ACL Reconcentration

8/7/2019 ACL Reconcentration

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ACL Reconstruction

Warning. You may not want to read this page if you are of a squeamish disposition. It

contains explicit descriptions and pictures of a surgical procedure.

The Injury

In December 1996, I moved to San Francisco. That Christmas and New Year, my friend Nick

came to visit, and we decided that to fit in with the locals, I'd have to do all of the things thelocals do. So we went out mountain biking, tasted the local wine, visited the microbreweries,

went to the beach, and hired roller blades on a quiet afternoon.

I had ice skated a little bit, but never used roller blades before. I quickly found it to be harder

than I expected, there was a lot less resistance from the blades. Very soon after we started, I

found myself on a shallow slope, got out of control, and fell over while desperately trying to

keep my balance. As I fell my right lower leg twisted outwards, I heard a loud popping sound,and I ended up on the ground. There wasn't much pain and I was able to stand up shortly, so Ididn't think I had done anything serious. In fact I continued to skate for a short while afterwards.

Over the next day my knee swelled up a little bit and was painful. I wasn't able to go cyclingagain during that vacation. I used a support bandage for a couple of weeks, but when it became

obvious that I wasn't getting any better, I consulted my medical insurance and then went to seethe Orthopaedics clinic at Stanford University, close to where I work in Menlo Park.

Diagnosis

The initial diagnosis took some time, probably because I was being very protective of the kneeand unconsciously tensing the muscles around the joint when the doctor manipulated my knee;

the muscles had not been damaged, so tensing them masked the looseness of the joint. An MRIscan settled the matter, it was clear that the anterior cruciate ligament (ACL) had been

completely separated. This ligament is internal to the knee joint, and prevents excess motion ofthe joint surfaces forwards and backwards.

This was also bad news because I had been intending to learn to ski properly that winter, and the

ACL is very important in stabilising the knee joint for the sort of turning motions experiencedduring skiing.

The Decision

I didn't want to rush into anything immediately, so after the diagnosis I gathered as much

information as I could about ACL injuries. The doctor told me that there would not be muchdamage caused by the lack of an ACL for a while (in fact some people elect not to have any

operation, and get by fine for the rest of their lives without an ACL). This allowed me to delaythe decision on whether to get an operation, and see how much functionality I could restore.


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I attended the Stanford Sports Injuries and Rehabilitation clinic for several weeks, working onexercises to strengthen the muscles around the joint and increase its flexibility. By the summer, I

was mountain biking and swimming again, but I had a constant low-level pain in my knee duringhard exertion.

I also found out as much as I could about the surgery available. The doctors explained the typesof operation available, the operation procedures, success rates, and what the operations wereexpected to achieve. The ACL reconstruction operation is a functional restoration operation, if

successful it allows a complete or near-complete return to pre-injury functionality of the joint.There was some speculation amongst the doctors that it may help prevent premature arthritis in

the joint, but there had been no long-term studies to prove or disprove this.

During this period I also found out that ACL injuries were very much more common than I'dthought; when I mentioned it, I found that many people I met had had knee surgery.

Preparation for the Operation

During the summer I made the decision that I wanted to have the ACL restoration by an allograft(tissue taken from a cadaver). The alternative operation would be to take a part of one of my

other ligaments and use it, but I decided against that because I did not want to potentially impairmy functionality in other ways. I felt that if the allograft did not take, I would not be in anyworse condition than before, and if it did work I would potentially be much better. I must admit

that I gave the speculation about premature arthritis too much weight, even though it isunproven.

Once I had decided that I would have the operation, I started preparing myself for it. I knew that

there would be a lot of rehabilitation exercises, and that a lot of them would hurt. I wanted to be

highly motivated to do my exercises; I decided that it would be easier if I was fitter and in aregular exercise schedule. At that time, I was also a little bit overweight, at over 77kg (170 lbs).

I kept a normal calorie intake, but changed my diet to cut out a lot of fat (I don't have a sweettooth, so I didn't need to do much on reducing sugars). I started weight training (concentrating on

exercises which would also be beneficial to my archery, and I increased the regularity withwhich I commuted by bicycle and Caltrain, even until I was enjoying cycling in the rain. I started

swimming regularily. By the time of my operation, I had lost about 9kg (20lbs), and was muchfitter and motivated to exercise than before.

The OperationI finally had the ACL reconstruction on 22nd January 1998. The operation was delayed a coupleof times because of scheduling problems with the surgeon and the Christmas/New Year holiday

periods. During the delay I was beginning to reconsider whether I really needed the operation; Iwas fit, exercising, and worried about could go wrong. Talking to the doctors did not help, theyreiterated all of the information they had provided earlier, but provided no help in making a


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judgement. I finally decided to go through with it after a late-night phone conversation with Nickthe night before the operation.

I had the first operation of the morning; I was in the hospital at 7am, into the operating theatre at

9am, out by about 11am, and a friend drove me home by lunchtime.

The operation was done arthroscopically. Several small incisions were used to insert a videocamera lens into the joint, and other small incisions were used to insert tools and the replacement

ligament. The operation was video taped, some stills from the video are shown here. In general,the video is rather boring. It is not easy to follow without knowledge of exactly what is going on

during the operation. The operation was done under general anaesthetic; I had the option ofgeneral or epidural, I decided that I didn't want to be aware of anything, since the surgeons

would be sawing and drilling into bone.

The first part of the arthroscope video shows a lot of examination and

probing of the joint. The space where my torn ACL used to be is visible in

these sections. The ACL was completely torn, and in the time between theinjury and the operation the remains of it had all but disappeared.

After all of the probing, the joint capsule was cleaned and somedamaged cartlidge trimmed. Various implements were used for this, including a rotary

cutter. The implements in these pictures look huge, but actually are very small. The lens onthe arthroscope camera enlarges the apparent size significantly.

Attaching a new ligament to replace the ACL is not quite

straightforward. The ligament can't just be sewn into place (stitches wouldnot hold in the ligament, and since the ligament attaches to bone it would

also be impossible to sew if the previous ligament is completely gone). TheACL reconstruction operation involves cutting bone out either end of the

ligament site. The replacement ligament is cut with bone each end, and thebone each end is screwed into the prepared sites. The bone eventually assimilates to provide the

strength of the graft. This stage was cutting away the bone at the sites where the replacementligament would be attached.

The site for the ligament is prepared, and thereplacement ligament is drawn into place by a guide-

wire through the joint. The bone is drilled, and a smallhex-head screw is used to attach the graft. The hex-

head screw looks huge in the pictures here, but isactually only a couple of millimetres diameter.

The other end of the graft was attached with a couple of metal staples. The

replacement ligament was now in place. Finally all the instruments wereremoved, including the arthroscope camera (giving an impression of ``Fantastic

Voyage'' as it came out of the guide-tube, with a glimpse of the operating theatreat the end).


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The first few days after the operation I count amongst the worst of my life. The painkillers I hadbeen prescribed were not sufficient to completely numb the pain, and they had unpleasant side-

effects on my metabolism. I stopped using them after a few days and just suffered the pain. Oneof the worst problems was having to keep the knee elevated above head-height for the first few

days; this pretty much meant I had to lie flat on my back, a position from which it is difficult to

read, operate a computer, or do just about anything else.

I was greatly relieved when I could sit up, but the extra pressure in the joint from standing up and

moving about was excruciating. I was very grateful to have a friend come in and make mydinner, do my laundry and my shopping several times, and even more grateful that one of my

neighbours opened the apartment door for her; I live on the top floor of an apartment block, andthe apartment door does not have a remote release on it.

Rehabilitation

The rehabilitation process was painful at times, tedious at other times. There were some

moments when it seemed like having the operation was a big mistake.

My rehabilitation was at Stanford Rehabilitation Clinic again. The first time I visited was very

difficult. I tried to used public transport to get to the clinic from San Francisco, and found it to bevery awkward moving around. After that, I cajoled and prevailed upon colleagues and friends totake me to and from the clinic.

Patients having ACL reconstructions used to be put into in a full-length cast for six weeks or so,

and then on crutches and braces for months afterwards. The current experience indicates thatgetting the leg moving and act ive as soon as possible after the operation is beneficial, so at my

first appointment the physiotherapists started manipulating the leg. There was quite a bit of

swelling from the operation, and the muscles around the knee joint were not responding.

I had a post-operative knee brace with a range of motion lock; initially the brace was kept locked

in full extension, with the range of motion slowly increased over several weeks. I found sleepingvery difficult with my leg locked straight out; I normally sleep lying straight anyway, but it's

rather different trying to sleep with a brace preventing the leg from being bent at all and the legelevated. Some times during recovery I twitched in my sleep, involuntarily contracting the

muscles around the knee. This would result in me waking up instantly in pain; it was not apleasant experience.

