ACL REHABILITATION

– Dr. Pradnya Mahajan

ACL REHABILITATION RATIONALE

Reduction of Full ROM Avoid

inflammation arthrofibrosis

Functional REHABILITATION Early weight

training RATIONALE bearing

Early
Neuromuscular
Ability to initiation of
&
return pre- hammstring &
proprioception
injury quadriceps
retraining
activities activity
 Conservative/surgical treatment?
 Activity
 Degree of instability
 Associated abnormalities
 Social factors, such as cost of treatment.
 ACL REHABILITATION

PRE- POST-
CONSERVATIVE
REHABILITATION REHABILITATION
 PRE-REHABILITATION

• Decrease • Pain control &

• Cryotherapy 20-30 swelling
swelling & min ,IFT, TENS management
inflammation • Elevation & ankle • Edema
pumps(10 rep/min) management
• Decrease pain 20-30 min &
• Increase compression bandage
• Isometric exercises –
quadriceps
strength quadriceps, • Graduated exercise
hammstring
• Maintain hip to improve
• Pain free ROM of knee
strength neuromuscular co-
• AROM – hip ordination
abduction, adduction,
extension • Emphasis self
management of
ROM program
• Prepare for transfer
 POST-REHABILITATION
 ACL Arthroscopic Reconstruction
Graft selection/fixation
a) Bone –patellar tendon- bone autograft
 Advantages -
1. High tensile strength/stiffness similar or greater than ACL
(2977 N)
2. Rapid vascularization/biological fixation(6 weeks)
3. Ability to return to pre-injury –high demand activities
safely.
 b) Hammstring (tendon-bone fixation)
Advantages-
1. High tensile strength/stiffness greater than ACL.
(4000 N)
2. Strongest fixation with least amount of slippage

.
Graft fixation-
PHASE -1 (Day 1- week 4)
 Goal 1st –protect the healing graft(0-2
week)
• Intervention – immobilisation & bracing
• Two forms of braces – rehabilitative braces &
functional braces.
1. Rehabilitation braces –
 Used in early post-op period
 Drop lock rehabilitation braces is commonly
used.
Structure & biomechanics of rehabilitation braces
. Functional braces-
2.
Provide additional protection as
rehabilitation is completed & a
patients return to normal activities.
To reduced the risk of re-injury
during the advanced phases of
rehabilitation & when participating in
high demands sports or heavy manual
labor
 Goal 2nd – To decrease
swelling ,inflammation & pain.
• Intervention –
1. Cryotherapy- 5 times for 15-20 mins
2. Therapeutic laser- GaALA laser with the
intensity 1592 mw/cm square for 10 min.
 Goal 3- Allow protective weight bearing
 As tolerated with 2 crutches as early as
possible with long knee brace
 Progressed during the next 2 to 3 weeks based
on patients symptoms
 FWB & ambulation without crutches is
permitted by 4 weeks
 Evidence – Tylor & colleagues
 Goal 4th – To enhance voluntary isometric &
dynamic activation of knee musculature
Intervention
1. Electrical muscle stimulation-
 Improves quadriceps strength
 Contraction time 10 secs followed by 50 sec rest for 10-
15 contractions.
 Electrical stimulation + exercise was more efficient
 Evidence – Fitzgarald & associates…
2. Biofeedback –
Useful for re-education
of the muscles
Encourages increased
neuromuscular
contractions
Promote timing of
muscle activation which
benefits in dynamic
stabilization of the knee.
 Isometrics of quads

SLR

Supine heel slides

Hammstring curl
Scooting forward
Goal 5th – Improve ROM & patellar mobility
Patellar mobilisation Gatrocnemius stretching

Hammstring stretching Prone leg hangs

 Supine heel prop

sitting assisted flexion

hangs Passive
overpressure
with load
Goal 6th - Education of functional training &
enhance neuromuscular control

i. Aerobic conditioning

Well leg
bicycling

UE Ergometry
ii. Proprioception-
 stable platform eyes open &
closed,
 seated ball throwing & catching.
 Week 2-4
mini squats 0-30 degree upper extremity ergometry,

leg press
 marching
stair walking

Aquatherapy

pool walking pool jogging

proprioceptive activities
 PHASE 2 MODERATE PROTECTION PHASE:
Week 4-10
Goals:
• Full painfree ROM
• 4/5 muscular strength
• Dynamic control of knee
• Improve kinesthetic awareness
• Normalize gait pattern
 Intervention

• Multiple angle isometrics

• PRE & leg press 0-60degree
• Step up lateral and forward
• Double/ single leg squat
• Lunges in multiple plane
• Lower extremity stretching
• Proprioception training:single leg stance on
balance board
 leg press 0-60degree

Step up lateral
and forward

single leg
stance on
balance
board
Functional training
• Continue bicycling
• Pool running
• Stair steeper
• Cross country skiing machine
• Stair jogging
• Stepping drills
• Balance beam
 Stair steeper

Cross country skiing machine

Balance beam

Stepping drills
Phase 3: Minimum protection phase (week11-24)

• Lower extremity stretching

• Lower extremity stregthening
• Elliptical stepper
• Stair steeper
• Box jump
• Jumping rope
• Mini tramp bouncing
• Ball throwing / catching on unstable surface
• Shuttel run
Lower extremity strengthening
Advance proprioceptive
Agility drills – shuttle run
 Conservative management
• The rehabilitation program for the conservatively
managed ACL injury is similar to management after
reconstruction.
• Derotation brace may be used to provide additional
stability.
• The principles of initial reduction of swelling & pain,
restoration of full ROM, increase muscle strength,
functional rehabilitation, & finally return to sports all
apply.
• The rate of progress may be slower or faster than after a
reconstruction depending on degree of instability.
• The agility drills & sports specific drills may not be possible
in patients with ACL deficiency.
 Outcome measures
• Subjective
i. Lysholm knee score
ii. Tenger activity scale
iii. Cincinnati knee rating system.
• Functional outcome
i. Hop test
Recent advance
 The Effect of Virtual Rehabilitation Added to an Accelerated
Rehabilitation Program After Anterior Cruciate Ligament
Reconstruction: A Randomized Controlled Trial

• Methods: A total of 22 males who had undergone ACL reconstruction were divided
into Nintendo and control groups. Both of the groups received six week accelerated
rehabilitation in our department, and the Nintendo Wii© (Nintendo, Washington,
USA) balance games were added to Nintendo group after three weeks for forty
minutes a day, three times a week. Patients were evaluated for pain (visual analog
scale), functionality (Lower Extremity Functional Scale), center of gravity (COG) and
balance (Nintendo Wii©) at the baseline and end of the 3th and 6th week of
rehabilitation program.

• Results: Similar improvements were determined in the pain, functionality, COG and
balance scores of the two groups at the end of the treatment program and there
were no significant differences between the groups in the amount of change in all
parameters (p= 0.256, 0.393, 0.707, 1.000).

• Conclusion: According to the results of this study the Nintendo Wii© balance games
applied in the clinic under physiotherapist supervision did not change the outcome
of the rehabilitation in early period after ACL reconstruction
 References
• Therapeutic exercises – Carolyn Kisner
• Clinical sports medicine – Peter Brunker &
Karim Khan
• Clinical orthopedic rehabilitation - Brent
Brotzman.
• Rehabilitation of post-surgical orthopedic
condition – Lisa Maxey
• Orthotics & prosthetics in rehabilitation-
Lusardi.
Thank You!