QLRC

ACLReconstructionRehabilitationProgram

ThishandoutisforpatientsandtheirfamilieswhohaveorareplanningtohaveanACLreconstruction.Everypatienthasslightlydifferentexpectationsintermsoftheirneeds.Wemodifytreatment

andrehabilitationtosuittheindividual.

AnACLinjuryisapotentiallydevastatingdiagnosisthatcanchangethecourseofapatientslife.TheACLisoneoftheprimarystabilisingligamentsintheknee.Itconnectsthethighbone(femur)totheshinbone(tibia)andpreventsthekneefrompivotingortwistingtoofarwhenweturntochangedirection.

AnACLrupturecommonlyoccurswhenthekneetwists too far, eitheron landinga jumporduringsport from a tackle.We now know that there arefactors that predispose certain patients tohavingACLinjuries,and it is important toassessand address these factors as part of a treatmentprotocol.

WhenanACLisruptured,manypatientshearapoporacrackinthekneeandareinimmediatepain.ThekneeusuallyswellsastheinjuredACLbleedsinto the knee joint. It is also possible to sustaindamagetothemeniscusandcartilageofthekneejointwhentheACLisinjured.

Following injury, if prompt medical attention issought, thenadiagnosis canbemadeandaplanput in place for rehabilitation and surgery ifappropriate. Unfortunately many injuries arenotdiagnosed, and it ispossible forapatient torecover from the injury and return to sportwithout realising that their knee is no longerstructurallyintact.

Images courtesy of AAOS Orthinfo

Ifthediagnosisisdelayed,thereispotentialforthekneetobeunstablewhichmeansthatitwillgivewayunexpectedlyduringdailyactivitiesorduringsport.Ifthisoccurs,itispossibletodamagethemeniscusofthekneewhichinturnwillleadtodamageinthejointcartilageandsubsequentosteoarthritis.

AnACLreconstructionisaprocedurethataimstorestorethestabilityofthekneebyrecreatingthestructureoftheligament.Typically,tunnelsaredrilledintothefemurandthetibiaandagraftoftendontakenfromanotherpartofthebody(usuallyoneofthehamstringtendons)isfixedthroughthetunnels.The complications associatedwith this surgerywill be discussed individuallywithyouduringyourconsult.Followingthesurgery,aprogramwillbeput inplacetoguideyourrehabilitationandreturntosport.

ThetimeframeforfullrehabilitationfromanACLreconstructionis,onaverage,9-12months,buteveryoneisdifferent.Yourrehabilitationisonlycompleteonceyouhavesafelyreturnedtosportand/oryourphysicalactivitygoals.Thereisnohurrytorushyourprogressionthroughtheprogramandyouwillbeguided by Dr Maine and your treating physiotherapist throughout. It isextremely important thatyou follow theseguidelinesandcontinuewith theexercisesevenafteryourpainhasgoneandyouhavefullmovementofyourknee.

Yourhospitalstay:

Whenyouwakeafteryouroperationyouwillhaveabraceonyourkneeandbegivenpainrelief,asrequired,bythenursingstaff.Therewillbeaperiodoftimeafteryouroperationwhereyoumaynotbeabletoputweightthroughyourleg.Thistimeperiodwillbedeterminedbythetypeofsurgeryyouhavehad.Thisexpectationshouldbeadheredto, toensure thebesthealingandoutcome foryourknee.Usually,youwillbeabletoleavehospitaladayafteryouroperation.

Aphysiotherapistwillvisityouthemorningafteryouroperationto:

-Helpyoutogetoutofbed

-Teachyouhowtowalkwithcrutchesandnegotiatestairs.

-Gothroughyourhomeexerciseprogramandguideyouastowhenyouaresafetoremoveyourbracetodoso.

-Organisefollowupphysiotherapyclosetoyourhome.

Followup:

YouwillbereviewedbyDrMaineapproximately2weeksafteryouroperation.Youwillbeadvisedwhentoprogressyourweightbearingstatusandwhentoremovethebrace.Afterthisyouwillneedanappointmentwithaphysiotherapistwhowillco-ordinateyourrehabilitation.

Ifyouoryourchildareanathletelookingtoreturntocompetitivesport,weofferareturntosportprogramthatincludesreferraltoaSportsPhysicianalongwithReturn to Sport testing to ensure that you have done everything possible tominimiseyourriskofre-injury.Theriskofgraftruptureinyoungpatientshasbeen reported as up to 30%. It is critical that you do everything possible tominimiseyourriskinthisregard.Pleaseletusknowifyouwishtoproceedwiththisoption.

Yourrehabilitationjourney…

Thereare5stagestoyourACLrehabilitation.Yourphysiotherapistwillguideyouthrougheachstageandprovideyouwithspecificexercises.

