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. Figure 4: Figure-8 Compression Wrap
& Fu, 1992; Millett et al., 2001), and prolonged postoperative immobilization (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 autograft is harvested (Harner et al., 1992; Logerstedt & Sennett, 2007; Millett et al., 2001). While performing knee extension motion in patients with arthrofibrosis, the scar nodule impinges underneath 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 effusion 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 reconstruction surgery with the attempt to resolve the preoperative impairments may result in better postoperative outcomes (T. O. Smith et al., 2010). One of the goals of ACL rehabilitation is to restore full knee extension early after ACL injury and ACL reconstruction. Loss of knee extension ROM immediately following ACL reconstruction is common (Adams et al., 2012). Early emphasis on restoring knee extension 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 placing 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 gastrocnemius muscles stretching exercises can be performed early after surgery to restore full knee extension. The use of a knee brace locked in full extension is also suggested in the immediate postoperative stage following ACL reconstruction to reduce the likelihood of developing knee extension ROM deficits. Patients with persistent knee extension deficits beyond the second 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).
Note . From Western Schools, ©2018. 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 intervenes with the rehabilitation program progression. 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 patients 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 osteoarthritis (Shelbourne, Patel, & Martini, 1996; Shelbourne, Urch, et al., 2012). ROM deficits may result from several factors, including 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,
Figure 5: Knee Stretching Techniques
Note . From Western Schools, ©2018.
Patella mobilization in all directions can be initiated with the knee joint in full extension. Then, inferior patella glide can be performed 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).
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Book Code: PTNJ0824
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