ACL-surgery



ACL-surgery

ANTERIOR CRUCIATE LIGAMENT TEAR (ACL)

When is ACL-surgery necessary to repair a torn anterior cruciate ligament?

Indications for ACL-surgery (Who Needs Surgery, When, Why, and Goals)

  • Athletes who regularly perform sports that require pivoting, cutting, and jumping and landing
  • Patients with recurrent giving way or knee instability, despite 3 to 6 months of an adequate rehabilitation program
  • Patients with an anterior cruciate ligament (ACL) tear and a reparable meniscus tear
  • Patients with an ACL tear and other ligament injuries in the same knee

ACL-surgery usually is not recommended until the injured knee has full range of motion and muscle control of the thigh (usually 3 or more weeks following injury). In surgical repair of an ACL tear, the torn ligament is replaced because the ligament, when torn, usually cannot be repaired (sewn together). Results after repair of the ligament are not as good as after reconstruction (replacement) of the ligament.

The goal of the operation is to restore the function of the torn ligament—that is, to allow a return to sports that require pivoting, cutting, change of direction, and jumping and landing. ACL grafts undergo a degeneration process (the graft is usually at its weakest 6 weeks after the surgery) followed by a regeneration process, which may take up to 1½ years.

Contraindications (Reasons Not To Operate)

  • In those individuals who do not perform sports that require pivoting, cutting, and jumping and landing frequently, surgery usually is not required.
  • Individuals who exercise by jogging, cycling, or swimming only usually do not require ACL-surgery.
  • Persons who demonstrate an inability or unwillingness to complete the postoperative program or to perform the rehabilitation necessary should not have surgery.
  • Infection of the knee, current or previous, is a concern but not an absolute contraindication.
  • If the patient is not yet fully grown (skeletal immaturity), surgery may not be recommended until the patient is fully grown, but this is not an absolute contraindication.
  • Persons with severe knee arthritis should not have surgery.

Risks and Complications of Surgery

  • Infection; bleeding; injury to nerves (numbness, weakness, paralysis) of the knee, leg, or foot (it is not uncommon to have some numbness, temporary or permanent, on the outer part of the upper leg)
  • Rupture or stretching of the reconstructed ligament, causing recurrent instability
  • Knee stiffness (loss of knee motion)
  • Rupture of the patellar tendon or patellar fracture (both uncommon)
  • Pain from screw used to hold the graft (rare)
  • Clot in the veins of the calf or thigh (deep venous thrombosis, phlebitis) that may break off in the bloodstream and go to the lungs (pulmonary embolus) or brain (causing a stroke)

Technique (What Is Done)

ACL-surgery is usually performed with the assistance of an arthroscope; it may be done on an outpatient basis (you go home the same day), or you may stay in the hospital overnight. The torn ACL is replaced by a graft. Grafts most commonly used include (1) the central third of the patellar tendon, from the same or opposite knee; (2) hamstring tendon; (3) quadriceps tendon; and (4) allograft (transplant from a cadaver) patellar tendon or Achilles tendon. Each graft has its benefits and risks, and the type used for your graft is determined based on a discussion between you and your surgeon.

When the torn ACL is removed, some bone in the knee is shaved to help the surgeon see where the graft goes and to help reduce pressure on the graft. Other structures in the knee are examined at the time of reconstruction, including the meniscus and articular cartilage. Bone tunnels are drilled in the leg bone and the thigh bone to place the ligament in almost the exact same position as the torn ACL was. The graft is held in position with screws, heavy sutures (stitches), spiked washers, or posts. The devices used to hold the graft in place usually do not need to be removed.

Postoperative Course

  • This surgery is often felt to be therapy dependent. In other words, much of the success of ACL reconstruction is dependent on the patient and therapist and being able to follow through on and maintain the therapy schedule.
  • Keep the wound clean and dry for the first 10 to 14 days after surgery.
  • Ice the knee for 20 minutes every 2 to 3 hours while awake for the first 1 to 2 weeks after surgery.
  • Your physician will prescribe pain medications. Take only as directed and only as much as you need.
  • You may be given a knee brace after surgery.
  • Goals for rehabilitation after ACL-surgery / reconstruction include reducing knee swelling, regaining knee range of motion, and regaining strength in the leg and thigh muscles. Check with your surgeon or physical therapist for the exact exercises to perform. Often a graduated program is specified.

Return To Sports

You may return to sports when there is no pain and when full knee range of motion, muscle strength and endurance, and functional use has been restored. This usually requires 4 to 6 months following ACL-surgery.

