Reconstructive surgery of the ACL has become one of the most common orthopedic surgical procedures performed in the United States. The surgical technique and graft sources were described in a previous chapter. The surgeon works with the patient to plan the surgery after the patient has regained his or her ROM and normalized muscular function. This may require recommending preoperative physical therapy visits if the patient appears to be having difficulty performing activities independently.
The therapist must know the type of graft and fixation used to best design the early phases of the rehabilitation program. In general terms, the normal initial progression/ maximal protection phase is to achieve full extension in the immediate postoperative week, use protected weight bearing until the patient can activate the quadriceps effectively to absorb and transfer loads (1 to 3 weeks), maintain patellar mobility, regain quadriceps control, and prevent development of a chronic effusion.
The patient progresses after becoming fully weight bearing to an integrated approach of open- and closed-chain activities. Bilateral closed-chain activities progress to unilateral demands, and core strengthening is often added to be emphasized in the home exercise program. Therapists are urged to be aware of red flags such as difficulty in regaining motion, development of chronic effusion, and inability to adequately control the extremity during normal activities of daily living and functional tasks.
Readers are urged to examine the numerous protocols that are available for these procedures through university and sports medicine center Web sites. It is important to see these materials as guidelines because the unique circumstances of the patient may require adjustments, particularly if the protocol is somewhat time focused in its approach. The special clinical pearls for ACL reconstruction rehabilitation include the following:
1. Prevent problems rather than treat them whenever possible; see problems emerging and treat them early.
2. Imperative: Get extension early and in the first few days, be protective of requested function; do not "beat" a dead extremity.
3. Know which graft is used: If a hamstring graft, avoid isolated open-chain hamstrings for several weeks; if contralateral patellar tendon, implement donor site tendon program; if ipsilateral patellar tendon, get patellar mobility.
4. Quadriceps activation is facilitated by working in flexion and not attempting to activate initially in full extension.
5. Do not discard assistive device until able to activate the quadriceps effectively and demonstrate a normal gait.
6. Integrate your program; do not use just open chain or closed chain; integrate both to gain complete rehabilitation.
7. You may wish to avoid large loads in terminal extension (particularly open chain) during the initial months postoperatively.
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