Early phase of ACL rehabilition

Early phase of ACL rehabilition

Contents of Article

  1. Aim
  2. Introduction
  3. Functional anatomy
  4. Mechanism
  5. Clinical examination
  6. Rehabilitation plan after anterior cruciate ligament reconstruction
  7. Pre-surgery / pre-op / pre-rehabilitation
  8. Post op ‘Early phase’
  9. References
  10. About the Author and disclaimer
  11. Comments

Aim

The aim with this blog series is to share some thoughts about rehabilitation, reconditioning and return to sport and performance following an Anterior Cruciate Ligament (ACL) injury.

We hope that it will inspire both health professionals and athletes recovering from ACL injuries.

Introduction:

An ACL injury is a devastating injury for athletes of all levels and often sidelines them from their sport. When the ACL ruptures, the knee often becomes unstable with impaired limb function and decreased quality of life (QoL). The goal for the rehabilitation process is to allow the athlete to return to their pre-injury strength and function, while also minimizing the risk of re-injury and possible early onset of osteoarthritis. Luckily, ACL injuries are NOT a common injury in sports, with an overall incidence rate 1.52 per 10.000 athletic exposure (AE) across different sports (Montalvo et al., 2018).

An ACL injury commonly requires extensive rehab before returning to their pre-injury strength level. Having a plan and following a roadmap can optimize the rehabilitation process, which is crucial for a successful long-term return to their sport.

Athletes with ACL injuries tend to have very high expectations prior to ACLR, which do not match average outcomes. In a study by Feucht et al. in 2014, all of the athletes expected to return to normal knee function within 12 months of surgery, 91% expected to return to sport within one year of surgery and 98% expected little to no increased risk of knee osteoarthritis after ACLR.

Even though ACL reconstruction (ACLR) is the most common treatment for ACL injuries, surgery does not always result in a return to pre-level activity. A study published by Ardern et al. (2014) showed that only 63% of athletes returned to pre-injury level, 44% returned to competitive sports and approximately 65% did not return to pre-injury level after 12 months. However, 80% of the ACL patients in this study returned to some form of sport within 1 to 2 years post-op (Ardern et al., 2014). Among elite athletes, return to sport (RTS) rates are much higher with 83% returning to pre-level sport within 13 months post-op ACLR (Lai et al., 2018), and 94% of elite footballers (Ekstrand, 2010).

With the low numbers of RTS in mind, ACLR is not always the right treatment for ACL injuries, and RTS depends on many multifactorial contextual factors.

In fact, one prospective RCT by Frobell et al. (2013) found that by delaying the ACLR at least 10 weeks, 50% of the athletes did not need a ACLR at all. After 5 years, no difference was found between ACLR or those treated conservatively with rehabilitation alone. This has been further investigated by Grindem (2018) who proposed a prediction model for a more accurate two year prognosis for those who were treated with the non-surgical method. Athletes who were older, women, and individuals with better knee function early after ACL rupture were more likely to have successful two-year outcomes. These RTS numbers drop further if the athlete has a revision ACLR (Grassi, 2015).

Therefore, clearing the athlete for RTS is not a straight forward procedure, which has also been highlighted in a consensus statement on RTS (Ardern, 2016) which explains how its multifactorial, biological, psychological and social factors might influence treatment and outcomes (Ardern, 2016). RTS criteria will be discussed in a future blog post.

This information should be delivered in a way that is comprehensible to the patient to make informed, shared decisions before deciding to pursue ACLR or conservative rehabilitation (Feucht, 2014).

Functional anatomy

The ACL is located in the center of the middle of the knee and runs between femoral condyle and into the tibial bone. The ACL is the primary restraint to anterior translation of the tibia relative to the femur and secondary to internal rotation. The restraints from the ACL help with controlling the glide in the knee joint throughout the movement in various range of motions. Damage to the ACL can disrupt this system, resulting in aberrant movement during activities and causing a general feeling of instability.

Mechanism

The fairly common description of an ACL injury involves a ‘non-contact’ episode where the athlete typically describes a twisting sensation occurring during change of direction (pivoting) or landing from a jump. The athlete often reports a ‘popping’ or ‘snapping’ sound associated with pain and swelling shortly after the injury.

A common injury pattern has been observed during multidirectional activities (football, soccer, rugby, basketball) with up to 85% of the ACL injuries being non-contact injuries (Walden, 2015). The injury typically appears during 1) change-of-direction maneuvers such as jumping, cutting and pivoting movements, 2) re-gaining balance after kicking or 3) landing with hyperextended knee.

