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ACL Reconstruction

What is Anterior Cruciate Ligament (ACL) surgery?

Your surgeon will reconstruct the damaged Anterior Cruciate Ligament. This is done by replacing the damaged tissue with healthy tissue (known as a graft). The most common method of replacing the ACL is by using a tendon graft taken from elsewhere in the patient’s body; this is called an autograft. The best autograft sources are the patellar tendon or hamstring tendons. The choice is dependent on the quality of the graft, the patient’s occupation, sport and your surgeon’s preference.

Rehabilitation Goals/Principles

Your surgeon will reconstruct the damaged Anterior Cruciate Ligament. This is done by replacing the damaged tissue with healthy tissue (known as a graft). The most common method of replacing the ACL is by using a tendon graft taken from elsewhere in the patient’s body; this is called an autograft. The best autograft sources are the patellar tendon or hamstring tendons. The choice is dependent on the quality of the graft, the patient’s occupation, sport and your surgeon’s preference.

Before the Operation

On admission to hospital, you will be seen by most members of the healthcare team, which includes a physiotherapist who will usually see you before you go to theatre. The physiotherapist will teach you some simple breathing and circulation exercises to minimise any post-operative complications. They will also show you some of the knee exercises that you will be required to do following your surgery, and may teach you how to use crutches.

After the Operation

You should expect a degree of swelling, redness, warmth and discomfort. However, you will be given pain relief regularly, which is important to enable you to perform the exercises and walk relatively pain free. It is at this stage that a balance between rest (including icing) and your exercises should be found. Your physiotherapist will advise you on this. It is important to understand that the increased discomfort as you perform your exercises does not mean that you are harming your knee. However, take care with bending/flexion exercises, especially if a hamstring tendon graft has been used, as the hamstring has been injured by the grafting procedure.

It is most important to fully straighten your knee immediately following your reconstruction. This is because of a possible build up of scar tissue where the new ligament inserts on the tibia (lower leg).

Post-operation rehab principles (inpatient)

Aims

• Decrease pain and control swelling
• Regain joint range of motion (bend and straighten knee)
• Regain muscle tone and control of knee/prevent muscle wasting
• Walking with crutches.

Day of Operation

• Bed exercises – breathing and circulation
• Bed exercises – Static quads, straight leg raises, knee ‘hangs’ and bending as able
• Mobilise with crutches
• Ice therapy using Cryocuff or ice packs when the dressing is removed
• Zimmer splint at night (on consultant request).

Post Operation; 1 day to Discharge

• Bed exercises continue
• Progress mobility – increase time and distance
• Stairs as able
• Continue ice therapy – 4 times a day, 15-20 minutes
• Teach home exercise programme – to be commenced as an inpatient
• Zimmer splint at night (on consultant request)
• Patellar mobilisations.

Using a rolled up towel under your heel when resting is highly recommended. Although it may not be a comfortable position, try to spend as long as possible allowing your knee to ‘hang’ fully straight several times a day.

What happens when I am back on the ward?

You should commence your breathing and circulation exercises immediately to decrease any risk of developing a chest infection or blood clot/DVT.

Ongoing Rehabilitation

A successful outcome following ACL reconstruction is dependent on many factors, of which rehabilitation is of great importance. The process starts immediately post-operatively and continues for up to 6-12 months. It is vital that you, the patient, play an active and committed role in the programme, to achieve the best long-term results and return to activity and sport.

Rehabilitation Aims

• Pain and swelling control
• Restoration of range of movement
• Improving muscle strength and control
• Normalisation of walking
• Improvement of joint balance (proprioception).
Progression to
• Jogging
• Agility work
• Sports specific rehabilitation and return to sport.

Ice Therapy

Once your bandage has been removed, you can apply ice to the knee. A packet of frozen peas in a pillow case applied to the top of the knee for 15-20 mins will be effective. If you do not have a waterproof dressing, ensure the wound stays dry. The ice pack can be applied 3 or 4 times a day for 20 minutes. This will reduce swelling and pain, aiding movement of the joint.

