Physiotherapy after ACL reconstruction

Contents:

1. The aims of rehabilitation
2. Braces
3. Increasing range of motion in the joint
4. Balancing and proprioception exercises, strength training
5. Physical therapy

The aims of rehabilitation

When carried out properly, postoperative rehabilitation of a reconstructed anterior cruciate ligament aims to restore full function to the patient after an injury. Getting back to work or sport depends on a few factors: the absence of pain and swelling, full range of motion of the knee joint, regaining muscle strength and being able to walk normally. It is also important to generally take care of the cardiovascular system, correct proprioception and regain full trust of the limb after the operation. That's why no matter what the rehabilitation plan, it is important to include certain elements of physiotherapy. 

Using a brace

It is important to think about using a brace directly after ACL reconstruction. This allows you to maintain or increase the current range of motion of the knee joint. It will also improve the knee’s ability to cope with different side and medial forces, improve joint stability and prevent further injury in the first weeks of rehabilitation. You wear the brace whilst performing normal everyday activities. The brace is removed during rehabilitation.

Increasing range of motion in the joint

The next important element of the postoperative rehabilitation program is introducing exercises that increase the range of motion in the joint. This means being able to fully straighten the knee as quickly as possible. This is why it is important to start moving the quadriceps early, because whether or not it functions properly will affect whether the knee joint will fully be able to move. Later on in the program we focus on being able to fully bend the knee. Restoring proper range of motion should be planned bearing in mind the process of rebuilding the graft so it doesn’t become strained or weaken the stability of the knee.

Balancing and proprioception exercises, strength training

Balancing and proprioception exercises are just as important. These kinds of exercises improve feeling in the knee, increase muscle strength, improve function and help you get back to full movement. It is also worth noting that neuromuscular training and proprioception exercises are a good precautionary measure to prevent further injury to the knee. It is also necessary to remember about appropriate strength training. To this end we use two different kinds of exercises: closed kinetic chain exercises are introduced in the early stages of rehabilitation because of the way they dynamically stabilise the joint and stimulate proprioceptors, as well as open kinetic chain exercises that stimulate more isolated muscle work which allows for more focused muscle strengthening.

Physical therapy

After ACL reconstruction, you can improve the effectiveness of physiotherapy by also applying some methods from the field of physical therapy which will be a form of adjunctive therapy to the conventional muscle training methods. One of them is electrical muscle stimulation. In the first days after the reconstruction the natural instinct is to not move the quadriceps because of swelling and pain, which does not able you to consciously engage your muscles in activity. That is also why applying this method shortly after the operation has a positive influence on increasing the strength of the quadriceps.

By consciously combining the above methods and introducing them to match the current functional abilities of the patient, postoperative rehabilitation aims to get you back to normal activity within 6 weeks while not causing more damage to the ACL.

Below is an example of a rehabilitation program after ACL reconstruction with the use of the semitendinosus tendon:

PHASE 1: 0-4 weeks.

WEIGHTBEARING – with the use of orthopaedic balls*

BRACE 0-1 week: brace worn locked in extension for ambulation and sleeping

             1-4 weeks: unlocked for ambulation, removed for sleeping**

RANGE OF MOTION – as tolerated

THERAPEUTIC EXERCISES

• Gliding the heel along the tibia of the other leg,
• quadriceps exercises,
• patella mobilisation,
• stretching the gastrocnemius and soleus muscles***,
• lifting the straightened leg in a brace until the quadriceps loses strength and cannot fully straighten.

PHASE 2: 4-6 weeks.

WEIGHTBEARING – gradually stop using the balls

BRACE – stop using if the patient can completely extend the leg without any problems.

RANGE OF MOTION – can fully straighten and there is progression with bending

THERAPEUTIC EXERCISES

• Move on to training the gastrocnemius and soleus muscles and continue with closed kinetic chain exercises,
• begin stretching the back thigh muscles

PHASE 3: 6 weeks - 4 months

LOAD – full, without the use of balls, keeping a normal walking model

BRACE – none

RANGE OF MOTION – full, pain free

THERAPEUTIC EXERCISES

• Begin strengthening the back thigh muscles,
• continue with closed kinetic chain exercises
• progress with proprioception exercises
• exercises on Stairmaster, Nordic Trac,
• running forwards in the 12th week

PHASE 4: 4-6 weeks.

LOAD – full

BRACE – none

RANGE OF MOTION – full, pain free

THERAPEUTIC EXERCISES:

• develop flexibility/strength
• function improves: running forwards/backwards, grape vine exercises etc.
• beginning of plyometric training
• exercises specific for a given sport

PHASE 5: 6 months onwards

LOAD – full

BRACE – none

RANGE OF MOTION – full, pain free

THERAPEUTIC EXERCISES:

• Gradually return to sport,
• maintain the strength and endurance program

comments:

*Change in the case of simultaneous reconstruction/graft of the meniscus or joint cartilage

**The brace can be removed for bed after the first appointment after surgery (day 7-10)

***This exercise must be done in a position which doesn't cause overload

****You cannot stretch the back thigh muscles until 4 weeks after the operation