INERTIA: A Therapist's Thoughts

At about four weeks removed from surgery, this patient presented as doing and feeling fairly well. At this point, regular daily tasks return to normal for the most part. The patient is walking normally and is feeling less overall soreness and discomfort. The patient presented today with completely normal range of motion in the surgically repaired knee.

Knee flexion increased to 145 degrees and extension increased to 5 degrees. We will no longer focus on range of motion during treatment but rather check it quickly each week to make sure that normal motion is maintained. 

As far as exercises and strengthening goes, the next month or so is kind of the doledrums of ACL rehab. I say that because the type of exercises don't really change much but rather are progressed in weights/repetitions (reps) and patients get eager to do more. It is my job to vary things just enough to keep the patient sufficiently challenged and interested.

The goal for the next two months is gaining muscle strength and mass. To that end, with each workout, the goal is to fatigue the quadriceps primarily and the hamstrings to a lesser degree. The overload principle is applied with strength exercises where each exercise should be done at an intensity (weight/reps) that induces fatigue. Ideally the number of reps should be three sets of 8-10 reps and the weight adjusted accordingly to achieve that number of reps. This will result in the greatest strength gains.

The patient is given instructions to continue with the prescribed exercises two additional times beyond the therapy session each week with a rest day in between workouts. 

Below is a list of strength exercises performed by the patient during this visit:

• Double leg press 9pl 2x10
• Two up, one down leg press 7pl 2x10 (eccentrics)
• Single leg press 6pl 3x10 (involved leg)
• Steamboats for balance x 20 reps each direction
• Lateral step downs 4" 3x10
• Forward step ups 12" 3x10

 

Hamstring strengthening for this patient is still avoided because of the surgical procedure to attempt to harvest a hamstring tendon graft. Hamstring strengthening will begin in two weeks.  

In general this patient is progressing very well and certainly faster than some.  Each patient progresses at his or her own rate so what is shown here may be somewhat different for another patient depending on a number of factors.  

In coming posts, I may fast forward a few weeks because what I described above does not change much in activities and exercises.  Looking forward, our goals are to light impact at weeks eight and nine and interval jogging possibly as early as week 10. 
   

With the patient now three weeks removed from ACL reconstruction, we are continuing to see steady progress.  During this appointment, the patient reports the knee feeling a little warm and still a bit sore.  Both are not unusual complaints at this point as some effusion or joint swelling is still present from surgery. Looking at the knee, we see the incision is healing well, swelling is minimal and there are no signs of active infection. OK to proceed. 

After a brief bike warm-up, a few manual therapy techniques are used to work the scar and to mobilize the kneecap. I then do a few range of motion exercises for knee flexion and extension. A new measurement is taken and we record further progress: The patient's knee flexion has increased to 135 degrees. The patient's knee extension or straightening has also increased so that now there is actually about 2 degrees of hyperextension. Most people have at least a degree or two of hyperextension with some having as much as 10 degrees.  So this finding is completely normal. 

The same exercises performed at the last session were again repeated with progression of either increased weights or repetitions.  The patient progressed with balance exercises to include the use of resistive bands to provide additional challenge.  In addition to these progressions, we added both forward step ups on a 6" step and side step downs on a 2" step.  Both the step ups and step downs are excellent functional exercises as they closely relate to the task of climbing and descending stairs and work on quad strength and hip control, both important concepts in ACL rehab. 

Our ACL patient is now two weeks removed from surgery. On this date, the patient reported that her knee still "feels tight but there is not much pain." The patient presented to the clinic wearing a compression stocking to assist in controlling the swelling in the knee. At this point, residual swelling is still very normal after an ACL reconstruction and will be one of the primary reasons for continued discomfort be it pain or tightness in the knee. The swelling is also the main reason that knee range of motion is not yet normal.

On this date, the patient presented to the clinic no longer using crutches. The patient's walking gait was not quite normal yet but close enough to ditch the crutch. The patient presented with improved knee range of motion. The knee flexion measurement increased to 127 degrees (normal being 140-145 degrees) and knee extension was 0 degrees or completely straight, which is normal. The patient demonstrated improved isolated quadriceps contraction again.

