Progressive rehab while deciding on surgery (I)

Rehabilitation after a cruciate injury is a progressive process. Physiotherapist Lesley Hall explains...

First published in 2008, and reviewed August 2023 by Dr Sheila Strover (Clinical Editor)

 

I have divided this section into stages but progression from one stage to the next will be dependent on you rather than a definite time scale.

You should be able to complete exercises at each level without experiencing pain or instability before you move on - this is particularly important when moving from stages 3 to 4 and from 4 to 5. If you experience instability or giving way you may have tried to progress too soon.

 

Stage 1

The early acute days - follow the PRICE regime - see Tutorial Part II. Move on to stage 2 when your swelling has settled down.

 

Stage 2

• Regain full range of movement equal to your other uninjured leg.
• Basic strengthening exercises - The emphasis is on simple closed chain exercises and specific hamstring exercises. Everything should be in a straight line - no twisting, turning or change of direction activities at this stage.
• Walking re-education - weaning off crutches, eradication of limp.

Let's look at some examples -

 

	Heel slides - place your leg on a slippy surface and slide the heel back towards you, gradually increasing the bend. You can use a belt or strap around the foot to assist the movement. Be sure to keep the heel in contact with the surface. Spend a few minutes only doing this but do it regularly (5/6 times daily)
	Abduction - lie on your good side with your injured leg straight and in line with your body (shoulder, hip and ankle in line). Lift the injured leg up approximately 18 inches and gently down - build up to 50 repetitions (5 sets of 10). Do NOT rotate the leg towards the ceiling - lead with the outside of the ankle and keep the knee pointing forwards.
	Assisted knee flexion - lie on your front, bend your knee up behind and then bring your good leg up underneath for support. Use the good leg to gently increase the bend of the affected leg. Once you reach maximum, hold for a slow count of 15 then gradually lower. This is a good way to gently stretch - you have full control, do not force the leg but do take it to its limit each time. The limit will steadily increase until you have flexion equal to your other leg. Aim to do 3 stretches at least twice a day.
	Hamstring curls - lie on your front and bend the affected leg up behind. Once swelling has settled you can add an ankle weight to increase resistance. Begin with a low weight, perhaps 1 kg and gradually increase.
	Kneel on all fours, you will probably want to start by kneeling on a cushion until you are comfortable with the position. Gently take your buttocks back towards your heels. This is a great way of stretching because you have control of how much weight and pressure is on the injured leg and it is easy for you to compare with the good side. Do not overdo this initially, just a few stretches each day.

 

When trying to increase the bend, take the knee to its limit, feel a gentle stretch but do not force - no need to bring tears to your eyes - hold for 30 seconds and then gently release. Repeat 3 times, at least twice a day.

 

	1 Mini-squats - place your feet hip distance apart so that your legs are parallel. Keep your feet flat (this limits the amount of bend) and slowly bend the knees, hold for a few seconds and slowly straighten up. Hips, knees and ankles should all remain in alignment throughout the movement. Don't try to do too many in one go - begin with 10/15 but repeat regularly.		4 Gentle leg-press - lie on your back with your knees bent, your feet flat and slightly apart, against a large gym ball. Push your feet into the ball to straighten your knees, hold for a few seconds and release slowly. Try to build up to 50 repetitions - if the ball is inflated too much this will be more difficult, in which case start with the knees less bent and do fewer reps.
	2 Gentle lunging - you can do this on the bottom stair, gradually increase the bend.		5 Hamstring curls - start with your legs straight and resting on top of the ball. Bend your knees by pressing your heels into the ball and then drawing the ball towards you, then straighten out. Again, build up to 50 reps.
	3 Low step-ups - begin with 10 repetitions, with each leg leading. Gradually increase numbers.		6 Hip extensions - start in the same position as the previous exercise. Keep your knees straight, your feet still and lift your hips off the floor - hold for a few seconds and lower slowly.
The main emphasis here in 1, 2 and 3 should be control - do the exercises slowly, and if necessary hold onto a support, in case you feel unstable.

 

Most of these are easy to practice at home. It is better to do a few exercises regularly throughout the day, rather than try to do too many in one go - 10 minutes four or five times a day is better than 45 minutes at once, at this stage. You do not have to do all of them four or five times, just make sure you do something for increasing bend and something for strength at each session - vary the exercises and mix & match so you don-t get bored. You do not want to aggravate the knee or cause it to swell. Begin with just a few repetitions of each exercise and gradually increase, providing the knee does not react.

When you have full range of movement, can walk without a limp and are confident on stairs you can move to stage 3 which you will find in Part 7b.

 

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