Physiotherapy and rehabilitation after ACL reconstruction - Henry Atkinson August 2009

Physiotherapy and rehabilitation following anterior cruciate ligament reconstruction
Henry Dushan Edward Atkinson,  Jennifer Michelle Laver,  Elizabeth Sharp

Mr Henry D.E.Atkinson, MBChB, BSc Med Sci, MRCS, FRCS Tr & Orth
Consultant Trauma and Orthopaedic Surgeon
North Middlesex University Hospital, Sterling Way, London N18 1QX
North London Sports Orthopaedics

Miss Jennifer Michelle Laver, B App Sc (Physio)(Hons)
Senior Lower Limb Sports Physiotherapist
SportsMed SA, 32 Payneham Road, Adelaide 5069, Australia

Mrs Elizabeth Sharp MSc (Man Ther) MCSP Grad Dip Phys
Clinical Director ESPH
ESPH ES Physical Health, 116 Lordship Lane, London, SE22 8HD
ESPH, 22 Harley Street, London W1G 9PL


Introduction
Soft-tissue knee surgery is performed for a multitude of conditions and encompasses a large number of procedures. The postoperative management of these conditions is constantly evolving as a result of advances in technology and a better understanding of human physiology; however there remains no consensus on the ideal timeframe over which progression of loading can be achieved. This review aims to establish an evidence-based approach to the postoperative rehabilitation of the knee following anterior cruciate ligament reconstruction (ACLR), arthroscopic menisectomy, and meniscal repair surgery.
Exercise prescription is a fundamental part of physiotherapy and the following types of exercise are important elements in a rehabilitation programme. Closed kinetic chain (CKC) exercises are weight bearing exercises performed where patients use their own body weight and/or an external weight. The distal end of the limb is fixed distally to a surface such as the ground, and cannot move freely. These exercises typically involve squats, leg presses, and lunges and concentrate on the co-contraction of the surrounding musculature (such as the quadriceps, hamstrings, hip flexors, and calf muscles). Open kinetic chain (OKC) exercises are non-weight bearing exercises performed with the feet/distal segment free to move. Any additional weight is applied to the distal part of the limb. These exercises typically involve knee extension, straight leg raises (SLR), hamstring curls and kick-backs. Eccentric exercises are those in which the muscle fibres elongate under load, while concentric exercises involved the muscle fibres shortening. The joint angles change in both eccentric and concentric exercises. Isometric exercises are a form of strength training in which the joint angles and muscle lengths are static and do not alter during contraction. The limb either works against an immovable force (overcoming isometric) or is opposed by resistance (yielding isometric). Isokinetic exercises are a form of dynamic muscle activity performed on specialized apparatus that provide a variable resistance to movement such that the movement is maintained at a constant angular velocity. These exercises are used to test and improve muscular strength and endurance. Plyometric exercises involve rapidly lengthening and shortening muscle fibres against resistance, and are used to develop explosive speed. Sport-specific exercises consist of multiple joint movements. Pilates is an exercise system that focuses on building core strength and muscle patterning, improving flexibility and agility. The use of a Pilates reformer machine allows the patient to be positioned in such a way as to help to remove gravity from the equation.

Anterior Cruciate Ligament Reconstruction
Various rehabilitation programmes have been proposed for patients undergoing ACLR. Many of these have been based on the differing surgical approaches and graft materials utilized, and some have evolved from individual practioners, experience and opinion-based practice. There are very few well-designed and executed long-term prospective randomized controlled studies (RCT) comparing these various methods, and many have flawed methodology (1,2). One must also remember that these guidelines must be adapted according to individual patient needs, and should factor patient age and general physical condition, the previous condition of the joint, strength, psycho-social problems, the technical aspects of the surgery, and any surgical complications.

