Anterior cruciate ligament injuries & its physiotherapy treatment (part-2)

 Importance of ACL

ACL is a key structure in the knee joint kinematics as it resists tibial translation & rotational loads. Almost 85% of total restraining force of anterior translation is provided by ACL, and it also prevents excessive medial and lateral rotation tibia, as well as Varus and valgus stresses. It also has a primary role in proprioceptive function because of the mechanoreceptors in the it.

As a consequence of its complex role in the kinematics of the knee, when an ACL injury occurs there are both clinical signs and subjective instability and therefore a comprehensive rehabilitation programe is needed.

ACL injury is relatively common knee injuries among athletes and females as we discussed in the previous blog. Injury can range from mild (small tears, grade 1) to severe (complete ligament tear, grade 3)

When ACL has complete rupture and there are clinical and subjective signs of instability, a surgical reconstruction is needed. ACL rehabilitation is for both, conservative and surgical option.

 

ACL courses anteriorly, medially and distally across the joint as it passes from the femur to tibia. As it does, it turns on itself in a slight outward (lateral) spiral.

ACL doesn’t have very good vascular supply and its located within the fibrocartilage are of intercondylar fossa. The coincidence of poor blood supply and presence of fibrocartilage explains the poor healing capacity of the ligament.

Treatment criteria

It is useful to remember that ACL injuries rarely occur in isolation. extent of other injuries may affect the approach of ACL management. In most cases the mechanism of injury can damage the Medial collateral ligament or the meniscus. Other associated injuries could be micro-fracture or bone contusion, both with or without chondral injuries. In those cases, the ACL rehabilitation program must be not standardize and consider the comorbidity (more than one physical problem at once).

The major goals of the knee:

·        Gain full ROM of knee

·        Repair muscle strength and proprioception

·        Gain good functional stability

·        Reach the best possible functional level (walking, running, jumping)

·        Decrease the risk of re-injuries

·        Return to sport if athlete

Phases of ACL rehabilitation:

1.      Acute stage

2.      Pre-operative stage / conservative treatment

3.      Post-operative stage

4.      Return to sport

Acute stage:

After an ACL injury, regardless of whether surgery will take place or not, physiotherapy management focuses on regaining ROM, strength, proprioception and stability. In the acute stage PRICE should be used in order to reduce swelling and pain, to attempt full ROM and to decrease joint effusion.

In some patients use of crutches and knee immobilizer could there but it should not be used for a longer period of time to avoid quadriceps atrophy.

Pre-operative/ pre-habitation

·        Exercise counselling in important to gain patient’s confidence.

·        As upper limb will be playing an important role after surgery basically for mobility assistance in order to handle crutches or walking frames, upper limb exercises as in strengthening and endurance training will be vital and useful.

·        As well as upper limb core muscle strengthening is also important as it contributes to knee stability.

·        Lower limb stretching exercises (for hip flexors  & iliopsoas) are helpful to ease the pain and provide relaxation. (in cases of hip fractures better to avoid this step)

·        Active exercises for hip, knee and ankle joint is done for activation of quadriceps, hamstring, hip abductors, glutes and calf muscles for training and activation purpose.

·        Functional education and training is important in initial phases and guidance about sports specific training will help patient to understand the course of training.

To assist pre-operative optimisation, given protocol should be followed whether its conservative treatment of if preparing the patient for post-surgical approach:

·        Passive knee extension: physical therapist can use gentle force to achieve full range

·        Patellar self-mobilisation

·        Heel slides

·        Static quadriceps exercise

·        SLR

·        Passive knee bending

·        Knee flexion in prone

·        Wall slides

·        Knee flexion-extension in sitting

·        Ankle DF/PF/circumduction

·        Gluteal exercise in prone (hip extension with knee extended)

·        Weight transfer in standing (forwards/backward/side-side)

Neuromuscular electrical stimulation (NMES) combined with exercise is more effective in improving quadriceps strength than exercise alone.

