Rehabilitation After ACL/PCL Surgery

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Questions and Answers

At what week should hamstring contractions be initiated after a PCL reconstruction?

4-6 weeks

2-4 weeks

6-8 weeks (correct)

8-10 weeks

What is the primary complication associated with a combined ACL/PCL procedure?

Swelling in the knee

Risk of infection

Chronic pain

Loss of knee flexion (correct)

When can a patient expect to return to full activity after a combined ACL/PCL procedure?

10-12 months

4-6 months

6-7 months

8-9 months (correct)

Which exercise is delayed until 6 weeks post combined ACL/PCL procedure?

Open chain resisted hamstring exercises Signup and view all the answers

What mobility support is required during the first 6 weeks of rehabilitation for a combined ACL/PCL procedure?

Brace locked in extension Signup and view all the answers

What percentage of ACL injuries are categorized as non-contact injuries?

80% Signup and view all the answers

Which of the following symptoms is commonly associated with ACL injuries?

Joint effusion and 'giving way' Signup and view all the answers

What is a critical pre-operative consideration for ACL surgery?

Establishing 0-120 degrees of ROM Signup and view all the answers

What is the initial strength of the central third of the patellar tendon compared to the native ACL?

186% of native ACL Signup and view all the answers

At what point after ACL reconstruction does revascularization of the graft begin?

8-10 weeks Signup and view all the answers

What is a significant indicator of failure to prepare for post-operative rehabilitation?

Presence of knee extensor lag Signup and view all the answers

Which of the following is NOT a consideration for post-operative ligament rehabilitation?

Psychological assessment Signup and view all the answers

What common concomitant injury is associated with ACL injuries, often referred to as O'Donoghue's Unhappy Triad?

Of the MCL, meniscus, and ACL Signup and view all the answers

What is the strength of the graft one year post-operatively compared to the native ACL?

30-50% Signup and view all the answers

What happens to graft strength during the period of necrosis?

Strength decreases Signup and view all the answers

What is a notable difference in healing between allografts and autografts six months post-op?

Allografts demonstrate a greater decrease in structural properties Signup and view all the answers

What is indicated if full extension is not achieved by four weeks post-operation?

Inform the surgeon Signup and view all the answers

What condition can reduced quadriceps function lead to following PTB autograft?

Patellofemoral arthrofibrosis Signup and view all the answers

What is the passive joint range of motion goal within two weeks post-operative?

Full passive extension Signup and view all the answers

Which exercise is commonly used to restore quadriceps function?

Quad Sets Signup and view all the answers

What does the prolonged presence of an inflammatory response indicate in comparison between autografts and allografts?

Allografts have a slower biological incorporation rate Signup and view all the answers

What is the recommended arc of motion for open chain leg extension to minimize strain on the ACL graft?

90-60 degrees Signup and view all the answers

How long should aggressive strengthening be avoided after a patellar fracture?

6-8 weeks Signup and view all the answers

Which exercise progression should begin approximately 6 weeks post-op for strengthening?

Leg extension and curl machines Signup and view all the answers

What is the initial weight used for the leg press exercise after ACL reconstruction?

50 to 75% of body weight Signup and view all the answers

What condition may indicate a surgeon should be notified within 1-2 weeks post-operatively?

Persistent extensor lag with SLR Signup and view all the answers

What should be avoided for 12 to 16 weeks after a patellar tendon rupture?

High eccentric loading Signup and view all the answers

Which exercise initiation is appropriate when the patient can fully weight bear without crutches post-operatively?

Closed chain exercises like squats Signup and view all the answers

In post-op ACL rehabilitation, what may be necessary to address altered proprioception and muscular control?

Incorporate functional retraining programs Signup and view all the answers

What is the recommended duration for avoiding resisted knee flexion exercises after a hamstring injury?

4-6 weeks Signup and view all the answers

What is a key consideration for patients who have undergone an allograft procedure?

Return to activity should be more gradual compared to autograft procedures. Signup and view all the answers

During the first four weeks after a concomitant meniscal repair, what is the recommended approach to weight-bearing?

Weight bearing as tolerated with a brace locked in extension Signup and view all the answers

Which diagnosis is characterized by posterior knee pain and limited flexion beyond 90 degrees?

