REVALIDATION PROTOCOL AFTER THE ACL RECONSTRUCTION

You should know that rehabilitation after an anterior cruciate ligament tear starts before intervention.

The purposes of this pre-operative rehabilitation are:

to control pain and swelling,

to recover articular amplitudes,

to maintain muscle strength,

to mentally prepare the patient before surgery.

 

Controlling pain and inflammation: 
Pain and inflammation will be controlled with painkillers and anti-inflammatory drugs for 5 to 7 days.

To immobilize the knee, a removable splint will be usedto keep the knee extended. With splints, patients can resume support on the leg helped by two crutches. The splint can be removed at rest, and we encourage limitation of prolonged use to limit quadriceps atrophy.

 

 

Exercises for the articular amplitude recovery: 
Extension recovery is the main point of concern. Patients can perform two exercises by themselves:

In supine position, patients place a roll under the sole of the foot, keeping the knee relaxed in extension. Completely relaxing the thigh muscles, a maximum extension of the knee should be achieved (photo 1).

With the patient in prone position and knee over the bedside, thigh muscle relaxation is attempted, to achieve a maximum extension (photo 2).

For flexion rehabilitation,the patient will lie in supine position with his/her foot placed on a wall. With the healthy foot pressing on the bad foot, the patient will tryto gradually achieve a maximum knee flexion (photo 3).

The same exercise can be performed with the patient lying down, with legs stretched. Slightly flex the bad knee using the other leg to flex better by pulling on the opposite ankle. As soon as the end of flexion is reached, keep the position for 5 seconds; if the patient reaches 90° or even more, he/she can help with his/her arms. (photo 4).

Maintaining muscle strength:
We advise using a stationary bike; swimming can also help maintain good muscle tone.

Mental preparation:
Patients must understand well the intervention drawbacks and benefits. They must be prepared for the postoperative rehabilitation sessions with their physical therapists. Patients should be prepared for absence from work, for between 6 weeks and 3 months according to the type of activity.

The resumption of sports cannot be taken into account before 6 to 9 months.

 

Here is a summary of the steps to be observed during rehabilitation:

 

 

STEP 1: THE FIRST POSTOPERATIVE DAY

Painmanagement→ painkillers and anti-inflammatory drugs will be prescribed by the anaesthetist, according to a predetermined regimen.
– Use of ice→ recommended to reduce inflammation. If using cryotherapy sleeve (plastic coating containing cold water), the rate is 3 to 4 times/day, 30 minute-sessions.
– Use of stockings → patients will wear stockings before surgery.
– Knee splint → removable splints are used with knee in extension (same as before surgery), or we can consider using articulated splints that will be locked in extension in the beginning.

 

 

STEP 2: Day 1 to Day 7

Purposes:

  • Controlling pain and inflammation,
  • Walking rehabilitation, maintaining the articular amplitudes, passive extension rehabilitation, muscle toning, achieving active blockage and learning how to walk with help.

The patient must try to use ice as often as possible, to alleviate knee inflammation.
It is desirable to maintain a slightly inclined position, with a pillow placed under the leg when the patient is lying down.
Avoid being seated with shaking foot.
Painkiller adjustment will be made based on the pain felt.
Walking will be done with the aid of crutches; it is desirable for patients to limit their movement.
They may start using astationary bike (of course without the splint); the seat should be high and the effort must be made by the opposite foot. The foot that was operatedon should only be placed on the pedal, without forcing or pushing it.
The removable splint will be kept on day and night for the first two weeks; then, only during the day for another 1 to 2 weeks.
The actual rehabilitation will include medical massage, mobilization of the patella, prevention of phlebitis, active mobilization, aided flexion/extension with or without Artromot devices, toning of the quadriceps, and learning how to walk with a splint and walking stick.

Quick extensionreadjustment

Exercise 1: Remove knee splint for 2-3 hours. Rest the heel on a roll or pillow with the knee not touching the bed. Keep the knee in this position for 10 to 15 minutes, relaxing the hamstring. This exercise can be performed in a seated position with heel on a stool. (photo 1)

Exercise 2: Active assisted extension using the opposite leg. The patient sits on the table’s edge, the healthy leg below the thighoperated on (legs crossed) and lift the leg operated on with the healthy leg. (photo 5)

Exercise 3: Passive flexion of the kneeoperated on. Seated on the table’s edge, cross the healthy part of legs, push the footoperated on to get a maximum flexion. This position is maintained for 6 seconds, the exercise is performed 4 to6 times per day for 10 minutes. Normally, 90° flexion is obtained in one week. (photo 6)