The first few physiotherapy sessions concentrated on activating the quadriceps. This muscle is

used to extend the lower leg. Initially I could not even tense that muscle. When thephysiotherapist asked me to try, I felt that every other muscle in my body was tense, but I justcouldn't activate the quads. By using electrical stimulation and bio-feedback devices, we quickly

reached the point where I could activate the muscle and then do exercises to strengthen it. I wasamazed at how quickly muscles will atrophy if not used. The preparation I had put in before the

operation helped, I was diligent in doing all of my exercise sets, and keen to get back fit andriding my bicycle.


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Even with several daily exercise sets, it was a couple of weeks before I could lift my leg on itsown without assistance from my hands. I remember that moment as a major achievement; it may

sound patronising, but the experience of not being able to move my leg at will gave me a lot ofrespect for what disabled people endure.

Another good moment early in the recovery was when I managed to rotate my feet all the wayround in my bike pedals. I had bought a bike trainer to help with my recovery, and was using itfor range of motion exercises on it, rocking the pedals backwards and forwards. Later in my

recovery I used it for hamstring and quad strengthening, doing both single-leg cycling,endurance exercises and interval training until I felt confident enough to take the bike back on

the road.

I was able to dispose of my crutches a few weeks after the operation, and walk with great careusing only my knee-brace. My parents visited me from the middle to end of February, and by the

end of that time I was just able to drive again. While my parents were visiting I also foundanother use for a knee-brace; we got seated early in a restaurant we visited because the staff did

not want me standing around in pain. I've resisted the temptation to put the knee-brace on just toget priority seating since I stopped needing it. I had arranged to work from home during this

period, which I was very glad of, since it was also the period when the worst of the El Niostorms were starting to hit California.

The knee-brace came off after another few weeks, when I was able to walk without risk of re-injuring myself through weakness in the knee. There then followed one of the more tedious parts

of the rehabilitation, doing more and more of the same exercises to build strength, and extend therange of motion. I spent a lot of time working on quad strength, without realising how much my

hamstring strength had also been affected. It was a bit dispiriting to find out how much work Ihad to do on that too.

The exercises in the first weeks ranged through quad tightening, terminal knee extensions, calf

stretches to leg lifts, wall squats, leg shuttles and stationary bike work. I found that getting thephysiotherapist to show me a range of exercises which I could choose some different ones from

helped prevent me from getting too bored with the same sets.

Once I was able to ride my bicycle on the road again, the quad strength became less of aproblem. Initially I experienced some pain in the knee and had to be very careful about high-

stress cycling, such as riding out of the saddle, and avoided stationary holds or other tricks.Cycling is a good low-impact activity for rehabilitation.

The final phase of the recovery was the closed-chain exercises, which are designed to providefeedback through the leg to the knee. These exercises were the turning and cutting motions that

are stressful to the knee. I didn't think I had any problems with them until I tried to go runningone day. I've never been much of a runner, so this was also an experiment to see whether I could

avoid getting bored (which was always the problem I had with running before). In the first fewsteps, I found out how little impact my knee could really tolerate. When I got back from my run,

I was surprised to find that while my right quad was fine, my left one ached! Fortunately, my


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tolerance for impact has increased a lot, and I now sometimes run as part of my exerciseprogramme.

I also took my bike off-road again around this time, to make sure that I could manage some more

technical riding, and reinstated my medical certificate for my pilot's license.

In July 1998, I proved to myself that my knee was sound again by backpacking into thewilderness with Nick and Jeff and climbing Glacier Peak, a 10,500 foot volcano in Washington

State's Cascade range. I did get some swelling after our final day, which involved 30 miles ofwalking and about 3 miles of elevation change, including a good bit of ice climbing on the

glaciers.

Aftermath

On 10th August 1998, I had my final doctor's appointment, and was signed off to go and do

whatever exercise I want, with a knee brace recommended for high impact activity. My plans

now are to learn to rollerblade and ski! This time, I'm going to learn to rollerblade properly. I'lluse a knee brace, stay off slopes until I can skate and stop on the flat, and learn to breakfallproperly.

The irony is that I had full protective gear on when I fell. If I'd accepted that I was going to falland had controlled the fall instead of trying to stay upright, I probably wouldn't have hurt myself

at all.

I can't finish without thanking Bob, Laura, Danni, and the others at Stanford RehabilitationClinic. My recovery is now almost complete; there are some motions that cause me pain (breast

stroke kick, for example), but overall I now have less trouble than before the operation, and am

optimistic about a total restoration of functionality. I'm planning on getting back into karate,which I haven't been able to practice properly since the injury.

Anterior Cruciate Ligament Reconstruction

(ACL) - Recovery and Rehabilitation


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Medication

Analgesics or pain killers are prescribed for several days following discharge from hospital.

Anti-inflammatory tablets may also be taken if the analgesics alone do not control the pain.However anti-inflammatory tables should be stopped as soon as the knee is comfortable and

analgesics then continued if necessary.

Physiotherapy

The physiotherapist will see you immediately after surgery. Continuous

passive motion may be used to assist in knee flexion. The physiotherapist will see you again on

your return to the ward and explain static quadriceps exercises, exercises to encourage full kneeextension and to begin knee flexion. Patients are usually able to stand and walk gently with

crutches within 24 hours of surgery. Crutches may be discarded as soon as possible and usuallyin 2-4 days following surgery. A supporting knee brace is usually used for the first f4-6 weeks.

This is useful if it is locked in the straight position at night. This encourages full knee extension.Patients are usually discharged from hospital 48 - 72 hours after surgery.

After discharge it is important to continue with the rehabilitation protocol. The physiotherapist

should give a program to you at the time patients leave hospital. The physiotherapist should alsoarrange for follow up physiotherapy. This should be undertaken two or three times a week for sixweeks and then perhaps once a week for another six weeks. Physiotherapy will be directed

initially at controlling any pain or swelling of the knee and regaining a full range of knee motionby 6 weeks. Subsequently physiotherapy will be directed towards balance, muscle reaction and

reflexes and proprioception. This is an essential stage in the rehabilitation protocol. Thesupporting knee brace can usually be removed after 4 weeks. Driving, static cycling and pool

exercises can be undertaken after 4 weeks and gentle crawl swimming and gently low weight


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gym exercises after 6 weeks. Normal cycling, swimming, jogging and golf can usually berestarted after 12 weeks. Squash, tennis and field sports can usually be undertaken after 6

months.

+find out more about Physiotherapy

Results and Complications

You will find that the leg may be painful for the first few hours aftersurgery. This is quite normal and the pain usually eases by the following day. Generally by the

first day after your operation you will be able to get around walking with crutches without toomuch difficulty. Repair of the ACL usually involves a total of 1 to 2 days in hospital. After you

go home, you should keep bending and lifting your knee in order to strengthen the muscles andregain movement. The dressings should be removed after 5 days and the wound inspected. If

there is any excessive redness or infection patients should return to the GP or the clinic. Ten to

14 days following the operation you should return to the GPs clinic to have the stitches removedand the wound inspected. Crutches will be used for only 2 - 4 days. A brace is often used toprotect the knee for the first 4 weeks when walking outdoors. This has the effect of avoiding

excessive activity in this period. The brace is usually worn at night for 4 weeks locked in fullknee extension to reduce the degree of morning stiffness.

ACL reconstruction by the use of a Patellar Tendon graft is a very safe and successful procedure.

Mr. Johnson expects that almost all of his patients should be able to return to twisting, pivotingor contact sports without restriction. A brace is not usually required for these activities.

Complications (anaesthetic, medical and surgical) can occur after any surgical procedure. Everycare is taken to minimise such problems. The occurrence of such problems should in total be less

than in 1% of cases. Possible problems include infection (antibiotics are given at the time ofsurgery to prevent this), bleeding, swelling, stiffness and venous thrombosis (blood clots). A

fever or redness and swelling around the wound, or an unexplained increase in the pain maysuggest infection. Increasing calf pain or intermittent chest pain may suggest a venous

thrombosis. As with all surgery if at any stage anything seems amiss it is better to telephone orsee your local doctor rather than wait and worry.


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In the first 6 weeks the graft is held in position by only 2 small screws. Any excessive force onthe knee produced by tripping, stumbling or doing incorrect or unsuitable exercises may disrupt

the integrity of the ligament and it will fail. So take care and listen carefully to the advice givenby the physiotherapist. One particular problem is the formation of excessive scar tissue inside the

knee. Early movement and physiotherapy minimises the problem. Very occasionally further

arthroscopy after 3 months is sometimes necessary.

