Changi Sports Medicine Centre. ACL Programme

Transcription

1 Changi Sports Medicine Centre ACL Programme

2 Dear. I will like to welcome you to our Changi Sports Medicine Centre Anterior Cruciate Ligament (ACL) Programme. This is a unique and comprehensive treatment programme specifically tailored for you to recover from your ACL injury. Programme Goals The primary aim is to achieve a stable knee so as to prevent further injuries to the meniscus and cartilage of the joint and the secondary aim is to enable you to return to your favourite sport activities. How This Programme Will Help You 1. We will help you understand your injury and treatment options by providing relevant information and instructional video aids. 2. Your progress in this programme will be closely monitored by the attending Sports Orthopaedic Surgeon, Sports Physiotherapist and Sports Trainer who will be with you until the end of your treatment. 3. You will have access to the latest technology and gym equipment to help you recover. 4. You will be trained on how to prevent future knee ligament injuries. Please bring along this booklet whenever you visit us in Changi Sports Medicine Centre. Yours sincerely Dr Chang Haw Chong Programme Director 2

3 Contents Understanding ACL injuries & Treatment Options 4 Frequently Asked Questions 6 Pre Surgery Assessment 10 Rehabilitation Phase I VI Functional Evaluation ACL Prevention Log Sheet 11 The Team Looking After You Orthopaedic Surgeon Sports Physiotherapist You can contact us: Phone: CSMC Receptionist /6 CSMC Gym/Physiotherapy CGH Appointment Centre acl@cgh.com.sg - We are committed to get You back into the Game. 3

4 Understanding ACL Injuries The ACL The anterior cruciate ligament (ACL) is the major stabilizing ligament of the knee. The ACL is located in the center of the knee joint and runs through the femur (thigh bone) to the tibia (shin bone). In this position, it prevents a buckling type of instability of the knee. Tearing of the ACL occurs with a sudden direction change or when a decelerating force crosses the knee. The patient often feels or hears a popping sensation, has a rapid onset of knee swelling, and develops a buckling sensation in the knee when attempting a direction change. Most patients will recall at the time of injury the occurrence of: - a POP from the injured knee - rapid development of a swollen knee - inability to continue playing the game How This Programme Will Help You The Untreated ACL Studies have shown: 1. Up to 86% of these knees gave way within four years. 2. Only 14% of athletes were able to return to unlimited athletic activities. 3. Increased incidence of meniscus injuries in the ACL deficient knee. 4

5 4. After 10 years, up to 78% of the knees treated without surgery showed osteoarthritis. 5. ACL deficient knees are plagued by long term swelling and stiffness. Treatment Options Give Up Sports The ACL is only required for pivotal motions (rapid change in direction when running). If you walk on smooth surfaces and do no pivotal sports, you can get by without an ACL. Many fitness activities such as running, biking, rowing may be done without undergoing surgery. Use of Brace +/- Arthroscopy The use of a functional brace may be required if you want to return to recreational activities. The brace will stabilize a knee to allow low level recreational sports but is not effective for sports such as soccer. Some sports such as wrestling, judo, rugby do not allow use of a brace. Since about 50% of ACL injuries have associated meniscal tears, the joint may have to undergo arthroscopy to deal with the tear. In the older patient, removal of a portion of the meniscus is the usual treatment. In the younger patient, the repair of the meniscus is preferable. However, the result of meniscal repair are more successful when the ACL is also reconstructed. This is why the younger athlete who is involved in competitive sports is advised to have a surgical reconstruction. We also know that the long term results of surgery depend upon having a normal intact meniscus. Surgical Reconstruction This is indicated for the young, competitive, athletic patients whose goal is to continue an active lifestyle and whose sport activities involve a lot of knee pivoting actions, jumping and cutting. 5

6 ACL Reconstruction Surgery Once you have decided to have your ACL surgically reconstructed, you might want to find out how this is performed. During this surgery, the remnants of your torn ACL need to be removed, and a similar ligament from somewhere else around your knee needs to be inserted in the place of the original ACL. Using a ligament from somewhere else around your knee may sound like robbing Peter to pay Paul, and in fact it is, for each of the grafts that are used for ACL surgery has some drawbacks. The grafts that are most commonly used in our Centre are the medial hamstring tendons. Other graft options include the central third of your patellar tendon and occasionally an allograft from a cadaver is used. You can speak to your surgeon regarding the advantages and disadvantages of these grafts. As part of this Programme, you will be asked to view a brief video on how the surgery is done. ACL Reconstruction Educational Video viewed on Frequently Asked Questions Can my torn ACL heal? Complete tear of the ACL does not heal. It is a permanent injury. How long does the surgery take? The surgery takes about 1 1 /2 to 2 hours depending on whether additional procedures such as meniscus repair or resection are needed at the time of ACL reconstruction. You will spend another 1 to 2 hours in the recovery room after surgery. 6