Accelerated rehabilitation programmes
There has been a gradual move away from traditional methods towards accelerated rehabilitation programmes (ARP) for ACLR, following the observation that patients who had been non-compliant with traditional rehabilitation progressed more rapidly (3,4). These accelerated programmes aim to overcome the common post-surgical problems of prolonged knee stiffness, anterior knee pain, difficulty gaining full extension, and delays in the strength recovery, whilst maintaining knee stability (4). There is an emphasis on regaining knee extension and range of motion (ROM) from the first post-operative day (3,4). Strengthening (1,5) and neuromuscular control (1,6) are also commenced early, and patients are encouraged to immediately fully weight bear as pain allows (3-5,7). Patients are progressed in such a way as to minimize inflammation, pain and swelling8 and not overstress the healing graft; and must fulfill every criteria from each phase before progressing to the next9. Timeframes for recovery vary between different accelerated programmes, and even though some aim for a return to sport (RTS) as early as 4-6 months (4,9),  patients more commonly RTS around 9-12 months post ACLR (1).
ARPs have been shown to lead to an earlier restoration of ROM and full quadriceps strength (3,5,7,10), an earlier RTS (4,7,9,10) and less patellofemoral pain (5), with no differences in knee laxity (KT-1000? Arthrometer, MEDmetric Corporation, San Diego, CA, and International Knee Documentation Committee (IKDC) assessment) (7,10,11), patient satisfaction (measured by KOOS), functional performance (on the single-leg hop test), or biomarkers for articular cartilage metabolism in the synovial fluid between the methods (11). A survey of Australian Knee Society members found no significant differences in the ARPs used by those surgeons utilizing patellar tendon or hamstring grafts (12), and thus it is probably reasonable to rehabilitate all ACLR patients based Shelbourne?s ARP (4).

How much physiotherapy?
The number and timing of physiotherapy sessions varies within the literature (3,7,10,13,14), however the majority of patients are seen at two, four, and eight weeks, and three, four and a half, and six months post-operatively unless there are complications or issues with compliance. The role of these sessions is to assess the patient, monitor their progress, give advice and provide education on the progression of their rehabilitation1,(10,14-16). Some, however, have advocated that a structured home-exercise programme with minimal supervision from a physiotherapist may be sufficient (6,13,14,17). Three months of performing home-exercises only was found to be more effective in gaining ROM than regularly attending physiotherapist-supervised sessions (17 sessions over the first 12 post-operative weeks), and no significant differences in long-term ROM with gait, ligament laxity (13), flexion range, isokinetic strength and subjective ratings were seen (14). Patients attending regular physiotherapy sessions had significantly less knee hyperextension (14). Two other RCTs similarly showed no additional strength or functional outcome benefits in those patient attending supervised group exercise sessions in addition to home exercises (15,17). Non-compliant patients may however have greater improvements in the Lysholm score in a group environment (17).

An accelerated rehabilitation programme can be broken down into stages.

Early stage (0-4 weeks)
During the inpatient (typically overnight) stay and the first 2 post-operative weeks
-    Education
-    Activation of quadriceps
-    Range of motion 0-90 degrees
-    Control of knee effusion
-    Full weight bearing and gait re-education

Education
Patients are given verbal and printed information about the operative procedure, expected length and pace of rehabilitation, a schedule of targets and the likely clinical outcomes (16).

Exercises
Basic exercises are commenced in hospital, including ROM, ankle pumps, passive knee extension, static quadriceps, SLR, non-weight bearing (NWB) calf stretches with a towel, and mini-squats with co-contraction. The initial aims are to regain early full knee extension (3,4,7,9,10,16,18,19), quadriceps control (4,7,9,10,19), and 90 degrees of knee flexion (4,7,9,10,18-20). Immediate post-operative quadriceps exercises (isometric/static quadriceps and SLR) lead to a faster recovery in ROM compared with no quadriceps exercises in the first two weeks (9,16,18,21). In an RCT patients also had significantly more favourable Cincinnati Knee Rating System (CKRS) scores, a lower incidence of abnormal knee laxity (KT-1000), less knee instability during sports at 6 months, and better overall symptom scores (21). Active quadriceps contraction also mobilizes the patella and increases the patellar tendon length, which is thought to minimize the incidence of infrapatella contracture (19). A survey of Australian hospitals found that 91% prescribed static quadriceps exercises, 49% SLR and 30% inner range quadriceps during the inpatient phase post-ACLR, and most commenced quadriceps exercises by the first post-operative day (22).

