Post-operative rehabilitation is necessary for the patient to return to the prior level of functioning. Rehabilitation starts with the counseling of the patient. Counseling of patients is necessary, with the main focus being on discouraging the patients from going back to pivoting sports for a minimum of 9-12 months. Another important step in the rehabilitation process after ACL surgery is quadriceps rehabilitation. Quadriceps rehabilitation focuses on the range of movement, increasing strength, eccentric control, and proprioception (Blom et al.). Patients should also be encouraged to take part in PEP (Prevent injury and Enhance Performance) programs. These programs help prevent active injury and reduce the risk of ACL re-injury. It focuses on warm-up muscle exercises and stretches to increase strength, awareness, and neuromuscular control (Blom et al.).
The rehabilitation of the knee joint is a continuous process that can be done with a linear periodization model. This can be divided into four phases, as shown in the table below.
|Phase 1||Protection/ROM/Muscle Initiation
|· Partial weight-bearing with gradual weaning of crutches or assistive device. Full weight-bearing gradually 2-3 weeks after surgery
· Tibiofemoral extension and flexion for 10 minutes each
· Passive patellofemoral mobilizations for 10 minutes
· Quad sets-bio feedback for 1 minute in the first week, post-op.
· Edema management/soft tissue mobilization for 10-20 minutes in the first week, post-op.
· Gait training on a level surface for 5-10 minutes over the next six weeks.
|Sequential development of muscular endurance, strength, and power.||· Wall squat holds (Quad). 30-120 sec per set. (2-4 sets)
· Total body resistance exercise (quad). 30-120 sec per set. (2-4 sets)
· Supine bridge with hamstring curl (Hamstring). 15-20 reps. (2-4 sets)
· Resisted lateral steps (Glutes). 15-20 reps. (2-4 sets)
· Alternating lunge holds (Quad). 30-120 sec per set. (2-4 sets)
|Phase 3 (15 – 21 weeks)||Regaining muscular strength||· Single leg squat (Quads). 30-120 sec per set. (3-5 sets)
· Front squats and reverse lunges with Dumbbell. 6-8 reps (3-5 sets)
· Weighted reverse lunges (Quads). 6-8 reps (3-5 sets)
· Nordic hamstring curl (Hamstrings). 8 -15 reps (3-5 sets)
|Phase 4 (22 + weeks)||· Development of muscular power, speed, and agility
· Return to full activity.
|· Front Squat (Strength). 6-10 reps / 3-5 sets
· Nordic Hamstring Curls (Strength). 12-20 reps / 3-5 sets
· Abdominal crunch Isometric hold (core strengthening). 45 sec / 4 sets
Phase 1 aims to protect the repaired ACL and restore the range of motion at the tibiofemoral and patellofemoral joints. Besides this phase being a protection phase, it also promotes quadriceps activation and resolves the joint’s effusion aspect, hence reducing oedema. The ACL needs to be protected to avoid further tears or dislocations. Moreover, it is important to allow a 0-90-degree knee extension and flexion during gait activities (Bousquet et al.). These are enhanced by a post-operative hinged knee that is placed on the patient. The stated activities should take place for at least six weeks. During this phase, the patient should be allowed to ambulate but with just partial weight-bearing. This can be achieved by using crutches. Full weight-bearing is achieved gradually, 2-3 weeks after surgery.
Post-surgery maintaining a range of motion early enough reduces many complications that arise after surgery. The repaired ligaments are agile in nature and can endure passive extension and flexion at the tibiofemoral joints. Therefore, post-surgically, passive range of motion is well tolerated and thus not restricted. The patient’s report of pain is evaluated to assess the extent of the range of motion that can be tolerated (Arundale et al.)
Phase 2 focuses on periodized strength development and muscular endurance. The knee joint and soft tissues should be loaded progressively to enable the development of muscular endurance, strength, and power (Bousquet et al.). Major muscle groups, such as the quadriceps, should focus on muscle strengthening in Phase 2. The patient should take part in an endurance-based strength training program two to three times a week with a rest period of at least 48 hours between each event. Loads of <50% of the patient’s weight should be used in strength training for more than 15 repetitions per set. The patient should perform two to four sets with < 90-second rest periods.