If all goes well you may expect a knee that is stable, does not give way, has a full range of

motion, is pain free and you will be able to play sport at the same level as prior to injury. Ifskiing I always advise the use of a brace to protect the new ligament. Despite all the efforts of the

patients, the surgeon and physiotherapists and usually as a result of a further significant injury, invery a small proportion of patients the ligament will fail. In this situation further measures may

be considered.

Mr. Johnson normally expects the vast majority of ACL reconstruction patients (in the region of95%) to be able to return to their chosen sport without any significnat knee problems.

Return to Work / Sport

If your job is sedentary and mostly sitting you may wish to returnto work after only 1 or 2 weeks. If your job is physically demanding and requires standing or

walking for most of the day, your return to work may take 6 to 8 weeks. Driving can usually beperformed after 4 weeks providing that the knee is pain free and you are able to make an

emergency stop.

Exercises in a pool can usually be started after two weeks when the wounds have healed. Gentle

swimming and cycling on an exercise bicycle should be undertaken after 4 weeks and lightweight training may be undertaken after 6 weeks. This will speed up the rehabilitation.

Breaststroke swimming should be avoided during this time. The knee should be protected from

impact and excessive strain during this time.

After 3 months normal outdoor cycling, normal swimming, weight training and golf may be

undertaken. Gentle jogging on a straight line on a running machine or grass should be performed.After 6 months normal running including rough ground and twisting can be performed. Tennis,

badminton and non competitive squash is allowed. Training for soccer, rugby, hockey andbasketball may be started with gentle kicking of a ball but tackling should be avoided in


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recreational athletes at this time. Professional atheletes may wish to return at a slightly earliertime in the rehabiltation process.

After 9 months competitive, soccer, rugby, hockey and basketball may be undertaken but the

ligament will not reach its full strength for 12 months, so take care. At 12 months full return to

sporting activity and skiing is allowed.

Follow-up Appointments

The first follow up appointment is usually arranged for 3 weeks after surgery and subsequently 3and 9 weeks later. Progress is again assessed after 6 and 12 months.

Accelerated ACL Reconstruction

Rehabilitation Program

About the

Author:

Mark De Carlo, PT, MHA,

SCS, ATC, Chief Operating

Officer Methodist Sports

Medicine Center, Indianapolis,

Indiana, USA

Mark De Carlo is the ChiefOperating Officer at Methodist

Sports Medicine Center in

Indianapolis, Indiana. He is

responsible for overall clinicadministration and direction all

aspects of the Center includingthe physical therapy department,

scholastic healthcare

coordination, clinical researchand patient care. He has

presented many lectures

nationally and internationally

including over 70 lectures over

the past 4 years alone on topics

related to orthopaedic and sports

physical therapy.

Mark has over 35 published


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This update on ACL rehabilitation was kindly written and put

together by Mark De Carlo and his team, exclusively for Chester

Knee Clinic website, for which we are very grateful. The text,images and videoclips should not be used without authors permission.

Rehabilitation following anterior cruciate ligament (ACL)reconstruction has changed dramatically over the past few decades. Thestaff of Methodist Sports Medicine Center in Indianapolis has over 15

years experience with patients sustaining injury to the anterior cruciateligament. Over this time we have developed a progressive

philosophical approach to rehabilitation following ACL reconstruction.

Our present philosophy on rehabilitation following ACL reconstructionhas evolved through observation of our patients and documented

clinical results. We have continually attempted to modify and updateour protocol as a means of improving patients final outcome following

surgical reconstruction. The ideal situation is one in which the patientwith ACL deficiency undergoing surgical reconstruction will ultimately

have a result of excellent stability, full range of motion and strength,and normal function.

Conventional rehabilitation emphasized early protection of the ACL reconstructed knee byrestricting knee motion, weight bearing, and rate of return to functional activities. In 1982, the

surgical leg was placed in a cast at 30 degrees of flexion to avoid excessive graft stress. Weightbearing without a brace was not allowed for 6-8 weeks following surgery and most patients were

restricted from full participation in sports activities for the first year. The high rate ofpostoperative complications, including permanent knee stiffness, knee pain and low

predictability with return to high level sports, has brought about a number of changes in ACLpostoperative rehabilitation.

In 1985, we conducted a study comparing compliant patients with those who progressed more

rapidly than we recommended (noncompliant patients). To our surprise, the noncompliantpatients demonstrated fewer long-term knee motion problems and fewer subjective complaints

than their compliant counterparts, without difference in long-term stability. Through this process,we learned that:

y an early loss of knee extension often led to long-term loss of extension accompanied by

subjective symptoms,

y patients who failed to regain early leg control often struggled with regaining full quadriceps

muscle strength later on, and

y patients who returned to sporting activities before recommended had similar knee stability to

patients who were compliant with our restrictions.

This helped us to place emphasis on factors felt to be of primary importance. These include:

y restoration of full hyperextension equal to the uninvolved knee,

y regaining of good quadriceps muscle leg control, and

articles and book chapters in the

area of sports physical therapy.De Carlo received his Bachelor

of Science degree in Secondary

Education/Athletic Training

from West Virginia University.He then received a Master of

Science degree from the

University of Indianapolis

Krannert School of Physical

Therapy. He is certified as a

Sports Clinical Specialist by the

American Board of Physical

Therapy Specialties and has

completed a Master of Science

degree in Health Administrationat Indiana University.

Mark is currently serving aspresident of the Sports Physical

Therapy Section of the

American Physical Therapy

Association, treasurer of the

Journal of Orthopaedic and

Sports Physical Therapy, Inc.

Board of Directors and member-

at-large of the International

Federation of Sports

Physiotherapy.


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y allowing for early wound healing.

Phase I (Preoperative)

Rehabilitation for the injured knee begins immediately following ACL injury. The clinical goals

for Phase I include restoring full range of motion (ROM) and normal strength and controlswelling prior to surgery. Patients are also to completely understand the basic principles ofaccelerated rehabilitation including full terminal knee extension, early weight bearing, and

closed and open chain strengthening. The time needed to accomplish these goals can be as littleas 1 week or as long as 2 months, depending on how the knee responds to the initial injury.

To reduce swelling, a cold compression cuff (Cryo/Cuff) (Fig. 1) is applied to the knee and filled

with ice-cold water. The patient can wear the cuff continually except when walking. Swellingreduction eases the return of normal range of motion.

Returning full knee range of motion equal to the uninvolved

knee prior to surgery decreases complications such as post-operative knee stiffness. To restore full range of motion, thepatient is instructed in several exercises including heel props

(Fig. 2), prone hangs (Fig. 3), and towel extensions (Video 1)for extension and wall slides (Video 2) and heel slides (Video

3) for flexion. If the patient has problems attaining fullterminal extension with the exercises, he or she may be giving

a hyperextension device (extension board) (Fig. 4) to assist ingaining full hyperextension.

Figure 2

Figure 3

Figure 4


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Video 1 (1.3mb / mpeg)

Video 2 (2.5mb / mpeg)

Video 3 (970k / mpeg)

Encouraging the patient to move from partial to full weight bearing as tolerated stresses theimportance of restoring a normal gait. Full passive extension and quadriceps control is necessary

before normal gait con be accomplished. Therefore, the emphasis of gait instruction is onachieving full knee extension at heel strike with full weight bearing on the involved side. The

patient is expected to be walking normally prior to surgery.

To encourage early strengthening, the patient is instructed in several closed kinetic chainexercises including leg press (Fig. 5), squats (Fig. 6), step-downs (Fig. 7), bike (Fig. 8), and

Stairmaster (Fig. 9). These exercises are introduced after swelling from the injury has decreasedand ROM has been restored.

Figure 5

Figure 6

Figure 7


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Figure 8 Figure 9

During the initial evaluation, the functional demands of the patient are assessed including

activities of daily living and athletic and recreational activities. School, work, and familyschedules are also examined to determine the most appropriate time to schedule surgery.

Phase I also includes patient counseling on the concepts of our approach to rehabilitation, the

timing of surgery with details of the reconstructive procedure, and specific postoperativerehabilitation goals and expectations. Because mental preparation is a very important aspect of

success of the surgical reconstruction and rehabilitation, it is essential that the patient understandthe goals of rehabilitation process and how these goals will be achieved.

Phase II (Immediate Postoperative)

The clinical goals of Phase II include decreasing swelling, obtaining full passive knee extension,and obtaining 110 degrees of flexion. Additional variables include performing an independent

straight leg raise and restoring normal walk.

