Knee rehabilitation after anterior cruciate ligament reconstruction using the patellar tendon secured with two interference screws (Kenneth Jones)

Mobility  (anterior cruciate ligament rehabilitation)

The knee should be mobilized immediately after intervention: during the first 15 days, flexion should reach 110° to 120°, achievable with gentle dailyexercises. Complete flexion (the heel touches the buttock) generally requires 90 days to be obtained. Extension is recovered immediately post-operative, without any risk to the graft. (biblio art.1). Hyper extension (physiological in a knee recurvatum) should not be sought even if a recurvatum exists in the controlateral side. Often the surgeon recommends a fixed flexion protection (of 5°) during the first 45 days to avoid all recurvatum.

Muscular reprise and musculation  (anterior cruciate ligament rehabilitation)

Return to a good muscular contraction (in particular of the vastus medialis), is the first objective of post-operative care.

To obtain this, we suggest:

• electrostimulation: it facilitates the muscular "awakening" "I mean : the muscle that is able again to contract itself again after surgery"
• the exercises are practised in a closed kinetic chain, and not in an open kinetic chain. This means that it is better to carry out the exercises by reinforcing the muscle with the foot supported on the ground. Isometric contraction (contraction without articular movement) is a useful complement. Work in an open chain (contraction with articular movement) is appropriate at the end of the rehabilitation program, when the patient is almost ready to go back to sport. Isokinetics are not advised during the first 4 months. Isokinetic exercises, however, are very important in the muscular evaluation just before the return to sport. (biblio art. 3 and 4).

Proprioceptive rehabilitation

Proprioception plays an important role after anterior cruciate ligament graft. This type of rehabilitation does not present risks to the graft. It is essential  for the prevention of iterative accidents. A study carried out by the team of Prof. Cerulli (biblio art. 5) on 600 football players, of which 300 integrated  proprioceptive work during their training over a three year period, showed 10 anterior cruciate injuries in the "proprioception" group compared with 70 in the players having had a traditional training without proprioception.

Stretching  (anterior cruciate ligament rehabilitation)

Very important: stretching must be combined with muscle building exercises.

Knee braces.

The authors advise the use of a post-operative rest splint fixed at approximately 20° . It protects the transplant during the first hours in particular after the intervention by avoiding any accidental hyperextension. It will be discarded 10 -15 days after intervention. 
A brace, on the other hand, is not necessary: no study has shown their total stabilizing effectiveness. Their only real advantage is the comfort which they give to the patient. Certain patients feel better with a flexible brace when returning to sports, but it does not have any mechanical role. Certain authors recommend that it facilitates a proprioceptive answer.(biblio art. 6)

Crutches

The authors advise walking without crutches 20-30 days after surgery. During the first few days,  partial support is allowed.

Bibliography

"Actualités dans la rééducation. Sport et rééducation du membre inférieur." Sous la direction de P. Chambat, Ph. Neyret, M. Bonnin, D. Dejour - Sauramps Medical - 2001

Art. 1 : Wascher e al. "Direct in vitro measurement of force in the cruciate ligaments." J.Bone Joint Surg. (am) 1993; vol. 75

Art. 2 : Snyder-Mackler L. - Ladin Z. - Schepsis A.A.  et al. "Elecrical stimulations of the thigh muscles after the reconstruction of the ACL." J. Bone Joint Surg. 1991; 73A, 1025:1035

Art. 3 : Middleton P. Isocinetisme et rééducation des lésions du LCA. Actualités dans la rééducation, Lyon Octobre 1997: 68.

Art. 4 : Middleton P. et al. "Rééducation après ligamentoplastie du LCA par la technique du DIDT: variantes par rapport au protocole après transplant libre au tendon rotulien." Sport Med. 2001 ; 129, 18:20.

Art. 5 : Caroffa A., Cerulli G., Proietti M., Aga G., Rizzo A. "Prevention of anterior cruciate ligament injuries in soccer." Knee Surg. Sports Traum. Arthr. 1996, 4; 19:21.

Art. 6 : Tolin B.S., Friedman M.J. "Autograft reconstruction of the antrerior cruciate ligament-semitendinous reconstruction. In Jackson D. W. et al. (eds). The anterior cruciate ligament. Current and future concepts." Raven Press Ltd. New York, 1993;305:324.