REHABILITATION

increased incidence of ACL injury. Therefore the typical landing training work including vastus medialis and gluteal co-activation remains a key element in post-operative rehabilitation. Inadequate VM control will often result in anterior knee pain once intensity of plyometric training increases and will therefore limit rate of progression in addition to the safety aspect discussed above.

■ Pre-injury fitness level will have a significant impact on an individual’s ability to tolerate an aggressive rehabilitation programme. Lower general fitness levels will result in earlier fatigue during exercise, limiting training time and possibly plac- ing the patient at risk through reduced dynamic control if these signs are ignored. This is often a factor that causes frustration in recreational athletes, as the goals they have set may have been based on information they gained through the media, which will inevitably refer to the progress of high performance athletes. Conversely, a professional athlete aiming to return to previous competitive level will need to achieve a much higher fitness and level of control to tolerate the high intensity train- ing and competitive programme against very skilled opponents. Therefore the benchmarks indicating appropriate return to sport will be at a higher level.

■ Social circumstances will have a significant impact on the time available to commit to a rehabilitation programme. Discussion regarding a realistic timetable as early as possible is essential in order to minimise the frustration and subsequent reduced adherence that tends to occur when a recreational sportsperson with a full time job and a family compares themselves with a high profile professional athlete. Explanation of the rate of pro- gression possible related to the amount of training time will increase the chances of adherence to the rehabilitation

programme as well as facilitate a negotiated timetable of exercise that will fit into the individual’s lifestyle.

■ Motivation to return to previous injury levels of sports partici- pation will have a similar effect to the social circumstances outlined above. There is an optimal level of motivation that maximises adherence, with too much or too little motivation both having a negative impact on outcome. Motivation can also change considerably throughout the rehabilitation period and maintaining the appropriate level is an important skill for the treating physiotherapist. Achievable and realistic goal setting has been shown to maximise adherence to rehabilitation programmes (11).

Anecdotal clinical experience has highlighted some key tips that often have a significant impact on the eventual outcome outlined in table 2. Early goals centre on achieving a normal reciprocal gait as soon as possible. This may involve encouraging the use of one or even two crutches for longer than is needed from a tissue heal- ing, mechanical or pain viewpoint. Re-educating and progressing gait to running is easier in the longer term if bad habits, gained through trying to achieve full weight bearing before acquiring good control, are avoided by allowing partial weight bearing for a few days longer when needed. Similarly, re-educating gluteal and core stability control during this period can minimise secondary biome- chanical-related soft tissue problems when patients return to full sport.

During the mid to late stages, exercise selection with progression or regression dependent on good form of movement is an important aspect for consideration. A common mistake is to progress onto more difficult exercises in response to signs of boredom or frustra- tion in the patient, when the exercise should either be varied at the

TABLE 2: TREATMENT TIPS FOR EARLY MID AND LATE STAGES Early ■ Regain full extension as soon as possible - providing this is allowed by the surgeon (some still brace 10o

■ Translate the range of extension gained into functional use during the weightbearing phase of gait ■ Encourage the use of reciprocal knee flexion rather than hip hitch on the swing-through phase of gait

■ Gluteal re-education can be started early, in addition to the more obvious quadriceps/hamstring work and is another way of varying exercises safely

■ Re-educate co-activation of quadriceps, hamstrings and gluteals in weight bearing, using visual, auditory and tactile feedback Mid

■ Once good quadriceps/hamstring/gluteal control is achieved, strength work can be progressed in more dynamic, functional positions

■ Re-educate co-activation of trunk and lower limb muscles in more dynamic activities such as step up and down or lunging ■ Introduce more perturbation and secondary activities into balance work

■ Progress to including a flight phase into neuromuscular control work – eg. leap from step, jump. (A hop will be the last task achievable after a step or leap)

Late ■ Once a hop is controlled, running activities can be pushed ■ Change of direction can be introduced once straight line running is achieved with confidence ■ Dynamic hamstring strength needs to be actively encouraged – especially eccentric work for patients with a hamstring graft

■ Once change of direction with a secondary skill is achieved, more sports specific work needs to be introduced – especially if the sport involves contact e.g. rugby or high impact landing eg. gymnastics.

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

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