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 posterior 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 motion (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). However, 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), evidence suggests that current functional bracing technologies do not sufficiently restore normal biomechanics to the ACL-deficient knee, protect the reconstructed ACL, or improve long-term patient outcomes (S. D. Smith, LaPrade, Jansson, Årøen, & Wijdicks, 2014). Functional bracing does not result in superior functional 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 bracing is now less common. Quadriceps strengthening Quadriceps muscle strength deficits, ranging from 15% to 40%, and atrophy of the involved limb are the predominant impairments 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 injury 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 preoperative quadriceps strength deficit as part of the preoperative rehabilitation program is crucial for functional recovery and better outcomes after ACL reconstruction surgery. Quadriceps weakness may persist up to 5 years after reconstruction surgery (Hartigan et al., 2010; Lewek, Rudolph, Axe, & Snyder-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 returning to high-demand physical activities. Patients with quadriceps weakness demonstrate greater knee movement asymmetries between limbs on hop tests for distance and altered knee joint biomechanics compared to patients with high quadriceps strength (Palmieri-Smith & Lepley, 2015; Schmitt et al., 2012; Zwolski et al., 2015). However, quadriceps strength alone is not sufficient to restore symmetrical movement patterns (Arhos et al., 2021). Several strength training and electrotherapy modalities have been used to help resolve quadriceps strength deficits and activation failure in patients with ACL injury and ACL reconstruction surgery. Isometric quadriceps exercise is a safe strengthening exercise that can be administered immediately after surgery and it has no negative impact on knee laxity (Isberg et al., 2006; Shaw, Williams, & Chipchase, 2005). Early initiation of high-intensity neuromuscular electrical stimulation (NMES) has been found to be effective in improving quadriceps muscle activation and strength after ACL injury and construction surgery (Kim, Croy, Hertel, & Saliba, 2010; Lynch et al., 2012; Rice & McNair, 2010; Snyder-Mackler et al., 1994). In addition to NMES, quadriceps strength training may include the use of high- intensity, low-repetition weightbearing (WB), non- weightbearing (NWB), and eccentric exercises. These strengthening techniques may be augmented with NMES. Progression through quadriceps strength training is based on criterion-based guidelines to maximize the quadriceps strength. Hamstrings strengthening Hamstrings muscles work as an ACL agonist in controlling the anterior translation of the tibia (Imran & O’Connor, 1997, 1998). Inability of the hamstrings muscles to provide adequate force to stiffen the knee joint during dynamic activities has contributed to the ACL injury in female athletes (Beynnon & Fleming, 1998; Hewett et al., 2005). Therefore, training the hamstrings muscles in patients with ACL injury may contribute to knee stability during participation in functional activities and prevent subsequent injury to the knee structures. In patients who are managed operatively, hamstrings weakness may fail to provide enough force to stabilize the knee joint and to control the forward forced anterior tibia translation. This in turn may place more tension load on the graft tissue and lead to graft failure. Increased muscle strength difference between quadriceps and hamstrings muscles may contribute to graft failure after ACL reconstruction surgery in patients who return to preinjury activity levels (Kyritsis et al., 2016). The rehabilitation programs for operative and nonoperative programs after ACL injury should address hamstrings weakness to improve patients’ outcomes and to prevent unnecessary knee injuries. Hamstrings strengthening exercises can be integrated early in the ACL injury rehabilitation to improve muscle strength. Strength exercises for the hamstrings include isometric hamstring contraction, hamstrings curl in sitting and supine positions, reverse leg curl, and Nordic/Russian hamstrings exercises. Exercises that emphasis hip extension may also strengthen the hamstrings muscles, including squatting, single-leg ball pickup, lunge with weight, and pelvic bridging exercises. Isometric hamstrings contraction and exercises that do not include loads are performed first, then progression is made toward exercise with loads. The progression strategies for strengthening the hamstrings muscles include increasing the weight load and the numbers of repetitions as patients proceed toward the late phase of the rehabilitation program. Nordic hamstrings exercise can be performed on a low mat table and requires a one-on-one treatment from the therapist. To perform the exercise, the patient takes a kneeling position while the therapist holds the patient’s ankles to provide stability. The first phase of the exercise consists of eccentric hamstrings activity as the patient lowers his or her torso down toward the mat. The second phase of the exercises is a concentric contraction as the patient moves up to the initial kneeling position. In the early stage of the rehabilitation program, the
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