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ACL Rehabilitation

Kim Perkins

Date: 11/16/2005

The major goals of rehabilitation following the anterior cruciate ligament (ACL) surgery are restoration of joint anatomy, provision of static and dynamic stability, maintenance of the aerobic conditioning and psychological well being, and early return to work and sport (www.sportsci.org/encyc/aclinj/aclinj.html). Put into smaller terms, the rehabilitation process gears the patient towards reaching the highest functional level, of the injured knee, possible when the rehabilitation process has ended. The rehabilitation process is very intense and sometimes excruciating, but it is worth all the hard work and determination in the end as the “new” knee is healthy and, in most cases, even stronger than the knee that was not injured.

The first step in the rehabilitation process is to “reduce the swelling and inflammation” in the knee (Wilk KE; Reinold MM; Hooks TR). When the inflammation is down, the knee increases its range of motion (extension and flexion), which is also a goal in the first phase of the rehabilitation program. Another goal is to strengthen the quadriceps, which have weakened dramatically since the surgery has taken place. Jane Fonda’s are a popular exercise to strengthen all the quadriceps. The knee also has to get used to having the patellar (kneecap) slide in the groove of the tibia again and the only way for this to happen is by moving the knee properly; this goal can be attained by either walking or by doing heel slides on a table during the rehabilitation session. Patients are usually “encouraged to weight – bear within the first week after an ACL reconstruction.” (Kvist J et. Al.) Even though the patient is walking again, they still do heel slides during physical therapy sessions; this repetition helps the knee to “remember” the correct movement that has to take place so that there will be no further injury to it.

The second phase, about two to six weeks out of surgery, of the rehabilitation process is much like the first; there is just an “emphasis on increasing the range of motion, increasing weight – bearing, and gaining hamstring and quadriceps control.” (www.sportsci.org/encyc/aclinj/aclinj.html) During this phase, most of the exercises are centered around balancing and making the surrounding muscles of the knee stronger, like the quadriceps, hamstrings, and the calf muscles. These exercises include, but are not limited to, non – weight bearing single leg squats (done when laying down on the single leg squat machine), calf raises (also done on the same machine as the squats), step – downs (stand on a box and lower yourself so your heel touches the ground), and hamstring curls (usually done with a thera –band). These exercises not only strengthen the muscles around the knee but they also strengthen the other ligaments that stabilize the knee, like the lateral collateral ligament (LCL) and the medial collateral ligament (MCL). In order for the patient to maintain the conditioning aspect of their lifestyle, especially for athletes, riding on a stationary bike or, “biofeedback techniques and pool work,” are implemented during this phase. (www.sportsci.org/encyc/aclinj/aclinj.html)

At the third stage, the patient is about six to twelve weeks out of surgery; this phase places an “emphasis on improved muscular control, proprioception and general muscular strengthening.” (www.sportsci.org/encyc/aclinj/aclinj.html) During this stage, the patient usually starts to lift weights (light), continue to balance, but with some distraction (having a ball thrown at them while balancing), and beginning to jog. The patient should have full range of motion and have full control over their quadriceps and hamstrings. The patient should also start being able to “cut” on the knee. The patient should ease into cutting, as they do not want to put too much stress on the knee and cause it too much pain. Too much pain will only hinder the rehabilitation process and make the patient ease up on the exercises, maybe even have to take a couple of days off.

In the final stage, the patient is about twelve weeks to six months out of surgery. The exercises included in this stage are “improving agility and reaction times and increasing total leg strength.” (www.sportsci.org/ency/aclinj/acling.html) The patient really has to listen to their knee during this stage because they do not want to re – injure the knee that they have just rehabilitated. They also have to keep the swelling and inflammation down by icing after doing any physical activities.

Some things to keep in mind for the rehabilitation process is that different people recover at different rates. Some people might come back in six months while others can come back in four; it does not matter how long it takes the patient to return to their daily activities just as long as the knee is fully rehabilitated and they have full function of their knee. It is also imperative that their knee is not in any pain and if inflammation or swelling occurs after physical activities, that does not go away even after icing, the patient needs to ease off the extracurricular activities until the swelling goes down again. Athletes also have more incentive to come back earlier as they want to get on the playing field again. Their activities may be more rigorous during the rehabilitation process and this influences their recovery after surgery to be shorter than most of the regular patients. According to Wilk KE, Reinold MM, and Hooks TR et. Al., “for an athlete to return to competition, it is imperative that he or she regain muscular strength and neuromuscular control in their injured leg while maintaining stability.” The physical therapists recognize that muscle strength and control are very important for the athlete to have in order to play their sport and integrate certain exercises that work on these earlier than regular patients. Not all rehabilitation programs are successful, either; according to one study, “the rehabilitation program used in their study resulted in an acceptable failure rate of 5%.” (Barber – Westin SD, Noyes FR, Heckmann TP, Shaffer BL) Most patients should not look at this statistic, though, because they have a greater chance of succeeding with their rehabilitation than not succeeding.

Another very important thing for the patient and physical therapist to remember is not to push the knee too hard. If it hurts too much or swelling and inflammation flares up again, it is alright for the patient to take the day off. It is better to be safe than sorry in this matter. If the patient tries to push through the pain, it might come back and haunt them later on in the process and may even set them back further then where they were to begin with.

The rehabilitation of the ACL after surgery is imperative if the patient wants to have a functional knee joint for the rest of their life. It is also pertinent if they want to go back to their regular routines and activities before they obtained the injury. According to Rousseau, Dauty, Letenneur, Sauvage, and De Korvin, “the bone – tendon technique for anterior cruciate ligament reconstruction is compatible with an outpatient rehabilitation program if quality medical and surgical follow – up is ensured.” This means that as long as the patients partake in rehabilitation exercises, be it with a physical therapist or someone else, their knee will have a much greater chance of recovering to its “normal” state than if they did not participate in any rehabilitation exercises at all.

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