Early Post-Operative Treatment Following Anterior Cruciate … · 2020-05-05 · Early Post-Operative Treatment Following Anterior Cruciate Ligament Reconstruction Aaron Reynolds,

Early Post-Operative Treatment Following Anterior Cruciate

Ligament Reconstruction

Aaron Reynolds, PT, OCS, CSCS

Elite OrthoSport Physical Therapy and Performance

Los Angeles, CA

I have nothing to disclose.

Objectives

• Review foundational principles to prepare for successful ACLR rehab

• Identify potential risk factors leading to complications in later stages of ACLR rehab

• Provide current clinical practice techniques and concepts related to early ACLR rehab

• Demonstrate manual techniques used in ACLR rehab

Scenario

• Player injured, holding knee

• Felt/heard pop

Scenario

• On field assessment• Subjective info

• ROM, diagnostic testing, etc.

• Rule out fracture, vascular injury

• Meniscus injury? Cartilage injury?• Assist in walking off playing field

Scenario

🤷🏻‍♂️

Scenario

•What happens next?• X-Ray/imaging • Schedule with ortho

• MRI, diagnosis

Scenario

•What happens next?• Before appt with ortho

• Crutches/AD

• Manage swelling, pain, maintain ROM

• Normalize extension for optimal quad activation

• If suspect meniscal or cartilage involvement, do not force flexion ROM

Scenario

•ACL rupture is confirmed

•What now?• Discuss meaning with athlete/patient, family, coaches, etc• Schedule surgery• Establish short term pre-op goals

Scenario

•ACL rupture is confirmed

•What now?• Discuss post-op rehab

• Short term goals and milestones

• Long term goals and milestones

• Return to play

Pre-op Rehab

“preoperative exercises not only prevented quadriceps weakness, but also accelerated the recovery of muscle strength”

Pre-op Goals

• Minimize pain and swelling

• Normalize ROM

• Improve quad activation

• Normalize gait

• Education

Pre-op Goals

•Prepare patient for post-operative status• Daily exercises prior to post-op outpatient rehab• Home• School• Work

Pre-op Goals

•Minimize pain and swelling• Modalities

• Rest

• Cryotherapy

• Compression

• Elevation

• Kinesiotape

• Manual therapy• Effleurage

Pre-op Goals

•Normalize ROM• Extension

• Terminal knee extension required for optimal quadriceps activation

• Allows for normal gait mechanics• May be inhibited by hamstring guarding/spasm

Pre-op Goals

•Normalize ROM• Flexion

• Get MRI report from surgeon – cartilage fragment, meniscus tear blocking flexion?• If no MRI available – what is the end feel?

• Swelling will inhibit flexion

Pre-op Goals

•Quadriceps Activation• Pain and swelling inhibit quadriceps activation

“…effused knee and painful knee groups demonstrated quadriceps muscle dysfunction…strength deficits were not magnified when these 2 stimuli were present simultaneously.”

Pre-op Goals

•Quadriceps Activation• Pain and swelling inhibit quadriceps activation

“Patients presenting to physical therapy after ACL injury should be treated with high-intensity neuromuscular electrical stimulation to help normalize this activation.”

Pre-op Goals

•Quadriceps Activation• Requires terminal knee extension• Quad sets – use NMES with volitional contraction• Allows for SLR without lag → heel strike at initial contact

Pre-op Goals

•Normalize Gait• Must have terminal knee extension• Quad activation & SLR• Proprioception (must be able to balance in SLS)

Pre-op Goals

• Education• Graft selection

• Were options given to patient?

• Function/anatomy of ACL• Visual models (athletes often

visual learners)

Pre-op Goals

• Education• Goals following surgery

• Return to or avoiding sport?

• Time frames/milestones post-operatively• Lay out expectations for patient

• Duration/frequency of physical therapy• May not have realistic understanding of post-operative rehab

Pre-op Goals

•Prepare for post-operative status• Home modifications

• Stairs, rugs, meals, etc

• Work modifications• Plan ahead – surgery Friday, resume work early following

week?

• Able to work from home?

• Allotting time for post-op rehab during work/school week?