Notify Our Office if:

  • You experience pain, numbness, or coldness in the foot and ankle
  • Blue, gray, or dusky color appears in the toenails
  • You experience increased pain, swelling, redness, drainage, or bleeding in the surgical area
  • You have signs of infection (headache, muscle aches, dizziness, or a general ill feeling with fever)
  • New, unexplained symptoms develop (drugs used in treatment may produce side effects)
  • Contact 401-632-0868 or through our website
  • my-physical-therapy-coach.com

Do not eat or drink anything before surgery. Solid food makes general anesthesia more hazardous.


EXERCISES after ACL-surgery

RANGE OF MOTION AND STRETCHING EXERCISES •

Anterior Cruciate Ligament Tear, Surgery For—Phase I

These are some of the initial exercises you may start your rehabilitation program with for the first 2 weeks after surgery, until you see your physician, physical therapist, or athletic trainer again. Please remember that it is critical that you follow the instructions of your physician, physical therapist, or athletic trainer.

Regaining your range of motion, especially the ability to fully straighten out your knee as soon as possible after surgery, is critical. Based on your individual needs and your surgery, your physician, physical therapist, or athletic trainer may choose a more or less aggressive approach than the exercises presented.

RANGE OF MOTION Knee Flexion

1.Lie on your back with your legs out straight.
2. Slowly slide your heel toward your buttocks. Bend your knee as far as is comfortable to get a stretching sensation.
3. Hold for _____ seconds.
4. Return your leg to the starting position.
5. Repeat exercise _____ times, _____ times per day.



RANGE OF MOTION • Knee Flexion and Extension

1.Sit on the edge of a table or chair.
2. Use the uninjured/unaffected leg to straighten (extend) and bend (flex) the injured/affected leg.
3. Flexion— Cross your ankles, placing the uninjured or unaffected leg on top of the injured/affected leg. Pull your heel(s) backward under the surface you are sitting on to increase the amount you can bend your knee.

4. Extension— Cross your ankles, placing the uninjured or unaffected leg under the injured/affected leg. Pull your heel(s) backward under the surface you are sitting on to increase the how much you can straighten your knee.
5. Repeat exercise _____ times, _____ times per day.

RANGE OF MOTION Knee Extension, Prone

1.Lie on your stomach on a bed or sturdy table with your knee and leg off the table. The kneecap should be off the edge of the bed or table.
2. Allow gravity to straighten your knee for you.
3. Hold this position for _____ seconds.
4. Repeat exercise _____ times, _____ times per day.

Note: If authorized by your physician, physical therapist, or athletic trainer, you may place a _____ weight on your ankle to obtain a more effective stretch.



RANGE OF MOTION • Knee Extension Sitting

1. Sit with your leg/heel propped on another chair as shown. You may also prop your foot up on a rolled-up towel, a table, or a foot stool.
2. Relax, letting gravity straighten out your knee.
3. Hold this position for _____ seconds.
4.Repeat exercise _____ times, _____ times per day.

Note: If authorized by your physician, physical therapist, or athletic trainer, you may place a _____ weight on your thigh just above your kneecap to obtain a more effective stretch.



RANGE OF MOTION • Gravity Knee Flexion

1. Lie on the floor as shown with your toes/foot lightly touching the wall.
2. Allow your toes/foot to slide down the wall, allowing gravity to bend your knee for you.
3. Obtain a “comfortable” stretching sensation.
4. Hold this position for _____ seconds. Then return the leg to the starting position.
5. Repeat exercise _____ times, _____ times per day.



STRENGTHENING EXERCISES • Anterior Cruciate Ligament Tear, Surgery For—Phase I

These are some of the initial exercises you may start your rehabilitation program with for the first 3 weeks after surgery, until you see your physician, physical therapist, or athletic trainer again. Please remember that it is critical that you follow the instructions of your physician, physical therapist, or athletic trainer. Based on your individual needs and your surgery, your physician, physical therapist, or athletic trainer may choose a more or less aggressive approach than the exercises presented. Please remember:

  • Strong muscles with good endurance tolerate stress better.
  • Do the exercises as initially prescribed by your physician, physical therapist, or athletic trainer. Progress slowly with each exercise, gradually increasing the number of repetitions and weight used under their guidance.