7 When can I return to sports? The entire treatment process of surgery and post-surgery intensive physiotherapy rehabilitation takes up to six months. In some patients it can be up to nine months. Do I need crutches after surgery? Yes, this is to help you get around in the early postoperative days. Most patients stop using the crutches after 1 to 2 weeks when they regain muscle control of the operated thigh and leg and feel secure. When can I start driving? This is usually possible once you discard the use of your crutches. Do check with your surgeon if you are not sure. Can I put weight on my operated leg when I walk? Most patients are allowed to walk full weight bearing immediately after the surgery. In certain cases where cartilage surgery was also performed, the surgeon might advise the patient to offload the operated knee for a few weeks. When can I take a shower? It is important to keep the wounds dry for about 7 to 10 days after the surgery. Showers can be taken as long as protective coverings are applied to keep the wounds dry during this period. How much time off work should I take? One to two weeks for a desk-type job. It can be up to three months for moderately physical work and up to six months for strenuous physical work. Examples: Student, secretary, computer operator: 1 to 2 weeks Army soldier, airline baggage attendant: 2 to 3 months (with restricted work duties) Construction worker: 4 to 6 months 7

8 How long will I use the knee brace? Between six weeks to two months unless otherwise instructed by your doctor. The brace is used to protect your knee in risky situations and until you gain the confidence and strength to go without it. It does not need to be applied when you are resting at home and not walking. Why is my knee/leg numb? The numb area along the front and outside of your knee (and sometimes lower leg) is the expected result of making the incision in the front of the knee. The incision interrupts small superficial skin nerves that supply the skin on the front and outside of the knee. The area of numbness shrinks in size over time, so that what starts out as a large area usually ends up as only a small area. The process can take six months to a year. This area of numbness is not harmful, but can be annoying. It occurs in everyone and is permanent. Also, if the operation takes two hours or more, some people experience a transient feeling of numbness in the whole leg which disappears in 24 to 48 hours. How much activity can I do after surgery? Initially most of your activity is done in physical therapy. Swimming and stationary exercise biking are two activities you can do early in rehabilitation, followed by stairmaster and threadmill later on. It will take about six months for you to return to strenuous physical activity such as soccer. The reason you need to avoid strenuous physical activity is that the ACL graft, which is placed in your knee at the time of surgery, takes about six months to re-vascularize and become strong again. The graft usually gets weaker for a period of time after it is implanted. Will my replacement ACL be as good as the original one? The answer to this question is a bit complicated. From a functional point of view, we can say that many athletes who have torn their ACL, and have opted for a surgical reconstruction and rehabilitation, have returned to their sports, won 8

9 national championships, and enjoyed long professional careers. Most people who are recreational athletes are also very satisfied with the results of knee surgery and find that they can continue doing all of the things that they like to do after the surgery and rehabilitation. From this point of view, the function of the knee is nearly completely restored by reconstructive surgery. However, from a scientific point of view, it is clear that a replacement ACL does not function as well as the original ligament. This is because the original ligament has special nerve fibres that provide each person with a sense of the position of his or her joint. This function is not replaced when a new ligament is used to reconstruct the original one. The native ACL also has special properties that allow it to stretch and relax, and it has a complicated arrangement of individual fibres that perfectly balance the tension in the ligament during flexion and extension of the knee. These properties are also not completely restored when the ligament is replaced. This is why most patients can always tell the difference between which knee was injured and which one wasn't, even many years after their surgery. Surveys of patients have indicated that in the long run, nearly ninety percent of people who have had ACL surgery say they are very glad they had it done, and would choose to have it done again. 9

10 Pre-Surgery Assessment History of Injury Questionnaire Tegner Activity Level Scale Pre-Injury Current 2000 IKDC Subjective Knee Evaluation Form 2000 IKDC Objective Knee Evaluation Form Lysholm Knee Score KT-1000 (Knee Laxity Measurement using Arthrometer) KT1000 (25º) Right Knee Left Knee Side-To-Side Difference KT1000 (75º) Date: 10