Pre-op Goals

• Travel modifications• Handicap placard• Realistic expectations for driving (R vs. L leg)

•Post-op rehab accommodations• What times/days of week will work with patient’s

schedule?• Prepare for duration of post-op rehab

Pre-op Goals

•Prepare for post-operative status• Home exercise program for p/o week 1

• Ankle pumps

• Hamstring stretch

• Calf stretch

• Knee extension stretch

• Quad set

• Heel slides (or does surgeon prescribe CPM?)

• DO NOT place pillow under knee (prop up heel instead)

Pre-op Goals

•Prepare for post-operative status• Home exercise program for p/o week 1

Post-op Rehab

• Evaluation• Get the operative report

• Investigate cartilage health, involvement of meniscus, etc.

• Axillary Crutches• Check/correct sizing, crutch training

• Immobilization brace• Locked in extension? 0 ≠ full extension

• No brace? Gait training is even more critical

Post-op Rehab

• Evaluation• Weight bearing

• WBAT if isolated ACLR• Stitches

• Typically removed 10-14 days p/o• Circulation

• Screen for DVT• Pulses, Homan’s

• Ask questions, educate patient• Reference Wells’ Score

Post-op Rehab

• Evaluation• Inspect incision when able to

• Good wound closure

• Measure ROM• Flexion – do they have a CPM? Often d/c at “90 degrees”

• Girth measurements• Stay consistent – establish landmarks with yourself and/or

colleagues

Post-op Rehab

• Evaluation• Assess quad activation

• Inhibited by:• Pain

• Swelling

• Knee extension deficit

• Hamstring guarding

• Posterior tibial glide

Post-op Rehab

• Evaluation• Patellar mobility

• Inferior, medial, superior typically most limited

• Patellar tendon mobility• Important if BTB autograft

PT mobility Patellar mobility

Post-op Rehab

•Week 1 GOALS• Reduce/mobilize swelling• Symmetrical knee extension• Good quad activation w/ posterior tibial glide• SLR without minimal to no lag

• Unlock brace when lag is absent

Post-op Rehab

•Week 1 GOALS• Mobilize patella and patellar tendon• Gradual increase in knee flexion• Normal gait with unlocked brace and 1-2 axillary crutch• Begin glute/core strengthening

Post-op Treatment Strategies – Week 1

•Reduce/mobilize swelling• Contrast bath

• Ice in dependent position

• Heat in extension (heel propped)

• Effleurage in dependent position


•Reduce/mobilize swelling• Compression

• Compression sock

• Ace bandage for more significant swelling

• Look at ankle/foot

• Kinesiotape• Post-treatment squid tape

• Other considerations:• Alcohol, diet (Na+)


• Symmetrical Knee Extension• Beware of cyclops lesion

• Proliferative fibrous nodule formation in intercondylar notch

• Loss of terminal knee extension

• ~10% of post-ACLR population

• Anterior knee pain (deep to infrapatellar fat pad)


• Symmetrical Knee Extension• Hamstring guarding/spasticity


• Symmetrical Knee Extension

“Good prediction of QF atrophy in the first postoperative month can be made from studied variables, with isometric endurance and knee extension ROM deficit being the most significant contributors.”


• Symmetrical Knee Extension• Posterior thigh soft tissue

mobilization:• Hamstring guarding/spasticity• Gastrocnemius, popliteus

guarding/spasticity• Stretching:

• Hamstring• Gastrocnemius

• Knee extension with overpressure


• Symmetrical Knee Extension• Joint mobilization:

• Posterior tib-fem glide/tilt


Posterior tib-fem glide


Posterior tib-fem tilt


•Good quad activation• Should demonstrate posterior tibial glide with quad set• NMES w/ volitional quad set

• Sequencing matters

• Perform once maximum knee extension is achieved on that day• After manual treatment, stretching, etc

• NMES w/ straight leg raise (SLR)• Once good volitional quad set is performed, and SLR observed

without extensor lag


• SLR with minimal to no extensor lag• Criteria* to unlock post-op immobilizer with ambulation• Requires:

• Full passive knee extension

• Good quadriceps activation with posterior tibial glide

• SLR with extensor lag → increased load across PFJ and PT


•Mobilize patella• Prioritize inferior, medial, superior mobilization• Inferior glide:

