ACL Rehab: Why it’s Essential to Start Off With the Essentials
The ACL rehab process is an extreme marathon ranging from 6-12 months in length. It will challenge you in ways you do not think were even possible.
Used to running a 4.4 forty? Thinking of walking 40 yards in your first week will make you sweat and exhausted.
Causally able to squat 300 pounds? Just lifting your leg onto a couch will take every ounce of effort and likely require you using your hands in the first couple weeks.
Each step in this marathon builds on top of each other, and you can’t skip steps. Miss a step and your progress and ultimately performance gets delayed. We highlighted the absolute essentials for you or your child to accomplish immediately post-op.
ABSOLUTE Essentials to Accomplish Following ACL Reconstruction
1. Full Knee Extension
Simply put you need to have your knee as completely straight (or extra straight) as your OTHER knee. This right here is the most pivotal step in all ACL rehab. Lack just a couple degrees of full extension and it will make this already long road much longer. It will alter your gait (walking) pattern because when you make contact with the ground your knee should be straight. It will affect the ability for your quadriceps to fully contract and stabilize your knee as you move (aka no more buckling).
Unfortunately, it appears that inability to achieve full extension may lead to earlier osteoarthritic changes in the knee. (Shelbourne, 2012). There also appears to be a 4-8 week window to achieve full extension and individuals that are with 3-5 degrees of full extension at 4 weeks are more likely to attain full extension. (Noll, 2015)
2. Achieving Full Quadriceps Activation
This goes hand in hand with step 1. While some individuals are able to get to full extension by stretching it, having someone else (PT) push on it, or gravity assisting it, they still lack the ability to ACTIVELY and INDEPENDENTLY straighten their knee all the way with purely their quadriceps muscle.
An example of this would be you are able to straighten without much difficulty lying on a table/floor/bed but as soon as you stand up you are unable to keep your knee straight and it wants to buckle. Most surgeon’s post-op phase 1 guidelines emphasize full knee extension or ability to perform a straight leg raise without an extensor/quadriceps lag (which requires full extension to achieve). See below.
Flexing those quads is key
That right there is a deficiency in your quadriceps muscle. You probably already noticed your quad is half of what it used to be, and even have difficulty doing simple tasks such as lifting your leg up. The unfortunate response from the human body following the ACL reconstruction is that quadriceps gets inhibited and it takes time to bring it back (more fancily known as arthrogenic muscle inhibition). Failure to activate the quads may result in more effusion (swelling) of the knee which may result in more pain and loss of motion. (hence why attention to detail in ACL Rehab is crucial).
*Consider either borrowing/renting a Neuromuscular Electrical Stimulation Unit from your PT in order to help stimulate the quads through electrical stimulation. Do not use unless guided by a PT!*
3.Walking With a Normal Pattern ASAP
Being able to walk with proper form will allow for better distribution of the forces that go through our body with walking. This will decrease pain with walking. Also, with proper gait technique we will optimally use the muscles of the knee such as the quadriceps through the stance/single support phase, further helping them reactivate.
4. Progress Your Knee Flexion (bending)
People may be reading this and wonder why this is so further down the priority list. As it is easy to see your own progress with how much your knee bends it does not take precedence over full knee extension and adequate quad contraction and control. Having full knee extension is involved in every functional task of daily living including walking, standing, stairs and getting up from a chair.
Very few daily or even sport tasks require absolute full knee bend besides wrestling and gymnastics. Not to say it is not very important to get full knee bend and should be accomplished in everyone’s ACL rehab, it just needs to be focused on after the previous mentioned essentials.
5. Appropriate Management (Not Elimination) of Swelling
Back in the day we would want to ice you almost to the point of freezer burn in order to eliminate post-op swelling. The old school thought was swelling was the enemy and showed that you are still traumatized. We now know that swelling is part of the healing process as it delivers oxygen and nutrient blood to the area.
Now excessive swelling is “too much of a good thing” and can limit the amount of ROM in the knee and the ability to activate the quad. So we still encourage using ice and elevation immediately post especially if you can keep the knee straightened as you do it. Consult with your surgeon, ATC or PT on the appropriate amount of swelling following the surgery.
The ACL Reconstruction surgery and ACL Rehab is a daunting road. However, starting on the right foot can make it a lot easier and get moving through the phases of the rehab with less speed bumps. Make sure to work with your entire sports medicine team to determine what is best for you to focus on each step of the way. Trust the process and you will come out stronger than you have ever been!
Trust the Trifecta,
Dr. Boyd
Feature Image Courtesy of https://unsplash.com/@chris_chow
References:
Chmielewski TL, , Stackhouse S, , Axe MJ, , Snyder-Mackler L. and A prospective analysis of incidence and severity of quadriceps inhibition in a consecutive sample of 100 patients with complete acute anterior cruciate ligament rupture. J Orthop Res. 2004; 22: 925– 930.
Fahrer H, , Rentsch HU, , Gerber NJ, , Beyeler C, , Hess CW, , Grunig B. and Knee effusion and reflex inhibition of the quadriceps. A bar to effective retraining. J Bone Joint Surg Br. 1988; 70: 635– 638.
Mauro, CS, Irrgang, JJ, Williams, BA, Harner, CD. Loss of extension following anterior cruciate ligament reconstruction: analysis of incidence and etiology using IKDC criteria. Arthroscopy. 2008;24:146–153.
Noll S, Garrison JC, Bothwell J, Conway JE (2015) Knee extension range of motion at 4 weeks is related to knee extension loss at 12 weeks after anterior cruciate ligament reconstruction. Orthop J Sport Med 3:2325967115583632
. Rice DA, , McNair PJ. and Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Arthritis Rheum. 2010; 40: 250– 266
Shelbourne KD, Freeman H, Gray T. Osteoarthritis after anterior cruciate ligament reconstruction: the importance of regaining and maintaining full range of motion. Sports health. 2012;4:79–85.
Snyder-Mackler L, , De Luca PF, , Williams PR, , Eastlack ME, , Bartolozzi AR, 3rd. and Reflex inhibition of the quadriceps femoris muscle after injury or reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am. 1994; 76: 555– 560.
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