Exercise 4: Isometric contraction of the quadriceps, in supine position. Perform contractions of the quadriceps without lifting the heel from the bed. Conduct three sets of 10 contractions  threetimes a day. Each contraction lasts 6 seconds. This exercise is important to strengthen the quadriceps muscle; it also helps to decrease inflammation in the knee. (photo 7)

Exercise 5:Lift stretched leg 8 times, 10 lifts 3 times a day; knee splint must be always maintained. In supine position, lift the knee between 5° and 60° and hold it in this position for 6 seconds. Gently lower leg, relax the muscles. This exercise can be performed without the splint from the time when you are able to hold the knee in full extension by contraction of the quadriceps (quadriceps perfectly block the knee). (photo 8)

Exercises for the hamstring muscle
Patients who had an ACL reconstruction with the half-tendinous and/or rightinternal muscle, must start these exercises in postoperative week 7. These muscles require six weeks to heal and any contraction may lead to pain of the inner side of the thigh.

Exercise 6: In supine position, flex the knee for 10° – 15° more and hold it in this position for 5 seconds. Then flex for another 10-15° and hold for 5 seconds more. Continue in 15-25° steps to obtain a 90° flexion. Full extension and then relaxation.Repeat this exercise 10 times, 3 sessions per day. (photo 9)

 

STEP 3: Day 8 to Day 14

Purposes:

  • – Continuing physiotherapy,
  • – Achieving better flexion and extension,
  • – Resuming work.

After three weeks, apply Vaseline or other healing ointments to the wound to aesthetically improve the scar.
The scar should not be exposed to sunlight for a year.
It is important to remove the splint 4 to 6 times a day for 10 to 15 minutes to allow the maintenance of a full extension.

 

STEP 4: WEEK 3

Purposes:

  • – Maintaining full extension and 100-120° flexion must be achieved
  • – Muscle toning.

Continue exercises for passive expansion. Work to achieve about 90-100° flexion. Improve muscle control (partial squat).
Exercise 7: Upright, about 30 to 40 cm from a table, touch the table with your fingers to keep your balance. Bend your knee slightly to 30 to 40° and hold this position for 5 seconds, then extend your knee. Repeat10 times in 3 daily sessions. (photo 10)
Exercise 8: In the same position as in exercise 7, near a table, contract the leg muscles and rise up on your toes, hold the position for 6 seconds. Repeat the same exercise 10 times in 3 sessions. (photo 11)
Splint should be left at home; use only one walking stick, then, depending on muscle recovery, eventually you can leave the second stick as well. If you must use a stick, always use it on the opposite side. Continue exercises with the stationary bike, at first without resistance and after six weeks start cycling normally and even against a slight resistance. At first, sessions should last 5 minutes, thenthey can be increased up to 20 minutes.
Driving can be attempted after 4 to 6 weeks. Patients who drive automatic vehicles and whose surgery was on the left leg, can start driving sooner (2 to 3 weeks).

STEP 5: WEEK 4 – 6

Purposes:

  • – Recovery of normal amplitudes of the knee,
  • – Muscle toning.

At this step, we expect to exceed a flexion of 120° with a full extension; continue exercises to strengthen the quadriceps.

Beginning the sixth week, patients can go to the gym and perform exercises with weights (foot pushing weights); they can also use elliptical bikes for 15 to 20 minutes per day. Swimming is recommendedquickly enough, since week 4.

You must climb and descend stairs carefully.

STEP 6: Week 7 to Week 12

Purposes:

  • -Reaching 135° flexion
  • – Continuing muscle toning.

Patients may start walking on the treadmill. Continue using the stationary bike. For treadmill, use normal walking speed without resistance.

 

STEP 7: WEEK 12 TO WEEK 20

Continue toning. Patients may start lightly running; running must be on flat ground, allowing for fast changes of the running direction.
At this stage, patientsreach the stage of intensive rehabilitation for a maximum recovery of amplitudes, strength and stability of the knee, to resume sports.
To resume sports, a maximum recovery of the quadriceps in closed chain and hamstring muscles in opened and closed chain is desirable. In fact, the quadriceps must be recovered 80% (compared with the healthy foot), hamstring muscles 80% and there must be a full recovery of the mobility. Knee should not be swollen, but stable. Patients must be able to perform jogging programs with quick changes of direction.

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