Phase IIa: (1 to 6 days)

To minimize pain and swelling, a Cryo/Cuff is placed on the patients knee immediatelyfollowing the operation. The Cryo/Cuff remains on the knee at all times, except when performing

motion exercises. Continuous passive motion is initiated following discharge from the recoveryroom and the machine is set to 0-30 degrees. The CPM machine is to remain on, with the

patients leg in it at all times, except when doing motion exercises and going to the bathroom.

Exercises for regaining full ROM are begun the day of surgery. Hyperextension is maintainedwith 10 minutes of heel prop exercises every waking hour. Flexion exercises are performed six

times daily. This can easily done by slowly increasing flexion of the CPM machine to the 110degrees and holding the position for 10 minutes four times a day. Once maximal flexion has been

attained in the CPM machine, patients can continue to increase bend beyond 110 degrees bypulling leg further to buttocks with their hands.

Leg-control exercise is started on the day of surgery and consists

of quadriceps contraction exercises and independent straight leg

raises. Active heel height exercises (Figure 10) are performed topromote leg control and to minimize the potential for a patellarcontracture. During the first week patients are to remain lying

down as much as possible. However, when getting up to go tothe bathroom patients is encouraged to be weight bearing as

tolerated. Crutches may be used for the first few days tofacilitate a normal walking pattern

Figure 10


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The patient will report to physical therapy one week after surgery and should have full terminalextension and flexion to 110 degrees, minimal swelling and soft tissue healing, and normal

walking.

Phase IIb: (7 to 14 Days)

The patient is evaluated at the one-week visit by both the surgeon and the physical therapist. The

patients rehabilitation program is advanced concentrating on swelling control, ROM, quadricepsleg control, and walking.

Regaining full extension range of motion is the most critical factor in this phase. Full

hyperextension is maintained with heel prop and prone hang exercises. As in the preoperativephase, if the patient has problems maintaining full hyperextension, an extension board may be

used. The CPM is discontinued at one week. Flexion range of motion is progressed with wallslides and heel slides. The Cryo/Cuff is stilled used on a regular basis to control swelling when

the patient is not performing exercises.

The patient is encouraged to progress from partial to full weightbearing without crutches (Video 4). Walking activities involve heel to

toe walking, retro-walking, and high-knee activities. The focus onretro-walking is to fully extend the knee when going from toe to heel.Practicing walking in front of a mirror greatly aids in the return of a

normal walking pattern. The mirror gives patients an immediate visualcue as to how they are walking. It is very important to emphasize leg

control early in the rehabilitation program. Through early extensionand normal gait the patient is able to regain good quadriceps tone and

leg control. This combination of clinical variables will set the pace for

the entire rehabilitation program and a successful outcome.

The patient is encouraged to lock out the knee by standing with the

weight shifted to the ACL reconstructed leg so that extension is fulland the knee is fully locked (Video 5). This exercise is referred to as

single leg stance and is preferred whenever the patient is standing.Single leg stance on the involved leg is an effective method of

working on full ROM and leg control, while giving the patientconfidence in standing on the injured leg to begin to do functional activities.

Once the patient has regained full knee extension and is ambulating normally it is possible to

implement strengthening exercises. Leg strengthening exercises include bilateral one-quarterknee bends and calf raises. It is felt that this type of exercise facilitates return of lower extremity

strength with minimal stress to the joint.

Patients will return 2 weeks following surgery for a physician and therapy visit. At that time, the

patient should have full extension, flexion to 130 degrees, controlled swelling, normal walking,and able to return to school or sedentary work.




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Phase III: (2 to 4 weeks)

Phase III begins at the second postoperative visit two weeks after surgery. Clinical goals forPhase III include full terminal extension and full flexion to 130 degrees, consistent weight room

and moderate speed strengthening, and early return to agility and sports specific drills.

Maintaining full knee extension is continued with exercises including prone hangs, passive and

active heel lift, and, if needed, a hyperextension device. Increasing flexion is achieved byexercises such as heel slides and by using a stationary bike to facilitate flexion ROM.

Functional strengthening is initiated once the patient has sufficient leg control to perform a

unilateral knee bend without difficulty. Exercises include one-quarter squats, unilateral leg press,unilateral calf raises, unilateral step-downs, Stairmaster, and riding the stationary bike.

Swimming and other hydrotherapy exercises can be started once the incisions have healed. Ourpreferred exercise progression includes short arc quadriceps from 90 to 30 degrees, knee bends,

step-ups and leg press. These exercises are started with lower weight and then gradually

progressed to higher weight with lower repetitions.

If full ROM and other goals have been met sport specific and agility drills may be initiated

including jump rope, single leg hop, and easy position drills.

After Phase III, the patient will return to physical therapy every 4 to 6 weeks until 6 months, then

again at 9, 12, and 24 months following surgery.

Phase IV: (4 weeks on)

The emphasis in Phase IV is on advanced strengthening and return to sports. To advance into thefinal phase of the rehabilitation program, the patient needs to have nearly full ROM. Our goal isto reach this phase by four to five weeks after surgery. However, if the patient has not achieved

the goals of the previous phase, advanced agility and sport specific activities are not yet initiated.The clinical goals for Phase IV include full ROM including terminal extension, improved

quadriceps tone, at least 70% strength, agility specific program, complete a sport specificfunctional progression and return to full activity.

Exercise instruction includes an increase in weight room and home strengthening activities.

Exercises include unilateral leg press, unilateral leg extensions, unilateral step-downs, unilateralcalf raises, full squat to no more than 90 degrees, and lunges. Patients are encouraged to progress

from high repetition/low weights to low repetition/high weights. Also, some type of moderatespeed strength and cardiovascular activity should be continued such as bicycling, swimming, or

using a Stairmaster.

The patients first visit during Phase IV is four weeks after surgery. This visit will include the

first isokinetic strength test (Fig. 11), a isometric leg press test (Fig. 12) and a KT-1000ligamentous stability test (Fig. 13).


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Figure 11

Figure 12

Figure 13

Factors influencing the patients return to controlled agility training and sport specific activity

includes the patient subjective rating, as well as isokinetic and isometric test scores. If thepatients strength ratio is at least 65%, agility activities are started. These activities include

lateral shuffles, cariocas, cross over drills, and backward running. Patients may also begin solosports such as shooting a basketball or hitting a racquetball. These early agility activities promote

patient confidence, facilitate moderate-speed strength, and re-develop quickness, agility, andsport specific skills. As the patient progresses, agility workouts become more vigorous to include

activities such as figure of eights and half to full speed running. The speed of progression isbased on the specific athletic and recreational desires of the patient. Sports specific activities are

incorporated into the progression with specific focus on athletic goals.

Although many patients ask when can I start running again at the beginning of Phase IV,

running for conditioning or rehabilitation actually is the final step in the rehabilitation process.We prefer that the patient work on agility drills and sport specific skills instead of running two to

three miles. Running long distances at this time leads to swelling and, therefore, can cause adelay in the rehabilitation process.

The athlete must participate in sport specific activities. Although we allow them to and they can

successfully return to practice and playing early after surgery, it can take two to three months ofsport specific activities (both practicing and playing) before the athlete will feel completely

comfortable with their knee and recover 100% of their quickness.

The patient is followed every four to six weeks for up to six months, but is allowed to return topractice and playing as they feel comfortable and as our evaluation allows. Specific testing

strategies at each visit consist of isokinetic and isometric strength testing, single leg hop, andKT-1000 measurements.


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A knee injury involving the anterior cruciate ligament (ACL). The ACL runs diagonally acrossthe front of the knee from the underside of the femur (the thigh bone) to the top of the tibia (the

bigger bone in the lower leg).

Symptoms of an ACL injury include:

y Feeling or hearing a pop in the knee at the time of injury.

y Pain on the outside and back of the knee.

y The knee swelling within the first few hours of the injury. This may be a sign of bleeding inside

the knee joint. Swelling that occurs suddenly is usually a sign of a serious knee injury.

y Limited knee movement because of pain or swelling or both.

y The knee wobbling, buckling, or giving out.

There are 3 Types of Grades associated with ACL injuries :

Grade I sprain

y The fibers of the ligament are stretched, but there is no tear.

y There is a little tenderness and swelling.

y The knee does not feel unstable or give out during activity.

Grade II sprain

y The fibers of the ligament are partially torn.

y There is a little tenderness and moderate swelling.

y The joint may feel unstable or give out during activity.

Grade III sprain

y The fibers of the ligament are completely torn (ruptured); the ligament itself has torn

completely into two parts.

y There is tenderness (but not a lot of pain, especially when compared to the seriousness of the

injury). There may be a little swelling or a lot of swelling.


