ACL Reconstruction

ACL stands for Anterior Cruciate Ligament. It is very thick and strong fibrous bands, which acts as  direct bond between tibia and femur to maintain the stability of knee joint. It is called anterior cruciate as it begins from anterior part of intercondylar area of tibia runs upwards, backwards and laterally and is attached to the posterior part of medial surface of lateral condyle of femur. It is taut during extension of knee. Injury to the AcL can occur due to the twisting injury to the knee or jumping during running or sports activities.

The healing capacity of a torn ACL is poor therefore surgical intervention is required to restore stability particularly in young and active individuals. The incidence of ACL re-injury is less after ACL reconstruction than with conservative management. Many patients who have sustained in a acute primary ACL injury consider conservative course of treatment before choosing surgical methods.

Indications for Surgery:

1) Disabling instability of the knee caused by complete or partial acute ACL tear or chronic ACL laxity 

2) Frequent episodes of the knee giving away during routine activities of daily life.

3)Injury of the MCL at the time of ACl injury to prevent lax healing of the MCL

4)  Increased risk of re-injury because of participation in high demand work, sports or recreational activities.

Rehabilitation:

Advances in surgical technique and a better understanding of graft healing and the impact of stress on the healing graft, early post operative motion and weight bearing (accelerated rehabilitation) has become the standard of care after primary ACL reconstruction typically in young patients.

Accelerated rehabilitation is done when we know that the graft is a strong enough to withstand stresses of early motion and wait bearing and subjected to favorable healing condition in respond to stresses.

Post operative management

1) Immobilization 

Immobilization by bracing is mandatory after surgery for about 4-6 weeks in the early phase of rehabilitation. The duration depends it depends on the type of graft, quality of fixation and patient assessment post surgery. It is of two types:

a) Rehabilitative bracing: It uses a hinged orthosis with a locking mechanism that can restrict the allowable Range of motion. It is worn only for first 6 weeks following surgery.

b) Functional Bracing: Functional Brace is worn when returning to high demand activities such as sports or any avoid reinjury related to work demands.

The patient can be weaned from the brace at about 6 weeks once full extension is achieved. Full, active extension and 90-100 degrees of flexion is expected by 4 to 6 weeks post surgery.

 During Day 1 to Week 4

Goals: 

Protect the healing tissues.

Prevent reflex inhibition of muscles

Decrease joint effusion while working on the Range of motion of knee joint.

Home Exercise program.

Intervention:

1) The patient is instructed to apply hot fomentation before exercises on the surrounding muscles of the knee i.e. thigh, hamstring muscles behind the thigh and calf muscles.  No Hot fomentation on the knee.

2) Icing is mandatory around the knee joints after exercises and at least every two hours to reduce pain and swelling in the knee.

3) Maintain compulsory bracing, rest, ice compression and mobility through exercise.

4) Gait Training: Teaching the patient to walk with the walker or crutches.

5) Muscle setting exercises: Static Quads, Static hams, static glutes.

6) Active or Passive Movements: ATMs, SLR, Abduction and side lying exercises.

7) Stretching exercises for the calf and Hamstring.

Week 5- Week 10

Goals:

Full, painfree ranges

Strength: 4/5

Dynamic control of knee

Normal walking and activities of daily living.

Intervention:

1) Advanced Strengthening exercises and flexibility exercises.

2) Stabilization exercises

3) Balancing Exercises

4) Proprioceptive training

Week 11- Week 24

Goals:

 No joint instabilty

Full Knee ROM and strength.

Symmetrical Gait.

Unrestricted ADL

Reduce risk of reinjury

Intervention:

1)  Initiate running, jumping.

2) Advanced closed chain exercises

3) Initiate plyometric drills e.g. bouncing, jumping ropes

4) Simulated Work or sport specific training.

5) Transition to full speed jogging, running.

Reference: 

1) B.D Chaurasia Anatomy

2) Maggee

3)  Therapeautic Exercise: By Carolyn Kisner.

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Call: +919082137433

Email: mumbaiphysios25@gmail.com