Surgery for Anterior Cruciate Ligament Tear

with Phase I Rehab

The goal of ACL reconstruction surgery is for the patient to regain full function of the knee joint which will allow him or her to return to sports. ACL grafts undergo a degeneration process (the graft is usually at its weakest 6 weeks after the surgery) followed by a regeneration process, which may take up to 10 years.

Surgery is typically performed 3 or more weeks after the date of injury, when the knee has a full range of motion and the individual has control of the thigh muscle. ACL surgery usually requires replacing (reconstruction) of the injured ligament because ACL's usually cannot be sewn back together (repaired).

INDICATIONS FOR SURGERY

  • Individuals who regularly need to pivot, cut, jump or land on knee.

  • Patients with recurrent giving way or knee instability, despite 3 to 6 months of participation in a conservative (non-surgical) rehabilitation program.

  • Patients with an anterior cruciate ligament (ACL) tear and a reparable meniscus tear.

  • Patients with an ACL tear and other ligament injuries in the same knee.

REASONS NOT TO OPERATE

  • Individuals who do not regularly need to pivot, cut, jump, or land.

  • Individuals who exercise by jogging, cycling, or swimming only.

  • Inability or unwillingness to complete the postoperative rehabilitation program.

  • Infection of the knee, current or previous, is a concern but not an absolute contraindication.

  • If the patient is not yet fully grown (skeletal immaturity), surgery may not be recommended until the patient is fully grown, but this is not an absolute contraindication.

  • Persons with severe knee arthritis should not have surgery.

RISKS AND COMPLICATIONS

  • Risks of surgery:

  • Infection.

  • Bleeding.

  • nerve damage (numbness, weakness, paralysis) of the knee, leg, or foot, although it is not uncommon to have some numbness, temporary or permanent, on the outer part of the upper leg.

  • Stretching or tearing of the reconstructed ligament, causing recurrent instability.

  • Knee stiffness or loss of knee motion.

  • Rupture of the patellar tendon or patellar fracture (both are uncommon).

  • Pain from screw used to hold the graft (rare).

  • Clot in the veins of the calf or thigh (deep venous thrombosis, phlebitis) that may break off in the bloodstream and go to the lungs (pulmonary embolus) or brain (causing a stroke).

PROCEDURE

Most ACL reconstruction surgeries are performed with the assistance of an arthroscope to help the surgeon view the knee joint without needing a large incision. These procedures may be completed and you can go home the same day (outpatient basis), or you may need to stay in the hospital overnight. The torn ACL is removed and replaced by a graft. There are many different graft options for ACL reconstructions:

  • The central third of the patellar tendon, from the same or opposite knee.

  • The hamstring tendon.

  • The quadriceps tendon.

  • Transplant from a cadaver (allograft) patellar tendon or Achilles tendon.

The different types of grafts each have their own advantages and disadvantages. The type of graft used should be discussed with your surgeon.

After the torn ACL is removed, the surgeon will shave part of the bone in order for the graft to fit well in the joint. The surgeon will also look at the other structures of the knee that may have been damaged during the injury, and these may be fixed. In order for the new graft to be placed in the joint, two tunnels are drilled in the bones of the knee. The graft is then secured into the tunnels with screws, heavy stitches (sutures), spiked washers, or posts. The devices used to hold the graft in place usually do not need to be removed.

Do not eat or drink anything before surgery. Solid food makes general anesthesia more hazardous.

HOME CARE INSTRUCTIONS

Your surgeon will recommend that you complete a rehabilitation program after surgery in order to regain full function of your injured knee. The success of an ACL reconstruction surgery often depends on the patient and therapist and being able to follow through on and maintain a proper therapy schedule.

  • Keep the incision sites dry and clean for two weeks after surgery.

  • Ice the knee for 20 minutes every 2 to 3 hours while awake for the first 1 to 2 weeks after surgery.

  • Prescription pain medications will be given by your caregiver. Use only as directed and only as much as you need.

  • You may be given a knee brace after surgery.

  • Goals for rehabilitation of ACL reconstruction include reducing knee swelling, regaining knee range of motion, and regaining strength in the leg and thigh muscles. Check with your caregiver for the exact exercises to perform. Often a graduated program is specified.

RETURN TO SPORTS

You may return to sports when your therapist gives you permission to do so. Return to sports is usually allowed when the knee has a full range of motion, muscle strength is regained, and functional use has been restored. This usually requires 4 to 6 months following ACL reconstruction.

SEEK MEDICAL CARE IF:

  • You experience pain, numbness, or coldness in the foot and ankle.

  • Blue, gray, or dark color appears in the toenails.

