significantly different between the graft types (Krych et al., 2008; Tibor et al., 2010). Functional outcomes have been shown to be Impairment-based interventions Although ACL reconstruction is performed in the attempt to restore knee joint stability, many patients continue to present with poor functional performance after ACL surgery (Lohmander et al., 2004; Nawasreh et al., 2016; von Porat et al., 2004; Thoma et al., 2019). It has been estimated that up to 60% of patients fail to return to preinjury activity levels following ACL reconstruction due to the presence of postoperative impairments (Ardern et al., 2011a; Chmielewski, 2011). Postoperative impairments may include pain secondary to surgery and at the donor site (Kartus et al., 2001), quadriceps strength deficits (Chmielewski et al., 2004; Hartigan et al., 2009), neuromuscular dysfunction (Hewett, Myer, Ford, & Slauterbeck, 2007), knee joint effusion, limited ROM (especially into knee extension (Millett et al., 2001), and altered gait patterns (Rudolph et al., 1998; Capin, Zarzycki, Khandha, Arundale, et al., 2018; Capin, Zarzycki, et al., 2017; Capin, Zarzycki, et al., 2019; Hart et al., 2016; Kaur et al., 2016). Pain control and effusion management Knee pain related to the surgical incision or donor site morbidity is common after ACL reconstruction, especially in patients who have received patellar tendon autograft. Although anterior knee pain is common following ACL reconstruction, it is not restricted to those patients with patellar tendon autograft. Evidence suggests that patients with STG autograft may also experience moderate anterior knee pain after ACL reconstruction (Yunes, Richmond, Engels, & Pinczewski, 2001). A study by Corry, Webb, Clingeleffer, & Pinczewski (1999) reported no significant differences between anterior knee pain with patellar tendon and hamstrings autografts; however, pain with kneeling is commonly associated with patellar tendon autograft (Corry et al.,1999; Li et al., 2011). Most patients complain of local anterior knee pain (described as pinpoint pain); others complain of diffuse pain. Cryotherapy and electrical stimulation may be applied in an attempt to alleviate joint or anterior knee pain after ACL injury and reconstruction surgery. Noxious electrical stimulation (2,500 Hz, 50 bursts/second, 12 on/8 off) for 10 to 15 minutes can be used to manage localized pain (Manal, 2001). The noxious stimulation device has two pads (typically 2 × 3 cm) that can be placed on the painful area with 1 to 2 cm between the pads. The therapist instructs the patient that the treatment will be painful (noxious), with an initial tingling sensation progressing to noxious pain. In addition, patients are instructed to inform the therapist if the noxious stimulation feels like a ‘hot poker’ or if it causes a burning sensation. In cases of more diffuse pain, a transcutaneous electrical nerve stimulation (TENS) can be used (4,500 Hz, 50 bursts/second, continuous [set off time to 0]) for 15 to 20 minutes (Bjordal, Johnson, & Ljunggreen, 2003). The TENS device has the option of a configuration of either two or four pads, depending on the size of the painful area. The noxious electrical stimulation and TENS can be administered for multiple times (two to three times) during the first week after surgery for patients presenting with severe knee pain. However, the number of times of using the noxious stimulation and TENS can be decreased based on the patients’ needs. There are no restrictions on the intensity and the patients’ position during the administration of noxious electrical stimulation and TENS, with the intensity being set to the patients’ tolerance; it can be increased in the subsequent session. The patient’s position 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, Palmer, & Macmillan, 2004). Patients with patellar tendon autograft continue to exhibit
similar between autografts and allografts (Foster et al., 2010; Reinhardt et al., 2010).
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 encountered as an adverse effect during training. Excessive knee joint effusion 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; Spencer et al., 1984). In addition to alleviating anterior knee pain, cryotherapy may decrease joint effusion, especially when augmented with massage, compression wraps, and elevation (Raynor, Pietrobon, 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 changes 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 rehabilitation program. This issue could be of high importance during the later phase of rehabilitation program after surgery, when patients start running, agility exercises, and returning to sport activity training. Some patients may continue to experience joint effusion 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 effusion 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 reconstruction 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 drainage 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, & Cosgarea, 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 injured 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 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
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