PCL injury Signup and view all the answers

What aspect of rehabilitation should be emphasized early on for PCL injury treatment?

Quad strengthening Signup and view all the answers

What is a recommended activity timeline for returning to full activity after a PCL injury?

Full activity at 10-12 weeks Signup and view all the answers

Which exercise should be avoided in the first six weeks following a meniscal repair?

Closed chain exercises Signup and view all the answers

When can a patient progress to full weight bearing without crutches?

When experiencing no pain during ambulation Signup and view all the answers

What does the term 'quadriceps neutral angle' refer to?

The knee flexion range that avoids shear force Signup and view all the answers

What is the necessary quad strength percentage of the uninvolved limb needed to begin treadmill running?

70% Signup and view all the answers

What must a patient tolerate in order to progress to agility training?

Track or road running for 1 to 2 miles without pain Signup and view all the answers

What is the recommended approach when beginning agility activities?

Start with 50% effort Signup and view all the answers

What percentage of quad function of the uninvolved limb must be achieved to progress to lower level sport specific skill training?

85% Signup and view all the answers

Which condition allows a return to sport after successful practice activities?

No difficulty with any practice activities Signup and view all the answers

What is a common issue associated with Patellar Tendon Autograft?

Higher incidence of patellofemoral pain Signup and view all the answers

Why can the Semitendinosis Autograft have complications during recovery?

Not as strong fixation as bone-tendon-bone procedure Signup and view all the answers

Study Notes

Knee Ligaments Injury

ACL injuries are 80% non-contact
Non-contact mechanisms include: foot planted, valgus/rotational load (cutting, pivoting); hyperextension load (step in pot hole)
Contact mechanisms include: posteriorly directed blow to anterior femur (hyperextension)

ACL Injury: Signs and Symptoms

Severe pain with joint effusion
"Popping", "Giving way", "Buckling"
Continued effusion, recurrent "giving way" with ADLs
Quad inhibition
Limited motion in flexion and extension
Lachman/Anterior Drawer, pivot-shift
Flexed knee gait

Differential Diagnoses

Meniscal involvement
Multiple ligament involvement
"Unhappy Triad of O' Donoghue"

Important Issues In Post-operative Ligament Rehabilitation

Pre-op Considerations
Post-op Considerations for Graft Healing
Joint Mobility
Muscle Function
Neuromuscular Control
Criterion Based Progression of Function
Modifications Related to Graft Type
Modifications with Meniscal Repair
Modifications for Combined Ligament Procedures

Pre-operative Considerations

Pain
Effusion
Range of motion
Muscle function
Modalities to decrease pain and swelling
Resolving knee extensor lag prior to surgery
Establishing 0-120 degrees of ROM

ACL Reconstruction

Graft passed through tunnels drilled in the tibia and femur

Post-operative Considerations

Initial graft strength
Fixation
Healing and maturation of the graft

Initial Graft Strength

Central third of patellar tendon: 186% of native ACL
Semitendinosis: 70% of native ACL
Gracilis: 49% of native ACL

Histological Considerations of the Graft

Initially: the graft is avascular
6 weeks: the graft shows signs of avascular necrosis
8-10 weeks: revascularization begins; mesenchymal cells invade the graft
16 weeks: vascularization is complete; mesenchymal cells proliferate and form collagen
Implications for return to full activity before 16 weeks post-op?
1 year post-op: graft takes on the appearance of a ligament, with dense, oriented collagen bundles; strength and stiffness of the graft is 30-50% of the native ACL
Graft strength decreases during the period of necrosis and then increases as it remodels and matures, but it does not reach the original strength of the native ACL

Autograft vs. Allograft

6 months post-op allografts demonstrate: greater decrease in their structural properties from the time of implantation; slower rate of biological incorporation; a prolonged presence of an inflammatory response as compared with autografts

Implications for Rehab

Rehab following allograft reconstruction may need to be less aggressive compared to rehab of an autograft.
Little is known about the graft's ability to withstand loads and strain during healing and maturation.

