Anterior Cruciate Ligament Rehabilitation

In the US, anterior cruciate ligament tears are a frequent type of injury. Over 200,000 injuries are thought to be diagnosed annually in the US. Sport-related injuries account for the majority of tears, whereas accidents account for the remainder. ACL tears are more common in women than in males. The purpose of treating an ACL injury is to assist patients feel less discomfort and swell less, restore their strength and mobility, and resume their intended activities (Buckwalter, 2010). The femur and tibia are joined at the knee joint by a band of tissue called the anterior cruciate ligament. A tear of the ACL result from a sudden stop while running, jumping and then landing on an extended knee, suddenly shifting the weight of one leg to the other, stretching the knee further than its usual range of motion exercises.

Management of ACL injuries varies depending on the needs of the patient. Treatment includes both the nonsurgical and the nonsurgical management. The latter is preferred for old patients who are less active. It includes bracing and physiotherapy. Surgical management is the preferred form of treatment for tears which are extensive. Injury of the anterior cruciate ligament leads to an alteration in the functionality requiring surgical interventions followed by extensive rehabilitation. In the US, out of the total number of ACL injuries, approximately 1000,000 undergo reconstruction surgeries. Following surgery, various treatment modalities are employed depending on the needs of the patients, the type of surgery. Weight-bearing is used depending on the nature of the reconstruction surgery received, and the physiotherapist guides the patient on the full weight bearing. Bracing is employed to help in the reduction of the knee movement following surgery. Others include movement exercises, electric stimulation, and strengthening and balance exercises.

Rehabilitation of patients post operatively begins with passive range of motion as well as weight-bearing activities immediately after the ACL surgery. Other activities include the proprioceptive training and strengthening exercises which are started after two weeks. They is then followed by neuromuscular control drills which are then advanced to include the dynamic stabilistion and controlled perturbation training which are done 2 to 3 weeks after the surgical operation at the 10th to the 12th week upon achievement of the neuromuscular strength, running and cutting are started (Herrington, Myer & Horsley, 2013).

Rehabilitation following an injury to the anterior cruciate ligament plays a significant role in the resumption of normal daily activities. Also, physiotherapy helps in regaining the strength and motion of the knee. Ideally, physiotherapy aims at returning the movement to the muscles as well as the knee joint. A rehabilitation program is necessary to help a patient protect the newly formed ligament through gradual strengthening by increasing stress across the ligament. The current rehabilitation programs being used in the healthcare emphasizes on the full restoration of full passive knee extension, functional exercises, weight-bearing a quick motion.

The rehabilitation program will aim at restoring the neuromuscular control. The program should start during the second week postoperatively after control of pain, swelling as well as the quadriceps control. The initial training will begin with basic exercises which include e repositioning of the joint as well as weight bearing exercises which are carried out in the medial-lateral and diagonal patterns as well as the mini squats. The squats are performed on an unstable surface such as tilt board as the patient exhibits a good posture. According to Chmielewski, Wilk & Snyder (2012), the most considerable amount of quadriceps and hamstring contraction is achieved when an individual exercises 3o degrees knee flexion during a squat.

Other exercises include the single-sided balance exercises which are performed on a piece of foam with a flexed knee which is then continued through the incorporation of a random movement of the upper extremity to bring an alteration of the center of mass (Malliaras, Morrissey & Antoniou, 2013). These exercises are used to promote dynamic stabilization and the recruitment of different muscles. The lateral lunges are also performed to encourage the neuromuscular function. In these activities, the patient is instructed to lunge on the side, land on a flexed knee and then hold in that position for 1 to 2 seconds (Holcomb et al., 2007)

While restoring the patient neuromuscular functioning, it is essential to regain the patient confidence to ensure the best possible outcomes following the ACL surgery (Holcomb et al., 2007). The perturbation skill has been shown to improve the patient's belief significantly. Research shows that active rehabilitation and return to sports following ACL surgery has been enhanced by the performance of the weight bearing and the non weight bearing exercises (Norouzi et al., 2013). However, new research has emerged on that execution of the WBE has more associated benefits such as the reduction of pain, achievement of knee stability, better results resulting to more patient satisfaction as well as a quick return to daily activities and sports. Training of the neuromuscular system has involved the WBE on the affected extremity ( Nyland, Brand & Fisher, 2010). Others include the plyometric jumping drills which are performed for the facilitation of dynamic stabilization as well training of the dissipation at the knee joint.

Rehabilitation during the preoperative phase aims at reducing the swelling, pain, inflammation as well as restoration of normal range of motion as well as reduction of muscle atrophy before surgery. This ensures that the knee returns to its pre-injury, normalized state as well as in obtaining tissue homeostasis (Escamilla et al., 2009). Patient education is also crucial since it prepares the patient before the surgical operation as well as during the postoperative rehabilitation. Therefore, there is the need for the healthcare provider and more so, the physiotherapist to provide the most appropriate training to the individuals of ACL injury to help in the achievement of the best possible outcomes.

Early rehabilitation following an ACL injury is crucial with the aim of regaining the control of the biceps, allowing immediate weight bearing, restoring full passive knee extension and gradual restoration of flexion (Sigward, Lin & Pratt, 2016). Rehabilitation of patients before surgery and after surgery is crucial for the achievement of the best possible outcomes. Preoperatively, rehabilitation mentally and physically prepares patients for surgery. The aim of the rehabilitation programs following ACL surgery helps in the restoration of the complete functionality which is unrestricted as well as returning to the patient of the pre-injury status through the achievement of the best possible long-term outcomes.

References

Buckwalter, J. A. (2010). Articular cartilage: injuries and potential for healing. Journal of Orthopaedic & Sports Physical Therapy, 28(4), 192-202.

Chmielewski, T. L., Wilk, K. E., & Snyder-Mackler, L. (2012). Changes in weight-bearing following injury or surgical reconstruction of the ACL: relationship to quadriceps strength and function. Gait & posture, 16(1), 87-95.

Escamilla, R., Zheng, N., Imamura, R., Macleod, T., Edwards, W. B., Hreljac, A., ... & Andrews, J. (2009). Cruciate ligament force during the wall squat and the one-leg squat. Medicine+ Science in Sports+ Exercise, 41(2), 408.

Herrington, L., Myer, G., & Horsley, I. (2013). Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary. Physical Therapy in Sport, 14(4), 188-198.

Holcomb, W., Rubley, M. D., & Girouard, T. J. (2007). Effect of the simultaneous application of NMES and HVPC on knee extension torque. Journal of sport rehabilitation, 16(4), 307-318.

KiM, K. M., Croy, T., Hertel, J., & Saliba, S. (2010). Effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: a systematic review. journal of orthopaedic & sports physical therapy, 40(7), 383-391.

Malliaras, P., Morrissey, D., & Antoniou, N. (2013). Rehabilitation of extreme sports injuries. In Adventure and Extreme Sports Injuries (pp. 339-361). Springer London.

Norouzi, S., Esfandiarpour, F., Shakourirad, A., Salehi, R., Akbar, M., & Farahmand, F. (2013). Rehabilitation after ACL injury: a fluoroscopic study on the effects of type of exercise on the knee sagittal plane arthrokinematics. BioMed research international, 2013.

Nyland, J., Brand, E., & Fisher, B. (2010). Update on rehabilitation following ACL reconstruction. Open access journal of sports medicine, 1, 151.

Sigward, S. M., Lin, P., & Pratt, K. (2016). Knee loading asymmetries during gait and running in early rehabilitation following anterior cruciate ligament reconstruction: A longitudinal study. Clinical Biomechanics, 32, 249-254.