• Knee Injury Rehabilitation Guide

    The current thoughts on ACL rehabilitation are based on the so-called accelerated programme, first used in the early nineties by American surgeon Donald Shelbourne. Shelbourne and his colleagues astutely noticed that those patients who did not adhere to the ‘softly softly’ program used then, actually got better more quickly than those who did and, furthermore, they had less instability in the knee. The key observation made by Shelbourne was that the patients who achieved early full range of motion tended to do better.

    Based on these findings, a four stage rehabilitation protocol has been devised. In all cases, the surgeon dictates the type of rehabilitation followed, depending on the surgical technique used. It must be stressed that this progamme is only appropriate if the surgeon uses a bone patella tendon bone graft.

    Although it is called the pre-operative stage, this stage is undertaken whether the patient is going to have surgery or undergo a ‘conservative’ physiotherapy programme. It involves the patient having their injury evaluated and explained by a doctor and chartered physiotherapist. The patient should have an opportunity to discuss all the available options and the most appropriate course of action decided, depending upon the patient’s activity level and age.

    The degree of functional instability, and the level of sporting or occupational activity, largely influence the decision as to whether surgery is appropriate. In the long term, an unstable knee joint may lead to Osteoarthritis of the Knee.

    The aims of physiotherapy during this stage are to:

    • Restore a normal gait pattern.
      This is achieved through progressing from non-weight bearing on crutches to what is called heel to toe walking.
    • Reduce knee joint swelling.
      Principally through applying a cold compress to the knee joint.
    • Regain full range of extension.
      Through the patient lying on their front with their knee hanging over the edge of the bed.
    • Improve range of flexion.
      Mainly through what are called heel sliding exercises, where the patient uses a friction free surface to slide their heel towards their bottom.

    Once the swelling around the knee has resolved then the surgery can take place, if it is appropriate.

    The goals of this stage are to reduce swelling and restore range of motion. As in the pre-operative stage, this is acheived by using a cold compress to reduce swelling, at the same time as the patient undergoes early exercises to restore the range of knee motion.

    Early restoration of knee extension is considered most important. Initially, the heel is propped up with the knee unsupported in order to make the knee extend fully. Full extension of the knee is further encouraged by getting the patient to lie on their front with the knee overhanging the physio bed.

    Static quadriceps muscle contractions should be practised every hour, both to help decrease the knee swelling and to start the process of regaining strength. Some surgeons like the patient to use a continuous passive movement (CPM) machine that automatically bends and straightens the knee, encouraging the dispersal of swelling and the restoration of range of movement.

    As long as the patient feels well enough following the anaesthetic, they are taught how to get around on crutches by a physiotherapist and a normal walking pattern is encouraged. Rehabilitation exercises are started as soon as possible and, as soon as 70 degrees of knee flexion is possible, static cycling can be initiated.

    The gains made during the first week after surgery are maintained during stage 3. Range of motion exercises are continued until the patient has full knee extension and flexion. As soon as possible the crutches are discarded and the physiotherapist should make sure the patient is walking normally and is able to deal with stairs, both up and down.

    The patient can continue stationary cycling and progress to the step machine. Quadriceps and hamstring strengthening is progressed mainly through squatting type exercises, although the physiotherapist must take care not to subject the shin bone to excessive forward movement during strengthening exercises.

    As well as regaining normal strength and range of motion around the knee, the physiotherapist must enhance proprioception – that is the sensation of joint movement and joint position sense, which are so crucial to sporting activity.

    The knee, and its range of movement, should now be essentially normal during everyday activities. This should be maintained during the late stage. Strengthening and proprioception exercises should be progressed and, once the operated knee has achieved 90% of the normal leg in these aspects, functional activities can be undertaken. In a sporting individual, these activities consist of sport-specific drills and movements, the intensity, frequency and duration of which should be gradually increased until normal function is achieved.

    The following pictures show examples of advanced proprioception and plyometric activities:

    Once the surgeon is satisfied that the operated knee has sufficient muscle strength, functional exercises can begin. These start with straight line running.

    Jogging should be progressive:

     
      Day 1Jog 100 metres, walk 50 metres (x 6).Day 2Jog 150 metres, walk 50 metres (x 6).Day 3Jog 200 metres, walk 50 metres (x 8).Day 4Jog 200 metres, walk 50 metres (x 12).Day 5Jog 2000m.  
     

    The progression to functional activites can begin once the player can jog without pain and is comfortable doing plyometric drills. The idea of this stage is to take the player from gentle exercise to the high intensity activity at which games are played. All exercises are preceded by a warm up. As each exercise is a progression, they should be completed at least one day apart.

