Improving Rehabilitation After ACL Reconstruction

More than any other sports injury, rupture of the anterior cruciate ligament (ACL) in the knee has received a great deal of attention. Athletes can sustain this type of injury and still return to full sports participation. There is a concerted effort among researchers to find the best rehabilitation protocol for the fastest and safest return-to-sports.

There are many different ways to approach the rehabilitation of ACL injuries. Sometimes it is possible to complete a conservative plan of exercise without surgery. This approach is most likely for the less active individual or the patient who did not completely rupture the ligament.

Most of the time, active participants in sports and especially those players with a complete ACL rupture require surgery to reconstruct the ligament. Graft tissue taken from the patellar or hamstring tendons is used to replace the destroyed ligament. Rehab is always necessary after surgery. The goals are to regain motion, strength, and balance. Athletes have the additional goal of eventually returning to full level of sports play.

In some places, early, aggressive rehab is started right away during the recovery process. This is referred to as accelerated rehabilitation. In other practices, bracing is used following surgery. Results or outcomes for both of these treatment interventions are reviewed and summarized in this article. The authors systematically review articles related to ACL rehab and published between 2006 and 2010.

Evidence for other types of treatment currently used in ACL rehabilitation are also reviewed by these authors. For example, level one and level two evidence is presented regarding home-based rehab, vibration training, and proprioception and neuromuscular training.

Here’s what you don’t need:

  • Bracing (any kind of bracing for any period of tiem) after ACL reconstruction isn’t needed. It doesn’t give the patient any advantage over those patients who don’t use braces. It’s simply an added, unnecessary cost.
  • Continuous passive motion (automatically moving the knee in a device made for that purpose) doesn’t result in more joint motion or improved proprioception (joint sens of position) for the patient. It is another added cost that can be done away with.
  • Mega-doses of vitamin C have not yet been shown to increase muscle fiber size or strength; there may be other added benefits to taking this supplement but more study is needed before a recommendation can be made.

    The jury is still out on:

  • The use of hyaluronic acid injections into the knee jointmay have some benefit but further cost-benefit analysis is needed.
  • Neuromuscular exercises won’t hurt after ACL reconstruction but they might not help much. At this time, this rehab tool should be in addition to traditional strengthening and range of motion exercises (not in place of).
  • Vibration therapy to help restore the joint’s sense of position (proprioception) and therefore improve knee joint stability might be helpful. But more study and high-level evidence is needed before specific recommendations can be made.

    Now for what is important:

  • Muscle strengthening and range of motion exercises should be started early and continued at home; these are essential parts of the post-operative rehab program.
  • Early, aggressive therapy is safe and may restore strength faster.
  • Patients can put weight on the leg right after surgery; they can move the knee from a fully straight position up to 90 degrees of flexion.
  • Closed-chain exercises (foot is planted on the floor or solid surface) can be safely started right away after surgery, too.
  • Eccentric quadriceps strengthening and isokinetic hamstring strengthening can be started three weeks after surgery.

    Systematic reviews like this that summarize current evidence around a topic like rehab after ACL reconstruction are important. They help us see trends over time: what works, what doesn’t, and what needs further study. They also help find cost effective ways to speed up recovery and return patients to full function and athletes to full sports participation.