Early range of motion
The initiation of early range of motion (on the first post-operative day) has not been shown to increase joint effusion, haemarthrosis or soft tissue swelling following ACLR (23), and no deleterious effects such as graft-stretching have been measured on KT-1000? Arthrometry (23). It also reduces the risk of cartilage deterioration, peripatellar tissue tightness, stiffness and joint contracture (23). Full passive extension of the knee allows the ACLR (3,10,19) to fit perfectly within the intercondylar notch (10,19) and helps to prevent scar tissue formation (10,24). A loss of ROM, particularly extension, can alter gait patterns (8,16), cause quadriceps weakness (8) and overload the patella-femoral joint (PFJ) (8,16). Some authors do not actively encourage hyperextension past neutral as it can place excessive force on the ACL graft (23).

Management of the knee effusion
Knee effusions increase pain, impede wound healing, limit knee flexion range and delay progression to the later rehabilitation phases (19). They also inhibit quadriceps function (18,24) and reduce torque production in the quadriceps and hamstrings (23). Quadriceps inhibition has been shown to be greatest in knee extension when intra-articular pressures are at a peak (24). Patients should be encouraged to use limb elevation, ankle pumps and rest to minimize swelling in the first post-operative week7-10,(19).
Cryotherapy (using the Cryo Cuff, Aircast®, or other commercial cold packs) has been used to reduce knee swelling during the inpatient stage (7), for the first 7-10 days (3,8), first two weeks (19), and even up to five weeks post-operatively (14). Some studies have shown that it is effective in reducing pain and analgesic requirement (25,26), and can improve patient weight bearing and compliance (25); while other studies have found no particular benefits (27,28). A survey of Australian physiotherapists found that 42% routinely used cryotherapy in the acute post-operative inpatient phase, with 58% using cryotherapy occasionally (29); 48-50% of surveyed Australian Knee Society surgeons used cryotherapy post-operatively (12).

Knee bracing
Patients should be mobilized without any braces, splints (20) or crutches (4,7,18,19). Previously many professionals had recommended using an immobilizing brace for the first 7-10 days of ambulation, followed by a functional brace for next five weeks (4), however the routine use of post-operative bracing has declined since the onset of accelerated rehabilitation protocols (4,10). Recent surveys on the use of knee bracing following ACLR have not found a consensus among surgeons or physiotherapists (12,29). Risberg et al found no statistically significant differences in relation to joint laxity (KT-1000), ROM, muscle strength, functional knee tests or pain, with the use of functional knee braces (30). The braced group did however have significantly improved Cincinnati knee scores for knee function and increased thigh atrophy at three months post-operatively (300. Other studies have also found no statistically significant differences in functional scores (Lysholm, Tegner and IKDC)(20,31,32), knee stability (20,32) or isokinetic muscle torque at one, two and five years post-operatively between braced and unbraced patients (32).

Immediate weight bearing
Many have advocated immediate weight bearing following ACLR (1,3,4,7). Early weight bearing and the restoration of a normal gait pattern (9,16,18) probably encourages early quadriceps activity more than any other specific exercise(19), and may help to strengthen the graft (7,19).  It does not compromise knee stability and has been shown to result in less anterior knee pain in an RCT (33).