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y The ligament cannot control knee movements. The knee feels unstable or gives out at certain

times.

The focus of this write up is not to discuss exactly what happens when an ACL injury occurs, this write up

will focus on the rehabilitation process to go through before and after an ACL reconstruction operation.

It is usually a patient who suffers from a Grade III Sprain that undergoes the reconstruction surgery,

however the exercises and rehabilitation process in these article can be useful for everyone who suffers

an ACL injury.

Preoperative period

It is very important for people who have decided to undergo the reconstruction surgery to try and

regain full Range of Motion (ROM) on the injured leg. This means that you should be able to flex and

extend your injured knee as far as the uninjured side.

During this period of time, you should concentrate on maintaining as much strength as possible in the

quadriceps muscle. The quadriceps muscle brings your knee into full extension. This is one of the

strongest muscles in your body, but unfortunately, it can loose a significant amount of strength after any

type of knee surgery.

Regaining the strength in your quadriceps muscles can be difficult, because your knee may hurt quite a

bit in the first few weeks after your injury. The following exercises are recommended to help regain

ROM and increase strength in the muscle : These exercises ideally should take place at least 6 weeks

before your operation. The completion of a preoperative program has been shown to significantly speed

up postoperative recovery.

Exercises:

1.Knee extensions and quad sets:To perform these two exercises, place the heel of your injured

leg on an object that is a few inches thick (like a phone book). Gradually relax and let your leg

come to full extension. This first part of the exercise helps you to maintain a normal range of

motion.

2.Quad sets: After your knee has stretched out for a while, perform a set of ten quadriceps

contractions with your leg in the same position as in the Knee extensions. Without lifting your

heel up in the air, tighten your quadriceps muscle as hard as you can for ten seconds. Then relaxfor ten seconds before tightening your muscle again. Repeat this ten times.This exercise helps

you to maintain quadriceps strength.

3.Heel Slides:For this next exercise, start with you injured leg stretched out.Then, while keeping

your heel on the floor, gradually bend your knee and slide your heel towards your buttock. Bend

your knee until it becomes just slightly uncomfortable and you can feel a bit of pressure inside

your knee. Hold it in this position for ten seconds. Then straighten your knee out again and relax


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for ten seconds. Repeat this exercise ten times as well.This exercise will help you to maintain

range of motion.

4.Straight leg raise:This exercise helps you maintain your quadriceps strength. Start with your leg

flat on the bed. Begin by tightening your quadriceps, as in the quad sets exercise. Then lift your

leg off the bed until your heel is approximately eighteen inches off of the bed and build up to

holding for ten seconds. Lower your leg back down and repeat. Repeat this exercise five times.

5.Prone leg raise: This exercise helps to maintain the hamstring strength. This is done in a similarly

to the straight leg raise but with you lying on your stomach. Begin by lying face down. Then lift

your leg off the floor until your foot is at least 6 inches from the ground. Keep the elevated leg

as straight as possible - hold this position for ten seconds. Repeat this exercise five times.

As soon as the knee feels capable, begin to use a stationary bike. This will help with the ROM and help

maintain the quadriceps strength. Begin by doing five minutes with low resistance and gradually build

up the time and resistance. This is a very beneficial exercise for pre and post operation as it helps regain

ROM and work the quadriceps.

Preoperative Tips:

y Put plastic chair into shower to sit on when washing

y Have plenty of ice packs to keep rotation of cold packs (4+)

y If one lives alone, make copies of keys to give to trusted friends + family to bring food and help

y Have easy ready to eat stuff floating around or go hungry

y Make a home on the couch with everything, connect power boards near couch-home, plug all

gadgets (chargers, phones, laptops etc) in so everything is reachable when lying down.

y Have torch nearby just in case, and plug in a desk lamp on above power board - you wont want

to be switching off lights you forgot about

y If you have a dvd collection to watch - and a laptop - watch em on the laptop - you wont want to

get up to put the dvds in the player by the tv

y Keep an ACL journal - To help keep you motivated and show progress

y Keep a plastic bottle by couch bed. You will wake up and need to go to the toilet

y Keep a water bottle by couch too. IMPORTANT: Don't get bottles confused in the night.

y Keep towels around the shower area, especially1-2 to use on the floor - crutches can slip and

cause re-tear

y Always travel with backpack - even to Kitchen or bedroom, will be invaluable for bringing items

back with you.

Postoperative period

Physical therapy will help your regain knee flexion (bending). However, being able to fully extend

(straighten) your knee soon after surgery is vital! If full extension is not achieved within the first eight

weeks, a second surgery may be necessary.

With this in mind, you must NEVER put anything under your knee when you are resting, sleeping, or


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propping your leg up. The pillow must go under the heel.

IMPORTANT : NEVER put anything under your knee (see above)

Concerns:

1.Numbness around the incision site on the outside part of the knee is a result of a disruption of a

superficial nerve during the operative procedure. Most of this will resolve over time but a small

area the size of a quarter usually remains numb. This is unavoidable because of the proximity of

the nerve to the incision.

2.A sudden rush or feeling of fullness with pain when going from a sitting to a standing position in

the knee is common after surgery.

Reduce Swelling

You will meet with a physiotherapist after surgery, if possible try and locate a Cryo Cruffto use for the

first week after surgery. This will help reduce swelling at a much quicker rate.

The use of one of these will help speed up the rate at which you can begin your rehabilitation program.

Week 0 - 2:

y The goals of the first two weeks of post-operational rehabilitation are to reduce swelling,

restore full range of motion in extension and flexion, ambulate without the use of crutches, and

sit down and stand from a seated position.

y Proprioception is diminished following injury to the ACL, and it is therefore very importantthat this is regained following reconstructive surgery.After surgery, pain and swelling can

inhibit the activity of your muscles. This can quickly result in muscle wasting whichultimately can lead to abnormal joint movement and can therefore create furtherproblems.

y During the first week after surgery, rehabilitation is mostly passive. Regular icing and elevation

are used to reduce swelling. Your goal is full extension (or 10 degrees short of that) and 70


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degrees of flexion by the end of the first week.You should ice the knee as often as possible

(especially after exercising) to reduce swelling and discomfort. Do not ice the knee more than 20

minutes at a time. Let the knee warm up before reapplication. Avoid getting your wound wet.

Some exercises that you may be able to perform near the end of Week1

:

1. Gentle knee cap (patella) mobilizations : Sitting with you leg out straight and wellsupported, remove or undo your brace. Feel for the edges of your kneecap and usinggentle pressure, slowly push your kneecap from side to side 5-10 times, and also glide ittop to bottom 5-10 times.

2. Passive knee stretch / Knee hang: It is important to regain full extension of your knee aswell as flexion. Place your heel on a block or rolled up towel so there is no supportbeneath it, let the knee hang for 3-5 mins or as tolerated.

3.Ankle Pumps : With each foot separately or at the same time, point and flex the toes as if

pumping the gas pedal of a car repeatedly, 25-50 times every five to 10minutes.

4.Ankle Circles : With each ankle separately or at the same time, rotate the ankles in a large circle

about 10 times each direction, 25-50 times every five to 10minutes.

Repeat 4-5 times a day or as necessary to get your knee straight

Week 2 - 6:

SECTION 1: RANGE OF MOTION EXERCISES

Days per week: 7Times per day: 2 - 3

1.Knee extensions :To perform these two exercises, place the heel of your injured leg on an

object that is a few inches thick (like a phone book). Gradually relax and let your leg come to full

extension. This first part of the exercise helps you to maintain a normal range of motion.

2.Quad sets: After your knee has stretched out for a while, perform a set of ten quadriceps

contractions with your leg in the same position as in the Knee extensions. Without lifting your

heel up in the air, tighten your quadriceps muscle as hard as you can for ten seconds. Then relax

for ten seconds before tightening your muscle again. Repeat this ten times.This exercise helps

you to maintain quadriceps strength.3.Heel Slides:For this next exercise, start with you injured leg stretched out.Then, while keeping

your heel on the floor, gradually bend your knee and slide your heel towards your buttock. Bend

your knee until it becomes just slightly uncomfortable and you can feel a bit of pressure inside

your knee. Hold it in this position for ten seconds. Then straighten your knee out again and relax

for ten seconds. Repeat this exercise ten times as well.This exercise will help you to maintain

range of motion.


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4.Straight leg raise:This exercise helps you maintain your quadriceps strength. Start with your leg

flat on the bed. Begin by tightening your quadriceps, as in the quad sets exercise. Then lift your

leg off the bed until your heel is approximately eighteen inches off of the bed and build up to

holding for ten seconds. Lower your leg back down and repeat. Repeat this exercise five times.