Phase 3 focuses on periodized strength development in the muscles. Notably, this is a shift from muscular endurance in Phase 2 to regaining muscular strength. The focus is on the quadriceps muscles. This phase is characterized by an increase in load and reduced repetition (Bousquet et al.). Agility progression should be added to ensure that the patient returns to full activity by the end of this phase. As in Phase 2, the patient should perform strength training exercises 2-3 times a week with rests occurring for at least 48 hours between the sessions. This phase requires 60- 67% of the patient’s weight loads. In addition, one to twelve repetitions are needed per set and a total of two to six sets to maximize strength gains. Rest times of two to five minutes are encouraged.
Phase 4 focuses on muscle power, speed, and agility. The end goal of this phase is a full return to activity. The focus in this phase shifts from strict strength in Phase 3 to power and strength maintenance. Optimal power speed and agility can be achieved using intense and brief activities to avoid fatigue (Bousquet et al.).
Arundale, Amelia J.H. et al. “Functional and Patient-Reported Outcomes Improve Over The Course Of Rehabilitation: A Secondary Analysis Of The ACL-SPORTS Trial”. Sports Health: A Multidisciplinary Approach, vol 10, no. 5, 2018, pp. 441-452. SAGE Publications, https://doi.org/10.1177/1941738118779023. Accessed 10 May 2022.
Blom, A., Warwick, D., Whitehouse, M., & Solomon, L. Chapter 31: Injuries of the knee and leg.. In Apley & Solomon’s System of Orthopaedics and Trauma. Essay, CRC Press, 2018.
Bousquet, Brett A et al. “POST-OPERATIVE CRITERION BASED REHABILITATION OF ACL REPAIRS: A CLINICAL COMMENTARY”. International Journal Of Sports Physical Therapy, vol 13, no. 2, 2018, pp. 293-305., https://doi.org/10.26603/ijspt20180293.
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CASE STUDY: Design a post-physical Therapy rehab program for someone who is recovering from ACL surgery. Consult local resources and therapy textbooks for the most updated information
Reading Assignment: Chapters 12-14
Exercise Therapy Edition 3
Karl G, Knopf, EdD
Orthopaedic Conditions, Sensory Impairments, and Other Conditions
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) – This site provides information on the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases. Use this site for more information on Arthritis.
http://www.niams.nih.gov/ (Links to an external site.)
National Fibromyalgia Association – A nonprofit organization whose mission is to develop and execute programs dedicated to improving the quality of life for people with fibromyalgia.
www.fmaware.org (Links to an external site.)
National Cancer Institute – conducts and supports research, training, health information dissemination, and other programs with respect to the cause, diagnosis, prevention, and treatment of cancer, rehabilitation from cancer, and the continuing care of cancer patients and the families of cancer patients.
http://www.cancer.gov/ (Links to an external site.)
American Congress of Obstetricians and Gynecologists (ACOG) – works as a strong advocate for quality health care for women while increasing awareness among its members and the public of the changing issues facing women’s health care. Visit this site for more information on pregnancy and exercise guidelines.
Exercise During Pregnancy (Links to an external site.)
Information on orthopaedic conditions – including affected anatomy and description of various conditions
https://www.universityorthopedics.com/what_hurts/index.html (Links to an external site.)
Information on studies regarding visual and auditory impairments: https://www.ncbi.nlm.nih.gov/m/pubmed/1576574/ (Links to an external site.)
Exercise considerations for individuals with orthopaedic conditions – the site also contains more general information regarding orthopaedic conditions and treatment
: http://orthoinfo.aaos.org/topic.cfm?topic=a00100 (Links to an external site.)
Video link to a discussion about the importance of proper posture (Dr Kelly Starett)
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