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The knee joint complex is extremely elaborate and includes three articulating surfaces,
which form two distinct joints contained within a single joint capsule: the patellofemoral
and tibiofemoral joint. The static stability of the knee joint complex depends on four
major knee ligaments, which provide a primary restraint to abnormal knee motion. These
are the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), Medial
(tibial) collateral ligament (MCL) and lateral (fibular) collateral ligament (LCL).

The ACL is a unique structure and is one of the most important ligaments to knee
stability, serving as a primary restraint to anterior translation of the tibia relative to the
femur, and a secondary restraint to both internal and external rotation in the non– weight-
bearing knee. The ACL originates on the inner aspect of the lateral femoral condyle in the
intercondylar notch and travel obliquely and distally through the knee joint. It inserts on
the anterior intercondylar surface of the tibial plateau, where they partially blend with the
lateral meniscus.

The Ligaments of the Knee Joint

Anterior Cruciate Ligament Reconstruction

Surgical management of the injured ACL is done using arthroscopically assisted or

endoscopic techniques to reduce tissue morbidity and reduce recovery time. ACL
reconstruction is done using an autograft, which may be a bone-patellar tendon-bone graft,
or a semitendinosus-gracilis tendon autograft (hamstring tendon graft). A protective brace
may be used after surgery for protection of the graft and to prevent of knee flexion
contracture during early rehabilitation.

Rehabilitation after Anterior Cruciate Ligament Reconstruction

The postoperative management comprises of four phases.

Phase 1: Immediate Postoperative Phase

The goals of this phase are:

• Diminish joint swelling and pain
• Restore full passive knee extension
• Restore patellar mobility
• Improve knee flexion
• Re-establish quadriceps control
• Restore independent ambulation

Phase 1 essentially consists of land-based rehabilitation, as healing of the tissues is

required for hydrotherapy. Ice packs may be used for 20 minutes every hour with the leg
elevated and the knee in full extension. It relieves pain and swelling. Passive full knee
extension and passive or assisted active knee flexion exercises (limited to 90 degrees)

should be included. Patellar mobilisations can also be included to prevent adhesions.
Isometric quadriceps exercises may be carried out to prevent muscle atrophy. This may be
combined with electrical stimulation of the muscle to prevent muscle atrophy. Other
exercises include ankle pumps, hip abduction and adduction and assisted straight leg
raising. Gait training should be done with crutches with weight bearing as tolerated.

Phase 2: Early Rehabilitation Phase (Week 2 through Week 4)

The goals of phase 2 are:

• Maintain full passive knee extension
• Gradually increase knee flexion
• Diminish swelling and pain
• Muscle training
• Restore proprioception
• Patellar mobility
• Independent ambulation

During this phase, hydrotherapy can be initiated as wound closure should be complete by
two weeks. Buoyancy assisted exercises may be done in water to increase and maintain
range of knee extension and flexion. These exercises may be done in standing. Buoyancy
resisted exercises may be done for strengthening of the lower limb musculature.
Simultaneously, the warm environment of the pool water may allow muscles to work
effectively owing to arise in temperature and of relaxation of any muscle spasm. It may
also have a pain relieving effect. On the other hand, land based strengthening and
mobilisation exercises do not provide such relief and relaxation.

Hydrotherapy has also been found to reduce joint effusion more effectively than land-
based exercises due to effects of hydrostatic pressure. Furthermore, there is an enhanced

delivery of manual techniques such as patellar mobilisations in water than on land.
Propriceptive exercises and balance training may be effectively carried out both on land
and in water. However, fear of water and poor balance may impede such exercises in the

At this phase of rehabilitation, the patient must be able to ambulate independently.

However, because of pain gait training may be difficult. Thus, gait training in water is
facilitated due to the effect of buoyancy, which reduces weight bearing on joints as the
percentage of body immersion increases. Gait training in water should thus progress from
deep to shallow waters.

Phase 3: Intermediate Phase (Week 4 through Week 10)

The goals of phase 3 are:

• Restore full knee range of motion (0° to 125 degrees)

• Improve lower extremity strength
• Enhance proprioception, balance, and neuromuscular control
• Improve muscular endurance
• Ambulate without assistive device and protective brace using a normal gait pattern.
• Improve cardiopulmonary fitness

Phase 4: Late Rehabilitation Phase

The goals of phase 4 are:

• Normalize lower extremity strength

• Enhance muscular power and endurance

• Normalize neuromuscular control
• Return to previous activities

Further strengthening in water may be done by using other properties of water such as
turbulence and drag which increases resistance to exercise. Equipments such as hydro-
tone boots and fins can be used to generate more resistance when performing buoyancy-
resisted exercises. In addition, increasing the speed of motion through water generates
further drag. Metacentric exercises can be done in water to improve balance. Deep and
shallow water running may be done to improve endurance. Other exercises such as
swimming may be done to improve cardiovascular fitness.

The final aim of rehabilitation is sociocultural reintegration. Thus, the individual should
be able to return back to his/her previous activities. For example, an athlete should
practice his style of running in water.


The physical properties of water result in beneficial effects on the body such as the
reduction in pain, increases in ROM, improved coordination of movement and early
restoration of joint ROM. Thus, a hydrotherapy programme is recommended in addition
to a land based for a quicker and safe rehabilitation. However, the aim of rehabilitation
should be that the individual is fully functional on land as humans do not live in water!