  • You experience increased pain, swelling, redness, drainage, or bleeding in the surgical area.

  • You have signs of infection (headache, muscle aches, dizziness, or a general ill feeling with fever).

  • New, unexplained symptoms develop (drugs used in treatment may produce side effects).

EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Anterior Cruciate Ligament Tear, Surgery For Phase I

These are some of the initial exercises that your physician, physical therapist or athletic trainer may have you perform during the first 2 weeks after your surgery when beginning your rehabilitation. In order to get the best results from your rehabilitation, it is important that you gain the ability to fully straighten your knee as soon as your body allows after surgery. When you demonstrate gains in your flexibility and strength, your clinician will progress you to Phase II exercises. The intensity of these exercises will be determined after your physician identifies your needs and how well you are healing. As you perform these exercises, remember:

  • These initial exercises are intended to be gentle. They will help you restore motion without increasing any swelling.

  • Completing these exercises allows less painful movement and prepares you for the more aggressive strengthening exercises in Phase II.

  • An effective stretch should be held for at least 30 seconds.

  • A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue.

RANGE OF MOTION - Knee Flexion, Active

  • Lie on your back with both knees straight. (If this causes back discomfort, bend your opposite knee, placing your foot flat on the floor.)

  • Slowly slide your heel back toward your buttocks until you feel a gentle stretch in the front of your knee or thigh.

  • Hold for __________ seconds. Slowly slide your heel back to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

STRETCH - Knee Flexion, Supine

  • Lie on the floor with your right / left heel/foot lightly touching the wall (place both feet on the wall if you do not use a door frame).

  • Without using any effort, allow gravity to slide your foot down the wall slowly until you feel a gentle stretch in the front of your knee.

  • Hold this stretch for __________ seconds. Then return the leg to the starting position, using your healthy leg for help, if needed.

Repeat __________ times. Complete this stretch __________ times per day.

RANGE OF MOTION - Knee Flexion and Extension, Active-Assisted

  • Sit on the edge of a table or chair with your thighs firmly supported. It may be helpful to place a folded towel under the end of your right / left thigh.

  • Flexion (bending): Place the ankle of your healthy leg on top of the other ankle. Use your healthy leg to gently bend your right / left knee until you feel a mild tension across the top of your knee.

  • Hold for __________ seconds.

  • Extension (straightening): Switch your ankles so your other leg is on top. Use your healthy leg to straighten your right / left knee until you feel a mild tension on the backside of your knee.

  • Hold for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

STRETCH - Knee Extension Sitting

  • Sit with your right / left leg/heel propped on another chair, coffee table, or foot stool.

  • Allow your leg muscles to relax, letting gravity straighten out your knee.*

  • You should feel a stretch behind your right / left knee. Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

*Your physician, physical therapist or athletic trainer may instruct you place a __________ weight on your thigh just above your kneecap to deepen the stretch.

STRETCH - Knee Extension, Prone

  • Lie on your stomach on a firm surface, such as a bed or countertop. Place your right / left knee and leg just beyond the edge of the surface. You may wish to place a towel under the far end of your thigh for comfort.

  • Relax your leg muscles and allow gravity to straighten your knee. Your clinician may advise you to add an ankle weight if more resistance is helpful for you.

  • You should feel a stretch in the back of your knee. Hold this position for __________ seconds.

Repeat __________ times. Complete this stretch __________ times per day.

STRENGTHENING EXERCISES - Anterior Cruciate Ligament Tear, Surgery For Phase I

These exercises may help you when you begin to rehabilitate during the first 3 weeks after your surgery. Your physician, physical therapist or athletic trainer will advise you which exercises you should complete based on your healing and progress. It is very important that you exercise within the guidelines provided by your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises.

  • Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Progress the resistance and repetitions only as guided.

  • In order to return to more demanding activities, you will likely need to progress to more challenging exercises. Your physician, physical therapist or athletic trainer will advance your exercises when your tissues show adequate healing and your muscles demonstrate increased strength.

STRENGTH - Quadriceps, Isometrics

  • Lie on your back with your right / left leg extended and your opposite knee bent.

  • Gradually tense the muscles in the front of your thigh. You should see either your knee cap slide up toward your hip or increased dimpling just above the knee. This motion will push the back of the knee down toward the floor/mat/bed on which you are lying.

  • Hold the muscle as tight as you can without increasing your pain for __________ seconds.

  • Relax the muscles slowly and completely in between each repetition.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Quadriceps, Straight Leg Raises

Quality counts! Watch for signs that the quadriceps muscle is working to insure you are strengthening the correct muscles and not "cheating" by substituting with healthier muscles.