STRENGTH • Quadriceps, Isometrics

1. Lie flat or sit with your leg straight.
2. Tighten the muscle in the front of your thigh as much as you can, pushing the back of your knee flat against the floor. This will pull your kneecap up your thigh, toward your hip.
3.Hold the muscle tight for _____ seconds.
4. Repeat this exercise _____ times, _____ times per day.


STRENGTH Quadriceps, 7 Count

The quality of the muscle contraction in this exercise is what counts the most, not just the ability to lift your leg!

1. Tighten the muscle in front of your thigh as much as you can, pushing the back of your knee flat against the floor.
2. Tighten this muscle harder.
3. Lift your leg/heel 4 to 6 inches off the floor.
4.Tighten this muscle harder again.
5. Lower your leg/heel back to the floor. Keep the muscle in front of your thigh as tight as possible.
6. Tighten this muscle harder again.
7. Relax.
8. Repeat exercise _____ times, _____ times per day.

STRENGTH Hamstring, Isometrics

1. Lie on your back on the floor or a bed.
2. Bend your knee approximately _____ degrees.
3. Pull your heel into the floor or bed as much as you can.
4.Hold this position for _____ seconds. Rest for _____ seconds.
5. Repeat exercise _____ times, _____ times per day.

STRENGTH Hamstring, Curls


1. Lie or your stomach with your legs out straight.
2.Bend knee to 90 degrees. Hold this position for _____ seconds.
3. Slowly lower your leg back to the starting position.
4. Repeat exercise _____ times, _____ times per day.

Additional Weights: OK TO USE DO NOT USE!!!

If okay’d by your physician, physical therapist, or athletic trainer, a _____
pound weight may be placed around your ankle for additional weight.



STRENGTH • Quads

1. Stand with your feet shoulder-width apart and place equal weight on both legs.
2. Keep your kneecaps in line with your toes.
3. Slowly bend both knees, keeping equal weight on both legs, and return to a standing position.
4. Do not bend your knees more than 90 degrees.
5. You may use the edge of a table or counter for balance if needed.
6.Repeat exercise _____ times, _____ times per day.

STRENGTH Isometric Quad/VMO

1. Sit in a chair with your knee bent 75 to 90 degrees as shown in the drawing.
2. With your fingertips, feel the muscle just above the kneecap on the inside half of your thigh. This is the VMO.
3.Push your foot and leg into the floor to cause the thigh muscles to tighten.
4. Concentrate on feeling the VMO tighten. This muscle is important because it helps control the position of your kneecap.
5. Tighten and hold for _____ seconds.
6. Repeat exercise _____ times, _____ times per day.

STRENGTH Hip Abduction


1. Lie on your side as shown with the injured/weak leg on top.
2. Bend the bottom knee slightly for balance. Roll your top hip slightly forward.

3. Lift your top leg straight up, leading with your heel. Do not let it come forward. Hold this position for _____ seconds.
4. Slowly lower your leg to the starting position.
5.Repeat exercise _____ times, _____ times per day.

STRENGTH Hip Extensors

1. Lie on your back as shown with your knees bent and feet flat on the floor.
2. Fold your hands over your stomach or chest.
3.Tighten your buttocks, push down with your feet, and raise your buttocks as high as possible.
4. Hold this position for _____ seconds.
5. Repeat exercise _____ times, _____ times per day.



STRENGTH • Plantarflexors

1. Stand with feet shoulder-width apart. Hold on to counter or chair if necessary for balance.
2. Rise up on your toes as far as you can. Hold this position for _____ seconds.
3.Complete this exercise using only one leg if it is too easy using both legs.
4. Repeat exercise _____ times, _____ times per day.

PATELLA Self Mobilization, Knee Extended


1. Sit with your knee straight out in front of you.
2. Grasp your kneecap with the thumb and index finger of both hands as shown in the drawing.

3. Slide your kneecap toward the inside and outside of your leg, toward your hip, and toward your toes as shown.
4. Hold each position for _____ seconds.
5.Repeat exercise _____ times, _____ times per day.



RANGE OF MOTION AND STRETCHING EXERCISES •

Anterior Cruciate Ligament Tear, Surgery For—Phase II

These are some of the exercises you may progress to in your rehabilitation program after surgery. These exercises are usually done during the third to sixth weeks. Please remember that it is critical that you follow the instructions of your physician, physical therapist, or athletic trainer. Regaining your full range of motion is critical. You should have at least 75% of your normal range of motion by this point in time. If you do not have sufficient range, please continue all Phase I exercises. You may also use a bike for obtaining range of motion, as illustrated below along with the other exercises presented. Based on your individual needs and your surgery, your physician, physical therapist, or athletic trainer may choose a more or less aggressive approach than the exercises presented.

