INERTIA: A Therapist's Thoughts

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.