  • Lay on your back with your right / left leg extended and your opposite knee bent.

  • Tense the muscles in the front of your thigh. You should see either your knee cap slide up or increased dimpling just above the knee. Your thigh may even quiver.

  • Tighten these muscles even more and raise your leg 4 to 6 inches off the floor. Hold for ____________________ seconds.

  • Keeping these muscles tense, lower your leg.

  • Relax the muscles slowly and completely in between each repetition.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Hamstring, Isometrics

  • Lie on your back on a firm surface.

  • Bend your right / left knee approximately __________ degrees.

  • Dig your heel into the surface as if you are trying to pull it toward your buttocks. Tighten the muscles in the back of your thighs to "dig" as hard as you can without increasing any pain.

  • Hold this position for __________ seconds.

  • Release the tension gradually and allow your muscle to completely relax for __________ seconds in between each exercise.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Hamstring, Curls

  • Lay on your stomach with your legs extended. (If you lay on a bed, your feet may hang over the edge.)

  • Tighten the muscles in the back of your thigh to bend your right / left knee up to 90 degrees. Keep your hips flat on the bed/floor.

  • Hold this position for __________ seconds.

  • Slowly lower your leg back to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

OPTIONAL ANKLE WEIGHTS: Begin with ____________________, but DO NOT exceed ____________________. Increase in 1 pound/ 0.5 kilogram increments.

STRENGTH - Quad/VMO, Isometric

  • Sit in a chair with your right / left knee slightly bent. With your fingertips, feel the VMO muscle just above the inside of your knee. The VMO is important in controlling the position of your kneecap.

  • Keeping your fingertips on this muscle. Without actually moving your leg, attempt to drive your knee down as if straightening your leg. You should feel your VMO tense. If you have a difficult time, you may wish to try the same exercise on your healthy knee first.

  • Tense this muscle as hard as you can without increasing any knee pain.

  • Hold for __________ seconds. Relax the muscles slowly and completely in between each repetition.

Repeat __________ times. Complete exercise __________ times per day.

MOBILIZATION – Patella

  • Sit on the floor or on a bed so that your right / left leg can comfortably lie straight. It may be helpful to place a folded washcloth or hand towel under your knee.

  • Gently grasp the edges of your knee cap with your thumbs and index fingers.

  • Imagine your knee cap is a clock face. Keeping your leg muscles relaxed, gently slide your knee cap from the center toward each of the 12 numbers on the clock until you feel some resistance but no pain. Return to the center after you complete each number.

  • Hold each position __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Hip Abductors, Straight Leg Raises

Be aware of your form throughout the entire exercise so that you exercise the correct muscles. Sloppy form means that you are not strengthening the correct muscles.

  • Lie on your side so that your head, shoulders, knee and hip line up. You may bend your lower knee to help maintain your balance. Your right / left leg should be on top.

  • Roll your hips slightly forward, so that your hips are stacked directly over each other and your right / left knee is facing forward.

  • Lift your top leg up 4-6 inches, leading with your heel. Be sure that your foot does not drift forward or that your knee does not roll toward the ceiling.

  • Hold this position for __________ seconds. You should feel the muscles in your outer hip lifting (you may not notice this until your leg begins to tire).

  • Slowly lower your leg to the starting position. Allow the muscles to fully relax before beginning the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Hip Extensors, Bridge

  • Lie on your back on a firm surface. Bend your knees and place your feet flat on the floor.

  • Tighten your buttocks muscles and lift your bottom off the floor until your trunk is level with your thighs. You should feel the muscles in your buttocks and back of your thighs working. If you do not feel these muscles, slide your feet 1-2 inches further away from your buttocks.

  • Hold this position for __________ seconds.

  • Slowly lower your hips to the starting position and allow your buttock muscles relax completely before beginning the next repetition.

  • If this exercise is too easy, you may cross your arms over your chest.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH – Quadriceps, Squats

  • Stand in a door frame so that your feet and knees are in line with the frame.

  • Use your hands for balance, not support, on the frame.

  • Slowly lower your weight, bending at the hips and knees. Keep your lower legs upright so that they are parallel with the door frame. Squat only within the range that does not increase your knee pain. Never let your hips drop below your knees.

  • Slowly return upright, pushing with your legs, not pulling with your hands.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTH - Plantar-flexors, Standing

  • Stand with your feet shoulder width apart. Steady yourself with a wall or table using as little support as needed.

  • Keeping your weight evenly spread over the width of your feet, rise up on your toes.*

  • Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

*If this is too easy, shift your weight toward your right / left leg until you feel challenged. Ultimately, you may be asked to do this exercise with your right / left foot only.