    A Guide to Warming Up

     
      Exercise 1Variable pace running with the gradual introduction of turns.The player runs round a 20m diameter figure-of-eight course. The figure-of-eight course puts very gentle stress on the knee and prepares the player for later turning drills.The pace is limited to walking, jogging or half pace running and is determined by the physiotherapist who shouts out the desired pace. The physiotherapist also shouts the commands to stop and start. This re-introduces the player to the variable demands of a game of football.The session should last about 25 minutes.Exercise 2Variable pace running with gradual turns and various starting positions.The player starts at one end of the course, makes a straight 30m run up to the 20m diameter semi-circle, around which he gently turns before completing another straight 30m run back to the finish. The pace of the run is dictated by the physiotherapist and is either a jog or half pace. The starting position should be different for each run (standing, lying on back, lying on front, sprint start position, squatting, right side lying, left side lying, jumping, hopping, facing backwards).The player should complete 20 runs.Exercise 3A progression of exercise 1.Variable pace running with slightly tighter turns. The player runs round a 10m diameter figure-of-eight course. The figure-of-eight course puts stress on the knee and prepares the player for later turning drills.The paces used are walking, jogging, half pace running, and three quarter pace running and are determined by the physiotherapist who shouts out the desired pace. The physiotherapist also shouts the commands to stop and start. This re-introduces the player with the variable demands of a game of football.The session should last about 25 minutes.Exercise 4A progression of Exercise 2.Variable pace running with gradual turns and various starting positions. The player starts at one end of the course makes a straight 30m run to a 20m diameter semi-circle, around which he gently turns before completing another straight 30m run back to the finish. The pace of the run is dictated by the physiotherapist and is either three quarter or full pace. The starting position should be different for each run (standing, lying on back, lying on front, sprint start position, squatting, right side lying, left side lying, jumping, hopping, facing backwards).The player should complete 20 runs.Exercise 5Two 5m diameter circles are placed 30m apart. Travelling at full pace, the player makes a run with a football at his feet, goes round the far circle and then back to the finish.This should be repeated 20 times.Exercise 6As Exercise 5, but single cones are used instead of 5m diameter circles.Exercise 7Six cones are placed 5m apart in a straight line. The player completes a shuttle run, at full pace, turning alternately to the left and right.This should be repeated 10 times.  
     

    Before making a return to full training, the player should also be happy with all normal ball work drills, all types of passing (instep, side foot, front foot, outside of foot, side foot volley, laces volley, half volley) over all distances, heading, jumping and heading, and tackling. A gradual return to training may then be considered.

    ACL Knee Injury & Reconstruction in Depth AKA: Anterior Cruciate Ligament Rupture

    Common Signs & Symptoms
    Pain Swelling Stiffness Weakness Instability Locking
       

    Anterior Cruciate Ligament Injury (ACL tear)

    The anterior cruciate ligament is located deep in your knee joint and prevents the shin bone (the tibia) from slipping forward from the thigh bone (the femur).

    Symptoms:

    Following a collision or fall to the ground you will experience an Instant pain in the knee, which increases with weight bearing . You will be unable to play on after this type of knee injury. You may hear a popping sound at the time of the injury and the knee will feel unstable. Swelling will usually occur within 2 hours. You are likely to have reduced range of motion in the knee in the following 48 hours and pain on weight-bearing.

    ACL injuries often occur in combination with other injuries, such as meniscal tears, medial collateral ligament (MCL) tears and occasionally fractures and vascular injuries that need immediate medical attention.

    Onset:

    Is sudden and can be traumatic e.g. a tackle or collision but the majority of cases are actually non -traumatic and occur when quickly changing direction, slowing down or landing .

    Aggravating Factors:

    Weight-bearing / walking /instability when changing direction or twisting/ pivoting on the knee.

    Easing Factors:

    Avoiding aggravating factors/ Using Ice and devices to enable you to strengthen whilst reducing the load placed on your e.g a knee support or hydrotherapy belt.

    Management:

    Some people will have surgery to reconstruct the ACL ligament using either the hamstrings or patellar tendon graft. Others will not undergo surgery but both groups will undergo an intensive course of rehabilitation for around 12 months. Whether your management is surgical or non-surgical your rehab will involve the principles of POLICE. (protection , optimal loading , ice, compression and elevation).

    In the acute phase, pain and swelling management is key and can be achieved with the use of ice (cryotherapy products) alongside medication. The use of products such as hydrotherapy belts and braces to offload the knee joint, whilst still allowing for joint movement and muscle strengthening, is advised.

    Achieving a normal walking pattern, full knee range of motion and lower limb Strength, kinetic (neuromuscular) control and endurance are all key. Specific drills and tests for a variety of sports under the supervision of a physiotherapist are essential before returning to play.

    References:

    Alshewaier S, Yeowell G, Fatoye F. The effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury: a systematic review. Clin Rehabil. 2017;31(1):34-44.

    Grindem H, Granan LP, Risberg MA, Engebretsen L, Snyder-Mackler L, Eitzen I. How does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL Cohort and the Norwegian National Knee Ligament Registry. Br J Sports Med. 2015;49(6):385-9

    Monk AP, Davies LJ, Hopewell S, Harris K, Beard DJ, Price AJ. Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database Syst Rev. 2016;4:CD011166.

    van Melick N, van Cingel RE, Brooijmans F, Neeter C, van Tienen T, Hullegie W, et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med. 2016;50(24):1506-15.

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