The Science Behind ACL Rehabilitation
There are 11 RCTs comparing use of brace in the immediate postoperative period following ACL reconstruction. There is no evidence that use of a rehabilitation brace improves pain, graft stability or helps regain earlier full extension There is one study suggesting that hyperextension brace at -5 or -10 degrees can help avoid extension deficits in BTB reconstructions. There is also no evidence that functional braces give protection from subsequent injury.
Wright RW, Preston E, Fleming BC et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J Knee Surg. 2008 Jul;21(3):217-24
Wright RW, Preston E, Fleming BC et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics.
McDevitt ER, Taylor DC, Miller MD, et al. Functional bracing after anterior cruciate ligament reconstruction: a prospective, randomized, multicenter study. Am J Sports med. 2004;32:1887-1892.
Beynnon BD, Fleming BC, Churchill DL, Brown D. The effect of anterior cruciate ligament deficiency and functional bracing on translation of the tibia relative to the femur during nonweightbearing and weightbearing. Am J Sports Med. 2003;31:99-105.
Moller E, Forssblad M, Hansson L, Wange P, Weiden-hielm L. Bracing versus nonbracing in rehabilitation after anterior cruciate ligament reconstruction: A randomized prospective study with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2001;9:102-108.
Risberg MA, Holm I, Steen H, Eriksson J, Ekeland A.The effect of knee bracing after anterior cruciate ligament reconstruction: a prospective, randomized study with two years follow-up. Am J Sports Med.1999;27:76-83.
Early Weight Bearing
Immediate weight bearing does not affect ACL graft integrity and has the potential to enhance the return of quadriceps muscle and knee extension. In patients with simultaneous meniscal repair, early motion has no adverse effect. Noyes had patients partial weight bearing for 3 weeks whilst Barber showed no adverse effect on healing. Weight bearing has the potential to increase gapping in the tear.
Tyler TF, McHugh MP, Gleim GW, Nicholas SJ. The effect of immediate weightbearing after anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 1998;357:141-148.
Buseck MS, Noyes FR. Arthroscopic evaluation of meniscal repairs after anterior cruciate ligament reconstruction and immediate motion. Am J Sports Med. 1991 Sep-Oct;19(5):489-94
Barber FA, Click SD. Meniscus repair rehabilitation with concurrent anterior cruciate reconstruction. Arthroscopy. 1997 Aug;13(4):433-7.
Continuous Passive Mobilisation
ACL reconstructions are most often done as daycase procedure. CPM can increase hospital stay. Pinczewski also showed that there is increased swelling and pain with CPM usage. It is also questionable whether CPM increases graft laxity.
Engstrom B, Sperber A, Wredmark T. Continuous passive motion in rehabilitation after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc1995;3:18-20
O’Meara PM, O’Brien WR, Henning CE. Anterior cruciate ligament reconstruction stability with continuous passive motion. The role of isometric graft placement. Clin Orthop Relat Res. 1992 Apr;(277):201-9
Witherow GE, Bollen SR, Pinczewski LA. The use of continuous passive motion after arthroscopically assisted anterior cruciate ligament reconstruction: help or hindrance? Knee Surg Sports Traumatol Arthrosc. 1993;1(2):68-70.
Early Active extension and passive extension
In ACL deficient knees, active extension shows increased sagital plane laxity. In the reconstructed knee, commencing early active and passive extension training, without any restrictions in extension does not appear to increase post-operative knee laxity.
Isberg J, Faxén E, Brandsson S, Eriksson BI, Kärrholm J, Karlsson J. Early active extension after anterior cruciate ligament reconstruction does not result in increased laxity of the knee. Knee Surg Sports Traumatol Arthrosc. 2006 Nov;14(11):1108-15.
Kvist J. Sagittal tibial translation during exercises in the anterior cruciate ligament-deficient knee. Scand J Med Sci Sports. 2005 Jun;15(3):148-58
Icing and Cryocuff
Use of ice with or without compression does not do any harm. Routine use of a cryocuff has been controversial. It does not affect hospital stay, early range of movements, swelling or pain control. Barber showed that continuous flow cold therapy reduces pain.
Barber FA. A comparison of crushed ice and continuous flow cold therapy. Am J Knee Surg. 2000;13(2):97-101
Dervin GF, Taylor DE, Keene GC.Effects of cold and compression dressings on early postoperative outcomes for the arthroscopic anterior cruciate ligament reconstruction patient. J Orthop Sports Phys Ther. 1998 Jun;27(6):403-6
Konrath GA, Lock T, Goitz HT, Scheidler J.The use of cold therapy after anterior cruciate ligament reconstruction. A prospective, randomized study and literature review. Am J Sports Med. 1996 Sep-Oct;24(5):629-33. Review
Daniel DM, Stone ML, Arendt DL The effect of cold therapy on pain, swelling, and range of motion after anterior cruciate ligament reconstructive surgery. Arthroscopy. 1994 Oct;10(5):530-3
Open and Closed Chain Exercises
Both Open Chain Exercises and Closed chain exercises have a role to play in knee rehabilitation following ACL reconstruction.
During the early phase of rehabilitation the goals are to avoid excessive strain on the ACL graft and excessive patellofemoral joint stress. Hence Closed Chain exercises are recommended for the first 3 months post reconstruction. Heijne showed that early start of OKC quadriceps exercises after hamstring ACL reconstruction resulted in significantly increased anterior knee laxity.
When improvement in quadriceps function is an essential treatment goal especially during the middle period of rehabilitation, therapists may need to combine OKC exercises with CKC exercises to provide optimal training stimuli. Rehabilitation with OKC quadriceps exercise led to significantly greater quadriceps strength compared with rehabilitation with CKC quadriceps exercise with significantly higher number of athletes returning to their previous activity earlier. Patients with ACL deficiency may need OKC quadriceps strengthening to regain good muscle torque. OKC and CKC knee extensor training in the middle period of rehabilitation after ACL reconstruction surgery did not affect knee laxity (Perry).
