Letter from the Physiotherapist introducing the rehabilitation program

ACL Protocol Patellar Tendon and Hamstring Grafts Letter from the Surgeon with operation findings Letter from the Physiotherapist introducing the rehabilitation program Pre-Operative Phase: GOALS: 1. Patient should have full understanding of the operative procedure and postoperative rehabilitation 2. No effusion, full ROM, good quadriceps/hamstrings strength. Post-Operative Phase: GOALS: 1. Physiotherapy should begin day 1 after surgery. 2. Final - Full range of motion, no effusion, and strength equal to opposite knee. Knee Rating System Sports Activity Scale: Level I - jumping, hard pivoting, cutting sports (basketball, volleyball, football, hurling gymnastics, soccer) Level II - running, twisting, turning (tennis, racquetball, handball, hockey, skiing) Level III - light recreational sports (bicycling, swimming - no running, twisting, jumping) Level IV - no sports, activities of daily living only 1

Physiotherapy Visit Timeline Phase Weeks Post Op Min Visits Max Visits 1 1~2 2 4 2 3~4 2 4 3 5~6 1 2 4 7~8 1 2 5 9~12 1 2 6 13~26 2 3 7 27~52 2 4 Total 11 21 Physician Notification The physician will be notified if the patient (1) Fails to meet the expected goals for each phase of the protocol (2) Has a persistent joint effusion (3) Develops a chronic pain syndrome (4) Develops abnormal AP displacement (5) Complains of giving-way (6) Has difficulty with walking (7) Has a limitation of knee motion or patellar mobility. These problems could result in a modification of this protocol and necessitate further visits to the physiotherapist or consultant. 2

Discharge Criteria: Patients will be tested using Biodex System 3. This machine tests the strength of hamstring and quadriceps muscle groups which are responsible for stabilising the knee. The data collected is used to analyse the current condition and strength of these muscles. Stage of recovery and indication for discharge is determined. Sports Activity High Level or Heavy/Very Heavy Occupational Rating No pain, swelling, giving-way Biodex strength testing: quadriceps & hamstrings strength > 90% of opposite limb Function testing: 2 hop tests (jump to distance and timed three hop jump), Limb symmetry > 90% Sports Activity Low Level (ADL) or Very light Occupational Rating No pain, swelling, giving-way Biodex strength testing: quadriceps & hamstrings strength > 80% of opposite limb Function testing: 2 hop tests, limb symmetry > 80% Return to strenuous activities after major knee ligament surgery carries the definite risk of a repeat injury or the potential of compounding the original injury. These risks cannot always be scientifically assessed. Patients are warned to return to athletic activities carefully and to avoid any activity in which pain, swelling, or a feeling of instability is present. Patients desiring to return to sports or strenuous work activities may require 4-6 more physiotherapy visits during postoperative weeks 25-52 for advanced neuromuscular, strength, and activity-specific training to prevent re-injury. 3

1. IMMEDIATE POST OPERATIVE PHASE Day 1 Weight Bearing: - Two Crutches PWB 50% Exercises: Ankle pumps ROM knee flexion/extension limits 0-90 Straight leg raises (SLR) Static quads Patellar mobilization Ice and Elevation: - Ice for 20 minutes every hour and elevate with knee in extension Day 2 5 Weight Bearing: - Two Crutches PWB 50% Exercises: As for day 1 SLR (all 4 directions) Multi angle isometrics for quads at 90º, 60º and 30º Prone lying hip extension Prone lying - Hamstring Curls (0-90º) only for patellar tendon grafts (PTG) Calf stretch with towel Prone leg hangs Discharge Criteria Pain/swelling under control. ROM 0-90. Quads control - statically and ability to SLR without lag. Mobility - independent with crutches. Points of Note: Refer in index for exercises Day 1 to Day 5 4

Day 5-7 Weight Bearing: - Two Crutches up to 70% PWB Exercises: SLR (all 4 directions) Multi angle isometrics for quads at 90º, 60º, 30º and 0º Active knee extension 90 to 40º Passive knee extension to 0º Standing weight shifts and mini squats with crutches (0 to 30º) Intermittent ROM exercises Patellar mobilization Ankle pumps Leg press with theraband Prone lying hip extension Prone lying - Hamstring Curls (0-90º only for patellar tendon grafts (PTG)) Calf stretch with towel Prone leg hangs (hamstring stretch read a book for 20 minutes!) To simplify exercises for patients, keep exercises to 10 repetitions and 3 sets, done three times per day Ice and Elevation: - continue ice and elevation with knee in extension as previous Points of Note: Refer in index for exercises Day 5 to Day 7 Hamstring grafts No active hamstring curls week 1 5

