QLRC ACL Reconstruction Rehabilitation Program · The time frame for full rehabilitation from an...
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QLRC ACL Reconstruction Rehabilitation Program This handout is for patients and their families who have or are planning to have an ACL reconstruction. Every patient has slightly different expectations in terms of their needs. We modify treatment and rehabilitation to suit the individual. An ACL injury is a potentially devastating diagnosis that can change the course of a patients life. The ACL is one of the primary stabilising ligaments in the knee. It connects the thigh bone (femur) to the shin bone (tibia) and prevents the knee from pivoting or twisting too far when we turn to change direction. An ACL rupture commonly occurs when the knee twists too far, either on landing a jump or during sport from a tackle. We now know that there are factors that predispose certain patients to having ACL injuries, and it is important to assess and address these factors as part of a treatment protocol. When an ACL is ruptured, many patients hear a pop or a crack in the knee and are in immediate pain. The knee usually swells as the injured ACL bleeds into the knee joint. It is also possible to sustain damage to the meniscus and cartilage of the knee joint when the ACL is injured. Following injury, if prompt medical attention is sought, then a diagnosis can be made and a plan put in place for rehabilitation and surgery if appropriate. Unfortunately many injuries are not diagnosed, and it is possible for a patient to recover from the injury and return to sport without realising that their knee is no longer structurally intact. Images courtesy of AAOS Orthinfo
Transcript of QLRC ACL Reconstruction Rehabilitation Program · The time frame for full rehabilitation from an...
QLRC
ACLReconstructionRehabilitationProgram
ThishandoutisforpatientsandtheirfamilieswhohaveorareplanningtohaveanACLreconstruction.Everypatienthasslightlydifferentexpectationsintermsoftheirneeds.Wemodifytreatment
andrehabilitationtosuittheindividual.
AnACLinjuryisapotentiallydevastatingdiagnosisthatcanchangethecourseofapatientslife.TheACLisoneoftheprimarystabilisingligamentsintheknee.Itconnectsthethighbone(femur)totheshinbone(tibia)andpreventsthekneefrompivotingortwistingtoofarwhenweturntochangedirection.
AnACLrupturecommonlyoccurswhenthekneetwists too far, eitheron landinga jumporduringsport from a tackle.We now know that there arefactors that predispose certain patients tohavingACLinjuries,and it is important toassessand address these factors as part of a treatmentprotocol.
WhenanACLisruptured,manypatientshearapoporacrackinthekneeandareinimmediatepain.ThekneeusuallyswellsastheinjuredACLbleedsinto the knee joint. It is also possible to sustaindamagetothemeniscusandcartilageofthekneejointwhentheACLisinjured.
Following injury, if prompt medical attention issought, thenadiagnosis canbemadeandaplanput in place for rehabilitation and surgery ifappropriate. Unfortunately many injuries arenotdiagnosed, and it ispossible forapatient torecover from the injury and return to sportwithout realising that their knee is no longerstructurallyintact.
Images courtesy of AAOS Orthinfo
Ifthediagnosisisdelayed,thereispotentialforthekneetobeunstablewhichmeansthatitwillgivewayunexpectedlyduringdailyactivitiesorduringsport.Ifthisoccurs,itispossibletodamagethemeniscusofthekneewhichinturnwillleadtodamageinthejointcartilageandsubsequentosteoarthritis.
AnACLreconstructionisaprocedurethataimstorestorethestabilityofthekneebyrecreatingthestructureoftheligament.Typically,tunnelsaredrilledintothefemurandthetibiaandagraftoftendontakenfromanotherpartofthebody(usuallyoneofthehamstringtendons)isfixedthroughthetunnels.The complications associatedwith this surgerywill be discussed individuallywithyouduringyourconsult.Followingthesurgery,aprogramwillbeput inplacetoguideyourrehabilitationandreturntosport.
