Anterior Cruciate Ligament (ACL) Reconstruction - Importance of Early Stage Rehabilitation
In the sports world, few injuries are as feared as the Anterior Cruciate Ligament (ACL)Tear. Both professional and recreational athletes who have experienced this injury understand the physical and psychological effect of ACL injury on not only their sport, but also their ability to perform daily activities. The ACL is the most commonly injured knee ligament, accounting for approximately half of all reported knee injuries, with females experiencing more ACL injured in comparison to male counterparts.
If you are experiencing knee pain or have experienced ACL injury, then stick till the end of this article and find out what the ACL is, the types of treatment options used, typical rehabilitation time frames along with the importance of early stage rehabilitation.
Purpose of ACL - What Does it Do?
The ACL is one of the four major ligaments of the knee. Anatomically it is composed of two bundles of fibers namely Anteromedial and Posterolateral bundles which connect Femur to Tibia. Each bundle has a distinct function and length during the cycle of knee movements It plays a crucial role in stabilising the knee joint by restricting rotational motion and anterior movement of femur on tibia; thus making it one of the static stabilisers of the knee.
It essentially acts as an important component of the knee during specific movements such as sudden stops (decelerations), and directional changes, especially in certain sports like Soccer, Basketball and Skiing. We can think of Anterior Cruciate Ligament as the anchor that supports the knee during fast paced movements.
Types of ACLR Surgeries and Graft choices
The first step in the treatment of ACL injuries is conservative treatment in order to regain the original knee stability and function. The cross-brace protocol isa contemporary conservative management option that minimises structural instability whilst allowing the injured ACL to heal. In some cases however, especially in athletes that compete in high-intensity, pivot sports, surgical reconstruction of the torn ACL may be deemed necessary.
The Anterior Cruciate Ligament surgery has changed over the course of years. With more research coming in, the paradigm has shifted from primary repair to reconstruction due to insubstantial healing capacity of the ACL. The latest approach is to reconstruct an ACL as anatomically identical to the natural ACL as possible, restoring the normal range of motion.
Anew ACL is reconstructed from an existing ligament, either from the patient’s own tissue (autograft) or from a donor’s tissue (allograft). An ideal graft should mirror the biological and mechanical properties of the Anterior Cruciate Ligament, be easily extracted from its native site, and have the least possible receiver site morbidity. There are a range of ligaments considered to be the most suitable for ACL reconstruction, these include the Patellar tendon, Hamstring tendon and Quadricep tendon each with its pros and cons. Despite extensive research, the best graft Is still an ongoing debate and clinically a matter of the surgeon’s choice, the patients injury history and sport/activity demands.
To further improve the post-operative stability of the knee joint with the reconstructed ACL, orthopedic surgeons may opt for additional procedures such as Lateral Extra-Articular Tenodesis. This procedure aims to reduce and ideally prevent the rotational instability that usually follows ACL reconstruction surgery. Research highlights that this procedure reduces the risk of graft failure.
Recovery Time - When Can I Get Back to Sport?
The most commonly asked question by patients when it comes to ACL reconstruction is, ‘’When will I be up and running in my normal daily routine?”, there is no single absolute answer for this as recovery depends on a variety of factors including the individual patient healing response, the type of graft, and the surgical technique employed.
The usual recorded recovery time is in the range of 9 to 12 months. Accelerated rehabilitation protocols which have looked to return patients to full sport activity at 6 months post-op have been utlisied, however the re-injury rate in this population is significantly higher. A periodised approach to rehabilitation is important for ACL and joint reconditioning. Failure to address key factors during the early stages of rehabilitation can result in complications during latter phases of rehabilitation and increased injury risk.
Importance of Early Phase Rehabilitation
Early phase rehabilitation post-op is crucial for maximising the new graft function and joint health. Key goals such as reducing inflammation and restoring joint range of motion are key priorities. Swelling is a common occurrence after the ACL reconstruction surgery. Some basic measures include icing, compression and elevation of the surgical site to promote fluid drainage through the lymphatic system and reduced swelling. Further, soft tissue techniques can also be used to promote lymphatic drainage and reduce joint swelling.
Another post-op complication to be addressed is abnormal walking patterns (gait) as ACL reconstruction affects the normal kinematics of the knee. It Is important to restore normal walking patterns to allow the surgical site to heal properly. Targeted exercises, manual therapy techniques and gait mechanics exercises aimed to restore normal gait are commonly employed. Video analysis also serves useful to provide visual feedback regarding your gait, along with mirror therapy. These techniques pave the way to improve proprioception and enable the knee joint to bear weight facilitating the smooth shift from assisting devices such as crutches towards independent movement. Research suggests that a major difference is felt in gait re-education after 12 weeks of Physiotherapy.