Heijne A, Werner S. Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc. 2007 Apr;15(4):402-14.
Perry MC, Morrissey MC, King BJ, Morrissey D, Earnshaw P. Effects of closed versus open kinetic chain knee extensor resistance training on knee laxity and leg function in patients during the 8- to 14-week postoperative period after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13:357-369.
Bynum EB, Barrack RL, Alexander AH. Open versus closed kinetic chain exercises after anterior cruciate ligament reconstruction: a prospective randomized study. Am J Sports Med. 1995:23:401-406
Tagesson S, Oberg B, Good L, Kvist J. A comprehensive rehabilitation program with quadriceps strengthening in closed versus open kinetic chain exercise in patients with anterior cruciate ligament deficiency: a randomized clinical trial evaluating dynamic tibial translation and muscle function. Am J Sports Med. 2008 Feb;36(2):298-307.
Hooper DM, Morrissey MC, Dreschler W, Morrissey D, King J. Open and closed kinetic chain exercises in the early period after anterior cruciate ligament reconstruction: improvements in level walking, stair ascent, and stair descent. Am J Sports Med. 2001;29:167-174
Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sports Traumatol Arthrosc. 2000;8:337-342
Home Based Programme
A structured, minimally supervised rehabilitation program can be as effective as clinic based programmes in achieving acceptable knee range of motion in the first 3 months after anterior cruciate ligament reconstruction Various studies on different rehabilitation programmes support a home-based programme.
Grant JA, Mohtadi NG, Maitland ME, Zernicke RF. Comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction: a randomized clinical trial. Am J Sports Med. 2005 Sep;33(9):1288-97.
Fischer DA, Tewes DP, Boyd JL, Smith JP, Quick DC. Home based rehabilitation for anterior cruciate ligament reconstruction. Clin Orthop. 1998;(347):194-199
Timm KE. The clinical and cost-effectiveness of two different programs for rehabilitation following ACL reconstruction. J Orthop Sports Phys Ther. 1997;25:43-48.
Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of evidence for anterior cruciate ligament rehabilitation: How much and what type. Phys Ther Sport. 2004;5:125-145.
Beard DJ, Dodd CA. Home or supervised rehabilitation following anterior cruciate ligament reconstruction: a randomized controlled trial. J Orthop Sports Phys Ther. 1998;27:134-143.
Schenck RC, Blaschak MJ, Lance ED, Turturro TC, Holmes CF. A prospective outcome study of rehabilitation programs and anterior cruciate ligament reconstruction. Arthroscopy. 1997;13:285-290.
Proprioceptive and Neuromuscular Training
- Patients with anterior cruciate ligament deficiency have impaired proprioception and neuromuscular control of the knee in the involved and noninvolved limbs when compared with a control group.
- After ACL reconstruction, patients continue to have deficits in proprioception and neuromuscular joint control at least 6 months and for as much as 1 year postoperatively and this is worse in females.
- When assessing proprioception and neuromuscular control of patients with either anterior cruciate ligament deficiency or after reconstruction, the contralateral limb may not be a suitable control because of the bilateral deficits.
- Proprioceptive and neuromuscular training have to continue during all phases of rehabilitation.
Weightbearing mobilisation initiates proprioceptive training. Closed chain activities assist in recruitment of neuromuscular control of the hamstring musculature. Exercises such as wall sits, minisquats, and lunges help initiate quadriceps and hamstring cocontraction. Gait retraining is done best on a treadmill. Single leg stance, single leg dips, sidestepping, running, standing on a trampoline or roller board bring in progressively advanced proprioceptive input between 3-6 months. After the above targets have been achieved, plyometric exercises and sports specific drills help in advanced neuromuscular training.
Hewett TE, Paterno MV, Myer GD. Strategies for enhancing proprioception and neuromuscular control of the knee. Clin Orthop Relat Res. 2002 Sep;(402):76-94.
Barrack RL, Skinner HB, Buckley SL: Proprioception in the anterior cruciate deficient knee. Am J Sports Med 17:1-6, 1989.
MacDonald PB, Heeden D, Pacin O, Sutherland K: Proprioception in anterior cruciate ligament-deficient and reconstructed knees. Am J Sports Med 24:774-778, 1996.
Noyes FR, Dunworth LA, Andriacchi TP, et al: Knee hyperextension gait abnormalities in unstable knees: Recognition and preoperative gait retraining. Am J Sports Med 24:35-45, 1996.
Co FH, Skinner HB, Cannon WD: Effect of reconstruction of the anterior cruciate ligament on proprioception of the knee and the heel strike transient. J Orthop Res 11:696-704, 1993.
Harrison EL, Duenkel N, Dunlop R, Russell G: Evaluation of single-leg standing following anterior cruciate ligament surgery and rehabilitation. Phys Ther 74:245-252, 1994.
Return to Sport
Return to sport cannot be based purely on time from surgery. There is uniform consensus patients should not return to sport within 6 months after ACL reconstruction. Most surgeons prefer 6-9 months as a time frame. The knee should be quiescent with no swelling and good range of movements. Agility, strength, prioprioception and confidence have to be developed to prevent further injuries.
Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. Am J Sports Med. 1997;25:786-795.
Risberg MA, Mørk M, Jenssen HK, Holm I. Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2001 Nov;31(11):620-31.
Risberg MA, Holm I, Myklebust G, Engebretsen L. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial.Phys Ther. 2007 Jun;87(6):737-50.