ThetimeframeforfullrehabilitationfromanACLreconstructionis,onaverage,9-12months,buteveryoneisdifferent.Yourrehabilitationisonlycompleteonceyouhavesafelyreturnedtosportand/oryourphysicalactivitygoals.Thereisnohurrytorushyourprogressionthroughtheprogramandyouwillbeguided by Dr Maine and your treating physiotherapist throughout. It isextremely important thatyou follow theseguidelinesandcontinuewith theexercisesevenafteryourpainhasgoneandyouhavefullmovementofyourknee.
Yourhospitalstay:
Whenyouwakeafteryouroperationyouwillhaveabraceonyourkneeandbegivenpainrelief,asrequired,bythenursingstaff.Therewillbeaperiodoftimeafteryouroperationwhereyoumaynotbeabletoputweightthroughyourleg.Thistimeperiodwillbedeterminedbythetypeofsurgeryyouhavehad.Thisexpectationshouldbeadheredto, toensure thebesthealingandoutcome foryourknee.Usually,youwillbeabletoleavehospitaladayafteryouroperation.
Aphysiotherapistwillvisityouthemorningafteryouroperationto:
-Helpyoutogetoutofbed
-Teachyouhowtowalkwithcrutchesandnegotiatestairs.
-Gothroughyourhomeexerciseprogramandguideyouastowhenyouaresafetoremoveyourbracetodoso.
-Organisefollowupphysiotherapyclosetoyourhome.
Followup:
YouwillbereviewedbyDrMaineapproximately2weeksafteryouroperation.Youwillbeadvisedwhentoprogressyourweightbearingstatusandwhentoremovethebrace.Afterthisyouwillneedanappointmentwithaphysiotherapistwhowillco-ordinateyourrehabilitation.
Ifyouoryourchildareanathletelookingtoreturntocompetitivesport,weofferareturntosportprogramthatincludesreferraltoaSportsPhysicianalongwithReturn to Sport testing to ensure that you have done everything possible tominimiseyourriskofre-injury.Theriskofgraftruptureinyoungpatientshasbeen reported as up to 30%. It is critical that you do everything possible tominimiseyourriskinthisregard.Pleaseletusknowifyouwishtoproceedwiththisoption.
Yourrehabilitationjourney…
Thereare5stagestoyourACLrehabilitation.Yourphysiotherapistwillguideyouthrougheachstageandprovideyouwithspecificexercises.
Stage1:Immediatepost-operativestage
Stage2:Strengthening+NeuromuscularControlPhase
Stage3:StrengthandEndurance(Approx.weeks6to12)
Stage4:Creatingaplatformforrunning,agilityandlandings(Approx.weeks12to18)
Stage5:Preparingtoreturntosport+returningtosport+injuryprevention(Approx.weeks18to26weeksandbeyond)
Stage1:Immediatepost-operativestage(Weeks0-2)Initiallyyourkneewillbequitestiffandsoreandyourexerciseswillbelimitedtohelpyouregain
yourconfidenceinyourabilitytomoveandstrengthenyourknee.Ifyouarefindingthatyourkneeisswellingandaching,youmaybedoingtoomuch.Discussthiswithyourphysiotherapistandthey
willguideyouinwaystoreducetheswellinganddiscomfort.
Aims:
- Decreaseswelling
- Minimisepain
- Regaincomfortablekneemovement-notpushinginto‘hyperextension’(ie.paststraight)
- Regainmuscleactivationofquadriceps,hamstringsandgluts
- Tocreateaplatformtoenableyoutotoleratewalkingonyourlegwithnoaids.
ExerciseSuggestions:
Swellingmanagement:Rest,ice,compression,elevation,Anklepumps
Flexibility:Heelslides
MuscleActivation/strength:
- VMOactivation- Co-contractionsofquads/hamstrings- Glutsqueezes
UsefulOutcomeMeasurestoguideprogressiontoStage2:
Stroketest(Sturgill,2009)=1+
Kneeextension=-5o–0o(Norkin&White1995)
Quadricepslagtest=0o–5o
Stage2:Strengthening+NeuromuscularControlPhase(Weeks2-6)AtthispointyouwillbeguidedbyDrMainewhenyoucanremoveyourbraceandwhenyoucanstart
puttingcontrolledweightthroughyourlegunaided.