• Reduces strain on PT incision

• Improves knee flexion ROM

• Superior glide:• Improves quad activation

• Be mindful of superior mobilization with PBTB autograft

• Medial glide:• Often tight laterally (TFL/ITB, VL)


•Gradual increase in knee flexion• Must mobilize patella (prioritize inferior mobility)• Seated at edge of table with leg supported

• Patient will be more relaxed than in supine

• Facilitate use of gained knee flexion in pre/early swing• Heel slides at home


•Gradual increase in knee flexion• Must mobilize patella (prioritize inferior mobility)


Inferior Patellar Mobilization


•Normalized gait with brace and AD as needed• Manual facilitation of proper gait mechanics• Heel strike/initial contact

• Full knee extension, volitional quad activation• Loading response/midstance

• SLB, volitional quad activation• Pre/initial swing

• Passive knee flexion• Relax rectus femoris/quadriceps

Post-op Treatment Strategies – Week 1Manual facilitation of proper gait mechanics


•Begin glute/core exercises• Start day 1 (use brace as needed)

“Rehabilitation including hip strengthening exercises appears to improve sagittal plane dynamic balance at three months post ACLR as compared to traditional rehabilitation”


•Begin glute/core exercises• Start day 1 (use brace as needed)


•Begin glute/core exercises


•Begin glute/core exercises• Look for muscular imbalances that

may inhibit gluteal activation• TFL tightness

• Psoas tightness

• Mobility exercises and/or manual release for more productive gluteal strengthening


•Personalized Blood Flow Restriction (PBFR) Training

“In addition to recovering muscle to a greater extent than standard rehab alone, the addition of BFR to ACL rehab exercises appears to have a protective effect on bone.”



“The results indicate that the occlusive stimulus effectively diminishes the post-operation disuse atrophy of knee extensors.”


•Personalized Blood Flow Restriction (PBFR) Training• Increased strength and hypertrophy with low load

resistance training• Able to protect graft/repair while maximizing exercise benefits

• Reduce atrophy due to immobilization and decreased WB

• Positive effect on post-operative bone loss• Benefits shown proximal and distal to cuff


•Personalized Blood Flow Restriction (PBFR) Training• Can be implemented once good wound closure is

observed (within 7 days p/o)• Utilize with low load exercises in p/o week 1-2

• Quad sets

• Terminal knee extension

• NWB gluteal exercises (clams, sidelying hip abduction, prone hip extension)


•Personalized Blood Flow Restriction (PBFR) Training• 80% of full LE occlusion• Sets/Repetitions: 30/15/15/15 at 20-30% 1RM• “Cell Swelling” protocol• “Ischemic Pre-Conditioning (IPC)” protocol• Nutrition – ensure adequate protein intake (2g/kg BW)



•Quad Sets



Terminal Knee Extension


•Personalized Blood Flow Restriction (PBFR) Training• Benefits both proximal and distal to cuff

“Isokinetic testing showed greater increases in knee extension peak torque (3% vs 11%)”

“BFR training had similar strengthening effects on both proximal and distal muscle groups”



NWB Gluteal Exercises



Kyle KimbrelOwens Recovery Science

Post-op Treatment Strategies – Weeks 2-4

• Continue exercises from week 1

• Suture removal (if applicable)• Initiate stationary bike for ROM

• Gait w/ 1 crutch if ready by week 2-3, wean off by week 3-4• 1 crutch in uncontrolled, public environment (i.e. school), practice

without crutch in controlled environment (i.e. home, office)


• Leg press 0-60° by end of week 2• DL and SL (incorporate BFR)

• Single leg balance


• Core strengthening (front, side planks if pain-free)

• DL partial squat once good quad control and SLB is observed• Hinge at hip

• Increase gluteal/posterior chain activation

• Avoid anterior knee translation• Decrease load across patellar tendon for BTB autografts

• Patellar tendinitis is NOT a complication of a BTB autograft – it is a CONSEQUENCE of careless rehab!


DL Squat

1. Hinge at hip

2. Trunk forward

3. Tibias vertical


• Progress squat to include lateral/diagonal stepping• Introduces SL excursion

• Be mindful of gluteal compensations (trunk lean, pelvic drop, etc.)

• Progress balance (unstable surface, dual-task, etc.)

