surgery to restore full knee extension. The use of a knee brace locked in full extension is also suggested in the immediate post- operative stage following ACL reconstruction to reduce the likeli- hood of developing knee extension ROM deficits. Patients with persistent knee extension deficits beyond the sec- ond postoperative week can begin stretching exercises – such as prone hangs and bag hangs with weights – that use low-load and long-duration principles to achieve full knee extension (Figure 5; Adams et al., 2012; Wilk, Reinold, & Hooks, 2003). In persistent cases of knee extension ROM loss or knee flexion contracture, drop-out casting may be used to resolve extension ROM deficits. Drop-out casting maintains the length of the connective tissues by applying a constant load over long periods (Adams et al., 2012).
One of the goals of ACL rehabilitation is to restore full knee exten- sion early after ACL injury and ACL reconstruction. Loss of knee extension ROM immediately following ACL reconstruction is com- mon (Adams et al., 2012). Early emphasis on restoring knee exten- sion is paramount in maximizing short- and long-term outcomes. To achieve full knee extension motion, several techniques can be employed immediately after the surgery. They can include plac- ing the foot of the reconstructed limb on a pillow or hard object or on the contralateral foot and for a short time (5 to 10 minutes). During that time, the patient should be instructed to press down by activating the quadriceps muscle. Additionally, superior patella mobilization, straight leg raises, and hamstrings and gastrocne- mius muscles stretching exercises can be performed early after
Figure 5: Knee Stretching Techniques
Note . From Western Schools, © 2018.
evidence suggests that current functional bracing technologies do not sufficiently restore normal biomechanics to the ACL-defi- cient knee, protect the reconstructed ACL, or improve long-term patient outcomes (S. D. Smith, LaPrade, Jansson, Årøen, & Wi- jdicks, 2014). Functional bracing does not result in superior func- tional or patient-reported outcomes and has not been shown to reduce risk of reinjury following surgery (Birmingham et al., 2008). Although the standard of care in the past has been to prescribe functional knee bracing following ACL reconstruction for return to sports (Marx, Jones, Angel, Wickiewicz, & Warren, 2003), knee Quadriceps muscle strength deficits, ranging from 15% to 40%, and atrophy of the involved limb are the predominant impair- ments after ACL rupture and can persist for years after ACL reconstruction (Chmielewski et al., 2004; de Jong et al., 2007; Feller & Webster, 2003; Hartigan et al., 2009). Strength deficits, often attributed to quadriceps activation failure after ACL in- jury or surgery, have a negative impact on knee joint functional performance (de Jong et al., 2007; Hartigan et al., 2009; Keays, Bullock-Saxton, Newcombe, & Keays, 2003; Schmitt, Paterno, & Hewett, 2012). Moreover, strength deficits have been associated with increased risk of second ACL injury (Hurley, Jones, Wilson, & Newham, 1992; Schmitt et al., 2012) and the development of knee osteoarthritis (Tourville et al., 2013). Quadriceps activation failure is the result of intra-articulate changes in the knee joint, a condition called arthrogenic muscle inhibition (Hart et al., 2010; Lynch et al., 2012). Preoperative quadriceps strength can predict the knee function after the surgery (de Jong et al., 2007; Eitzen et al., 2009; Logerstedt et al., 2013a). Therefore, addressing pre- operative quadriceps strength deficit as part of the preoperative rehabilitation program is crucial for functional recovery and better outcomes after ACL reconstruction surgery. bracing is now less common. Quadriceps strengthening Quadriceps weakness may persist up to 5 years after reconstruc- tion surgery (Hartigan et al., 2010; Lewek, Rudolph, Axe, & Sny- der-Mackler, 2002; Nawasreh et al., 2016; Petersen, Taheri, Forkel, & Zantop, 2014; Rosenberg, Franklin, Baldwin, & Nelson, 1992). This issue may affect the patient’s physical readiness for return- ing to high-demand physical activities. Patients with quadriceps weakness demonstrate greater knee movement asymmetries be- tween limbs on hop tests for distance and altered knee joint bio- mechanics compared to patients with high quadriceps strength
Patella mobilization in all directions can be initiated with the knee joint in full extension. Then, inferior patella glide can be per- formed at the end of the available knee flexion ROM. The knee brace can be set to allow knee motion between 0° and 90° after the second week postoperatively. Patients should be instructed to perform these activities at home two to three times per day. During the first week after surgery, the passive/active knee ROM should be between 0° and 90°. By the end of the second week postoperatively, the patient should achieve full knee extension and 110° flexion. Knee flexion deficit can be within 10° 4 weeks operatively, and full knee ROM should be achieved between 6 and 8 weeks postoperatively (Adams et al., 2012). To restore knee flexion ROM, various techniques, such as wall slides, stationary biking, and patellar mobilization, can be used immediately after ACL reconstruction. However, these techniques must be used with care within the constraints of protective ROM to avoid stressing the newly harvested graft tissue and disrupting the incision site stitches. Flexion ROM exercises may be limited by concomitant surgical procedures, such as meniscal repair or MCL reconstruction. Between 3 and 5 weeks after ACL reconstruction surgery, the therapist may also begin applying anterior to pos- terior tibiofemoral mobilizations at different knee joint angles to facilitate flexion ROM gains. ROM exercises should be continued with patients until ROM in the surgically repaired knee is equal to ROM in the contralateral knee. Bracing and crutches Patients will typically use a knee immobilizer such as a drop-lock knee brace while walking and sleeping during the immediate postoperative phase to protect the graft and restore full knee mo- tion (Adams et al., 2012; Yabroudi, & Irrgang, 2013). During the immediate postoperative phase, patients require axillary crutches and are educated to ambulate with weightbearing as tolerated. By the second week postoperatively, crutches can be discontinued if the patient is able to ambulate without pain (Adams et al., 2012). Once patients are able to perform straight leg raises without lag and knee joint effusion is minimized, the knee immobilizer may be replaced with a functional knee brace (Adams et al., 2012; Chew, Lew, Date, & Fredericson, 2007; Wright & Fetzer, 2007). How- ever, the use of a functional knee brace is surgeon-dependent and becoming less routine. Although functional knee bracing is also often recommended for patients with ACL-deficient knees (Logerstedt et al., 2010a; Swirtun, Jansson, & Renström, 2005),
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