By Tony Thomas

In my previous article in May, I talked about knee ligament injuries and particularly focused on Anterior Cruciate Ligament (ACL) tears.

This article will discuss the rehabilitation required following surgery to reconstruct this ligament.

The majority of the sporting and military population who completely rupture their ACL end up having surgery to reconstruct it.

There are a few cases where people with a complete rupture do not end up requiring surgery. These people manage to gain enough control from their muscle system following a thorough physiotherapy program.

Sadly in the military and sporting world this is often not enough and when performing activities that require pivoting and turning, the knee continues to give way. These are the cases that almost inevitably require surgery.
Before surgery it is highly beneficial to have completed a physiotherapy program aimed at improved quadriceps and hamstring muscle strength, and lower limb balance exercises.

Physiotherapists generally find that patients with good strength, range of movement and little to no swelling prior to surgery do better post-operatively.

The main objectives for the first six months following surgery are:

• Minimise rehabilitation time and complications.
  
• Achieve a full pain-free range of motion.
  
• Achieve a stable and fully functional knee joint.
  
• Maintain general physical and emotional well-being.
  
• Early return to work.
  
• Return to normal work and recreational activities.
  

Immediately post operatively, most patients remain in hospital three to five days, during which time they are taught primarily quadriceps, hamstrings and range of movement exercises. Prior to discharge from hospital they are taught to walk safely with crutches.

Formal rehabilitation will start shortly after discharge from hospital and over the next six to 12 months physiotherapists, PTIs, coaches and trainers will progressively guide patients through varying exercises to regain function, strength and balance.

Full recovery following ACL reconstruction takes from six to 12 months.

For most people wanting to return to contact sports, this time period is closer to 12 months.

There are three important factors to consider during the rehabilitation period.

First, a balance must be found between doing what is necessary (enough), without doing too much – quality is better than quantity.

Pain and/or swelling may occur with too much or inappropriate activity. Pain and swelling, in turn, will inhibit range of motion and quadriceps activity.

Second, between six and 12 weeks post-operatively, the graft (reconstructed ligament) is at its weakest and most vulnerable to damage.

During this period, the graft changes, takes on the characteristics of a ligament and begins to establish its own new blood supply.

The graft will get as weak as 45 per cent of the original ACL during this time and must be protected from undue stress and inappropriate or excessive load such as jogging and impact type activities.

Third, to minimise the load on the new graft it is important to employ co-contraction and closed-kinetic-chain exercises as directed by a physiotherapist.

The time frames will vary from one person to another. Associated problems, such as other damaged structures within the knee, response to surgery and pain, post-operative complications and type of surgical technique will affect the speed of recovery.

Overall the rehabilitation process generally runs smoothly but it does rely on compliance from the patient with medical advice.

Success rates are very high, so my advice to all patients following ACL reconstruction is be committed to your rehabilitation and follow the advice of medical staff.

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