WHY DO I NEED TO DO POST OPERATIVE REHABILITATION?

Following your ACL surgery Physiotherapy is essential to restore:

  1. Full range of movement,
  2. Full strength,
  3. Excellent motor control,
  4. Functional stability
  5. High level proprioceptive control.

There is no short cut in achieving these movement goals. It requires extreme dedication from you as the patient but will greatly increase your chances to return to sport and will reduce risk for knee problems in the future. Those who return to sport too early are at high risk of rupturing the other side or re-injuring the reconstructed side. You must be aware that surgery only restores the anatomical stability of the knee, it does not address the potential cause for the injury in the first place or any post operative weaknesses. Though it is a long process your rehabilitation programme is vital for a full recovery and when done well patient’s are usually stronger and fitter than they were prior to the surgery. Too often I see patients that have decided they have ‘fully recovered’ when they are able to run and return with ongoing pain or new pain that has only further delayed their original goals.

HOW LONG IS THE TREATMENT?

If you aim to return to full sport that imposes heavy rotational stress to the knee your recovery can take anything between 12-18 months. The first 6-9 months is predominantly spent with a physiotherapist, treatment past this stage will involve cross over with a strength and conditioning coach to restore maximum power to the lower limb as well as preparing your physically and mentally for return to sport. As mentioned in one of my previous blogs, it is also strongly advised that you do 4-6 weeks of prehab (recovery prior to the surgery) to ensure you go into the operation with full range of movement and good muscle activation. The longer this is delayed the longer it can take to recover so make sure you are prepared!

If you are already very active and enjoy training in the gym you know that results do not happen in weeks but over months so if you are consistent with your rehabilitation and adhere to the programme designed for you then you are giving yourself the best possible chance for an excellent recovery.

NOTE: DO BEAR IN MIND THAT IF YOU SURGERY HAS INVOLVED ADDITIONAL REPAIRS I.E. MENISCAL REPAIR THEN YOUR RECOVERY MAY BE A LITTLE DIFFERENT.

Below I will walk you through a very general rehabilitation programme following ACL reconstruction. I will mention that some surgeons can often impose different restrictions on certain activities at different times specific to you as an individual and according to their preferred protocol.

PHASE 1 (WEEKS 0-4)
  • I like to see my post op ACLR patient’s around day 7-10 post surgery. Prior to this you will be recovering from the effects of the general anaesthetic and resting.
  • Before you are discharged from the hospital a physiotherapist should have shown you how to use your elbow crutches as well as having given you some basic exercises to start working on at home. You will have a compression bandage around the knee and small plasters over the port holes where the surgeon operated. When these are first removed the area can look bruised, swollen and a little bloody around the wound sites but this is soon tidied up and your knee starts to look more normal.
  • In this first stage post op the aims are:

 

