Rehab of ACL reconstruction

[rajah]

I would like to know when we can start resisted exercises to quads?How much weight is safe at first time?also what is the difference in rehab with patella tendon rehab and hams tendon rehab?

Thanks

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[neurospast]

Rajah,
1 the patella tendon has to do with extension of the knee, the hamstrings with the flexion of the knee. which means their function is completely different.
2 Because of the difference in position and function the emphesis in training will be completely different.
The time to start with resisted exercises will be according to the progress made by your patient; there is no such thing as a protocol. Also because you do not tell us after what sort of injury before starting rehab. To think that one exercise will do it for all tendon injuries around the knee seems to me strange. The load will always be depending on the persons physical abilities (and maybe mental aswell) and in that way you have to think of % and not in Lbs or Kg. Also it is depending where you want to apply the load what sort of machine you are thinking of (the Tibia will function as an arm. =biomechanics)
So hand out a little bit more information for a proper answer.
Cheers.

[mageshanand]

Hi Rajah,

i do completely agree with neurospast, but supposing that the patient has had a surgery with the quadriceps tendon graft, and the lesion is more localized to ACL alone, the first thing that has to come in to your mind is that, the role of ACL is to prevent anterior translation of tibia, and quadriceps function is also the same, (basically when you extend at your knee your tibia translates anteriorly),,


so some texts suggests that the knee kept in 30 degree flexion and to start isometric quads, you can start that as early as the second to third day post post op*(provided that the surgeon gives consent)

the problem with these post surgery rehabilitation is that the surgeon should give the pass for any thing, in the hospital where i work , we have three units, ortho 1 , 2 and 3. ortho 1 will want to start the quads exercises with knee in 30 degree flexion but ortho 3 will want to do it in full extension, both the units gives good results,

so its basically the confidence the surgeon has in his surgery and ofcourse the associated complications,

i would suggest start with isometrics and gradually progress on according to the patients response

cheers

[rajah]

Thanks mahesanand &Neuropast for yr valuable comments.I have successfully rehabilitated so many cases of acl Reconstruted patients without any complications.I came across mostly patella tendon graft reconstruction.

Here i give diffrent views regarding ACL Rehab,

1.Some say CPM can be used same day after surgery.Others say no flexion exersices until 2 weeks.


2.Then CKC is better than OKC.

3.Active extension exercises @ early stages may cause tendon rupture.So we have to give assisted knee extension &active flexion.

awaitng for your suggestions,

cheers.

[mageshanand]

Hi rajah

coming straight to your questions,

there are studies done as early as 1987, which advocates to imply early knee flexion in post surgical ACL reconstruction by 48 hrs, you can CPM or even gentle assisted movements but the bottom line is early knee mobilisation is in use, i have attached two abstracts supporting my argument,

and yes CKC is the must to do exercise in ACL reconstruction, cos the contraction of hamstrings will prevent the anterior translation of tibia,

see ya man,

cheers


Author/Association: Noyes FR, Mangine RE, Barber S
Title: Early knee motion after open and arthroscopic anterior cruciate ligament reconstruction
Source: The American Journal of Sports Medicine 1987 Mar-Apr;15(2):149-160
Method: clinical trial
Method Score: 3/10 [Eligibility criteria: Yes; Random allocation: Yes; Concealed allocation: No; Baseline comparability: No; Blind subjects: No; Blind therapists: No; Blind assessors: No; Adequate follow-up: No; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*
Abstract: The hypothesis proposed in this study was that the initiation of active and passive knee motion within 48 hours of major intraarticular knee ligament surgery would not have the deleterious effects of increasing knee effusion, hemarthrosis, periarticular soft tissue edema, and swelling. We conducted a prospective study with randomized assignment of 18 patients into two groups: 9 patients in the "motion" group began 10 hours of daily continuous passive motion (CPM) on the 2nd postoperative day, while the remaining 9 in the "delayed motion" group used a soft hinged knee brace with knee hinges locked at 10 degrees of flexion and entered into the motion program on the 7th postoperative day. All knees were allowed full 0 degrees to 90 degrees of motion except for a total of seven knees with concomitant mensicus repairs and extraarticular reconstructions where 20 degrees to 90 degrees of motion was allowed, limiting the last 20 degrees of knee extension for the first 4 postoperative weeks to protect the repair. In all other respects, the rehabilitation program after surgery was the same for the two groups, including postoperative compression dressings, exercises, and weight-bearing status. Ten of the eighteen patients had acute ACL disruptions and 8 had chronic ACL insufficiencies. There was an even distribution of acute and chronic knee cases and of open and arthroscopic ligament procedures in the early and delayed motion groups. Associated surgery included four meniscus repairs, three medial collateral ligament repairs, and one lateral collateral ligament repair. Special suturing and fixation techniques were used at surgery to maintain the integrity of ligament and meniscus structures, allowing the surgeon to feel safe in subjecting the joint to early postoperative motion. The objective parameters measured were KT-1000 arthrometer measurements, Cybex isokinetic testing, girth measurements at four lower limb locations, range of motion goniometer measurements, postoperative pain medications, and days of hospitalization. Starting intermittent passive motion on the 2nd postoperative day did not increase joint effusion, hemarthrosis, or soft tissue swelling. In both motion groups, postoperative joint effusions were absent after the 14th postoperative day. There was no statistically significant difference in knee extension or flexion limits, pain medication used, or hospital stay in comparing the two knee motion programs. An important finding of this study was the significant decreases in thigh circumference that occurred within the first few weeks of surgery, which progressed despite a closely supervised inpatient and outpatient rehabilitation program. The decreased thigh girth was related to the type of operative procedure. Arthroscopic reconstructions had only 25% to 38% of the loss of thigh girth found in open operative procedures. By the 7th postoperative day, the average circumference loss for the open reconstruction group (motion at 7th postoperative day) was nearly 4 cm, compared with the arthroscopic group's average of 1 cm. By the 21st postoperative day, all patients who underwent open procedures sustained an average of 6.5 cm thigh circumference decrease compred with a 2 to 3.5 cm loss in the arthroscopic group. We concluded that traditional rehabilitation protocols are often ineffective in preventing the significant quadriceps muscle atrophy that may occur within the first few days of surgery. Of importance was the finding that initiating early knee motion did not stretch out ligamentous reconstructions. We strongly recommend an early motion program to decrease the morbidity of major intraarti ligamentous procedures. The program is initiated within the hospital setting immediately after knee sugery.