2. MAXIMUM PROTECTION PHASE Weeks 2 to 4 Goals: Control of external forces and protect graft Control swelling Muscle control 3/5 no extension lag ROM 0 to 125º, minimum 90º Knee extension gain full knee extension/hyperextension, the rehab will not move forward until this goal is achieved Weight Bearing: - Two Crutches PWB 50 75% Exercises week 2: SLR initiate progressive resistance exercises PRE (less than 10% BW) Multi angle isometrics for quads at 90º, 60º, 30º and 0º Active / passive knee extension 90 to 0º Inner range quads (IRQ) Standing weight shifts and mini squats with crutches (0 to 30º) Intermittent ROM exercises Patellar mobilization Ankle pumps Leg press with theraband Prone lying hip extension Prone lying - Hamstring Curls ( 0-90º) only for patellar tendon grafts (PTG) Calf stretch with towel Prone leg hangs Exercises week 4: - Same as Week 2 PROM exercises 0 to125º as tolerated without pain Closed kinetic chain (CKC) exercises: Step-ups 4 block Mini squats 2 legs Points of Note: Refer in index for exercises weeks 2 to 4 PTG begin active full knee extension exercises 70% WB with crutches at week 4 evidence of chondrol cartilage damage during inflammatory phase post operatively 6

3. CONTROLLED AMBULATION PHASE Weeks 5 to 6 Goals: Full weight bearing ROM 0 to 130º and greater Muscle endurance Increase ADL Minimal swelling Recognition of complications Exercises week 5 to 6: - Same as Week 4 Walking practice ensuring full knee extension at heel strike Initiate swimming, flutter kick Hamstring grafts can begin PRE s using ankle weights/therobands Active knee extension 90 to 0º - initiate PRE (less than 10% BW using ankle weights / therabands) Closed kinetic chain (CKC) exercises: Step-ups/ Step-downs: progressing from 4 6 block Lateral steps-ups: progressing from 2 4 6 block Mini squats 2 1 leg progression Wall sits 2 1 leg progression Balance program: Biodex balance assessment Single leg 1 minutes eyes open Single leg 1 minutes eyes closed Stretching program: Calfs Hamstrings Hip flexors Quads Adductors Walking program: Aim to increase time/distance without increases in pain or swelling Walk 20 to 30 minutes without pain Points of Note: Refer in index for exercises weeks 5 to 6 7

Weeks 7 to 9 Exercises week 7 to 9: - Same as Week 6 Continue PRE s for quads and hamstrings Initiate stationary bicycle at week 7 Swimming: Easy jogging in waist deep water Straight leg kicking exercises in water Front/back crawl if comfort permits Walking program: Begin agility drills at slow walking speeds Aim to increase time/distance without increases in pain or swelling Box drill: 10 steps forward, 10 steps side shuffle right, 10 steps backwards, 10 steps side shuffle left Figure of eights, slalom s Closed kinetic chain (CKC) exercises: As for week 6 Bridging 2 legs Lunging forward and reverse Russian hamstring curls / Nordic hamstring curls Balance program: As for week 6 Introduce wobble board for home use Cardiovascular program: Bicycle stationary or road bike Stair machine Ski machine Outcome Measures: Pass Biodex balance test level 8 ROM 0 to 125º Minimal swelling Points of Note: Refer in index for exercises weeks 7 to 9 8

