ACL Rehabilitation: Acute Management After Surgery

What Is an ACL Tear?

There are four primary ligaments in our knee, two collateral and two cruciate, namely, anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL). They hold the bones together like a rope. The ACL controls the rotational and forward movement of the tibia (shinbone). More than 50 percent of injuries occur to the ACL with damage to its surrounding structures, like the meniscus, articular cartilages, and other ligaments of the knee. It usually occurs for athletes and sports people in contact sports.

What Is a Sprain?

A sprain is an injury to the ligament, causing it to strain or tear. Symptoms of a sprain include pain in the affected area, swelling around it, bruising of the skin, and inability to move that joint. A pop or tear is usually experienced after a sprain.

Is It Possible to Treat an ACL Without Surgery?

A torn ACL will not heal without surgery. However, for old patients and people who have low activity levels and if the stability of the knee is intact, nonsurgical options are preferred. Bracing is done to protect the knee from instability. Crutches are given to the patient to prevent them from putting weight on the leg. After the swelling and pain go away, physiotherapy is done.

What Are the Surgical Options for Torn ACLs?

The ACL is usually replaced by ACL reconstruction surgery. A graft is taken and placed in the place of the torn ligament. It can be autograft (from the same individual) or allograft (from another individual, usually a deceased person who has donated their body). Autograft is taken from the patellar tendon, hamstring tendon, and quadriceps tendon.

What Should Be Done After ACL Surgery

Immediately after an ACL reconstruction surgery, rehabilitation should be done to restore function and get back to routine. Rehabilitation is a six-month-long protocol, and it is divided into seven timelines. The timelines are divided based on the goals met: range of motion and stability, strength and endurance, proprioception, gait, and cardiovascular fitness. After each timeline, the progression is calculated by a LEFS (lower extremity functional scale) score. It is used to evaluate the normal functioning of the lower extremities, and it is a self-reporting questionnaire.

What Are the Timeline Goals in Rehabilitation After ACL Repair?

• Range of Motion (ROM) and Flexibility- After ACL reconstruction, it is important to restore ROM and flexibility. It is done by quadriceps retraining and a stretching program.

• Gait Retraining- Altered gait is usually seen after ACL reconstruction, and it is brought back by treadmill training.

• Muscular Strength and Endurance Training- Depending on the graft used for ACL repair (ACLR), specific strength deficits have been found. Open and closed kinetic exercises are done in muscle training. Isolated hamstring strengthening is started around the sixth week.

• Neuromuscular and Proprioceptive Training- Proprioceptive training should be started immediately after the ACL surgery. It improves the strength of the quadriceps and hamstrings muscles.

What Is the Duration of Rehabilitation?

Rehabilitation is done for six months, and each week has a different set of exercises to meet different goals. It contains five phases to meet different goals. They are:

1. Acute management.

2. Basic strength and proprioception.

3. Dynamic neuromotor strength, endurance, and coordination.

4. Athletic enhancement and return to activity.

5. Rehabilitation of athletic movement and return to sport.

How Is Acute Management Done?

This phase starts immediately after surgery and continues for two to four weeks. In this stage, progression is done according to the individual and also not so rapidly. The following goals are met during this phase:

1. Achieving full active knee extension like that of the unaffected leg.

2. Eliminating the swelling.

3. Restoring the weight-bearing function of the leg.

4. Achieving knee flexion of up to 125 degrees.

5. Lifting the leg in all directions without assistance.

6. Normalizing walking patterns using crutches and braces.

Range of Motion Exercises:

All the exercises have to be performed in this after taking the braces only on the advice of a physician.

1. Extension on a Bolster - Try sitting down and supporting the heel on a towel roll. Straighten the knee and apply pressure on the thigh using both hands. Be careful not to apply pressure over the knee cap. Hold this stretch for one to five minutes and take a rest for 30 to 60 seconds. Repeat these three to five sets for three to five sessions daily.