SECTION 2: STATIONARY CYCLING

Days per week: 5Times per day: 1

At this time, you can begin stationary cycling with both legs, using a spin or light resistancemode. Initially it is suggested that you set the seat height higher than normal so that it is easier to

complete the cycling motion. As the cycling becomes easier, you can adjust the seat height toyour normal level. Begin very slowly; as the knee feels stronger and more comfortable, increase

the rpms with a spin or light resistance mode. Start with approximately 10 - 15 minutes; yourgoal will be to achieve 30-45 minutes of cycling.

SECTION 3: WATER WORKOUT

Days per week: 3

Times per day: 1

Another excellent way of being able to perform some type of activity, and at the same time keep

range of motion and work the cardiovascular system, is to use the aquajogger exercise program.It is essential to find a pool that is deep enough so that the feet do not touch the bottom. This

exercise is totally non-weight bearing and will allow for a very low impact type of movementsequence. We suggest between 20 and 30 minutes of actual jogging in the water per session.

SECTION 4: BALANCETRAINING ( PROPRIOCEPTION )

Days per week: 5

Times per day: 1

After ACL surgery you need to retrain your leg by also completing balancing exercises. These involve

standing on one leg (your injured leg) and maintaining balance for120 seconds. When you are

comfotable doing this, then you try and repeat but this time closing your eyes. This increases the

difficulty.


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Two extra items that can be handy for proprioception are a wobble board and a mini trampoline.These

will greatly help in the balance training.

If you purchase a wobble board and/ or mini trampoline then exercise guides come with them. You can

also continue to do the exercise mentioned above. Always try and build up to120seconds and beyond.

Step 1 is with eyes open, Step 2 with eyes closed and Step 3 is looking at feet and then looking to the

side.

Week 6 - 11:

From six to twelve weeks, emphasis is placed on improved muscular control, proprioception and general

muscular strengthening. Proprioceptive work progresses from static to dynamic techniques including

balance exercises on the wobble board and eventually jogging on a mini-tramp. The injured party should

have a full range of motion during this stage and gentle resistance work should be added. By the end of

this period the patient should be able to cycle normally, swim with a straight leg kick and be able to jog

freely on the mini-tramp.

Continue exercises from the previous section while adding the following :

Lunges:

y Stand with injured foot forward, other foot back about 3 feet apart. Bend the knees to lower the

body towards the floor. Keep the front knee behind the toes and be sure to lower straight down

rather than forward.

y Keep the torso straight and abs in as you push through the front heel and back to starting

position.

y Don't lock the knees at the top of the movement.

y Hold for five seconds and repeat five times.

Lunges should be done for both legs, make sure the knee never goes out in front of the toe.

Squats:

y Place your back against a wall or swiss ball resting on a wall. Position your feet slightly wider

then hip-width apart with your toes slightly turned out.


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y Slowly and under control bend your knees and lower yourself to a 90 degree angle without

lifting your heels off the floor and then after a brief pause at the bottom push your weight back

up until you are back at the starting position

y Do 10 to 15 repetitions to finish one set before resting. You can repeat the set, but use your own

discretion as to how much you can manage. Try to go for 5 sets.

Step ups:

Stand behind a 15-inch platform or step. Place the injured foot on the step, transfer the weight to the

heel and push into the heel to come onto the step. Concentrate on only using the injured leg, keeping

the other leg active only for balance.Slowly step back down and repeat all reps on the injured leg before

switching to the other leg. Perform 1-3 sets of10-16 reps.

Leg Press: Single Leg

Note: Only perform on the uninjured leg, do not use injured leg for this. You want to build up the

strength in the healthy leg.

Hamstring Exercise:

Placing your back against a wall or door, bend the knees to 90 degree angle . Have your feet 12 inches

out in front. Push back against wall/door and hold for ten second. Repeat five times.

Swimming:

Swimming can commence at this stage, but ensure that you only use the flutter kick, avoid breaststroke

until 4 months after surgery as this puts pressure on the ligament. Build up resistance and don't over do

it.

Increasing Load:

During this time period you should look to increase your work in the water and on the stationary bike.

Swelling around the knee should be reduced and you should be pain free. Increase time and resistance

on the bike and begin to swim in order to build back up cardiovascular fitness.

Continue Proprioception drills, e.g. wobble board exercises balancing on two legs, balancing on one leg,

ball tosses while balancing, done with the eyes closed for advanced drills. Repeat for mini- trampoline.

Months 3 - 6From 3 Months to 6 Months continue with your exercises.You can often begin light jogging(figure of

eight rotations), cycling outdoors, and pool workouts. Side-to-side, pivoting sports -- such as basketball,

soccer and football -- must be avoided.

Toward the end of this phase, some people can begin shuttle runs, lateral shuttles and jumpingrope. I recommend running in a pool throughout this phase while building confidence in theknee.


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Month 6 & Beyond

Increase cardiovascular work and build overall leg strength. If your knee is feeling strong you can begin

to do more dynamic moves like hopping along with vertical and multiple jumps, both legs; hops, one leg

at a time;

continue to concentrate on building hamstring strength to help prevent future injury. Single leg squats

(have a bench behind you when practicing - so if you lose balance you can sit back on the bench) should

be emphasized to help build on the strength you have returned to your knee.

Conclusion

The road back from ACL surgery is a long one, after the initial gains you will find that progress is slow,

your knee feels different and you begin to wonder if it ever will be the same. If you follow a healthy

rehab program and monitor your knee you should beable to return to competitive sports.

Note: Don't worry too much about the 'crunching' sound you will hear/feel when you begin to run again,

this is built up scar tissue that will eventually break down. My main tip is to try and get confidence in the

knee as your muscle - mind connection will have been severly damaged after surgery. It takes a while to

build this back up - and remember warm up & warm down before exercise. I find a stationary bike is

good for loosing my knee before any exercise where i need to use my knee and gives me extra

confidence it wont break down.

If you've recently suffered an anterior cruciate ligament injury (ACL) the following exercises canget you on the road to recovery.

Exercises you can do as tolerated, include the following.

y Heel slide: Sit on the floor with legs outstretched. Slowly bend the knee of you injured legwhile sliding your heel/foot across the floor toward you. Slide back into the starting position and

repeat 10 times.y Isometric Contraction of the Quadriceps: Sit on the floor with your injured leg straight and

your other leg bent. Contract the quadricep of the injured knee without moving the leg. (Pressdown against the floor). Hold for 10 seconds. Relax. Repeat 10 times.

y Prone knee flexion: Lie on your stomach with your legs straight. Bend your knee and bringyour heel toward your buttocks. Hold 5 seconds. Relax. Repeat 10 times.


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Add the following exercises once knee swelling decreases and you can stand evenly on both legswithout favoring the injured knee.

y Passive knee extension: Sit in a chair and place your heel on another chair of equal height.

Relax your leg and allow your knee to straighten. Rest in this position 1-2 minutes several times

a day to stretch out the hamstrings.y Heel raise: While standing, place your hand on a chair/counter for balance. Raise up ontoyour toes and hold it for 5 seconds. Slowly lower your heel to the floor and repeat 10 times.

y Half squat: Stand holding a sturdy table with both hands. With feet shoulders width apart,

slowly bend your knees and squat, lowering your hips into a half squat. Hold 10 seconds andthen slowly return to a standing postion. Repeat 10 times.

y Knee extension: Loop one end of Theraband around a table leg and the other around the ankleof your injured leg and face the table. Bend your knee about 45 degrees agaist the resistance ofthe tubing and return.

y One Legged Standing: As tolerated, try to stand unassisted on the injured leg for 10 seconds.

Work up to this exercise over several weeks.

The anterior cruciate ligament (ACL) is a vital ligament for proper movement. The ACL receivesmore injuries than the other ligaments.

[which?]Injuries of the ACL range from mild such as small

tears to severe when the ligament is completely torn. There are many ways the ACL can be torn;

the most prevalent is when the knee is bent too much toward the back and when it goes too far tothe side. Tears in the anterior cruciate ligament usually take place when the knee receives direct

impact[clarification needed]

while the leg is in a stable position. Torn ACLs are most often related tohigh impact sports or when the knee is forced to make sharp changes in movement and during

abrupt stops from high speed. These types of injuries are prevalent in soccer, high jump,

basketball, and American football. Research has shown that women involved in sports are morelikely to have ACL injuries than males. ACL tears can also happen among older individuals byslips and falls and they are seen mostly in people over forty due to wear and tear of the

ligaments. An ACL tear can be determined by an individual if a popping sound is heard afterimpact, swelling after a couple of hours, severe pain when bending the knee, and when the knee

buckles or locks during movement.