Joint Mobility: Post-op

Full passive extension within 1-2 weeks post-op
Full active extension within 3-4 weeks post-op
90 to 100 degrees of flexion within 2-3 weeks post-op
Full flexion by 4-6 weeks post-op

Problems with Restoration of Joint Motion

Restricted mobility of incision/portal scars
Patellofemoral entrapment
"Cyclops" lesion
Poor graft placement
Surgeon should be notified if full extension is not achieved by 4 weeks post-op

Restoring Quadriceps Function

Quadriceps activation failure a problem with PTB autograft
Reduced quad function can lead to patellofemoral arthrofibrosis
Restoration of quad function correlates with ADL function in early stages of recovery
Quad Sets
Straight Leg Raises
With and without Biofeedback
Active Knee Extension Against Gravity: No Added Resistance
2500hz, 75 burst/sec
10 contractions
10 on/ 50 off
Stimulates full, sustained quad contraction with evidence of superior patellar glide

Special Concerns for Quad Strengthening after Patellar Tendon Autograft Reconstruction

Patellar fracture : no aggressive strengthening for 6-8 weeks; avoid high eccentric loading for 12-16 weeks
Patellar Tendon Rupture: persistent extensor lag with SLR at 4 weeks post-op; inability to perform a SLR 1-2 weeks post-operatively; surgeon should be notified

Lower Extremity Strengthening

Use a combination of open and closed chain exercises
Open chain leg extension limited to 90-60 arc of motion to minimize strain on ACL graft.
Open chain leg curls limited to 0-90 to avoid active insufficiency and hamstring cramping
Use cuff weights initially until patient can tolerate 3 sets of 12 to 15 reps with 10 pounds (4.5 kg). Then progress to leg extension and leg curl machines
Begin leg extension and curl machines about 6 weeks post-op.
1 plate X 3 sets of 10
Progress to 1 plate - 10 reps, 2 plates - 6-8 reps, 3 plates - 3-5 reps
Add 1 plate to each set when tolerates 2 consecutive sessions
Leg curl machine progressed in similar fashion
Initiate closed chain exercise with body weight when patient can fully weight bear without crutches.
Double and single leg squats (0-45), Lateral and forward step ups, Calf raises
Progress to leg press when tolerating 3 sets of 15 reps for two consecutive sessions without pain, swelling, instability
Begin leg press with double leg and eventually progress to single leg
Begin with 50 to 75% of body weight
Use similar progression of plates as described for leg extension

Neuromuscular Control

Altered proprioception and lower extremity muscular control has been associated with ACL injury
Unclear if these deficits fully resolve after ACL reconstruction
Functional retraining programs for post-op ACL rehab may need to emphasize enhancement of lower extremity neuromuscular control strategies

Progression of Weight Bearing

Post-op Brace locked in extension for PWB ambulation with cruthces for 1st week
Unlock brace during ambulation after 1 week
Emphasize heel-toe gait pattern, discourage flexed knee gait pattern
Progress to Full weight bearing without crutches when: no extensor lag during straight leg raise, 90 to 100 degrees of knee flexion, no pain during ambulation

Progress to Straight Running

Begin with treadmill running. Must meet following criteria: all criteria for full weight bearing ambulation, quad strength = 70% of uninvolved limb
Progress to track and road running when tolerating 1 to 2 miles of treadmill running without pain, swelling, instability

Criteria for Advancing to Agility Training

Track or Road Running for 1 to 2 miles without pain, swelling, instability
Quad Strength = 80% of uninvolved limb
Begin agility activities with 50% effort, progress to 75% then 100% effort provided no pain, swelling, instability

Criteria for Lower Level Sport Specific Skill Training

Tolerating all agility training at 100% effort without pain, swelling, or instability
Quad function = 85% of uninvolved limb

Progress to Sprinting

Tolerating all agility and low level sport specific training
Quad strength 85 to 90% of uninvolved limb
Begin with running at 50 and 75% effort, progress to 100% when tolerating these without pain, swelling, instability

Return to Sports

Tolerating 100% Sprinting
Begin with opposed practice of sport specific skills (training partner)
Return to practice with team when tolerating opposed practice of skills
Return to sport when no difficulty with all practice activities