11 Rehabilitation Phase I : Preoperative Period The goal is to achieve full range of knee motion and to maintain as much strength as possible in your quadriceps (anterior thigh) muscle. Exercises for you to do at home: 1. Knee Extensions Place the heel of your injured leg on a rolled towel. Gradually relax and let your leg come to full extension. 2. Heel Slides Start with your injured leg stretched out. Keep your heel on the floor and gradually bend your knee and slide your heel towards your buttock. Bend your knee until it becomes slightly uncomfortable and hold the position for ten seconds. Then straighten the knee out again and relax for ten seconds. Repeat this 50 times. 11

12 3. Static Quadriceps Strengthening With your leg in a straight position, perform a set of ten quadriceps contractions. Without lifting your heel up in the air, pushdown on the towel and tighten your quadriceps muscle as hard as you can for ten seconds. Then relax for ten seconds before tightening your muscle again. Repeat this 50 times. 4. Straight Leg Raise Start with your leg flat on the bed. Begin by tightening your quadriceps. Then lift your leg off the bed until your heel is about two heels distance from the bed. Count to ten seconds and gently lower the leg. Relax for ten seconds and repeat 50 times. Surgical reconstruction of your torn ACL will not be attempted until your knee shows full range of motion. 5. Inner Range Quadriceps This is similar to isometric quadriceps strengthening. Push down on the towel with the quadriceps and then lift heel off the floor. Repeat 50 times. 12

13 6. Hip Abduction Lie on the unaffected side with lower leg bent. Lift upper leg as shown, hold for 5 seconds and repeat 50 times. 7. Hip Adduction Lie on affected side with upper leg bent. Lift lower leg as shown and hold for 5 seconds. Repeat for 50 times. 8. Hip Extension Lie on your stomach. Lift affected leg as shown and hold for 5 seconds. Repeat for 50 times. 13

14 9. Wall Squats Lean against wall, tighten quadriceps and slide down until you are at 90 degrees to the floor. Hold 10 seconds. Phase II: 0-2 weeks after surgery The goal is to obtain full knee extension and minimize the amount of knee swelling. Never place a pillow under the back of your operative knee as this causes the knee to flex and impedes full knee extension. You should ice and elevate your knee as much as possible and avoid spending time on your feet. You will be given a special pair of socks called TED stockings that will help the swelling to go down. These socks may itch and drive you crazy but they can significantly speed up the process of removing the swelling. You will be seen by your Physiotherapist in the Sports Centre by the second or third post-operative day where your wound dressings will be changed and simple exercises will commence. You will be advised to attend three therapy sessions a week at our Sports Centre during the immediate post-operative period. The therapist will work with you to get your leg muscles activating again. 14

15 The exercises for you to do at home will be the same ones as in phase I and they are: Knee Extensions Heel Slides Static Quadriceps Strengthening Straight Leg Raises Inner Range Quadriceps Hip Abduction Hip Adduction Hip Extension Wall Squats Phase III: 3-5 weeks after surgery The goal is to maintain full knee extension and gradually increase the amount of knee flexion. If meniscal repair was done during the ACL reconstruction, you will not be allowed to flex your knee beyond 90 degrees for the first month after surgery. The knee flexion can be increased after a month has passed. Your therapist will gradually work you towards using an exercise bicycle and a stairmaster as long as your knee does not hurt or swell significantly after exercise. It is important to continue to ice the knee after your physiotherapy sessions. Phase IV: 6 weeks after surgery The goal is to work on building your strength back while allowing the ligament to heal into the bone tunnels in your femur and tibia. Your therapist will prescribe closed-chain kinetic exercises during this phase. 15

16 In this type of exercise, your foot is planted on the floor and is not free to move about. Squats are an example of a closed-chain kinetic exercise. You will also be asked to perform open-chain kinetic exercises such as quadriceps extension exercises on a weight training machine. You will be asked to use the elliptical machine to help build up your knee range of motion, muscle power and endurance during this period of your recovery. Phase V: 3 months after surgery The goal is to improve muscle endurance and agility. Your therapist will get you to perform jogging exercises on a treadmill. As you progress, your therapist will prescribe agility drills for you to improve your knee agility and train your balance skills. This is important to prevent future injuries to your knee. Phase VI: 6 months after surgery Upon completion of 6 months of rehabilitation, your physiotherapist will assess your knee functional status. This involves a series of jumping and hopping tests to compare the function of your reconstructed knee to your normal knee. If the knee function is less than 80% of the normal knee in any of the tested station, you will require further physiotherapy until you have achieved the necessary functional status. A satisfactory functional evaluation will be the ticket for you to start resuming your sports activities. 16

