Doni Agustian

Goals
Regain normal knee stability: less than 3 mm of increased anteroposterior
(AP) displacement on knee arthrometer testing, negative or trace pivot
shift
Control joint pain, swelling, and hemarthrosis
Regain a normal range of knee motion
Restore a normal gait pattern and neuromuscular control for ambulation
Recover normal lower limb muscle strength
Regain normal proprioception, balance, coordination, and neuromuscular
control for desired activities
Achieve optimal functional outcome based on orthopedic and patient goals
Modalities
In the immediate postoperative period (1-3 days) knee effusion must be
controlled
The most widely used modality after ACL reconstruction cryotherapy,
which is begun in the recovery room after surgery
standard method of cold therapy an ice bag or commercial cold pack
Cryotherapy is used for 20 minutes at a time from three times per day to
every waking hour
Cryotherapy is typically done after exercise or when required for pain and
swelling control and is maintained throughout the entire postoperative
rehabilitation protocol
Postoperative Bracing
The use of postoperative braces after ACL
reconstruction controversial
The primary indication for the use of a brace
protection of the patient during weight bearing
in the event of a fall and to initiate early, more
comfortable weight bearing during the first few
postoperative weeks.
The brace should be rigid in nature and the
knee held initially at 0 degrees
The brace is opened based on the protocol to
allow normal knee flexion during ambulation
Range of Knee Motion
The goal in the first postoperative
week obtain a ROM of 0 to 90
degrees.
Patients perform passive and active
ROM exercises in a seated position
for 10 minutes per session,
approximately four to six times per
day
 Full passive knee extension
must be obtained immediately
to avoid excessive scarring in the
intercondylar notch and
posterior capsular tissues
Maintained for 10 minutes and
repeated four to six times per
day
 Full knee extension should be
obtained by the second
postoperative week.
If this If not accomplished, or if
the clinician notes a firm end
feel, then an extension board or
additional weight of 15 to 20
pounds is used six times per day
 If this is still not effective, a
dropout cast is implemented for
24 to 36 hours for continuous
extension overpressure.
 Knee flexion gradually increased
to 120 degrees by the third to
fourth postoperative week and 135
degrees by the fifth to sixth
postoperative week.
Passive knee flexion exercises
initially in the traditional seated
position, using the opposite lower
extremity to provide overpressure.
Other methods : chair-rolling, wall
slides, knee flexion devices, and
passive quadriceps-stretching
exercises
Patellar Mobilization
Restoring normal patellar mobility
critical to regain a normal range
of knee motion
The loss of patellar mobility
often associated with arthrofibrosis
and, in extreme cases, the
development of patella infera
sustained pressure applied to the
appropriate patellar border for at
least 10 seconds, 5 minutes before
ROM exercises.
performed for approximately 6
weeks postoperatively
Weight Bearing
Partial weight bearing permitted immediately postoperatively as
long as pain and swelling are controlled and a voluntary quadriceps
contraction is demonstrated.
Initially, bilateral crutches may be used, and 50% body weight is
placed on the involved foot progressed as tolerated to allow full
weight by the third to fourth postoperative week
Flexibility
Hamstring and gastrocnemius-
soleus flexibility exercises begun
the first day after ACL
reconstruction
A sustained static stretch is held for
30 seconds and repeated five
times.
The most common hamstring
stretch is the modified hurdler
stretch, whereas the most common
gastrocnemius-soleus stretch is the
towel pull
 Quadriceps and iliotibial band
flexibility exercises performed
to assist in achieving full knee
flexion and controlling lateral hip
and thigh tightness.
Strengthening
Strengthening program begins at the first postoperative visit
Isometric quadriceps contractions rules of 10-second holds, 10
repetitions, 10 times per day.
Straight-leg raises initiated on the first postoperative day in the
four planes of hip movement
As these exercises become easy to perform ankle weights are
added. Initially, 1 to 2 pounds of weight are used, and eventually up
to 10 pounds is added as long as this is not more than 10% of the
patients body weight
 Closed kinetic chain exercises
initiated in the first
postoperative week.
Minisquats from 0 to 45 degrees
are begun when tolerated by the
patient. Initially, the patients
body weight is used as
resistance, and TheraBand or
surgical tubing is gradually used
as resistance mechanisms.
 Toe raises for gastrocnemius-soleus
strengthening and wall-sitting
isometrics for quadriceps control
begun in the second
postoperative week
The goal of wall-sitting is to
improve quadriceps contraction by
performing the exercise to muscle
exhaustion
knee flexion angle is held between
30 and 45 degrees, until muscle
fatigue occurs, repeated three to
five times
 Lateral step-ups are begun when
the patient has achieved full
weight bearing
The height of the step is
gradually increased based on
patient tolerance.
 Hamstring curls begun with
Velcro ankle weights within the
first few weeks and eventually
advanced to weight machines
Hamstring strength critical to
the overall success of the
rehabilitation program because
of the role that this musculature
plays in the dynamic stabilization
of the knee joint.
