Rehabilitation and Return to Play After Anatomic Anterior Cruciate Ligament Reconstruction
Keywords
• Anterior cruciate ligament • Surgery • Knee • Rehabilitation
Key Points
Introduction
Rehabilitation after anterior cruciate ligament (ACL) reconstruction has evolved over the past 20 years and continues to advance rapidly. The evolution in rehabilitation after ACL reconstruction is in part a result of the development of different surgical procedures that address ACL injuries. In particular, recent efforts to anatomically reconstruct the ACL, which is defined as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites1 is an important consideration for postoperative rehabilitation. Anatomic ACL reconstruction may result in a more rapid return of range of motion (ROM); however, the in situ forces in an anatomically placed graft are greater (comparable with the native ACL) than those in a nonanatomically placed graft (less force than the native ACL as a result of nonanatomic position of the graft).2 As a result, rehabilitation and return to sport after anatomic ACL reconstruction may need to be progressed slower than after traditional, nonanatomic ACL reconstruction.
The safety and speed of returning patients to activity and sports after ACL reconstruction depends on the rehabilitation protocol. Initial protocols for ACL rehabilitation favored immobilization and only limited protected motion. Based on the observed problems with joint stiffness, more aggressive accelerated protocols that allowed early full ROM and immediate weight bearing became more widely accepted.3–5 A randomized clinical trial conducted by Beynnon and colleagues6 reported that no adverse effects were associated with accelerated versus traditional nonaccelerated rehabilitation in patients who underwent bone-patellar tendon-bone ACL reconstruction. In a recent systematic review, Wright and colleagues7 evaluated studies that investigated accelerated rehabilitation. In addition to the randomized trial conducted by Beynnon and colleagues,6 the systematic review identified 1 other study that reported no significant differences between a 6-month or 8-month rehabilitation program at 12 months.
Early postoperative stage (first 4–6 weeks after surgery)
The main goals of this stage (Table 1) are to control pain and swelling, protect the healing graft, minimize the effects of immobilization, obtain full passive and active extension of the knee symmetric to the noninvolved knee, achieve 100° to 120° of knee flexion, preserve quadriceps muscle function, restore the ability to perform a straight-leg raise (SLR) without a quadriceps lag, progression to full weight bearing, and achieve normal gait. To progress to the next stage, an individual should be able to walk normally without crutches or gait deviation; have full passive knee extension symmetric to the noninvolved knee, and 100° to 120° of knee flexion; have no evidence of an extensor lag, and minimal effusion or other signs of active inflammation (Table 2).
Table 1 Summary of the primary goals for each stage of rehabilitation after anatomic ACL reconstruction
| Early Postoperative | Strengthening and Neuromuscular Control | Return to Activity and Sports |
|---|---|---|
| Controlling pain and edema Protecting the healing graft Minimizing the effects of immobilization Obtaining full passive and active extension of the knee symmetric to the noninvolved knee Achieving 100° to 120° of knee flexion Preserving quadriceps muscle function Restore the ability to perform straight-leg raise without a quadriceps lag Progression to full weight bearing Achieving normal gait | Progression of strengthening Neuromuscular control Improving balance Preparation for the return to activity and sports stage | Complete the entire functional rehabilitation spectrum Make a full return to the patient’s previous level of daily, occupational and athletic activity, and sport participation |
Table 2 Summary of the critical milestones for progression of rehabilitation after anatomic ACL reconstruction
| Early Postoperative | Strengthening and Neuromuscular Control | Return to Activity and Sports |
|---|---|---|
| Patients should be able to walk normally without crutches or gait deviation Have full passive knee extension symmetric to the noninvolved knee Have at least 100°–120° of knee flexion Have no evidence of an extensor lag Have minimal effusion or other signs of active inflammation | Patients should have no difficulty with daily activities Should tolerate all strength and flexibility exercises without evidence of joint pain or inflammation Should be able to jog 3.2 km (2 miles) (if possible previous to injury) and tolerate submaximal multidirectional functional activities | Patients should achieve a quadriceps index of 85% or greater Have satisfied all the previous criteria (appropriate ROM, strength, proprioception, and endurance) for functional progression Able to tolerate full-effort sprinting, cutting, pivoting, jumping, and hopping drills |
Controlling pain and swelling is one of the most important goals in the early postoperative rehabilitation stage after ACL reconstruction. Reducing pain and swelling leads to improved ROM and quadriceps function and reduces the risk of limited ROM and contracture, which could later cause gait abnormalities and delay in the progression to the next stage. Control of pain and swelling can be achieved by following the ICE (ice, compression, and elevation) principle. A combination of these techniques results in better outcomes. Cryotherapy has been found to cause significant decrease in postoperative pain.8 In some challenging cases, nonsteroidal antiinflammatory drugs may be prescribed to control postoperative swelling and inflammation.
To protect the graft early after surgery, crutches and a postoperative brace are used. Patients typically ambulate with axillary crutches weight bearing as tolerated (WBAT), with knee brace locked in full extension for 1 week. After 1 week, unless the patient has a concomitant meniscus repair, the brace can be unlocked for ambulation. If the patient had a meniscus repair, the brace should remain locked in extension for ambulation for 4 to 6 weeks to reduce shear stresses on healing meniscus during ambulation.9 The brace is continued until the patient has comfortably achieved at least 100° to 120° of knee flexion.
Restoration of ROM is also crucial in this stage. Achieving full extension symmetric to noninvolved knee and 100° to 120° of flexion is important in the early postoperative stage of rehabilitation. If the patient had a concomitant meniscus repair, they progress more slowly because knee flexion should be limited to less than 90° for 4 weeks after surgery. Failure to achieve these ranges may lead to gait abnormalities, patellofemoral pain, and in the long-term may contribute to degenerative joint disease. Activities to increase ROM after ACL reconstruction include the immediate initiation of heel slides, gastrocnemius and hamstring stretches, and passive, active-assisted, and active knee flexion exercises. Pedaling a stationary bicycle through a partial revolution progressing to a full revolution is also beneficial for restoring the range of knee flexion. A continuous passive motion (CPM) device may be used for select cases; however, 2 systematic reviews have shown no substantial advantage for the use of CPM except for a possible decrease in postoperative pain.10,11 Patellar mobilization is used to maintain or increase patellar mobility. Inferior mobilization for the patella should be used if the patient has loss of passive flexion and decreased inferior patellar translation during mobility testing. Superior glide of the patella is important to ensure full active knee extension, which requires the quadriceps to pull the patella superiorly.
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