PRACTITIONER PROMPT PATIENT ADVICE

ACL reconstruction rehabilitation Part 1

1) Dynamic control and proprioception exercises
Closed chain exercise progression for hamstring co-activation
Closed chain exercise progression Hamstring co-activation should be encouraged at all times, tension monitored in the hamstrings either through EMG biofeedback or palpation. Correct lower limb alignment must be emphasised at all times and the exercises should be pain free. The patients should carry out 3x15 repetitions. The exercise should only be progressed when the patient can carry out 3x15 repetitions pain-free with correct lower limb alignment and hamstring co-activation.

Hop Step to Step down with weight Step down Step up with weight

Step up One leg minisquat with weight One leg minisquat without support One leg minisquat with support Bilateral minisquat with weight Bilateral minisquat without support Bilateral minisquat with support

Control of lower limb alignment (rotation)

q Gluteus medius & foot supinator

co-activation
q Start partial weight bearing -

maximum visual cues

q Increase limb load (follow closed

chain exercise progression)

q Decrease visual cues q Uneven/mobile surfaces q Use of orthotics to control

pronation

Proprioception exercise progression

Soft surface partial weight bearing minisquat - visual then non visual cues

Soft surface single leg minisquat - visual then non visual cues

Step on and jump onto leg - visual then non visual cues

Soft surface single leg stance visual then non visual cues

Single leg stance - visual then non visual cues ie. eyes open to eyes closed

Weight shifts

Progressing proprioception further When this step on stage is reached the patient should start with a small step onto the leg and progressively increase the size of this step until they are jumping onto the leg (this looks like the step phase of the triple jump). This can be progressed further by jumping onto the leg from a low step, then nally hopping onto the one leg initially in the forward direction only and then hopping around at 90 degree changes of direction and ultimately 180 degree changes of direction. To add the element of unexpected movement any of these stages can also be done as above with eyes open progressing to eyes closed and onto a soft surface again with visual and non visual cues.

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negligence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.

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PRACTITIONER PROMPT

ACL reconstruction rehabilitation Part 2

2) Strength, tness and function
Progressive resistive strengthening exercise
q Quadriceps - closed and open chain exercises (in appropriate q Lower limb extensor muscle strength (isokinetic eccentric and

concentric) LSI > 85%

q 1RM single leg press LSI > 125% q Isometric 1/2 and 1/4 squat > 45 seconds with eyes closed or

open LSI = Limb symmetry index, divide mean of involved leg by mean of uninvolved leg x 100

range of movement) q Hamstrings - outer range strength and strength at high velocity contractions q Gastrocnemius q Hip adductors & abductors - inner range strength to maintain joint alignment

Hop tests
q One leg hop for distance - stand on leg, hop as far as possible q Timed one leg hop - time to hop 6m q Triple one leg hop for distance - stand on leg hop for three hops

Progressive cardiovascular and functional training

q Static bike q Rowing, stepper, cross trainers q Challenge cardiovascular system - monitor heart rate and set

as far as possible q Cross over hop - stand on leg hop for three hops as far as possible, crossing a centre line with each hop Aim - 85% LSI

appropriate targets q Running at 12 weeks post op (if proprioception and dynamic control adequate) q Sport specic training (if passed functional tests) 20-24 weeks post op

Multiple single hop stabilisation test

Set a 2.5cm target in a diagonal distance set at 50% of patients height. The patient must land onto the mark and hold the position for 5 seconds with hands always on iliac crests. Error scoring Landing

3) Functional testing
Screening criteria for functional performance testing
q q q q q

not covering tape mark stumbling on landing foot not facing forwards hands off iliac crests

Balance

No pain No effusion No crepitus Full active range of movement Symmetrical gait including stair ascent and descent

- touch down with non-weight bearing limb - non-weight bearing limb touching weightbearing limb - non-weight bearing limb moving into excessive exion, extension or abduction - hands off iliac crests

Barrow zig-zag run Run right and left handed for timed symmetry score. Aim 85% LSI.

3m Start

Finish

5m

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negligence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.

WWW.SPORTEX-MEDICINE.COM

PATIENT ADVICE

ACL rehabilitation programme

Anterior cruciate ligament function
The anterior cruciate ligament (ACL) is one of the most important ligaments of the knee. It plays a central role in controlling the locking of the knee and excessive movement of the tibia on the femur, both in a forwards and rotary direction. Without the ACL stabilising knee movements and providing proprioceptive feedback, the knee can become unstable during functional/sporting activities causing further trauma to the knee.

Hop Step to (side to side)

Step down with weight Step down Step up with weight

Step up One leg minisquat with weight

The rehabilitation programme

Your home exercise programme has specic exercises not only to strengthen certain important muscles, but also to improve dynamic control of the knee and knee joint position sense (proprioception). When carrying out the strengthening exercises it is essential that correct lower limb alignment is maintained at all times, to decrease the rotational stress on your knee. Also, while doing these exercises you should tense your hamstring muscles to restrict forward slide of your tibia. The proprioception exercises improve your sense of knee position. These should be carried out maintaining correct limb alignment and the minimum of upper body movement particularly with the arms.

One leg minisquat without support One leg minisquat with support Bilateral minisquat with weight Bilateral minisquat without support Bilateral minisquat with support

Proprioception exercise progression

Soft surface partial weight bearing minisquat - visual then non visual cues

Soft surface single leg minisquat visual then non visual cues

Step on and jump onto leg - visual then non visual cues

Progression speed
Your therapist will advise you on the speed with which you progress on the strengthening/movement control and proprioception progression programme. Progression is not just about being able to do the exercise but to do it correctly, with appropriate control. Remember poor practise leads to poor performance and potential strain on your ligament graft. If at any time you feel pain or discomfort stop the exercises and consult your therapist.

Soft surface single leg stance - visual then non visual cues

Single leg stance visual then non visual cues (ie.eyes open to eyes closed)

Weight shifts

The information contained in this article is intended as general guidance and information only and should not be relied upon as a basis for planning individual medical care or as a substitute for specialist medical advice in each individual case. To the extent permissable by law, the publisher, editors and contributors accept no liability for any loss, injury or damage howsoever incurred (including negligence) as a consequence, whether directly or indirectly, of the use of any person of the contents of this article.

WWW.SPORTEX-MEDICINE.COM