Rehabilitation of anterior cruciate ligament Dr. Ali Abd El-Monsif Thabet

Operative treatment Operative treatment (either arthroscopic or open surgery): Uses a strip of tendon, usually taken from the patient's knee (patellar tendon- BPTB) or hamstring muscle - STG, that is passed through the inside of the joint and secured to the thighbone and shinbone. Is followed by an exercise and rehabilitation program to strengthen the muscles and restore full joint mobility.

Pre-surgical phase (Phase 1) Psychological preparation of patients to surgery and rehabilitation is very important to obtain their maximum commitment.

Before surgery, the patient must reach these goals 1- Control of pain and swelling with rest, cryotherapy 2- Recovery of full ROM 3- Reestablishment of normal gait by walking with crutches 4- The patient must also regain muscle strength (quadriceps and hamstrings).

The goals of rehabilitation after ACL reconstruction 1- joint stability (protection of the healing graft) 2- full ROM (including extension at levels of the uninvolved side), 3- muscle strength (both concentric and eccentric), 4- proprioception, 5- improve cardiovascular endurance 6- preinjury levels of activity.

Phase 2: First and Second Postoperative Weeks GOALS 1- wound healing 2- reduce swelling and pain 3- regain full extension 4- regain 90°- 110° flexion 5- Initiate muscle control 6- gradual weight bearing

Phase 2: First and Second Postoperative Weeks 1- Cryotherapy 2- Active foot flexion-extension 3- Full knee extension : 4- Static quadriceps contractions:

Phase 2: First and Second Postoperative Weeks 5- Knee flexion: 6- Gait: partial weight bearing with two crutches 7- At the end of every exercise session, 20min of cryotherapy must be performed. 8- EMS: it is possible to perform electrical quadriceps stimulation 9- Warning: to prevent loss of extension, the patient must not place supports under the knee.

Phase 3: Third and Fourth Postoperative Weeks GOALS 1- Increase active range of motion 2- Develop muscular control of quadriceps and hamstring 3- Increase weight bearing during gait 4- Improve cardiovascular endurance

Phase 3: Third and Fourth Postoperative Weeks If there is lack of extension, a new exercise is added to the protocol Muscle exercises: 1- Straight leg raises with weight on the thigh (Fig. 8) 2- Two-legged minisquat with up to 450 of knee flexion using crutches 3- Active extension 900 to 450 (stopping at 450) without resistance while sitting (Fig. 10) 4- Active knee flexion in standing position.

Phase 3: Third and Fourth Postoperative Weeks 5- Active assisted flexion 6- Cocontraction: simultaneous isometric (60°) contractions of quadriceps and hamstrings muscles. 7- Gait, increase weight bearing gradually as tolerated with one crutch. 8- Swimming pool. 9- Stationary bicycle for 10 min two to three times a day slowly, without wheel resistance, and pedaling with the forefoot (Fig. 12)

Phase 4: Second Postoperative Month Goals 1- Restore full ROM 2- Improve muscle strength 3- Full weight bearing

Phase 4: Second Postoperative Month 1- In comparison with the contralateral knee, 2- Flexion must be more than 1200 and gradually reach the contralateral level (full ROM). 3- Gait the patient can walk without crutches 4- Stationary bicycle; 15 min three times a day with low wheel resistance (50 W) simulating a slow -ride on level road, pedaling with the forefoot.

Phase 4: Second Postoperative Month 5- Muscle strengthening exercises with elastic tubing are useful because they allow gradual resistance: 6- Exercises to be performed in the swimming pool are

Phase 5: Third Postoperative Month Goals 1- full active ROM 2- Increasing muscle strength 3- Proprioceptive training

Phase 5: Third Postoperative Month 1- eccentric quadriceps strengthening exercises like two-legged squatting up to 900 (on land and in a swimming pool), 2- climbing and descending stairs into the water (20-40 cm, gradually increasing), 3- concentric quadriceps strengthening exercises (active full knee extension-flexion without resistance)

Phase 5: Third Postoperative Month 4- one-legged proprioceptive exercises on unstable surfaces 5- Jumping on springboards is useful for enhancing proprioception without overloading the knee joint patient 6- Bicycling can be started for brief periods (10-15 mm) on a level road. 7- Jogging is allowed on a straight course for 10 min/day.

Multidirectional rolling movement

Single leg stand on balance board

Phase 5: Third Postoperative Month Attending a gym

Phase 6: Fourth Postoperative Month Goals 1-Increase leg strength 2-Advanced proprioception

Phase 6: Fourth Postoperative Month 1- jogging time and distance may be increased, adding change of direction 2- uphill and downhill. 3- Bicycling is possible with increased distance and also uphill and downhill. 4- The swimming pool should be attended, performing freestyle and jumping into the water. 5- Proprioceptive exercises are continued. 6- Concentric quadriceps strengthening must be performed

"Kickers" use an elastic band fixed to the distal aspect of the involved or uninvolved limb. The athlete attempts to balance while executing short kicks with either knee extension or hip flexion. This exercise is most difficult when performed on unstable surfaces.

Fifth postoperative month Goals functional training (prepare for return to sport and recreational lifestyle )

Fifth postoperative month 1-The patient can practice running with acceleration, deceleration, and "stop and go" 2- return to sport-specific activities can begin including normal running, jumping, cutting, double and single hopping, vertical jumping.

Plyometrics begin with low-impact hopping, progressing to double-leg bounding, and finally single-leg hopping.

Sixth post­operative month Goal Return to activity safely

Sixth post­operative month Return to sports 1-Full training for 1 month prior to active return to competitive sport

Criteria for return 1- No joint effusion 2- Full ROM 3- isokinetic testing indicates that strength of hamstring and quadriceps is 85- 100° of the uninvolved leg 4- Satisfactory ligament stability testing using KT 1000 arthrometer 5- Successful performance during functional testing

Thank you