At this visit we were also able to progress the strengthening exercises quite a bit. I had the patient start using the leg press, which is like a squat machine, using both legs at first and then some with just the repaired knee. The patient also progressed with balance activities including the use of a balance board and increased holds on single-leg-standing to further progress proprioception. We also initiated the use of the stationary bike for light aerobic conditioning. I continue to use ice and electrical stimulation at the end of the treatment to help decrease remaining swelling and inflammation.

Overall the patient is progressing well and as expected. Next week a few new exercises will again be added.

Sorry for the delay on the progress of our ACL case.  Life and work tends to get away from me bit and one week easily turns into two or three.   

I next saw this ACL patient six days later or one week after surgery.  At this visit, the patient had the bandages removed by the surgeon’s office and steristrips were placed over the incisions. The patient had two small scope incisions and one larger incision over the front of the knee where the patellar tendon graft was harvested. The incisions generally appeared to be healing well without excessive redness or drainage present.   

On this date the patient presented to the clinic walking with one crutch on the left side of the body. Definite progress was made from the first visit in which the patient could hardly put any weight on the affected leg. The patient complained of some pain and pressure especially behind the knee, which is a typical report because of the presence of increased swelling within the joint.   

Treatment today consisted of soft tissue mobilization to the back of the knee and hamstrings to help resolve tightness. The hamstrings were also gently stretched and the patient was instructed on how to do this at home.  Patellar mobilizations were performed in which I manually glide the kneecap in all directions to help restore normal joint play which will assist in regaining full motion and quadriceps muscle function. The exercises from the first visit were reviewed. I particularly noted a much better quadriceps contraction this visit.     

I then added three new exercises to the program. I first added side-lying leg raises to address gluteal strength. The gluteals help to provide stability and assist with knee control during weightbearing activities. I also added single leg standing to improve balance and proprioception, which is the body’s position sense. Lastly, I started the patient on standing minisquats with body weight. The patient will add these exercises to the ones given on the first visit. I finished the day's treatment with ice and electrical stimulation for pain and edema control. The patient’s knee flexion measurement today had increased to 118 degrees.   

Overall from one day to one week post-op the patient demonstrated the following progress: walking improved with one crutch instead of two, increased knee flexion from 35 degrees to 118 degrees, and improved quality of quadriceps contraction.   

Stay tuned for week two to see what progress is made. 

Sorry, I'm back.  Not sure where I was but time gets away from me!   I thought I would start a series of posts following the progress of a patient who recently underwent anterior cruciate ligament (ACL) reconstruction surgery. I plan to do this with weekly posts to provide you with inside look of what ACL rehab is like at our facility.    

The ACL is one of four primary stabilizing ligaments within the knee joint.  It is definitely the most often injured ligament in the knee and thus something that we see hundreds of per year at the Sports Medicine Center.   

The two most common graft types are patellar tendon and hamstring tendon autografts (taken from the individual's own body). This particular patient received a patellar tendon autograft to replace the damaged ACL after an attempted hamstring graft was aborted due to poor condition of the hamstring tendon. 

I first saw this patient one day after surgery (post-op day one).  That may seem a bit soon, but I really like this approach and have found patients to do very well when they get an early start on their rehabilitation. The earlier patients start to bend their knee and work their quadriceps muscle the quicker they progress to normal walking. In most cases, the physical therapy visit one day post-op is fairly minimal. I help the patient bend and straighten their knee some and instruct them on how they can do this at home. We also initiate quad sets to start to “waken” that muscle from the deep sleep of anesthetic. If the patient does well with quad sets, straight leg raises are started. We then cover some simple weight shifting and proper use of crutches for walking and putting some weight on the injured leg.

Yes, most ACL reconstructions are weightbearing as tolerated (WBAT) this soon after surgery and do quite well with this. Lastly we finish with ice and elevation to help reduce the edema from surgery.  The patient will be icing frequently each day during the first week while at home. 

Next week, I'll summarize the post-op one week visit and see how our patient is progressing.  I'll also discuss how we organize rehab to protect the ACL graft.