Aims:
-Togainfull,painfree,activemovement(nothyperextension)-Toreturntonormalwalkingwithoutcrutches-Regainmusclestrengthofquads,hamstrings,gluts-Balanceonsingleleg
ExerciseSuggestions:
Manualtherapy:Patello-femoralMobilisations
RangeofMotion:
- Heelslides- Proneassistedkneebends- Pronekneehangs- Hamstringandcalfstretches
Strength:
- VMOactivation- Co-contractionsofquads/hamstrings- Bridging- Calfraises- Wallsits- Stepups- Pronekneecurlsàaddtheraband- MinisquatsàProgressedasable- MinilungesàProgressedasable
Balance/Proprioceptiveexercises:
- Balance-singleleg,wobbleboard- Glutmedactivationinstanding
CardioExercises:
- Exercisebikewithlowresistance
NOTE:Ifameniscusrepairhasbeendonetherewillberestrictionsontheamountofweightedkneeflexion
thatcanbedone.
Youmaystartsomegentlehydrotherapyinthepoolatthisstageoncesurgicalwoundshavehealed.Thismaycompriseofwalkinginwater,minisquats,calfraisesandlunges.YoushouldNOTcommencekicking(eitherfreestyleor
breaststroke)untilclearedbyyoursurgeon/physiotherapist(usuallyafter3-6
months).
OutcomeMeasurestoguideprogressiontoStage3:
- Kneeflexion=90o–100o(Norkin&White1995)- Calfraises=Toachieve10xminimalsupport,kneefullyextended- Balancetesting- FunctionalAlignmentTest
Stage3:StrengthandEndurance(Weeks6-12)Atthisstage,aplatformshouldhavebeencreatedwhereyoufeelconfidentintheabilitytotakecontrolledweightthroughyourknee.Yourswellingshouldbeminimalandyoushouldbeabletomoveyourkneethroughacomfortablerange.TheimportantaspectatthisstageistheWINDOW
periodfrom6-10weeksafteryouroperationiswhenthegraftisatitsWEAKEST.Itisimportantthatyoudonotattempttodotoomuchandreturntoactivities/sporttooearly.
Aims:
-Improvestrengthandendurance
-Strengthensafelyisthemainpriority-youwanttoCREATEAPLATFORMforyourkneetotoleraterunningandproprioceptiondrills.
ExerciseSuggestions:
ROM:Continueduntilfullpainfreerange
Strength:
6weeks:
- Stepups/downs- Wallsits- Pronekneecurlswiththeraband- Squats–singleleg- Lunges- Eccentrichamsdrills- Corestabilityexercises–planks,sideplanketc
8weeks:(Aim-Fullrangeofmotion)
- Increasedepthsquats+lunges- Concentrichamstringswiththeraband–proneandstanding- Pronealternatecurls(legwts-2kg)- Overedgeofbedflicksandwobbles(2kg)- Therabandresistedhipextensioninstanding- Chairbridging(2legs)
GymProgramcanbestartedaroundthistime.
- Legpress- Inclinelegpress- SeatedhamstringcurlsàPronehamstringcurls
10-12weeks(cantoleratetheaboveprogramfor2/52)
- Splitsquats- DeadLifts- Walkinglunges+weight
Important!Maintaingoodcontrolwithallexercises
duringthistime.Noopenchainkneeextensionexercises.