Kinesio taping is considered to useful to provide stability and encourage reduction of swelling.

one leg standing, reach-outs in one leg standing are helpful exercises to improve proprioception.

 

 

Post-operative rehabilitation

Week 1:

·        Regular icing and elevation are used to reduce swelling.

·        By the end of first week, achieving 70 degree of knee flexion is the initial goal.

·        If needed walking aids like crutches or walking frames are used and in some cases knee braces are recommended by the surgeon.

·        Patellar multi-directional mobilisation is included and can be used up to 8 weeks postoperative management.  

·        Stretching exercises for calf, hamstring, and quadriceps (Vastus medialis) can be perform in supine or prone position. This will help to reduce the swelling, pain.

·        By doing full extension VMO  will be strengthen and more active which will help to decrease inflammation.

·        Isometric quadriceps exercises are safe to conduct in 1^st week. Same way early weight bearing is beneficial to reduce patellofemoral pain.

Week 2:

·        For further functional improvement closed kinematic chain exercises are added which will ultimately provide weight bearing and improvement of hams and quads. i.e., mini squats/ modified lunges (according to the patients need an condition)

·        Leg press

·        Calf muscle exercise: ATM, heel raise etc.

·        Proprioception exercises (may add core strengthening)

·         Stationary bike

·        Upper body conditioning exercises

If hamstring graft, NOACTIVE hamstring exercise until 2 WEEKS and no open chain resisted leg extension at any point.

Week 3-4:

·        Icing will not give any significant benefit after 1^st week.

·        Main goal is to achieve further degree of knee flexion every week and maintain full degree of extension.

·        Try to genuinely increase the stance phase in an attempt to walk with one crutch. With good hamstring/quadriceps control, the use of crutches can be reduced earlier.

·        Strengthening exercises for the calf muscle, hamstring and quadriceps (vastus medialis) can be performed sitting using a stationary bicycle or light weights . The progress of the exercise depends on pain, swelling and quadriceps control.

·        Starting eccentric quadriceps training (in CKC) from 3 weeks after ACLR is safe and contributes to a bigger improvement in quadriceps strength than concentric training

·        In some patient with good hamstring/quadriceps control it is possible to genuinely attempt some exercise in Closed Kinetic Chain.

The combination of early knee extension, early weight bearing, and closed kinetic quadriceps strengthening allows the patient to progress through the post-operative rehabilitation period at a rather rapid pace without compromising ligamentous stability.

    Week 5:

·        Passive mobilizations should normalize motility but flexion should not yet be thorough.

·        Tonification of hamstrings and quadriceps can start with more intensity both in open and close chain exercises. The exercises should be started on light intensity and progressively increased

·        The closed chain exercises should be built from less responsible positions such as leg press or steps to more congested starting positions like squatting. (The progress of the exercise depends on pain, swelling and quadriceps control.)

·        Proprioception and coordination exercises can evolve if the general strength is good. This includes balance exercises on boards and toll.

     Week 10:

·        The progression of loading is the fundamental from now on.

·        The proprioception and coordination exercise could be more specific to the individual sporting needs of the patient. If the patient does not wish to return to sport these exercises full-fill his ADL needs (climbing stairs, walking uphill or downhill, skating, swimming.)

·        Forward, backward and lateral dynamic movements can be included as well as isokinetic exercises

 

Return to sport:

·        After 3 months the patient can move on to functional exercises such as running and jumping.

·        As proprioceptive and coordination exercises become more intense, faster changes in direction are possible.

·        To stimulate coordination and control through afferent and efferent information processing, exercises should be enhanced by variation in visible input, surface stability (trampoline), speed of exercise performance, complexity of the task, resistance, one or two-legged performance, etc

·        The final goal is to maximize endurance and strength of the knee stabilizers, optimize neuromuscular control with plyometric exercises and to add the sport-specific exercises.

·        Acceleration and deceleration, variations in running and turning and cutting manoeuvres improve arthrokinetic reflexes to prevent new trauma during competition.