At the 2-week post-operative review
-    Education
-    Exercise progression
-    Hydrotherapy and the stationary bike
-    Proximal stability and strength training for the upper body
-    Soft tissue release and scar tissue mobilisation

This session generally coincides with the surgeon?s review. The patient is educated on graft incorporation, and cautioned to avoid vigorous activity during graft revascularization and ligamentisation. All implanted ACLR tissue grafts initially lose strength, with the weakest point estimated at between 6-8 weeks (16,34) to12 weeks (9,18). It can take up to 10 months for the graft to gain normal tensile strength, and 3 years to become ligamentous. Shelbourne et al stated that collagen synthesis was greater than collagen degradation in the acute stages following ACLR (based on clinical findings and animal based studies), and proposed that if subthreshold load was applied through functional activity then ligamentization could occur over a shorter time period(7).

Progression of exercises
The basic exercises are progressed and can include bilateral squats, calf raises, heel slides, active assisted flexion, towel extensions, lateral knee bends (3,4,10,19), isometric minisquats (8,9), SLR with hip flexion, abduction and adduction (9,11), weighted knee extensions in a seated position with the knee unsupported (8,18), and maintenance of calf and hamstring flexibility (9,16). Cadaveric studies have shown no increase in ACL strain with hamstring activity, so early open kinetic chain (OKC) hamstring work may also be commenced (35). The stationary bike can also be introduced at 2-3 weeks (3,4,11,19).

Hydrotherapy
Swimming has been recommended from 2-3 weeks as part of an ARP (4), and swimming with a flutter kick from week three11. An RCT demonstrated that both land and water based exercise was as effective in regaining ROM and quadriceps strength, however water-based activity was not as effective in regaining hamstring strength (36). However, specific exercises in water may minimize the amount of joint effusion, and patients have better self-reported Lysholm score function than with land-based exercises (36).

Other treatment    
Massage of the arthroscopic portals and incisions has also been advocated from week two, both for scar desensitization as well as to assist with PFJ mobility(18).

Middle stage (4-8 weeks)
After the 4-week post-operative review
-    Gym programme, including treadmill, stationary bike, weights and swimming
-    Range of motion 0-130 degrees
-    Active closed chain weight bearing exercise to include squats, lunges, wall slides
-    Closed chain leg press progress from 50% to 150% body weight in eccentric mode
-    Open and closed chain hamstring starting at 40% body weight torque
-    Proximal stability and strength training for the upper body
-    Pilates equipment exercise for core stability strength and co-ordination

A gym programme is commenced which includes the use of a stationary bike, treadmill, OKC and CKC hamstrings (hamstring curls, low cable hamstring kick backs), calf, gluteal and core strengthening (through calf raises, and low cables with hip abduction, adduction, hip flexion), and CKC quadriceps (though leg press and single leg squat). Shelbourne et al commenced their patients with leg presses at 2-3 weeks (4,7,10,19), others started weight-training (leg press, quarter squats and calf raises in squat machines) from 3-4 weeks (3,9), while some choose to avoid gym-work until 5-8 weeks (18). Resistance training in healthy adults should consist of a minimum of 8-10 repetitions to near fatigue, 2-3 days per week, and should be progressive in nature (37). However if gym exercises are progressed too quickly they may cause PFJ irritation due to quadriceps weakness (16). Swimming freestyle and flutter kicks (3), cycling (for faster speed workouts as well as for ROM and cardiovascular fitness)(3,9), and progression to the Stairmaster (4,9) have also been recommended from 3-4 weeks.