    • Reduce Pain: You will have been given some medication to help you settle pain when you leave the hospital. Most people do not like taking medication but in the early stages it is important as it makes movement easier and also enables you to rest and sleep. It is important that you start the mobility exercises early to avoid the knee getting stiff. It only makes things a lot more uncomfortable when your physiotherapist starts working on it! Eventually pain will ease and you will find that you will naturally wean yourself off the drugs.
    • Reducing swelling: this will ease with time but use of an ice pack for 10-15 mins 2-3 times a day in the early stages can help significantly. As you start moving the knee more the swelling will also start to disperse naturally.
    • Range of movement: in the first 4 weeks my priority is to gain full knee extension. If terminal range is not achieved then this can have significant effects on the mechanics of the knee, altering joint loads and effecting gait patterns. I emphasise this strongly to all my patients as in extreme cases, when range is not restored further surgery may be required. Bending (or flexion) is also worked on but is considered less important at this stage.
    • Wound management: as mentioned above, you will have some small wounds or port holes following the surgery. These will heal fast but it is important to keep the areas clean and dry. Any sign of the skin becoming very red, angry and sore then be sure to contact your consultant or GP immediately as any infection needs to be treated fast. When the skin has healed then you will be taught be your physiotherapist to start doing some light scar massage. This helps keep the scars, soft and malleable so they don’t feel tight as you start moving the knee.
    • Gait / walking re- education: as the mobility in your knee increases and the muscles start to switch on more effectively you will gain confidence in taking more weight through the effected limb. It is important that you avoid a limp as early as possible by moving through a heel to toe pattern and allowing the knee to naturally bend through the stance phase prior to taking the next step. You physiotherapist will work closely with you to achieve this and you will gradually wean yourself off the crutches.
    • Lastly, you will also be able to start some light strengthening exercises: focus will be on muscle activation through the quadriceps, hamstrings, calf muscles and gluteal muscles. You will be able to start on a stationary bike in the gym working on range of movement and even light balance exercises can be introduced within this time period. Everyone progresses at different stages and this is where working with your physiotherapist is essential to ensure you are progressed at the right pace with the right exercises.
PHASE 2 ( WEEKS 4-8):
  • The above factors are still essential to consider into stage 2 and will still be worked on as we add more strength work.
  • Through weeks 4-8 I spend a lot of time on double leg, functional exercises including sit to stands, double leg bridges and heel raises. Neuromuscular control is essential at this stage i.e. good execution of each exercises avoiding any cheating or compensatory movements. Again, this is where working with a physiotherapist is essential as they will be able to modify your exercises accordingly to ensure you achieve the right movement patterns. Failure to do so at this stage only compounds problems at later stages. It can often be a boring and frustrating stage but also one of the most important.
  • You will also start to gradually increase you cardiovascular fitness working for longer periods on the bike and also increasing your walking distances as your knee gets stronger. 1 crutch may still be required if you are on your feet for very long periods to avoid soreness but again, you will slowly adapt and find you naturally forget about it.
  • Proprioception/ balance re training is a big focus through the entire rehabilitation programme and will start in a basic fashion at this stage. Confidence is essential as you will not feel you can trust the leg. Consistency in doing your exercises both during physiotherapy sessions and at home will see faster progress.
PHASE 3 ( WEEKS 8-16)
  • At this stage you will have full range of movement, minimal swelling, little pain, a normal gait pattern and good muscle activation.
  • Strength work will progress to single leg exercises building smooth movement patterns from the ankle to knee, knee to hip and hip to trunk. Exercises will include linear and lateral movements and will also start to involve more load i.e. use of dumbells and the leg press machine.
  • Through this sage we are preparing the knee to tolerate the loads of running. Toward the later weeks of this stage you may start some light jumping drills as you prepare to land on the effected limb.
  • The development of strength and good movement patterns takes time and effort. You will not be able to start running until your physiotherapist feels you are robust enough to cope with these loads. The only way to achieve this is to be consistent with your programme. By this stage you can often start to feel quite ‘normal’ and thus desperate to start running. A lot of people, however, do attempt to run far too early which can lead to all sorts of secondary problems and thus further delays recovery. It is not easy but try to be patient. You are better to take your time and do it right than rush and cause yourself further issues later down the line.
PHASE 4 (MONTH 4-6)
  • Strength continues to be a focus. Repetitions lower and weight increases.
  • Cardiovascular fitness is pushed working on the bike, x trainer, rower etc
  • Proprioception and stability is challenged further with advanced level exercises.
  • Jumping and landing control is a big emphasis as you start to introduce a return to running programme.
  • The intensity of work outs increase and exercises become more specific to the sport(s) that you wish to return to.
PHASE 5 ( MONTH 6 -9)
  • There can be overlap in these final stages according to the individual.
  • Agility drills become a large focus at this stage including figure of 8s, shuttle runs, cutting and turning, acceleration and deceleration and introduction of a ball if this is required for your sport.
  • Ultimately the exercises become very sport specific but lack the unpredictable nature and competitive element of the sport itself.
  • Strength work still continues and running distances can be gradually increased.
PHASE 6 (9 MONTHS +)
  • Sports that impose heavy rotational forces to the knee i.e. football, netball, skiing, basketball, rugby etc will require extensive terminal stage recovery and it is at this stage that a strength and conditioning coach should be involved. For higher level athletes the sports coach also becomes involved as rehabilitation sessions prepare you for return to sport.

DO I REALLY HAVE TO DO ALL OF THIS? I ONLY WANT TO PLAY 5 ASIDE FOOTBALL TWICE A WEEK!

In short: YES! It is this category of patient that are often at even greater risk of re injury as they feel that they don’t stress their knees as much as the higher level athlete. It does not matter the level of play. There is a reason as to why you ruptured your ACL in the first place and though this may have been anatomically repaired, returning to play with a knee that has even greater functional deficits will place you at an even higher risk of re rupture. Surgery is not your cure. A FULL COMPREHENSIVE REHABILITATION PROGRAMME IS A MUST.

SO IN SUMMARY……….

ACL REHABILITATION HAS NO SHORT CUTS
FOR RETURN TO SPORT YOU NEED TO BE ABLE TO RUN AS WELL AS CHANGE DIRECTION, PIVOT, ACCELERATE AND STOP QUICKLY (TO NAME JUST A FEW REQUIREMENTS) YOU NEED TO HAVE CLEARED ALL THESE MOVEMENT GOALS IF YOU ARE TO REDUCE RISK OF RE-INJURY AS YOU RETURN TO SPORT
START YOUR REHABILITATION EARLY (EVEN PRIOR TO THE SURGERY) TO OPTIMISE RECOVERY
ONLY YOU CAN DO THE WORK, IT MAY TAKE TIME AND EFFORT BUT IF SPORT IS AN IMPORTANT PART OF YOUR LIFE THEN DEDICATION TO THIS PROGRAMME IS ESSENTIAL
Davina Sherwood
Specialist Musculoskeletal Physiotherapist