4. MODERATE PROTECTION PHASE Weeks 10 to 15 Goals: ROM equal bilaterally Muscle endurance and strength training Running program Minimal swelling Recognition of complications Exercises week 10 to 15: - Same as Week 9 Bicycle for endurance 30 minutes, hill programs Vigorous walking program Weight training: Endurance: 15 reps X 4 Sets Strength: 10 reps X 3 Sets Begin using both limbs and progress to individual limbs by week 12 Knee extension Leg press Hamstring curl Squat bar / dead lifts Running program: Based on quad tone, no swelling and no antalgic gait. Commence jogging at week 12. Progress in small increments Aim for 30 minutes pain free jogging by week 15 Begin backward running Jumping program: Commence skipping at week 10 to 12 Skipping for 1 minutes X 10 per session Trampoline 2 legs Ice and Elevation: - continue to ice after exercise sessions Outcome Measures: Pass Biodex balance test level 6 ROM equal bilaterally Minimal swelling 9

5. LIGHT ACTIVITY PHASE Months 4 to 6 Goals: Prepare to begin return to sport / functional activities Biodex test 1 Muscle strength and power training Running program Jumping program Exercises month 4 to 6: - Same as Week 15 Weight training: Strength: 10 reps X 3 Sets X 65-75% of 3 repetition maximal Power: 4-6 reps X 2 Sets X 80-90% of 3 repetition maximal Individual limbs where possible Knee extension Leg press Hamstring curl Squat bar / dead lifts Refer in index for weights program Running program: Progress to full speed and agility 30 minutes pain free jogging must be achieved Increase speed from ¼ to ½ to ¾ to full speed for the following: Straight line Slalom Figure of 8 Zig zag Stars Stop starts and cutting right/left Running upstairs / downstairs Carioca s Ladder drills Refer in index for running program 10

Jumping program: Skipping for 1 minutes X 10 per session Trampoline single leg 2 legged jumping progressing to single leg jumping for the following: Vertical Jump to distance Forward / backward jumps Spin jumps (90 180 360º) Lateral jumps Depth jumps Box drills Refer in index for jumping program Ice and Elevation: - continue to ice after exercise sessions Outcome Measures: Biodex test 1 and test 2 Pass Biodex balance test level 4 Single leg hop test Jump to distance comparison Speed and Agility tests Bilateral comparison for 3 repetition maximums in gym 11

6. RETURN TO SPORT / ACTIVITY Months 7 onwards Goals: Return to sport / functional activities Biodex test 3 - final test Final consultation with Mr. Long Muscle strength and power training ongoing Complete Running / Jumping and balance programs Exercises month 7 onwards: - Same as month 6 Weight training: Complete weight program operated limb should be within 10% of unaffected limb, as tested on the Biodex test 3 Patient should aim to continue weights program twice weekly Running program: Progress to full speed and agility Complete running program Begin return to sport Jumping program: Complete jumping program Ice and Elevation: - continue to ice after exercise sessions Outcome Measures: Biodex test 3 (final assessment before return to sport) Pass Biodex balance test level 1-2 Jump to distance comparison Speed and Agility tests Bilateral comparison for 3 repetition maximums in gym 12

RETURN TO SPORTS FROM No effusion 60-70% hamstring quads ratio as tested on Biodex Strength and power should be within 90% of the unaffected limb Final approval by Mr. Long following last Biodex test 13

INDEX Running Program: Agility and speed are extremely important aspects that all good athletes need to possess. The definition for agility is the ability to change direction rapidly while maintaining a constant velocity. Agility also includes the ability to change your center of gravity to match your moves in an efficient manor. 1. Straight Line 20m * * ¼ ½ ¾ Full pace (FP) Slalom x5 x5 x5 x5 20m 2. * * * * * ¼ ½ ¾ FP x5 x5 x5 x5 3. Figure of 8 * * ¼ ½ ¾ FP * * * x5 x5 x5 x5 * * (Start cones at 20m circles for each loop and progress to smaller sharper loops) 14

4. Zig Zags 10m * * * * * * * * ¼ ½ ¾ FP x5 x5 x5 x5 (Start cones at 2m apart and progress to smaller sharper spacing e.g. 0.5m) 5. Stars * 10m ¼ ½ ¾ FP * * x5 x5 x5 x5 10m * (Start cones at 10m apart and progress to smaller sharper turns e.g.5m) Points of Note: Start at ¼ pace and after each repetition take 30 seconds rest interval. The running program is designed to stress your knee in a progressive controlled manner. It is not to be used as a fitness program. You may progress to the next level once you can complete your current level at ¾ pace. 15