[edit] Epidemiology

Mountcastle et. al performed a study on gender difference in ACL tears in relationship wih

physical activities.[1]

The researchers performed an epidemiology study on young athleticpopulations. Preceding studies have signified that women that participate in the same physical

activities as men are more at risk for ACL injuries. The authors hypothesize that the frequencyrate for males and females in the athletic and college aged population is the same. The

procedures for the study was college graduation classes from 1994-2003 at a major institutions.The players who received a whole tear were examined for apparatus of injury and the type of

sport they played when the injury occurred. The authors calculated the accident rate, opinion ofdanger, gender incidents, class year, and the accident rate differentiating men and women. There


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was 353 ACL injuries in 10 classes during the span of the study. The researchers calculated a 4year accident proportion of 3.24 per 100 students for men, and 3.51 for women. Overall, the

ACL injury rate not including male only sports was substantial greater in women with anincidence ratio of 1.51 (pg 5). Women are more likely to get injured at gymnastics course with

an incidence ratio of 5.67, with an indoor obstacle course test is 3.72, and 2.42 incidence ratio on

basketball. The authors concluded that there is slim gender difference in gender ACL tear. Onthe other hand, there were significant gender differences ACL injury rates when particularspecific sports and physical activites were compared. Also, when male only sports were detached

from the whole rate evaluation.

A notable finding is that women are three times more likely to have an ACL injury than men.The reason is because of the variation of hormone levels. Also, ligament strength of the ACL

handles more force in men than in women. Most importantly, there is substantial differenceneuromuscular coordination and control in landing, women have less hip and knee flexion.

Athletic trainers and team physicians advise female athletes to adapt an ACL conditioningprogram.

[edit] Symptoms

Symptoms of an ACL injury include hearing a sudden popping sound, swelling, and instability ofthe knee (i.e., a "wobbly" feeling). Pain is also a major symptom in an ACL injury and can range

from moderate to severe.[2]

Continued athletic activity on a knee with an ACL injury can havedevastating consequences, resulting in massive cartilage damage, leading to an increased risk of

developing osteoarthritis later in life.

[edit] Causes

ACL injuries occur when an athlete rapidly decelerates, followed by a sharp or sudden change in

direction (cutting). ACL failure has been linked to heavy or stiff-legged landing; as well astwisting or turning the knee while landing, especially when the knee is in the valgus (knock-knee)

position.

Women in sports such as football (soccer), basketball, tennis and volleyball are significantly

more prone to ACL injuries than men. The discrepancy has been attributed to differencesbetween the sexes in anatomy, general muscular strength, reaction time of muscle contraction

and coordination, and training techniques. A recent study suggests hormone-induced changes inmuscle tension associated with menstrual cycles may also be an important factor

[3]. Women

have a relatively widerpelvis, requiring the femurto angle toward the knees[4]

. Recent researchalso suggests that there may be a gene variant that increases the risk of injury [5]

The majority of ACL injuries occur in athletes landing flat on their heels. The latter directs the

forces directly up the tibia into the knee, while the straight-knee position places the lateralfemoral condyle on the back-slanted portion of the tibia. The resultant forward slide of the tibia

relative to the femur is restrained primarily by the now-vulnerable ACL.


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[edit] Diagnosis

The pivot-shift test, anterior drawer test and the Lachman test are used during the clinicalexamination of suspected ACL injury. The ACL can also be visualized using a magnetic

resonance imaging scan (MRI scan).

An ACL tear can be determined by the an individual if a popping sound is heard after impact,

swelling after a couple of hours, severe pain when bending the knee, and when the knee bucklesor locks during movement.

Though clinical examination in experienced hands is highly accurate, the diagnosis is usually

confirmed by MRI, which has greatly lessened the need for diagnostic arthroscopy. MRI has ahigher accuracy than clinical examination in detecting ACL tears when multiple ligaments are

torn. This is of particular benefit if there is a coexisting posterolateral corner injury. Addressingthe posterolateral corner injury at the time ofACL reconstruction will prevent premature graft

failure.

[edit] Anterior drawer test

The anterior drawer test for anterior cruciate ligament laxity is one of many medical tests used to

determine the integrity of the anterior cruciate ligament.[6]

It can be used to help diagnose sprain

and tears.

The test is performed as follows: the patient is positioned lying supine with the hip flexed to 45

and the knee to 90. The examiner positions themselves by sitting on the examination table infront of the involved knee and grasping the tibia just below the joint line of the knee. The thumbs

are placed along the joint line on either side of the patellar tendon. The index fingers are used to

palpate the hamstring tendons to ensure that they are relaxed; the hamstring muscle group mustbe relaxed to ensure a proper test. The tibia is then drawn forward anteriorly. An increasedamount of anterior tibial translation compared with the opposite limb or lack of a firm end-point

indicates either a sprain of the anteromedial bundle of the ACL or a complete tear of the ACL.This test should be performed along with other ACL-specific tests to help obtain a proper

diagnosis.

[edit] Lachman test


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Lachman test

y The knee is flexed at 30 degrees

y Doctor pull on the tibia to identify frontward motion of the lower leg in comparison to the upper

leg.

y

A knee that has an ACL tear will have a lot of forward motion at the conclusion of the movement

The Lachman test is a medical test used for examining the anterior cruciate ligament (ACL) inthe knee for patients where there is a suspicion of a torn ACL.[7] The Lachman test is recognized

by most authorities as the most reliable and sensitive clinical test for the determination ofanterior cruciate ligament integrity, superior to the anterior drawer test commonly used in the

past. To do this, lay the patient supine on an examination table. Put the patient's knee in about20-30 degrees flexion, also according to Bates' Guide to Physical Examination the leg should be

externally rotated. The examiner should place one hand behind the tibia and the other on thepatient's thigh. It is important that the examiner's thumb be on the tibial tuberosity. On pulling

anteriorly on the tibia, an intact ACL should prevent forward translational movement of the tibia

on the femur("firm endpoint").

Anterior translation of the tibia associated with a soft or a mushy endpoint indicates a positive

test. More than about 2 mm of anterior translation compared to the uninvolved knee suggests atorn ACL ("soft endpoint"), as does 10 mm of total anterior translation. An instrument called a

"KT-1000" can be used to determine the magnitude of movement in mm.

This test can be done in an on-the-field evaluation in an acute injury setting, or in a clinical

setting when a patient presents with knee pain. In either situation, ruling out fracture is importantin the evaluation process. Also when evaluating the integrity of the ACL, it is important to test

the integrity of the MCL, because this is a common ligament torn in an ACL injury as well.[8]

This test is named afterorthopaedic surgeon, John Lachman.

[edit] Pivot Shift Test

y Person lies on one side of the body

y Knee is extended and internally rotated

y Doctor applies stress to lateral side of the knee, while the knee is being flexed

y A positive test indicates a crash felt at 30 degrees flexion.

[edit] Prevention

Research has shown that the incidence of non-contact ACL injury can be reduced anywhere from20% to 80% by engaging in regular neuromuscular training that is designed to enhanceproprioception, balance, proper movement patterns and muscle strength.

[9]

A National Institutes of Health funded study is underway with the objective of identifying uniquemovement patterns that predispose female athletes to ACL injuries and evaluate and improve

injury prevention programs. The study is overseen by Dr. Christopher Powers at the Universityof Southern California's Division of Biokinesiology. An initial phase of the project evaluated the


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Prevent Injury and Enhance Performance (PEP) program developed by the Santa MonicaOrthopaedic and Sport Medicine Research Foundation. During the final stage of the study, the

Competitive Athlete Training Zone ("CATZ") in Pasadena, CA the ACL injury preventiontraining program is being enhanced and continually improved by CATZ founders Jim Liston and

Kevin Wentz. Information on the PEP program, and the latest developments at CATZ can be

monitored at the project website.

[10][11]

[edit] Treatment

The ACL primarily serves to stabilize the knee in an extended position and when surroundingmuscles are relaxed; so if the muscles are strong, many people can function without it. Fluids

will also build the muscle.

The term for non-surgical treatment for ACL rupture is "conservative management", and it oftenincludes physical therapy and using a knee brace. Lack of an ACL increases the risk of other

knee injuries such as a torn meniscus, so sports with cutting and twisting motions are strongly

discouraged. For patients who frequently participate in such sports, surgery is often indicated.

