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Physiotherapy, Rehabilitation, and Post-Operative Aspects Pertaining to Ligament Surgeries
See also Evaluation of the Reconstructed Knee , Post-Reconstruction Problems: Infection, Impingement, Arthrofibrosis, Cyclops Lesions, Baker's Cysts and Proprioception and Neuromuscular Considerations. (Note that rehabilitation from non-ligamentous problems, for example meniscal/articular-cartilage repair and patellofemoral issues, is covered under the respective sections of these topics. If you are looking for articles on rehabilitation in these areas, please return to the Main Index Page and scroll down to the appropriate section.)
For a brief overview of knee anatomy, physiology, and biomechanics, please click here.
For knee-rehabilitation resources, including rehabilitation protocols and exercises, please visit General Knee-Rehabilitation Resources (protocols, exercises, etc.).
Note: Chapters from the superbly detailed and highly readable book Knee Ligament Rehabilitation, edited by Todd Ellenbecker and published by Churchill Livingstone in 2000, can be found under Textbook Chapters, Conference Proceedings, and Other Resources. This book, destined to become a classic, provides a very comprehensive yet wonderfully understandable discussion of all facets of knee-ligament rehabilitation.
Low-Intensity Pulsed Ultrasound Accelerates and a Nonsteroidal Anti-inflammatory Drug Delays Knee Ligament Healing, Stuart J. Warden et al.; The American Journal of Sports Medicine, Baltimore; July 2006, Vol 34, p. 1094-1102. Comments: This intriguing study, done on rats, shows that ultrasound accelerates medial-collateral-ligament healing and NSAIDs (non-steroidal anti-inflammatory drugs, such as Advil) delay it. However, the quality of the actual healing apparently remained unaffected. Still, it might be advisable to avoid excessive use of anti-inflammatory drugs (which have been heavily marketed by the drug companies) and instead rely on more traditional anti-inflammatory means such as icing. This is something to discuss with one's orthopedist and physiotherapist. (The authors quote Provenzano, who researched the effects of different flexion angles and loadings on knee ligaments and healing.) As with any laboratory-only study, keep in mind that the results have not yet been confirmed clinically in humans. Remember, too, that the human knee is far more highly stressed that the knee of a rat. Not only do humans have much longer legs (both in absolute terms and proportionally in terms of overall body size), but human walk on two legs and thus exert vastly higher forces (including torques and dynamic loadings) on their knees. But in any case, the worrisome side effect of NSAIDs (in this case, slower graft incorporation, hence more opportunity for the graft to be damaged) remains. In short, please remember that there is no such thing as a drug without side effects! Note that even though this study looked at MCL "self-healing" (remember that the MCL is the only knee ligament capable of meaningful self-healing via scarring-over, and even then results are imperfect), the NSAID-healing-inhibition effect would be expected to apply to any ligament injury, including ligament reconstruction (ACL, PCL, LCL, etc.).
Bone Mineral Density in the Proximal Tibia and Calcaneus Before and After Arthroscopic Reconstruction of the Anterior Cruciate Ligament, Bo Zerahn et al.; Arthroscopy: The Journal of Arthroscopic & Related Surgery; March 2006, Vol 22, p. 265-269. Comments: This study found that bone-mineral density (BMD) drops after ACL reconstruction, but eventually recovers to a level approaching that of prior to surgery. Exercise improves the BMD recovery, both in terms of rapidity of regainment and in terms of amount regained. Again, we see the importance of a well-organized, diligently pursued physiotherapy regimen.
