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Cruciate ligament rehabilitation - Part 9 - Rehab after surgery

In this section I will give you a series of practical exercises after surgery, both in hospital and as you get back to normal activities.

In hospital

Control of pain and swelling are the priorities immediately after surgery.

cpm machine

You must inform the medical/nursing staff if your pain relief is not adequate. It is important to take prescribed medication regularly to keep on top of pain, do not let it get out of control. Having said that, pain is not usually a big issue following ACL reconstruction, immediate post-operative discomfort is usually felt at the donor site more than the graft site. As we have already discussed, excessive swelling in the joint inhibits both movement and muscle activity. You should keep the leg elevated at all times when resting and may use cold therapy (ice packs or cryocuff).

Depending on the surgeon, you may use a 'CPM' (continuous passive movement) machine in the early stages. The benefit of this is that the leg is kept in elevation and the machine gently keeps the joint moving thus avoiding stiffness. Machines are very expensive and often in short supply, your outcome will not be affected if you do not use a machine, you will just have to work a little harder to get the movement on day one!

Exercises

These exercises should be done regularly throughout the day - every hour if possible - little and often is best while the knee is inflamed.

Quadriceps bracing - with your legs straight out in front of you, pull your toes up towards you from the ankle and tighten the thigh muscle as hard as you can. Hold for a count of 10 and gently relax.
Flexion - with your legs out in front of you, gently bend your knee, sliding your heel up towards you. You can hold under your thigh and lift to assist the movement initially if you wish but do not lift the heel. There is no restriction to the amount of bend and the sooner it bends fully the better, aim for 90º by the end of the first full day after surgery.
Extension stretch - sit or lie with your leg elevated and rest your heel on something at least the same height or preferably higher than your chair (a footstool, coffee table or the arm of the settee!). Let your leg relax so that gravity will help to bring the knee back fully straight. You may only be able to tolerate this position for a couple of minutes initially, (especially if you have had a hamstring graft) that is OK, it will get slightly easier each time you do it. Gradually build up to 10 minutes and repeat this 5/6 times a day. Once you can do this for the full 10 minutes, it is a good idea to do the quadriceps bracing while in this position. Let the leg relax for a few minutes then do 10 braces, then relax for the rest of the stretch time.

 

You will be allowed to walk on your leg as soon as you are over the anaesthetic and any nerve blocks have worn off, the physiotherapist will get you up for the first time and will fit you with crutches if appropriate. Some centres do not provide crutches and will get you walking on your leg straight away, others will give you crutches for a few days while you become confident. The important thing is that you must put some pressure through the leg (do not hop) but you must be safe.

Once you are up and mobile you will be able to do some simple closed chain exercises while standing. Hold a support for balance:

  • Heel raises - Keep your knees straight and your feet a few inches apart, lift up onto your toes and gently lower back down. Try to keep your weight even over each leg, repeat 10 times.
  • Mini-dips - Again keeping your weight even and your feet flat on the floor, gently bend both knees, hold for a few seconds, straighten and brace back. Repeat 5 times but build up to 10 gradually. The aim of this exercise is control - not to see how far you can bend; keeping the heels flat on the floor will naturally restrict how far you bend.
  • Wall-slides - lie with your bottom approx 12 inches from the wall and your legs up the wall. Gradually let your knee bend and your heel slide down the wall. Initially you may put your other foot under your leg for support and when able use your other leg to add to the stretch. Take the knee to its maximum bend, hold for a few seconds and then straighten.

This video shows the exercises you can be doing within the first week after your operation. Again these exercises should be done regularly throughout the day. Exercise little and often.

 

General advice:

  • Initially support your operated leg whilst getting on and off the bed or lifting your leg up onto a foot-stool.
  • Do not do repetitive leg extensions as an exercise.
  • Do not be on your feet unnecessarily in the first 7-10 days, this will aggravate swelling. Short walks to the bathroom, bedroom and lounge only - no standing making food or drinks!!
  • You will need to go up and down stairs one stair at a time initially. Going up, lead with the un-operated leg and bring the operated leg up to it. Going down, lead with the operated leg. This method ensures that your good leg is doing all the lifting and lowering.

Early Progressions at Home

As you become more confident moving around you can add to your exercises but be aware of any increase in swelling.

