sport testing.

43. ligamentous
• When combined ACL-MCL injuries occur,
during the preoperative stage, modifications
to the rehabilitation process are warranted.
Treatment should be restricted to the
exercises/movements performed in the
sagittal plane for 4 to 6 weeks to allow for
MCL healing.

44. ligamentous
• Multiligament instability (ie, knee dislocation) occurs
when the ACL, posterior cruciate ligament, and
either the medial structures or the lateral and
posterolateral structures of the knee are ruptured.
• Typically, a 6- to 8-week period of non–weight
bearing is recommended after multiligament
stabilization surgery.
• Individuals who had a posterior cruciate ligament
reconstruction concomitant with ACL reconstruction
should follow the more conservative posterior
cruciate ligament postsurgical rehabilitation
guidelines.

45. Revision ACLR
• Following a revision ACL
reconstruction, the
rehabilitation guidelines
may need to be modified
to account for possible
fixation concerns and
complications from
previous procedures by
slowing the progression.

46. THANK
YOU

47. Infrared thermal images of the anterior aspect of the bilateral lower extremities
taken 2 weeks following left anterior cruciate ligament reconstruction. The
temperature scale is on the right side of the images.
FIGURE 1A was taken prior to physical therapist intervention and demonstrated a
broad pattern of hyperthermia at the anterior aspect of the left knee region,
consistent with inflammation associated with the recent surgery.
FIGURE 1B was taken 20 min following physical therapist intervention but prior to the
application of ice, and demonstrated a more localized pattern of hyperthermia at the
anterior aspect of the left knee region compared to the left knee image in FIGURE
1A .
J Orthop Sports Phys Ther 2012;42(3):292. doi:10.2519/jospt.2012.0405