For a good discussion of rehabilitation considerations pursuant to ACL reconstruction, please see the November 2005 article Clinical Sports Medicine Update: Treatment of Anterior Cruciate Ligament Injuries, Part 2, by Bruce Beynnon et al., in the ACL Reconstructions via Patellar-Tendon Autografts Subsection. For insight into the benefits obtained by adding resistance to the standard ACL-rehabilitation exercise of single-legged squats, see the October 2005 article Neuromuscular Control of the Knee During a Resisted Single-Limb Squat Exercise, by Shields et al., in the Proprioception and Neuromuscular Considerations Subsection. Rehabilitation After Anterior Cruciate Ligament Reconstruction -- A Prospective, Randomized, Double-Blind Comparison of Programs Administered Over 2 Different Time Intervals, Bruce D. Beynnon et al.; The American Journal of Sports Medicine, Baltimore; March 2005, Vol 33, p. 347-359. Comments: The authors found that delayed and accelerated ACL-reconstruction-rehabilitation protocols both bring good results. However, they looked for more than just the improvement in knee stability, and delved into the issue of long-term effects on articular cartilage. They noted with concern that the levels of articular-cartilage biomarkers remained elevated for extended periods; this is something which merits further investigation. But the elevated biomarkers do indeed confirm that an ACL-injury history has a major impact on articular cartilage.
For insight into how tensile loadings in the ACL and PCL (or ligament grafts) are influenced by contractions of both the hamstring and quadriceps groups, see Effects of Applied Quadriceps and Hamstrings Muscle Loads on Forces in the Anterior and Posterior Cruciate Ligaments, by Keith L. Markolf et al., in the Knee Biomechanics, Functional Anatomy of ACL Subsection. Bilateral Anterior Cruciate Ligament Reconstruction as a Single Procedure — Evaluation of Cost and Early Functional Results, Christopher M. Larson et al.; The American Journal of Sports Medicine, Baltimore; January 2004, Vol 32, p. 197-200. Comments: This article shows that when someone presents with bilateral ACL tearing, having both ACLs reconstructed simultaneously engenderes benefits of time saved and less cost. From the patient's point of view, the real benefits might apply more to the insurance companies (who, of course, are forever interested in inbuing orthopedic surgeries with the efficiency of a high-speed office photocopier); however, patient benefits of simultaneous reconstruction could accrue in the form of less likelihood of developing limping (a consequence of many types of assymetry, including having one freshly reconstructed knee and one nonreconstructed knee, at any point in time) and reduced time consumed in rehabilitation (given that both knees can be exercised simultaneously, and so the overall time spent in rehab would theoretically be halved; therefore one could anticipate a sooner return to sports). Many people with bilateral ACL tearing have staggered ACL reconstructions, but some go the simulataneous route. (The founder of Bob's ACL WWWBoard, software developer Bob Willmot, tore both ACLs simultaneously in an alpine-skiing accident but underwent staggered ACL reconstructions; however, keep in mind that this was back in 1996.) Note that if the bilateral ACL tearing is accompanied by meniscal tearing (especially if the meniscal tearing is also bilateral), and if said meniscal tears are repaired (as they should be; note that repair is far superior to partial menisectomy), then being non-weight-bearing for a number of weeks will be indicated...and in such a case, having surgery on both knees at the same time would present heightened postoperative mobility concerns. (In this study, no one underwent meniscal repair.) As with all knee surgeries, these are issues to discuss in depth with both one's orthopedic surgeon and one's physiotherapist.
. Sagittal plane knee translation and electromyographic activity during closed and open kinetic chain exercises in anterior cruciate ligament-deficient patients and control subjects, Joanna Kvist; The American Journal of Sports Medicine, Baltimore; Jan/Feb 2001, Vol 29/1, p. 72. Comments: Kvist notes that for ACL-deficient knees, closed-kinetic-chain exercises are preferable to open-kinetic-chain exercises. This is also true for nascent-ACL-harbouring knees. (Closed-kinetic-chain exercises are characterized by the foot bearing weight throughout the entire exercise.) Anterior Cruciate Ligament Reconstruction: Evolution of Rehabilitation, K. Donald Shelbourne and Rocci V. Trumper; Knee Ligament Rehabilitation, edited by Todd S. Ellenbecker.
Philadelphia, Pennsylvania: Churchill Livingstone (Harcourt), 2000. Pages 106-116.