17 Functional Evaluation Operation Date: Pre Op Date: 6/12 Post Op Date: Left Right Left Right KT º mm mm mm mm KT º mm mm mm mm Single Hop 3 Hop Cross Over Hop SL Stand secs secs secs secs Leg Press 1RM lbs lbs lbs lbs Leg Curl 1RM lbs lbs lbs lbs Leg Extension 1RM lbs lbs lbs lbs Standing Board Jump Shuttle Run secs secs ACL Injury Prevention Our Sports Physiotherapist will advise you on ACL injury prevention as well as how to plan your training to enable you to return to your sport activities safely and fruitfully. 17

18 Rehabilitation Schedule ACL Reconstruction Physiotherapy Intervention Phase 1 3 times a week 1 st POD* to 2 nd Week POD* Control Swelling Minimise Pain Restore Knee Extension Knee Flexion as Tolerated Maintain Quads Maintain Hams Cryotherapy Electrotherapy Soft Tissue Massage Stretching TEDS Stocking Wound Care *Post-Operative Day Phase 2 3 times a week 2 nd Week to 4 th Week Control Swelling Minimise Pain Restore Knee Extension Knee Flexion as Tolerated Increase Quads Increase Hams Cryotherapy Electrotherapy Soft Tissue Massage Stretching Phase times a week 4 th Week to 8 th Week Promote Knee FROM Increase Quads Increase Hams Improve Proprioception Cryotherapy Electrotherapy Soft Tissue Massage Stretching Manual Therapy Phase times a week 8 th Week to 12 th Week Maximise Strength Maximise Propriception Agility Functional Training Soft Tissue Massage Stretching Manual therapy 18

19 Exercises Static Quads +/- Functional Electrical Stimulation Straight Leg Raising Hip Flexion/Extension/Abduction/Adduction Bridging Active Knee Flexion Dorsiflexion/Plantarflexion Lower Limbs Stretching Functional Activity/Sports Progress to Full Weight Bearing and Normal Gait Pattern Static Quads +/- Functional Electrical Stimulation Straight Leg Raising Hip Flexion/Extension/Abduction/Adduction Bridging Active Knee Flexion Dorsiflexion/Plantarflexion Lower Limbs Stretching Leg Press Leg Curl 1 /2 Ball Squat Ham Ball Curls Calf Raises Non Impact Cardio (eg. Bike, Rower, Elliptical Full Weight Bearing) Leg Press Leg Curl Leg Extension 1 /2 Ball Squats Ham Ball Curls Lunges Calf Press/Raises Smith Machine Exercises Balance Training on Trampoline/Bosu Single Leg Resistance Work Unidirectional Agility Non Impact, No Turning/Twisting Walking on Treadmill Leg Press Leg Curl Leg Extension 1 /2 Ball Squats Ham Ball Curls Lunges Calf Press/Raises Smith Machine Exercises Balance Training on Trampoline/Bosu Single Leg Resistance Work Jogging Progressing to Running Agility Ladder/Dots Pylometrics Return to Sports 19

20 Sports Physiotherapy Log Operation Details: Operation Date: Week Day Physio Progress/Remarks

21 Week Day Physio Progress/Remarks

22 Week Day Physio Progress/Remarks

23 Week Day Physio Progress/Remarks Anterior Cruciate Ligament Programme - The Team Programme Director Dr Chang Haw Chong Sports Orthopaedic Surgeons Dr Chang Haw Chong A/Prof Lam Khee Sien Dr Chan Beng Kuen Dr Chong Kian Chun Sports Physiotherapists Ms Pauline Leong (i/c) Mr Darek Lam Research Co-ordinator Ms Sarina Abdul Karim 23

24 TAMPINES MRT T A M P I N E S A V E N U EASTPOINT P A N - I S L A N D E X P R E S CHANGI GENERAL HOSPITAL S I U P P E R C H A N G I R O A D E 2 M E I S T R S W A E E T Y SIMEI MRT CHANGKAT PRIMARY SCHOOL EAST POINT GREEN S I M E I S T R E E T S I M E I A V E N U E TANAH MERAH MRT 1 3 B E D O K R O A D U P PER X I L I N AV E N U E P A N - I S L E AS T C H A N G I R OAD A N D E X P R E S S W A Y E A S T C O A S T P A R K W A Y C H A N G I C O A S T R O A D CHANGI AIRPORT 2 Simei Street 3 Singapore Tel: Fax: Reg No R Accredited by: 11/2005