Patients are unable to fully straighten their knee after ACL reconstruction. Restoring this complete knee extension is one of the top priority tasks to be achieved in the early phase of rehabilitation as it becomes the landmark for subsequent restoration of normal functional activities. Prolonged impairment, inadequate efforts in the rehabilitation regime or lack of patient compliance leads to the formation of scar tissue, which can significantly impact function and recovery. Passive stretching, joint mobilizations, and progressive loading exercises are used to regain full active and passive knee extension range of motion. The goal is to restore complete extension while reducing the risk of secondary issues including patellofemoral dysfunction and graft impingement.
To Finish
In conclusion, ACL reconstruction is a common procedure performed for those who have ruptured their ACL. The early stages of rehabilitation are important to address key functional limiting factors, plan and periodise latter stages of rehabilitation, and provide a solid foundation for progressions in rehabilitation. A holistic approach is important – to identify the key limiting factors apparent post-op and provide individualized therapy that lays the foundation for successful joint reconditioning and return to function.
If you have experienced an ACL injury or are awaiting surgery, consider a physiotherapy consultation for tailored, data-driven care and rehabilitation.
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References
1. Norwood, Lyle A.and Mervyn J. Cross. “Anterior cruciate ligament: functional anatomy of its bundles in rotatory instabilities.” The American Journal of Sports Medicine 7 (1979):23 - 26.
2. Arnoczky, StevenP.. “Anatomy of the anterior cruciate ligament.” Clinical orthopaedics and relatedresearch 172 (1983): 19-25 .
3. Duthon, VictoriaLysiane Agnes et al. “Anatomy of the anterior cruciate ligament.” Knee Surgery, SportsTraumatology, Arthroscopy 14 (2006): 204-213.
4. Norris, Rory et al. “The Effect of AnteriorCruciate Ligament Reconstruction on the Progression of Osteoarthritis.” The Open Orthopaedics Journal 6 (2012): 506 - 510.
5. Van de Velde, Samuel K. et al. “The Effect ofAnterior Cruciate Ligament Deficiency and Reconstruction on the PatellofemoralJoint.” The American Journal ofSports Medicine 36(2008): 1150 - 1159.
6. Vaishya, Raju et al. “Current Trends inAnterior Cruciate Ligament Reconstruction: A Review.” Cureus 7(2015): n. pag.
7. Kiapour, Ata M. and Martha M. Murray. “Basicscience of anterior cruciate ligament injury and repair.” Bone & Joint Research 3 (2014): 20 - 31.
8. Fu, Freddie H.. “What’s new on ACL surgeryhorizon?” Current Reviews inMusculoskeletal Medicine 4(2011): 35-36.
9. Dhammi, Ish Kumar et al. “Graft choices foranterior cruciate ligament reconstruction.” Indian Journal of Orthopaedics 49 (2015): 127 - 128.
10. Dheerendra,Sujay K. et al. “Anterior Cruciate Ligament Graft Choices: A Review of CurrentConcepts.” The Open OrthopaedicsJournal 6 (2012):281 - 286.
11. Mall,Nathan A. et al. “GRAFT SELECTION IN ANTERIOR CRUCIATE LIGAMENTRECONSTRUCTION.” (2012).
12. Bonasia,Davide Edoardo and Annunziato Amendola. “Graft choice in ACL reconstruction.”(2012).
13. Getgood,Alan M. J. and Gilbert Moatshe. “Lateral Extra-articular Tenodesis in AnteriorCruciate Ligament Reconstruction.” Sports Medicine and Arthroscopy Review (2020): n. pag.
14. Cerciello,Simone et al. “Extra-Articular Tenodesis in Combination with Anterior CruciateLigament Reconstruction: An Overview.” Clinics in sports medicine 37 1 (2018): 87-100 .
15. Feng,Jing et al. “Anterior cruciate ligament reconstruction with lateralextra-articular tenodesis reduces knee rotation laxity and graft failure rate:A systematic review and meta-analysis.” Journal of Orthopaedic Surgery 30 (2022): n. pag.
16. Meighan,A. et al. “Outcome after reconstruction of the anterior cruciate ligament inathletic patients. A comparison of early versus delayed surgery.” The Journal of bone and joint surgery. British volume 85 4 (2003): 521-4 .
17. Wasilewski,Stephen A. et al. “Effect of surgical timing on recovery and associatedinjuries after anterior cruciate ligament reconstruction.” The American Journal of Sports Medicine 21 (1993): 338 - 342.
18. Eriksson,Karl et al. “Acute ACL Surgery Decreases First Year Socio Economic CostsCompared to Delayed Reconstruction.” Orthopaedic Journal of Sports Medicine 4 (2016): n. pag.
19. Shelbourne,K. Donald et al. “Update on accelerated rehabilitation after anterior cruciateligament reconstruction.” TheJournal of orthopaedic and sports physical therapy 15 6 (1992): 303-8 .
20. Lynch,Andrew D. et al. “Criterion-Based Approach for Rehabilitation After ACLReconstruction.” (2017).
21. Winiarski,Sławomir and Andrzej Czamara. “Evaluation of gait kinematics and symmetryduring the first two stages of physiotherapy after anterior cruciate ligamentreconstruction.” Acta ofbioengineering and biomechanics 14 2 (2012): 91-100 .