• Assisted eccentric SL excursion at week 6 if appropriate• TRX, tandem, valslide, etc. to provide balance and strength assist

• Eccentric SL control key for successful running

• Elliptical at week 6

Prepare For Jogging

Full body weight jogging at 12 weeks* if:

1. Good eccentric SL control• Pain-free• Control knee valgus• Combined hip/knee strategy• Pelvic and trunk symmetry (watch for Trendelenburg)

2. Good core strength• Front/side plank 30+ seconds with good form

3. Elliptical pain-free

References1. Bowman, E. N., Elshaar, R., Milligan, H., Jue, G., Mohr, K., Brown, P., … Limpisvasti, O. (2019). Proximal, Distal, and Contralateral Effects of Blood

Flow Restriction Training on the Lower Extremities: A Randomized Controlled Trial. Sports Health: A Multidisciplinary Approach, 11(2), 149–156. doi: 10.1177/1941738118821929

2. Garrison JC, Bothwell J, Cohen K, Conway J. Effects of hip strengthening on early outcomes following anterior cruciate ligament reconstruction. Int J Sports Phys Ther. 2014;9(2):157–167.

3. Guerra-Pinto F, Thaunat M, Daggett M, Kajetanek C, Marques T, Guimaraes T, et al. Hamstring Contracture After ACL Reconstruction Is Associated With an Increased Risk of Cyclops Syndrome. Orthopaedic Journal of Sports Medicine 2017;5:232596711668412. doi:10.1177/2325967116684121.

4. Jackson DW, Schaefer RK. Cyclops syndrome: Loss of extension following intra-articular anterior cruciate ligament reconstruction. Arthroscopy: The Journal of Arthroscopic & Related Surgery 1990;6:171–8. doi:10.1016/0749-8063(90)90072-l.

5. Kim DK, Hwang JH, Park WH. Effects of 4 weeks preoperative exercise on knee extensor strength after anterior cruciate ligament reconstruction. Journal of Physical Therapy Science 2015;27:2693–6. doi:10.1589/jpts.27.2693.

6. Lambert B, Hedt CA, Jack RA, Moreno M, Delgado D, Harris JD, et al. Blood Flow Restriction Therapy Preserves Whole Limb Bone and Muscle Following ACL Reconstruction. Orthopaedic Journal of Sports Medicine 2019;7. doi:10.1177/2325967119s00196.

7. Lynch AD, Logerstedt DS, Axe MJ, Snyder-Mackler L. Quadriceps Activation Failure After Anterior Cruciate Ligament Rupture Is Not Mediated by Knee Joint Effusion. Journal of Orthopaedic & Sports Physical Therapy 2012;42:502–10. doi:10.2519/jospt.2012.3793.

8. Ohta H, Kurosawa H, Ikeda H, Iwase Y, Satou N, Nakamura S. Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. Acta Orthopaedica Scandinavica 2003;74:62–8. doi:10.1080/00016470310013680.

9. Palmieri-Smith RM, Villwock M, Downie B, Hecht G, Zernicke R. Pain and Effusion and Quadriceps Activation and Strength. Journal of Athletic Training 2013;48:186–91. doi:10.4085/1062-6050-48.2.10.

10. Rice DA, Mcnair PJ, Lewis GN, Dalbeth N. Quadriceps arthrogenic muscle inhibition: the effects of experimental knee joint effusion on motor cortex excitability. Arthritis Research & Therapy 2014;16. doi:10.1186/s13075-014-0502-4.

11. Selkowitz, D. M., Beneck, G. J., & Powers, C. M. (2013). Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. Journal of Orthopaedic & Sports Physical Therapy, 43(2), 54–64. doi: 10.2519/jospt.2013.4116

12. Žargi T, Drobnič M, Stražar K, Kacin A. Short–Term Preconditioning With Blood Flow Restricted Exercise Preserves Quadriceps Muscle Endurance in Patients After Anterior Cruciate Ligament Reconstruction. Frontiers in Physiology 2018;9. doi:10.3389/fphys.2018.01150.

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Early Post-Operative Treatment Following Anterior Cruciate … · 2020-05-05 · Early Post-Operative Treatment Following Anterior Cruciate Ligament Reconstruction Aaron Reynolds,