OKC versus CKC exercises
In most instances tissues heal in response to appropriate loading forces(18,38), however strain forces are detrimental to healing(1,38). The ACLR graft must be optimally loaded to encourage healing, while avoiding strain forces which may rupture the ligament (1,18). Many authors support the use of CKC exercises. They help to restore proprioception (5,16), place functional stresses and compressive forces on the knee, and aid stability (4,5,9). They may place a lower load on the PFJ and are reported to be better tolerated than OKC (3,5,8,39). However, patients treated exclusively with CKC were shown to have difficulty in gaining sufficient muscle torque for RTS activity at 6 months, in an RCT comparing CKC exercises alone and CKC exercises combined with OKC programmes(40).
    There is a fear that OKC exercises may impose shear forces across the joint (4,5,9), however this is inconclusive(16), and one author reported that OKC may not be any more detrimental than squatting (41). In practice, no clinically significant differences have been seen in gait analysis (during level walking, stair ascent and stair descent)(42), anterior knee pain or joint laxity in several RCTs comparing OKC and CKC in ACLR; and either is probably suitable(1,40,42-44). Another RCT found no differences in knee laxity (KT-1000) when combining OKC and CKC exercises, however patients had significantly increased quadriceps torque when compared with CKC exercises alone, and a significantly higher proportion of patients had earlier returns to pre-surgery sporting levels (40). Thus the literature appears to support a combination of OKC and CKC exercises to get a maximal training effect (38).

Pilates
The additional use of Pilates reformer machines according to the principles of the Austalian Physiotherapy and Pilates Institute (APPI) may allow for earlier progressive load-bearing and squatting/lunging activities in an ARP. The theory behind this approach is to introduce consistent motion and defined joint ranges early in the rehabilitation period, using zero-gravity spring-based resistance. This allows for exact functional patterns and muscle memory to be retrained, and thus when the patient is ready to weight-bear into a squat or lunge, the motion has already been learned. Though there is currently little scientific data to support this new approach, it may shorten rehabilitation by as much as 4 weeks, with the largest effect seen within the first 2 months.

Late stage (8-12 weeks)
At the 7/8-week post-operative review
-    Gym progression with strength and agility training
-    Treadmill jogging on flat and slopes progressing to running
-    Squats and lunges
-    Open chain hamstring exercise, both concentric and eccentric to 60% body weight
-    Balance work and strengthening for hamstring on gym ball
-    Upper body resistance machines in gym

Gym
Running, agility and sports specific rehabilitation are introduced (7,10,19). Strength training is intensified to facilitate a more rapid return to sport(19). Patients are also introduced to unstable surfaces, such as a wobble-board, for single leg postural control (34,43). At 10-12 weeks DeCarlo et al recommended removing the block to the last 20 degrees of extension when performing isokinetic strength testing, at a time when the patient was more confident and able to fully extend without apprehension (3). Perry et al compared laxity and function in OKC (unilateral ankle weights or knee extension/hamstring curl machine through to end of range) and CKC (unilateral leg press) exercises (during the period 8-14 weeks) and found no significant differences between the two groups of patients (45).

Jogging
Early return to sporting activity may not be safe if the patient does not have adequate strength, neuromuscular control and functional stability to help protect the weakened healing graft. There is a lack of objective criteria for reliably progressing a patient through to end-stage rehabilitation safely, though good control and strength with a single leg squat and lunges has been described as an appropriate signal to commence early stage return to sporting activity (34). Shelbourne et al allowed their patients to start a jogging programme from five weeks if they had 70% strength of the unaffected leg on strength testing (19), while others have only allowed their accelerated rehab patients to start running from week eight11, or even as late as from 12 weeks if showing satisfactory muscle strength and proprioception on clinical examination (9). Meyer et al encouraged symmetry with running (34) while Eckersley et al start their patients with a walk/jog/walk progression, and later progressed to include cutting and jumping (16). Jogging on hard surfaces is discouraged; grass is inconsistent; bitumen or a treadmill are preferable.

