Rehabilitation for a tear in the anterior cruciate ligament


Post-surgery rehabilitation

After an operation on the anterior cruciate ligament, a rehabilitation period of at least 5-6 months is planned, which begins in the hospital or in a physiotherapist’s office and then continues in the sports hall or in the swimming pool .

The surgeon will decide how to proceed as the post-operative protocol will vary depending on the tendon being transplanted and the surgical technique.

When performing the exercises, it is important to consider the pain threshold ; attempting to shorten times to complete the rehab process early is counterproductive. The new ACL requires 6 months of exercise therapy
for full fixation . Rapid rehabilitation is now possible thanks to highly stable implants, especially when using the patellar ligament; however, the exact times are determined by the surgeon.

Studies have proven that it is better not to immobilize the lower limb for 1-2 months as used to be done; Mobilization must begin the day after the operation and includes bending and stretching movements of the knee joint.
For this purpose, passive mobilization is carried out with the motor movement splint (Kinetec): this device ensures a rhythmic flexion and extension of the knee joint; electrostimulation can also be used to maintain optimal trophicity in the thigh muscles, particularly the quadriceps.

If the patient has already completed good preoperative movement therapy, he already knows the exercises to be performed after the operation and also knows how to use the armpits (similar to the forearm crutches, but without upper arm cuffs and handles, also known as American crutches).

The objective of rehabilitation of the anterior cruciate ligament is:

  • pain relief;
  • recovery of muscle trophy and tone;
  • Regaining range of motion (ROM) of the entire lower extremity;
  • Return to sport-specific activity.

As   a complication after an operation, it can happen that the knee joint cannot be fully straightened; in this case, some specific exercises must be carried out, avoiding hyperextension, which has adverse effects.
Rehabilitation begins at the hospital or clinic where the operation was performed. A splint
is used for the first few days to hold the knee in an extended position. The flexion movement of the knee joint is initially only allowed in the form of exercises performed during the day. This is important to protect the tendons that made up the new ligament. In the days after the operation, the cold therapy
applied; Ice packs are applied several times a day for 15-20 minutes each to relieve pain and swelling ; to avoid complications, the ice must not come in too close contact with the skin.

Follow-up protocol for autologous patellar tendon implant

The operated leg must be loaded with the body weight at an early stage in order to avoid signs of degeneration in the bones and joints .
Although opinions differ on this point, weight bearing can be started as early as the third day after the operation, as this does not increase the tension exerted on the ACL and thus does not jeopardize its attachment to the bone.
In this phase, the movements are performed taking into account the pain threshold; in the first two weeks, a degree of flexion of at least 90° must be achieved, and in the second week the patella is also mobilized.
In the first few days after the operation, the knee joint should be bent and stretched in addition to working with the movement splint; to do this, the seated patient lets a skateboard roll back and forth with his foot. As soon as possible, the patient can train on the ergometer, with a high saddle position helping to avoid severe pain. From the beginning, the patient must perform isometric contraction exercises of the hamstrings (hamstrings) with 60° flexion of the knee joint.
Once the stitches have been removed and the wound is dry, the scar is massaged to prevent the scar tissue from sticking to the other layers of tissue.
The friction technique is mainly used for this.

In order to avoid that the healthy leg also becomes stiff and the muscle tone decreases, isotonic exercises for the ankle, hip and knee joints must be carried out.

In this phase, the knee joint should be cooled with cold compresses after the exercises to prevent inflammation.
After the stitches have been removed, a rehabilitation cycle in the swimming pool is recommended; Aqua aerobics help regain flexibility and lead to a rapid improvement in muscle tone and overall physical fitness .

In the second month, the workload is progressively increased

Once normal walking is possible again, the knee extension splint worn at night and when walking can be removed and replaced with a knee bandage when walking; the use of crutches is no longer necessary.

Consistent training on the ergometer gradually leads to almost full flexion and full extension of the knee joint by stretching the hamstrings, calf three-headed muscles, using the gravity-maintained stretch positions, and using ankle weights .

To improve muscle strength , perform isometric quadriceps contraction exercises with a flexion angle of 30-40° and begin isotonic leg press exercises or squats, never flexing the knee more than 30-35°.
The hamstrings, i.e. the hamstrings, work first isometrically and later isotonic with low loads.

In the first 2-3 months, the full range of motion must be achieved when bending and stretching.

Third and fourth month

In this phase, the entire joint function is restored, muscle building and proprioceptive movement training are now in the foreground.

The ligament is not yet fully fixed and must not be overloaded; the exercises to strengthen the quadriceps muscle of the thigh must be done exclusively in a closed kinetic chain , ie the foot is firmly on the support surface and must not move freely.
Stretches behind the knee with an elastic band, exercises on the leg press and squats are useful ; the knee joint may be bent up to 60°.
The strengthening of ankles, hips and healthy extremities will of course continue.
An important role in this phase of rehabilitation is played by proprioceptive movement training, ie a series of exercises and positions performed in an unstable state of balance in order to improve neuromotor coordination.
This activity plays an important role in preventing later relapses.

Fourth and fifth month

This is the final stage of rehabilitation when there are no complications.
If the doctor agrees, sporting activities can be gradually resumed.
While muscle-building and aerobic exercises continue, the running training begins , first on the flat, then on an incline, later in a circle and finally with changes of direction.
Isokinetic exercise can be harmful in the first 4 months; only when the bond is strengthened can it be tested whether competitive sport can be resumed; the only disadvantage is the cost involved in a session with the isokinetic device.
Little by little it cansport-specific training can be resumed , first alone, then in a team.
Proprioceptive rehabilitation must continue after fixation of the anterior cruciate ligament and return to competition.

What are the recovery times?

The hospital stay is about 2-3 days after the operation.
In the case of predominantly sedentary work, the return to work can take place as early as 10 days after the procedure; if the profession involves heavy physical activity, at least 3 months must elapse after the procedure.
After 1 ½ months you can actively drive again.
The scar must not come into contact with water for at least 20 days, so swimming in the sea and swimming pools are prohibited.
Athletes can resume training after 5 months and competitive activity after about 6 months if the patellar ligamentwas used; if a hamstring tendon has been used, it will take about two more months, but the surgeon will decide.
Under no circumstances should competitions be held before the end of the 6 months after the procedure, otherwise the ligament could tear again.

If the rehabilitation is not done correctly, the pain in the operated knee could persist and movement could be limited. For example, the patient might not be able to fully extend the knee; because of this, he limp and overloads the quadriceps.

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