instructed to keep the knee wrapped and elevated as long as possible to improve fluid reabsorption, especially during the first week after injury or surgery. Patients are also instructed to unwrap the knee every 2 hours to prevent blocking circulation to the lower leg and foot. By reducing impairments, cryotherapy can enhance rehabilitation and improve the functional outcomes in patients with ACL deficiency and ACL reconstruction. In challenging cases, a patient might be referred back to his or her surgeon for further medical care managing joint effusion. Surgeons may prescribe nonsteroidal anti-inflammatory drugs to help reduce the joint effusion and inflammation. Fluid drainage can also be performed in case of excessive joint effusion that in- tervenes with the rehabilitation program progression. Figure 4: Figure-8 Compression Wrap
and TENS, with the intensity being set to the patients’ tolerance; it can be increased in the subsequent session. The patient’s posi- tion should be comfortable; suggested positions could include the supine position on the treatment table with the knee fully extended or sitting with the knee in static flexion position. Most patients exhibit minimum to no pain after the first 1 to 2 weeks following surgery, and the minimal pain requires less extensive management modalities. Patellar taping may also be effective in managing anterior knee pain during exercise (Whittingham, Palm- er, & Macmillan, 2004). Patients with patellar tendon autograft continue to exhibit anterior knee pain due to the graft morbidity, specifically during activities that involve kneeling. These patients are recommended to use pads specific to the knee joint or place a spongy pillow or cushion beneath the knee to prevent pain. Knee joint effusion is one of the most predominant symptoms of ACL injury and reconstruction surgery and is frequently encoun- tered as an adverse effect during training. Excessive knee joint ef- fusion after ACL reconstruction may aggravate knee pain and may induce an intra-articular pressure that affects the sensitivity of the joint mechanoreceptors (Palmieri et al., 2003, 2004, 2005; Spen- cer et al., 1984). In addition to alleviating anterior knee pain, cryo- therapy may decrease joint effusion, especially when augmented with massage, compression wraps, and elevation (Raynor, Pietro- bon, Guller, & Higgins, 2005). Cryotherapy can be applied over the swollen knee as a cold pack or crushed ice in a plastic bag for 10 to 15 minutes or as an ice massage for up to 5 to 8 minutes. Cryotherapy can be initiated as early as the first day after surgery and can be used multiple times (three to four times) per day early after ACL reconstruction surgery. As the joint effusion improves by decreasing in size, the number of times that cryotherapy is used also decreases. Therapists may assess the joint effusion using the modified stroke test prior and post to the training session to monitor the chang- es in the joint effusion in response to the training (Sturgill et al., 2009). The pre- to post-training session changes in joint effusion can be used to guide the patient progression through the reha- bilitation program. This issue could be of high importance during the later phase of rehabilitation program after surgery, when pa- tients start running, agility exercises, and returning to sport activ- ity training. Some patients may continue to experience joint effu- sion with increased training load and frequency. Patients should be instructed to keep applying cryotherapy as needed, especially after completing the training session or at the end of working day. The use of cryotherapy is recommended as long as pain and effu- sion persist, even months after surgery. However, it should not be used for longer than the recommended time period per treatment session because it may result in frostbite or skin burn. Administering cryotherapy as part of the postoperative ACL re- construction program has been found to be effective to decrease the knee pain after surgery (Martimbianco et al., 2014; Raynor et al., 2005); however, it has no effect on the knee ROM and drain- age after surgery (Hubbard & Denegar, 2004; Martimbianco et al., 2014; Raynor et al., 2005; van Melick et al., 2016). Cryotherapy is fairly inexpensive, is easy to use, and rarely has adverse effects (Raynor et al., 2005; Rice, McNair, & Dalbeth, 2009). Controlling knee pain and effusion is important to the progression of the rehabilitation program. Excessive knee joint effusion may result in ROM deficits, quadriceps inhibition, altered gait patterns, and a prolonged rehabilitation process (Cascio, Culp, & Cosgar- ea, 2004; Rice & McNair, 2010). Other therapeutic techniques used in adjunct to cryotherapy for reducing effusion after ACL injury or reconstruction surgery are compression wraps and elevation. It is recommended to apply cryotherapy with the patient in the supine position, with the in - jured or reconstructed limb elevated above the heart level. The therapist can teach the patient to wrap the knee using an elastic bandage and fabric pad, also known as a donut cushion . Patients start wrapping by placing the donut cushion on the top of the knee and then wrapping the elastic bandage from the lower leg up to the thigh using a figure-8 pattern (Figure 4). Patients are
Note . From Western Schools, © 2018.
ROM deficit management In the operating room, knee ROM is assessed to ensure that full ROM has been restored and to verify that the harvested graft did not limit knee motion. ROM deficits are not restricted to those pa- tients undergoing ACL reconstruction. However, ROM deficits are common impairments after ACL injury and reconstruction surgery and are associated with poor knee functional outcomes (Benum, 1982; Shelbourne, Urch, Gray, & Freeman, 2012). Moreover, ROM could affect the patient’s gait, because some patients continue to walk with asymmetrical knee angles for long periods after ACL reconstruction (Roewer, Di Stasi, & Snyder-Mackler, 2011; Hart et al., 2016; Kaur et al., 2016). Walking with a stiff knee may alter articular cartilage loading and aggravate osteoarthritis processes in the knee joint (Andriacchi et al., 2009; Khandha et al., 2017). Persistent knee extension motion deficit may also cause anterior knee pain, quadriceps weakness, and increased risk of knee os- teoarthritis (Shelbourne, Patel, & Martini, 1996; Shelbourne, Urch, et al., 2012). ROM deficits may result from several factors, includ- ing preoperative motion loss (Mauro et al., 2008; Shelbourne & Johnson, 1994), length of time between the injury and surgery (Kwok, Harrison, & Servant, 2013), surgical techniques including improper surgical techniques (Harner, Irrgang, Paul, Dearwater, & Fu, 1992; Millett et al., 2001), and prolonged postoperative im- mobilization (Cosgarea, Sebastianelli, & DeHaven, 1995). Knee extension deficits are common following ACL reconstruction in patients with bone-patella tendon-bone autografts. Some authors suggest that arthrofibrosis scar nodules, also known as cyclops lesions , may develop within the joint when a patellar tendon au- tograft is harvested (Harner et al., 1992; Logerstedt & Sennett, 2007; Millett et al., 2001). While performing knee extension mo- tion in patients with arthrofibrosis, the scar nodule impinges un- derneath the femoral notch and blocks the terminal knee motion. Arthroscopic debridement has been effective in improving knee extension ROM when arthrofibrosis is the cause of knee extension deficits (Jackson & Schaefer, 1990). Additionally, reconstruction surgery on a knee that is inflamed and has excessive joint effu- sion and ROM deficits may also contribute to the development of arthrofibrosis and postsurgical ROM deficit (Shelbourne & Patel, 1999; T. O. Smith et al., 2010). Therefore, delaying the reconstruc- tion surgery with the attempt to resolve the preoperative impair- ments may result in better postoperative outcomes (T. O. Smith et al., 2010).
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