Bed Exercises

For Breathing and Circulation

These are commenced immediately post-operation to decrease the risk of complications such as Deep Vein Thrombosis (DVT) and chest infection. The risk is increased because you have had a general anaesthetic and are not as mobile as normal.

1. Deep Breathing Exercises

Take 3 deep breaths in through your nose trying to expand your lower ribs and then breathe out completely through your mouth. If this brings up phlegm, cough to clear. Repeat until you no longer bring up any mucus. Repeat hourly.

2. Ankle Pumps

Pump feet and ankles forwards and backwards and round in circles. Continue for a few minutes. Repeat hourly.

3. Gluteal (buttock) Contractions

Clench your buttocks together and hold for a few seconds. Repeat ten times. Repeat hourly.

4. To Increase Strength and Movement

These exercises should be performed four times a day, ten repetitions each. Increase repetitions as able. Prior to the next three exercises it is important to first rest your leg fully extended. You can do this by putting a rolled up towel under your heel so that your knee ‘hangs’. This will create a straighter knee and better performance of the next three exercises. Avoid resting with a towel under the knee. Aim to increase this to 20 mins as comfort allows.

5. Static Quadriceps Contraction

While resting your leg flat on the bed or on the rolled towel, tighten your thigh muscles so that the back of your knees push into the bed. Hold for a few seconds and repeat. Repeat 10 times.

6. Straight Leg Raises

First bend your non-operated leg up for support. Start as in the first exercise by tightening your thigh muscles. Then raise your leg a few inches off the bed keeping it as straight as you can. Ensure the movements are slow and controlled. Hold for a few seconds and repeat. Repeat 10 times.

7. Knee Flexion

Start with your leg straight on the bed. Then slowly slide your heel up the bed so that your hip and knee bend. Bend until you feel it tighten. This is often restricted due to swelling. Do not force this movement - only move as far as comfortable. Repeat 10 times.


Continue your current exercises but add the following as directed by your physiotherapist. Depending on your graft type some exercises will not be started until 2 weeks following the surgery.

Programme: Exercises in sitting


1. Hamstring Stretch

Sit up in bed with your operated leg stretched out in front of you. Arch your back slightly. Lean forward until you feel a stretch down the back of your leg. Hold for 15 seconds and release. Repeat without bouncing - 4 reps, twice a day.

2. Patellar Mobilisations

Your physiotherapist will demonstrate this.

Weight Shifts

Move your knee cap up and down and side to side for a few minutes a few times a day until less stiff. Do not put your fingers on your incision site.


Exercising in standing - Repeat all of these exercises 4 times a day

1. Weight shifts

Transfer your weight from one leg to the other, firstly with your operated leg in front and good leg behind (front to back). Then legs shoulder width apart, transfer your weight side to side.

2. Mini-Squats

Equal weight bearing through both legs, bend at your knees, lowering yourself about 3 inches. Straighten up fully, ensuring your knee is completely straight. Repeat 5-10 times.

3. Knee Extensions in Standing

Stand up straight. Brace both knees back to straighten them by tightening your thighs and buttocks. Hold for 5 seconds and then relax. Aim for equal weight on both legs. Repeat 5-10 times.

4. Heel Raises

With your feet shoulder width apart, and equal weight through both legs, lift your heels and stand on your toes. Relax and repeat. Repeat 5-10 times.

Stairs

Going up and down stairs: It is important that you successfully complete a flight of stairs before discharge. This is so that when you go home you will know the correct technique for negotiating your stairs at home.

1. Going up stairs

Hold the stair rail on one side and your crutches on the other side. Place the unoperated leg up first followed by the crutches and the operated leg to the same step.

2. Going down stairs

Hold the rail on one side and your crutches on the other side. Place the crutches and the operated leg down first, followed by the unoperated leg onto the same step. Remember the crutch and the operated leg move together.

Going up and down stairs with 2 elbow crutches

Going up stairs

Place unoperated leg up first, then crutch and operated leg together.

Going down stairs

Place crutches with operated leg down first, then unoperated leg.