Modifications Based On Graft Type

Patellar Tendon Autograft: higher incidence of patellofemoral pain, persistent quad weakness, injury to extensor mechanism; avoid early heavy eccentric loading of extensor mechanism; use modifications in quad strengthening to reduce patellofemoral joint stress
Semitendinosis Autograft: fixation not as strong as bone-tendon-bone procedure; disruption of hamstring; weight-bearing restrictions may be prolonged (4 weeks); avoid resisted knee flexion ex for 4-6 weeks; may need to emphasize hamstring stretching to reduce spasm and pain
Allograft (Patellar or Achilles tendon): slower rate of biological incorporation, greater decrease in structural properties of graft compared to autograft from time of implantation; weight-bearing restrictions may be prolonged; return to activity will need to be more gradual than autograft procedures

Modifications For Concomitant Meniscal Repair Procedure

Must protect meniscal repair site
Weight bearing as tolerated with knee brace locked in extension for first 4 weeks
Avoid closed chain ex for first 4 weeks, then limited arc closed chain ex (0-45)
Resisted hamstring ex and forceful stretching into flexion should be avoided for first 6 weeks

Modifications for Combined ACL/MCL procedure

Must control valgus forces
Rehab brace 4-6 weeks
Avoid adduction SLR
Some patient produce excessive valgus thrust on climbing machines
Greater risk of losing motion. Early motion in rehab is critical.

PCL Injury: Mechanisms

Hyperflexion
Fall on flexed knee with foot PF
Hyperextension Mechanisms
- Blow to anterior tibia (dashboard)
- Step in pot hole

PCL injury: Signs and Symptoms

Posterior knee pain
Not as much effusion as ACL
Flexion beyond 90 may increase pain (non-wt. bearing)
10-20° limitation in knee flexion
Difficulty descending stairs, squatting, running
Not as much problem with quad inhibition
- sag sign, post drawer with reduced palpation of step off

PCL Tests

Sag Sign or Chair Test
Posterior Drawer with Step-Off Palpation

Differential Diagnosis

Patellofemoral Pain: Patients with chronic PCL insufficiency can develop PF pain. Why?
Need to rule out posterior-lateral complex involvement

PCL Injury: Non-operative Treatment

Early mobility, quad strengthening
No flexion beyond 60 with quad strengthening
Full wt. bearing at 3 weeks
Begin hamstring strengthening at 5 weeks post-injury
Agility and Sport Specific Activity at 6-8 weeks
Return to full activity at 10-12 weeks

Quadriceps Neutral Angle

Knee flexion range at which tension in the quadriceps does not create anterior or posterior shear force. Less than 60 produces anterior shear. Greater than 75 produces posterior shear.

PCL Reconstruction

Bone-tendon-bone autograft used to reconstruct PCL deficiency
Posterior view inlay technique tibia

PCL Reconstruction: Post-op Rehab

Early mobility (0-90), posterior proximal tib should be supported by therapist
P-F mobility
Quad isometrics and strengthening (0-60)
No hamstring contractions
6-8 weeks, Initiate hamstring contractions with wt. bearing activities at 6-8 weeks
Gradual increase in wt. bearing from 2-6 wks (brace locked in ext 4-6 weeks)
Initiate full flexion ROM at 6-8 weeks
Return to running at 5-6 months, light athletics at 6-7 months, full activity at 9 months

Combined ACL/PCL Procedure

First 8 weeks is similar to PCL post-op rehab guidelines
Need to protect PCL graft, limit posterior tibial translation forces
Primary complication is loss of knee flexion
Full passive extension achieved in 1 week
Passive flexion performed with therapist supporting posterior proximal tibia, 0-90 for first 6 weeks
Initiate full flexion beginning at 6 weeks, should be achieved by 8-10 weeks
WBAT with brace locked in extension for 4-6 weeks. Full weight bearing from 6-8 weeks
Quad isometrics and limited arc leg extensions (60-45)
Closed chain ex for quads and hamstrings delayed until 6 weeks
Avoid open chain resisted hamstring ex
Low impact aerobics (walking, cycling, swimming) at 8 weeks
Initiate running at 6 months
Initiate agility and sport specific skill training at 6-8 months
Return to full activity at 8-9 months

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Test your knowledge about the rehabilitation process following combined ACL and PCL reconstruction. This quiz covers key recovery milestones, potential complications, and exercise protocols to ensure a safe return to activity. Prepare to learn about the critical aspects of rehabilitation and recovery timelines.