At the 3-month post-operative review
Isokinetic test at 12 Weeks
Isokinetic open chain quads and hamstring tests on KIN-COM at slow speed (30 degs/second), and fast speed (180 degs/second) and an endurance test of 15 repetitions at 120 degs/second  

Functional fitness (3-6 months)
-    Core stability and Pilates strengthening exercises on all equipment
-    Running, agility and plyometric drills
-    Interval training
-    Sports specific drills
-    Residual deficits are addressed through an isokinetic rehabilitation programme

The patient should undergo isokinetic quadriceps and hamstring testing on the KIN-COM dynamometer in open chain and in both concentric and eccentric modes at 3 months, providing that all other rehabilitation goals have been successfully completed without complication. Isokinetic testing is a reliable, objective and reproducible method of testing and rehabilitating muscle torque and endurance in the peripheral muscles (46,47). If any weaknesses or inconsistencies are discovered then they can be addressed by changing the functional programme to focus on the weak muscle. If the deficit is greater than 20%, then the patient is put through an isokinetic rehabilitation programme specifically aimed at the deficit; often 6-8 isokinetic sessions are sufficient to overcome deficits of 20%-30% (46,47). Following knee examination gym technique and progress are reviewed. Strength regimes can include slow repetitions with increasing resistance, fast repetitions with light weights, and half-maximum fatigue resistance.

Agility
A running programme, with agility and plyometric drills can be commenced from 3-4 months (9), and this is broken into 3 phases. Phase I (simple) includes intervals, walk lunges forwards, forwards and backwards changing on the ACLR leg, stop/starts, curves, figure 8s, zig-zags, straight cuts, running in a grid, and baulking. Phase II (athletic) includes high knees, heel to buttocks, cross-overs, high skipping, and crouch start accelerations. Phase III (plyometrics and landing) includes hopping (concentrating on springing up and landing technique), hopping in a grid pattern, jumping to land on the ACLR leg (hopping off a progressively higher step) and jumping for height (and landing on a bending knee). DeCarlo et al increased agility work from the 10-week mark, adding figure 8s, backwards running, half-sprints and sprints, as knee agility improved (3). Beynnon et al added lateral shuffles, backwards running and a jumping-rope from 12 weeks, but no figures 8s, or plyometrics until 16 weeks in their accelerated rehab group (11). Agility exercises appear useful in improving proprioception, quickness and fast speed strength, and improve confidence with cutting activities later in the rehabilitation (3). They may be more important in improving reaction times than isotonic or isokinetic strengthening exercises(10). These exercises must be progressed from a series of low risk to high demand manoeuvres in a controlled environment, thus balancing the overload principles and not exposing the patient to risk of injury(34).


Neuromuscular training
Mykelbust et al found that ACL injuries in elite handballers might have been prevented by the implementation of neuromuscular training, but that success depended on the compliance of the athlete. The programme was designed to improve knee awareness and control during landing, jumping, cutting and standing manoeuvres, and included floor, wobbleboard and mat exercises. It focused on core stability and the position of the hip and knee relative to the foot (ie: foot over knee)(48). Caraffa et al also found that proprioceptive training in the form of various wobbleboard exercises, significantly reduced the incidence of ACL injuries in soccer players(49). Hopper et al noted that most knee injuries in netball were the result of poor neuromuscular coordination, causing a slip, fall or incorrect landing(50).
An RCT comparing proprioceptive training and strength training programmes found a greater percentage gain in isokinetic quadriceps and hamstrings strength in the proprioceptive rehabilitation group (comprising of balance, agility and perturbation exercises) compared with the strength training group(51). There were, however, no changes between the two programmes in terms of functional (one-legged single hop for distance, one-legged timed hop) and subjective scores(51).

At the four and a half-month post-operative review
The patient's knee is examined and their progress and gymwork are assessed. Patients are progressed to faster and heavier weights, with fewer repetitions, to build power(37). Knee agility and technique are also checked, and patients are progressed to increased speeds, with more advanced plyometrics and landing. The aim is to progress from mid-level double leg plyometric activity to increased single leg power and endurance(34). Hopping places more demand on the knee than jogging or walking, and is more comparable to the types of loads placed on the knee with higher level sporting activities, thus it therefore gives more information on knee stability with dynamic activity(52).