Balance/Proprioceptiveexercises:
- Balance-singleleg,wobbleboard- Flicks&wobbles(dynamichams)- Singlelegrebounderbalance
CardioExercises:
- Exercisebikewithincreasingresistance- Pool Poolrunning(vestorflotationbelt)
C-VTraining(intervalsforgeneralfitnessetc)
- Rower(notmeniscalrepairs–DrBartlett)- Stepper/Versa-climber(90degreesonly,notmeniscalrepairs)- Walker
Stretches:
- Calf- Hamstring- Quads- ITBstretches
OutcomeMeasurestoguideprogressiontoStage4:
Test AimSinglelegchairbridges 10repetitionswithgoodcontrol
Sidebridgeendurancetest Comparetootherside
Singlelegpress 80%ofoppositeleg
Starexcursionbalancetest(Gribbleetal2012)
80%ofoppositeleg
Stage4:Createaplatformforrunning,agilityandlandings
(Weeks12-18)Bythistimeyoushouldfeelasthoughyourkneeisquitestableandisimprovinginstrength.YouarenowaimingtoCREATEAPLATFORMforyourkneetotolerateSPEEDandChangesinDIRECTION.
Aims:
- Ongoingimprovingofstrengthandendurance
- Improveproprioception
- Initiatepoweranddynamicactivities
ExerciseSuggestions:
StrengthExercises:
- Squats+weight- Walkinglunges+weight- Clocklunges- Singlelegsquats- Hamstringcurls(therabandorweights)- Singlelegbridging–onball+hamstringcurls
DynamicExercises:
12Weeks
- Jumpingonspot/fwds/bwds(2legs)- Jumpingside-side(2legs)
14Weeks
- Hoppingdrills(jump-stop,hop-stop,from10cmto20cmetc)- Obstaclehopping,gridhopping- Steprunning- Ladderrunning- Boxjumps
Balance/Proprioceptiveexercises:
- Rebounderjogsandstops(2pillowsathome)CardioExercises:
- Bikeworkwithcleatscanbeintroduced- Asbefore
Poolprogram:
- Canstartkickingwhenclearedbysurgeonandthenprogresstoflippers.
*Previousexercisessuchasproprioceptionandstrengthshouldcontinue*
From16WeeksRunningProgramcancommenceif….
Runningshouldbeprogressedgraduallyfromthereboundertotechniquerunningintheclinic(towardsamirror),andprogressedbyaboutthe16weeksmarktotreadmillrunning(3-5minsmax).Ifyouaretoleratingthiswell,progresstofield:joggingincombinationwithwalking(i.e.walking30m-jog30m).Graduallyincreasethejogcomponentofthisonceyouhavegoodconfidenceina
straightline.
Progressions:
- StraightlinerunningonflatsurfacesàStairsàHills/slopes- Increasingdistance,thenspeed- Shuttlerunning
Indicationsofprogressiontorunning:
Abilitytohopandlandsoftlywithoutanykneevalgus
SingleHopTest
Right=Left
Triplecrossoverhoptest
Right=Left80%+
Modifiedlandingerrorscoringsystem(Padua2009) Anysignsofkneeswellingandaching,youmaybedoingtoomuch.Ensureyoutakerestsasrequired.
Stage5:Preparingtoreturntosport+Injuryprevention
(Weeks18-26weeksandbeyond)
Atthisstageyourkneeshouldbestrongandmuscularendurancedevelopingviathestrengthandrunningprogram.ItisatthisstagethatyourrehabilitationisaimedatCREATINGAPLATFORMforyour
kneetotolerateRETURNINGTOSPORT.
Aims:
- Concentrateonpowerdevelopment- Increasingrunningspeed- Increasingdistance- Changeofdirectiontobeintroduceslowlythenprogressedtoshortersharperagilitydrills.
ExerciseSuggestions:
- Hopping+jumpdrillscontinue- Figure8running- Diagonalrunning- Changeofdirectiondrills- Sportspecificdrillsandskills(from26weeks+)
WhenamIreadytoreturntosport?
9-12months…
- MelbourneReturntoSportScore- Whenyou,DrMaineandyourphysiotherapistareconfidentandcomfortableyouarereadyto
return.ExamplePreventionprograms:
- PEPprogram
- FIFA11+
- NetballKNEEProgram(NetballAustralia)