Author/Association: Trees AH, Howe TE, Dixon J, White L
Title: Exercise for treating isolated anterior cruciate ligament injuries in adults (Cochrane Review) [with consumer summary]
Source: Cochrane Database of Systematic Reviews 2005, Issue 4
Method: systematic review
Method Score: This is a systematic review. Systematic reviews are not rated.
Abstract: [This version first published online: 19 October 2005 in Issue 4, 2005. Date of Most Recent Substantive Amendment: 8 June 2005] BACKGROUND: The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. Injury causes pain, effusion and inflammation leading to the inability to fully activate the thigh muscles. Regaining muscular control is essential if the individual wishes to return to pre-injury level of function and patients will invariably be referred for rehabilitation. OBJECTIVES: To present the best evidence for effectiveness of exercise used in the rehabilitation of isolated ACL injuries in adults, on return to work and pre-injury levels of activity. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PEDro - The Physiotherapy Evidence Database, CINAHL, AMED, and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials and quasi-randomised trials testing exercise programmes designed to rehabilitate adults with isolated ACL injuries. Trials where participants were randomised to receive any combination of the following: no care, usual care, a single-exercise intervention, and multiple-exercise interventions. The primary outcome measures of interest were returning to work and return to pre-injury level of activity post treatment, at six months and one year. DATA COLLECTION AND ANALYSIS: All trials judged to have met the inclusion criteria were independently assessed for methodological quality by use of a 15 point checklist. Pairs of authors independently extracted data. For each study, relative risk and 95% confidence intervals were calculated for dichotomous outcomes and mean differences and 95% confidence intervals calculated for continuous outcomes. MAIN RESULTS: Nine trials, involving 391 participants met the inclusion criteria of the review. Only two trials, involving 76 participants, reported conservative rehabilitation and seven trials, involving 315 participants, evaluated rehabilitation following ACL reconstruction. Methodological quality scores varied considerably across the trials, with the nature of participant and assessor blinding poorly reported. Trial comparisons fell into six categories. Pooling of data was rarely possible due to lack of appropriate data as well as the wide variety in outcome measures and time points reported. Insufficient evidence was found to support the efficacy of one exercise intervention over another. AUTHORS' CONCLUSIONS: This review has demonstrated an absence of evidence to support one form of exercise intervention against another and the use of supplementary exercises in the management of isolated ACL injuries. Further research in the form of large scale well designed randomised controlled trials with suitable outcome measures and surveillance periods, using standardised reporting should be considered.

Residents of some countries have free access to the full text of the systematic reviews in the Cochrane Library http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/DoYouAlreadyHaveAccess.html?CRETRY=1&SRETRY=0" TARGET=

[nasde]

in brukner and Khan's "clinical sports medicine" - they put the date at 2-6 weeks for resisted knee exercise - and by this they mean bodyweight exercises such as - bilateral semi squats, progressing to step ups/downs. They do say that they are only meant as a guide to rehab and that all exercises should be individualised to the patient. They do not mention wether the ACL programme is for a quads tendon or hamstring graft rehab.

In my personal experience i find that the hamstring grafts tend to rehab quicker due to less pain around the anterior knee, and a subsequently faster pain free progression through an exercise protocol. Bruckner and Khan suggest rehabing a hamstring graft like a hamstring tear, in terms of restoring full movement and strength to it as part of the knee rehab.

I would agree with what the other guys have said re: following the surgeon's protocol. I have never used a CPM with ACL rehab patients, and I have never had a surgeon instruct a patient to not flex their knee. I believe that RESISTED extension exercises are a no-no, but active extension exercise is ok, although CKC stuff is better (in terms of safety for the graft)

hope that helps

[mageshanand]

hi there guys, i came across this doc here in my hospital, he said in a hamstings tendon graft, the patient is going to have pain on knee extension and hence the knee is taken in to extension gradually, what we have to realise here is that, when the grafting is done they would not graft it in such a way that it would prevent complete knee extn,(with in normal limits), instructing the patient not to extend it completely is more of a prophylactic measure to avoid any unwanted circumstances arising thats it,

so i wonder why the knee should not be taken into full extension if the surgeon is confident about his surgery and with regard to hams graft, extn is avoided in the earlier stages probably to splint pain....!