Isfahan university of medical siences physiotherapy department faculty of rehabilitation

Evidence-based rehabilitation following

anterior cruciate ligament reconstruction

ISOMETRIC از استاتیک شکل یک ایزومتریک های انقباض

که هستند عضله تغییر forceانقباض بدون رامفصلی حرکت بدون و عضله طول در محسوس

. لحاظ از گرچه کنند می فراهم مشاهده قابلمقداری ولی نمیگردد انجام کار و forceمکانیکی

 tension . كار انقباض این در شود می تولیدبود .  خواهد صفر با مساوی عضالنی

 

ISOKINETIC: از داینامیک شکل یک ایزوکینتیک انقباضاتی

شدن طویل و کوتاه سرعت که است انقباضاتو شده تعیین قبل از اندام ای زاویه سرعت و عضلهبه که سرعت کننده محدود ی وسیله یک ی بوسیله

است معروف داینامومتر شود holdایزوکینتیک میبا. که دارد حرکتی به اشاره ایزوکینتیک اصطالح

 . مفیدترین انقباض این افتد می اتفاق ثابت سرعتعضله . آسیب میزان است ورزش در انقباض نوع

. است حداقل

ISOTONIC کنترل یا ایجاد منظور به عضله در تنش تولید شامل

. عضله در تنش تغییرات باشد می مفصل در حرکتمی رخ مفصل زاویه در تغییر واسطه به

انقباض. شامل ایزوتونیک انقباض دهد  .   انقباض  این در باشد می واکسنتریک کانسنتریک

ثابت كمیتی ، شود می وارد عضله بار با كه نیروییكند . نمی تغییر انقباض عمل طول در و داشته

The injury mechanism is a valgus/external rotation trauma with a slightly bend knee

Because the ACL is a primary stabilizer of the knee, a rupture can lead to functional instability

In the long term, an ACL rupture can cause further intraarticular damage like meniscal tears cartilage defects and osteoarthritis

The younger and more active the patient, the earlier surgical reconstruction is chosen

medication, exercises, postsurgical compression

wraps and elevation, cryotherapy is advised as it

significantlyreduces postsurgical pain

ONE POINT

The results clearly indicated that an accelerated protocol without postoperative bracing, in which reduction of pain, swelling and inflammation, regaining range of motion, strength and neuromuscular control are the most important aims, has no important advantages and does not lead to stability problems.

POSTSURGERY, PHASE 1 (WEEK 1)

controlling pain,swelling and inflamation recovery of ROM and neuromuscular control There are no long-term advantages of bracing

Aggressive control of pain, swelling and inflammation prevents

quadriceps inhibition maintains full knee extension and makes immediate weight bearing possible

exercises postsurgical compression wraps and elevation Cryotherapy reduces postsurgical pain

Immediate recovery of passive and active ROM (emphasis on full extension) reduces pain stimulates the homeostasis of cartilage prevents patellofemoral problems alterations in gait pattern quadriceps atrophy and arthrofibrosis

Multidirectionalmobilizations of the patella

patellar immobility leads to decreased ROM and quadriceps inhibition

Initioted Muscul control:

by isometric exs closed chain (CC, safe range 0_–60_)

open chain (OC)safe range (90_–40_)

without additional weight.

muscle setting exercises straight leg-raising (SLR) heel slides

Multidirectionalmobilizations of the patella

HEEL SLIDESHeels slide

Short ARC quad set.

Quad set with towel roll under heel.

STRAIGHT LEG-RAISING (SLR)

(A )SLR flexion; )B( SLR abduction; )C( SLR adduction; )D( SLR extension.

mini squads (0_30 flexion)

OC extension (90_40)

shifting body weight

OC flexion (isolated hamstring) exercises   Full weight-bearing without crutches within

10 days

MINI SQUADS(0_–30_ FLEXION),

PHASE 2 (WEEK 2 TO WEEK 9)

Cryotherapy should be continued

Flexion can be increased gradually

while full extension and patellar mobility will be maintained

THE STRENGTH OF THE GRAFT IS NOT OPTIMAL

Quadriceps and hamstring strength by isometric isotonic and isokinetic exs

Isotonic strength training in a safe range (CC: 0–60, OC: 90–40),

Increasing endurance and strength of quadriceps significantly has no negative

effect on anterior knee pain and knee laxity

MINI SQUAT WITH RESISTIVE BAND.

safe range (CC: 0–90, OC: 90–0) neuromuscular training for loss of

proprioception

prevention (re-rupture)

Quadriceps atrophy persistent quadr lag with SLR

incomplete extension and gait impairmentsin

week 5 are predisposing factors for quadrice weekness after 6 month

NEUROMUSCULAR TRAINING SHOULDSTART AS SOON AS WALKING WITHOUT

CRUTCHES IS POSSIBLE

gentle non-complex exercises using minimal weight

developing from static to dynamic balance training

plyometric exercises into agility training

sport specific exercises

Gait training on a treadmill or flat surface without

crutches is still necessary

SIDE STEP WITH RESISTIVE BAND.

GAIT TRAINING ON A TREADMILL

SPECIFIC EXERCISES FOR PHASE 2

walking on a treadmill

cycling on an ergometer

swimming from week 3

stair-stepping machine from week4

jogging in a straight line

outdoor cycling from week8

STEP DOWNS.

PHASE 3 (WEEK 9 TO WEEK 16)

o obtaining and maintaining full ROM

o increased further with CC and OC

o Neuromuscular control:o slowly increasing functional dynamic

balance training

o plyometric exs

TRAINING OF FUNCTIONAL MOVEMENTPATTERNS (TRUNK, HIP, KNEE AND ANKLE)

Plyometric exs

agility training

variation in visible input surface stability speed of exercise performance complexity of the task Resistance One or two-legged performanc etc

SPECIFICEXERCISES FOR PHASE 3 normalization of runing

(gradually increasing duration and speed to

decrease neuromuscular adaptation and recovery time)

from week 9, jogging outdoors starts in week13

PHASE 4 (WEEK 16 TO WEEK 22)

Maximizing endurance and strength of the knee stabilizers

optimizing neuromuscular control with plyometric exercises

agility training and sport-specific exs: with variations in running, turning and

cutting maneuvers

acceleration and deceleration, improves arthrokinetic reflexes

CC and OC exercises form the ideal basis for sport-specific functional

training in phase 4

TO EVALUATE PERIODICAL RECOVERY AND TO CORRECTLY TIME RETURN TO SPORTS,

(VAS): for pain Goniometer:active and passive ROM Measurements (IKDC): a knee-specific questionnaire Hop tests: measures total leg function. Isokinetic tests:objective measurement

of strength and endurance of the knee stabilizers

IF GOALS OF THE PREVIOUS PHASE ARE MET,THE NEXT PHASE CAN BE STARTED

if full ROM is achieved, the hop tests and strength of the hamstrings and quadriceps are at least 85%

compared to the contralateral side hamstring/quadriceps<15% compared to the contralateral side patient tolerates sport-specific activities (no increase in pain and swelling).

THE END

Thanks for your attention