The ACL will typically rupture during a forceful valgus moment at 5-30 degrees of knee flexion, where the knee is closer to the midline of the body than the ankle. While the tibia is moving forward and rotating internally, the forces from the foot-contact to the ground is compressing the tibia against the femur and elongating the ACL more than tolerated. The rupture occurs in approximately 17 to 50 milliseconds after this initial ground contact (Walden et al., 2015; Jordan et al., 2017).

An injury to the ACL often occurs concomitantly with damage to other knee joint structures such as the meniscus, articular cartilage and medial and collateral ligament which can influence the rehabilitation time and surgical procedure.

Clinical examination

  • History: An ACL rupture should always be suspected if the patient reports the previously mentioned injury mechanism combined with hearing or feeling a “pop” in addition to knee swelling and if the athlete has a perception of an “unstable” knee.
  • Test: Several clinical tests can be used to detect an ACL rupture. The Lachman test is the most accurate clinical diagnostic test with a pooled reported sensitivity of 85% and specificity of 94%. A positive result with the pivot shift test is a very clear indication of an ACL rupture (98% specificity). A negative test, however, is not sufficient to rule out possible injury (24% sensitivity). The anterior drawer test has high sensitivity and specificity for chronic ACL ruptures (92% sensitivity and 91% specificity), but lower accuracy for acute cases. (Filbay, 2019). All of the above tests measure a form of knee laxity.
  • Magnetic resonance imaging (MRI): If the above history and clinical test indicate an ACL injury, MRI can be used to determine if the ACL is ruptured. ACL ruptures often occur with concomitant ligament sprains, meniscus tears, bone marrow lesions, articular cartilage injuries, and intra-articular fractures with a prevalence of 30% and 42%, respectively for medial collateral ligament (MCL) injuries and meniscal tears. The rates of concomitant lateral collateral ligament (LCL) and posterior cruciate ligament (PCL) injuries are generally lower (Frobell, 2006).

Rehabilitation plan after anterior cruciate ligament reconstruction

Over the past few decades, rehabilitation protocols after ACL injuries have moved away from strict time-based protocols to more criteria-based guidelines. Programs are often individualized to the person’s injury, training status/experience and expectation for the rehab. Progressing from one phase to the next only occurs when the patient meets specific clinical milestones. One of the first milestones is to regain full range of motion (knee extension and flexion) pain-free, optimizing muscular strength and function and being familiar with basic post-operative exercises and expectations (patient education). However, creating a long-term rehabilitation plan can be challenging, therefore short-term milestones built on a combination of time-frame and criteria-based decision-making are advisable for building up a plan for your athlete. These time-frames are often called early phase, intermediate phase, late/advanced phase (Filbay, 2019), sports specific, return to participation, return to sport and return to performance (Ardern, 2016).

Timeline and criteria-based road map 

The figure below is an example of what a simple roadmap can look like:

Range of motion Motor control Muscle strength
Early phase Daily/weekly measurable skills and task: E.g. pain, swelling, range of motion. Early phase exercises
Milestone / Criteria Milestone / Criteria Milestone / Criteria
Intermediate phase Functional test, intermediate level exercises, preparing for return to run and jump
Milestone / Criteria Milestone / Criteria Milestone / Criteria
Advance/late phase Functional test, advanced level exercises, return to running, jumping and preparing for sport.
Milestone / Criteria Milestone / Criteria Milestone / Criteria
Main goal – Return to Sport

Pre-surgery / pre-op / pre-rehabilitation

The rehabilitation process prior to the ACL surgery is termed “preoperative rehabilitation” or just pre-op.

In the first days and weeks after the injury, the focus is to restore full range of motion, control swelling and pain, and good quadriceps activation. Later in the pre-op, the goal is to either prepare the athlete for surgery or nonoperative management.

After the injury, the athlete can be subclassified into:

  1. coper (athlete that can resume previous recreational activities without reconstruction)
  2. non-coper (athlete that requires ACLR because of recurrent give-away episodes in activities of daily living)
  3. adaptors (athletes that can manage without reconstruction by modifying/lowering their activity level).

Thoma et al. (2019) showed that almost half (45%) of initial potential noncopers became potential copers after a 5 week pre-op neuromuscular strength training program, while only 13% of initial potential copers became noncopers after the training program.

The program consisted of progressive strengthening, plyometric, and neuromuscular exercises (Eitzen, 2010).

