ACL INJURY REHABILITATION
Injuries to the ACL are relatively common knee injuries among athletes. They occur most frequently in those who play sports involving pivoting (e.g. football, basketball, netball, soccer, European team handball, gymnastics, downhill skiing). They can range from mild (such as small tears/sprain) to severe (when the ligament is completely torn). Both contact and non-contact injuries can occur, although non-contact tears and ruptures are most common when the limb is in non contact and combined with valgus and internal rotation trauma It appears that females tend to have a higher incidence rate of ACL injury than males, that being between 2.4 and 9.7 times higher in female athletes competing in similar activities, and an acute rupture of ACL is a common trauma, it is incidence up to 84/ 100000 persons in USA, 78/100000 persons for Sweden with 32 years is the mean age of injury.
REHABILITATION
ACL rehabilitation has undergone considerable changes over the past decade. Intensive research into the biomechanics of the injured and the operated knee have led to a movement away from the techniques of the early 1980’s characterized by post operative casting, delayed weight bearing and limitation of Range of Motion (ROM), to the current early rehabilitation program with immediate training of ROM and weight bearing exercises.
The ACL rehabilitation is both for conservative and surgical options. Conservative treatment of an ACL injury could be the best choice for sedentary patients. Indeed patient age, sportive activities and foremost subjective instability symptoms in daily life activities should be considered when deciding for or against ACL reconstruction. In those cases a physiotherapic program of complete re-gain of ROM, a comprehensive program of reinforce and restore of proprioception and a normal gait pattern training could be the best rehabilitation protocol. However if symptomatic instability of the knee is not reduced after physiotherapy nor after adjustment of activity, anterior cruciate ligament reconstruction is recommended. This might prevent multiple interventions because of further meniscal and cartilage damage. ACL tear
It is useful to remember that injuries to the ACL rarely occur in isolation. The presence and extent of other injuries may affect the way in which the ACL injury is managed. Indeed the mechanism of injury can damage also the Medial Collateral Ligament (MCL) or the meniscus. Other associated injuries could be microfractures or bone contusions, both with or without chondral injuries. In those cases the ACL Rehabilitation program must be not standardize and consider the comorbidity.
The major goals of general rehabilitation of the ACL-INJURY:
- Gain full ROM of the knee
- Repair muscle strength and proprioception
- Gaan in good functional stability
- Reach the best possible functional level (walking, running, jumping…)
- Decrease the risk for re-injury
- (Return to sport)
Phases of ACL rehabilitation
The physiotherapy intervention could be divided in phases:
- Acute Stage
- Pre-surgical Stage or Conservative Treatment
- Post-surgical Stage
- Return to sport
Acute Stage
After an ACL injury, regardless of whether surgery will take place or not, physiotherapy management focuses on regaining range of movement, strength, proprioception and stability. In the acute stage PRICE or PEACE AND LOVE should be used in order to reduce swelling and pain, to attempt full range of motion and to decrease joint effusion. Appropriate anti-inflammatory medications are used to help control pain and swelling.
The indication of use crutches and eventually a knee immobilizer could be appropriate in some patients. However extended use of the knee immobilizer should be limited to avoid quadriceps atrophy.
The neuro-muscular inhibition of the quadriceps caused by intrarticular effusion may have a negative effect on the strengthening. In any case exercises should encourage range of movement, initial strengthening of the quadriceps and hamstrings, and eventually proprioception. In fact, strength and proprioceptive alterations occur in both the injured and uninjured limb. To assist pre-operative optimisation, the following guidelines are recommended in the acute and early sub acute stages post injury:
- Full extension is obtained by doing:
- Passive knee extension: the physiotherapist can provide the passive knee extension both with manual therapy and teaching exercises adding leverage to gently force extension,
- Patellar self-mobilisations,
- Heel Props,
- Prone hang exercise,
- Static quads/SLR;
- Bending (Flexion) is obtained by doing:
- Passive knee bend: the physiotherapist can provide the passive knee flexion both with manual therapy and teaching exercises adding leverage to gently force flexion,
- Knee flexion in prone (gentle kicking exercises),
- Wall slides,
- Heel slides;
- Knee flexion/extension in sitting;
- Ankle DF/PF/circumduction;
- Glutes medius work in side lying;
- Gluteal exercises in prone;
- Weight transfers in standing (forwards/backwards, side/side).
It is also demonstrated that Neuromuscular Electrical Stimulation (NMES) combined with exercise is more effective in improving quadriceps strength than exercise alone.
It could be useful also to consider taping to provide stability and to encourage reduction in swelling.
There is not a clear-cut transition from the Acute stage to the Pre-operative stage, each stage could last some days or several months before surgery. Didactically the end of the acute stage occurs when the patient regains the full range of motion of the knee in extension and at least 110 degrees of flexion or a near-normal gait pattern.