 Other muscle groups : included
in this routine are the hip
abductors, hip adductors, hip
flexors, and hip extensors
These muscle groups can be
exercised on either a multihip or
cable system machine
Balance, Proprioceptive, and Perturbation
Training
Balance and proprioceptive training the first postoperative week.
Initially, the patient simply stands and shifts weight from side to side
and from front to back encourages confidence in the legs ability to
withstand the pressures of weight bearing and initiates the stimulus
to knee joint position sense.
 Cup walking begun when the
patient achieves full weight
bearing to promote symmetry
between the surgical and
uninvolved limbs
helps develop hip and knee
flexion and quadriceps control
during midstance of gait to
prevent knee hyperextension
 Double- and single-leg balance
exercises in the stance position are
beneficial early postoperatively
The objective is to remain in this
position until balance is disturbed
To provide a greater challenge,
patients may assume the single-leg
stance position and throw and
catch a weighted ball against an
inverted minitrampoline
 Perturbation training techniques
initiated at approximately the
seventh to eighth postoperative
week during balance exercises
The therapist stands behind the
patient and disrupts her or his
body posture and position
periodically to enhance dynamic
knee stability.
 Half round foam rolls also
used in this time period as part
of the gait retraining and
balance program
Developing a center of balance,
limb symmetry, quadriceps
control in midstance, and
postural positioning benefits
developed from this type of
training
 Use of the Biomechanical Ankle
Platform System (BAPS [AliMed])
in double-leg and single-leg
stances is another effective
balance and proprioceptive
exercise
Conditioning
The primary consideration for a conditioning program throughout the
rehabilitation period is to stress the cardiovascular system without
compromising the knee joint
begun as soon as the patient can sufficiently tolerate the upright
position
Early goals of these programs include facilitation of full ROM, gait
retraining, and cardiovascular reconditioning
should be performed at least three times per week for 20 to 30
minutes, and the exercise should be performed to at least 60% to 85%
of maximal heart rate
Running and Agility Program
majority of patients initiate running at approximately 16 to 20 weeks after surgery
In exceptional cases does this program begin before this time period
when muscle strength has returned to normal,
no pain of joint effusion is present, and
no concurrent operative procedures were performed, such as a complex meniscus repair or other
ligament reconstruction
performed three times per week on opposite days of the strength program
The first level consists of straight-ahead walk-run combinations. Running distances are
20, 40, 60, and 100 yards (18, 37, 55, and 91 m) in both forward and backward directions
The second level is lateral running and crossover maneuvers
The third level of the running program incorporates figure-eight running drills
The fourth phase in the running program introduces cutting patterns (directional changes
at 45- and 90-degree Angles)
Plyometric Training
Important parameters :
surface,
footwear, and
Warmup
performed two to three times
each week, along with strength
and cardiovascular endurance
exercises
 Once the patient can perform level four double-leg hops, the same
exercises are done on a single leg
The initial exercise time period is 15 seconds. The patient is asked to
complete as many hops between the squares as possible in 15
seconds
Three sets are performed for both directions, and the number of hops
is record
Return to Sports Activities
1. Knee examination
ROM: International Knee Documentation Committee (IKDC) rating of normal or nearly normal
Lachman test: IKDC rating of normal or nearly normal
Pivot shift test: IKDC rating of normal or nearly normal
Patella pain: none
Effusion: none
2. KT-2000 (MEDmetric)
Less than 3-mm reconstructed compared with contralateral knee (if normal), 134-N total AP displacement.
3. Quadriceps and hamstrings muscle strength and endurance tests: less than 10% deficit compared with contralateral side, based on equipment available:
Isokinetic 180 degrees/sec and 300 degrees/sec
Isometric portable fixed or hand-held dynamometer: quadriceps 60-degree flexion, hamstrings 60- or 90-degree flexion, three repetitions each, use average69,71,72
If isokinetic or isometric equipment is not available, a onerepetition maximum bench press and leg press is recommended if weight room equipment is available, along with an
experienced test administrator and a sufficient amount of time to safely conduct these tests.29,65
4. Single-leg hop tests: 15% or less deficit lower limb symmetry on single-hop and triple crossover hop tests (may videotape to provide subjective analysis of balance and
landing position)
5. Video drop-jump
If software is available, 60% or greater normalized knee separation distance
If software is not available, use video for subjective analysis of landing position (varus, valgus, neutral): no valgus, knees flexed for controlled landing
6. Single-leg squat, five repetitions: no knee valgus, mediolateral movement, or pelvic tilt
7. Video plant-and-cut drill: subjective rating of high hip and knee flexion, upright posture, and no valgus collapse (This test should be done in the manner described by Pollard
and associates, in which the patient runs 5 meters to a spot designated on the floor with tape, plants on the reconstructed leg, and then performs a 45-degree cut. If the
right leg was reconstructed, the cut should be to the left. Cones may be set up to direct the patient to perform the angle of 45 degrees.)
 Terima Kasih