 

Knee flexion - use a strap around the foot to gently pull to increase the bend. You can also use an elastic exercise band to push against, to straighten the knee.
Bridging - lie with your knees bent and your feet flat. Keeping your stomach muscles tight, lift your hips clear of the floor, hold for a few seconds and gently lower. Begin with 10 repetitions.
Adduction - Lie on your operated side with the opposite leg flexed and behind. Keeping your ankle flexed and your knee straight, lift the operated leg 6 inches off the floor, hold and lower, repeat 5 times then rest. Build up to 6 sets of 5.
Abduction - Lie on your side with your operated leg uppermost. Bend the lower leg so that you are balanced. Keeping your ankle, hip and shoulder in line (do not let your hip roll back or bring your leg forwards), lift your leg and lower - repeat 10 times then rest the leg and repeat. Build up to 5 sets of 10.
Assisted flexion - Lie on your front. Gently bend your knee, bringing your foot up behind you. Use the opposite leg to assist in the early stages, particularly if you have had a hamstring graft. You may find that you need to assist to initiate the movement but once started you can manage. The aim is to gradually increase the amount of bend, but also to encourage the hamstring muscles to work.
Extension stretch - you have already done this in sitting, this is another method which is effective. Lie on your front with your legs overhanging the end of the bed, so that your knees are just over the edge. Just relax in this position for 5-10 minutes. If you have a very soft bed, you can place a small rolled-up towel under your thigh to support it.

 

 

 

Patella Mobilisation -This is particularly important if you have had a PTG but is worth doing regardless of graft type. Your physiotherapist will show you how to do this effectively.

Sit with your leg straight out in front of you and thigh muscle relaxed; feel the kneecap (if you are relaxed it should feel loose). Now, using the fingers of each hand on either side, gently move the kneecap as far as you can from side to side. You should also try to move the kneecap up and down (use index fingers below the kneecap and thumbs above).

If you have had a PTG, the donor site will be healing with scar tissue, scar tissue has a tendency to tighten as it matures therefore it is vitally important that you keep the tendon mobile and flexible. Work on your mobilisations twice a day and continue to do so for the first few months post-operatively.

Exercise of course also mobilises the tendon and will help to stimulate the healing.

Ice - If you still have swelling once you are at home then you can apply ice packs regularly throughout the day.

Crushed ice wrapped in a damp towel is the best. If you use gel packs make sure your skin is protected, wrap these also in a damp towel. (Gel packs can be frozen to well below zero so do be careful). Leave pack in situ for 15 -20 minutes maximum and do not re-apply for at least 2 hours.

Progressions (day 10 onwards)

Once you have weaned off crutches (so are walking without a limp), your wounds are healed and your swelling has settled you are ready to gradually progress your exercise regime.

There are no strict time restraints here but you should progress stage by stage and only move on when confident and ready. Your physiotherapist should be guiding you through this process.

If, at any time, your knee swells, feels unstable or is painful you should see your clinician.

Aims at this stage:

  • Restore normal gait pattern
  • Regain full range of flexion and extension (hopefully you already have this) equal to your opposite knee
  • Restore normal balance and co-ordination (motor function)
  • Improve muscle strength, endurance and timing
  • Progress functional activities

NB: Some surgeons may place certain restrictions on specific activities in the early stages i.e. no running for 3mths; no open chain quads etc. Obviously you will have been made aware of these restrictions and must comply with your surgeons protocol.

Guidelines - Up to 3 months - exercises should be geared to achieving full range of movement and strengthening should be in a 'straight line' direction. Open kinetic chain exercises are OK for hip muscles and hamstrings, but stick to closed kinetic chain for the quadriceps. Some balance and co-ordination training is incorporated.

The video at the end of this section gives examples of gradually progressive activities which you can steadily work through but only move on when exercises are comfortable, controlled and providing the knee is not reacting in any way (ie. swelling or feeling unstable). You will see that you gradually increase the level of balance and co-ordination required.

Brisk walking 6Km/hr  

 

Towards the end of this phase you could also start to attend the local gym - all the aerobic equipment is closed chain in nature and therefore safe for you to use. Begin with just a few minutes on a variety of exercises rather than a prolonged time on just one piece, and gradually build up.

Weights: It is OK to use the leg press machine (low weight, lots of reps), but avoid leg extensions at this stage (they are open chain quadriceps exercises).

Hamstring curls are also important - they reinforce the action of the ACL so will give the ligament protection, and they also need additional strengthening if you have had a hamstring graft.

You will also be able to start going out on a road bike - sensible general cycling, no extreme hills or cross country at this stage.

Swimming is an unlimited activity (providing you have no discomfort) but do be careful on slippery floors and beware of children jumping in!

 

Updated: 05 Jan, 2017
ABOUT THE AUTHOR

Mrs Lesley Hall

Physiotherapist
Degrees: 
MSc MCSP
HPCR
Particular Expertise: 

Mrs Lesley Hall, MSc MCSP, discusses rehabilitation after cruciate ligament injury or surgery.

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