 

Exercise Description Sets/reps
Stationary cycle Continuous warm-up at your preferred resistance 10 min
Treadmill Continuous warm-up at your preferred speed. Walking or running 10 min
Elliptical trainer Continuous warm-up at your preferred resistance 10 min
Single-limb squat Maintain knee-over-toe position 3 × 8
Step up Maintain knee-over-toe position 2 x 10
Squat on BOSU Maintain knee alignment and core stability. Squat quickly down and up 2 x 20
Single-limb leg press Start in 90° knee flexion 3 x 6 (+2)
Single-limb knee extension Start in 90° knee flexion 4 x 6 (+2)
Squat Squat slowly down to 90° knee flexion, stop, lift quickly up again 3 × 8 (+2)
Leg curl Lift quickly up, stop, and then slowly down to full extension 3 × 8 (+2)
Hamstring on Fitball One foot on top of the ball, lift back and pelvis up, pull ball towards you 3 × 6
Single-leg hop Hop up on step, stop, continue down and directly 1 hop forward with a soft controlled landing 1 × 15
Progressively perturbation training Includes balance and stability exercises on custom-made roller board, rocker board, and platform, and involved perturbation of the support surface that allowed altered forces and torques to be applied to the injured limb in multiple directions in a controlled manner

Eitzen et al. (2009) have also shown that quadriceps strength limb symmetry with a deficit below 20% is a significant predictor of knee function two years after an ACL injury. Similarly, another systematic review from Ashewaiver et al. (2016) analyzed 451 patients (15-57 years), showing that a 3-14 weeks pre-op period with an average training of three times per week improved the outcomes of patients with ACLR.

A part of getting the athlete ready for surgery could be obtaining a list of objective and subjective data that can be used to guide the rehabilitation. These test could involve: muscle testing (with hand held dynamometer (HHD), nordbord/physiometer or isokinetic device), jump testing (using force platform, mobile app like MyJump2 or use measuring tape and stopwatch to record limb symmetry in distance- or numbers for single leg jump for distance, 6-m jump test, triple cross-over test, cross-hop for distance, side hop, countermovement jump, functional testing a numbers of single leg squat, % of RM in back squat, deadlift etc.

My recommendation is to choose a handful of tests that are available, time-saving and fit in our facilities. Furthermore, questionnaires like Tegner scale, IKDC2000, KOOS. ACL-RSI, Tampa Scale of Kinesiophobia (TSK-11) can be useful to track the rehabilitation.

In study by Ardern et al. (2013), it was suggested that a score of ≥ 56 points on the ACL-RSI scale increased the odds by four of RTS, which may help to identify at-risk athletes with lower points.

Post op ‘Early phase’

Following ACL surgery, a period of protected loading is recommended due to the graft healing, pain, swelling, limit range of motion and muscle control in order to limit muscle atrophy and avoid arthrogenic muscle inhibition. Acute management should adhere to the general principles of POLICE (Protection, Optimal Loading, Ice, Compression and Elevation) to ensure joint protection, removal of pain and swelling, meanwhile maintaining a gradual restoration of function.

The athletes are presented with a set of surgical restrictions set by the surgeon depending on the surgical procedure and the surgeon clinical experience. These restrictions are often based on graft-type where bone-to-bone (BTB) and hamstring tendon is among the most common for first choice ACLR. Comorbidities of knee joint structures may involve meniscus meniscectomy, meniscus repair, lateral tenodesis (ALL), cartilage damage and in rare cases high tibial osteotomy. Each surgery is slightly different and can influence the progression in the first phase of rehabilitation and therefore it is important to fully understand the surgical procedure.

In the early phase rehab, training should focus on patient education, pain/swelling, range of motion (ROM), motor control and muscle strength to minimize the loss of muscle strength and volume. The goals through the early phase can be visualized as below.

 

Range of motion Motor control Muscle strength
Early phase Daily/weekly measurable skills and task: E.g. pain, swelling, range of motion. Early phase exercises
Criteria based rehab (Ardern, 2018, Wilk 2018) Milestone: Have minimal/trace effusion or zero swelling. (Measure with stroke test and knee circumference). Have minimal or no pain (0-2 NRS). Full active extension, 120 degrees active knee flexion. Walking without crutches, walking on stairs. Stationary bike. Drive car. Full quadriceps activation without quadriceps lag in single leg raise. Restore balance and perform mini squat weight shift. Ability to hold terminal knee extension during single leg standing without support 10 sec.
Intermediate phase Functional test, intermediate level exercises, preparing for return to run and jump
Milestone / Criteria Milestone / Criteria Milestone / Criteria
Advance/late phase Functional test, advanced level exercises, return to running, jumping and preparing for sport.
Milestone / Criteria Milestone / Criteria Milestone / Criteria
Main goal

In the early phase we recommend beginning training with low to moderate intensity (e.g. 12-20 RM in multiple set) and slowly progressing to support more optimized muscle hypertrophy and strength.

