ACL REHABILITATION

TABLE 1: A SELECTION OF KEY MILESTONES IN A TYPICAL ACL REHABILITATION PROTOCOL USING EVALUATION BASED PROGRESSION CRITERIA MATCHED TO TYPICAL TIMING

Evaluation criteria ■ Pain controlled without drugs

■ Negligible effusion ■ Full extension

As above + ■ No swelling

■ Flexion 130o ■ 20 minutes pain free walking ■ Quads/hamstring strength – unaffected leg 20-30% of affected leg

As above +

■ Able to perform a single hop and land comfortably and confidently

As above + ■ Quads/hamstring strength –

unaffected leg 75% of affected leg ■ Ratio affected to unaffected limb performance in hop tests 75% ■ Run 1/2 pace in straight line comfortably

As above +

■ Quads/hamstring strength – unaffected leg equal/90% of affected leg

■ Ratio affected to unaffected limb performance in hop tests equal/90%

■ Able to sprint, cut, change direction/ perform task to auditory and/or visual command

■ Smooth, precise, efficient task performance *decelerated programmes refer to non-accelerated programmes

prescription rather than advisory guidelines. Any early manage- ment, whether exercise prescription or gait re-education will have to factor in limitations, such as restriction of available range of movement through bracing or limiting weightbearing. For example if flexion is only permitted to 90∫, then a low resis- tance exercise bike can not be used to maintain any form of cardiovascular fitness. A patient is also unlikely to be able to use a public swimming pool session unaccompanied if they are still non or partial weightbearing.

■ Any additional injury, such as meniscal or posterolateral complex repair, posterior cruciate ligament or medial collateral ligament has been shown to increase the time to eventual recovery. The clinical evidence suggests that these patients would be unsuit- able for an accelerated rehabilitation programme (10).

FACTORS AFFECTING LATER STAGES ■ Graft selection does not necessarily affect the overall planning

of the rehabilitation programme, although different modifica- tions during treatment are sometimes needed depending on the donor site. Patients with patellar tendon grafts, particularly

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females, sometimes need to regress weight bearing quadriceps work such as step exercises because of anterior knee pain. On the other hand patients with hamstring grafts sometimes struggle to regain full sprint speed and need to work at this area for slight- ly longer. These are generalisations taken from clinical observa- tion and the peer reviewed literature available is very mixed regarding later stage outcome.

■ Residual effusion remains a key limiting factor. Any increase in effusion following exercise should be viewed as a sign that the patient is not ready to progress further, although there is not always a necessity to regress functional work. The subsequent vastus medialis inhibition mentioned above could put the patient at risk of further injury if they continue to push more complex motor control work with a functional instability resulting from reduction in dynamic control of extension.

■ Vastus medialis control is a limiting factor in itself as it does not necessarily result only from an effusion. The ACL injury preven- tion literature has suggested a link between the typically female style of landing in a relatively valgus knee position with

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12-16 weeks (longer in a - Run (º pace) in straight lines decelerated programme*) - Progress to multiple hop drills

14-28 weeks (longer in a - Increase straight running distance/speed to sprint decelerated programme*) - Increase intensity of plyometric drills with change of direction/surfaces

- Introduce running, backwards, sideways, fig 8 etc - Start responding to external stimuli (visual or auditory)

- Use of controlled sport specific skills eg ball work (no contact)

6-12 months

- Increase sports specific drills - Introduce contact if appropriate - Return to sport

10-14 weeks - Initiate landing drills – jump/leap - Progress to single hop (no change of direction) Approximate

post-operative timing 2-4 weeks

Functional progression indication - Walk unaided