1. An Accelerated Rehabilitation Programme for Endoscopic Anterior Cruciate Ligament Reconstruction Mr R Clifton

2. Stage I 1.Biofeedback may be used to encourage early return of co- ordinated muscle function if necessary. Caution should be taken following patellar tendon grafts in stimulating the quadriceps mechanism as patella fracture has been reported. 2.Early active quadriceps strengthening-static co-contraction with hamstrings emphasising VMO control at various angles of knee flexion and progress into weight bearing positions. 3.Gentle hamstring stretching-minimise painful adhesions. Hamstring tears with the patient reporting a ‘pop’ about the posteromedial thigh is common within the first 14 days and even within the first 6 weeks. 4.Early active hamstring strengthening-static weight bearing co- contractions and progresses to active free hamstring contractions by day 14. Resisted hamstring strengthening should be avoided for at least 4-6 weeks. At 10-14 days post operatively, the dressings will be removed and the wound checked. NB: Quadriceps exercises are to be closed chain only during the first four stages. TIME PERIOD AIMSGOALSPOSSIBLE PROBLEMSTREATMENT DAY 1- DAY 141.post-operative pain relief and manage soft tissue surgical trauma 2.Wean off crutches 3.gait re-education 1.wound healing 2.manage the graft donor site morbidity i.e. pain and swelling 3. decrease swelling 4. restore full extension 5. establish muscle control 1. infection 2.post-operative haemorrhage 3.hamstring strain or pain 4.DVT 5.Stiffness due to early arthrofibrosis or reflex sympathetic dystrophy 1.reduce swelling & pain 2.PWB-FWB as pain and swelling allows 3.AROM-full ext by 14 days 4. patella mobilisations 5. gait re-education

3. Stage II – Over view TIME PERIOD AIMSGOALSPOSSIBLE PROBLEMSTREATMENT 2-6 weeks1. return to normal function 2. prepare for next stage 1. obtain full unrestricted ROM 2.develop good muscle control and early proprioception 3.restore normal gait 4.reduce persistent effusion 1. stiffness 2. recurrent hamstring strain 3.Increasing laxity of graft 4. graft failure 1. full ROM-active and passive techniques 2. co-contractions-increase repetition, length of contraction, position e.g. 2leg ¼ squats, lunges, stepping, theraband 3.swimming once wound healed 4.gym equipment-static bike, stepper, leg press, trampet (once effusion settled) 5. reduce swelling 6.hamstring strengthening &stretches. Including open chain maybe painful

4. Stage II TIME PERIOD AIMSGOALSPOSSIBLE PROBLEMS TREATMENT 3-4 weeks1. return to normal function 2. prepare for next stage 1. obtain full unrestricted ROM 2.develop good muscle control and early proprioception 3.restore normal gait 4.reduce persistent effusion Low resistant (1-2Kg ankle weight) bilateral hamstring curls progressed to unilateral curls as pain allows 4-6 weeks1. return to normal function 2. prepare for next stage 1. obtain full unrestricted ROM 2.develop good muscle control and early proprioception 3.restore normal gait 4.reduce persistent effusion 1.Hamstring straining may occur and impede further progression 1.low resistance, high repetitions to increase endurance 2. intensive hamstring stretching Week 61. return to normal function 2. prepare for next stage 1. obtain full unrestricted ROM 2.develop good muscle control and early proprioception 3.restore normal gait 4.reduce persistent effusion 1.graft is not mature- risk of failure NB patients can feel very confident by 6 this stage but must be aware of their functional restrictions to avoid graft failure. 1.eccentric hamstring strengthening 2.hamstring curl equipment 3.check Gluteals, hamstrings, ITB, gastrocnemius, soleus for deficits 4.education re graft maturity and patients functional restrictions

5. Stage III Proprioception TIME PERIOD AIMSGOALSPOSSIBLE PROBLEMSTREATMENT 6-12 weeks 1.improve neuromuscular control and proprioception 1.improve total leg strength 2.improve endurance capacity of muscles 3. increase confidence 1. arthrofibrosis 2.patello-femoral irritability 3.chronic inflammation 4.graft laxity and rupture 1.progress co-contractions-step lunges, half squats 2.dynamic proprioception -lateral stepping, sliding board 3.jogging on straight lines on the flat 4.Progress resistance on gym equipment. Hamstring programme to progress power and speed of contraction 5.cycling on a bike 6.static control, emphasise endurance-wall squats 7.pelvic and ankle control 8 cardiovascular fitness 9. Solo sports e.g. jogging, swimming, cycling with little or no restrictions at this point. 1.NO OPEN CHAIN QUADS

6. Stage IV Sport Specific TIME PERIOD AIMSGOALSPOSSIBLE PROBLEMS TREATMENT 12 weeks - 5 months 1. prepare to return to sport 1.incorporate sport specific activities 2.introduce agility and reaction time into proprioception work 3.increase leg strength 4.develop confidence 1.patella-femoral irritability 1.progress general strength e.g. half squats with resistance, leg press, leg curls, wall squats, step work, stepper, rowing machine 2.Proprioception-hopping, jumping. Emphasise good landing. Include lateral movements 3.Agility-shuttles, ball skills, sideways running, skipping 4.Low impact and step aerobics 5.Hydrotherapy with flipper 6.Sports specific- Tennis-lateral step lunges, forward and backwards running drill: skiing-sliding board, lateral box stepping,,jumping, zigzag hopping; volleyball/basketball-vertical jumps. 5-6 monthsReturn to sport safely and with confidence 1.incorporate sport specific activities 2.introduce agility and reaction time into proprioception work 3.increase leg strength 4.develop confidence 1.patella-femoral irritability 1.open chain quadriceps 2.progress plyometrics and sport specific drills 3.Return to training and participation in skill exercises 4.improve power and endurance 5.Education-modifications to return to sport e.g. football-use running shoes or short sprigs and at low grades; skiing-groomed slopes, avoid moguls and off piste, racers to lower DIN settings Stage IV Return to Sport