In addition, a focus on non-weightbearing exercises such as lumbopelvic hip exercise, upper body and cardio can be used to stimulate the exercise program. In addition, modalities such neuromuscular electrical stimulation (NMES) or blood flow restriction can be used to enhance muscle activation and growth. Furthermore, cross-education training with heavy strength training of the non-injured leg, shortly after ACLR has demonstrated improvement in quadriceps muscle strength at 8 weeks when perform 3 or 5 days per week compared with control which did not receive cross-educational training (Papandreou et. al. 2012). Similar result has been reported after 24 weeks when trained 3 times per week (Harput, 2019), however Zult et al. did not got these results. One explanation could be that the intervention group only performed cross-education training group twice a week. This illustrate, that there might be a dose-response relationship in cross-education training, recommend at least 3 times per week. Although further research should be conducted to investigate the long-term effects of cross-education training in ACLR rehabilitation.

Post op ‘Early phase’ exercises

Before beginning rehabilitation consider following restriction.

  • Follow surgical advice
  • ACLR: Full weightbearing, no brace
  • ACL + lateral tenodesis: Full weight-bearing + brace 0-90° for 4-6 weeks. Be careful with lateral weighted exercises.
  • ACL + Meniscus repair: Protected weight-bearing + brace 0-90° for 4-6 weeks (different protocols).
  • POLICE protocol for management of pain and swelling.

0-2 weeks

Milestones:

  • Control pain, swelling, range of motion (0-105°+ (Wilk, 2018)), restore balance, minimize loss of muscle strength.
  • Criteria to phase 2 includes: closed wound, full active knee extension, 120°+ knee flexion, little to no effusion, active dynamic gait pattern without crutches, ability to hold terminal knee extension during single leg (Arderen, 2018, Gokeler, 2017).
Exercise Description Sets/reps
Patella mobilization Patella mobilization (Superior/inferior and medial/lateral directions). 1-2 min
Knee flexion Towel slide, sitting on a chair and passive flexion and extension assisted by the “good” leg, wall slide 3 set x 15 reps+. multiple times per day
Static Quads-activation Contract m. quadriceps in several seconds (see if you can lift the heel from the surface) 3 set x 15 reps+. multiple times per day
Straight leg raises Lift up your leg without lag of extension 3 set x 15 reps+. multiple times per day
Superman prone straight leg raise extension 3 set x 15 reps per day
Prone assisted hamstring curls Prone position and flex your assisted by the opposite foot under the ankle 3 set x 15 reps per day
Side lying hip abduction/clams Be careful if the patient has undergo meniscus repair 3 set x 15 reps per day
Side lying hip adduction Start in week 2-3 if not pain. 3 set x 15 reps per day
Calf: Seated calf raises Bed based/seated plantar flexor strengthening. 3 set x 15 reps+. multiple times per day
Balance exercises Challenge the oculomotor, vestibular and proprioceptive system. Single leg balance with open, close eyes, rotational head movement eg. other body part. 3 set x 15 reps+. multiple times per day
Terminal Knee Extension 3 set x 15 reps per day
Squat 3 set x 15 reps per day
Step up 3 set x 15 reps per day
Lunges ACL in front starting week 2 3 set x 15 reps per day
Upper body driven core exercises
Gait re-education (March walk, hurdle walk, side walk)
Cardio: SkiErg, Concept2 Rowing
Neuromuscular Electrical Stimulation (NMES)

