REHABILITATION

ANTERIOR CRUCIATE LIGAMENT

REHABILITATION

Anterior cruciate ligament (ACL) injury is a frequent occurrence in sport, often resulting in ACL reconstruction (1,2,3). Surgeon preferences for choice of techniques and grafts will vary considerably, sometimes creating a challenge for physiotherapists planning rehabilitation programmes for these individuals post-operatively. An increasing media interest in the recovery progress of high performance athletes, such as footballers, has also led to a changed level of expectation amongst the average recreationally active individual undergoing the same procedure. The following text will attempt to address some of these issues by discussing the parameters that could affect rate of progression and choice of exercise.

By Dr NiCki PhilLips, PhD, MSc, MCSP

For those readers seeking a short answer or a magic formula to ACL rehabilitation, unfortunately there does not appear to be one, with the evidence available regarding outcome of post ACL reconstruc- tion programmes being very varied in both methods used and results (4,5,6). Therefore the method of decision-making regarding progression used in this discussion has been based on a criteria based protocol rather than a time based one. A time driven proto- col would typically state specific days or weeks following recon- struction when certain activities or exercises would be allowed. A criteria or evaluation based protocol would typically use specific milestones related to symptoms or functional markers, in addition to knowledge of healing times, to indicate progression to a more advanced stage of rehabilitation. A sample of this type of protocol can be seen in Table 1. More comprehensive examples of both accel- erated and decelerated protocols such as those used in the Cincinnati Knee Clinic can be seen on the web page link provided.

FACTORS AFFECTING EARLY STAGE REHABILITATION There are a number of factors that will have an effect on how easily a patient can be progressed to increased strengthening or functional work. Some are not under the control of the treating physiotherapist, necessitating different management strategies for each situation. Others can be more easily controlled by the physio- therapist through education, advice and appropriate passive treat- ment when necessary.

■ Graft selection is entirely under the control of the orthopaedic surgeon. The choice is generally surgeon preference, relative to individual patient situations. This topic has been discussed in

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the two previous articles and beyond the remit of this paper but rehabilitation suggestions in this paper are generally based on A hamstring graft. In general, early protection of the tibial fixation is more of an issue in hamstring than patellar tendon grafts, otherwise there is little difference in approach in the early stages. There is little evidence available yet regarding treatment consid- erations following the newer double bundle grafts, which more closely reproduce the femoral attachment of the original ACL.

■ Post-operative effusion and pain are elements that the physio- therapist has more control over. Even relatively small amounts of effusion have been shown to inhibit vastus medialis (VM) func- tion (7,8) and thus, by implication, reduce control of knee extension in stance. It is therefore a crucial symptom to control as early as possible. This could initially be through modalities such as ice, which also helps control pain, although the value of using cold modalities has been questioned (9). Other, possibly more important strategies are adequate education of the patient to control activity such as walking relative to the reaction of the knee to increased movement. Rest in elevation when possible and repeated VM contractions in non-weightbearing and weight- bearing positions throughout the day in short bursts could be considered key elements in addressing the adverse effects of effusion or pain induced inhibition. Most patients are usually prescribed some form of oral pain relief to facilitate earlier pro- tected function. However pain can also be a useful benchmark to educate patients about when to stop and how hard they can push themselves.

■ The surgeon’s preferred post-operative protocol will have a significant impact on what can be achieved in the early stages, especially when it can in some, now rarer, instances be a strict

sportex medicine 2007:33(Jul):16-19