Education and helping the patient adapting to the new “post-surgery” situation as quick as possible is one of our main goals as Physiotherapists at Movement Perfected. This goes hand in hand with regaining and achieving full range of movement and the patient’s pre-surgery level (back to work, sports and hobbies) within reasonable time. Therefore we created a schema how to treat a patient after having an ACL- reconstruction, adaptable to individual post-surgical instructions and showcase of the patient. To have a better overview we differentiate in between different stages of rehabilitation, structured according to the weeks post-op and the physiological healing time of the operated structure (keeping in mind that patient’s individual development is left out, but put into attention during physiotherapy).
Next to manual therapy, exercising is an important part of physiotherapy from the early beginning of rehabilitation after surgery, which is approached by exercises coming from sports and exercise physiotherapy as well as pilates.
This is an exemplary guideline for strengthening and movement increasing exercises after ACL-reconstruction, combining trainings routines from Pilates and from the classic sport physiotherapy point of view.
- Early stage after surgery and adapting to the post-surgery situation:
- Education (“handling”) how to cope with the brace and why it is important to have it. Information about: preventive, functional and post-op braces available at: http://www.aafp.org/afp/2000/0115/p411.html
- Education and modification of ADLs with the brace in combination with the correct management and use of crutches (gait, stairs, carrying things etc)
- Gait training to avoid secondary-effects caused by mal-adaption to brace/crutches (antalgic gait, back pain, shoulder pain etc)
- Soft tissue techniques to decrease swelling, pain, intra-articular pressure and post-surgery affects
- Increase ROM (inside and outside of brace):
- Patella mob
- Mobilisation with movement to activate muscles (passive, actively-assisted and active)
- Adequate strengthening with evaluation of the status quo to prevent hypotrophy as much as possible
- focus on leg axis
- Compex electro therapy, information available at: http://www.thesportsphysiotherapist.com/the-benefit-of-electro-stimulation-following-acl-reconstruction/
- Gait: roll over heel-to-toe → ergonomic gait pattern (preventing secondary-side-effects)
- Proprioception information available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540881/ )
- Exercises (composition of an individual home exercise programme):
- Functional lifting (ext/flex) of the leg in brace and out of brace
- Balance training single-leg-stance (non operated leg)
- Swaying from left to right → getting used to partial-body-weight bearing (feedback with scales)
- Dangling the leg from a higher surface (high stool/table): ext/flex with traction of own weight of the limb (increase: from dangling to actively extend and flex the knee)
- Sitting (with floor contact): foot on small ball/towel extend and flex knee (leg axis, activation quad)
- High squats: within allowed ROM (pain free), leg axis and partial weight bearing on the operated leg
- Bridging with legs on Swiss-ball (core stability, glute strengthening, hamstring activation, leg axis etc);increase with ball between knees
- squatting with Pilates ring or bosu ball between knees
- Post- brace and crutches → early to mid stage of rehab :
- Gait training, whining from crutches → ergonomic gait-pattern
- Increase ROM (manual therapy knee joint/ patellofemoral joint)
- Soft tissue techniques, fascial release, mobilisation with movement
- Strengthening (!)
- Exercises (extract of possible exercises):
- Diversity of trainings-therapy: variations of squats, lunges, unstable surfaces, exercises from the APPI pilates concept; generally exercises focusing on the patient’s hobbies/future goals i.e.: sports he/she wants to practice again (cycling, running, yoga etc); adapted to the increasing and decreasing pain/mobility situation the patient’s shows and personal preferences.
- Pilates Reformer standing: Scooter, Standing side splits…
- Late stage of rehab:
- By now full ROM should have been achieved
- Focus on muscle imbalances and deficits
- Focusing on individual problems/weaknesses doing ADLs or returning to sports, hobbies etc.
- Rising awareness to the patient of the importance of continuing training and exercising at this level post rehab, even though there might only be minor issues left
→ general and sport specific personal training sessions are additionally available in our clinic, supported by a team of qualified Physiotherapists/Sport Scientist/Sports Physiotherapist, if the patient wants to carry on training/ rehabbing with us. Research shows, that there is special need for more than the common 6month rehabilitation schema, and advise to carry on with rehab. The time frame for returning to sports, however, remains within the 6 months timing (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3448301/)
→ the exercises listed are only a small extract of the vast catalogue of exercises our Physiotherapists have in peto
→ through CPD our team uses latest research and current literature to make sure treatment techniques and exercises programmes are up-to-date and match our patient’s and client’s needs
Post surgery strength/flexibility and endurance training exercises:
Post surgery all muscles/structures get weakened; atrophy of the quads and hamstrings occur, alteration of the gait even after whining from the crutches. To build up and train the lower limb accurately after ACL-reconstruction, especially at the beginning of the rehab, a controlled and supervised training (program) is essential. Information available on: https://www.ncbi.nlm.nih.gov/pubmed/23307572 . Example exercises how to increase proprioception, strength, endurance and mobility additional to increased levels are listed below. Same as with exercises with a sport physiotherapy background, repetitions and sets can be done with the pilates exercises.
Pilates Reformer exercises :
- Open V-position: muscle focus on hamstrings, quadriceps and hip adductors
Straighten legs completely, keep heels still throughout the movement, aligning hip, knee and foot.
Increase: add more springs/increase resistance, combine with core work/movement with magic ring, dumbbells
- Calf raises: tip toes on barren, knees stay straight whilst bending and extending both ankles; increase single leg calf raises, holding other leg in tabletop position
- Prances: muscle focus on foot plantar flexors, stretching of calves and hamstrings; tip toes on the barren, whilst alternating one ankle is flexing and extending – knees bend alternating with plantarflexed ankle
- Frog: same starting position as in the V-position, main focus on hip/knee extensors; feet are in straps, higher degree of stabilization since the feet are in the air; imagery: “frog jumping”
- Bottom lift/ Bridging: focus on glutes, hamstrings and abs; tip toes on foot barren, range of lifting higher than on the floor because the feet are elevated; tucking in pelvis anteriorly, rolling up the spine until shoulder, pelvis/hips and knees are in one line.
- Scooter: main focus hip and knee extensors; lunge position on the Reformer, one knee on the slay, other knee is the stabilizer on the floor, positioning hands on the foot barren if necessary (or on hips), come from an flexed knee and hip position into and extended hip and knee position whilst keeping the trunk and pelvic stable; by decreasing the tension of the strings, the glutes, hip extensors have to work more (less tension, less stability)
- Single Leg Skating: main focus on glute med/hip abb and quadriceps → important for the gait cycle; standing leg (on the frame) is the basis to work from, the moving leg performs the abduction movement by sliding a completely straight leg to the side- control the pushing movement and the sliding back movement; keep pelvis stable
- Hamstring curl: main focus on hamstrings; patient in supine on the long box on top of the reformer (adapted sphinx position, elbows over the edge of the lon box), feet in the strings, knees extended → when flexing knees press pubic symphysis into the box, keeping the hips extended, then slightly extend within the resistance of the strings and bend back again;