2. Prone Hangs - Lie downwards on a bed or table facing down, and legs stretched outside the bed. Now place the unaffected heel over the affected heel and try to stretch downwards. This might cause discomfort in the back of the knee. Hold this stretch for one to five minutes and take a rest for 30 to 60 seconds. Repeat these three to five sets for three to five sessions daily. (Only exercise one or two should be done, based on the advice of a physiotherapist).

3. ROM (Range of Motion) Wall Slides - Lie on the floor near a wall on the back and place the affected foot on the floor. Now try to slowly pull that leg using the unaffected leg down the wall. Hold this position for five to ten seconds. Then try to push the affected leg upwards until the knee is at a right angle to the wall. Push into the wall for ten seconds, followed by upward sliding of the knee until it is fully extended. Repeat this exercise 15 to 25 times, for three to five sessions a day.

4. Heel Slides With an Assist - Lie on the back and slide the affected foot towards the hip using the other foot to push. Hold for five to ten seconds, and repeat 15 to 25 times for two to three sessions per day.

5. Seated Knee Flexion - Sit at the edge of a chair and bend the affected knee as far as possible using the other leg. Hold for five to ten seconds, and repeat ten to 20 times for three to five sessions per day.

6. Patellar Mobilization - Palpate the edge of the patella (kneecap) using fingers and glide in all four directions. Hold for two seconds at the end of the glide. This will prevent scar tissue formation. Glide for four minutes, one minute in each direction, and perform three to five times per day.

Muscle Activation:

1. Straight Leg Raises: Try lifting the leg for up ten to 12 inches, maintaining full knee extension, and holding for five to ten seconds. Repeat ten to 15 times.

2. Hamstring Sets: Sit on the floor, knee bent slightly, and push the affected heel to the floor. Hold for five to ten seconds and relax for five seconds. Repeat for two to three minutes. (Not to be performed if it is a hamstring graft).

3. Standing Leg Lifts: Standing with the unaffected leg, try lifting the affected leg forward and straight. Hold for two seconds and do this in all directions. Repeat five to ten times a day.

4. Weight Shifting: Stand with both feet shoulder-width apart, and knees slightly bent forward. Try shifting weight from one foot to another and also forward and backward directions by placing the leg forward. Hold for five to ten seconds in each direction for two to three minutes.

5. Double Leg Mini Squats: Stand with both feet shoulder-width apart, and knees slightly bent forward to do a mini-squat and flex hips. Repeat one to three sets ten to 15 times.

Core Body Training:

1. Abdominal Isometrics: Lying down on the back or standing, try to draw the stomach inwards and keep in mind to not hold the breath and not to flex the trunk. Hold for ten seconds, repeat one to three sets of ten to 15 repetitions.

2. Crunches: Clasp both hands behind the head and lie on the floor back and try to curl up by tightening the abdomen. The head and shoulder should be away from the floor while doing this.

3. Reverse Crunches: Lie on the back with hands on the sides and try to lift the affected foot off the floor and hold it for a few seconds.

4. Back Extension: Lie on the stomach and clasp both hands behind the back and try lifting the chest.

Ambulation:

1. Diagonal Weight Shifting: Stand with both feet shoulder-width apart with the affected foot to the front, while only the heel touches the floor. Try to put the whole weight on it slowly and allow the entire foot to contact the floor meanwhile. Hold for five seconds, repeat two to three sets of 15 to 20 repetitions.

2. Backward Stepping: Try to walk backward, raising the leg and avoiding swinging the legs outside. Try to lift the toes off the ground before the heel and do this for two to three sets, walking 50 to 75 feet each.

3. Step Overs: Place paper cups one step apart on the floor and walk forward and backward, bending the knee to step over them. Do two to four sets continuously for 30 to 45 seconds.

Conclusion:

Acute management of ACL repair has to be done cautiously and after getting concerns from an orthopedician or authorized personnel. Every step has to be done properly and with patience. Also, if there is any kind of excruciating pain, discontinue and consult a physiotherapist to get a proper insight. Adjustable aluminum crutches are available for support for an ACL injury.