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Key Principles of Rehabilitation

after ACL Reconstruction


Dr Rajesh Purushothaman
Associate Professor of Orthopaedics
Govt Medical College, Kozhikode

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ACL Outcomes

Reasons for inability to return to


Only 72% of football players return to playsports
Fear of reinjury
At 7 years only 36% continue to play
Limitation of ROM
Professional football players’ careers are shortened by
approximately 2 years
Instability
Overall performance is decreased by 20%
Pain

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Evolution of ACL rehab

Surgery-modified
rehabilitation
Rigid Immobilisation
Outcome
1983- Continuous
modified
passive motion
rehabilitation and
1990- Accelerated surgery
protocols

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University of Delaware -
Criterion-based rehabilitation guidelines

• First published in 1996 and updated in 2012

• Multiple phases

• Evidence based on biologic healing times

• Entry into each phase is criterion based

• Each phase has milestones to achieve

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Phases
• Preoperative phase

• Immediate postoperative phase (Week 1)

• Personalise
Early rehab phase depending
(Week 2-4)
on original injury and milestones achieved
• Controlled ambulation phase (Week 4-10)

• Advanced rehab phase (Week 10-16)

• Return to activity phase (Week 16-22)

• Return to sports phase

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Key Focus of Rehab
Range of motion

Patellar mobilisation

Muscle strengthening

Proprioception

Neuromuscular control

While maintaining static stability and allowing


incorporation of graft and preventing graft failure
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Pre-operative Phase- Goals
Diminish inflammation, swelling, and pain

Restore normal range of motion (especially knee


extension)

Quadriceps strengthening

Mobilisation of patella

Provide patient education to prepare patient for


surgery

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Pre-operative Phase -
Control of pain and swelling
Compression sleeve to reduce swelling

Brace to immobilise

NSAIDs

Cryotherapy and elevation

Weight bearing as tolerated with or without crutches

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ROM - Full extension

The most common complication and


cause of poorer outcomes following
ACL reconstruction is restriction of
ROM, particularly loss of full knee
extension.

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Gastrocnemius
stretch

Prone Hangs

Supine Hamstring Stretch Low Load


Long Duration
Stretch

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Pre-Operative Phase-
Exercises
Ankle pumps

Passive knee extension to 0°

Passive knee flexion to tolerance

Straight leg raises (flexion, abduction, adduction)

Quadriceps setting

Closed chain quadriceps exercises only (Foot in contact


with ground)

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When is the patient ready for
surgery?
1. No joint reaction

2. Full ROM

3. Normal gait

4. 90% quadriceps index

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Immediate Post-Operative
Phase (Day1-7) - Goals
Diminish joint swelling and pain

Restore patellar mobility

Restore full passive knee extension

Gradually improve knee flexion

Re-establish quadriceps control

Restore independent ambulation

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Post-Op Day 1

• Brace - Locked in full extension

• Weight Bearing - As tolerated with 2 crutches

• Ice and elevation

• Exercises

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Post-Op Day 2-7
Brace - Locked in full extension during ambulation, unlocked
during sitting

Weight bearing - With 2 crutches as tolerated

ROM exercises - 4-6 times a day


0 0
Knee flexion of 90 by day 5 and 100 by day 7

Full extension

Ice and elevation

Exercises

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Early Rehab Phase - 2-4 W
Entry Criteria
1. Quadriceps control (ability to perform good quadriceps
set and straight leg raise)

2. Full passive knee extension

3. PROM of 0° to 90°

4. Good patellar mobility

5. Minimal joint effusion

6. Independent ambulation

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Early Rehab Phase -
Goals
Maintain full passive knee extension

Gradually increase knee flexion

Diminish swelling and pain

Muscle training

Restore proprioception

Patellar mobility

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Early Rehab Phase - Week
2-4

Weight bearing - Discontinue crutches at 10 days

Brace - Discontinue at 4 weeks

ROM Exercises - Maintain full passive extension and


increase flexion to 1150

Exercises

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Controlled Ambulation Phase
Week 4-10 - Entry Criteria
1. Active ROM of 0° to 115°

2. Quadriceps strength greater than 60% of


contralateral side (isometric test at 60° of knee
flexion)

3. Laxity (+1 or less)

4. Minimal to no joint effusion

5. No joint line or patellofemoral pain

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Controlled Ambulation Phase
Week 4-10 - Goals
Restore full knee ROM (0°-125°)

Improve lower extremity strength

Enhance proprioception, balance, and neuromuscular


control

Improve muscular endurance

Restore limb confidence and function

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Advanced Activity Phase
(Week 10-16) - Entry Criteria
1. AROM of 0° to 125° or greater

2. Quadriceps strength greater than 79% of contralateral side

3. Quadriceps to Hamstring ratio of 70% to 75%

4. No pain or effusion

5. Satisfactory clinical exam

6. Hop test (80% of contralateral leg)

7. Subjective knee score (ie, Cincinnati Knee Rating System) of 80


points or higher

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Advanced Activity Phase
(Week 10-16) - Goals

Normalise lower extremity strength

Enhance muscular power and endurance

Improve neuromuscular control

Perform selected sport-specific drills

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Return to activity phase
(Week 16-22) - Entry criteria
Full ROM

Quadriceps bilateral comparison (80% or greater)

Hamstring bilateral comparison (110% or greater)

Hamstrings-quadriceps ratio (70% or greater)

Functional hop test (85% or greater of contralateral side)

Satisfactory clinical exam

Subjective knee score (Cincinnati Knee Rating System) of 90


points or higher

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Return to activity phase
(Week 16-22) - Goals

Gradual return to full, unrestricted sports

Achieve maximal strength and endurance

Normalize neuromuscular control

Progress skill training

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Return to Sports

• Minimum 12 weeks postoperative

• 90% or greater on quadriceps index

• 90% or greater on all hop tests

• 90% or greater on KOS-ADL

• 90% or greater on global rating score of knee function

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Modifications

• Active hamstring exercises started only after 4 weeks


if hamstring graft is used

• Meniscus balancing needs no modification

• Meniscus repair needs non-weight bearing

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Conclusions

• Rehabilitation is extremely important to achieve the


best outcome

• Start pre-operatively

• Rehabilitation should take biologic tissue healing times


into consideration

• Progress in phases

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Conclusions

• Entry into phases is criteria based

• Each phase has milestones to achieve

• Rehab should be individualised based on criteria

• Avoid open chain quadriceps exercises in the first 4


weeks - FOOT IN CONTACT or BRACE LOCKED IN
EXTENSION

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That’s it Friends
Hope it was useful

Thanks

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