1. Sit on the bike in a comfortable position.
2. Use the leg that did not have surgery to assist in regaining motion in the knee that had surgery. Push the pedals of the bike backward and forward to help stretch the knee and regain motion.
3.With permission of your surgeon, physical therapist, or athletic trainer, this exercise may be started earlier than week 3.

STRETCH Quadriceps, Prone

1. Lie on your stomach as shown.
2. Bend your knee, grasping your toes, foot, or ankle. If you are too “tight” to do this, loop a belt or towel around your ankle and grasp that.

3. Pull your heel toward your buttock until you feel a stretching sensation in the front of your thigh.
4. Keep your knees together.
5.Hold this position for _____ seconds.
6. Repeat exercise _____ times, _____ times per day.



STRENGTHENING EXERCISES • Anterior Cruciate Ligament Tear, Surgery For—Phase II

These are some of the exercises you may progress to in your rehabilitation program after surgery. These exercises are usually done during the third to sixth weeks. Please remember that it is critical that you follow the instructions of your physician, physical therapist, or athletic trainer. Based on your individual needs and your surgery, your physician, physical therapist, or athletic trainer may choose a more or less aggressive approach than the exercises presented. Please remember:

  • Strong muscles with good endurance tolerate stress better.
  • Do the exercises as initially prescribed by your physician, physical therapist, or athletic trainer. Progress slowly with each exercise, gradually increasing the number of repetitions and weight used under their guidance.
  • Continue all Phase I exercises as needed.

STRENGTH• Quadriceps, Bike


1. Start this exercise when you can make a full circle with the pedals.
2. Sit in a comfortable position on the bike.
3. Set the resistance so that you feel your quadriceps (muscles in front of your thigh) work when you pedal.
4.Pedal for a total of _____ minutes per day.
5. For a harder workout, pedal with only the operated knee/leg.




STRENGTH • Quadriceps, Step-Ups

1. Use a step or books.
2.Place your foot on the step or books approximately _____ inches in height. Make sure that your kneecap is in line with the tip of your shoe or your second toe.
3. Hold on to a hand rail, chair, wall, or another object for balance if needed.
4. Slowly step up and down. Make sure that the kneecap is always in line with the tip of your shoe or your second toe. Lightly touch the heel of the opposite leg to the floor and return to the starting position.
5. Repeat exercise _____ times, _____ times per day.



STRENGTH • Quadriceps, Wall Slide

1. Stand with your back against the wall. Your feet should be shoulder-width apart and approximately 18 to 24 inches away from the wall. Your kneecaps should be in line with the tip of your shoes or your second toe.
2. Slowly slide down the wall so that there is a _____ degree bend in your knees. (Your physician, physical therapist, or athletic trainer will instruct you how to progress the amount of bend based on your symptoms and diagnosis.)
3. Hold this position for _____ seconds. Stand up and rest for _____ seconds.
4. Repeat exercise _____ times, _____ times per day.

STRENGTH Quads
1. Lie on your back as shown in the drawing.

2. Bend your hip to 90 degrees as shown, and use both to hold the back of the thigh of the leg that has had surgery.
3. Slowly straighten your knee against gravity. Slowly return to your starting position.

4. Go as far as you can without discomfort.
5. Repeat exercise _____ times, _____ times per day.

STRENGTH Hip Extension

1. Lie on your back with your knees bent and feet flat on the floor.
2.Push down, raising your hips/buttocks off the floor.
3. Keep your pelvis level. Do not allow it to turn/rotate.
4. You may do this exercise with both legs together (which is easier) or with just one leg as shown (which is harder). Hold this position for _____ seconds.
5. Slowly lower to the starting position.
6. Repeat exercise _____ times, _____ times per day.


STRENGTH • Hip Adduction

1. Lie on your side as shown with the injured/weak leg on the bottom.

2. Place the foot of your top leg flat on the floor for balance. It may be in front or behind the bottom leg.
3. Lift the bottom leg as shown. Hold this position for _____ seconds.

4. Slowly lower your leg to the starting position.
5. Repeat exercise _____ times, _____ times per day.







For specific physical therapy guidelines after ACL-surgery related to your condition contact us to make an appointment

To access our therapeutic exercise members site for fully animated illustrations of exercises after ACL-surgery click here


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