Anterior Cruciate Ligament (ACL) Rehabilitation Paper.

Anterior Cruciate Ligament (ACL) Rehabilitation Paper.

ACL rehabilitation has undergone considerable changes over the past decade. Intensive research into the biomechanics of the injured and the operated knee have led to a movement away from the techniques of the early 1980's characterized by post operative casting, delayed weight bearing and limitation of ROM, to the current early rehabilitation program with immediate training of ROM and weight bearing exercises.Anterior Cruciate Ligament (ACL) Rehabilitation Paper.

The major goals of rehabilitation of the ACL-injured knee:

  • Gain good functional stability
  • Repair muscle strength
  • Reach the best possible functional level
  • Decrease the risk for re-injury

Closed kinetic chain exercises (CKC) and Open kinetic chain exercises (OKC) play an important role in regaining muscle (quadriceps, hamstrings) strength and knee stability.

Closed kinetic chain exercises have become more popular than Open kinetic chain exercises in ACL rehabilitation. Clinicians believe that CKC exercises are safer than OKC exercises because they place less strain on the ACL graft. Besides, they also believe that CKC exercises are more functional and equally effective as OKC exercises[3]

Clinically Relevant Anatomy

Please see these pages for relevant anatomy: Anterior Cruciate Ligament (ACL) and Anterior Cruciate Ligament (ACL) - Structure and Biomechanical Properties

General Considerations

Acute Stage

After ACL injury, regardless of whether surgery will take place or not, physiotherapy management focuses on regaining range of movement, strength, proprioception and stability.

PRICE should be used in order to reduce swelling and pain, to attempt full range of motion and to decrease joint effusion.

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Exercises should encourage range of movement, strengthening of the quadriceps and hamstrings, and proprioception. Consider integrating any of these exercises into a rehabilitation programme at this stage as appropriate for the client:

  • Static quads/SLR
  • Ankle DF/PF/circumduction
  • Knee flexion/extension in sitting
  • Patellar mobilisations
  • Glut med work in side lying
  • Glut exercises in prone
  • Knee flexion in prone (gentle kicking exercises)
  • Weight transfers in standing (forwards/backwards, side/side)

Neuromuscular Electrical Stimulation (NMES) combined with exercise is more effective in improving quadriceps strength than exercise alone.Anterior Cruciate Ligament (ACL) Rehabilitation Paper.

Also consider taping to provide stability and to encourage reduction in swelling.

Before Surgery

RICE and electrotherapy can be applied during several weeks ahead of the surgery in order to reduce swelling and pain, to attempt full range of motion and to decrease joint effusion. This will help the patient to regain better motion and strength after the surgery. The patient must be mentally prepared for the surgery.

Before proceeding with surgery, the acutely injured knee should be in a quiescent state with little or no swelling, have a full range of motion, and the patient should have a normal or near normal gait pattern.Important is to prepare the knee for the surgery. This are the guidelines:

  1. Immobilize the knee: Use a knee immobilizer and crutches until you regain good muscular control of the leg. Extended use of the knee immobilizer should be limited to avoid quadriceps atrophy.
  2. Control Pain and Swelling: Icing and anti-inflammatory medications are used to help control pain and swelling.
  3. Restore normal range of motion: Quadriceps isometrics exercises, straight leg raises, and range of motion exercises should be started immediately to achieve full range of motion as quickly as possible.A. Full extension is obtained by doing the following exercises: Passive knee extension, Heel Props, Prone hang exercise.B. Bending (Flexion) is obtained by doing the following exercises: Passive knee bend, Wall slides, Heel slides.
  4. Develop muscle strength: Once 100 degrees of flexion has been achieved you may begin to work on muscular strength. Examples of exercises are: Stationary Bicycle, Swimming, Low impact exercise machines such as an elliptical cross-trainer, leg press machine, leg curl machine, and treadmill can also be used.
  5. Mental preparation: Patient must know what to expect of the surgery and understand the rehabilitation phases after surgery.

Pre-op therapy should encourage strengthening of the quadriceps and hamstrings. Range of motion exercises should be included if there is no pain involved. See below for examples of appropriate exercises.

Pre Operation ACL ex.PNG

After Surgery

  • Week 1
    • Regular icing and elevation are used to reduce swelling. The goal is full extension and 70 degrees of flexion by the end of the first week. The use of a knee brace and crutches are imperative.Anterior Cruciate Ligament (ACL) Rehabilitation Paper.
    • Multidirectional mobilizations of the patella should be included for at least 8 weeks. Other mobilization exercises in the first 4 weeks are passive extension of the knee (no hyperextension) and passive and active mobilization towards flexion. Strengthening exercises for the calf muscle, hamstring and quadriceps (vastus medialis) can be performed.
  • Week 3-4
    • The patient must 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.
  • Week 5
    • The use of the knee brace is progressively reduced. Passive mobilizations should normalize motility but flexion should not yet be thorough. 9 Tonification of hamstrings and quadriceps (vastus medialis) can start in close chain exercises. The exercises should be started on light intensity (50% of maximum force) and progressively increased to 60-70%. The closed chain exercises should be built from less responsible positions (bike, leg presses, step) to more congested starting positions (ex.squad). The progress of the exercise depends on pain, swelling and quadriceps control. Proprioception and coordination exercises can start if the general strength is good. This includes balance exercises on boards and toll.
  • Week 10
    • Forward, backward and lateral dynamic movements can be included as well as isokinetic exercises.
  • Month 3
    • After 3 months, patient can move on to functional exercises as running and jumping. As proprioceptive and coordination exercises become heavier, quicker 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.
  • Month 4-5
    • 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 manoeuvers improve arthrokinetic reflexes to prevent new trauma during competition.