Stage1:Immediatepost-operativestage

Stage2:Strengthening+NeuromuscularControlPhase

Stage3:StrengthandEndurance(Approx.weeks6to12)

Stage4:Creatingaplatformforrunning,agilityandlandings(Approx.weeks12to18)

Stage5:Preparingtoreturntosport+returningtosport+injuryprevention(Approx.weeks18to26weeksandbeyond)

Stage1:Immediatepost-operativestage(Weeks0-2)Initiallyyourkneewillbequitestiffandsoreandyourexerciseswillbelimitedtohelpyouregain

yourconfidenceinyourabilitytomoveandstrengthenyourknee.Ifyouarefindingthatyourkneeisswellingandaching,youmaybedoingtoomuch.Discussthiswithyourphysiotherapistandthey

willguideyouinwaystoreducetheswellinganddiscomfort.

Aims:

- Decreaseswelling

- Minimisepain

- Regaincomfortablekneemovement-notpushinginto‘hyperextension’(ie.paststraight)

- Regainmuscleactivationofquadriceps,hamstringsandgluts

- Tocreateaplatformtoenableyoutotoleratewalkingonyourlegwithnoaids.

ExerciseSuggestions:

Swellingmanagement:Rest,ice,compression,elevation,Anklepumps

Flexibility:Heelslides

MuscleActivation/strength:

- VMOactivation- Co-contractionsofquads/hamstrings- Glutsqueezes

UsefulOutcomeMeasurestoguideprogressiontoStage2:

Stroketest(Sturgill,2009)=1+

Kneeextension=-5o–0o(Norkin&White1995)

Quadricepslagtest=0o–5o

Stage2:Strengthening+NeuromuscularControlPhase(Weeks2-6)AtthispointyouwillbeguidedbyDrMainewhenyoucanremoveyourbraceandwhenyoucanstart

puttingcontrolledweightthroughyourlegunaided.

Aims:

-Togainfull,painfree,activemovement(nothyperextension)-Toreturntonormalwalkingwithoutcrutches-Regainmusclestrengthofquads,hamstrings,gluts-Balanceonsingleleg

ExerciseSuggestions:

Manualtherapy:Patello-femoralMobilisations

RangeofMotion:

- Heelslides- Proneassistedkneebends- Pronekneehangs- Hamstringandcalfstretches

Strength:

- VMOactivation- Co-contractionsofquads/hamstrings- Bridging- Calfraises- Wallsits- Stepups- Pronekneecurlsàaddtheraband- MinisquatsàProgressedasable- MinilungesàProgressedasable

Balance/Proprioceptiveexercises:

- Balance-singleleg,wobbleboard- Glutmedactivationinstanding

CardioExercises:

- Exercisebikewithlowresistance

NOTE:Ifameniscusrepairhasbeendonetherewillberestrictionsontheamountofweightedkneeflexion

thatcanbedone.

Youmaystartsomegentlehydrotherapyinthepoolatthisstageoncesurgicalwoundshavehealed.Thismaycompriseofwalkinginwater,minisquats,calfraisesandlunges.YoushouldNOTcommencekicking(eitherfreestyleor

breaststroke)untilclearedbyyoursurgeon/physiotherapist(usuallyafter3-6

months).

OutcomeMeasurestoguideprogressiontoStage3:

- Kneeflexion=90o–100o(Norkin&White1995)- Calfraises=Toachieve10xminimalsupport,kneefullyextended- Balancetesting- FunctionalAlignmentTest

Stage3:StrengthandEndurance(Weeks6-12)Atthisstage,aplatformshouldhavebeencreatedwhereyoufeelconfidentintheabilitytotakecontrolledweightthroughyourknee.Yourswellingshouldbeminimalandyoushouldbeabletomoveyourkneethroughacomfortablerange.TheimportantaspectatthisstageistheWINDOW

periodfrom6-10weeksafteryouroperationiswhenthegraftisatitsWEAKEST.Itisimportantthatyoudonotattempttodotoomuchandreturntoactivities/sporttooearly.

Aims:

-Improvestrengthandendurance

-Strengthensafelyisthemainpriority-youwanttoCREATEAPLATFORMforyourkneetotoleraterunningandproprioceptiondrills.

ExerciseSuggestions:

ROM:Continueduntilfullpainfreerange

Strength:

6weeks:

- Stepups/downs- Wallsits- Pronekneecurlswiththeraband- Squats–singleleg- Lunges- Eccentrichamsdrills- Corestabilityexercises–planks,sideplanketc

8weeks:(Aim-Fullrangeofmotion)

- Increasedepthsquats+lunges- Concentrichamstringswiththeraband–proneandstanding- Pronealternatecurls(legwts-2kg)- Overedgeofbedflicksandwobbles(2kg)- Therabandresistedhipextensioninstanding- Chairbridging(2legs)

GymProgramcanbestartedaroundthistime.