[edit] Conservative

A torn ACL is less likely to control the movements of the knee. When tears to the ACL is not

repaired it can sometimes cause damage to the cartilage inside the knee because with the tornACL the tibia and femur bone are more likely to rub against each other. Immediately after the

tear of the ACL, the person should rest it, ice it ever fifteen to twenty minutes, producecompression on the knee, and then elevate above the heart; this process helps decrease the

swelling and reduce the pain. The form of treatment is determined based on the severity of thetear on the ligament. Small tears in the ACL may just require several months of rehab in order to

strengthen the surrounding muscles, the hamstring and the quadriceps, so that these muscles cancompensate for the torn ligament.

[edit] Surgery

Main article: ACL reconstruction

If the tear is severe, surgery may be necessary because the ACL can not heal independentlybecause there is a lack of blood supply going to this ligament. Surgery is usually required amongathletes because the ACL is needed in order to perform sharp movements safely and with

stability. The surgery of the ACL is usually done several weeks after the injury in order to allowthe swelling and inflammation to go down. During surgery the ACL is not repaired instead, it is

reconstructed using other ligaments in the body. There are three different types of ACL surgery.Patella tendon-bone auto graft and hamstring auto graft are the most common and preferred

because it produce the best results. After the surgery, rehabilitation is required in order tostrengthen the surrounding muscles and stabilize the joint.

There are two main options for ACL graft selection, allograft and autograft. Autografts are the

patients' own tissues, and options include the hamstringtendons or middle third of the patellatendon. Allograft is cadaveric tissue sourced from a tissue bank. Each method has its own


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advantages and disadvantages; hamstring and middle third of patella tendon having similaroutcomes. Patellar grafts are often incorrectly cited as being stronger, but the site of the harvest

is often extremely painful for weeks after surgery and some patients develop chronic patellartendinitis. Replacement via a posthumous donor involves a slightly higher risk of infection.

Additionally, donor grafts eliminate tendon harvesting which, due to improved arthroscopic

methods, is responsible for most post-operative pain.

The surgery is typically undertaken arthroscopically, with tunnels drilled into the femurand tibia

at approximately the original ACL attachments. The graft is then placed into position and held inplace. There are a variety of fixation devices available, particularly for hamstring tendon

fixation. These include screws, buttons and post fixation devices. The graft typically attaches tothe bone within six to eight weeks

[citation needed]. The original collagen tissue in the graft acts as a

scaffold and new collagen tissue is laid down in the graft with time. Hence the graft takes oversix months to reach maximal strength.

[citation needed]

After surgery, the knee joint loses flexibility, and the muscles around the knee and in the thigh

tend to atrophy. All treatment options require extensive physical therapy to regain musclestrength around the knee and restore range of motion (ROM). For some patients, the lengthy

rehabilitation period may be more difficult to deal with than the actual surgery. In general, arehabilitation period of six months to a year is required to regain pre-surgery strength and use.[citation needed]

This is very dependent on the rehabilitation assignment provided by the surgeon aswell as the person who is receiving the surgery. External bracing is recommended for athletes in

contact and collision sports for a period of time after reconstruction. It is important however torealize that this type of prevention is given by a 'surgeon to surgeon' basis; all surgeons will

prescribe a brace and crutches for post surgery recovery total usage time is one month. Aftersurgery no sports for 6 to 7 months. Whether the ACL deficient knee is reconstructed or not, the

patient is susceptible to early onset of chronic degenerative joint disease.

[edit] Rehabilitation

The rehabilitation process is the most important part of the surgery. There is a long and rigorous

process involved in getting back to one hundred percent. The doctor will start the patient on therehabilitation program, which is broken down into phases:

Phase 1: This step is called the early rehabilitation phase. This is basically the things that were

covered in short term, things to reduce pain and swelling while gaining movement.

Phase 2: This phase covers weeks 3 and 4. At this point the pain should be subsiding and the

patient will be ready to try more things that their knee isnt willing perform. That is why there isa lot of emphasis put on joint protection during this step. The patient will be able to start doingexercises such as mini wall sits and riding stationary bikes. The aim of this is to be able to bend

the knee 100 degrees.

Phase 3: This phase is known as the controlled ambulation phase and it covers weeks 4 to 6. At

this point the patient will be doing the same exercises from phase 2 plus some more challenging


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ones. The patient will try to get their knee to bend 130 degrees during this stage. The aim duringthis period is to focus heavily on improving balance.

Phase 4: This is the moderate protection phase and it covers weeks 6 to 8. In this period the

patient will try to obtain full range of motion as well as increase resistance for the workouts.

Phase 5: This is the light activity phase and it covers weeks 8 to 10. This period will placeparticular emphasis on strengthening exercises with increased concentration on balance and

mobility.

Phase 6: This is the return to activity phase and it lasts from week 10 until the target activity

level is reached. At this point the patient will be able to start jogging and performing moderatelyintense agility drills. Somewhere between month 3 and month 6 the surgeon will probably

request that the patient perform physical tests so s/he can monitor the activity level. When thedoctor feels comfortable with the progress of the patient, s/he will clear that person to resume a

fully active lifestyle.[12]

[edit] Prevention

ACL injury prevention should be taken sincerely. The best way to prevent an ACL injury is to

implement and add warm up drills like jumping and balancing. These drills will induce increaseneuromuscular control and conditioning. In turn, muscular reactions will improve thus

decreasing the risk of an ACL injury. A warm up program of at least 15 minutes 2-3 times perweek is essential in order to prevent an ACL injury. Identifying the causes of the ACL and how

painful they are the best way to avoid or escaped a painful experience it is to stretch the ligamentbefore a physical activity. The leg muscles like the quadriceps and hamstrings have to be made

stronger.

y Backward running to warm up the hip extensors and hamstrings

y One of the fundamental ways to avoid an ACL injury is to not wear shoes that have cleats in

contact sports.

y When a person has already suffered an ACL injury, but wants to return to competitive sports,

the best way to prevent another injury is to strengthen the quadriceps and hamstrings.

y Another way is to change mechanics like pivoting, cutting excessively because it puts extra stress

on the knee.

y Overall, sports like football, soccer, basketball, and other contact sports the risk is always high.

y The best way is to wear a knee brace.

Stretching

Stretching the quadriceps and hamstrings before an event will also prevent ACL injury because it

promotes flexibility, decrease firmness, and increase performance. The muscle stretching has tobe done in reps.

File:Quad stretches.jpg


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Quaricep Stretching

y Calf Stretch 1-2 minute of stretching the lower leg muscles. Ankle circles will stretch the

gastrocnemius.

y Quadriceps- 23 minutes of seated butterfly 3 reps of 20 seconds

y

Hamstrings-1

minute of wall sits 2 reps of 30

secondsy Inner thigh stretch- 1 minute of knee to chest

y Hip flexors-2 reps of at least 20 seconds of lunges

Accelerated Rehabilitation FollowingAnteriorCruciate Ligament Replacement Surgery

Bertram Zarins,MD,WilliamB.Workman, MD,Alex Petruska, PT

Sports Medicine Service, Massachusetts General Hospital

INTRODUCTION

Operative procedures to stabilize knees that have suffered ligamentous injuries have recently undergonedramatic changes. Knees that have sustained multiple ligament tears are often initially treated non-operatively to allow the collateral ligaments to heal. The torn cruciate ligaments are replaced at a latertime using arthroscopic techniques.

Concepts regarding post-operative rehabilitation following reconstructive knee surgery have alsochanged. Instead of immobilization, early motion is encouraged after surgery. An extension of thisapproach is to use immediate and continuous controlled motion of the knee following anterior cruciateligament (ACL) replacement surgery. Donald Shelbourne developed the concept of acceleratedpostoperative rehabilitation. (9,10) This article will describe the postoperative rehabilitation proto-col thatis used by the senior author (BZ) at the Massachusetts General Hospital that balances early return tosports participa-tion with adequate time for graft healing.

METHODS

We use the accelerated rehabilitation protocol when we replace a torn anterior cruciate ligament with amid-third patellar tendon graft (bone-tendon-bone) using the endoscopic method. Bioabsorbableinterference screws are used in the distal femur and proximal tibia, providing graft fixation comparable to

metal screws. (18,19) This technique provides immediate stable fixation and allows the knee to be safelymoved using the continuous passive motion (CPM) machine after surgery.

We believe the autologous mid-third patellar tendon graft is the best graft for ACL replacement surgery,and we use this graft in all patients in whom we are replacing a torn ACL unless the patient stronglydesires an alternative graft. If the patient has had a prior patellar tendon graft that has failed, we usehamstring tendon autograft for revision surgery, if available.We do not use the accelerated rehabilitationprogram described herein following revision ACL replacement surgery.


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Dr. Zarins is Chief, Sports Medicine Service,Massac

Documents

ACL Reconcentration