Three factors are important: 1) early terminal knee extension equal to the contralateral side, 2) early weight bearing, and 3) closed and open kinetic chain strengthening exercises. Early knee extension establishes the foundation for the entire rehabilitation program. The incidence of knee flexion contracture with associated quadriceps weakness and extensor mechanism dysfunction following ACL reconstruction has significantly decreased with accelerated knee extension immediately after surgery. Quadriceps strength is enhanced with early extension and weight bearing. 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.Anterior Cruciate Ligament (ACL) Rehabilitation Paper.Early weight bearing appears beneficial and may decrease patellofemoral pain. Early motion is safe and may help avoid problems with later arthrofibrosis. Continuous passive motion is not warranted to improve rehabilitation outcome in patients and can avoid the increased costs associated with CPM. Minimally supervised physical therapy in selected motivated patients appears safe without significant risk of complications. Postoperative rehabilitative bracing either in extension or with the hinges opened for range of motion does not offer significant advantages over no bracing.The need for postoperative functional bracing and for consensus involving the duration of the bracing in many rehabilitation protocols comes into question. Harilainen et al have compared the effects of functional bracing after ACL reconstruction against not bracing post- operatively. No significant difference in functional outcome, degree of stability, or isokinetic muscle torque was detected at 1 and 2 yrs postoperatively between the two groups. In a similar study, Risberg et al found no significant differences in knee-joint laxity, range of motion, muscle strength, functional knee tests, or pain.

Open versus Closed Kinetic Chain Exercise

Closed Chain Exercise

Open-Kinetic-Chain exercises:

Characteristics
  • Non-weight bearing
  • Movement occurring at a single joint: isolation movements that promote more shearing forces
  • Distal segment free to move
  • Resistance is usually applied to the distal segment
Open-Kinetic-Chain Knee-Extension exercises

These exercises have a limited role in ACL rehabilitation programs, because research showed that OKC-extension exercises from 60° to 0° flexion, markedly increase anterior tibial translation in the ACL-deficient knee, as well as ACL graft strain in the reconstructed knee[2].

Despite these findings, OKC-extension exercises aren’t excluded in ACL-rehabilitation programs, because the same research has shown that OKC-extension exercises from 90° to 60° of flexion could be done safe, without increasing anterior tibial translation or ACL graft strain[2].Anterior Cruciate Ligament (ACL) Rehabilitation Paper.

In short, OKC-extension exercises in ACL rehabilitation programs could be done safe in a ROM from 90° to 60° flexion and are furthermore useful to train the quadriceps isolated.

Open-Kinetic-Chain Knee-Flexion exercises

OKC-flexion exercises play an important part in the rehabilitation process because research showed that there is no anterior tibial translation or ACL graft strain during these exercises. Besides, they result in isolated hamstrings muscle contraction[10].

Closed-Kinetic-Chain Knee exercises:

Characteristics

-Weight bearing- Movement at several joints: compound movements that generally incur compressive forces - Distal segment fixed to a surface:the extremity remains in constant contact with the immobile surface, usually the ground - Resistance may be applied both proximally and distally:the entire limb is loaded.

Closed-Kinetic-Chain Knee exercises

CKC-exercises play an important role in ACL-rehabilitation because they result in a hamstrings-quadriceps co-contraction that reduces tibiofemoral shear forces. Besides, research showed that during CKC-exercises body weight provides tibiofemoral joint compression, that also reduces tibiofemoral shear forces [7].

CKC exercises have several advantages compared with OKC exercises

  • Increase stability in the knee joint (more joint compression)
  • Functional load
  • Strong coordinative training
  • Minimal shear force
  • Less stress on the ACL
  • Training of the entire extension chain
  • No selective muscle training
  • Weakest link in the chain is feeling the most "overload" and the corresponding largest trainings effect
  • Fewer complications such as patellofemoral symptoms
  • CKC-exercises are earlier to apply than OKC-exercises

Bynum et al. (1995) concludes that closed kinetic chain exercises are safe, effective, and sacrifice some important advantages over open kinetic chain exercises.

A more recent systematic review of RCTs comparing OKC vs CKC exercises in patients post-ACLR has found that:

  • there is no or insufficient evidence to demonstrate difference between OKC & CKC for pain scores or joint laxity
    • the former could be explained by (1) lack of sensitivity with used questionnaire, (2) statistical power of analysis was insufficient, or (3) there is actually no difference in pain experienced by patients undertaking OKC vs CKC
  • "there is weak evidence that open chain exercises are better for improving knee extensor strength, this is countered by weak evidence for better active knee flexion in closed chain activities."Anterior Cruciate Ligament (ACL) Rehabilitation Paper.