References

  1. Waldén M, Krosshaug T, Bjørneboe J, et al, 2015, Three distinct mechanisms predominate in non-contact anterior cruciate ligament injuries in male professional football players: a systematic video analysis of 39 cases
  2. Jordan, M.J., Aagaard, P., & Herzog, W. (2017). Anterior cruciate ligament injury/reinjury in alpine ski racing: a narrative review. Open access journal of sports medicine.
  3. Eitzen, I., Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2010). A Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury. Journal of Orthopaedic & Sports Physical Therapy, 40(11), 705–721. doi:10.2519/jospt.2010.3345
  4. Ardern CL, Taylor NF, Feller JA, et al., Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factorsBritish Journal of Sports Medicine 2014;48:1543-1552.
  5. Frobell, R. B., Roos, H. P., Roos, E. M., Roemer, F. W., Ranstam, J., & Lohmander, L. S. (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ, 346(jan24 1), f232–f232. doi:10.1136/bmj.f232
  6. Grindem, H., Wellsandt, E., Failla, M., Snyder-Mackler, L., & Risberg, M. A. (2018). Anterior Cruciate Ligament Injury—Who Succeeds Without Reconstructive Surgery? The Delaware-Oslo ACL Cohort Study. Orthopaedic Journal of Sports Medicine, 6(5), 232596711877425. doi:10.1177/2325967118774255
  7. Eitzen, I., Holm, I., & Risberg, M. A. (2009). Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. British Journal of Sports Medicine, 43(5), 371–376. doi:10.1136/bjsm.2008.057059
  8. Alshewaier, S., Yeowell, G., & Fatoye, F. (2016). The effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury: a systematic review. Clinical Rehabilitation, 31(1), 34–44. doi:10.1177/0269215516628617
  9. Logerstedt et. al., Single-legged hop tests as predictors of self-reported knee function after anterior cruciate ligament reconstruction: the Delaware-Oslo ACL cohort study, 2012 Am J Sports Med.
  10. Andrea Reid, Trevor B Birmingham, Paul W Stratford, Greg K Alcock, J Robert Giffin; Hop Testing Provides a Reliable and Valid Outcome Measure During Rehabilitation After Anterior Cruciate Ligament Reconstruction, Physical Therapy, Volume 87, Issue 3, 1 March 2007, Pages 337–349, https://doi.org/10.2522/ptj.20060143
  11. Filbay SR, Grindem H, 2019, Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture, Best Practice & Research Clinical Rheumatology, https:// doi.org/10.1016/j.berh.2019.01.018
  12. Frobell, R. B., Lohmander, L. S., & Roos, H. P. (2006). Acute rotational trauma to the knee: poor agreement between clinical assessment and magnetic resonance imaging findings. Scandinavian Journal of Medicine and Science in Sports
  13. Feucht, M. J., Cotic, M., Saier, T., Minzlaff, P., Plath, J. E., Imhoff, A. B., & Hinterwimmer, S. (2014). Patient expectations of primary and revision anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 24(1), 201–207. doi:10.1007/s00167-014-3364-z
  14. Ardern, C. L., Glasgow, P., Schneiders, A., Witvrouw, E., Clarsen, B., Cools, A., … Bizzini, M. (2016). 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British Journal of Sports Medicine, 50(14), 853–864. doi:10.1136/bjsports-2016-096278
  15. Ardern CL, Ekås GR, Grindem H, et al2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuriesBritish Journal of Sports Medicine 2018;52:422-438.
  16. Wilk, K.E., and A.Arrigo, Rehabilitation: Common Problems and Solutions, 2018, Clinics in Sports Medicine Volume 37, Issue 2, April 2018, Pages 363-374
  17. Montalvo AM, Schneider DK, Yut L, et al“What’s my risk of sustaining an ACL injury while playing sports?” A systematic review with meta-analysisBritish Journal of Sports Medicine 2019;53:1003-1012.
  18. Ekstrand, J. (2010). A 94% return to elite level football after ACL surgery: a proof of possibilities with optimal caretaking or a sign of knee abuse? Knee Surgery, Sports Traumatology, Arthroscopy.
  19. Grassi A, Zaffagnini S, Marcheggiani Muccioli GM, et al, 2015, After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis, British Journal of Sports Medicine
  20. Ardern, C. L., Taylor, N. F., Feller, J. A., Whitehead, T. S., & Webster, K. E. (2013). Psychological Responses Matter in Returning to Preinjury Level of Sport After Anterior Cruciate Ligament Reconstruction Surgery. The American Journal of Sports Medicine,
  21. Thoma, L. M., Grindem, H., Logerstedt, D., Axe, M., Engebretsen, L., Risberg, M. A., & Snyder-Mackler, L. (2019). Coper Classification Early After Anterior Cruciate Ligament Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: The Delaware-Oslo ACL Cohort Study. The American Journal of Sports Medicine, 036354651982550. doi:10.1177/0363546519825500
  22. Papandreou M, Billis E, Papathanasiou G, Spyropoulos P, Papaioannou N. Cross-exercise on quadriceps deficit after ACL reconstruction. J Knee Surg. 2013;26(1):51–58. doi:10.1055/s-0032-1313744
  23. Harput G, Ulusoy B, Yildiz TI, et al. Cross-education improves quadriceps strength recovery after ACL reconstruction: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):68–75. doi:10.1007/s00167-018-5040-1
  24. Zult T, Gokeler A, van Raay JJAM, et al. Cross-education does not accelerate the rehabilitation of neuromuscular functions after ACL reconstruction: a randomized controlled clinical trial. Eur J Appl Physiol. 2018;118(8):1609–1623. doi:10.1007/s00421-018-3892-1
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Andreas Bjerregaard
Articles: 305

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