Bismillahirahmanirahim ,
For this entry i would like to share one of the protocol of the guideline after went
Anterior Cruciate ligament Replacement patella tendon autograft.
ACL RECONSTRUCTION REHABILITATION PROTOCOL
PROCEDURE :PATELLA TENDON AUTOGRAFT
GENERAL CONSIDERATION
1. Pre-surgical phase to explain the protocol ,condition ,non injured extremities
2. Shown post –op basic quad /hamstring /gastroc exercises
3. Gait training instruction with crutches -FWB as soon as tolerated
STAGE 1
GOAL
· Reduce pain/oedema and swelling
· Promote muscle activity and strength
· Maximum protection of graft
EVALUATION
1. Pain and swelling
2. Quadriceps contraction
3. Patella mobility
4. ROM
TREATMENT
DAY 1
· Brace locked 0 degree and worn 24 hours (keep extension 0 degree)
· Ice and elevation of knee – compression wrap should be warn to control swelling
· Active calf and ankle pumping
· Heel slides (as tolerated )
· Static quads to SLR
· Stretching hamstring and gastroc
DAY 2
· CPM (0- flexion as tolerated –heel slides
· Active /assisted ROM as tolerated
· Knee brace locked at 0 degree (aggressive measure must be taken to regain extension )
· PWB to FWB as tolerated –with bilateral axillary crutches
· SLR for quads (multiple angle )/isometics
· Balance /weight shifting
· Soft tissue treatment –gentle patella mobs and incision
· Hamstring set /slides ,resisted exercises with sand bag /theraband
· Hip abduction /adduction
· Stretching hamstring and gastrocnemius
· Finish with ice /IFT /current stimulation VMO
DAY 3-4
· Continue CPM and increase ROM as tolerated
· PWB to FWB as tolerated
· Start active /resisted exercises with sand bag /theraband
· Patella mobility
· Prone lying –prone hang for extension
· Finish with ice /IFT/current stimulation
DAY 4-7
· Discharge home –continue physio as out patient daily
· Achieve full extension knee /SLR /no ext lag
· Continue CPM until FROM
· Continue strengthening and stretching exercises for gastroc /calf raise up on steps
· Leg press <90 -0
· Continue with modalities and ice .
WEEKS 1
GOALS
· PROM 20-70 degree
· control of inflammation and effusion
· prevention of adhesion of patellofemoral joint
· WBAT
· Quadriceps set with patella movement
· promote muscle activity and strength
EVALUATION
1. pain
2. heamathrosis
3. patella mobility and ROM
4. quadriceps contraction
TREATMENT
· Pain management and control of hemarthrosis with ice ,EGS ,elevation ,ankle pumps 5’/hours for circulation
· Mobilisation of patella for 5 minutes /4x/day
· Rom exercises :heel slides /prone curl
· Muscle reeducation :Quad set ,hamstring set ,SLR in 2 position 10 sec x10 /SLR in supine ,electrical stimulation /biofeedback as needed for VMO reeducation
· Start stepper
· ROM brace 0-90 degree (open brace for quad function )
· Still locked in extension for sleep
· Balance and proprioceptive exercises
WEEKS 2-3
GOALS
1. Stitches /staple out at 2 weeks post op
2. PROM 0-125 degree /AROM >110degree
3. Quadriceps muscle control
4. Control of inflammation and effusion to prevent scaring
5. WBAT with crutches
6. Normal patella mobility
7. Prevent of quadriceps athropy
EVALUATION
1. Pain and effusion
2. Patella mobility
3. ROM
4. Muscle control
TREATMENT
· Continuation pain management and effusion control with ice , elevation ,continuation of ankle pumps
· Continuation of patella mobility
· ROM : heel slides ,AAROM on bike with no resistance (cycle with high reps /low torque),continuation of CPM until achievement of 0-120degrees
· Continuation of electrical stimulation biofeedback for VMO until good quad set with full patella movement
· Strengthening exercises :
Ø 4 ways SLR ,beginning weight proximal –distal when patient has good knee control
Ø Prone curl
Ø Sitting hip flexion ,weight proximal
Ø Pillow squeezes adduction
Ø Leg press are used within a pain free range of motion /stepper
Ø Weight –bearing exercises begin when 50% WB
Ø -toe raise on step
Ø Mini squat /mini wall squats -45 degree –progression from standing both legs to single leg
· Balance board
· Continuation of ROM brace 0-120 degree
· Water exercises may be recommended –home progress such as knee bending /straighthening and pool walking with emphasis on forward /backward and sideways movement –depend on surgical area
· Progression using a stairs ,stepper from sitting position to a standing position at 3-4 week if good quadriceps control present .
CRITERIA FOR PROGRESSION FROM ACUTE PHASE TO RECOVERY PHASE
1. Pain and effusion control
2. ROM 5-115 degrees
3. Quadriceps control ,ability to lift 8-10 lbs for SLR
4. Ambulation single crutches to independent –no crutches if possible
RECOVERY PHASE
WEEK 4-8
GOALS
1. ROM 0-135 degree push full ROM with normal patella mobility
2. 100% FWB with a normal gait and coordination
3. Improvement of muscular endurance and control
4. Control of inflammation and effusion
5. Fit with functional brace
EVALUATION
1. Pain and effusion
2. Patella mobility and ROM
3. Complete extension
4. Gait
5. Muscle control
TREATMENT
· Continuation of pain management /effusion control
· ROM ,flexibility (quad ,hamstring ,gastroc, illiopsoas )
· Strengthening /endurance training ;closed chain ,isotonic ,bike (increase resistance )
· Balance training(balance board ) ,bilateral stance activities progressing to single stance
· Addressing of gait abnormalities –gait training on the treadmill ,using slight incline and progress to pedaling backward
· Functional brace
· Calf stretching and strengthening , cont all previous hamstring exercises
CRETERIA FOR PROGRESSION FROM RECOVERY PHASE TO FUNCTIONAL PHASE
1. Absence of effusion
2. Joint stability
3. FWB with normal gait
4. Performance of ADL without pain
5. Knee ROM 0-135 degree to FROM
MAINTENANCE PHASE
WEEKS 8-24++
GOALS
1. Increase in strength and endurance so that there is no fatigue with ADLs
2. Preparation for return to sport activity
3. Sport –specific training to full return to athletic activity
4. Full ROM of the knee
EVALUATION
1. Swelling
2. PF mobility and crepitus
3. Ligament stability
TREATMENT
· Increase in isotonic exercises :per iodization or daily adjustable progression resistive exercises (DAPRE);initiation of isokinetics midrange velocity Q/H ,initiation of quads isotonics 90-30 degree with care for PF symptoms
· Aerobic conditioning :low –impact bike ;stairs masters ,treadmill ,swimming
· Proprioceptive training :progress to closed chain rehabilitation exercises /balance board
· Progression to jogging when medically cleared –individual progress
· Progression in sport –specific activity
· Maintenance and improvement in neuromuscular strength
· Cross over walking /figure of eight
·
CRITERIA FOR PROGRESSION FROM STAGE 111 TO RETURN TO SPORT
1. Absence of pain
2. Isokinetics test 80 % of uninvolved leg
3. Satisfactory clinical exam by physician
4. Normal performance of sport –specific exercises
Note :this general guideline for ACL Reconstruction .The exercises programs may be advance if patient tolerate more but careful assessment of laxity ,increases effusion or pain must be monitored by Physiotherapist .
Patient with collateral ligament involvement may need to avoid certain exercises in first 6 week period post-op ,however those with meniscus involvement should have no problems with this rehabilitation programs .
Wallahuaklam...
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