At the six-month post-operative review
The knee is checked for ROM, swelling, muscle bulk and stability. Agility is also tested (in particular hopping, jumping and landing) and instability, pain/hesitation, pace/speed, and technique are assessed.  KIN-COM isokinetic quadriceps and hamstring strengths are tested once more and any deficit is addressed. Prior to RTS the strength, power, agility, ROM, stability and symmetry must be satisfactory (4) and the ACLR knee should be at least 85-90% as strong as the normal knee(3,9,34). Patients should embark on 2-3 months of sports-specific training with a graduated RTS, aiming for unrestricted competitive sport by approximately 9 -12 months(16,18). A RTS too early, before the knee has good functional stability, can lead to poor outcomes(34).  
An assessment is made as to whether further review is necessary. Some recommend further isokinetic testing at 12 and 24 months(53) in order to establish acceptable hamstring/quadriceps ratios and equal torque for both quadriceps and hamstring muscles. The senior author has observed that autologous ACLR grafts can take several years before left to right parity in hamstring muscle torque is reached, and that it is possible to normalize hamstring/quadriceps ratios in allograft ACLR knees more quickly (possibly due to the avoidance of additional trauma to the knee during graft harvesting).

Variations
Variations from this suggested regime occur when there is additional knee pathology. If there is meniscal repair in conjunction with the ACLR, ROM should be restricted to <90 degrees for the first 6 weeks, and squats avoided for 3 months (see later).



Conclusion
Rehabilitation protocols provide basic guidelines through which effective outcomes can be achieved. However, the rate and extent of recovery will depend on many patient and external factors. It is still questionable whether full recovery, or return to normality is ever complete. The complex neuromuscular motor patterning, strength and control which are affected by the injury and the surgery is very difficult to gauge, and difficult to recreate. Isokinetic testing affords a validated, reliable and reproducible method of evaluating muscle strength, endurance and antagonist/agonist balance. It should be utilised at the earliest safe opportunity to establish the efficacy of the functional rehabilitation programme and can allow adjustments to be made to optimise outcomes. Future studies into the use of pilates programmes and their effect on earlier muscle pattern retraining may also allow for safer and earlier returns to sporting activity.   


Acknowledgements
John R Camens
B App Sc Physio Grad Dip Physio (Orthopaedics), SportsMed SA, 32 Payneham Road, Adelaide 5069, Australia.

Glenn Withers
B.Physio. MCSP Cert. Pilates Instructor MIAPI,
Pilates Art Physiotherapy / London Sports Medicine
50-52 Kilburn High Road, London, NW6 4HJ, UK

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Keywords
Rehabilitation, Physiotherapy, Pilates, Knee surgery, Anterior cruciate ligament reconstruction, Menisectomy, Meniscal repair.


Abstract
Soft-tissue knee surgery is performed for a multitude of conditions and encompasses a large number of procedures. The postoperative management of these conditions is constantly evolving as a result of advances in technology and a better understanding of human physiology, however there remains no consensus on the ideal timeframe over which loading can be progressed. Rehabilitation protocols provide basic guidelines through which effective outcomes can be achieved. However, the rate and extent of recovery will depend on many patient and external factors, and it is questionable whether full recovery or a return to normality is ever complete.
The complex neuromuscular motor patterning, strength and control which are affected by the injury and the surgery is very difficult to gauge, and difficult to recreate. Isokinetic testing affords a validated, reliable and reproducible method of evaluating muscle strength, endurance and antagonist/agonist balance. It may be utilised at the earliest safe opportunity to establish the efficacy of any functional rehabilitation programme and can allow adjustments to be made to optimise outcomes. Future studies into the use of pilates programmes and their effects on earlier muscle pattern retraining may also allow for safer and earlier returns to sporting activity.   
This review establishes an evidence-based approach to the postoperative rehabilitation of the knee following anterior cruciate ligament reconstruction, arthroscopic menisectomy, and meniscal repair surgery.


Volume 24 , Issue 2 , Pages 129-138 (April 2010)
http://www.orthopaedicsandtraumajournal.co.uk/article/S1877-1327%2810%2900031-X/abstract

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