Jumping Program: Your jumping program, drills, and exercises are designed to add speed to a drill to develop an explosive, reactive movement. Speed combined with strength results in POWER! Jumping exercises are considered the link between the weight room and the playing field. There are numerous jumping drills which include: 1. Skipping for 1 minutes X 10 per session 2. Trampoline 2 legged progressing to single leg jumping 3. 2 legged jumping progressing to single leg jumping for the following: Vertical jumps Jump to distance Forward / backward jumping Spin jumps (90 180 360º) Lateral jumps over cone Depth jumps Box drills (10 reps X 2-3 sets) (10 reps X 2-3 sets) (10 reps X 2-3 sets) (10 reps X 2-3 sets) (10 reps X 2-3 sets) (10 reps X 2-3 sets) (10 reps X 2-3 sets) Points of Note: These exercises are explosive and help build power, strength and speed. The most important element when considering technique is landing. When you land from a jump, you want to land softly with your weight on the balls of your feet rolling back to your heel with a bent knee. When considering jump training the number one concern is the readiness of the athlete. The key is to be smart, start gradually and never over do it. 16

Weights Program: Weight training: Individual limbs where possible Knee extension Leg press Hamstring curl Squat bar / dead lifts Endurance: 12-15 reps X 3-4 Sets X 55 65% of 3 repetition maximal (RM) Strength: 10 reps X 3 Sets X 65-75% of 3RM Power: 4-6 reps X 2 Sets X 80-90% of 3RM Points of Note: Overload: To see gains in endurance / strength / power you must always stimulate the muscle more than it is accustomed to. Progression: The active muscle must continue to work against a gradually increasing resistance in order to meet overload. Specificity: Gains you receive are dependent on the muscle group used, and movement pattern performed. Endurance (submaximal force that is repeated): If you are interested in gains in endurance, you should concentrate on lifting lower weights and higher repetitions. Strength: If you are interested in strength gains you want to train with higher weights and closer to your 3 RM. Power: If you are interested in power gains you want to train with weights as close to your 3 RM, concentrating on explosive, lower repetitions. Breathing: When lifting weight or working muscles against resistance, exhale through the mouth as you are performing the work. Caution: Failure to breathe correctly during heavy weight lifting may cause increases in blood pressure that may be harmful. 17

Balance Program: The great performers of their sport make their skills look so effortless, with such grace and rhythm. The #1 factor in this performance is BALANCE! The balance mechanisms are: Eyes Inner ear Proprioceptors With balance training the proprioceptors become more efficient as does the gyroscope type mechanism in the inner ear. Balance program: Single leg 1 minutes eyes open (tick box) Single leg 1 minutes eyes closed Biodex balance assessment using Balance Biodex system pass level 6-8 Trampoline Wobble board Dynamic stability of affected leg catching / throwing Final balance assessment using Balance Biodex system pass level 1-2 18

Stretching Program: Flexibility is the movement of body parts through a full range of motion. Range of motion is determined by flexibility but both speed and strength are greatly affected by flexibility. Flexibility is the key to success as well as preventing injuries! The importance of great flexibility in achieving ATHLETIC EXCELLENCE ranks as one of the top three areas in this all encompassing total training program. Flexibility is the biggest limiting factor in people s ability to generate power. POWER = FORCE X DISTANCE TIME The distance is determined by the individual s FLEXIBILITY! Stretching program: Calfs Hamstrings Hip flexors Quads Adductors (30 sec 1min X 2 per limb) (30 sec 1min X 2 per limb) (30 sec 1min X 2 per limb) (30 sec 1min X 2 per limb) (30 sec 1min X 2 per limb) Points of Note: By doing the stretches outlined above you can improve and maintain your range of movement, reduce post exercise soreness, reduce the risk of injury and improve your overall performance and power. Don t bounce or jerk when you stretch. Gently stretch to the point of tension and hold. Hold the stretch for a minimum of 30 seconds and progress to 1 minute holds. Breathe normally. Don t hold your breath. 19

ACL Rehabilitation Protocol Mr. Breandán Long MB BCh BAO FRCSI FFSEM Consultant Orthopaedic Surgeon Cootes Lane, College Road, Kilkenny. T: 056 7723252 Mr. Martin Phelan BSc Physiotherapy, MSc (Man Therapy) BSc Sports & Ex Sci, MISCP, MMACP 20