What type of rehabilitation is needed after surgery for cruciate ligament rupture?

After surgery on the anterior cruciate ligament a rehabilitation period of at least 5/6 months is required, to be performed initially in the hospital or in a physiotherapy clinic, then in the gym or in the pool.
Follow the surgeon’s instructions because the protocol depends on the transplanted tendon and the manner in which the operation was performed.

In performing the exercises, it is essential to respect the pain threshold.
Speeding up rehab times to complete sooner is counterproductive.
For complete fixation of the new ACL, 6 months of rehabilitation are required.
Accelerated rehabilitation is now possible thanks to a particularly strong graft, especially if the patellar tendon was used, but the surgeon must indicate the exact recovery times.

Studies have shown that it is best not to immobilize the limb for 1/2 months as was done in the past.
The mobilization should be started the day after the operation with the flexion-extension movement of the knee.
For this purpose passive mobilization  with the CPM (Passive and Continuous Movement) machine is performed: a machine that folds and extends the knee in a rhythmic way, electro-stimulation can also be used to maintain more muscle mass possible in the muscles of the thigh, especially the quadriceps.

If the patient has had a good pre-operative re-education, he is already aware of the exercises that will be done later and he knows how to use the crutches.

Adjustable rigid bracing

The objectives of anterior cruciate ligament rehabilitation are:

  • Reduction of knee pain ;
  • The recovery of resistance and movements of muscles;
  • Restoration of movement of the lower limb;
  • Training for recovery of athletic movement.

One of the complications that can occur after the surgery is that of not being able to extend the knee well, so it takes some exercises to lengthen the leg, being careful of hyperextension of the muscle because it would be harmful.
The first phase of rehabilitation occurs in the hospital or clinic where the operation was performed.
In the first day an orthosis is used that locks the knee in extension and allows the flexion during the day for the exercises.
It is important to preserve the tendons from which the new ligament derives.
In the early days, cryotherapy is applied for 15/20 minutes several times a day against pain and swelling , care must be taken not to place the ice too close to the skin to avoid complications.

 

Protocol for reconstruction of the cruciate ligament removed from the patellar tendon

We must discharge the weight of the body partially over the operated leg to avoid degenerative phenomena for the bone and the joint.
Not everyone agrees, but it is possible to begin rehabilitation within 2 days after surgery because the support does not increase the strain on the ACL affecting bone fixation.
At this stage the movements are made respecting the threshold of pain, in the first two weeks we must reach at least 90 ° of flexion, in the second week, the program also includes mobilization of the patella.
The first few days beyond the CPM it is helpful to work by folding and extending your knees while sitting or standing with your foot on a skateboard.
As soon as possible, the patient can work on the bike with the seat away from the pedals so as not to feel the sharp pain. From the start of rehabilitation, the patient should perform isometric contractions with the hamstring muscles (the front thigh muscles) with the knee flexed at 60 °.

After the stitches are removed, if the wound is dry it is necessary to begin the scar massage to prevent adhesions between the tissue and those with which it is in contact.
The technique mainly used is friction.
To prevent the healthy limb from becoming hard and hypotonic, it is necessary to perform isotonic exercises for the ankle, hip and knee

Spa Clinic with three swimming pools and two hot tubs for the vascular program.

At this stage, to prevent the worsening of the inflammatory process, hold the ice in the knee as a precautionary work, after doing the exercises.
After removing the stitches, a cycle of rehabilitation sessions in the pool is very useful, hydrokinesiotherapy helps in the recovery of the movements of the joints and above all, allows an early recovery of the  tone and muscular trophism  improving the physical condition.

 

In the second month progressively increases the work.

If the path is normal, the orthosis is the crutches that hold the knee extended at night and during walking can be removed by keeping only the knee while walking.
Keeping the activity on the ergometric bicycle can be achieved almost complete flexion and complete extension of the knee with the ischemic stretching, triceps, with  gravity- maintained  extension positions  and wearing weight ankles. For muscle strength, isometric contractions of the quadriceps are performed at 30/40 ° flexion and some knee flexion exercises are begun without ever exceeding 30/35 ° flexion. The ischemic muscles work in an isometric manner and later in an isotonic manner with low loads.

In the first 2/3 months, you have to reach full range of motion in flexion and extension.

 

The third and fourth month.

Exercise for strengthening the triceps sural.

At this stage the patient has already reached the complete movement, so he should work mainly on muscle strengthening and proprioceptive re-education.

The graft is not yet fully fixed, so be very careful not to force too much, the quadriceps strengthening exercises are exclusively in closed kinetic chain, ie with the extremity of the forced (non-free) limb (foot) to move .
The exercises to be done are extensions with elastic behind the knee, leg press and squat, you can get up to 60 ° of flexion.
Of course the ankle and hip reinforcement continues, even that of the healthy limb.
At this stage, proprioceptive rehabilitation plays a crucial role, this is a set of exercises or positions maintained under unstable equilibrium conditions to improve neuromuscular coordination.
This activity is essential to prevent relapses in the future.

 

The fifth and the sixth month

This is the last phase of rehabilitation unless there are complications.
When the doctor allows, gradually resume sports.
Continuing to strengthen muscles and improve aerobic capacity, one can start running first straight, then up, then in a circle and at the end with changes of direction.

Isokinetic work can be harmful in the first 4 months, only when the ligament is fixed and consolidated can you test to find out if you can resume athletic activity, the only downside is the excessive cost of sitting with the isokinetic machine.
Gradually you can begin work to regain athletic movement, first individually, then on the team.
It is necessary to continue proprioceptive rehabilitation, even when you return to running with the attached cruciate ligament.

 

What is the recovery time?

The stay in the postoperative hospital is 2-3 days.
In case of sedentary activities, return to work may occur 10 days after surgery, while heavy work should occur at least 3 months after surgery.
You can re-drive after a month and a half of the operation.
For at least 20 days it is forbidden to bathe the scar, therefore it is forbidden to swim in the sea or in the swimming pool.
For athletes, from the fifth month onwards it is possible to begin training, the return to races occurs about six months later in the case of a patellar tendon transplant, if instead the ischio-crural tendon is used, you need more time , at least two more months, but the surgeon must indicate the recovery time.

Be careful not to play before 6 months after surgery because it may break a second time.
If rehabilitation is not performed correctly, pain in the operated knee and movement restriction may remain .
For example, the patient may not be able to fully extend the knee, then limbs and overloads the quadriceps muscle.

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