- Legpress- Inclinelegpress- SeatedhamstringcurlsàPronehamstringcurls

10-12weeks(cantoleratetheaboveprogramfor2/52)

- Splitsquats- DeadLifts- Walkinglunges+weight

Important!Maintaingoodcontrolwithallexercises

duringthistime.Noopenchainkneeextensionexercises.

Balance/Proprioceptiveexercises:

- Balance-singleleg,wobbleboard- Flicks&wobbles(dynamichams)- Singlelegrebounderbalance

CardioExercises:

- Exercisebikewithincreasingresistance- Pool Poolrunning(vestorflotationbelt)

C-VTraining(intervalsforgeneralfitnessetc)

- Rower(notmeniscalrepairs–DrBartlett)- Stepper/Versa-climber(90degreesonly,notmeniscalrepairs)- Walker

Stretches:

- Calf- Hamstring- Quads- ITBstretches

OutcomeMeasurestoguideprogressiontoStage4:

Test AimSinglelegchairbridges 10repetitionswithgoodcontrol

Sidebridgeendurancetest Comparetootherside

Singlelegpress 80%ofoppositeleg

Starexcursionbalancetest(Gribbleetal2012)

80%ofoppositeleg

Stage4:Createaplatformforrunning,agilityandlandings

(Weeks12-18)Bythistimeyoushouldfeelasthoughyourkneeisquitestableandisimprovinginstrength.YouarenowaimingtoCREATEAPLATFORMforyourkneetotolerateSPEEDandChangesinDIRECTION.

Aims:

- Ongoingimprovingofstrengthandendurance

- Improveproprioception

- Initiatepoweranddynamicactivities

ExerciseSuggestions:

StrengthExercises:

- Squats+weight- Walkinglunges+weight- Clocklunges- Singlelegsquats- Hamstringcurls(therabandorweights)- Singlelegbridging–onball+hamstringcurls

DynamicExercises:

12Weeks

- Jumpingonspot/fwds/bwds(2legs)- Jumpingside-side(2legs)

14Weeks

- Hoppingdrills(jump-stop,hop-stop,from10cmto20cmetc)- Obstaclehopping,gridhopping- Steprunning- Ladderrunning- Boxjumps

Balance/Proprioceptiveexercises:

- Rebounderjogsandstops(2pillowsathome)CardioExercises:

- Bikeworkwithcleatscanbeintroduced- Asbefore

Poolprogram:

- Canstartkickingwhenclearedbysurgeonandthenprogresstoflippers.

*Previousexercisessuchasproprioceptionandstrengthshouldcontinue*

From16WeeksRunningProgramcancommenceif….

Runningshouldbeprogressedgraduallyfromthereboundertotechniquerunningintheclinic(towardsamirror),andprogressedbyaboutthe16weeksmarktotreadmillrunning(3-5minsmax).Ifyouaretoleratingthiswell,progresstofield:joggingincombinationwithwalking(i.e.walking30m-jog30m).Graduallyincreasethejogcomponentofthisonceyouhavegoodconfidenceina

straightline.

Progressions:

- StraightlinerunningonflatsurfacesàStairsàHills/slopes- Increasingdistance,thenspeed- Shuttlerunning

Indicationsofprogressiontorunning:

Abilitytohopandlandsoftlywithoutanykneevalgus

SingleHopTest

Right=Left

Triplecrossoverhoptest

Right=Left80%+

Modifiedlandingerrorscoringsystem(Padua2009) Anysignsofkneeswellingandaching,youmaybedoingtoomuch.Ensureyoutakerestsasrequired.

Stage5:Preparingtoreturntosport+Injuryprevention

(Weeks18-26weeksandbeyond)

Atthisstageyourkneeshouldbestrongandmuscularendurancedevelopingviathestrengthandrunningprogram.ItisatthisstagethatyourrehabilitationisaimedatCREATINGAPLATFORMforyour

kneetotolerateRETURNINGTOSPORT.

Aims:

- Concentrateonpowerdevelopment- Increasingrunningspeed- Increasingdistance- Changeofdirectiontobeintroduceslowlythenprogressedtoshortersharperagilitydrills.

ExerciseSuggestions:

- Hopping+jumpdrillscontinue- Figure8running- Diagonalrunning- Changeofdirectiondrills- Sportspecificdrillsandskills(from26weeks+)

WhenamIreadytoreturntosport?

9-12months…

- MelbourneReturntoSportScore- Whenyou,DrMaineandyourphysiotherapistareconfidentandcomfortableyouarereadyto

return.ExamplePreventionprograms:

- PEPprogram

- FIFA11+

- NetballKNEEProgram(NetballAustralia)