Surgery for Anterior Cruciate Ligament Tear

with Phase II 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

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

  • 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 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.

  • Tthe 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.

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.

RET URN 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

PHASE II EXERCISES

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

About 3 to 6 weeks after your surgery, your physician, physical therapist or athletic trainer will assess your knee to determine if it has made progress significant enough to begin more advanced exercises. If your knee has recovered at least 75% of its full range of motion, he or she may recommend that you complete some of the following exercises in order to help you regain the final 25%. If you have not achieved this level in your rehabilitation, continue with the Phase I exercises. While completing these exercises, remember:

  • These exercises are intended to help you restore motion without increasing any swelling.

  • Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

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

  • Your physician, physical therapist or athletic trainer will assess your body's unique healing and your activity needs in order to determine the level of intensity which is most effective for you. Continue to carefully follow all instructions provided by your care giver.

STRETCH - Quadriceps, Active-Assisted

  • Position the seat on a stationary, upright bicycle so that the ball of your right / left foot can rest flat on the pedal.

  • Sitting on the bike, use your opposite leg to push the pedal down until you feel a stretch in the front of your right / left knee. Hold this position for __________ seconds.

  • Release the stretch and then repeat. You will likely not be able to make a full revolution with the pedals when you begin. As you progress and can pedal all the way around, begin to lower the bicycle seat until your knees are at hip height when they are at the top of the rotation.

Repeat ____________________ times. Complete this exercise ____________________ times a day.

(Your physician, physical therapist or athletic trainer may begin you on this exercise earlier than 3 weeks after your surgery.)

STRETCH - Quadriceps, Prone

  • Lie on your stomach on a firm surface, such as a bed or padded floor.

  • Bend your right / left knee and grasp your ankle. If you are unable to reach your ankle or pant leg, use a belt around your foot to lengthen your reach.

  • Gently pull your heel toward your buttocks. Your knee should not slide out to the side. You should feel a stretch in the front of your thigh and/or knee.

  • Hold this position for __________ seconds.

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

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

These are some of the exercises you may progress to in your rehabilitation program at about 3-6 weeks after your surgery. Your surgeon will determine which exercises are best for you based on your needs and current status. It is critical that you follow the instructions of your caregiver and not progress to these Phase II exercises until directed. You may continue with all Phase I strengthening 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, Stationary Bicycle

Do not begin this exercise until you can complete a full circle while pedaling.

  • Set the seat height so that you can complete a full circle without pain or significant resistance from your right / left leg.

  • Select a resistance that challenges your right / left quadriceps muscles (the muscles in the front of the thighs). You should feel tension and possibly fatigue in the front of your right / left thigh.

  • Pedal for __________ minutes per day.

*Your physician, physical therapist or athletic trainer may instruct you to pedal with only your right / left leg in order to better challenge the muscles in that leg.

STRENGTH - Quadriceps, Step-Ups

  • Use a thick book, step or step stool that is __________ inches tall.

  • Hold a wall or counter for balance only, not support.

  • Slowly step-up with your right / left foot, keeping your knee in line with your hip and foot. Do not allow your knee to bend so far that you cannot see your toes.

  • Slowly unlock your knee and lower yourself to the starting position. Your muscles, not gravity, should lower you.

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

STRENGTH - Quadriceps, Wall Slides

Follow guidelines for form closely. Increased knee pain often results from poorly placed feet or knees.

  • Lean against a smooth wall or door and walk your feet out 18-24 inches. Place your feet hip-width apart.

  • Slowly slide down the wall or door until your knees bend __________ degrees.*Keep your knees over your heels, not your toes, and in line with your hips, not falling to either side.

  • Hold for __________ seconds. Stand up to rest for __________ seconds in between each repetition.

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

* Your physician, physical therapist or athletic trainer will alter this angle based on your symptoms and progress.

STRENGTH – Quads, Supine

  • Lie on your back. Raise your right / left knee directly over your right / left hip.

  • Support the back of your right / left thigh with either two hands, a towel or a belt.

  • Slowly straighten your knee as far as you can without increasing any pain in your knee. Hold right / left seconds.

  • Slowly return to your starting position, allowing your muscles to completely relax before beginning the next repetition.

Repeat exercise __________ times, __________ 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 buttocks muscles to 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 - Hip Adductors, Straight Leg Raises

  • Lie on your side so that your head, shoulders, knee and hip line up. You may place your upper foot in front to help maintain your balance. Your right / left leg should be on the bottom.

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

  • Tense the muscles in your inner thigh and lift your bottom leg 4-6 inches. Hold this position for __________ seconds.

  • 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.