Comments: Donald Shelbourne is a pioneer in ACL-reconstruction rehabilitation. This chapter describes how ACL-surgery rehabilitation has progressed from long immobilized periods and permanent stiffness (range-of-motion deficits) to the modern standard of immediate mobilization and (for first-time ACL reconstructions with no complicating factors such as multiple-ligament reconstructions or meniscal repair) prompt weight-bearing and accelerated ramping-up of activities. Shelbourne also discusses the evolution of ACL-reconstruction surgical procedures, and notes the close interrelationships between surgery and rehabilitation. Additionally, Shelbourne describes how he has learned from his experiences as a surgeon. He points out that the accelerated ACL-rehab protocol can be traced to patients who were noncompliant with the very restrictive original protocol. Shelbourne also notes the importance of early range-of-motion regainment, and the need for control of swelling. In practice, the measures taken for swelling control and range-of-motion regainment include the use of ice, compression, elevation, and CPM (continuous passive motion).
Evaluation of knee stability before and after participation in a functional sports agility program during rehabilitation after anterior cruciate ligament reconstruction, K. Donald Shelbourne; The American Journal of Sports Medicine, Baltimore; Mar/Apr 1999, Vol 27/2, p. 156. Comments: Shelbourne found that an accelerated rehabilitation programme, entailing nimbleness training in preparation for knee-demanding sports endeavours, did not cause loosening of the reconstructed ACL. The Effect of Exercise and Rehabilitation on Anterior-Posterior Knee Displacements After Anterior Cruciate Ligament Autograft Reconstruction, Sue D. Barber-Westin; The American Journal of Sports Medicine, Baltimore; Jan/Feb 1999, Vol 27/1, p. 84-93. Comments: This superb article is a classic in the field of ACL-reconstruction rehabilitation. It illustrates the importance of proper rehabilitation and well-chosen exercises to optimal recovery. It also shows that, for evaluating an ACL-reconstructed knee, more than just KT-1000/2000 arthrometer measurements are needed. For insight into the lasting impact of loss of the natural ACL on a person's gait (walking pattern), and also for rehabilitation suggestions in this regard, see the July 1997 article Gait adaptations before and after anterior cruciate ligament reconstruction surgery, by DeVita et al., in the Biomechanics (including Gait Dynamics), Knee Alignment, and Component Interdependency Subsection. Comparison of Intersegmental Tibiofemoral Joint Forces and Muscle Activity During Various Closed Kinetic Chain Exercises, Michael J. Stuart et al.; The American Journal of Sports Medicine, Baltimore; Nov/Dec 1996, Vol 24/6, pages 792-799. Comments: Using a well-equipped biomechanics laboratory, the authors used a motion analysis system (three-dimensional infrared video cameras and floor-mounted force plates) to determine the forces on the knee during several closed-kinetic-chain exercises: the power squat, the front squat, and the lunge. (Closed-kinetic-chain exercises involve the foot bearing weight throughout the exercise movement.) They found that the aforementioned exercises do not produce harmful anterior-drawer forcing (sagittal-plane shearing of tibia with respect to femur) of a magnitude sufficient to be worrisome for ACL-intact knees. Additionally, the note that harmful ACL shearing forces are mitigated by flexion the knee and trunk to more than 30 degrees. Furthermore, especially during squat-type exercises, the positional interrelationships between the hip, knee, and ankle are critical, since foot placement engenders substantial changes in ACL (or ACL-graft) forces throughout the knee's range of motion. However, they warn that additional research is needed in order to ascertain whether these particular free-weight closed-kinetic-chain exercises are safe for ACL-deficient, ACL-compromised, or recently ACL-reconstructed knees. The three exercises studied herein, as depicted in Figure 1 (and especially if done with a barbell weighing 50 pounds or more), could potentially be unsafe for a person with a recently injured or freshly ACL-reconstructed knee to pursue without specific recommendations and guidance from a knee-experienced orthopedic surgeon or a knee-experienced physiotherapist. For insight into the process of ACL-graft incorporation/ligamentization/remodelling and why an understanding of this process is central to physiotherapy and rehabilitation from ACL reconstruction, see the August 1992 article The Effect of a Ligament-Augmentation Device on Allograft Reconstructions for Chronic Ruptures of the Anterior Cruciate Ligament, by Frank R. Noyes and Sue D. Barber-Westin, in the Other Topics Pertaining to the Knee (RSD, Synthetic Grafts, etc.) section. Click here to return to the Main Entrance Page of the Knee Library.
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